Every finding on record at Laurels of Massillon, The

Based on observation, and interview, the facility failed to ensure residents received appetizing food served at palatable temperatures. This affected seven residents (#1, #31, #50, #53, #68, #89 and #117) of 37 residents interviewed for food and nutrition services. The facility census was 134. Findings include:An interview on 05/11/26 at 10:13 A.M. with Resident #53 revealed the food was undercooked especially on weekends. An interview on 05/11/26 at 10:18 A.M. with Resident #1 revealed the food was bland, tasteless and he had to order food out because of it. An interview on 05/11/26 at 10:41 A.M. with Resident #89 revealed he ordered take-out food a lot because the facility food was tasteless and undercooked. An interview on 05/11/26 at 11:39 A.M. with Resident #117 revealed she did not get fresh fruits to eat except banana; the vegetables were served mushy and sometimes the hot foods were served cold. An interview on 05/12/26 at 8:13 A.M. with Resident #68 revealed the food had no flavor and hot foods were served cold. An interview on 05/12/26 at 8:32 A.M. with Resident #50 revealed the food was bland and unappealing. An interview on 05/12/26 at 10:27 A.M. with Resident #31 revealed vegetables at meals were served overcooked and mushy. On 05/14/26 at 11:18 A.M., an observation of the lunch tray line revealed the temperature of the chicken patties were 189 degrees Fahrenheit (F), roasted potatoes were 169 degrees F, and the green beans were 181 degrees F. These temperature measurements were taken and verified by Dietary [NAME] (DC) #534 at the time of observation. On 05/14/26 at 12:37 P.M., a new pan of roasted potatoes was taken out of oven with a temperature reading of 167 degrees F and placed for lunch tray line service. On 05/14/26 at 12:58 P.M., the test tray started on tray line and was taken out of the kitchen directly into the dining room on an open cart. On 05/14/26 at 1:00 P.M., the test tray arrived in the dining room on an open cart. On 05/14/26 at 1:10 P.M., an observation of the test tray with Dietary Manager (DM) #539 revealed DM #539 taking the following food temperatures using a calibrated facility thermometer: the temperature of the chicken patty was 107 degrees F and was luke warm upon tasting, the roasted potatoes were 92 degrees F and luke warm upon tasting, and the green beans were 123 degrees F and warm upon tasting. An interview at the time of observation with DM #539 verified the findings of the test tray. DM #539 stated ideally hot foods would be served to residents at a temperature between 120 and 130 degrees F.

Based on observation, record review, interview and facility policy review, the facility failed to ensure infection control practices were implemented correctly during medication administration and urinary catheter care. This affected three Residents (#42, #60, and #89) of eight residents observed for medication administration and one (Resident #57) of one resident observed for urinary catheter care. The facility census was 134. Findings include:1. An observation on 05/14/26 from 8:02 A.M. to 8:20 A.M. with Registered Nurse (RN) #688 revealed the following: at 8:02 A.M. RN #688 was observed exiting Resident #89's room and hand hygiene was not observed prior to dispensing Resident #89's medication. RN #688 then donned personal protective equipment (PPE) which included a gown and gloves. RN #688 then administered Resident #89's medications. RN #688 then removed the PPE, and exited the room without performing hand hygiene; RN #688 then immediately moved the medication cart down the hall, and dispensed medications for Resident #42. RN #688 then entered Resident #42's room, put on gloves, completed a finger stick and glucometer (a machine that measures blood glucose levels) reading, administered the other medications, and exited the room. RN #688 removed their gloves at the medication cart, set the contaminated glucometer on top of the medication cart without cleaning it, and then immediately started to dispense the medications for Resident #60 without hand hygiene being completed. During the process of dispensing the medications for Resident #60, RN #688 dropped a pill on the top of the medication cart. RN #688 then used a glove to pick up the pill and add it to the cup of pills to be crushed prior to administration. RN #688 proceeded to crush the medications. RN #688 then placed the contaminated glucometer back into the medication cart, and then administered Resident #60's medications. An interview on 05/14/26 at 8:25 A.M. with RN #688 verified the above findings. A review of the facility policy titled Hand hygiene, dated 04/30/26 revealed that hand hygiene was considered the most important procedure for preventing infections, hand hygiene was to be performed before and after resident contact, hand hygiene was to be performed after contact with objects in resident rooms, hand hygiene was to be completed after removing PPE, and hand hygiene was to be performed after direct resident contact even if gloves are used. A review of the facility policy titled Medication Administration, dated 10/17/2023 revealed medications were to be dispensed in a sanitary manner, hand hygiene was to be performed prior to medication preparation, hand hygiene was to be performed after direct resident contact, and if a medication came into contact with the medication cart it was to be disposed of and not administered to the resident. A review of the facility policy titled Cleaning and Disinfecting Multi-Use Resident Equipment, dated 03/11/2026 revealed cleaning and disinfection of multi-use items was essential to not transmit germs to residents, multi-use items included glucometers, and multi-use items were to be cleaned or disinfected when they are visibly soiled, and on a regular schedule such as after each use. 2. Review of the medical record for Resident #57 revealed they were admitted to the facility on [DATE] with diagnoses including Amyotrophic Later Sclerosis (a progressive disease of the nervous system), obstructive and reflux uropathy, urine retention, and prostate cancer. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #57 was cognitively intact, did not reject care, was dependent on staff for toileting hygiene, and had an indwelling urinary catheter (a tube in the bladder which is left in place that allows for continuous drainage of urine). Review of the physician orders for Resident #57 revealed an order to cleanse the urinary catheter insertion site with soap and water, rinse, and pat dry every shift dated 02/13/26. A review of the care plan revealed Resident #57 was at risk for urinary tract infection related to an indwelling urinary catheter with a goal to be free from urinary tract infections dated 02/13/26. Interventions included cleanse peri-area front to back and provide catheter care per policy. An observation on 05/14/26 at 9:56 A.M. with Certified Nurse Assistant (CNA) #516 of urinary catheter care for Resident #57 revealed the following: CNA #516 donned PPE and entered Resident #57's room; CNA #516 then gathered supplies for catheter care and placed a basin and linens directly on the bedside table without a barrier; CNA #516 completed catheter care and external genitalia cleansing; CNA #516 then used the towel which was in direct contact with the bedside table to dry the catheter site and external genitalia; CNA #516 then removed her gloves and put on new gloves without hand hygiene performed; CNA #516 then continued with perineal care and used the brief which was in direct contact with the bedside table; CNA #516 then changed gloves without hand hygiene being performed; CNA #516 then retrieved a graduate (a container with markings used to measure the amount of urine emptied from a urinary catheter drainage bag) from the bathroom, placed it on a barrier, and emptied the urinary catheter drainage bag; CNA #516 then walked into the bathroom, emptied the graduate into the toilet, without changing gloves retrieved the basin of water from the bedside table, emptied it, grabbed the sink faucet handles to turn on the water, rinsed the basin, grabbed the sink faucet handles to turn off the water, and then used paper towels to dry the basin; CNA #516 then removed her PPE and completed hand hygiene. An interview on 05/14/26 at 10:10 A.M. with CNA #516 revealed the bedside table was not cleansed or disinfected prior to setting down the basin or linens and she was unaware hand hygiene was to be utilized after removing contaminated gloves before putting on new ones. During the interview CNA #516 verified the above findings. A review of the company policy titled Hand hygiene, dated 04/30/26 revealed that hand hygiene was considered the most important procedure for preventing infections, hand hygiene was to be performed before and after resident contact, hand hygiene was to be performed after contact with objects in resident rooms, hand hygiene was to be completed after removing PPE, and hand hygiene was to be performed after direct resident contact even if gloves are used.

