Every finding on record at Highland Square Nursing and Rehabilitation

Based on medical record review, review of a facility Self-Reported Incident (SRI), review of a facility investigation, review of text messages, review of a police report, review of the facility abuse policy, and interview, the facility failed to protect Resident #50's right to be free from sexual abuse by Housekeeper (HK) #208. This resulted in Immediate Jeopardy and the potential for actual physical and psychosocial harm beginning on 08/15/25 when Housekeeper (HK) #208 sent his picture and inappropriate text messages to Resident #50's phone asking for sexual favors to Resident #50 and then subsequently had the resident perform oral sex on him on two occasions, with evidence the resident performed the act out of fear. The facility failed to recognize the staff to resident sexual contact as abuse and failed to properly follow up with police regarding the incident. This affected one resident (#50) of three residents reviewed for abuse. The facility census was 63. On 09/16/25 at 4:28 P.M., the Administrator, Director of Nursing (DON) and Regional Director of Operations (RDO) #201 were notified Immediate Jeopardy began on 08/15/25 when the facility failed to prevent incidents of sexual abuse by HK #208 to Resident #50, a vulnerable resident with moderate cognitive impairment. HK #208 sent his picture and inappropriate text messages asking for sexual favors to Resident #50 and had Resident #50 perform oral sex on him out of fear. Based on HK #208's position of power, Resident #50's diagnoses and cognitive impairment, there was no evidence Resident #50 was able to consent to a sexual relationship. The facility also failed to recognize staff to resident sexual contact as abuse and failed to properly follow up with police. The Immediate Jeopardy was removed on 09/17/25 when the facility implemented the following corrected actions: On 08/19/25 Resident #50's friend updated facility staff that HK #208 came into Resident #50's room on two separate occasions in the previous week and made her perform oral sex on him. On 08/19/25 HK #208 was suspended pending further investigation. On 08/19/25 the facility opened a self-reported incident (SRI) tracking number 264268. On 08/25/25 HK #208's employment ended with the facility when the employee resigned. On 09/09/25 Resident #50 was signed up for psychological services with consent from her guardian and assistance from Social Services Designee (SSD) #212. On 09/16/25 Resident #50 was referred to follow-up with psychological services on 09/17/25 by Social Service Designee (SSD) #212 to evaluate mood the resident's status related to the incidents with HK #208. The social services designee also completed a depression test, Patient Health Questionnaire-9 (PHQ-9), to evaluate the resident's mood status related to the incidents with the staff member. On 09/16/25 at 4:45 P.M. the [NAME] President of Operations and [NAME] President of Clinical Services educated the RDO #201 on the following: Brief Interview for Mental Status (BIMs) assessment and scoring.Staff to Resident Relation (as included in updated facility abuse policy deeming this act abuse): At no time can staff develop, participate and/or engage in an emotional or physical intimate relationship with a resident. This would include, but not limited to, communication (text, phone calls, social media) and/or in person regardless of what resident BIMS assessment result is or if they consent. (as included in updated facility abuse policy deeming this act abuse).When a police report was made, staff would follow up with the police to determine if any charges would be pursued. Thorough Investigations: A thorough investigation must be completed for all investigations. A thorough investigation should include interviewing the resident, the accused, and all witnesses. Witnesses generally include anyone who: witnessed or heard the incident; came in close contact with the resident on the day of the incident (including other residents, family members); and employees who worked closely with the accused employee(s) and/or alleged victim the day of the incident. On 09/16/25 at 5:15 P.M. the [NAME] President of Clinical Services updated the facility Abuse Policy to include staff to resident relations. Specifically in the policy training section the facility added:Training would also include education on staff to resident relationships: At no time could staff develop, participate and/or engage in an emotional or physical intimate relationship with a resident. This would include, but not limited to, communication (text, phone calls, social media) and/or in person as this was abuse. On 09/16/25 at 5:20 P.M. the facility re-opened the SRI related to Resident #50. The police were updated that Resident #50 wanted to re-speak with them again. On 09/16/25 at 5:30 P.M. the RDO #201 and Regional Director of Clinical Services educated the Administrator and DON on the following:BIMs assessment and scoring.Staff to Resident Relation (as included in updated facility abuse policy deeming this act abuse): At no time can staff develop, participate and/or engage in an emotional or physical intimate relationship with a resident. This would include, but not limited to, communication (text, phone calls, social media) and/or in person regardless of what resident BIMS assessment result is or if they consent. (as included in updated facility abuse policy deeming this act abuse).When a police report was made, staff would follow up with the police to determine if any charges would be pursued. Thorough Investigations: A thorough investigation must be completed for all investigations. A thorough investigation should include interviewing the resident, the accused, and all witnesses. Witnesses generally include anyone who: witnessed or heard the incident; came in close contact with the resident on the day of the incident (including other residents, family members); and employees who worked closely with the accused employee(s) and/or alleged victim the day of the incident. On 09/16/25 at 5:30 P.M. the Administrator and DON educated the following staff members: Activities Director, Human Resources Director, Unit Manager, Wound Nurse, Maintenance Director, Social Services Director, Central Supply Clerk and Housekeeping Supervisor on the following:BIMs assessment and scoring.Staff to Resident Relation (as included in updated facility abuse policy deeming this act abuse): At no time can staff develop, participate and/or engage in an emotional or physical intimate relationship with a resident. This would include, but not limited to, communication (text, phone calls, social media) and/or in person regardless of what resident BIMS assessment result is or if they consent. (as included in updated facility abuse policy deeming this act abuse).When a police report was made, staff would follow up with the police to determine if any charges would be pursued. Thorough Investigations: A thorough investigation must be completed for all investigations. A thorough investigation should include interviewing the resident, the accused, and all witnesses. Witnesses generally include anyone who: witnessed or heard the incident; came in close contact with the resident on the day of the incident (including other residents, family members); and employees who worked closely with the accused employee(s) and/or alleged victim the day of the incident. On 09/16/25 at 6:00 P.M. the facility held an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting to review the incident involving HK #208 and Resident #50, the investigation and the facility abuse policy not outlining physical and emotional contact between staff and resident. The facility identified the root cause of the incident included that the facility policy did not outline physical or emotional contact between staff and resident or that Resident #50 was cognitively impaired. Staff in attendance included the Medical Director via phone, the Administrator, Director of Nursing (DON), Activities Director, Human Resources Director, Unit Manager, Wound Nurse, Maintenance Director, Social Services Director, Central Supply Clerk and Housekeeping Supervisor. On 09/16/25 at 8:15 P.M. the facility completed a Brief Interview for Mental Status (BIMs) Assessment on all residents. All care plans were reviewed regarding cognitive status after the BIMS assessments were updated. This was completed by the clinical management staff, Social Services Designee and Activity Director. On 09/16/25 at 7:00 P.M. the facility wound nurse completed skin assessments on all residents who had a BIMS of 12 or below. On 09/16/25 at 7:30 P.M. the facility Social Services Designee, Activity Director and the clinical management staff completed resident abuse questionnaires for residents with a BIMs score of 13 or above. On 09/16/25 at 7:45 P.M. all staff were educated on the following:BIMs assessment and scoring.Staff to Resident Relation (as included in updated facility abuse policy deeming this act abuse): At no time can staff develop, participate and/or engage in an emotional or physical intimate relationship with a resident. This would include, but not limited to, communication (text, phone calls, social media) and/or in person regardless of what resident BIMS assessment result is or if they consent. (as included in updated facility abuse policy deeming this act abuse).When a police report was made, staff would follow up with the police to determine if any charges would be pursued. Thorough Investigations: A thorough investigation must be completed for all investigations. A thorough investigation should include interviewing the resident, the accused, and all witnesses. Witnesses generally include anyone who: witnessed or heard the incident; came in close contact with the resident on the day of the incident (including other residents, family members); and employees who worked closely with the accused employee(s) and/or alleged victim the day of the incident. On 09/17/25 at 12:11 P.M. the facility notified the police department regarding the abuse allegation, re-opening of the facility investigation for sexual abuse and provided the alleged perpetrator's information. Beginning on 09/17/25 the facility implemented a plan to complete head-to-toe assessments on five random residents who had a BIMs score of 12 or less to assess for signs and symptoms of abuses, five times a week for four weeks then five residents weekly for four weeks. Beginning on 09/17/25 the facility would interview five random residents five times for four weeks and then five random residents weekly for four weeks with abuse questionnaires for residents with a BIMs of 13 or higher. Beginning on 09/17/25 the facility would complete five random staff questionnaires on new abuse policy five times a week for four weeks and then five random staff weekly for four weeks. Beginning on 09/17/25 RDO #201 and the Regional Director of Clinical Services would audit facility SRIs for a thorough and proper investigation. Beginning on 09/17/25 RDO #201 and the Regional Director of Clinical Services would audit SRIs for police notification.All discrepancies would be submitted to the QAPI Committee and revised as needed for three months. Although the Immediate Jeopardy was removed on 09/17/25 the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure continued compliance. Findings include: Review of the medical record for Resident #50 revealed an admission date of 09/19/24 with diagnoses including diffuse traumatic brain injury with loss of consciousness of 31 minutes to 59 minutes, hemiplegia affecting right dominant side and depression. The resident was noted to have a guardian. Review of the care plan dated 01/10/25 for Resident #50 revealed she had impaired cognitive function and thought process related to a traumatic brain injury related to a gun shot wound and skull fracture with impaired decision making and memory loss. Interventions included to communicate with the resident, family and caregivers regarding resident's capabilities and needs. Review of a Durable Power of Attorney and Guardianship document dated 05/09/25 for Resident #50 revealed she had a guardian in place. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #50 revealed she had an impaired cognition, scoring a nine out of 15 on the BIMs assessment. Review of text messages dated 08/15/25 and 08/16/25 revealed HK #208 sent Resident #50 his picture on 08/15/25. On 08/16/25 at 4:40 A.M. HK #208 asked Resident #50 to ensure her phone was locked as he did not want her to get caught with his picture on it. On 08/16/25 at 7:20 A.M. HK #208 stated he was working all day and asked if he could get these balls licked and see you jack that cat off. Resident #50 never responded. On 08/16/25 at 4:18 P.M. HK #208 sent another text asking if he could see her before he got off work. Resident #50 responded she had a boyfriend. Review of a facility SRI, tracking number 264268 dated 08/19/25 revealed Resident #50's friend notified the police, the facility compliance hotline and an attorney that Resident #50 had a sexual relationship with HK #208. When interviewed, Resident #50 stated she and HK #208 had begun communicating approximately two weeks prior but couldn't provide the exact dates. Resident #50 stated the conversations progressed to sexual topics and she performed oral sex on HK #208 twice, first on 08/15/25 and then on 08/16/25. Information included in the facility SRI revealed Resident #50 stated she had willingly participated during an interview with Activities Director #200. The facility conducted their investigation and concluded that Resident #50 willingly consented to a relationship with the staff member and the staff member did not try or have intent to cause harm to the resident. Review of police report #2025-00098017 completed by Patrolman #210 revealed on 08/19/25 at 9:34 P.M. the reporting officer arrived at the facility after being called for force of threat of rape to Resident #50. There report identified an unknown black male suspect. The narrative stated the victim was sexually assaulted by the suspect. Review of a facility investigation revealed a statement dated 08/19/25 at 9:15 P.M. by Licensed Practical Nurse (LPN) #209. The statement included the LPN interviewed Resident #50 related to the allegation of sexual abuse. Resident #50 stated the housekeeper came into her room on two separate occasions within the previous week and made her perform oral sex on him. She stated she did the sex acts out of fear. Resident #50 also stated that she had text (messages) on her phone from the staff member asking for sexual favors from her. Review of a BIMs assessment performed on 08/20/25 revealed Resident #50 scored 12 out of 15 which reflected the resident exhibited moderately impaired cognition. Review of a typed statement by Activities Director #200 on 08/20/25 for Resident #50 revealed Resident #50 was educated on the term of consensual and non-consensual sexual actions. She stated understanding of the definitions. Resident #50 stated that inappropriate communication with HK #208 had begun two weeks prior. She stated she had done it two times but did not profit. When asked what she meant regarding the statement Resident #50 stated I gave him head and he did not cum. Resident #50 stated she was not raped and was a willing participant. She stated on 08/15/25 she pulled out his penis from his clothing and put it into her mouth. She stated on 08/16/25 HK #208 pulled his penis out and put it into her mouth. Resident #50 stated she did not plan to give him head that day, but she did not tell him no. She stated when he attempted to contact her again, she told him she had a new boyfriend. Resident #50 signed the statement. Review of Resident #50's medical record revealed there was no further follow up with additional interventions to address the 08/15/25 and 08/16/25 incidents of sexual abuse. Interview on 09/16/25 at 8:37 A.M. with the Administrator revealed he believed that both the resident and the housekeeper were consenting to the sexual activity, and the facility abuse policy did not state staff and residents could not be intimate with each other. He stated the police did not open a case because both the resident and HK #208 consented to the relationship. During an interview on 09/16/25 at 8:47 A.M. with Resident #50 the resident stated she did consent to oral sex with HK #208 one time. She stated she performed oral sex on HK #208 the second time because she felt scared. Upon further conversation, the resident was unable to state what she was fearful of with HK #208. She then presented her cellphone and reviewed texts she had received from HK #208. Interview on 09/16/25 at 9:30 A.M. with Activities Director (AD) #200 revealed Resident #50 had told her she never refused to have oral sex with Housekeeper #208 and based on this, AD #200 stated she felt the interaction was consensual. Interview on 09/16/25 at 10:14 A.M. with RDO #201 revealed the RDO felt Resident #50 understood was consent meant and she ensured she cognitively understood what was being asked during the investigation. She stated in addition, to her knowledge the resident's guardian had no concerns with the incidents that had occurred. RDO #201 also stated the police were called and had no further concerns. Interview on 09/16/25 at 11:16 A.M. with RDO #201 revealed she suspended HK #208 on 08/20/25. The employee refused to give a statement but stated he denied the allegation of sexual abuse. RDO #201 stated HK #208 never returned to the facility to provide a statement and quit by voicemail. The facility had been unable to reach HK #208 since that time. Interview on 09/16/25 at 1:18 P.M. with the Administrator revealed Resident #50 and her friend spoke to the police in regard to the incidents with HK #208. He stated Resident #50's friend, who was another resident, had called the police to report an allegation of sexual abuse. The Administrator was unaware if anyone from the facility spoke to police while they were at the facility on 08/19/25. He verified the police report did not have HK #208 listed as the suspect. The Administrator also verified the facility had not updated the police department once they were made aware of the staff member (HK #208) involved. The Administrator revealed he believed the police would follow with the facility if there was a concern. The Administrator verified reviewing Resident #50's statement dated 08/19/25 with LPN #209 (which indicated the resident performed the act out of fear). Interview on 09/16/25 at 3:01 P.M. with Resident #50's guardian revealed she was contacted by the facility and Resident #50 that the resident had oral sex with HK #208 on two occasions. She stated she was told the first occasion Resident #50 had consented to and on the second she had not but performed oral sex out of fear. Resident #50's guardian stated she was concerned men would pray on Resident #50 due to her desperation and age. Interview on 09/17/25 at 10:39 A.M. with LPN #209 revealed Resident #50 had come to her to speak about a sexual abuse allegation on 08/19/25. She stated Resident #50's friend, another resident, stated he had called the police. She stated during her interview with Resident #50 she took her to a private location without any other staff or residents. She stated Resident #50 stated HK #208 had texted her sexually inappropriate statements and she had provided him oral sex on two occasions. She stated Resident #50 stated she had performed oral sex to HK #208 the first time willingly but did not want to the second time. LPN #209 stated Resident #50 told her she only performed oral sex the second occasion due to fear. She stated when the police arrived, they asked her where the resident's room was and then she had no further discussions with them. She stated when Resident #50 showed her the texts on her phone she was able to identify the picture as HK #208 and she updated the Administrator and RDO #201 with the information. She stated Resident #50 had a name saved in her phone that was not HK #208's name but was able to verify it was his picture. Attempted interview on 09/17/25 at 2:23 P.M. with Detective #211 with the police department major crimes unit was unsuccessful. Interview on 09/17/25 at 5:02 P.M. with Patrolman #210 revealed when he arrived at the facility he spoke to a couple of staff members inquiring on who the alleged perpetrator was. He stated the employees were unable to verify the suspect. He stated he had no contact with the facility staff after he left the building on 08/19/25. Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation of Resident Property, dated 10/27/17, revealed sexual abuse was defined as the non-consensual contact of any type with a resident. It also defined exploitation as taking advantage of a resident for personal gain through manipulation, intimidation, threats or coercion. The policy did not address staff to resident sexual relations as abuse situations despite a residents' cognition or willingness to consent. This deficiency represents non-compliance investigated under Complaint Number 2605456.

Based on observations, interview, and review of the facility policy, the facility failed to provide a clean, sanitary and well maintained environment. This affected eight residents (Resident #7, #27, #36, #37, #39, #44, #46 and #63) but had the potential to affect all residents. The facility census was 64.Findings include: 1.Observation on 08/19/25 at 10:00 A.M. of Resident #36's ceiling revealed a half basketball sized bubble of plaster/paint that was broken open in the center. At this time Assistant Director of Nursing (ADON) #336 verified the observation but stated she was not sure how long it had been there as she was rarely on this unit.2. Tour of the facility on 08/19/25 between 10:12 A.M. until approximately 10:30 A.M. with the Administrator revealed the following observations:a. On the first floor the carpet was moderately soiled throughout. Dried pink and yellow paint was observed on the bottom part of Resident #39's door, a large pink stain on the floor near Resident #37's room and peeling wallpaper near Resident #48's room.b. Observation of Resident #36's ceiling revealed the half basketball sized bubble was no longer present but a ring of plaster/paint remained. The Administrator stated he broke the bulging piece from the ceiling. Also noted in Resident #36's room was peeling wallpaper to the left of the air conditioning unit and to the right, lower part of the wall was torn wallpaper and crumbled pieces of wall.c. Observation of Resident #44's room revealed multiple, large brown water stains and peeling paint on the ceiling in the right corner near the window. The base board behind the bed was bulging from the wall and the wallpaper behind the bed was ripped.d. Observation of the inside of the elevator on the right side was multiple long scratches in the walls and the floor of the elevator was dirty with multiple areas of missing flooring. The elevator on the left side also had multiple long scratches in the wall. The grooves in the silver entryway to both elevators were heavily soiled .e. Observation of the third floor exiting from the elevator on the left were heavy, black marks that lead from the elevator through the walk through by the nurses' station. There were several markings on the floor causing the floor to have soiled appearance. Theses marking also led into Resident #63's room. The wall of the walk through near the nurses' station was heavily scuffed with dark markings.f. Observation of the second floor revealed the wallpaper near Resident #42's room was pulling off the wall at the seams and there was a baseball size patched hole with a tear in it. The wall of the walk through near the nurses' station was heavily scuffed, scratched and dirty.Interview on 08/19/25 with the Administrator verified all the above findings at the time of the tour. 3. Observation on 08/19/25 at 12:31 P.M. of Resident #7's room revealed the base board behind his bed was barely hanging onto the wall. The wall behind the base board was crumbling with multiple holes and foam exposed. Interview on 08/19/25 at 12:39 P.M. with the Administrator verified the wall in Resident #7's room.4. Observation on 08/20/25 at 9:09 A.M. in Resident #27 and #46's room revealed a baseball sized hole in the bottom portion of the wall near the base board where the tv and tv stand were located.Interview on 08/20/25 at 9:15 A.M. with Certified Nursing Assistant (CNA) #303 verified the baseball sized hole in the wall of Resident #27 and #46 's room. Review of the policy Cleaning and Disinfection of Environmental Surfaces, revised June 2009 revealed housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled.This deficiency represents non-compliance investigated under Master Complaint Number 2579281 and Complaint Number 2575188.

Based on observations, record review, and interviews, the facility failed to ensure residents attended physician ordered follow-up appointments status-post hospitalization and failed to ensure treatment orders were written for wound care. This affected one resident (Resident #65) of three residents reviewed for appointments and one resident (Resident #49) of four residents reviewed for wound care. The facility census was 64. Findings include: 1. Review of the closed medical record for Resident #65 revealed an admission date of 02/20/25 and a discharge date of 07/14/25. Diagnoses included congestive heart failure (CHF), ischemic cardiomyopathy, atherosclerotic heart disease, history of sudden cardiac arrest, and presence of coronary angioplasty implant and graft. Review of the progress note dated 06/10/25 at 12:41 P.M. revealed the Licensed Practical Nurse (LPN) #372 received a call from the nurse at the hospital regarding Resident #65 returning to the facility. The resident was admitted on [DATE] for shortness of breath (sob) and CHF exacerbation. Resident #65 was being treated with intravenous (IV) Lasix (diuretic) and would be receiving oral torsemide (diuretic) at the facility. Resident #65's pick up time from the hospital was at 1:00 P.M. Review of the hospital discharge summary with a discharge date of 06/10/25 revealed under future appointments was a follow-up appointment with cardiology in two weeks. Review of the physician orders revealed a follow-up with cardiology in two weeks dated 06/10/25. Further review of Resident #65's medical revealed no documentation that the follow-up cardiology appointment was scheduled or the resident went to the cardiology appointment. Interview on 08/20/25 at 10:51 A.M. with LPN #372 verified he was the nurse on duty when Resident #65 returned from the hospital on [DATE]. LPN #372 verified he entered the physician order into the medical record on 06/10/25 for the cardiology follow-up appointment but could not recall if he scheduled the appointment or if the resident went to the appointment. Interview on 08/20/25 at 12:22 P.M. with the Director of Nursing (DON) revealed she was unable to verify Resident #65's cardiology follow-up appointment was scheduled or if he went to an appointment with cardiology. 2. Review of the medical record for Resident #49 revealed an admission date of 06/17/25 with diagnosis including traumatic brain injury and multiple fractures after being hit by a motor vehicle. Review of the admission minimum data set (MDS) assessment dated [DATE] revealed moderate cognitive impairment, and the resident required set-up for assistance for eating, and the resident was dependent upon staff for all activities of daily living (ADLs) performance. Additionally, the resident had bilateral upper and lower extremity range of motion impairment and was frequently incontinent of bowel and bladder. Review of facility provided list of residents receiving wound care revealed Resident #49 was receiving wound care for an open area on his left shin. A review of the care plan for Resident #49 revealed no evidence of any impaired skin integrity or treatment to the resident's left shin. A review of wound care notes from the visiting wound care service dated 07/31/25 revealed Resident #49 had an open area on his left shin. The wound service noted the open area was a reopening of a surgical wound from surgical repair of their left tibia fracture. The wound service recommended daily cleansing of wound, apply mesalt, and cover with a super absorbent dressing. An observation on 08/20/25 at 9:13 A.M. for Resident #49's wound care with Wound Nurse (WN) #315 revealed the nurse cleansed the wound with normal saline, place mesalt on the wound and covered it with a super absorbent pad. After the wound care was performed, it was verified there was no order in the medical record for Resident #49 to receive wound care. An interview on 08/20/25 at 3:15 P.M. with WN #315 verified the order for wound care was not in the medical record and was not addressed in Resident #49's comprehensive care plan. WN #315 shared she knew what the visiting wound services wanted for a treatment to the resident's shin because she rounded with them weekly, received the wound care notes and put the orders into the medical record. Further interview with WN #315 shared they missed putting the order for wound care into the system. This deficiency represents non-compliance investigated under Master Complaint Number 2579281 and Complaint Number 2575188.

Based on closed record review and interview the facility failed to ensure adequate follow-up regarding optometry services. This affected one resident (#65) of three residents reviewed for ancillary services. The facility census was 64.Findings include: Review of the closed medical record for Resident #65 revealed an admission date of 02/20/25 and a discharge date of 07/14/25. Diagnoses included congestive heart failure (CHF), ischemic cardiomyopathy, atherosclerotic heart disease, history of sudden cardiac arrest, and presence of coronary angioplasty implant and graft.Further review of Resident #65's medical record including care plan revealed no documentation related to vision or optometry services.Interview on 08/20/25 at 11:05 A.M. with Social Services Director (SSD) #369 verified Resident #65 received glasses from the facility's contracted optometry service. SSD #369 stated she personally gave Resident #65 his glasses and initially he had no concerns. SSD #369 stated sometime later she was informed by Resident #65's family that he was unable to see out of the glasses. SSD #369 stated she contacted the contracted optometry service to add the resident to the list to be seen at the next visit. SSD #369 stated she did not follow-up with the resident and was unsure if he was seen by the contracted optometry services the next time they were in the facility. SSD #369 stated she had not documented anything related to Resident #369's glasses in his medical record. SSD #369 also stated she had not received any of the visit reports from the contacted optometry service since she started working at the facility at the end of March 2025. This deficiency represents non-compliance investigated under Complaint Number 2575188.

Based on record review, observation, staff interview and policy review the facility failed to ensure infection control guidelines were followed during incontinence care for Resident #7. This affected one resident (Resident #7) of three residents reviewed for activities of daily living. The facility census was 64.Findings include: A review of the medical record for Resident #7 revealed an admission date of 03/14/25 with diagnosis of left side hemiplegia, cognitive communication deficit, atrial fibrillation, and hypertension.A review of the admission minimum data set (MDS) assessment dated [DATE] revealed Resident #7 had a moderate cognitive deficit, impaired range of motion of his left upper and lower extremities, was dependent upon staff for performance of all activities of daily living, and was always incontinent of bowel and bladder.A review of Resident #7 physician orders revealed an order dated 03/25/25 for enhanced barrier precautions to be utilized during personal care due to a gastrostomy tube (G-tube) (a thin tube that is inserted through the abdomen into the stomach used for fluids and nutrition for individuals who are not able to eat or drink).A review of the care plan for Resident #7 revealed incontinence was to be managed by staff for Resident #7 and staff were to don personal protective equipment (PPE) including gloves and a gown while performing personal care.An observation on 08/19/25 at 1:38 P.M. with Certified Nursing Assistant (CNA) #388 revealed incontinence care provided to Resident #7. CNA #388 donned gloves but no gown. After removing soiled linens from the bed, and a brief soiled with fecal matter, CNA #388 placed the soiled items on the floor, next to the resident's bed. Once CNA #388 completed cleansed the resident's groin and buttocks, the CNA, while still wearing the same gloves used to remove feces from Resident #7's perineal area, touched clean linens and other surfaces in the room including the over bed table and bed controls. The CNA did not remove their soiled gloves and perform hand hygiene before touching clean linens and other surfaces in the resident's room.An interview with CNA #388 verified that they were aware that Resident #7 was on enhanced barrier precautions and they did not put on a gown to provide the resident care. Further interview verified they had placed contaminated items on the floor and did not remove their gloves and perform hand hygiene before touching clean surfaces in the resident's room. Review of facility policy titled Enhance Barrier Precaution (EBP) Policy and Procedure dated 04/01/14 revealed gown and gloves were required during high-contact resident care activities such as dressing, bathing/showering, transferring, changing linens, changing briefs or assisting with toileting, and wound care. The purpose of EBP is to minimize the spread of multidrug resistant organisms (MDRO) and are implemented for residents with wounds, indwelling medical devices regardless of MDROReview of facility policy titled Perineal Care last revised 10/10 revealed after cleansing the rectal area and disposing of disposable items, the caregiver is to remove their gloves and perform hand hygiene before repositioning bed linens. No instructions were given related to what to do with soiled linen and briefs once removed from the bed and resident. This deficiency is an incidental finding discovered during the complaint investigation.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed record review, review of the facility's investigation, review of facility timeline, review of emergency medical services (EMS) run report, staff interview, and policy review, the facility failed to provide basic life support (BLS), including Cardiopulmonary resuscitation (CPR) to Resident #61 per the resident's advance directive, when the resident was found unresponsive on the toilet. This resulted in Immediate Jeopardy and serious life-threatening harm and the subsequent of death of Resident #61 beginning on [DATE] when Certified Nursing Assistant (CNA) staff alerted Licensed Practical Nurse (LPN) #341 who assessed Resident #61 and found the resident to be unresponsive. Instead of providing immediate care, LPN #341 contacted LPN #346 who was working on another floor for guidance. LPN #346 then contacted Unit Manager #354, who was at home asking for guidance related to finding Resident #61's advanced directives. LPN #341 had a difficult time finding the resident's advanced directives as LPN #341 denied having immediate access to the computer and the resident's hard medical chart. EMS was contacted and arrived on-site at which time Resident #61 was pronounced deceased ; EMS staff indicated it was too late for CPR. This affected one resident (#61) of four residents reviewed for death in the facility. On [DATE] at 10:33 A.M. the Administrator, Regional Nurse, Regional Administrator and [NAME] President of Operations were notified Immediate Jeopardy began on [DATE] at approximately 11:30 P.M. when upon answering Resident #61's call light, CNA #329 and CNA #368 observed Resident #61 in the bathroom sitting on the toilet in distress. The CNA staff alerted LPN #341 who assessed Resident #61 and found the resident to be unresponsive. Instead of providing immediate care, LPN #341 contacted LPN #346 who was working on another floor for guidance. LPN #346 then contacted Unit Manager #354, who was at home asking for guidance related to finding Resident #61's advanced directives. LPN #341 had a difficult time finding the resident's advanced directives as LPN #341 denied having immediate access to the computer and the resident's hard medical chart. EMS was contacted and arrived on-site at which time the resident was pronounced deceased as EMS staff indicated it was too late for CPR. The staff had left Resident #61 slumped over on the toilet until EMS arrived (at approximately 11:45 P.M. per the facility timeline). The Immediate Jeopardy was removed on [DATE] and subsequently corrected on [DATE] when the facility implemented the following corrective actions. On [DATE] between 12:00 A.M.-4:00 P.M., the Director of Nursing (DON) provided education on Advance Directives, location of advanced directives, change of condition, and immediate response of CPR. The education was provided to all staff that were in-house and those not in-house received training via phone. Training was verified by review of sign in sheets. On [DATE] the DON and Administrator interviewed and/or collected statements from all staff working at the time of the incident involving Resident #61. All staff involved were on site for these interviews. On [DATE] at 1:35 P.M., a whole house audit of all residents was completed by the Regional Director of Clinical Services (RDCS) verifying code status, care plans and signed Do Not Resuscitate (DNR) forms. No concerns were identified. On [DATE] at 2:30 P.M. the Human Resource Director reviewed all nursing staff files to verify cardiopulmonary resuscitation (CPR) certifications were valid. All certifications were valid and up to date. On [DATE] at 2:35 P.M. the RDCS verified all laptops on the units were accounted for. Three laptops and two desktops were available. (One desktop at first and third floor nurse stations and three laptops on three of the six medication carts [one on each unit. One nurse passes medications for the entire unit. The nurse takes the laptop from one medication cart to the other]). This was verified via surveyor observation. On [DATE] at 4:30 P.M. the DON audited crash carts and all equipment was in place. On [DATE] at 7:30 P.M., an ADHOC Quality Assurance and Performance Improvement (QAPI) meeting was completed to discuss Advance Directives for all residents. The outcome of the meeting was the development of education pertaining to Advance Directives, location of advanced directives, change in condition, immediate response of CPR. All interdisciplinary team members including the Administrator, DON, Unit Manager, Maintenance Director, Activities Director, Dietary Director, Business Office Manager and Admission Director were in attendance with the Medical Director in attendance via phone. On [DATE] at 11:30 A.M. a second ADHOC QAPI meeting was held. Discussion included but was not limited to the different code status levels and how staff were expected to respond and implementation of the corrective action plan and if any adjustments were required. On [DATE] at 11:45 A.M., staff received education on advanced directives, location of the advanced directives, immediate response of CPR and change in condition by The RDCS and DON. Any staff who were unable to attend in-house were trained via telephone. Completion of this training was verified via review of staff sign-in sheets and random interviews with staff. Beginning [DATE] at 3:10 P.M. the facility implemented a plan for the DON/Designee to conduct Code Blue drills and location of advance directives on alternating shifts three times a week for four weeks then weekly thereafter. Audit completion was reviewed and confirmed via review of auditing documentation sheets beginning on [DATE]. Beginning [DATE] at 3:10 P.M. the facility implemented a plan for the Administrator/Designee to audit all deaths that occurred to ensure resident's advanced directives were honored per preference five times a week for four weeks, then weekly thereafter. Auditing was confirmed via review of auditing documentation sheets (there were three deaths reviewed (one occurred on [DATE], one on [DATE] and one on [DATE]); two residents had advance directives for a DNRCCA status, and one resident was a DNR-CC). Beginning on [DATE] at 3:10 P.M. the facility implemented a plan for the DON/Designee to conduct audits to ensure that residents' change in conditions were addressed five times a week for four weeks, then weekly thereafter. Audit completion was reviewed and confirmed via review of auditing documentation sheets beginning on [DATE]. Beginning on [DATE] at 3:10 P.M. the facility implemented a plan for the DON/Designee to conduct audits to ensure each unit had a laptop for nursing access five times a week for four weeks. Audit completion was reviewed and confirmed via review of auditing documentation sheets beginning on [DATE]. Findings include: Review of Resident #61's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cognitive social or emotional deficit following an unspecified cerebrovascular disease, mild vascular dementia, chronic obstructive pulmonary disease, atrial fibrillation (irregular heart rhythm), congestive heart failure, polyosteoarthritis, and old myocardial infarction (MI). Review of the physician's orders revealed an advance directive order dated [DATE] indicating the resident was a full code status. Review of Resident #61's care plan with a creation date of [DATE] revealed Resident #61 desired to be a full code (advance directives). A full code status indicates a resident wants all life-saving measures used in a medical emergency. Review of the admission Minimum Data Set assessment with an assessment reference date of [DATE] revealed Resident #61 had range of motion impairment to upper and lower extremities on one side and required substantial/maximal (staff) assistance with toilet transfers. Resident #61 utilized a manual wheelchair for mobility. Review of an untimed progress note dated [DATE] revealed Resident [Resident #61] expired [DATE] at 00:00. R [resident] assessed by nurse and other nurse in building. Contacted MD, DON, sister. Contacted summit county corner (sic) spoke with (name provided) at 00:16 gave permission to release r [resident] to funeral home. Contacted (name of funeral home) spoke with (name provided). Funeral home picked r [resident] up at 01:27 exited on elevator gave copy of face sheet & medication list. Review of an EMS run report revealed a public safety answering point of [DATE] at 11:41 P.M. EMS was at patient at 11:48 P.M. The incident/patient disposition indicated DOA (dead on arrival)-no resuscitation attempted. Primary impression indicated obvious death. The narrative indicated M9 dispatched to (address of facility) Skilled Nursing Facility. 67 yom (year old male) reports of not breathing. Upon arrival facility staff in room and state we think he's deceased . Pt (patient) has rigor set in and pooling noted. Pt is cold to touch, obvious signs of death and 3 lead ecg (electrocardiogram) shows asystole (no heartbeat). Pronouncement and after death care left to facility. Facility requested medic crew assistance moving body, declined by crew due to nature of pt and possible medical examiner investigation. Detailed findings indicated skin cold, mottled, lividity. Review of the timeline (and corresponding staff statements) provided by the facility revealed the following information: CNA #368 reported on [DATE] about 11:30 P.M. Resident #61's bathroom call light was on when she responded she saw Resident #61 appeared to be slumped over on his toilet and appeared to be talking with CNA #329. CNA #368 could hear CNA #329 talking but couldn't tell if Resident #61 was talking. CNA #368 reported she immediately called for the nurse. CNA #329 reported on [DATE] about 11:30 P.M. Resident #61 was banging on his wall and when he entered the room Resident #61 was saying something about getting off the toilet to his wheelchair; he appeared to be in distress, and CNA #368 and CNA #329 went and got the nurse. LPN #341 reported on [DATE] at 11:35 A.M. she was standing at the nurse's station when CNAs (unnamed) near Room (number provided) called her to the room. LPN #341 reported Resident #61 was slumped over, face was pale, and hands and feet were purplish. LPN #341 assessed Resident #61 and was unable to feel a pulse. LPN #341 then went and got the vitals cart and again no vital signs were detected. At 11:39 P.M. (verified with DON's phone) LPN #341 called and let DON know Resident #61 was in distress and was instructed to call 911. At 11:40 P.M. LPN #341 reported calling 911 while other nurse on duty (not identified) also assessed Resident #61 at this time and couldn't get a pulse. LPN #341 immediately went to get Resident #61's chart but couldn't find his chart, so she checked Point Click Care (PCC) for code status. When going to get the CPR equipment EMS arrived. At 11:45 P.M. EMS was on site in resident's room; hooked Resident #61 up to monitor and reported Resident #61 was deceased . EMS refused to assist with moving the resident. Between 11:50 P.M. and 12:00 A.M. staff assisted in getting Resident #61 from toilet to wheelchair to bed. On [DATE] at 12:00 A.M. the nurse (not identified) contacted the MD, DON and resident's sister to notify that Resident #61 had expired. Interview with LPN #354 (nurse supervisor) on [DATE] at 4:03 P.M. revealed she received a call from LPN #346 (on [DATE]) around 12:00 A.M. asking what she should do as staff didn't know what to do regarding Resident #61 being on the toilet unresponsive. The supervisor revealed LPN #346 was instructed to call EMS, get the crash cart and look for code status. Interview with LPN #346 on [DATE] at 11:39 A.M. revealed she was working on [DATE] on another unit downstairs when LPN #341 called for help. LPN #346 went to the third floor and assessed Resident #61 and asked staff for the resident's code status. However, they couldn't find Resident #61's chart. LPN #346 stated she checked for pulses, and the resident was mottled. When EMS arrived, they declared Resident #61 dead. LPN #341 said she called the DON at that point, and she called Resident #61's sister. There was a nurse and two CNAs working on the third floor at the time and no code was called. Interview with CNA #368 on [DATE] at 1:51 P.M. revealed on [DATE] she was working on the third floor and went into Resident #61's room. Resident #61 was on the toilet, and she saw his hands were yellowish, CNA #329 asked Resident #61 if he was okay. CNA #329 said Resident #61 mumbled. LPN #341 was in and out of room several times. CNA #368 reported Resident #61's pulse was faint at first, but a couple minutes later the pulse was gone. CNA #368 indicated Resident #61 was not taken off the toilet and CPR was not completed. EMS said Resident #61 was DOA and left the facility. CNA #368 reported the audible signal to the call light system was disconnected that night; the cord from the annunciator panel at the desk had been disconnected. CNA #368 revealed when she arrived for her night shift she saw Resident #61's call light was on but there was no sound. CNA #368 said she checked the call light panel and saw Resident #61's call light had been on for more than 30 minutes. Interview with LPN #341 on [DATE] at 1:56 P.M. revealed CNAs were outside of Resident #61's room when they heard a sound on the wall and they entered the room. When LPN #341 entered the room Resident #61 was on the toilet. LPN #341 checked for a pulse and found no signs of a pulse. Resident #61 was slumped forward, his hands were purplish, face was pale, and his skin was warm. LPN #341 said she called 911 and asked the aides for his chart. A second nurse came up to help. LPN #341 had looked at the computer and Resident #61 was a full code. EMS arrived and declared Resident #61 dead. LPN #341 reported they were not able to complete CPR because they could not get the resident off the toilet. A follow-up interview with LPN #341 on [DATE] at 8:09 A.M. revealed at the time of the incident, she went to the computer to find Resident #61's code status. LPN #341 stated she was not sure who found the chart, but it was nowhere to be found on the third floor. LPN #341 confirmed Resident #61 did not have a pulse when she first assessed him. Interview with LPN #307 (unit manager) on [DATE] at 8:33 A.M. revealed a resident's code status could be found in the electronic medical record and the nurses always had access to a computer. Review of the facility's Emergency Procedure-Cardiopulmonary Resuscitation policy and procedure dated [DATE] revealed if an individual was found unresponsive and not breathing normally, a licensed staff member who was certified in CPR/BLS was to initiate CPR unless it was known that a DNR order that specially prohibited CPR and/or external defibrillation existed for that individual or if there were obvious signs of irreversible death (e.g., rigor mortis). If the resident's DNR status was unclear, CPR was to be initiated until it was determined that there was a DNR or a physician's order not to administer CPR. This deficiency represents non-compliance investigated under Complaint Number OH00165334.