Based on observation, interview, record review, and review of facility policy, the facility failed to maintain the ceiling on the 100-hall in good repair and failed to ensure Resident #154's room furniture was in good repair. This affected 43 residents including all 42 residents (#4, #6, #10, #11, #12, #16, #21, #25, #28, #39, #43, #44, #45, #48, #49, #53, #54, #55, #64, #66, #68, #69, #71, #76, #79, #82, #83, #91, #95, #96, #102, #112, #114, #116, #122, #123, #126, #130, #132, #137, #139, and #142) residing on the 100 hall and Resident #154 of 134 residents observed for physical environment. The facility census was 134.Findings include: 1. Review of the service invoice dated 05/08/26 revealed a repair was scheduled on 04/14/26 for a leaking pipe on the 100- hall and the repair was completed on 05/08/26. On 05/11/26 at 2:02 P.M., an observation of the 100-hall revealed a large hole cut out of the ceiling in the resident common area. On 05/12/26 at 9:52 A.M., an observation of the 100-hall revealed a 12-inch by 18-inch section of drywall was cut out of the ceiling in the 100-hall day room common area. On 05/12/26 at 9:52 A.M., an interview at the time of observation with Maintenance Director #540 verified the drywall had been cut out of the ceiling on the 100-hall for a pipe repair and not been repaired yet. 2. Review of the medical record revealed Resident #154 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, diabetes mellitus type two, chronic kidney disease, and need for assistance with personal care. An interview on 05/11/26 at 2:55 P.M. with Resident #154 revealed she was alert and able to answer questions appropriately. Resident #154 revealed the facility supplied a recliner and the outer material covering on the front of the chair arms was peeling. Observation of the recliner revealed there was substantial peeling of the material covering the back head rest area and also the front of the chair arms. An observation on 05/14/2026 at 1:14 P.M. of Resident #154's recliner revealed it was in the same condition as observed on 05/11/26. An interview on 05/14/26 at 1:14 P.M. at the same time of observation with Resident #154 revealed the recliner had been in that condition since she was admitted the week prior and she was concerned with the condition of the recliner. An interview on 05/14/26 at 1:50 P.M. with Maintenance Director #540 verified the recliner had substantial peeling. An interview on 05/14/26 at 1:52 P.M. with the Administrator revealed the facility was responsible for inspecting and replacing the facility supplied recliners. The Administrator noted staff were to let the administrative team know of any issues regarding the recliners. The Administrator verified Resident #154 should not have been supplied a recliner with peeling material on it.

Based on observation, interview and review of facility policy, the facility failed to ensure the smoking policy was developed and being implemented to promote smoking safety in designated smoking areas. This affected four residents (#3, #61, #132 and #139) of four residents the facility identified as smokers. The facility census was 134. Findings include: On 05/12/26 at 10:07 A.M., an observation of the designated outdoor smoking area revealed more than 10 cigarette butts were disposed of inside a non-flame resistant trash can with combustible trash.An interview at the time of the observation with Maintenance Director #540 verified more than 10 cigarette butts were disposed of in a non-flame resistant trash can with combustible trash instead of into non-combustible containers. Review of the facility policy titled Smoking Policy, revised 06/16/25, revealed smoking should occur in designated outdoor areas only and ashtrays would be available in the designated smoking area for resident use. The policy indicated staff members could empty ashtrays as needed. The policy did not specify the use of non-combustible containers.

Based on record review, interview, and review of facility policy, the facility failed to notify the physician or nurse practitioner of Resident #148's significant weight loss. This affected one resident (#148) of four residents reviewed for nutrition. The facility census was 134. Findings include: Review of the closed medical record for Resident #148 revealed an admission date of 09/09/25 with diagnoses including moderate protein calorie malnutrition, chronic obstructive pulmonary disease, wedge compression fracture first lumbar vertebra, and displaced fracture of medial malleolus of left tibia. Resident #148 discharged from the facility to home on [DATE]. Review of Resident #148's admission weight revealed on 09/10/25 Resident #148 weighed 152.0 pounds. Review of the nurse's progress note dated 09/10/25 at 3:23 P.M. revealed Resident #148 had trace edema to bilateral lower extremities. Review of the skilled care note dated 09/11/25 revealed Resident #148 had no edema. Review of the nutritional risk screening dated 09/12/25, completed by Dietary Technician (DT) #633, revealed Resident #148 weighed 152 pounds, had a moderate decrease in food intake, and had moderate protein calorie malnutrition. Review of the nutritional risk screening dated 09/15/25, completed by DT #633, revealed Resident #148 weighed 152 pounds, had a moderate decrease in food intake, and had moderate protein calorie malnutrition. Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #148 had no cognitive impairment, no swallowing concerns, and no therapeutic diet. Review of the initial nutritional evaluation dated 09/16/25, completed by DT #633, indicated Resident #148 had moderate protein calorie malnutrition, varied intakes at meals, and a recommendation was made for a house supplement 120 milliliters (ml) twice daily for nutrition and weight maintenance. Review of the weekly weight dated 09/17/25 revealed Resident #148 weighed 142.6 pounds, which indicated a significant weight loss of 6.2 percent in seven days. Review of the re-weight dated 09/18/25 revealed Resident #148 weighed 144.3 pounds, which indicated a significant weight loss of 5.1 percent in eight days. Further review of the medical record for Resident #148 including review of nurse's notes, physician's notes, nurse practitioner's notes, dietary notes, and dietary assessments revealed there was no documentation to evidence the physician, or nurse practitioner was notified of the results of the re-weight from 09/18/25 and confirmed significant weight loss of 5.1 percent in eight days. There was also no evidence of any physician ordered interventions related to this re-weight and significant weight loss. Review of the dietary progress note dated 09/28/25 at 12:54 P.M., which was written by Registered Dietitian (RD) #671 six days after Resident #148 discharged from the facility, indicated Resident #148 experienced a significant weight loss of 5.15%, had discharged from the facility, and would be re-evaluated if she re-admitted . On 05/13/26 at 2:44 P.M., an interview with Director of Nursing confirmed there was no evidence that the physician or nurse practitioner was notified of Resident #148's re-weight on 09/18/25 and confirmed significant weight loss. Review of the facility policy titled Weight Management, dated 07/30/25, revealed residents would be monitored for significant weight changes on a regular basis and the evaluation of a significant weight change of a specific time period was important. The policy indicated any resident with unintended weight loss would be evaluated by the interdisciplinary team (IDT) and interventions would be implemented to prevent further weight loss. The dietary manager, unit manager, or RD were responsible for communicating weight changes to the IDT, practitioner, and the resident's responsible party and notification documented in the medical record. This deficiency represents noncompliance investigated under Complaint Number 2690307.