Based on observation of camera footage, interview, record review, and policy review the facility failed to ensure staff members remained awake and alert while on duty to prevent the potential for resident neglect. This had the potential to affect 39 residents (#14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #45, #46, #57, #48, 49, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69) of 39 residents the facility identified as residing on the second and third floors. The facility census was 68. Findings include: An interview was conducted on 04/07/25 at 10:45 A.M. with Resident #15 who reported staff on midnight shift sleep while on duty, and the other night he took several videos of facility staff asleep while call lights were going off. Resident #15 revealed he reported this to the Administrator, and the Administrator stated, I don't want to see those and refused to watch the videos. Resident #15 stated he had wanted facility management to review the videos. Resident #15 also revealed during the time he was taking the videos there were no staff, nurses or nursing assistants on the units except for the employee who was asleep. Review of the medical record for Resident #15 revealed an admitted [DATE]. Review of Resident #15's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had intact cognition. Review of the facility's concern log revealed Resident #15 reported on 03/14/25 that staff were sleeping at night. The Director of Nursing (DON) was assigned to the concern. The resolution stated the DON worked night shift on 03/16/25 and no one slept. The concern was marked as resolved, however, there was no evidence the facility investigated Resident #15's concern in relation to the specific direct care staff who worked the night shift on 03/14/25. Review of the staffing schedules for 03/13/25 from 7:00 P.M. until 03/14/25 at 7:00 A.M. revealed Certified Nursing Assistant (CNA) #417 was the only CNA assigned to the second floor, and Licensed Practical Nurse (LPN) #440 and LPN #319 were assigned to split the second floor for nursing coverage. Review of the staffing schedules for 03/14/25 7:00 P.M. until 03/15/25 7:00 A.M. revealed CNA #413 was the only CNA assigned to the second floor, and CNA #236 was assigned to the third floor. LPN #440 was assigned to the third floor and LPN #427 was assigned to the first floor and both were to split the second floor for nursing coverage. An observation was conducted on 04/07/25 at 12:45 P.M. with the Regional Director of Operations (RDO) #500 of the time stamped and date stamped videos and pictures Resident #15 had taken to share with facility management. The videos and photos revealed the following concerns. A photo dated 03/14/25 at 5:24 A.M. revealed CNA #417 was sitting on a chair at the nurse's station with the hood from her sweatshirt covering her head. Her arms spread on the table and her head was laying on her arms with her head face down on her arms. This location was on the second floor of the facility. A photo dated 03/15/25 at 3:08 A.M. of CNA #413 revealed she was sitting in a computer chair at the nurses station with her arm on the table, and she was bent over with her face on her arm facing the nurses station desk and her eyes were closed. This location was on the second floor. A photo dated 03/15/25 at 3:12 A.M. revealed CNA #413 was sitting in a computer chair at the nurses station with her arm on the table. The photo showed the back of her head as it was resting on her arm. The location was on the second floor. A photo dated 03/15/25 at 3:13 A.M. revealed Resident #28's call light was activated. A 15-second video dated 03/15/25 and timed 3:27 A.M. revealed CNA #413 was sitting at the nurse's station with her arm on the desk, her head resting on her arm with her eyes closed. The location was on the second floor. A 15-second video dated 03/15/25 at 3:28 A.M. revealed Resident #28's call light remained activated. A 15-second video dated 03/15/25 at 3:32 A.M. revealed CNA #236 was sitting at a dining table on the third floor. Her upper body was positioned on the dining table, head resting on her hands and her eyes were closed. This location was on the third floor. A 19-second video dated 03/15/25 at 4:04 A.M. revealed CNA #236 remained in the same position with her eyes closed. A six-second video dated 03/15/25 at 4:31 A.M. revealed CNA #236 remained in the same position with her eyes closed. Record review of statements dated 04/09/25 from of LPN #427 and LPN #319 revealed they were not aware of staff sleeping while on their shift. Interview on 04/09/25 at 6:12 A.M. with LPN #440 revealed she worked on 03/14/25 and 03/15/24 on night shift and was unaware whether or not the identfied CNAs were sleeping. LPN #440 confirmed no CNA had asked her to cover them for call lights or resident care on 03/14/25 and 03/15/25. LPN #440 stated if she had been aware of any staff sleeping on the job she would have notified management. Interview with the Administrator could not be conducted due to the Administrator being unavailable for interview. Interview on 04/09/25 at 2:00 P.M. with Regional Director of Operation (RDO) #500 revealed it was against facility policy for staff to sleep while on duty. RDO #500 stated if staff want to rest while on duty they can rest during their break time but they are required to do so in their vehicles or in a designated staff break area. RDO #500 verified the contents of the video footage and photos provided by Resident #15 and confirmed the staff assigned to the second and third floor on 03/14/24 and 03/15/25 were resting in resident care areas. RDO #500 stated the pictured CNAs reported that their nurses were covering while they slept but nursing interviews revealed they were not aware of the staff sleeping. Review of the Meals and Breaks facility form revealed Staff members rest breaks are assigned by the supervisor or department head and may be taken in the designated break areas for a total of 30 minutes and be taken in 15-minute increments and are paid. Review if the facility policy, Abuse, Neglect, Exploration, and Misappropriation of Resident property last revised 11/01/19 revealed the definition of neglect is the failure of the facility its employees, or facility service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish or emotional distress. This deficiency represents non-compliance investigated under Complaint Number OH00163855.

Based on observation, interview and policy review, the facility failed to ensure beard restraints covered the beard to prevent hair from contacting the food and failed to use sanitary methods when handling food items. This had the potential to affect 56 of 59 residents as three residents (Residents #51, #106, and #110) received no food by mouth (NPO). The facility census was 59. Findings include: The following observations were made and confirmed with the Regional Dietary Manager #483 and [NAME] #462 on 02/20/25 between 11:25 A.M. and 12:02 P.M.: 1. [NAME] #462's beard net was worn around his neck during the meal temperature observation and during the first meal in the service. The meal was discarded and [NAME] #462 pulled up the beard net over his cheeks and upper lip. 2. [NAME] #462 removed hamburger and hotdog buns from their bags with his hands instead of utilizing a pair of tongs. Interview with Regional Dietary #483 on 02/20/25 at 12:15 P.M. verified [NAME] #462 was not wearing the beard net properly. She also confirmed [NAME] #462 used his hands to remove hamburger and hotdog buns from their bags. Review of a list of resident diets revealed Residents #51, #106, and #110 were NPO. Review of facility policy Hair Covering, undated, indicated any exposed body hair needs to be effectively restrained. Review of facility policy Sanitation/Infection Control, undated, indicated appropriate utensils were used to serve food and they vary according to the type of food served. Tongs, ladles, and scoops were frequently used.

Based on observation, interview, and record review the facility failed to ensure Resident #43's received treatment and comprehensive care to ensure leg braces were in place. This affected one resident (Resident #43) of two residents reviewed for leg braces. The facility census was 59. Findings include: Review of the medical record for Resident #43 revealed an admitted [DATE]. Diagnoses included schizoaffective disorder, borderline personality disorder, and polyosteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had mild cognitive impairment. Resident #43 required extensive assistance for all activities of daily living. Review of the nursing progress note dated 01/14/25 revealed the bionics facility called to set up an appointment in the facility on 01/14/25 for her leg braces. Resident #43 agreed to the appointment. Review of the physical therapy evaluation dated 01/17/25 revealed Resident #43 wanted to wear her braces despite education on high risk for skin breakdown on left lower extremity due to blisters and picked open skin. Resident #43 refused therapy treatments on 01/22/25 and was seen and treated on 02/03/25 and 02/06/25. Review of the therapy notes from 02/03/25 and 02/06/25 revealed no information regarding her leg braces. Review of the care plan for Resident #43 dated 01/31/24 revealed no information regarding her leg braces. Review of the physical therapy discharge summary dated 02/06/25 revealed that Resident #43 requires 24-hour assistance and a mechanical lift for all transfer due to lower extremities contractures and inability to bear weight through lower extremities. Resident #43 may use a wheelchair in the facility with supervision from the staff. Interview with Resident #43 on 02/20/25 08:39 A.M. confirmed she does not want to wear the braces or participate in therapy because they never gave her a chance to wear them. Observation of the resident on 02/20/25 09:11 A.M. revealed Resident #43 sleeping in bed with no braces on. Interview during the observation with Licensed Practical Nurse (LPN) #410 reported she knew nothing about those braces and confirmed there was no order and it was not care planned. She reported to speak with therapy and maybe they knew something. She also reported that Resident #43 was extremely non-compliant with care. Interview on 02/20/25 at 9:15 A.M. with Activity Director #402 revealed Resident #43 refuses therapy a lot but she does wear the braces sometimes and is very non-compliant with them. Interview on 02/20/25 at 9:20 A.M. with Infection Preventionist #481 confirmed that Resident #43 does not have an order for the braces and does not have a care plan for the braces. She reported that the facility does not necessarily need an order for braces or a care plan if the resident is only wearing them during therapy. Interview on 02/20/25 09:34 AM with Occupational Therapist (OT) #482 revealed that the braces were just delivered to the facility with no notice. She reported that Resident #43 could not tolerate them. Therapy was unable to evaluate her safety with them. She was unsure if the physician was notified because there was no documentation. Review of the facility policy titled, Assistive Devices and Equipment, undated, revealed the facility provides, maintains, trains, and supervises the use of assistive devices and equipment for residents. Review of the facility policy titled, Care plan, Comprehensive Person-Centered, undated, revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physician, psychosocial and functional needs is developed and implemented for each resident.

Based on review of the medical record and interview with the staff the facility failed to ensure Resident #5 received his medication as ordered by the physician. This affected one resident (Resident #5) of three reviewed for mediation administration. The facility census was 58. Findings included: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included diabetes, pain in leg, psychoactive substance abuse, asthma, and muscle weakness. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #5 had intact cognition. He had no upper or lower extremity impairment and he was receiving physical and occupational therapy. Review of the physician's progress notes dated 07/22/24 revealed Resident #5 was seen in the office for epigastric pain and was ordered pantoprazole (stomach acid reducer) 40 milligrams (mg) once daily. Review of the physician's orders revealed Resident #5 was not ordered pantoprazole 40 mg once daily until 08/08/24. Review of the medication administration records revealed Resident #5 received his first dose of pantoprazole 40 mg on 08/08/24. Review of the pharmacy delivery sheets revealed Resident #5 received three tablets of pantoprazole on 08/10/24. Review of the progress note dated 09/14/24 at 10:00 A.M. revealed Resident #5 was complaining of nausea and vomiting, feeling hot, and his tonsils were sore. He vomited liquid. The physician was notified and new orders were given. Review of the physician's progress note date 09/14/24 revealed staff called the physician due to the resident was complaining of nausea and vomiting, onset was one to two days ago, and denied the nausea and vomiting increased after eating. The plan was for laboratory tests and continue Zofran four mg every six hours as needed. Review of the September 2024 physician's order revealed Resident #5 did not have an order for Zofran four mg every six hours as needed. Review of the September 2024 Medication Administration Record revealed Resident #5 was never ordered or administered Zofran 4 mg every six hours as needed Review of the progress note dated 09/16/24 at 3:00 P. M. revealed Resident #5 went to a doctors' appointment with his mother regarding his sore throat. He was later admitted to the hospital for tonsilitis. On 09/25/24 at 4:45 P.M. an interview with Regional Director of Clinical Services #403 verified there was an order for pantoprazole 40 mg for Resident #5 however they were not given the progress notes from the physician's visit. She stated she did not know if any of the staff reached out to the physician's office to see if there were any new orders. On 09/26/24 at 9:38 A.M. an interview with Family Member #500 revealed the facility knew Resident #5 had an appointment on 07/22/24 with his physician. She sated because their van was broken down and she had to take him. She stated she had to get permission from his facility counselor to take him. She stated the doctor gave her a prescription for Pantoprazole for his acid reflux and she went to the drug store to have it filled. She stated when she got to the facility, she handed it to Receptionist #522. She stated Receptionist #522 told her she would get the Administrator. She stated the Administrator told her the facility had their own pharmacy, she explained she would have to order them through their pharmacy and she would take the medication just in case they could not get it in. She stated she did not know they could not use another pharmacy. She stated one week later Resident #5 told her he still had not received the medication. She stated she spoke to the Administrator again and the Administrator told her Resident #5 was receiving the medication. She explained to the Administrator Resident #5 would know if he was getting the medication and the Administrator stated she would look into it. She stated another week went by and Resident #5 had not received his medication. She stated her and her son called the ombudsman and explained to her what was going on. She stated the Ombudsman went to the facility and the Administrator told her the medication was lost but they would get it taken care of that day. On 09/26/24 at 09/26/24 at 10:35 A.M. with Resident #5 revealed he did not receive his medication for his acid reflux for about two weeks after he brought it to the facility. On 09/26/24 at 11:10 A.M. an interview with Regional Director of Clinical Service # 403 revealed the facility was aware Resident #5 was going out to physician's appointments and they had sent paperwork with him to those appointments. She verified again none reached out to the physician's office to see if there was any paperwork or new orders. On 09/26/24 at 1:50 P.M. an interview with the Director of Nursing confirmed no order for Zofran was written on 09/14/24 and she would speak to the nurse who worked that day to find out why. On 09/26/24 at 2:05 P.M. an interview with Ombudsman Supervisor #530 revealed the Ombudsman covering the facility was on vacation however he had access to her notes. He stated the notes indicated that Resident #5 and his mother reached out to the Ombudsman, stated Resident #5 was ordered a medication for acid reflux and had not received it and it had been over two weeks. He stated the notes indicated the Ombudsman spoke to the Administrator about the issue and she verified the administrator stated they had received his mediation and it was in the medication cart however she would not say how long of a gap there was between receiving the medications and him actually getting the medication. Observation of medication with Licensed Practical Nurse #400 on 09/30/24 at 2:50 P.M. revealed the staff was using a bottle of 90 tablets of pantoprazole 40 mg from a local drug store. Review of the facility policy titled, Administering Medications, dated 12/12 revealed medication would be administered in a safe and timely manner and as prescribed. This deficiency represents non-compliance investigated under Complaint Number OH00157506 and OH00157525.

Based on review of the medical record, review of therapy notes, and interview with staff the facility failed to provide therapy services to Resident #5 after he won his appeal. This affected one resident ( Resident #5) of three reviewed for therapy services. The facility census was 58. Findings Included: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included diabetes, pain in leg, psychoactive substance abuse, asthma, and muscle weakness. Review of the physician's orders revealed Resident #5 had orders for physical therapy (PT) to evaluate and treat four times a week for four weeks and occupational therapy (OT)would evaluate and treat four times a week for four weeks dated 07/08/24. Review of the OT evaluation and plan of treatment dated 07/08/24 revealed Resident #5 was certified from 07/08/24 through 08/06/24 for four times per week for four weeks. Review of the PT evaluation and plan of treatment dated 07/08/24 revealed Resident #5 was certified from 07/08/24 to 08/05/24 for four times a week for four weeks. Review of the skilled review dated 07/11/24 revealed Resident #5 was due to be reviewed for further skilled services on 07/18/24 at 8:30 A.M. Items needed included medication administration records, treatment administration records, last seven days of narrative notes, physician's documentation, therapy notes target dated for discharge, and care conference notes. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #5 had intact cognition. He had no upper or lower extremity impairment and he was receiving physical and occupational therapy. Review of the occupation therapy notes revealed Resident #5 last day of OT was on 07/30/24. Review of the physical therapy notes revealed Resident #5 last of PT was on 07/31/24. Review of the appeal letter from Anthem dated 08/06/24 revealed Resident #5 was approved for more therapy days from 08/06/24 to 08/10/24 however he never received those extra four days of therapy he was approved for. On 09/26/24 at 09/26/24 at 10:35 A.M. with Resident #5 revealed he was cut from therapy at the end of July. He stated he appealed and won but never received anymore days. He stated therapy cut him because he refused to use the weight machine anymore because he felt something move in his back every time, he used it and he was not hurting himself. On 09/26/24 at 2;35 P.M. an interview with Regional Director of Operation #483 revealed the therapy department stated Resident #5 did not need any more therapy so they did not pick him up from 08/06/24 to 08/10/24. On 09/30/24 at 1:13 P.M. an interview with Director of Therapy #464 revealed Resident #5 last covered day was 07/31/24. However , he appealed and won more time. She stated she did not believe he needed more therapy due to he was up walking around with a walker independently. She verified normally when a resident appeals and wins they would continue therapy for the certification period but they did not for Resident #5. She stated his therapy was only approved for discharged purposes. On 09/30/24 at 4:40 P.M. an interview with Regional Director of Operations #483 verified the facility had no documentation indicating the certification period from 08/06/24 through 08/10/24 were for discharge planning only and not therapy. She verified he had not received therapy at this time. This deficiency represents non-compliance investigated under Complaint Number OH00157525.

Based on observation, staff interview and facility policy review the facility failed to maintain the kitchen in a clean and sanitary manner. This affected 57 of 57 residents who received meals from the kitchen. The facility identified one resident (#36) who received nothing by mouth. The facility census was 58. Findings included: On 07/23/24 at 9:40 A.M. observations during a kitchen tour with Dietary Manger #635 revealed there were several gnats flying around in the kitchen. The trash can by the hand washing sink had a red substance splashed all over the lid and the side. There was also a brown substance spilled all over the side of it. There was a three-tiered silver cart with two mixers on it that were dirty with dried build-up of food debris, a trash can in the middle of the kitchen was dirty and had no lid on it, the steam table was dirty with dried on food, the shelf underneath the steam table was dusty and dirty with food debris, the plate warmer was dirty with dried food debris, there were several three tiered carts that were dirty with food build up, and there was dirt and food debris on the floor of the freezer. On 07/23/24 at 9:50 A.M. an interview with Dietary Manger #635 verified the above concerns. Dietary Manager #635 revealed the steam table should be cleaned after every meal , the trash cans should be cleaned and have a lid on them. She stated she was going to throw away a few of the three-tiered carts but had not received the approval from corporate yet and she stated the freezers were to be cleaned daily. Review of the undated facility policy titled, Cleaning and Sanitizing Dietary Areas and Equipment, revealed all kitchen area and equipment would be maintained in a sanitary manner and be free of buildup of food, grease and other soil. This deficiency represents noncompliance as an incidental finding during the investigation of Complaint Number OH00155325.

Based on observation, interview with staff and review of the facility policy, the facility failed to implement the smoking policy to maintain a safe and clean environment free from discarded cigarette butts at the facility's side entrance door and the resident smoking area. This had the potential to affect all the residents in the facility. The facility census was 58. Findings included: Observation of the resident smoking area on 07/23/24 at 4:10 P.M. with the administrator revealed several cigarette butts (over 30) all over in the mulch. The cigarette butts were also observed on the facility window ledge. The administrator stated staff go out with the residents. She verified there were cigarette butts in the mulch. Observation of the side guest entrance of the facility on 07/24/24 at 11:35 A.M. revealed several cigarette butts (over 50) all over in the mulch and bushes. An interview at this time with the Administrator verified there were cigarette butts in the mulch. She stated she would have them cleaned up. Review of the undated facility policy titled, Smoking Policy and Procedure, revealed the residents may smoke in a designated area outside the building. Cigarette butts and other smoking debris must be discarded in the designated receptacle and should never be thrown on the ground and in the mulch. The staff would empty ashtrays and keep the area free of debris, at the end of each smoke break. This deficiency represents noncompliance as an incidental finding during the investigation of Master Complaint Number OH00155560.

Based on record review and interview the facility failed to ensure a palliative care consult was arranged for Resident #24 to address the resident's chronic pain. This affected one resident (#24) of three residents reviewed for pain management. The facility census was 58. Findings included: Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including osteoarthritis left knee, spinal stenosis, radiculopathy, pain in the left knee, benign prostatic hyperplasia, hypertension, chronic pain, alcohol abuse, anxiety disorder, and depression. Review of a progress notes dated 05/02/24 at 3:46 P.M. revealed the nurse spoke to the resident regarding his chronic pain. Resident #24 stated he had tried everything for pain and nothing seemed to be working. Resident #24 was informed that palliative care was an option to which he responded he would like to try it. A request was sent to the nurse practitioner. Review of the physician's order dated 05/04/24 revealed Resident #24 had an order for a referral for palliative care. Record review revealed no evidence the resident had been seen for palliative care as of this time. On 07/23/24 at 3:10 P.M. an interview with Resident #24 revealed he had pain in his lower back that was related to spinal stenosis. The resident stated there was some possibility of him having back surgery, but that seemed to no longer be an option at this time. The resident stated the head nurse (Director of Nursing) had spoken to him a while back and said they (the facility) would look into palliative care for him to help with his pain control; however, the resident stated he had not heard anything at all since that time (over two months prior per the facility written progress note). On 07/24/24 at 2:10 P.M. interview with the Administrator confirmed there had been no palliative care consultation completed for Resident #24 as of this date. This deficiency is a recite to the complaint survey completed on 06/27/24.