Based on record review, interview, and review of facility policy, the facility failed to ensure nutritional interventions were implemented for nutrition status maintenance for Resident #148. This affected one resident (#148) of four residents reviewed for nutrition. The facility census was 134. Findings include: Review of the closed medical record for Resident #148 revealed an admission date of 09/09/25 with diagnoses including moderate protein calorie malnutrition, chronic obstructive pulmonary disease, wedge compression fracture first lumbar vertebra, and displaced fracture of medial malleolus of left tibia. Resident #148 discharged from the facility to home on [DATE]. Review of the physician orders for Resident #148 identified orders for a regular diet with regular texture and regular consistency liquids effective 09/10/25. Review of Resident #148's admission weight revealed on 09/10/25 Resident #148 weighed 152.0 pounds. Review of the nurse's progress note dated 09/10/25 at 3:23 P.M. revealed Resident #148 had trace edema to bilateral lower extremities. Review of the skilled care note dated 09/11/25 revealed Resident #148 had no edema. Review of the nutritional risk screening dated 09/12/25, completed by Dietary Technician (DT) #633, revealed Resident #148 weighed 152 pounds, had a moderate decrease in food intake, and had moderate protein calorie malnutrition. Review of the nutritional risk screening dated 09/15/25, completed by DT #633, revealed Resident #148 weighed 152 pounds, had a moderate decrease in food intake, and had moderate protein calorie malnutrition. Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #148 had no cognitive impairment, no swallowing concerns, and no therapeutic diet. Review of the initial nutritional evaluation dated 09/16/25, completed by DT #633, revealed Resident #148 had moderate protein calorie malnutrition, varied intakes at meals, and a recommendation was made for a house supplement 120 milliliters (ml) twice daily for nutrition and weight maintenance. Review of the physician orders for Resident #148 revealed there were no orders added for a nutritional supplement after this recommendation was made by DT #633 on 09/16/25 for a house supplement 120 ml twice a day. Review of the weekly weight dated 09/17/25 revealed Resident #148 weighed 142.6 pounds, which indicated a significant weight loss of 6.2 percent in seven days. Review of the physician orders for Resident #148 identified an order to obtain a re-weight effective 09/18/25. Review of the re-weight dated 09/18/25 revealed Resident #148 weighed 144.3 pounds, which indicated a significant weight loss of 5.1 percent in eight days. Further review of the medical record for Resident #148 including review of nurse's notes, physician's notes, nurse practitioner's notes, dietary notes, and dietary assessments revealed no evidence the physician or nurse practitioner were notified of the re-weight, the confirmed weight loss and there was no evidence of a nutritional intervention in response to the weight loss confirmed on 09/18/25 prior to Resident #148 being discharged from the facility to home on [DATE]. Review of the dietary progress note dated 09/28/25 at 12:54 P.M., which was written by Registered Dietitian (RD) #671 six days after Resident #148 discharged from the facility, indicated Resident #148 experienced a significant weight loss of 5.15 percent, had discharged from the facility, and would be re-evaluated if she re-admitted . On 05/13/26 at 9:20 A.M., an interview with DT #633 verified Resident #148 experienced a significant weight loss and there was no evidence the nutritional supplement DT #633 had recommended was ever ordered by the physician. DT #633 stated she went on vacation after the weight loss occurred so did not know why the RD who was covering for her did not follow up on the weight loss timely. On 05/13/26 at 2:44 P.M., an interview with the Director of Nursing confirmed there were no physician orders for a nutritional supplement, so it was not implemented for Resident #148 as recommended by DT #633. Review of the facility policy titled Weight Management, dated 07/30/25, revealed residents would be monitored for significant weight changes on a regular basis and the evaluation of a significant weight change of a specific time period was important. The policy indicated any resident with unintended weight loss would be evaluated by the interdisciplinary team (IDT) and interventions would be implemented to prevent further weight loss. The dietary manager, unit manager, or RD were responsible for communicating weight changes to the IDT, practitioner, and the resident's responsible party and notification documented in the medical record. Review of the facility policy titled Nutritional Supplementation, dated 03/11/26, revealed it was the facility's policy to provide nutritional supplements when clinically necessary to maintain weight, health, and hydration of residents. Nutritional interventions and potential oral supplements would be utilized to prevent the onset and progression of significant weight loss, which would be three percent in one week, five percent in one month, seven and a half percent in three months, and 10 percent in six months. All supplements would be ordered by the physician.This deficiency represents noncompliance investigated under Complaint Number 2690307.