Based on record review and interviews, the facility failed to ensure pain medications were available and administered as ordered by the physician. This affected one (Resident #5) of three residents reviewed for pain management. The facility census was 57. Findings include: Review of the medical record for Resident #5 revealed an admitted [DATE] with diagnoses including chronic pain. Review of the physician's orders for Resident #5 revealed she had an order dated 01/29/24 for Methadone HCl 80 milligrams (mg) two times a day for pain. Review of the care plan dated 01/30/24 for Resident #5 revealed she was on pain medication related to having pain. Interventions included to take Methadone HCl 80 mg two times a day for pain. Review of the Medication Administration Record (MAR) for May 2024 and June 2024 revealed Resident #5 did not receive her Methadone HCl 80 mg on 05/18/24, 06/01/24, 06/09/24, 06/20/24 and 06/21/24 in the morning and on 06/09/24 and 06/20/24 at night. Review of the nursing progress notes for Resident #5 revealed on 05/18/24 at 8:10 A.M. her Methadone was not able to be giving due to unavailability. The pharmacy was notified and was going to deliver that day. The physician was not updated. The nursing progress note dated 06/01/24 at 8:33 A.M. revealed nursing staff were only able to provide Methadone 40 mg to Resident #5 as that was all that was available on her medication card. The pharmacy was updated and was going to send more that day. The physician was not updated on the decreased dose provided to Resident #5. The nursing progress note dated 06/09/24 at 8:31 A.M. stated Resident #5's Methadone was not available to administer and the pharmacy was notified. The physician was not updated. The nursing progress dated 06/20/24 at 8:06 A.M. stated Resident #5's Methadone was not available. The physician was not updated. The nursing progress note dated 06/21/24 at 2:49 A.M. stated the staff were waiting for the Methadone to arrive. The physician was not updated. Interview on 06/26/24 at 2:10 P.M. with Registered Nurse (RN) #268 verified Resident #5 had not received her Methadone as ordered on the dates and times listed above and the physician was not updated. Interview on 06/27/24 at 8:45 A.M. with Resident #5 verified she had gone without her pain medication because the nursing staff did not order her medications timely. She stated she did have other as needed pain medications available during those times. Review of the facility policy titled, Administering Medications, revised December 2012, revealed medications were to be administered in accordance with the orders.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of the facility assessment, visitation policy, substance use disorder program contract and interview, the facility failed to properly identify potential risks/hazards for residents with a substance use disorder and provide adequate supervision and/or supervised visitation to prevent intentional/unintentional drug overdoses for residents in the facility. This resulted in Immediate Jeopardy and actual harm on [DATE] when Resident #44 who had known substance abuse history was found unresponsive and required cardiopulmonary resuscitation (CPR) and hospitalization after a Fentanyl and Methadone overdose. The Immediate Jeopardy and actual harm continued on [DATE] when Resident #61 with a known substance abuse history was found unresponsive requiring CPR after a drug overdose. The Immediate Jeopardy continued on [DATE] when Resident #61 was assessed to be difficult to arouse and identified to have an overdose of Fentanyl leading to hospitalization . On [DATE] at 1:55 P.M. the Administrator, Director of Nursing (DON), Regional Director of Operation (RDO) #710, [NAME] President of Clinical Services #750 and Regional Nurse #700 were notified Immediate Jeopardy began on [DATE] following the identification of drug overdoses occurring in the facility. Resident #44 who had known substance abuse history was found unresponsive and required cardiopulmonary resuscitation (CPR) and hospitalization after a Fentanyl and Methadone overdose. The Immediate Jeopardy continued on [DATE] and [DATE] related to drug overdoses involving Resident #61. This affected two residents (#44 and #61) of four residents reviewed for substance use disorder. The facility identified 15 residents with active or current substance use disorders, ten residents with behavioral health needs and 14 residents (#7, #9, #12, #14, #19, #20, #23, #24, #28, #29, #37, #44, #47 and #52) who participated in the facility substance abuse program. The Immediate Jeopardy was removed, and the deficiency was corrected on [DATE] when the facility implemented the following corrective actions: On [DATE] at 9:32 P.M. Licensed Practical Nurse (LPN) #223 called 911 (related to Resident #44). On [DATE] at 9:36 P.M. the Director of Nursing (DON) was notified by LPN #216 of a possible overdose of Resident #44. On [DATE] at 9:38 P.M. Akron City Emergency Medical Services (EMS) arrived at the facility, administered Resident #44 Narcan. MD #800 was notified, orders to monitor resident and complete tox screen. LPN #223 was asked by LPN #216 to witness an interview with Resident #61 about an incident that occurred with Resident #44. When both nurses approached Resident #61's room, they observed the resident lying face down on his floor and unresponsive. LPN #223 initiated CPR and LPN #216 went to the third floor to alert the paramedics that were already in the building. On [DATE] at 9:42 P.M. DON was notified by LPN #223 that Resident #61 was found unresponsive of possibly an overdose. On [DATE] at 9:43 P.M. the DON advised charge nurses LPN #223 and LPN #216 to complete a head count of residents and check the status of all residents. All other residents were accounted for with no concerns. Charge nurses LPN #223 and LPN #216 were directed to obtain statements from all staff in the building regarding the incident. On [DATE] at 9:44 P.M. the DON notified the Administrator two residents (#44 and #61) were found unresponsive from a possible (drug) overdose. On [DATE] at 10:10 P.M. LPN #223 notified MD #800 of Resident #61 being unresponsive. On [DATE] at 10:35 P.M. the DON arrived at the facility. A whole house audit was completed to ensure no other residents had been affected. The DON went to Resident #61's room to check his status. Then, DON went to the third floor to check the status of Resident #44. On [DATE] at 10:45 P.M. Resident #44 and Resident #61 were placed on Q 15-minute safety checks. On [DATE] at 10:55 P.M. the Administrator arrived at the facility. On [DATE] at 11:10 P.M. LPN #223 received an order from MD #800 to complete urinalysis from both residents (#44 and #61). On [DATE] at 11:30 P.M. the Administrator reviewed and made a copy of the visitor log with the findings of a visitor for Resident #44 on [DATE] from 5:10 P.M. to 5:20 P.M. On [DATE] at 12:38 A.M. the DON received a call from nurse LPN #223 for a change in condition for Resident #44. MD #800 was notified and 911 was called and Resident #44 was transferred to the hospital. On [DATE] at 1:15 A.M. RDCS #700, the Administrator and the DON reviewed staff statements, and staffing list for current day. It was determined the root cause of the drug overdose incident was a facility failure to supervise visitation per the facility substance abuse program policy. On [DATE] at 1:00 P.M. education on the facility substance abuse program interventions and monitoring was initiated by the Administrator and DON for all facility staff. On [DATE] at 1:30 P.M. the third-party program residents were provided with their signed contracts in order to review the expectations of the contract by SS #276, the counselor from the program. On [DATE] at 2:00 P.M. at Quality Assessment Performance Improvement (QAPI) meeting was held with RDO #710 and MD #800 via telephone, RDCS #700, the Administrator, DON, Unit Manager/LPN #201, Medical Records (MR) #204, Admissions Director (AD) #205, Business Office Manager (BOM) #202, Human Resources (HR) #203, and Therapy Director (DOR) #720, to discuss the incidents on [DATE]. On [DATE] at 7:00 P.M. Resident #44 returned to the facility and agreed to participate in individual and case management services through the third-party program. Resident #44 had participated in the third-party program from [DATE] through [DATE] and then again began participation on [DATE]. On [DATE] at 9:44 P.M. LPN #216 notified the DON of concern for Resident #61 appearing under the influence due to resident being difficult to arouse and not acting like self. The nurse then called MD #800 and EMS to transport the resident to the hospital. EMS arrived at the facility with police due to concern of possible overdose. Staff at the facility searched Resident #61's room with police officers. Inside his notebook a folded-up bus pass was located with a black substance in it. Officers tested the substance which was positive for Fentanyl. On [DATE] at 3:55 A.M. Resident #61 returned to the facility after testing positive for Fentanyl in hospital. On [DATE] at 9:45 A.M. the facility clinical team met with SS #276 to discuss the incident that occurred on [DATE] involving Resident #61. On [DATE] at 10:00 A.M. the Administrator held a QAPI meeting to discuss the root cause of the [DATE] incident and determined facility failure to conduct adequate room searches. Staff in attendance at the QAPI meeting included RDO #710 and MD #800 via telephone, RDCS #700, the Administrator, the DON, Unit Managers LPN #201 and LPN #200, MR #204, AD #205, BOM #202, HR #203, and DOR #720. On [DATE] at 11:00 A.M. the Administrator and RDO #710 completed room searches for all residents in the substance use disorder program with no additional negative findings. Residents were observed at this time for any changes in behaviors such as slurring of words, change in cognition, increase in agitation and avoidance of eye contact or conversation. No concerns noted at this time. On [DATE] at 1:26 P.M. Resident #61 discharged from the facility. The resident was given discharge instructions and summary. MD #800 was in agreement with the resident's discharge. On [DATE] at 2:30 P.M. RDO #710 educated the department head team which included the Administrator, the DON, Unit Managers LPN #200 and LPN #201, MR #204, AD #205, BOM #202, HR #203 and DOR #720 on the facility's substance abuse disorder program policy with emphasis on random room searches, random search of any delivered packages and supervised visitation. On [DATE] at 6:00 P.M. department head (BOM #202, DON, the Administrator, HR #203, AD #205, Unit Manager/LPN #201, MR #204, Activities Director (AD) #208, and Minimum Data Set nurse (MDS) #207) education was provided regarding the substance abuse contract completed by RDO #710. On [DATE] at 6:20 P.M. all staff education was completed regarding the substance abuse contract by the department heads BOM #202, DON, the Administrator, HR #203, AD #205, Unit Manager/LPN #201, MR #204, AD #208 and MDS #207. On [DATE] at 6:30 P.M. Front desk staff receptionist (RCP) #265, RCP #266 and RCP #267 were re-educated on the process of supervised visitation by the Administrator: 1. Visitation would be conducted in the main lobby and would be supervised by the receptionist or designee. 2. In the event the phone rings during a visit, the phones would not be answered by the receptionist and would roll over to the floors. 3. If assistance was needed, notify another staff member. 4. In the event of needing to leave the desk notify another staff member to cover. At least once a week the administrator and clinical team meet with SS #276, the third- party counselor, on Wednesdays and as needed. During this meeting a discussion of all residents who were active with attending groups through third-party program. Discussion of the residents, discharge plans, meeting goals, progress, or any concerns such as decreased participation, changes in behaviors or at risk. The bed board was present to discuss any residents who were not active in the program for reassessment and encouragement to participate. At the time of this meeting, it would be discussed for room searches and random tox screens to be completed with the third-party program and at the facility level. Communication between the Administrator and the third-party program/counselor would be continuous and as needed if any concerns arise. On [DATE] the facility implemented a plan for the Administrator/designee to audit the visitation log, to include monitoring of the sign in book (for completion) and to ensure visitations five times per week for four weeks and then randomly thereafter. Discrepancies would be reviewed in QAPI and revised as needed. On [DATE] the facility implemented a plan for the Administrator/designee to audit to ensure random room searches of residents participating in the substance use disorder program were completed for three residents weekly for four weeks and then randomly thereafter. All audit findings would be submitted to QAPI for recommendations and review. Findings include: Review of the facility assessment dated [DATE] reflected 15 residents with active or current substance use disorders and ten residents with behavioral health needs. The assessment reflected the facility managed the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identified and implemented interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities. The facility made available a third-party program for case management and counseling for residents with substance use disorders. 1. Review of Resident #44's medical record revealed an admitted [DATE] with diagnoses including encephalopathy, multiple sclerosis, nicotine dependence and other psychoactive substance abuse. Review of Resident #44's medical record revealed a signed consent for the facility's Substance Use Disorder Program dated [DATE]. Review of the initial care plan dated [DATE] revealed Resident #44 had mood and behavior problems related to anxiety, depression, substance abuse and recent placement at facility. Interventions included consulting behavioral health as needed and educating the resident/family on expectations of treatment. The resident's plan of care was revised on [DATE] to reflect a third-party program which offered case management and counseling for residents with substance use disorder. The goal was for Resident #44 to remain substance free for duration of the stay. Interventions included the resident must adhere to the program's rules, have no leave of absences (LOAs), participation in the program's group activities and completing homework for the program. Review of a progress note dated [DATE] dated 1:28 A.M. and authored by LPN #223 revealed within the 9:00 P.M. hour (on [DATE]), Resident #44 was observed leaning forward in his wheelchair unresponsive to stimuli. LPN #223 initiated code status alert and called 911. LPN #223 wrote Resident #44's airway was patent, she did a sternum rub, bounding pulse noted. LPN #223 stated the response team used Narcan one time. Resident #44 was monitored every 15 minutes. LPN #223 notified MD #800 at 12:40 A.M. concerning the resident having shallow respirations. MD #800 gave an order to send the resident to the emergency room . Administration and DON were notified and had assessed needs until 911 arrived. Review of the incident report dated [DATE] at 9:36 P.M. and authored by LPN #223 revealed Resident #44 was found unresponsive in his wheelchair. LPN #223 checked the resident's pulse and initiated CPR. Airway was noted to be patent. Sternum rub was completed and 911 was called. EMS arrived on the scene and utilized Narcan on Resident #44 one time. EMS relayed since Resident #44 was responsive and vital signs were stable, he did not need to go to the emergency room . In the resident description Resident #44 initially stated he took Fentanyl and Methadone. The immediate action taken per the incident report indicated MD #800, the DON, RDCS #700, RDO #710 and the third-party program counselor were notified. The incident report indicated the predisposing factor was taking narcotic/analgesic. Under the area of other it noted Resident #44 had a history of substance use and a diagnosis of psychoactive substance abuse. The resident was in the facility's program. Resident #44 was not supervised during a visit prior to overdose. Review of the Change in Condition form dated [DATE] at 6:14 A.M. and authored by LPN #223 revealed around midnight Resident #44 had abnormal vital signs, an altered mental status and was unresponsive. MD #800 ordered urinalysis or culture. Under review of findings it was marked as opioid overdose. Family was notified. Review of a progress noted dated [DATE] at 9:24 A.M. and authored by LPN #218 revealed Resident #44 was admitted to the hospital with a diagnosis of urinary tract infection. The resident returned to the facility on [DATE] at 7:03 P.M. Review of a progress note dated [DATE] at 12:35 A.M. and authored by Registered Nurse #217 revealed Resident #44 was given a urine drug test which resulted positive for THC. Interview on [DATE] at 8:20 P.M. with LPN #223 revealed she was present on [DATE] as the third-floor nurse. She stated State tested Nursing Assistant (STNA) #226 found Resident #44 slumped over in his wheelchair in his room. She stated she started CPR and called 911. When EMS took over, LPN #223 stated she went to the second floor to speak to another resident (Resident #61) who Resident #44 hung out with regularly. She wanted to find out if this resident gave Resident #44 drugs. She stated at that time she found Resident #61 on the floor with an apparent drug overdose. She stated there were police who showed up but did not come into the building on [DATE]. During the interview, the LPN indicated the facility substance use disorder program was too much explaining the residents in the program were on all three units instead of one like it used to be. She also stated the facility was not enforcing the visitation policy. She acknowledged receiving education on supervised visits stating visits now had to happen in the lobby for any resident on the facility program. Interview on [DATE] at 8:35 P.M. with LPN #216 revealed she was the nurse on second floor and had been at work on [DATE]. She stated on [DATE] she was called to the third floor to assist with Resident #44's overdose. Once the EMS took over care of Resident #44, she and another nurse thought they should check with Resident #61 to see if he knew what Resident #44 took. Following the incident, LPN #216 stated staff were given education on the facility's (substance abuse) program and the need for enforcement of visitation. She stated the visits would now have to be supervised unlike before. Interview on [DATE] at 2:49 P.M. with the DON revealed she arrived at the facility on [DATE] at 9:50 P.M. after being notified of the resident drug overdoses. She stated Resident #44 had not gone on any type of leave of absences (LOA) prior to the incident, but did have a visitor on [DATE], his father. The DON denied knowing how Resident #44 acquired drugs. She stated Resident #44 initially refused to go to the hospital, but he was sent around 12:00 A.M. and was admitted . The resident returned to the facility on [DATE]. Interview on [DATE] at 9:20 A.M. with the Administrator revealed she had requested the EMS report for Resident #44 but had not received it during the survey. Interview on [DATE] at 3:15 P.M. with Regional Director of Operations (RDO) #710 revealed visitation should have always been restricted to common areas (based on the facility substance abuse program). However, this was not enforced until [DATE] and now all visitation was limited to the lobby area. RDO #710 revealed only one resident (#44) had been identified to have a visitor on [DATE] which was how they believed residents obtained the drugs. The residents, including Resident #44, were not being supervised for visitation (as per the facility protocol) prior to [DATE]. Interview on [DATE] at 4:54 P.M. with RDO #710 and the Administrator confirmed on [DATE], Resident #44 had an unsupervised visit with his father, and he was not assessed afterwards as per the facility policy. RDO #710 stated the facility's role was to provide a safe, structured environment. The Administrator stated she met with SS #276 every week, usually Wednesdays, and as needed to discuss residents with signed Substance Use Disorder contracts. Both RDO #710 and the Administrator reviewed their contract and indicated they were tightening up the program. 2. Review of the closed medical record for Resident #61 revealed an admitted [DATE] and a discharge date of [DATE]. Resident #61 had diagnoses including other psychoactive substance abuse, opioid dependence, cannabis use and nicotine dependence. Review of the medical record for Resident #61 revealed a signed consent for the facility's Substance Use Disorder Program dated [DATE]. Review of the initial care plan dated [DATE] revealed Resident #61 had mood and behavior problems related to anxiety, depression, substance abuse and recent decline in health related to substance abuse. The resident had an order for Naloxone (Narcan) as needed for opioid abuse. Interventions included consulting behavioral health as needed and educating the resident/family on expectations of treatment. The resident's care plan was revised on [DATE] to reflect a third- party program which offered case management and counseling for residents with substance use disorder. The goal was for Resident #61 to remain substance free for duration of the stay. Interventions included, he must adhere to the program's rules, have no leave of absences (LOAs), participation in the program's group activities and completing homework for the program. Review of a progress note dated [DATE] at 9:50 P.M. and authored by LPN #216 revealed the third-floor nurse, LPN #223, knocked on Resident #61's door. There was no response. She discovered the resident was lying on the floor face down and not breathing. The resident was turned over and CPR was initiated. While performing CPR Resident #61 began to breathe as EMS entered the room and took over care. Review of an incident report, noted Resident #61 sustained a fall on [DATE] at 9:50 P.M. The report was authored by LPN #216 and revealed upon entering Resident #61's room the resident was lying face down on the floor, unresponsive and not breathing. The floor nurse and STNA turned the resident over, and initiated CPR until EMS arrived. EMS administered Narcan twice. Resident #61 was responsive and immediately stood up. He refused to go to the hospital. Resident #61's description of what happened revealed he and another resident were smoking the same cigarette before this occurred. The immediate action taken was MD #800, the DON, the Administrator and SS #276 were notified. The predisposing factor was identified as taking narcotic/analgesic. The report revealed Resident #61 had a history of substance use and a diagnosis of psychoactive substance abuse. The resident was currently part of the facility program, and he was not supervised during visit. Review of a progress note dated [DATE] at 9:44 P.M. and authored by the DON revealed the DON received a call regarding Resident #61 being under the influence. The resident was not acting like his normal self but was alert and oriented. The DON instructed the nurse to complete vital signs, a drug test, search his room and do a head count on all residents. The DON was then notified that the resident was not easily arousable/unresponsive. Vital signs were checked again, and the resident's continuous pulse oxygen reflected 90%. The DON instructed staff to give Resident #61 two liters of oxygen, call MD #800 and call EMS. Resident #61 stated he was having sharp pain in his chest. EMS arrived and Resident #61 was taken to the hospital where he tested positive for Fentanyl. The local police were involved and stated Resident #61 would be charged with possession. Review of the incident report dated [DATE] at 9:44 P.M. and authored by the DON revealed the DON was notified of Resident #61 being under the influence. The resident was not acting like his normal self but was alert and oriented. The DON instructed the nurse to complete vital signs, a drug test, search his room and do a head count on all residents. The DON was notified the resident was not easily arousable/unresponsive. Vital signs were checked again, and his continuous pulse oxygen reflected 90%. The DON instructed to give Resident #61 two liters of oxygen, call MD #800 and call EMS. Resident #61 stated he was having sharp pain in his chest. EMS arrived and Resident #61 was taken to the hospital where he tested positive for Fentanyl. The predisposing factor was identified as taking narcotic/analgesic. The immediate action taken was MD #800, EMS, RDO #700 and DON were notified. EMS arrived and transferred the resident to the hospital where he tested positive for Fentanyl. The police were involved and stated he would be charged with possession. The report revealed Resident #61 had a history of substance use and a diagnosis of psychoactive substance abuse. The resident was currently part of the facility program. Resident #61 was discharged following the incident due to violating the program contract. The resident was discharged on [DATE]. Review of the police report dated [DATE] at 10:07 P.M. revealed police were present from 9:30 P.M. to 10:05 P.M. Resident #61 was identified as the suspect and event was identified as an overdose. Offenses listed were possession of drugs (Fentanyl), illegal conveyance of drugs of abuse and unintentional overdose. The police seized 1.56 grams of suspected Fentanyl which was found in folded bus pass. Review of the progress noted dated [DATE] at 3:55 A.M. authored by LPN #216 revealed Resident #61 returned to the facility. EMS stated resident was tested and results were negative with the exception of the Fentanyl results. Interview on [DATE] at 8:20 P.M. with LPN #223 revealed she was present on [DATE] as the third-floor nurse. She stated after STNA #226 found Resident #44 slumped over in his wheelchair and EMS took over care for the resident, she went to second floor to speak to Resident #61 (who Resident #44 hung out with regularly). She stated she wanted to find out if Resident #61 gave Resident #44 drugs. She stated she found Resident #61 on the floor with an apparent drug overdose. She stated there were police who showed up but did not come into the building on [DATE]. She stated she was not present on [DATE] when Resident #61 experienced a second overdose. She stated the substance use disorder program was too much explaining the residents in the program were on all three units instead of one like it used to be. She also stated the facility was not enforcing the visitation policy. She acknowledged receiving education on supervised visits stating visits now had to happen in the lobby for any resident on the facility program. Interview on [DATE] at 8:35 P.M. with LPN #216 revealed she was the nurse on second floor and present both times Resident #61 overdosed. She stated on [DATE] she was called to the third floor to assist with Resident #44's overdose. Once the EMS took over both she and another nurse thought they should check with Resident #61 to see if he knew what Resident #44 took. She stated they knocked on his door with no answer. They opened the door and found Resident #61 on the floor; he was blue. They started CPR, the STNA was getting a crash cart when Resident #61 started breathing and threw up. The other nurse got EMS who were present in the building on the third floor. They administered Narcan to Resident #61. Resident #61 jumped up and did not know what happened. He denied taking anything and refused to go to the hospital. The LPN revealed she was also working on [DATE] when Resident #61 again overdosed. LPN #216 stated he had been passing snacks with the STNA. Resident #61 came out of his room and his eyes were squinty, slurring speech and wobbly. He had gone to the room next door to visit another resident for a few minutes. When he went back to his room, LPN #216 heard a loud boom. When she checked Resident #61 was standing by his closet. He denied falling, stating it was the closet door. LPN #216 suspected he was reaching up in the ceiling tile. She stated the police found marijuana in a roach clip. The neighboring resident he visited, Former Resident #90, suggested they use Narcan on Resident #61. FSR #90 responded Oh, I don't know when asked why she would suggest Narcan. LPN #216 stated STNA #249 found Resident #61 lying on the foot of the bed perpendicular and not easily aroused. His legs were blue. STNA #249 got LPN #216 who called the DON. LPN #216 assessed Resident #61 who said he had pain. She called 911. EMS stated the resident's pupils were like needle points, but the resident denied drug use. LPN #216 stated she had tried to administer Narcan, but he refused. The resident initially refused to go to the hospital, but the EMS were able to convince him to go to the hospital. Afterwards the police searched the resident's room with staff. LPN #216 stated they found marijuana on a roach clip and a bus pass with black sand, Fentanyl. The police stated he would be charged, and they would get a warrant for his arrest. She stated Resident #61 was to be discharged because of violation of contract. LPN #216 stated they were given education on the facility's program and the need for enforcement of visitation. She stated the visits would now have to be supervised unlike before. Interview on [DATE] at 9:09 P.M. with STNA #249 revealed she was present on [DATE] for Resident #61's second overdose. She stated she found the resident; he was acting differently. She reported to the nurse the resident was turning colors even with oxygen. The nurse called 911. EMS took over. STNA #249 denied ever seeing drug exchanges. She stated she felt there should be more limitations to visitation. She stated she was off work the past two weeks and did not realize the facility had implemented supervised visitation until she returned. She stated the residents were not allowed to go into other residents' rooms and had to visit in common areas. Interview on [DATE] at 10:11 A.M. with SS #276 from the third-party program revealed he was limited on what he could share. He explained residents who come to the facility for the Substance Use Disorder program had to sign a contract prior to admission. Those residents were not required to participate in his program which offered case management and counseling. He stated he met with the facility team to discuss residents weekly and to encourage participation in the program. One of their main focuses was on harm reduction. Interview on [DATE] at 2:49 P.M. with the DON revealed she arrived at the facility on [DATE] at 9:50 P.M. after being notified of overdoses. The DON stated Resident #61 and Resident #44 would hang out with one pushing the other in the wheelchair. She stated Resident #61 did not have any LOAs or visitors. The DON stated following the incidents, they made changes to the visitation for those residents on their program. She stated they used to be able to go to the floors to visit but now they had to stay in the lobby. The receptionists were responsible to monitor and get any assistance as needed from nursing. She stated unfortunately, where there is a will there is a way. Interview on [DATE] at 9:20 A.M. with the Administrator revealed supervised visits were being tightened up. LOAs for medical appointments must be accompanied by staff. Packages for visitors and deliveries were searched. She stated no one on the facility's program had LOA privileges. The Administrator revealed she had been notified of the drug overdoses on [DATE] and then she came into the building. She stated she spoke to Resident #61 first, completed a room search and the resident denied doing any drugs. Resident #61 admitted to sharing a cigarette with Resident #44. The Administrator revealed a room search consisted of checking drawers, bathroom, above lights and the PTAC units. Staff were not permitted to search the resident/person. The Administrator revealed at the time of the incident on [DATE] Resident #61 was treated medically. He initially refused to go to the hospital, however he eventually went. The police called her to say they found (black sand). The police stated Resident #61 would be charged. The resident returned to the facility the next morning but was discharged on [DATE] in the afternoon. She stated she requested the EMS report for Resident #61 but had not received them during the survey. Interview on [DATE] at 3:15 P.M. with the Regional Director of Operations (RDO) #710 revealed visitation should have always been restricted to common areas. It was enforced starting [DATE] and now limited to the lobby area. RDO #710 revealed staff assumed on [DATE], Resident #61 had drugs left from [DATE]. They did not supervise visitation prior to [DATE]. Interview on [DATE] at 4:54 P.M. with RDO #710 and the Administrator revealed Resident #61 was not actively participating in the third-party program at the time of the overdoses. RDO #710 stated the facility's role was to provide a safe, structured environment. The Administrator stated she met with SS #276 every week, usually Wednesdays, and as needed to discuss residents with signed Substance Use Disorder contracts. Both RDO #710 and the Administrator revealed the facility was tightening up the program. Review of the facility undated Substance Use Disorder program contract revealed the objective was to decrease potential relapse of substance use disorder. All visitations must occur between the hours of 9:00 A.M. and 5:00 P.M. All visitations would be supervised. The facility could do random searches of any delivered packages. The facility did not provide any other policy and pro [TRUNCATED]

Based on observation, medical record review, policy review and interview, the facility failed to provide a phone in a private area where calls could be made without being overheard. This affected 47 residents (Residents #25, #11, #23, #40, #49, #45, #69, #53, #8, #3, #72, #52, #47, #2, #44, #63, #54, #57, #22, #55, #58, #19, #28, #33, #6, #66, #64, #27, #48, #31, #26, #32, #51, #16, #30, #35, #56, #69, #36, #61, #15, #29, #24, #14, #7, #62 and #10) who resided on the second and third floor units. The census was 74. Findings include: Review of the medical record for Resident #33 revealed an admitted [DATE] with diagnoses of diabetes, symbolic dysfunction, bipolar disorder, atrial flutter, psychoactive substance abuse, anxiety disorder and dementia. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #33 was severely cognitively impaired and independent with walking. Resident #33 resided on the third-floor unit. Review of the general progress note dated 12/28/23, timed 6:44 P.M. revealed Resident #33 was up to desk frequently wanting to use the phone. Resident #33 tried to pick up phone when the phone was ringing. The author of the note instructed Resident #33 the phone was used for business and could not always be used for personal phone calls. Resident #33 stated, bite me, I said I want to use the phone and I will. Resident #33 continued to come up to the desk. The progress indicated Resident #33 could not always be redirected. Review of the general progress note dated 01/04/24, timed 6:59 P.M. revealed Resident #33 came back from being out with significant other. Resident #33 wanted to use the phone to talk to him as he got in the elevator. Resident #33 was instructed she could not use phone since he was just here and that her clothes were covered in stool. Resident #33's comment to the nurse was, bite me, [expletive]. Review of the general progress note dated 01/12/24 timed 2:50 P.M. revealed Resident #33 requested to use the phone throughout the day. When told not at this time due to nurse needing phone or phone ringing, resident stated, bite me, [expletive]. Review of the general progress note dated 01/12/24 timed 5:17 P.M. revealed Resident #33 was instructed she could not use the phone because she had just used it five minutes ago. Resident #33 leaned over the desk and picked up the phone and dialed a number. Resident #33 was instructed she could not use phone at that time. Review of the general progress note dated 01/20/24 timed 12:57 P.M. revealed Resident #33 could not be redirected at times when using the phone. Resident #33 was told not to use the phone at a certain time because the phone was ringing but picked up the phone and used it against staff direction. Review of the psychiatry nurse practitioner note dated 02/01/24 revealed per staff, Resident #33 was noted to have increased behaviors. Resident was noted to attempt to use the phone without asking. Review of the general progress note dated 02/03/24 timed 5:57 P.M. revealed Resident #33 came to desk wanting to use the phone. When told she could not use the phone due to nurse needing the phone and resident just getting back from leave of absence (LOA), resident reached across the nurse and attempted to take the phone. Resident #33 was instructed to return to her room and eat supper. Review of the general progress note dated 02/14/24 timed 6:56 P.M. revealed Resident #33 was not listening to direction of staff. Resident #33 wanted to use the phone and cursed staff when told not at this time. Resident stated bite me, [expletive]. Review of the general progress note dated 02/18/24 timed 4:40 P.M. revealed Resident #33 was instructed by the nurse she could not use the phone since she had just used it and another resident wanted to use it. Resident #33 waited until the nurse went to aid another resident and reached over the desk and grabbed the phone trying to pull the phone out of the desk area. Resident #33 became belligerent and tried to strike the nurse. Review of the general progress note dated 02/18/24 timed 5:13 P.M. revealed Resident #33 returned to the desk. Resident #33 looked around to see if any staff members were by the desk and proceeded to reach for the phone. When instructed by the nurse she could not use the phone, Resident #33 became belligerent and started screaming, mind you own business, mind your own business, [expletive]. Resident #33 walked close to the nurse and stated, I can make something happen to you. Review of the general progress note dated 02/21/24 timed 9:50 A.M. revealed Resident #33 came to the desk wanting to use the phone. Resident #33 was instructed she could not use the phone since someone was on it. Resident #33 was instructed to come back later and Resident #33 yelled bite me, [expletive] and [expletive] you. Review of the general progress note dated 02/23/24 timed 4:00 P.M. revealed Resident #33 was at the desk to use the phone. The nurse was just getting ready to dial a nurse practitioner when Resident #33 tried to take the phone. The nurse instructed Resident #33 that nurse was calling a nurse practitioner for an order but she took the phone from the desk and tired to keep it from the nurse. When Resident #33 was instructed to hand the phone to the nurse, she threw it at the nurse striking the nurse's hand. Review of the behavior care plan updated 02/24/24 revealed Resident #33 had a behavior problem related to not always following physician orders, could be verbally aggressive to staff, using extreme profanity, yelling out and had the potential to be physically aggressive to staff. An intervention included to anticipate and meet the resident's needs. Observation on 02/27/14 at 8:10 A.M. revealed Resident #33 lying in bed in the fetal position, asleep in her third-floor room. State tested Nurse Aide (STNA) #2 served Resident #33 her breakfast tray and Resident #33 sat up on the side of the bed without assistance and began feeding herself. Resident #33's appeared disheveled and had involuntary face and bodily movements. Interview, during the observation, with Resident #33 revealed she did not know how long she had resided at the facility or the names of her children. Interview on 02/27/24 at 10:00 A.M. with Registered Nurse (RN) #6 revealed Resident #33 frequently used the two phones at the third-floor nursing station since there was no longer a phone in the dining room. Resident #33 did not have a phone to use in her room. RN #6 stated Resident #33 was able to dial the phone numbers herself. RN #6 reported that when the nurses were doing shift-to-shift report, residents were unable to use the phone due to the health insurance portability and accountability act (HIPPA). Observation on 02/27/24 at 10:15 A.M. revealed Resident #33 walking in a shuffling manner from her bedroom to the third-floor nursing station. Resident #33 asked STNA #3 if she could use her phone to call her husband and STNA #3 kindly responded, you just used the phone. Resident #33 continued to ask to use the phone. STNA #3 provided the phone to Resident #33 and Resident #33 dialed a phone number herself. Interview, during the observation, with STNA #3 and Licensed Practical Nurse (LPN) #4 revealed there used to be phone in the dining room however Resident #33 intentionally broke the phone a week or so ago because she became anxious when she could not get a hold of her significant other. Interviews on 02/27/24 between 10:35 A.M. and 11:00 A.M. with the Director of Nursing and Director of Maintenance (DOM) #7 revealed they were both unaware there had ever been a phone in the third-floor dining room. Observation on 02/27/24 at 11:10 A.M. of the third-floor unit with DOM #7 and Regional Director of Operations (RDO) #8 revealed there were two cordless phones at the nursing station on the third floor however neither of the cordless phones worked. Interview, during the observation, with DOM #7 and RDO #8 verified the two cordless phones did not work and the corded phones at the nursing station did not provide privacy to residents while on the phone. Observation on 02/27/24 at 11:15 A.M. of the second-floor unit with RDO #8 revealed there was a corded phone hanging in the second-floor dining room/activities room. Interview, during the observation, with RDO #8 verified the placement of the second floor phone did not provide privacy to residents while on the phone. Review of the facility's Resident Use of Telephones policy dated March 2017 revealed designated telephones were available to residents to make and receive private telephone calls. The telephones at the nursing stations should ordinarily be reserved for staff use, unless no other alternative was available. Residents should use telephones at the nursing stations for as brief a period as possible. Telephones would be in areas that offered privacy and accommodate the hearing impaired and wheelchair bound residents. Review of the facility census sheet revealed Residents #25, #11, #23, #40, #49, #45, #69, #53, #8, #3, #72, #52, #47, #2, #44, #63, #54, #57, #22, #55, #58, #19, #28, #33, #6, #66, #64, #27, #48, #31, #26, #32, #51, #16, #30, #35, #56, #69, #36, #61, #15, #29, #24, #14, #7, #62 and #10) resided on the second and third floor units.

Based on medical record review, Self-Reported Incident (SRI) review, employee warning notice review, policy review and interview, the facility failed to ensure Resident #38 was free from staff-to-resident abuse. This affected one (Resident #38) of three residents reviewed for abuse. The census was 74. Findings include: Review of the medical record for Resident #38 revealed an admitted [DATE] with diagnoses of injury in motor vehicle accident, opioid abuse with opioid-induced psychotic disorder, anxiety disorder, behavior insomnia of childhood sleep onset. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #38 was cognitively intact. Review of the behavior care plan updated 02/20/24 revealed Resident #38 had a behavior problem related to being very manipulative, would twist what people said to him and would state things that been proven not factual. Interventions included caregivers to provided opportunity for positive interaction/attention, approach/speak in a calm manner, divert attention, remove from situation and take to alternate location as needed. Review of the SRI dated 02/23/24 revealed an allegation of a staff-to-resident verbal altercation between Resident #38 and kitchen staff member, Dietary Aide (DA) #10. On 02/23/24, Resident #38, an alert and oriented times three spheres resident, went to the kitchen requesting two hamburgers stating he did not receive the burgers on his dinner tray. DA #10 stated the burgers were on the tray when the meal cart was sent out to the floor. Resident #38 became upset and began cursing and using foul language calling DA #10 a liar. DA #10 and Resident #38 began going back and forth regarding if the burgers were sent out. Resident #38 threatened DA #10, stating, I will beat your [expletive]. Review of the witness statement dated 02/23/24 timed 5:30 P.M. authored by Resident #38 revealed he had walked down to the kitchen to tell them he didn't get burgers. State tested Nurse Aide (STNA) #13 was already telling them and DA #10 screamed Resident #38 was lying. Resident #38 got his plate of food to show them he was not lying. DA #10 came out saying he did not care, he made the burgers. DA #10 started getting real loud and stood over Resident #38 and said, he don't feel good and ain't the one. I'm not gonna let some [NAME] punk me so Resident #38 stood up to be prepared to defend himself. The witness statement indicated I felt threatened enough to stand up and be ready to fight. Review of the witness statement dated 02/23/24, authored by Scheduler #11 revealed, on 02/03/24 just before 5:00 P.M., I was in my office on the first floor .when I heard two people yelling. I came out of my office and heard the yelling by the dietary door and when I came around the corner, I noticed [Resident #38] shove his rollator at least five feet from him and it hit the wall and he was yelling at [DA #10]. [Resident #38] was yelling for [DA #10] to come outside and handle [expletive]. [DA #10] replied back, go ahead and come out back, let's go. [Resident #38] also stated to [DA #10], fat [expletive] can't get me in time. At this point, I intervened in between [DA #10] and [Resident #38] and noticed that Cook #12 was observing the situation from the dietary door but did not intervene. I got in front of [DA #10] and tried to get him to calm down and to go back in the kitchen. After a couple of minutes, I did get [DA #10] back into the kitchen . Interview on 02/27/24 at 11:45 A.M. with Regional Director of Operations (RDO) #8 and Regional Director of Clinical Services (RDCS) #5 verified DA #10 should have de-escalated the situation and should not have threatened Resident #38 during the request for burgers. Review of the Employee Warning Notice dated 02/26/24 revealed DA #10 was terminated due failure to maintain a calm and nonjudgmental approach with a resident who was escalating. Review of the facility's Abuse, Neglect, Exploitation and Misappropriation of Resident Property policy updated 11/01/19 revealed the facility would educate its staff upon hire regarding the facility's Abuse, Neglect, Exploitation of residents and Misappropriation of Resident Property. The training sessions would include appropriate interventions to deal with aggressive and/or catastrophic reactions of residents. Review of the facility's undated Tips for Handling Patients When They Are Angry policy revealed de-escalation involved maintaining a calm demeanor and avoiding attempts to control the patient. It was okay to walk away from a situation if staff felt they were in danger. This deficiency represents continued non-compliance investigated under Complaint Number OH00151422.