Based on record review, interview, and policy review the facility failed to ensure Resident #48 was vaccinated for COVID-19 after consenting to the vaccine. This affected one (Resident #48) out of five residents reviewed for vaccinations. The facility census was 134.Findings include:Review of the medical record for Resident #48 revealed an admission date of 01/20/2025. Diagnoses included but were not limited to diabetes mellitus with diabetic chronic kidney disease, major depressive disorder, paroxysmal atrial fibrillation, and hypertension. Review of the residents' annual Minimum Data Set 3.0 revealed her cognition was intact.Review of the Consent/Declination of COVID-19 Vaccination form revealed Resident #48 consented to be vaccinated against COVID-19 on 11/26/25.Review of Resident #48's Physician orders from November 2025 until May 2026 revealed the COVID-19 vaccine was not ordered. Additional review of her Medication Administration Record through this period revealed the vaccine had not been administered to the resident.An interview on 05/12/26 at 2:55 P.M. with Assistant Director of Nursing #625 verified the facility failed to order and administer Resident #48's COVID-19 vaccine after she consented to receive the vaccine in 11/2025. Review of the facility policy titled COVID-19 Vaccination Policy dated 05/14/24 revealed the facility will obtain a signed consent form for the administration of the COVID-19 vaccine from the resident or the resident's designated health care representative(s). A copy of the consent form will be provided to the pharmacy, if required. The resident's Primary Physician/Practitioner will provide an order for COVID-19 vaccination following review of allergies, medications, and plan of care to determine if there are any.

Based on observation, record review and interview the facility failed to provide a comprehensive, resident centered treatment plan to accommodate Resident #5's identified physical and communication needs to assist the resident in achieving and/or maintaining her highest level of well-being and dignity. This affected one resident (#5) of three residents reviewed for accommodation of needs. The facility census was 130. Findings include: Review of the medical record revealed Resident #5 was admitted on [DATE] with diagnoses that included encephalopathy, type 2 diabetes, aphasia, generalized anxiety disorder, chronic pain syndrome, cerebral infarction, dysphagia, hemiplegia affecting the right side, and major depressive disorder. a. An occupational therapy treatment encounter note dated 11/20/24 revealed Resident #5 was referred for treatment for the ability to achieve increased active participation with basic activities of daily living, provide the most appropriate seating system, and for staff education. An occupational therapy treatment encounter note dated 11/21/24 revealed therapeutic activities included facilitation of postural control and wheelchair management. Wheelchair management included measurement/design of new wheelchair to enable functional independence, assessment of current seating system for appropriate modifications, and safe and efficient wheelchair mobility over various surfaces. An occupational therapy treatment encounter note dated 12/12/24 revealed Resident #5 was sitting in wheelchair with bilateral lower extremities propped on step for increased support. An occupational therapy treatment encounter note dated 12/18/24 revealed Resident #5 was provided with a facility wheelchair with bilateral lower extremity leg rests. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had cognitive impairment. The assessment also identified Resident #5 had impairment to one side of upper and lower extremity and used a wheelchair. An interview on 06/05/25 at 8:59 A.M. with Resident #5 revealed she did not get out of bed. Resident #5 pointed to a customized wheelchair located in her room and indicated she was afraid of falling from the wheelchair (to explain why she didn't get out of bed). An interview on 06/05/25 at 1:26 P.M. with Rehabilitation Director (RD) #219 revealed Resident #5 did not like to get out of bed or participate in therapy. However, during the interview the RD did not know what wheelchair the resident used or if the wheelchair was appropriate for the resident. An additional interview of 06/09/25 at 7:58 A.M. revealed occupational therapy (OT) would have used the wheelchair when treating Resident #5 and RD #219 denied awareness of any concerns Resident #5 had with the wheelchair. An interview on 06/05/25 at 2:51 P.M. with Certified Nursing Assistant (CNA) #585 revealed Resident #5 was afraid of sitting in her wheelchair. CNA #585 stated the wheelchair for Resident #5 had elevated footrests but Resident #5's legs did not fit appropriately and would fall through the footrests unless pillows were placed under Resident #5's legs. CNA #585 shared Resident #5 had previously reported the wheelchair did not fit her properly. An interview on 06/05/25 at 2:59 P.M. with Unit Manager/Registered Nurse (RN) #513 revealed Resident #5 did not like the wheelchair in her room but the UM/RN was unsure if the wheelchair was property of the resident or if the wheelchair had been provided by the facility. The UM/RN stated she would have to ask therapy if the wheelchair used by Resident #5 fit her correctly. An observation on 06/09/25 at 12:18 P.M. revealed Resident #5 was seated in her wheelchair in her room. Pillows were placed under Resident #5's legs and a wheelchair footbox (a padded unit designed to provide support, comfort, and assistance to the occupant of a wheelchair) was lying on Resident #5's bed. Resident #5 pointed to the footbox and indicated it was to be on her wheelchair but she was unsure why it was not. An interview on 06/09/25 at 12:23 P.M. with Occupational Therapist, Registered (OTR) #217 revealed Resident #5 needed a bariatric size footbox to her wheelchair. The footbox in Resident #5's room was not the correct size and Resident #5 had the same wheelchair since November or December 2024 and a footbox had not been used and a bariatric footbox had not been provided to the resident. b. Review of Resident #5's speech therapy evaluation and plan of treatment note dated 11/25/24 included treatment of speech, language, voice, communication and/or auditory processing. A speech therapy Discharge summary dated [DATE] revealed discharge recommendations for Resident #5 included to facilitate optimal cognitive-communicative performance. The following strategies recommended included training in use of concrete, one step directions by the speaker to increase comprehension, training in the use of short, direct comments to facilitate follow-through, training in use of consistent words/verbal directions to increase comprehension, caregiver instruction with emphasis in the use of visual aids to increase orientation and decrease wandering, and caregiver instruction with emphasis on the use of familiar visual stimuli to facilitate reminiscing. Resident #5 and caregivers were to be trained on communication techniques to facilitate improved follow-through instruction, as well as word finding strategies for Resident #5 to express wants and needs. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had cognitive impairment. The assessment revealed Resident #5 had unclear speech and was usually understood but had difficulty communicating some words and finishing thoughts but was able to if prompted or given time. Resident #5 was usually able to understand others but missed some part/intent of the message but comprehended most of the conversation. A care plan dated 02/28/25 revealed Resident #5 had impaired communication and usually understood and was usually understood by others. Interventions included to encourage Resident #5 to continue stating thoughts even if having difficulty, focusing on a word or phrase that made sense, or respond to the feeling Resident #5 was trying to express, observe for non-verbal indicators of attempts to express herself such as tears, furrowing of the brown, pursing of the lips, yelling, grabbing, reaching, gestures, et cetera. Resident #5 was to be referred to speech therapy as needed to evaluate Resident #5's dexterity and ability to use a communication board, writing, using a computer or use of sign language as an alternate communication to speech. When communicating with Resident #5, the person should speak clearly and distinctly, adjusting the volume and tone as needed. Communication techniques to enhance interaction included allowing adequate time for Resident #5 to respond, repeat as necessary, not to rush Resident #5, request feedback/clarification from Resident #5 to ensure understanding, face Resident #5 when speaking and to make eye contact, turn off the TV/radio as needed to reduce environmental noise, ask Resident #5 yes and no questions if appropriate, use simple, brief, consistent words/cues, use alternative communication tools as needed, such as communication book/board, writing pad, gestures, signs, and pictures, and validate Resident #5's message by repeating aloud. An interview on 06/05/25 at 8:59 A.M. with Resident #5 revealed she had difficulty saying the right words. Resident #5 revealed she would become frustrated with not being able to communicate clearly with family and caregivers. Resident #5 revealed additional speech therapy was needed to help her communicate appropriately. An observation of Resident #5 during the interview revealed Resident #5 would become frustrated when she was unable to convey clearly what she was trying to say. Resident #5 was not aware of any communication tools being available to use when she had difficulty expressing herself. An interview on 06/05/25 at 1:26 P.M. with RD #219 revealed Resident #5 was discharged from speech therapy on 01/04/25 and stated training provided to caregivers as indicated in the discharge summary was done with the nursing staff during Resident #5's treatment days. However, RD #219 was unable to say what training was provided and which caregivers had actually been trained. RD #219 was also unable to verify if any visual aids or communication tools had been provided to Resident #5. RD #219 stated a referral could be made again if Resident #5 required speech therapy services. An interview on 06/09/25 at 5:25 A.M. with Licensed Practical Nurse (LPN) #531 revealed staff were not aware of training on how to communicate effectively with Resident #5. On 06/09/25 at 5:28 A.M. an interview with Certified Nursing Assistant (CNA) #570 revealed they sometimes understood Resident #5 and did not rush Resident #5 when she talked. On 06/09/25 at 5:31 A.M. an interview with CNA #341 revealed they had not received any training on how to communicate with Resident #5. CNA #341 stated they were just patient with Resident #5. An additional interview on 06/09/25 at 9:08 A.M. with Resident #5 revealed speech therapy had just started again (after surveyor intervention). Resident #5 had a laminated picture communication form to use to communicate wants and needs. Resident #5 indicated this would help when she had trouble communicating. This deficiency represents non-compliance investigated under Complaint Number OH00166176.

Based on observation, record review, interview, and policy review the facility failed to provide privacy during care for Resident #92. This affected one resident (#92) of two residents reviewed for privacy. The facility census was 130. Findings include: Review of the medical record revealed Resident #92 was admitted on [DATE] with diagnoses that included congestive heart failure and morbid obesity. The annual Minimum Data Set assessment dated [DATE] revealed Resident #92 was cognitively intact. A physician order dated 05/06/25 revealed Resident #92's coccyx was to be cleansed with wound cleanser, patted dry, Triad paste (hydrophilic paste for light-to-moderate exudate to help maintain a moist healing environment) applied to the wound bed, and covered with a foam dressing every day and as needed. On 06/05/25 at 12:10 P.M. Registered Nurse (RN) #512 and Licensed Practical Nurse (LPN) #572 were observed completing wound care for Resident #92. At the time of the observation, Resident #92 was wearing a hospital style gown and the head of the resident's bed was against the wall to the right as you entered the room. RN #512 and LPN #572 assisted Resident #92 with removing her incontinence brief and turned Resident #92 on her left side. When Resident #92 was turned on their left side, Resident #92 was exposed from the upper back to the ankles. Resident #92 had a roommate, and the head of the roommate's bed was against the left side of the room. The roommate, Resident #70 was lying in bed and was able to see Resident #92's exposed back, buttocks, and legs. This surveyor asked if the curtain should be pulled between Resident #70 and Resident #92 to provide for Resident #92's privacy. RN #512 then verified via interview that the curtain should be pulled to provide Resident #92 privacy while treatment was being completed. Review of the Clean Dressing Change policy revised 09/18/23 revealed to provide privacy (after gathering and setting up supplies in the resident area and prior to beginning the procedure). This is an incidental finding discovered during the complaint investigation.

Based on record review, and interview, the facility failed to ensure a comprehensive person-centered care plan was developed and implemented for Resident #5. This affected one resident (#5) of three residents reviewed for care plans. The facility census was 130. Findings include: Review of the medical record revealed Resident #5 was admitted on [DATE] with diagnoses that included encephalopathy, type 2 diabetes, aphasia, generalized anxiety disorder, chronic pain syndrome, cerebral infarction, dysphagia, hemiplegia affecting the right side, and major depressive disorder. a. The plan of care dated 11/20/24 and revised on 06/06/25 revealed Resident #5 had a functional ability deficit and required assistance with self care/mobility. Interventions included reporting refusals of activities of daily living care, personal hygiene, nail care, bathing, and showers to the nurse. Resident #5 preferred a shower and liked to sleep in. The plan of care dated 11/21/24 revealed Resident #5 required 24-hour care/long term placement. Interventions included to observe and report changes in mood/behavior to social worker and/or physician as needed such as refusals of medications or care, being withdrawn or tearfulness. The plan of care dated 12/06/24 revealed Resident #5 was incontinent with bowel and bladder. Interventions included the use of disposable briefs, incontinence brief to be changed every two hours and as needed, and to be checked every two hours and as needed for incontinence. The plan of care dated 12/06/24 revealed Resident #5 had an alteration in neurological status. Interventions included a bowel and bladder program to improve or maintain continence as needed. A progress note dated 01/03/25 at 9:55 A.M. revealed Resident #5 refused to have incontinence care completed at 12:00 A.M., 6:45 A.M., and 8:45 A.M. Additional progress notes dated 01/13/25 at 4:46 P.M. and 01/18/25 at 2:29 P.M. revealed Resident #5 refused incontinence care. A progress note dated 01/24/25 at 6:48 A.M. revealed Resident #5 refused incontinence care and stated she did not like any of the staff and that it always hurt. A social service note dated 02/06/25 at 11:14 A.M. revealed Resident #5 tended to gravitate towards certain staff for care and would refuse the staff Resident #5 did not like. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had cognitive impairment. No behaviors were identified. The assessment revealed Resident #5 was dependent for toileting and was always incontinent of bowel and bladder. Review of behavior monitoring with interventions date 05/11/25 through 06/09/25 revealed Resident #5 had a behavior/refused on 05/15/25 at 9:04 P.M., on 05/18/25 at 9:41 P.M., 05/26/25 at 10:09 P.M. and on 06/04/25 at 4:21 A.M. An interview on 06/05/25 at 8:59 A.M. with Resident #5 revealed she had concerns with staff turning on the lights at night to provide care and the light hurt her eyes. Resident #5 stated she did not like to be woken up early in the morning. An interview on 06/05/25 at 2:51 P.M. Certified Nursing Assistant (CNA) #585 verified Resident #5 would refuse to allow some CNAs to provide care and Resident #5 often refused to allow incontinence care to be provided at night. CNA #585 stated that when she worked, she would change Resident #5 first thing at the start of her shift because Resident #5 probably had not had incontinence care provided all night. An interview on 06/09/25 at 5:25 A.M. with Licensed Practical Nurse (LPN) #531 revealed Resident #5 sometimes refused care. LPN #531 stated Resident #5 wanted only female caregivers, so the staff tried to accommodate the request. An interview on 06/09/25 at 5:28 A.M. CNA #341 revealed Resident #5 permitted incontinence care to be provided around 4:40 A.M. CNA #341 verified Resident #5 the resident sometimes refused care because she wanted to sleep. An interview on 06/09/25 at 6:12 A.M. with the Director of Nursing (DON) revealed she removed the light that shined down on Resident #5 when lying in bed. The DON stated Resident #5 would notify her spouse of the staff Resident #5 did not want to provide care and the facility would try to ensure there was someone available to provide care to Resident #5. The DON stated the CNAs documented Resident #5's refusals of care under behavior monitoring. On 06/10/25 at 9:23 A.M. during an interview with the DON, the DON revealed the care plan for 24-hour care/long term placement addressed Resident #5's refusal of care. An intervention was in place for the social worker or physician to be notified of the refusals. The DON verified there was not a care plan or intervention in place to address Resident #5's refusal of incontinence care, light bothering Resident #5's eyes, only wanting certain staff to provide care, or choosing to not have incontinence care provided if sleeping. The DON also verified the plan of care dated 12/06/24 for alteration in neurological status had an incorrect intervention for Resident #5 to have a bowel and bladder program. The DON verified Resident #5 had never been on a bowel and bladder program. b. In addition, an occupational therapy treatment encounter note dated 11/20/24 revealed Resident #5 was referred for treatment for the ability to achieve increased active participation with basic activities of daily living, provide the most appropriate seating system, and for staff education. An occupational therapy treatment encounter note dated 11/21/24 revealed therapeutic activities included facilitation of postural control and wheelchair management. Wheelchair management included measurement/design of new wheelchair to enable functional independence, assessment of current seating system for appropriate modifications, and safe and efficient wheelchair mobility over various surfaces. An occupational therapy treatment encounter note dated 12/12/24 revealed Resident #5 was sitting in wheelchair with bilateral lower extremities propped on step for increased support. An occupational therapy treatment encounter note dated 12/18/24 revealed Resident #5 was provided with a facility wheelchair with bilateral lower extremity leg rests. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had cognitive impairment. Resident #5 had impairment to one side of upper and lower extremity and used a wheelchair. An interview on 06/05/25 at 8:59 A.M. Resident #5 revealed she did not get out of bed. Resident #5 pointed to customized wheelchair. Resident #5 indicated she was afraid of falling. An interview on 06/05/25 at 1:26 P.M. with Rehabilitation Director #219 revealed Resident #5 did not like to get out of bed or participate in therapy. Rehabilitation Director #219 was not aware of what wheelchair Resident #5 used or if it fit her properly. An interview on 06/05/25 at 2:51 P.M. with Certified Nursing Assistant (CNA) #585 revealed Resident #5 was afraid of sitting in her wheelchair. CNA #585 stated the wheelchair for Resident #5 had elevated footrests but Resident #5's legs did not fit appropriately and would fall through the footrests unless pillows were placed under Resident #5's legs. CNA #585 revealed Resident #5 stated the wheelchair did not fit properly. An interview on 06/05/25 at 2:59 P.M. Unit Manager/Registered Nurse (RN) #513 revealed Resident #5 did not like the wheelchair in her room. Unit Manager/RN #513 was unsure if the wheelchair was Resident #5's or had been provided by the facility. Unit Manager/RN #513 stated she would have to ask the therapy department if the wheelchair fit Resident #513 correctly. An additional interview on 06/09/25 at 7:58 A.M. Rehabilitation Director #219 verified occupational would have used the wheelchair for Resident #5. Rehabilitation Director #219 was unsure if there were any concerns with the wheelchair Resident #5 had. On 06/10/25 at 9:23 A.M. with the DON verified there was not a plan of care in place addressing Resident #5 not wanting to sit in the wheelchair due to feeling unsafe. This is an incidental finding discovered during the complaint investigation.

Based on record review, facility policy review and interview, the facility failed to ensure Resident #5 was ordered the appropriate antibiotic to treat a urinary tract infection. This affected one resident (#5) of three reviewed for urinary tract infections. The facility census was 130. Findings include: Review of the medical record revealed Resident #5 was admitted on [DATE] with diagnoses that included encephalopathy, type 2 diabetes, aphasia, generalized anxiety disorder, chronic pain syndrome, cerebral infarction, dysphagia, hemiplegia affecting the right side, and major depressive disorder. A situation brief assessment recommendation (SBAR) dated 12/18/24 at 8:55 P.M. revealed Resident #5 had a change in condition. Urinalysis results were pulled from the system and revealed Resident #5's results were abnormal. The on-call physician was notified, and a verbal order was received for Macrobid (antibiotic) 100 milligram by mouth twice a day for seven days. The medication administration record (MAR) revealed Resident #5 received the 8:00 A.M. dose of Macrobid on 12/19/24. A certified nurse practitioner (CNP) note date 12/19/24 revealed Resident #5 was started on Macrobid, which did not cover any of the organisms listed on the urinalysis report. On 12/19/24 an order was received to discontinue Macrobid and start Rocephin (antibiotic) two grams intramuscularly one time and the Rocephin one gram intravenously daily for seven days. Review of the Urine Culture and Sensitivity Antibiotic Sensitivity Testing results collected 12/14/24 and reported 12/19/24 revealed the resident's urine contained the bacteria, Klebsiella pneumoniae. Macrobid was not on the sensitivity list to treat the bacteria. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had cognitive impairment. The assessment revealed Resident #5 was dependent on staff for toileting and was always incontinent of bowel and bladder. An interview on 06/09/25 at 6:11 A.M. with Assistant Director of Nursing (ADON) #514 verified Macrobid was ordered and administered to Resident #5. ADON #514 verified Macrobid did not meet the criteria for administration. Review of the facility Infection Control Antibiotic Stewardship and Multi-Drug Resistant Organism policy revised 04/17/25 revealed the antibiotic stewardship refers to coordinated interventions designed to improve and measure the appropriate use of antimicrobials, by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy, and route of administration. The program would encourage appropriate prescribing; and reduce adverse effects which often include gastrointestinal problems, clotridoides difficile diarrhea, yeast infections and antibiotic resistance in aging adults. The medical director and director of nursing would use their influence as medical and nursing leaders to help ensure antibiotics are prescribed only when appropriate. When a urine culture was positive, antibiograms and lab results would be utilized to help prescribers select the best antibiotic for each resident based on the guidelines for prescribing protocols. This deficiency represents non-compliance investigated under Complaint Number OH00166176.