Based on observation, medical record review, policy review and interview, the facility failed to provide care and services to ensure the safety of Resident #33 who had a diagnosis of dementia. This affected one (Resident #33) of three residents reviewed for dementia. The census was 74. Findings include: Review of the medical record for Resident #33 revealed an admitted [DATE] with diagnoses of diabetes, symbolic dysfunction, bipolar disorder, atrial flutter, psychoactive substance abuse, anxiety disorder and dementia. Resident #33 resided on the third-floor unit and the only emergency contact was her brother-in-law/significant other. Review of the weight note dated 11/08/23 revealed Resident #33 ate well but went on leave of absences (LOAs) where she did not get fed. Review of the general progress note dated 11/09/23 timed 5:17 P.M. revealed family was at the facility to take Resident #33 on LOA. Family member was instructed that resident did not feel well and should not go out of the facility. The family member stated, we are going out. The family member was told that the resident's shoes did not fit properly, and they posed a fall risk. Resident #33 and family member left the facility. Review of the psychiatry nurse practitioner note dated 11/14/23 revealed Resident #33 left on LOAs with a family member and staff continued to endorse concern of the possibility of illicit activity. Resident #33 returned from visits disheveled and in soiled pants. Review of the general progress note dated 11/15/23 timed 10:53 A.M. revealed the family member was at the facility and took Resident #33 out for the day. The family member was instructed that Resident #33 would miss insulin and medications. The family member stated they were still going out. Review of the general progress note dated 11/26/23 timed 5:03 P.M. revealed Resident #33's significant other came into the facility at approximately 12:00 P.M. stating he was taking resident out on LOA. The family member was instructed Resident #33 needed a winter coat to go outside in the cold weather. The family member stated, she's going to be in the car. When Resident #33 returned, she was walking with an unsteady gait and almost fell , her hair was messed up, she was sitting in a chair rocking pelvic area, and her pupils were dilated. The nurse practitioner (NP) was notified. Review of the general progress note dated 11/30/23 timed 5:08 P.M. revealed although Resident #33's significant other was instructed Resident #33 needed a coat to leave the facility, the significant other took Resident #33 out of the facility without a coat. Review of the psychiatry nurse practitioner note dated 12/06/23 revealed Resident #33 was asked about her LOAs and Resident #33 stated she went out with her husband. When asked what kind of activities they did, she stated, visit with his friends. The nurse practitioner asked what she did when visiting with her spouse's friends and the resident was slightly hesitant to answer then said they just talked. Resident #33 had been noted to leave the building without appropriate cold weather attire and she was noted to miss medications when she went on leave. Review of the Statement of Expert Evaluation dated 12/08/23 revealed there was an application for Guardianship for Resident #33. Resident #33 was mentally impaired as evidenced by diagnoses of bipolar disorder, anxiety disorder, psychoactive substance abuse, moderate dementia with agitation and tardive dyskinesia. Resident #33 had an impairment in orientation, motor behavior, thought process, memory, concentration and comprehension and judgment. Resident #33 referenced her brother-in-law as her husband which appeared to be reflection of their close relationship and she was aware they were not legally married. Per facility staff, concerns were noted about her frequent LOAs from the facility with her brother-in-law. Staff had noted that Resident #33 had been returned to the facility disheveled and disoriented. She had been noted several times to return from visits soiled from diarrhea. During interview, Resident #33 was hesitant to share details on her activities with her brother-in-law when she was on leave. She replied, we just talk and hang out. When asked directly she denied the relationship was abusive. Her response suggested some awareness of her actions but poor judgment and a lack of ability to perform basic activities of daily living with assistance. The evaluation indicated that overall, given Resident #33's cognition impairment and demonstrable inability to care for herself, establishing guardianship was warranted at this time. Review of the general progress note dated 12/13/23 timed 5:43 P.M. revealed Resident #33's significant other arrived as super trays were arriving. The nurse asked if he was supplying a meal for her, and he stated they were just going outside. Resident #33 still did not have a winter coat and was taken out of the building with a thin sweater against the nurse's wishes. The significant other was asked to please obtain a winter coat for Resident #33. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #33 was severely cognitively impaired and independent with walking. Review of the general progress note dated 12/24/24 timed 3:31 P.M. revealed Resident #33 was out with her significant other. The significant other was instructed that Resident #33 was missing blood sugar, medications and meal when she was taken out at that time of day. The significant other was instructed Resident #33 would need a meal while out or would need to be back by 5:00 P.M. Review of the general progress note dated 12/15/24 timed 4:18 P.M. revealed the significant other was at the facility to take Resident #33 out. The significant other was instructed Resident #33 needed to be back for insulin and meal and Resident #33 was consistently missing medications and meals going out at that time of day. Review of the LOA care plan updated 01/02/24 revealed Resident #33's brother-in-law/boyfriend interfered with her care. He took her out on LOA and she did not have medications during the time she was gone from the facility. Resident #33 was also incontinent of bowel and bladder at times and would return to facility with fecal matter dried on her skin from not being changed during the LOA. Review of the general progress note dated 01/04/24, timed 6:59 P.M. revealed Resident #33 came back from being out with significant other. Resident #33 wanted to use the phone to talk to him as he got in the elevator. Resident #33 was instructed she could not use phone since he was just there and that her clothes were covered in stool. Review of the general progress note dated 01/06/24 timed 4:56 P.M. revealed Resident #33 returned from LOA with family member. When Resident #33 left the facility, the nurse instructed the family member that Resident #33 would need to eat since he was taking her out prior to meals arriving to unit. Review of the general progress note dated 01/13/24 timed 5:15 P.M. revealed Resident #33 was back from LOA. The significant other was instructed to talk to nurse before taking resident out due to needed medications. The significant other became argumentative with the nurse stating, I signed her out. The significant other was instructed that he still needed to see a nurse not the STNA and he walked passed the nurse and got on elevator. Review of the general progress note dated 01/13/24 timed 5:21 P.M. revealed Resident #33 told the nurse she was hungry and she did not get a lunch. Resident #33 had left on LOA before lunch was served. Resident #33 said they were out and about. Resident #33 was cold to touch. Review of the general progress note dated 01/17/24 timed 4:07 P.M. revealed the significant other came to take Resident #33 out for several hours. The nurse requested that Resident #33 remain and eat dinner so that insulin could be given. The significant other said no and took the resident out. The nurse advised the significant other to get Resident #33 something to eat while out so that blood sugar would remain stable. Review of the general progress note dated 01/24/24 timed 6:27 P.M. revealed Resident #33 returned from being out with family member. Resident #33 returned with clothes soiled with bowel movement and stated she did not eat while out and was hungry. Review of the general progress noted dated 02/07/24 timed 10:02 A.M. revealed the significant other came to take Resident #33 out on LOA stating they would be back at 4:30 P.M. or 5:00 P.M. The family member was told Resident #33 would miss two blood sugars and her medications. The significant other did not respond to the nurse and turned his back to the nurse and left. Review of the general progress note dated 02/08/24 revealed per nurse practitioner, Resident #33 was given a no LOA order. Review of the general progress note dated 02/08/23 timed 3:15 P.M. revealed Resident #33 signed the LOA book to leave with her brother-in-law. Resident #33 and brother-in-law were educated that Resident #33 leaving was against medical advice (AMA). The brother-in-law and Resident #33 both stated that they were leaving and left. Review of the general progress note dated 02/21/24 revealed Physician #9 called in and rescinded the LOA order after recalling issues with brother-in-law taking Resident #33 out before. Physician #9 gave order for no LOAs. The note indicated Resident #33 was aware. Review of the February 2024 physician orders revealed Resident #33 did not have LOA privileges at that time. The order was written on 02/21/24. Review of the general progress note dated 02/23/24 timed 5:24 P.M. revealed Resident #33's significant other came to the desk to take Resident #33 down to smoke. He instructed the nurse she had doctor's appointment on Monday (02/26/24) at 11:00 A.M. with a medical doctor. The significant other was instructed Resident #33 couldn't be seen by medical doctors while at the facility but he began arguing with the nurse. The significant other was also instructed dinner was on the way and Resident #33 needed medication. The significant other responded they would return when they wanted to. Review of the general progress note dated 02/23/24 timed 6:29 P.M. revealed Resident #33's significant other instructed the nurse earlier that he was taking Resident #33 down to the front lobby to smoke and he would be gone approximately 30 minutes. The nurse went to administer medications when meal tray arrived and Resident #33 was not in her room. The significant other was called and the call went to voicemail. A voice message was left instructing the significant other to bring Resident #33 back. The Director of Nursing (DON) was notified. Observation on 02/27/14 at 8:10 A.M. revealed Resident #33 lying in bed, in the fetal position, asleep in her third-floor room. STNA #2 served Resident #33 her breakfast tray in her room. Resident #33 sat up on the side of the bed without assistance and began feeding herself. Resident #33's appearance and hair were disheveled, and the resident had involuntary face and bodily movements. Resident #33 was wearing a Wanderguard ankle bracelet (a device that sounds an alarm and/or locks designated armed doors when the bracelet is within a certain proximity of the door) on her left ankle. Interview, during the observation, with Resident #33 revealed she did not know how long she had resided at the facility or the names of her children. Attempts to interview Resident #33's brother-in-law/significant other/emergency contact on 02/27/24 at 9:25 A.M. and 11:25 A.M. were unsuccessful. Interview on 02/27/24 at 10:00 A.M. with Registered Nurse (RN) #6 revealed the DON told RN #6 that Resident #33 had an order for no LOAs because Resident #33's brother-in-law took the resident on LOAs during meal times and Resident #33 would miss meals and medications. Observation on 02/27/24 at 10:15 A.M. revealed Resident #33 walking in a shuffling manner from her bedroom to the third-floor nursing station. Resident #33 asked STNA #3 if she could use her phone to call her husband and STNA #3 responded, you just used the phone. Resident #33 continued to ask to use the phone and STNA #3 provided the phone to Resident #33. Resident #33 dialed a phone number herself. Interview on 02/27/24 at 10:35 A.M. with the DON revealed the facility had been working on obtaining Resident #33 a guardian. The DON stated a no LOA order was given because the resident's brother-in-law would take her out on LOAs during meals, without proper winter attire and she would not get fed and missed her medications. Interview on 02/27/24 at 3:00 P.M. with Regional Director of Operations (RDO) #8 and Regional Director of Clinical Services (RDCS) #5 verified Resident #33 lacked the mental capacity to make informed and appropriate decisions for her care and verified Physician #9 had a no LOA order due to Resident #33's brother-in-law's history of bringing Resident #33 back to the facility after missing meals and medications and she would be soiled from a lack of incontinence care. Review of the facility's Signing Residents Out policy dated August 2006 revealed restrictions noted on the resident's chart concerning who could not sign the resident out must be honored unless otherwise prohibited by facility policy or state/federal law governing such releases. If the resident chose to go with the individual, the DON and/or Administrator must be contacted and informed of the situation. Inquires concerning the signing out of residents should be referred to the DON or the Administrator. Review of the facility's Dementia Clinical Protocol policy dated March 2015 revealed the staff and physician would jointly define the decision-making capacity of someone with dementia, including the extent to which the individual could participate in making everyday decisions and considerations about healthcare treatments choices. The interdisciplinary team (IDT) would identify and address ethical issues and related treatment options; for example, management of continued functional decline or unplanned weight loss. The physician would order appropriate medications and other interventions to manage behavioral and psychiatric symptoms related to dementia based on pertinent clinical guidelines and regulatory expectations. The IDT would adjust interventions and the overall plan depending on the individual's responses to those interventions.