Based on observation, record review, and interview the facility failed to provide Resident #5 with speech therapy services as indicated in the plan of treatment and discharge summary. This affected one resident (#5) of three reviewed for therapy services. The facility census was 130. Findings include: Review of the medical record revealed Resident #5 was admitted on [DATE] with diagnoses that included encephalopathy, type 2 diabetes, aphasia, generalized anxiety disorder, chronic pain syndrome, cerebral infarction, dysphagia, hemiplegia affecting the right side, and major depressive disorder. Resident #5's speech therapy evaluation and plan of treatment dated 11/25/24 included treatment of speech, language, voice, communication and/or auditory processing. Resident #5 was referred to speech therapy due to a history of aphasia and dysarthria. The plan of treatment revealed Resident #5 was to receive speech therapy five times a week for six weeks. Review of the speech therapy treatment encounter notes from 11/25/24 to 01/04/25 revealed Resident #5 was evaluated and received treatment four days the week of 11/24/24. Resident #5 received treatment one day out of the five days as indicated in the plan of treatment during the week of 12/01/24. Resident #5 received treatment five days the week on 12/08/24 and four days the week of 12/15/24. Resident #5 received treatment three days, instead of the five days indicated in the plan of treatment, the weeks of 12/22/24 and 12/29/24. The speech therapy Discharge summary dated [DATE] revealed discharge recommendations for Resident #5 included to facilitate optimal cognitive-communicative performance. The following strategies recommended included training in use of concrete, one step directions by the speaker to increase comprehension, training in the use of short direct comments to facilitate follow-through, training in use of consistent words/verbal directions to increase comprehension, caregiver instruction with emphasis in the use of visual aids to increase orientation and decrease wandering, and caregiver instruction with emphasis on the use of familiar visual stimuli to facilitate reminiscing. Resident #5 and caregivers were to be trained on communication techniques to facilitate improved follow-through instruction, as well as word finding strategies for Resident #5 to express wants and needs. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had cognitive impairment. The assessment revealed Resident #5 had unclear speech and was usually understood but had difficulty communicating some words and finishing thoughts but was able to if prompted or given time. Resident #5 was usually able to understand others but missed some part/intent of the message but comprehended most of the conversation. A care plan dated 02/28/25 revealed Resident #5 had impaired communication and usually understood and was usually understood by others. Interventions included to encourage Resident #5 to continue stating thoughts even if having difficulty, focusing on a word or phrase that made sense, or respond to the feeling Resident #5 was trying to express, observe for non-verbal indicators of attempts to express herself such as tears, furrowing of the brown, pursing of the lips, yelling, grabbing, reaching, gestures, et cetera. Resident #5 was to be referred to speech therapy as needed to evaluate Resident #5's dexterity and ability to use a communication board, writing, using a computer or use of sign language as an alternate communication to speech. When communicating with Resident #5, the person should speak clearly and distinctly, adjusting the volume and tone as needed. Communication techniques to enhance interaction included allowing adequate time for Resident #5 to respond, repeat as necessary, not to rush Resident #5, request feedback/clarification from Resident #5 to ensure understanding, face Resident #5 when speaking and to make eye contact, turn off the TV/radio as needed to reduce environmental noise, ask Resident #5 yes and no questions if appropriate, use simple, brief, consistent words/cues, use alternative communication tools as needed, such as communication book/board, writing pad, gestures, signs, and pictures, and validate Resident #5's message by repeating aloud. An interview on 06/05/25 at 8:59 A.M. with Resident #5 revealed she had difficulty saying the right words. Resident #5 revealed she would become frustrated with not being able to communicate clearly with family and caregivers. Resident #5 revealed additional speech therapy was needed to help her communicate appropriately. An observation of Resident #5 during the interview revealed Resident #5 would become frustrated when she was unable to convey clearly what she was trying to say. An interview on 06/05/25 at 1:26 P.M. with Rehabilitation Director #219 revealed Resident #5 was discharged from speech therapy on 01/04/25. Rehabilitation Director #219 stated the reason for discharge from services was due to Resident #5 meeting maximum potential. Rehabilitation Director #219 revealed training provided to caregivers as indicated in the discharge summary was done with the nursing staff during Resident #5's treatment days. However, Rehabilitation Director #219 was unable to say what training was provided and which caregivers had actually been trained. Rehabilitation Director #219 was also unable to verify if any visual aids or communication tools had been provided to Resident #5. Rehabilitation Director #219 stated a referral could be made again if Resident #5 required speech therapy services. An additional interview on 06/09/25 at 7:58 A.M. with Rehabilitation Director #219 revealed Resident #5 did not receive speech therapy five times a week from 11/25/24 through 01/04/25, because there was not a full-time speech therapist at that time. Rehabilitation Director #219 revealed they just pieced in the speech therapy treatment to Resident #5 whenever a speech therapist was available. Rehabilitation Director #219 then indicated they had started speech therapy again on 06/06/25 for the resident (following surveyor intervention). An additional interview on 06/09/25 at 9:08 A.M. with Resident #5 verified speech therapy had started again. On 06/09/25 at 12:18 P.M. during an interview with Resident #5, the resident was tearful and stated she wanted to return home but did not feel she had made the progress necessary. Resident #5 stated sometimes she was unable to think clearly but became frustrated when she was unable to communicate clearly, especially with her spouse. This deficiency represents non-compliance investigated under Complaint Number OH00166176.