Based on observation, medical record review, review of a local police and missing persons' report, resident, family and legal guardian interview, staff interviews, local police detective interview, review of the National Weather Forecast, and review of the facility Elopement Policy and Procedure, the facility failed to provide adequate supervision to prevent Resident #71, who had a diagnosis of vascular dementia with moderate cognitive impairment from leaving the facility without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious harm, injury, death on [DATE] at 7:35 P.M. when Resident #71 exited the facility through a supervised smoking area door without staff knowledge. At 9:30 P.M. Licensed Practical Nurse (LPN) #309 noted Resident #71 was not in his room during medication pass. However, the resident's whereabouts were not further investigated by the LPN at that time. On [DATE] at 12:00 A.M. nursing staff began searching for Resident #71 (2.5 hours after the nurse initially observed Resident #71 not in his room and nearly 4.5 hours after the resident walked out of the facility). Resident #71 was unable to be located. At 12:43 A.M. the Director of Nursing (DON) was notified and at 1:02 A.M. a search for Resident #71 was re-initiated. At 1:31 A.M., the local police department was notified of Resident #71's elopement. The police arrived to the facility at approximately 2:00 A.M. to take a report and then subsequently issued a missing person alert. Resident #71 was missing from the facility for approximately 12 hours during which time it was noted he was confused and lost, walking along streets with two to four lanes of traffic with speed limits ranging from 25 to 35 miles per hour (mph), with inadequate lighting and remaining outside overnight in cold ambient air temperatures. The ambient air temperature outside from [DATE] through [DATE] was a low of 32 degrees Fahrenheit (F) to a high of 39 F. Resident #71 was subsequently found by a citizen of the community, who had seen the missing person alert, at a park located approximately 2.2 miles from the facility and assisted the resident back to the facility at 7:32 A.M. On [DATE] Resident #71 again exited the facility without staff knowledge. The resident exited the building through a door that alarmed when it was opened, however staff failed to timely respond to the door alarm to identify the resident had exited. This affected one resident (#71) of six residents reviewed for elopement. The facility identified 11 residents (#3, #22, #27, #28, #33, #35, #43, #57, #63, #71 and #74) who were at risk for elopement. The facility census was 72. On [DATE] at 4:05 P.M., the Regional Director of Operations (RDO) and Regional Director of Clinical Service (RDCN) #395 were notified Immediate Jeopardy began on [DATE] at 7:35 P.M. when Resident #71 exited the facility through the smoking area exit door without staff knowledge. Resident #71 was located approximately 12 hours later by a citizen of the community, after seeing a missing person alert, at a park located approximately 2.2 miles from the facility. Staff failed to timely identify the resident was missing from the facility, failed to timely initiate a search for the resident and failed to ensure the resident's safety was maintained. Resident #71 was placed at potential risk for injury or harm as a result of incidents including but not limited to being hit by a car while being lost and confused and walking through areas that had two to four lane roads of traffic with speed limits ranging from 25 to 35 miles per hour (mph), with inadequate lighting and remaining outside, overnight in cold air temperatures. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 7:35 P.M. per facility video camera footage, Resident #71 left the facility after holding the door for 15 seconds as the door was enabled allowing him to exit the door. The staff did not respond to the alarm. On [DATE] at 12:00 A.M. Licensed Practical Nurse (LPN) #309 notified in-house facility staff of concern for residents' whereabouts and staff began a search. Between 12:41 A.M. and 1:36 A.M. notification of the resident's elopement were made to the resident's legal guardian, DON, RDO and local (Akron) Police Department. On [DATE] at 2:00 A.M. the Akron Police Department arrived to the facility and a Missing Persons Report was filed. On [DATE] at 7:23 A.M. the resident was returned to the facility. On [DATE] at 7:30 A.M. the Director of Nursing (DON) completed a head-to-toe assessment of Resident #71 with no negative findings noted. Resident #71's care plan was updated to address the resident's level of supervision required for safety and elopement risk. On [DATE] at 8:30 A.M. Licensed Social Worker (LSW) #341 reviewed the Brief Interview for Mental Status (BIMS) scores for all facility residents to assist with evaluating the appropriateness of LOA status based on resident cognition. On [DATE] at 11:15 A.M. a Secure Care Representative was at the facility to inspect and assess functionality of alarming doors, increase in volume, and sensitivity. On [DATE] at 8:10 P.M. the Assistant Director of Nursing (ADON) and LPN Unit Manager #399 reviewed and updated elopement assessments for all facility residents to ensure LOA status was appropriate. On [DATE] at 2:00 P.M. Minimum Data Set (MDS) RN #355 updated Resident #71's care plan to reflect the resident had a no LOA order. The facility bed board was also updated on this date to reflect all resident LOA statuses. On [DATE] at 9:00 A.M. the facility conducted further investigation in which the facility identified a failure in processes for nursing staff to properly identify when a resident was on LOA and also failure to properly educate residents on need to sign out on a LOA when leaving and returning. In addition, the facility identified the need for education to families and guardians on safety of LOAs based on residents' diagnoses. On [DATE] the DON changed/updated nurse assignment report sheets to include a box identifying those residents who were are out on a LOA. The DON then conducted education to all nursing staff on the use of the box and to check it for those residents out on LOA. On [DATE] beginning at 9:35 A.M. the facility clinical team implemented education to all nursing staff that upon shift change they were to round on each resident at the beginning of their shift and re-education was provided that at least every two-hour rounding was to continue throughout the shift. Notification was to be made to the supervisor of any concerns or residents not identified who were not accounted for and who had not signed out on a LOA. A box would now be included on the shift-to-shift report form to check when a resident was out of the facility with an expected return time. On [DATE] beginning at 9:48 A.M. the DON/clinical team implemented education to all licensed nurses that a detailed shift to shift report must be made to include any residents who had gone out on an appointment or LOA and had not returned back prior to their shift end. The nurse would then reach out to the resident or responsible party to inquire on resident status. On [DATE] beginning at 10:10 A.M. the facility implemented a plan for all residents, power of attorneys (POAs) and/or legal guardians to be educated on the need for LOA books to be signed with their signatures upon leaving and returning to the facility. Education was also provided to ensure nursing staff were given an estimated return time. All residents, POAs and legal guardians would be educated and sign an acknowledgement of the need and in addition were educated on resident diagnosis that could cause safety concerns for allowed LOAs and that LOAs could require supervision. On [DATE] at 1:20 P.M. MDS RN #355 reviewed all resident care plans and updated for accuracy and completion of LOA status to include those residents who had independent LOA, LOA with assistance of friend, family or staff, or no LOA. On [DATE] at 2:30 P.M. a Quality Assessment Performance Improvement (QAPI) meeting was held with the clinical team which included the RDO, Medical Director, DON, MDS RN #355, Regional Director of Clinical Services (RDCS) #395, Regional Director of Operations, (RDO) #400, Business Office Manager (BOM) #374, Central Supply Manager #374, Maintenance Director #372, Medical Director #396 via phone, Housekeeping and Laundry Supervisors #334, Dietary Manager #332, and LSW #341 to determine the root cause of the incident involving Resident #71 on [DATE] and any other identified system failures. Beginning on [DATE] the facility implemented a plan for the DON/designee to audit resident change/concern for elopements which included a review of change in condition, new diagnosis, review of BIMS scores, elopement assessment, care plans, accuracy of LOA status (resident sign in and out, LOA binder for signatures) and staff response to door alarms five times a week for four weeks and then weekly for eight weeks. All audit findings would be submitted to the facility QAPI for recommendation/review. Beginning on [DATE] the facility implemented a plan for the DON/designee to audit the LOA book to ensure resident signatures were being obtained when leaving the building five times a week for four weeks and then weekly for eight weeks. All audit findings would be submitted to the facility QAPI for recommendation/review. Beginning on [DATE] the facility implemented a plan for the DON/designee to audit shift to shift report sheets to ensure LOAs were discussed in report five times a week for four weeks and then weekly for eight weeks. All audit findings would be submitted to the facility QAPI for recommendation/review. Beginning on [DATE] the facility implemented a plan for the DON/designee to audit that staff completed appropriate notifications if a resident had not returned from an LOA by the estimated time five times a week for four weeks and then weekly for eight weeks. All audit findings would be submitted to the facility QAPI for recommendation/review. Beginning on [DATE] the facility implemented a plan for the Maintenance Director/designee to audit staff responses to door alarms five times a week for four weeks and then weekly for eight weeks. All audit findings would be submitted to the facility QAPI for recommendation/review. On [DATE] at 8:15 A.M. Resident #71's guardian approved transfer to a nursing home with a secured unit. At 11:07 A.M. Resident #71 was transferred to a different nursing home with a secured unit. On [DATE] at 4:30 P.M. DON and Assistant Director of Nursing (ADON) #397 educated all staff on timely and appropriate response to door alarms. On [DATE] at 4:35 P.M. the facility implemented a 24-hour seven day a week door security staff to monitor the door alarm annunciator panel and respond to all door alarms. Until a full-time security guard was hired, this position would be staffed 24 hours seven days a week with STNA, dietary aid, or receptionist etc. On [DATE] at 5:30 P.M. a QAPI meeting was conducted with the DON. Administrator #405, RDO, [NAME] President of Operations, [NAME] President of Clinical Services, Maintenance Director, Scheduler #332, Admissions via phone, Activity Director #318, Housekeeping Director #334, Marketing #326, Dietary Manager #332, via phone, and the Medical Director. The Administrator/ designee would audit schedules daily to ensure the door security position was staffed 24 hours seven days a week. Audits would be completed five times a week for four weeks and then weekly for eight weeks. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #71's medical record revealed an admitted [DATE] with diagnoses including vascular dementia, major depression, cataract, abnormalities of gait and mobility, altered mental status, psychoactive substance abuse, and a history of traumatic brain injury (TBI). Additionally, Resident #71 had a legal guardian. Review of Resident #71's Intensive Outpatient Program (IOP) contract dated [DATE] (prior to admission) revealed for Resident #71 to be in compliance with the program the resident would have random room searches, random drug screens, supervised visitation and no leave of absence (LOA). A plan of care dated [DATE] revealed the resident's parole officer indicated the resident had cognitive issues and a decline had been noted over the past two years, the resident had gotten lost in town before from wandering and, at one point, did not remember his divorce from his ex-wife and tried to return home. On [DATE] the resident was found in the facility parking lot and redirected back into the facility. Interventions included monitoring behavior episodes, attempt to determine underlying causes and to intervene as necessary to protect the rights and safety of others. Lastly, the plan of care indicated Resident #71 spent [AGE] years in prison for involuntary manslaughter and was released in 2021. The resident did not have any type of plan of care addressing leave of absence (LOA) status, including the resident's ability to be unsupervised in the community and/or his supervision needs. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment, dated [DATE], revealed Resident #71 had a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident was moderately cognitively impaired. Additionally, at the time of the assessment, Resident #71 had a wander guard device in place (a device worn to trigger alarms and lock monitored doors and used to prevent a resident at risk for wandering/elopement from leaving the facility unattended). Review the care plan, dated [DATE], revealed Resident #71 was at risk for elopement and had security guard (wander guard) placement. The care plan was discontinued/resolved on [DATE] when the wander guard was removed. The care plan reflected Resident #71 was at risk for a mood problem related to homelessness and had a history of stimulant abuse. Review of an elopement risk assessment, dated [DATE], revealed Resident #71 was assessed to be at low risk for elopement. This assessment noted Resident #71 was cognitively intact, responsive to redirection and had no history of elopement. However, the assessment did also note the resident had diagnoses of vascular dementia and TBI and was able to ambulate. Review of the [DATE] physician orders revealed Resident #71 had no order for LOA and/or related to the resident's supervision status in the community. Review of the bed board sheet, dated [DATE] and used by staff to determine a resident's LOA status, revealed Resident #71 was coded as G and SS. Review of the codes revealed G was for guardian and SS indicated the resident was enrolled in an outpatient drug program with no LOA privileges. The top of the sheet noted No LOA for SS. Review of a nursing progress note, dated [DATE] and written by LPN #309, revealed Resident #71 was not observed in his room at 9:30 P.M. After completing patient care, around 12:00 A.M., LPN #309 and STNA staff began searching for the resident. On [DATE] at 12:43 A.M., the Director of Nursing (DON) was notified that the resident was missing. The note indicated at 1:02 A.M. the DON re-initiated the search for Resident #71. At 1:31 A.M., the local police department was notified of the missing resident. At 2:00 A.M. the police arrived and filed a report. Review of the LOA binder, located on the first floor where Resident #71 resided, revealed no evidence of an entry Resident #71 signed himself out on [DATE]. Review of the police report, dated [DATE] at 1:31 A.M., revealed Resident #71 was last seen at 7:00 P.M. on [DATE]. Officers reviewed cameras, capturing the exits of the facility, and Resident #71 was observed exiting the building at 7:35 P.M. LPN #309 stated Resident #71 was not allowed to leave the facility but, in the past, he had signed the signature sheet under another resident's page and left anyway. Review of the Ohio Attorney General Missing Person Unit, Endangered Missing Adult Alert revealed an alert was issued noting Resident #71 left the faciity on [DATE] at 7:45 P.M. and provided a picture and description of the resident. Review of a note handwritten by the RDO, dated [DATE] and untimed, revealed the resident was brought to the facility by a citizen and was found at a park at 7:35 A.M. The park was located approximately 2.2 miles from the facility. Interview on [DATE] at 6:50 A.M. with LPN #339 revealed he worked on the second floor the night Resident #71 eloped. LPN #339 stated he was not the resident's nurse. LPN #339 stated the facility initiated a search; however, he was unable to provide further information and referred to the facility administration for further details. Observation on [DATE] at 9:10 A.M. of Resident #71 revealed he was able to independently ambulate down the hall without difficulty. Interview on [DATE] at 11:30 A.M. with Resident #71 confirmed he left the faciity on [DATE]. During the interview, the resident stated he thought he left at about 9:00 P.M. Resident #71 was unable to articulate where he was during the nearly 12 hours he was gone from the facility or provide any other details, except to state a nice citizen drove him back to the facility. Resident #71 stated he pushed on the facility doors and walked out when staff were busy. While the resident stated the door alarm sounded, Resident #71 stated staff did not pay attention to the alarms. Interview on [DATE] at 12:05 P.M. with STNA #306 revealed Resident #71 would leave the facility at least once a week, during the day, for about an hour to go down the street to a shopping area. STNA #306 stated on [DATE], Resident #71 got lost on his way back to the facility and called it the great escape. Interview on [DATE] at 12:59 P.M. with STNA #315 revealed she worked on the first floor the night of [DATE] but was not assigned to Resident #71. STNA #315 stated she thought she last saw Resident #71 on [DATE] at approximately 8:00 P.M., eating pizza with two other residents. STNA #315 stated Resident #71 wandered throughout the building. STNA #315 stated LPN #309 indicated Resident #71 was not in his room later that night and a search was initiated. STNA #315 stated Resident #71 left the facility several times before and would leave when staff were busy. Interview on [DATE] at 2:07 P.M. with STNA #358 revealed she worked on the second floor the evening Resident #71 exited the building. STNA #358 stated she was unaware Resident #71 was missing on her shift. Interview on [DATE] at 2:15 PM with the (RDO) revealed she did not believe Resident #71 eloped but rather was on an LOA from the facility, stating Resident #71 was allowed LOA's without supervision. The RDO stated the facility required residents to sign out for LOAs; however, the RDO stated it was the resident's right to leave the facility and staff could not make them sign out. The RDO verified Resident #71 was currently on parole and had a legal guardian. The RDO also verified Resident #71 had previously utilized a wander guard device which was removed on [DATE] due to good behavior and the guardian wanted the resident to have access to the community. Video footage from [DATE] was requested but the RDO stated the footage was unavailable as it erased after 72 hours. Observation on [DATE] at 2:30 P.M. of a photo on the RDO's phone, reportedly taken of video footage from [DATE], with Regional Clinical Nurse (RCN) #395 revealed Resident #71 was standing in front of the smoking door. Resident #71 was dressed in a black coat, dark pants and a black hat. There was no time stamp indicating the date and time of the video footage captured in the photo, nor did it show Resident #71 exiting the facility. Interview on [DATE] at 3:51 P.M. with Resident #71's legal guardian confirmed she had previously voiced approval of the resident having LOAs during the day, but she had safety concerns related to the resident leaving the facility without staff knowledge, getting lost and being away from the facility all night. Following Resident #71's return to the facility, the guardian stated she requested a wander guard be placed on Resident #71 to prevent further elopements. Interview on [DATE] at 6:55 A.M. with STNA #379 revealed a nurse came to the third floor on [DATE], around 11:30 P.M., looking for Resident #71. On [DATE], at 2:00 A.M., STNA #379 stated a search was initiated and she was asked to do a head count while other staff were sent to search the area Resident #71 was known to frequent in the community. STNA #379 stated she was unsure if Resident #71 was able to leave the facility unsupervised. Interview on [DATE] at 9:15 A.M. with Medical Director (MD) #396 revealed he was notified of Resident #71's elopement and believed the facility initiated and followed the proper protocols. Although no specific reason was provided, MD #396 stated he was very concerned the resident was gone from the facility all night. Interview on [DATE] at 1:20 P.M. with Resident #71's daughter revealed she learned of the resident's elopement when she heard it on the news, with the facility returning her call about an hour later. Resident #71's daughter stated the resident had poor judgement and had difficulty understanding the difference between right and wrong. Observation on [DATE] at 8:00 A.M. of the park Resident #71 was located at revealed the park had a swimming pool. Basketball court lights were noted in the area. On the opposite side of the park was a large open field with no lighting observed. Interview on [DATE] at 9:32 A.M. with LPN #305 revealed she worked the day shift on [DATE]. LPN #305 stated at approximately 7:30 P.M. she exited the building through the front door, passing the smoking area door on her way out. LPN #305 stated she recalled seeing several residents in the area but did not recall seeing Resident #71. The following morning, [DATE], LPN #305 stated she was notified of Resident #71 exiting the building and arriving back to the facility around 7:30 A.M. LPN #305 stated she assessed Resident #71, and no injuries were noted. Resident #71 stated he had gotten lost after leaving the facility the previous evening and a citizen drove him back to the facility. Interview on [DATE] at 9:22 A.M. with Chemical Dependent Counselor Assistant (CDCA) revealed Resident #71 was enrolled in the Intensive Outpatient Program (IOP). The program had no control over any LOAs at the facility. CDCA stated the resident had cognitive issues that prevented him absorbing information to stay sober. The CDCA indicated leaving the facility without telling anyone was in poor judgement. The CDCA stated the facility turned a blind eye. The CDCA revealed the morning when Resident #71 returned to the facility she heard a staff at the nurses' station state to Resident #71 your back early. Interview on [DATE] at 10:09 A.M. with Local Police Detective (LPD) #378 revealed the missing person report completed indicated Resident #71 was not allowed to leave the facility. LPD #378 stated she was concerned about facility procedures since this was not the first resident to go missing from the facility in a short period of time. Interview on [DATE] at 11:29 A.M. with the DON confirmed she was notified Resident #71 was missing on [DATE] at 1:00 A.M. The DON stated LPN #309 did not see Resident #71 on her shift. LPN #309 had received a new admission and got busy. The DON immediately instructed LPN #309 to initiate a search and notify the police. Subsequently, the police issued a missing person alert. The DON stated she reviewed the camera video footage from [DATE] and Resident #71 was observed by the smoking area exit door. The resident was wearing a black coat, black sweatpants, black hoody, and a black hat. The DON stated she could not tell if the door was closed or ajar or if Resident #71 used a code to get out of the door. The DON was unable to tell from the video if the alarm was sounding. Interview on [DATE] at 12:40 P.M. with the RDO revealed she reviewed the camera video footage and knew the smoking area exit door alarm went off when Resident #71 exited the facility. The RDO could not tell if Resident #71 pushed open door or used a code to get the door open. The RDO stated she interviewed staff but did not know who reset the alarm. Interview on [DATE] at 3:13 P.M. with LPN #320 P.M. revealed she worked the evening Resident #71 exited the building. At approximately 7:30 P.M., LPN #320 supervised another resident on a smoke break. LPN #320 was told by administration, following Resident #71's elopement and administration review of the video camera footage, Resident #71 was viewed following her out of the building. LPN #320 did not remember seeing Resident #71 and stated she would have started a conversation with him if he had followed her out of the door. LPN #320 stated she did not hear any alarms. LPN #320 stated during the search for Resident #71, staff tried to locate the LOA binder to check Resident #71's LOA status and staff were unable to locate it. Review of the National Weather Forecast, located at https://www.accuweather.com, confirmed ambient air temperatures on [DATE] through [DATE] ranged from a low of 32 F to a high of 39 F. Review of Resident #71's late entry progress noted dated [DATE] at 11:00 P.M. created on [DATE] at 5:05 P.M. revealed Resident #71 was outside the facility after removing his wander guard. The resident was assessed and the physician was notified. Review of the progress note dated [DATE] at 11:30 P.M. by LPN #402 revealed prior to Resident #71's eloping, the resident was exit-seeking, and the wander guard bracelet (that had been applied following the resident's previous elopement) was removed by the resident. Upon the resident's return to the facility the resident was assigned to a one-to-one supervision level by staff. Review of Resident #71's progress note dated [DATE] at 11:15 P.M. and later corrected to be 11:30 P.M. revealed the resident was assessed upon his return to the facility. A new wander guard was applied to the left ankle and the resident was educated on the facility Intensive Outpatient Program (IOP) protocol. Review of Resident #71's late entry progress note dated [DATE] at 11:35 P.M. created on [DATE] at 7:55 A.M. revealed the DON called the resident's guardian and left a voicemail requesting a return call. Review of Resident #71's late entry progress note dated [DATE] at 8:59 A.M. created on [DATE] at 9:08 A.M. revealed the resident was discharged to a secured facility on this date. The guardian was notified of the time of transportation. Review of Resident #71's progress note dated [DATE] at 11:07 A.M. revealed the resident was discharged to a nursing home with secure unit. The resident was escorted by staff and facility driver. Review of camera footage on [DATE] at 9:30 A.M. with the DON revealed Resident #71 exited the facility on [DATE] at 10:41 P.M. through the vending area exit. He was wearing hat, black jacket and dark sweatpants. At 10:48 P.M. STNA #362 exited through the same vending door and returned through the same door at 10:51 P.M. At 10:55 P.M. STNA #362 was viewed coming through the front door with Resident #71. At 10:56 P.M. STNA #362 was seen resetting the alarm to the south door. There was a seven-minute delay from the time Resident #71 exited out the door to the time STNA #362 exited the door to locate Resident #71. Interview on [DATE] at 5:33 A.M. with LPN #402 revealed she was in a resident room administering medication when an STNA notified her that door alarms were sounding. LPN #402 instructed STNA #362 to check the doors and look for Resident #71. STNA #362 then drove her car to pick up Resident #71 and bring him back to the facility. LPN #402 stated there was an STNA who saw the resident's back walking away; however, she could not identify which STNA this was. Interview [DATE] at 8:45 A.M. with Resident #71 revealed he removed his wander guard and left through the exit located by the vending machine to get a coke at the drug store. He stated he was about a block away when an STNA told him to get in her car and returned him to the facility. Observation at this time revealed Resident #71 had a wander guard to the right ankle. Interview on [DATE] at 9:05 A.M. with STNA #362 revealed she was sitting at the nurses' station when STNA #312 told her Resident #71 went out the exit by the vending machine and to get him. She stated that another STNA was following Resident #71 and thought it might have been STNA #392. Review of STNA #362's witness statement dated [DATE] revealed she was sitting at the nurse's station and heard the (door) alarm go off. STNA #312 told her Resident #71 was outside with another STNA. She ran out the door to find Resident #71 and the STNA (unidentified) stated he was outside walking fast. STNA #362 went to get her car while another STNA followed behind him. STNA #362 got in her car and returned Resident #71 to the facility. Through interviews and camera footage there was no evidence Resident #71 was followed by a staff member. Interview on [DATE] 11:58 A.M. with STNA #392 revealed she was on the bus going to work. STNA #392 rang the bell for the next stop and saw Resident #71 walking in front of the church about a block away from the facility. An STNA asked if she saw Resident #71 and replied he was down the sidewalk a block away in front of the church. STNA #392 walked off the bus directly into the facility. Follow-up interviews on [DATE] at 1:01 P.M. and at 1:30 P.M. revealed her information of the incident remained consistent. Review of STNA #392's witness statement dated [DATE] taken by phone by DON revealed STNA #392 was outside and stated she saw Resident #71 exit the building. STNA #392 stayed with the resident until STNA #362 brought Resident #71 back into the building. This was contradictory to STNA #392's interview as she indicated she saw Resident #71 from the bus a block away from the facility and she walked off the bus directly into the facility. Interview on [DATE] at 12:17 P.M. with STNA #312 revealed she was leaving the building to go home at 10:43 P.M. She stated she walked past the smoking door and the south side vending door and both doors were alarming. STNA #312 opened Resident #71's room and saw he was not there. STNA #312 notified the charge nurse that Resident #71 was not in his room. STNA #312 told STNA #362 who was sitting at the nurses' station on the first floor that she may want to look for Resident #71 because he was not in his room. STNA #312 stated she did not see Resident #71 that night. A follow-up interview on [DATE] at 2:13 P.M. revealed her information remained consistent with the previous interview. Review of STNA #312 statement dated [DATE] taken by Clinical Regional Nurse (CRN) via phone stated she had seen Resident #71 with his hat and coat on during the shift and was a little antsy and the staff were watching him. A little later they heard the door alarming, STNA #312 checked Resident #71's room and identified he was not in his room and reported the finding to LPN #402. STNA #362 started running to the door alarming. This was contradicted by STNA #312's interview which stated she did not see Resident #71 that night. There was no documented evidence identifying who the staff were that were watching Resident #71.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed record review, review of a facility Self-Reported Incident (SRI), review of a Police Report, review of the facility Elopement Policy and Procedure, and interviews, the facility failed to provide adequate supervision and failed to respond and act appropriately when Resident #70, who was cognitively impaired, demonstrated exit seeking behaviors, and was ordered to wear a wander guard (a bracelet integrated with a security system to alert caregivers when residents have wandered from a protected zone), eloped from the facility. This resulted in Immediate Jeopardy and the potential for actual harm, injury, or death on [DATE] at approximately 7:28 A.M. when Resident #70 left the facility via an exit door without the knowledge of staff. State tested Nursing Assistant (STNA) #320 called the facility at 7:30 A.M. to alert staff that Resident #70 was walking through the parking lot. STNA #307 left the facility at 7:32 A.M. to locate Resident #70 and bring him back to the facility. Resident #70 refused to return to the facility with STNA #307. At 7:40 A.M. STNA #307 called and spoke with Licensed Practical Nurse (LPN) #367 who told STNA #307 to return to the facility without Resident #70. STNA #307 left Resident #70 at approximately 7:43 A.M. at the end of the facility parking lot. On [DATE] at approximately 12:20 P.M. Resident #70's friend found the resident approximately 25 miles away from the facility at a local bank. Resident #70's friend contacted the police to report Resident #70 was driving his car and was parked at a local bank. At 12:22 P.M. police arrived on scene and requested emergency medical services (EMS) to transport Resident #70 to the emergency department for a psychiatric evaluation. This affected one resident (#70) of three residents reviewed for elopement. The facility census was 65. On [DATE] at 3:45 P.M. the Administrator, Regional Director of Clinical Services (RDCS) #392 and [NAME] President of Clinical Services (VPCS) #393 were notified Immediate Jeopardy began on [DATE] at approximately 7:28 A.M. when Resident #70 exited the facility via an exit door without staff knowledge. After notification that Resident #70 was outside in the facility parking lot, STNA #307 exited the facility to locate Resident #70 and bring him back to the facility, which she was unsuccessful. STNA #307 was told by LPN #367 to return to the facility without Resident #70. Resident #70 was subsequently found approximately 25 miles from the facility driving his car and was at a local bank. Resident #70 was sent to the hospital for a psychiatric evaluation. The resident did not return to the facility following this incident. The Immediate Jeopardy was removed, and the deficiency corrected on [DATE] when the facility implemented the following corrective actions: On [DATE] the DON disciplined the nurse, LPN #367, who instructed State tested Nurse Aide (STNA) #307 to leave the resident and return to the facility for instructing STNA #307 to return to facility leaving resident unaccompanied, and failure to notify management in a timely manner of resident leaving the facility, unauthorized/elopement. On [DATE] 7:35 A.M. a head count of all residents was completed by Assistant Director of Nursing (ADON) #335 without any further concerns. On [DATE] at 8:44 A.M. the DON notified the local police department that Resident #70 was missing. On [DATE] at 10:40 A.M. the Medical Director was notified of Resident #70's elopement by the DON. On [DATE] at 1:00 P.M. the Regional Director of Clinical Services (RDS) #392 reviewed the Elopement policy with no changes were made at that time. On [DATE] at 11:00 A.M. the RDCS #392 in-serviced the DON and ADON #335 on the importance of keeping door codes private, on immediate notification to management staff for displays of removing wander guard, exit seeking, and increased speaking of leaving the building. On [DATE] immediate education was provided by the DON/designee to all staff to reiterate the importance of keeping door codes private. The facility implemented a plan for all new staff to be in-serviced upon hire by the DON/designee. Agency staff would be oriented by the DON/designee to the agency binders to include to view the elopement binders located on each unit. On [DATE] all staff were in-serviced by the DON/designee on immediate notification to management staff for displays of removing wander guard, exit seeking, elopement policy, and residents with increased speaking of leaving the building. A plan for all new staff to be in-serviced upon hire by the DON/designee. Agency staff would be oriented by the DON/designee to the agency binders to include to view the elopement binders located on each unit. This was verified by the sign in sheet for the in-service. On [DATE] elopement assessments were reviewed and updated for all residents in the facility by the DON/designee. Residents #12, #26, #27, #29, #32, #40, #47, #57 and #62 were identified as being at risk of elopement. On [DATE] elopement care plans were reviewed and updated as needed for residents at risk for elopement by the DON/designee. On [DATE] the elopement binders were updated on each unit by the DON/designee. On [DATE] Licensed Social Worker (LSW) #340 reviewed all residents Brief Interview for Mental Status (BIMS) scores. On [DATE] 9:15 A.M. an elopement drill (code amber) was completed by Maintenance Director #371 with no concerns identified. The facility implemented a plan for elopement drills to be completed on all shifts by the Maintenance Director weekly for four weeks and quarterly after. Beginning on [DATE] wander guard checks were completed by the DON/designee and would continue to be checked every shift by the DON/designee. Four residents (#26, #27, #32 and #40) were identified by the facility to require the use of a wander guard device. On [DATE] the door security codes were changed by Maintenance Director #371. Beginning on [DATE] daily clinical review, which included the DON, ADON #335, and Minimum Data Set (MDS)/ Registered Nurse (RN) #354 for any changes with residents related to elopement. The nurse on call would cover this review on the weekends. Beginning on [DATE] audits were implemented to be completed daily on five residents' times two weeks then five residents' weekly times two weeks and randomly thereafter for residents with wandering concerns, BIMS scores, and care plans by the DON/designee. Any discrepancies were to be reviewed in the Quality Assurance and Performance Improvement (QAPI) meetings. Beginning [DATE] reminders of the above in-services would be included in the monthly town hall meetings. Town Hall meetings were conducted by the DON, ADON #335, and the Administrator. All staff were required to come to the all-staff meetings. Beginning on [DATE] audits would be conducted by the DON/designee regarding staff covering keypads and keeping codes private three times a week on each shift for two weeks and then randomly thereafter. All audits would be reviewed in QAPI times three months and revised as needed. Interviews on [DATE] from 8:20 A.M. to 12:28 P.M. with the DON, Registered Nurse (RN) #359, LPN #305 #394, STNA #306, #337, #350, #362, #384 #387 revealed staff were knowledgeable regarding the elopement policy, importance of keeping the door codes private, on immediate notification to management staff for displays of removing wander guard, exit seeking, and increased speaking of leaving the building. Findings include: Review of the closed medical record for Resident #70 revealed an admitted [DATE] with diagnoses including aphasia following cerebral infarction, unspecified sequelae of other cerebrovascular disease, unspecified dementia, severe with agitation, transient ischemic attack, and cerebral infarction. Review of the Elopement Review assessment dated [DATE] revealed Resident #70 was assessed not at risk for elopement. Review of the Elopement Review assessment dated [DATE] revealed Resident #70 was assessed to be at high risk for elopement and a wander guard was placed to Resident #70's right ankle. Review of the Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #70 had severe impaired cognition with a Brief Interview for Mental Status (BIMS) score was a seven (out of 15). The assessment revealed Resident #70 did not show any behavior of wandering. Resident #70 required set-up or clean-up assistance with activities of daily living (ADL). Review of an investigation timeline, for an elopement incident (on [DATE]) involving Resident #70 revealed on [DATE] Registered Nurse (RN) #359 had noticed Resident #70 walk past an open elevator door without the wander guard alarm sounding at approximately 3:30 P.M. Upon immediate assessment RN #359 found that Resident #70 had removed his wander guard and placed it on the bedside table. RN #359 put the wander guard back on Resident #70. Resident #70 later asked RN #359 to use the phone and asked RN #359 how someone would leave this place. At shift change, approximately 7:00 P.M., RN #359 reported to oncoming LPN #367 that Resident #70 had behaviors throughout the day. Review of a witness statement dated [DATE] and completed by STNA #307 revealed upon receiving a phone call from STNA #320 indicating Resident #70 was walking in the parking lot, STNA #307 went downstairs and drove to the end of the parking lot where Resident #70 was seen walking from the facility. STNA #307 drove up to Resident #70 and asked Resident #70 to get in the vehicle, so she was able to take him back to the facility. Resident #70 said no and started walking in the opposite direction of her. STNA #307 turned around and parked at the end of the parking lot and tried to get Resident #70's attention by yelling his name which Resident #70 responded by saying hi and proceeded to continue walking away. STNA #307 stated she went back and called the nurse who told her that she didn't have to continue following Resident #70. Further review of the facility witness statements revealed no witness statement was obtained from or completed by LPN #367 related to the incident. Review of Police Report #,d+[DATE] dated [DATE] at 12:19 P.M. revealed emergency dispatch received a call from a community member regarding information on a missing person. The report revealed Resident #70 was found at a local bank at approximately 12:20 P.M. and was transported to the hospital by EMS for psychiatric evaluation. Review of Resident #70's medical record revealed no nursing progress note was completed/ documented on [DATE] related to the actual elopement incident. Review of a facility self-reported incident (SRI), tracking number 242836 revealed the facility filed a report for neglect/mistreatment. The SRI revealed on [DATE] at 8:31 A.M. the Administrator was notified Resident #70 was missing. The DON notified the resident's power of attorney (POA) at 8:08 A.M., the police at 8:44 A.M., and the medical director at 10:40 A.M. Administrative staff continued to drive around the area looking for the resident. On [DATE] at 12:24 P.M. Resident #70's POA called and informed the facility that Resident #70 was found approximately 25 miles from the facility at his friend's home where he picked up his wallet and keys to his vehicle and then went to a local bank. The family notified the police department who then escorted Resident #70 to a hospital for an evaluation. Review of the resident's medical record revealed the resident did not return to the facility following this incident. Weather conditions on [DATE] were cold, rainy and windy at the time of the incident. Review of a late entry general progress note dated [DATE] at 11:40 A.M. written by the Director of Nursing (DON) revealed she was notified on [DATE] by LPN #367 that Resident #70 was observed exiting the building and walking through the parking lot and attempting to exit the facility grounds. Nursing staff attempted to redirect Resident #70 back to the facility property but Resident #70 declined. Resident #70 had a diagnosis of aphasia and appeared to understand what he was doing as he was dressed appropriately for the weather by wearing a hat, winter coat, pants, and shoes. Resident #70's POA, police department, Administrator, and Medical Director were notified. Resident #70's POA had reached out to other contacts resident had due to Resident #70 still owned a vehicle, recreational vehicle (RV), and a boat on a nearby property. Resident #70's POA was informed that Resident #70 had picked up his vehicle to go to the bank. Police notified the facility that they were able to escort Resident #70 from the bank to a local hospital for evaluation. Conversation was had with Resident #70's POA who indicated that Resident #70 had previous impulsive behaviors and was not easily deterred and was going to do whatever he wants. Interview on [DATE] at 12:56 P.M. with STNA #307 revealed she met Resident #70 on [DATE] at the end of the facility driveway. STNA #307 stated that she attempted to have Resident #70 get into her car to return to the facility, but Resident #70 continued to refuse and walked away from her. STNA #307 called LPN #367 and notified her that Resident #70 refused to return, and LPN #376 told her to return to the facility without Resident #70. STNA #307 stated that she left Resident #70 at the end of the facility driveway at approximately 7:43 A.M. Interview on [DATE] at 3:16 P.M. with LPN #367 revealed she had received in report that Resident #70 had cut off his wander guard and the previous nurse had replaced it. LPN #367 stated Resident #70 did not have any behaviors during her shift from 7:00 P.M. on [DATE] to 7:00 A.M. on [DATE]. LPN #367 was unable to say if Resident #70 still had his wander guard on when she last saw him on [DATE] at approximately 6:00 A.M. when she gave him medication. LPN #367 confirmed that she had spoken with STNA #307 and advised STNA #307 to return to the facility without Resident #70 as he refused to come back with STNA #307. Interview on [DATE] at 3:28 P.M. with Resident #70's POA revealed Resident #70 remained at the hospital at this time pending placement to a secured/locked facility. Review of the facility policy titled Elopements, dated ,d+[DATE], revealed staff shall promptly report any resident who tried to leave the premises or was suspected of being missing to the charge nurse or the DON. If an employee observes a resident leaving the premises, they should attempt to prevent the departure in a courteous manner, get help from other staff members in the immediate vicinity, and instruct another staff member to inform the charge nurse or DON that a resident had left the premises. If an employee discovers that a resident was missing from the facility they shall determine if the resident was out on an authorized leave or pass. If the resident was not authorized to leave, initiate a search of the building or premises. If the resident was not located, notify the Administrator and the DON, the resident's legal representative, the attending physician, law enforcement officials, and volunteer agencies, provide search teams with resident identification information, and initiate an extensive search of the surrounding area. This deficiency represents non-compliance investigated under Self-Reported Incident, Control Number OH00149874.

Based on observation, interview, and record reviewed the facility failed to ensure Resident #73 was free from neglect. Actual harm occurred when Resident #73 was found to be incontinent by State tested Nursing Assistant (STNA) #19 on 07/19/21 at 7:30 A.M. and her bed linen was soaked. STNA #19 neglected to change Resident #73's bed linen leaving the resident in a wet bed until 9:50 A.M. This affected one resident (Resident #73) out of three residents reviewed for abuse and neglect. Findings include: Medical record review revealed Resident #73 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #73's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had intact cognition, was continent of bowel and bladder, and needed extensive assistance of one person for bed mobility, transfers, and toilet use. Review of Resident #73's care plan dated 05/07/21 revealed the resident had an activity of daily living (ADL) performance deficit related to a history of [CONDITION(S)] (CVA) obesity, and pain. Interventions included provide the resident extensive assistance for bathing and showering, set up and supervision for bed mobility, set up or supervision for toilet use, set up or supervision for transfers, and that the resident uses a bedside commode for toilet use. Observation on 07/19/21 on 9:14 A.M. of Resident #73's room revealed two dirty towels lying on the floor, bunched up used toilet paper beside and under the residents bed, dirty linens in a bag beside the residents bed, and a urine soaked sheet that the resident was lying on. The resident's room had a strong smell of urine. In the residents bathroom sat a beside commode over her toilet. The resident was sitting up in her bed without an incontinence brief or underwear. Interview on 07/19/21 at 9:14 A.M. with Resident #73 revealed she was using her bedside commode frequently from 11:00 P.M. through 12:00 A.M. the night before, and she stated that she was urinating and had bowel movements. She revealed around 12:25 A.M. she put her call light on but no one came in her room to empty her bedside commode. She stated she waited for approximately a hour. She said Licensed Practical Nurse (LPN) #100 came into her room and asked the resident what she wanted. Resident #73 stated that the nurse said, you wont be using that light all night long, and we ain't going to be emptying that. The resident stated LPN #100 was referring to her bedside commode. The resident continued and said that LPN #100 left without emptying her bedside commode. Resident #73 went on to say that she put her call light back on, but no one came again. The resident then went to the door and waved for the nurse to come in. At that time when she transferred to her wheelchair the resident knocked over the bedside commode and the urine and feces spilled on the floor. The resident then said when the nurse saw the bedside commode had tipped she became angry, and moved the bedside commode to the bathroom and placed it over the toilet. The resident then said that the nurse told her to go into the bathroom and use the toilet from now on, or go in your bed. The resident then stated that she told LPN #100 that she was in excruciating pain due to needing a knee replacement and did not want her bedside commode to be moved. Resident #73 then said that a female STNA came into her room and took out the dirty bucket that goes under the bedside commode and told the resident, I'm going to come in and put bleach in the room and you will have to smell it all night. The resident then pointed to the wet sheet and stated, this is abuse to have sit on a blanket and pee soaked sheet all night. She further revealed that she urinated in her bed three times throughout the night because she was unable to get to the bathroom because of her knee pain. She further revealed that STNA #19 was in that morning around 7:30 A.M. and changed her urine soaked gown, brought her a basin of soap and water, but no one has cleaned her room or changed her urine soaked sheets from during the night. Interview on 07/19/21 at 9:35 A.M. with Registered Nurse #17 verified the condition of the room, the smell of urine, toilet paper on the floor, urine soaked bed sheet, dirty towels on the floor, and that the bedside commode had been moved to the bathroom. She further reported she was notifying the Director of Nursing (DON). Interview on 07/19/21 at 9:46 A.M. with STNA #18 revealed she received report from LPN #100 that Resident #73 dumped her bedside commode bucket of urine so LPN #100 reported she took the bucket out of her room and told her to use the toilet. Interview on 07/19/21 at 9:50 A.M. with STNA #19 stated she received report from LPN #100 that Resident #73 dumped her bedside commode bucket on the floor, so she moved the bedside commode to the residents bathroom and placed it over the toilet. STNA #19 reported that around 7:30 A.M. she went into Resident #73's room and changed her urine soaked night gown and brought her a basin of soap and water to wash herself. She confirmed that the room smelled of urine, the residents sheets were wet from urine, and toilet paper was on the floor. She continued that she has not yet cleaned the room or changed the residents sheets, leaving the resident in a wet bed since 7:30 A.M. Interview on 07/19/21 at 10:00 A.M. with the Administrator and DON, while in Resident #73's room, confirmed the residents urine-soaked sheets, toilet paper on the floor, dirty towels on the floor, and the smell of urine in the room. Phone interview on 07/20/21 9:40 A.M. with LPN #100 revealed that she was working Sunday night 07/19/21 with STNA #20 and STNA #21. LPN #100 reported that around 11:00 P.M. she gave Resident #73 her medication, and at this time the resident was on her bedside commode. The resident came to her door and was making sounds indicating she would like her bedside commode emptied. LPN #100 reported that around 30 minutes later she went into the residents room to empty the bedside commode, and the resident had dumped urine on the floor. She reported she did not see her do this, but when she asked her, Did you dump this because it is taking me too long to get in here? the resident did not deny dumping it. LPN #100 stated that she removed the commode from her bedside and placed it over the toilet. She told the resident if she needs to use the toilet it would be in her bathroom from now on. LPN #100 did confirm that Resident #73 stated she needed her bedside commode, but that the resident is able to make it to the bathroom with her walker. LPN #100 then left the room, gathered towels and placed them on the floor to soak up the urine. LPN#100 then reported that Resident #73 called her lazy and she responded, I am not about to do all of this for her. She then left the room and went to assist another resident. She reported she asked STNA #21 to go in and get the dirty towels off the floor. LPN #100 reported that she did not go back into the residents room after the last interaction and that the resident did not press her call light after the incident. Phone interview on 7/20/21 at 12:30 P.M. with STNA #21 revealed that she was working on 07/19/21 with LPN #100 when she heard LPN #100 tell Resident #73 that she was moving her bedside commode into her bathroom. She stated that LPN #100 asked her to help put towels down on the residents floor. She did this and then around five minutes went back in to pick them up. STNA #21 confirmed that she did not disinfect the floor at this time or do any other cleaning. STNA #21 reported that this was around 1:00 A.M., and she did not go back into the residents room the rest of the night. Interview on 07/21/21 at 12:26 P.M. with Assistant Director of Nursing #1 revealed that any resident who is not independent should be checked, changed, and turned every two hours. Review of the facility undated policy Abuse and Neglect, stated The following policy will be adhered to in order to uphold the right of all residents to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect, and/or misappropriation of property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment of a person, including a person in a coma, with resulting physical harm, pain or mental anguish, or deprivation by an individual, including a caretaker of goods or services necessary to attain or maintain physical, mental, and psychosocial well-being.

Based on observation, staff interviews, resident interview, and record review, the facility failed to ensure one resident (Resident #49) had pressure ulcer prevention interventions in place, failed to timely assess a change in skin integrity, and failed to implement wound treatment in a timely manner. Actual harm occurred when Resident #49 was discovered with three unstageable pressure ulcers to his heels. This affected one of three residents reviewed for skin breakdown. The facility census was 93 residents. Findings include: Review of the medical record revealed Resident #49 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set 3.0 (MDS) assessment, dated 12/10/18 revealed Resident #49 was cognitively intact and required extensive assistance of two staff for bed mobility and transfers. The assessment indicated the resident had no pressure ulcers. Review of the admission nursing assessment identified Resident #49 was admitted with no areas of skin impairment. Review of the pressure ulcer risk assessment dated [DATE] revealed Resident #49 was at mild risk for the development of pressure ulcers. Review of the plan of care, dated 12/04/18, revealed Resident #49 was at risk for alteration in skin integrity due to impaired mobility, incontinence, diabetes, heart failure with [MEDICAL CONDITION], and resident preference to stay up in chair all day and not lie down throughout the day. Interventions included barrier cream to peri area, elevate heels as able, encourage to reposition as needed, observe skin condition with activities of daily living (ADL) care daily, and provide preventative skin care routinely and as needed. Review of the nurse's notes from 12/03/18 to 12/17/18 revealed no skin breakdown or interventions to prevent skin breakdown. Review of the pressure ulcer assessment dated [DATE] revealed the resident had unstageable pressure ulcers present on the right and left heel. The wound measurement for the left lateral heel measured 1.2 centimeters (cm) by 1.6 cm by undetermined depth (UTD) which appeared as a purplish/red discoloration. The area was closed but non-blanchable with surrounding skin [MEDICAL CONDITION]. The left heel bottom was noted to have a purplish/red non-blanchable discoloration measuring 2.0 cm x 1.4 cm x UTD. The area was closed, and surrounding skin was [MEDICAL CONDITION]. The bottom of the right heel wound measured 1.8 cm x 1.0 cm x UTD and appeared purplish/red in color, non-blanchable and closed. Treatment to all areas included cleansing with soap and water and applying skin prep. Interview on 12/17/18 at 2:20 P.M. with Resident #49 revealed he told the Nurse Practitioner (NP), the last time she saw him that he had a black spot on his foot and she told him to tell Registered Nurse (RN) #240. Resident #49 stated RN #240 was going to check it on 12/14/18 but did not look at it. Resident #49 stated no one had addressed his concern of the black spot on his foot and he had not received any [MEDICATION NAME] powder for his groin. Interview on 12/17/18 at 2:25 P.M. with RN #214 revealed Resident #49 did not have any skin concerns at this time. Observation on 12/17/18 at 2:30 P.M. of Resident #49's with RN #214 revealed the left heel had a dark spot about the size of a nickel on his inner left heel and another dark spot on the bottom of his left heel. Observation of Residents #49 right heel revealed a dark spot about the size of nickel on the bottom of his heel. RN #214 stated he did not know about the dark spots on Resident #49's heels and they looked to be pressure related. Interview on 12/17/18 at 2:40 P.M. with the Unit Manager for first floor, RN #240, revealed Resident #49 had told her the other day about the spot on his foot and wanted her to look at it. RN #240 stated she told him she was busy and to have his nurse look at it. She told him if she had time she would look at it. RN #240 verified she had not looked at Resident #49's heels. RN #240 was unable to say who the nurse was that was supposed to look at Resident #49's feet and could not remember the dated this occurred. An additional observation on 12/17/18 at 2:45 P.M. of Resident #49's heels with RN #240 revealed two pressure areas on the left foot and one pressure area on the right foot. RN #240 verified that the areas were related to pressure. Interview on 12/17/18 at 3:07 P.M. with Certified Nurse Practitioner (CNP) #223 revealed Resident #49 was one of her residents and she had seen him on 12/10/18. CNP #223 stated Resident #49 told her that his heel hurt, and she told him to tell RN #240. CNP #223 stated she spoke to the nurse about his heels and asked if he had any open areas. CNP #223 said she had not documented anything on her progress notes about the concern with is heels. CNP #223 stated Resident #49 wore compression stocking for his [MEDICAL CONDITION] and staff put them on and take them off daily and should have noticed any change in skin condition of his heels. CNP #223 verified she did not look at Resident #49's heels. This deficiency substantiates Complaint Number OH 1545 and Complaint Number OH 1569.

Based on medical record review and staff interview, the facility failed to ensure adequate staff assisted Resident #34 during a mechanical lift transfer which resulted in a laceration to the resident's right lower leg. The facility also failed to ensure fall preventions were in place at the time of falls, and new fall interventions were implemented for Resident #82. This affected two of four residents (#34 and #82) reviewed for falls. The facility census was 104 residents. Findings include: 1. A review of the medical record for Resident #34 revealed an admission to the facility on [DATE], and treatment for [REDACTED]. Resident #34 was also receiving coordination of services from Hospice. A care plan for Activities of Daily Living (ADL) Self Care Deficit, created on 08/30/06, indicated that Resident #34 required a full mechanical lift for all transfers. A review of the Interdisciplinary Progress Notes from 11/06/11 through 11/27/11 reveals no entry for an injury, transfer to hospital, or return from hospital for Resident #34. A review of an Incident Report dated 11/24/11 at 6:56 A.M., revealed Resident #34 had an open gash, actively bleeding at the right shin and was sent to the hospital for treatment. A review of the hospital Exit Care Patient Information Sheet for Resident #34, dated 11/24/11 at 8:58 A.M., revealed the resident had a "staple wound closure," and recommended physician follow-up in ten days. Further review of the medical record for Resident #34 revealed a physician order [REDACTED]. On 11/26/11, a Skin Alteration Record was initiated for Resident #34 and provided an assessment of a laceration to the right lower extremity including measurements of 11 centimeters (cm) long, 2.2 cm wide, and 0.2 cm deep. The wound was also described as dark pink/red tissue, with red drainage and the surrounding skin being reddened. On 11/28/11, the facility filed a Self Reported Incident Form with the Ohio Department of Health (tracking # ) for injury of unknown source. A review of the facility Investigation Report dated 11/28/11 revealed State tested Nursing Assistant (STNA) #50 used a mechanical lift unassisted by another staff member and moved Resident #34 from the bed to a chair. Resident #34's laceration was discovered directly after the move. A review of the personnel record for STNA #50 revealed an Employee Warning Notice dated 12/05/11 for the requirement to have a second staff member present when transferring anyone with a mechanical lift. A review of the Certified Nurse Practitioner (CNP) visit dated 12/15/11 revealed staple and sutures were removed from the leg laceration. On 03/22/12 at 2:00 P.M., an interview with the Director of Nursing verified the one-person mechanical lift transfer and wound documentation for Resident #34 on 11/24/11. 2. Resident #82 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. The admission fall risk assessment section for Resident #82 from 10/29/11 indicated he had a history of [REDACTED]. A fall risk care plan was initiated on 10/29/11 due to the resident's history of falls, weakness, incontinence and cognitive deficits. Interventions to reduce the risk of falls included a wedge cushion for positioning and ensuring the foot pedals are on for body positioning. During an interview with the floor nurse, Licensed Practical Nurse (LPN) #9, on 03/19/12 at 10:25 A.M., indicated Resident #82 had sustained a recent fall. Interview with the DON on 03/21/12 at 8:25 A.M., revealed the facility completed a fall risk assessment as part of the admission nursing assessment and this was only completed again if the resident sustains a fall. There was no numerical scoring system, and their tool identifies if the resident was at risk or not. The facility provided three fall investigations for the last six months for Resident #82. On 11/10/11, a state tested nursing assistant (STNA) was in the room with Resident #82 and was moving him in his wheelchair to position him for toileting and Resident #82 attempted to stand up and he slid onto floor. Resident #82 sustained a laceration on his left pinky toe. No measurements were recorded. The area was cleansed and a dressing was applied. Resident #82 was assisted to his chair with three staff. An additional note clarified that the STNA was positioning Resident #82's wheelchair for transfer using the stand lift to move him to the bedside commode. The laceration was to the bottom of his left 5th toe. Resident #82's toe continued to bleed after the treatment at the facility and he was sent to the emergency room where he required sutures to close the laceration. The facility indicated the new fall prevention intervention would be for a wedge cushion to be applied to his wheelchair for proper positioning. Resident #82's second fall occurred on 02/07/12 at 8:00 P.M. Resident #82 was in his wheelchair in his room with a staff person. The staff person removed the leg rests from the wheelchair and turned to position the stand lift while waiting for an additional staff person. Resident #82 slid out of his wheelchair and landed on his buttocks. The facility intervention was to educate staff not to remove the leg rests until Resident #82 was ready for the transfer with two staff in the room. There was no documentation found to indicate the wedge cushion was in place in Resident #82's wheelchair as planned to prevent him from sliding out. The third fall sustained by Resident #82 was on 03/08/12 at 10:00 A.M. Resident #82 was found on the floor by a STNA, on his left side next to his wheelchair holding his call light. Resident #82 could not recall what happened and was assisted back to bed with maximum assistance. He had audible wheezing and increased confusion was noted. The documentation section said Resident #82 was up in his wheelchair prior to the fall and required a mechanical lift for transfers. Resident #82 was described as having poor trunk control and unable to reposition without staff and that he leans forward and reaches for items in room. The investigation indicated they would implement a wedge cushion to assist with Resident #82 positioning. An interview was conducted with the director of care delivery services, Registered Nurse (RN) #4, on 03/20/12 at 4:40 P.M. Resident #82's three falls were reviewed. After his first fall on 11/10/11 a wedge cushion was implemented. The facility fall investigation for the second fall on 02/07/12 did not include any information to determine if the wedge cushion was in place when Resident #82 slid out of his wheelchair. Resident #82 slid out of his wheelchair again on 03/08/11 and there was no documentation in the facility fall investigation to indicate that the wedge cushion was in place as care planned. The evaluation of the fall indicated Resident #82 had poor trunk control and leaned forward, however, there were no new interventions to prevent further falls if the wedge cushion was no longer effective for fall prevention. RN #4 indicated the fall was related to Resident #82 having a urinary tract infection and increased confusion and there was an error on the investigation and a correction was done. A wedge cushion was not ordered, it had already been in place. RN #4 did verify that no new interventions were initiated to maintain his safety until the side effects of his infection resolved. All of these concerns were verified with RN #4. These concerns were also reviewed and verified with the director of nursing and the corporate nurse, RN #10, on 03/20/12 at 5:05 P.M.