Based on record review, facility policy review and interview the facility failed to ensure Resident #5, who was dependent on staff assistance for activities of daily living, was bathed per preference and as scheduled to promote optimal hygiene and resident well-being. This affected one resident (#5) of three residents reviewed for bathing. The facility census was 130. Findings include: Review of the medical record revealed Resident #5 was admitted on [DATE] with diagnoses that included encephalopathy, type 2 diabetes, aphasia, generalized anxiety disorder, chronic pain syndrome, cerebral infarction, dysphagia, hemiplegia affecting the right side, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had cognitive impairment. The assessment revealed Resident #5 required substantial to maximal assistance for bathing and personal hygiene. Review of the plan of care dated 02/28/25 revealed Resident #5 had functional ability deficits and required assistance with self-care. Interventions included refusals for activities of daily living care such as personal hygiene, bathing and showers were to be reported to the nurse. The plan of care also revealed Resident #5 preferred showers and required substantial to maximal (staff) assistance with bathing. The care plan did not address the resident's use of a shower chair or the resident's fear of the shower chair. Review of the facility bathing schedule revealed Resident #5 was scheduled to be bathed/showered twice a week on Tuesday and Saturday evening. Review of bathing documentation from 05/12/25 through 06/05/25 revealed Resident #5 received a shower/bath/bed bath. However, the documentation did not specify which type of bathing was provided, whether the resident received a shower, bath, or bed bath. Resident #5 was bathed on 05/12/25. Resident #5 was not bathed on 05/17/25. Review of the behavior monitoring for Resident #5 refusing care and peri care was marked yes on 05/18/25. The behavior monitoring did not indicate the type of care that was refused. The bathing documentation revealed Resident #5 was bathed on 05/19/25 and 05/22/25. The behavior monitoring for Resident #5 refusing care and peri care was marked yes on 05/26/25. The behavior monitoring did not indicate the type of care that was refused. The bathing documentation revealed Resident #5 was not bathed on the scheduled days of 05/27/25, 05/31/25, or 06/03/25 which revealed Resident #5 was not bathed from 05/22/25 until 06/05/25. The behavior monitoring for Resident #5 refusing care and peri care was marked refused on 06/04/25. The behavior monitoring did not indicate the type of care that was refused. Interview on 06/05/25 at 8:59 A.M. with Resident #5 revealed it was her preference to receive a shower. During the interview, the resident reported she had received maybe one shower at the facility. Interview on 06/05/25 at 2:51 P.M. with Certified Nursing Assistant (CNA) #585 revealed Resident #5 was afraid to use the shower chair so bed baths were provided for the resident. During the interview, CNA #585 verified bathing documentation did not support Resident #5 had been bathed at least twice a week (as scheduled). Interview on 06/05/25 at 2:59 P.M. with Unit Manager/Registered Nurse (RN) #513 revealed she audited the bathing documentation. RN #513 revealed she was not aware Resident #5 had not been bathed twice a week as scheduled. RN #513 stated if a resident refused to be bathed, the CNA was to notify the nurse. The nurse would then talk with the resident about the refusal and would document the refusal. An additional interview on 06/09/25 at 9:08 A.M. with Resident #5 revealed it hurt her to sit in the shower chair. Resident #5 was unable to comment further about why it hurt. An additional interview on 06/09/25 at 1:12 P.M. Unit Manager/RN #513 revealed showers were reviewed every day in the morning meeting. Unit Manager/RN #513 stated she reviewed the shower schedules with room changes and management staff assigned to residents as guardian angels, would ask residents if there were any concerns with showers. Unit Manager/RN #513 stated adjustments to the day and time of showers could be changed if a resident requested. Unit Manager/RN #513 revealed she was unaware Resident #5 was not comfortable in the shower chair and because Resident #5 had a stroke, the shower bed would not be appropriate due to weakness on Resident #5's right side. On 06/09/25 at 10:17 A.M. an interview with the Director of Nursing (DON) revealed CNA #585 reported a bed bath was actually provided to Resident #5 on 05/15/25 even though the electronic record showed documentation of Resident #5 not being bathed. Review of the Routine Resident Care policy revised 03/12/25 revealed showers, tub baths, and/or shampoos were scheduled according to person centered care or state specific guidelines. This deficiency represents non-compliance investigated under Complaint Number OH00166176.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and interviews, the facility failed to provide adequate supervision to prevent the elopement of a resident. This affected one (Resident #131) of three residents reviewed for elopement. The facility census was 130. Findings include: Review of the medical record for Resident #131 revealed an admitted [DATE] with diagnoses including traumatic brain injury, depression and hypertension. Resident #131 was discharged to the hospital on 07/27/24. Review of the physician's orders for Resident #131 revealed orders dated 07/26/24 to check the wanderguard placement on his right lower extremity, send him to the emergency room if he became violent, psychiatric referral and Lorazepam 0.5 milligrams to be given one time at bedtime as needed for agitation. Review of the care plan dated 07/26/24 for Resident #131 revealed he was at risk for exit seeking and wandering related to cognitive dysfunction, impulsivity and traumatic brain injury. Interventions included to apply a wanderguard per the physician's order, observe wandering behaviors, attempt diversional interventions, provide structured activities and redirect resident as needed. Review of the nursing progress notes dated from 07/26/24 through 07/27/24 for Resident #131 revealed he arrived at the facility on 07/26/24 at 12:10 P.M. He became agitated and began making verbal insults at his wife requiring de-escalating interventions by the nurse. On 07/26/24 at 1:50 P.M., he was assessed by the nurse practitioner and an order for a wanderguard was given due to his confusion and wandering. On 07/26/24 at 7:31 P.M. Resident #131 was noted to have one-on-one supervision and was in his room. He was noted to be agitated with the staff and visitors. His wife was updated on his behaviors and the need for him to transition to another facility due to his needs for a locked unit. On 07/26/24 at 8:19 P.M. the nurse updated the nurse practitioner on Resident #131's agitation and exit seeking. A return call was received at 8:45 P.M. and new orders for as needed anxiety medication was provided as well as an order to send him to the emergency for evaluation and treatment if he became violent. On 07/26/24 at 9:33 P.M. he was provided with the as needed anxiety medication. It was noted he was sexually inappropriate with staff and slamming his door. He would not allow the one-on-one male caregiver in his room. On 07/27/24 at 1:05 A.M. Resident #131's nursing progress note stated he returned to the facility with a nurse aid and nurse. A full head to toe assessment was performed and he had no injuries. The crisis center and police escorted Resident #131 to the hospital and his wife was present during this transfer. Review of the Elopement Incident Report dated 07/26/24 at 11:19 P.M. for Resident #131 revealed the floor nurse notified the Director of Nursing (DON) that he was not observed in his room and the screen was removed and his window was hyper extended. The staff began to search for the resident and called the local police department. Resident #131 was found at a local business by the nurse and aide. The local police were also present. The resident was then returned to the facility and assessed. He was alert, oriented to person and place. There were no injuries. Per the wife's statement, she stated he had called her and asked her to come get him. Review of the document Guest Location Visual Check dated 07/26/24 revealed Resident #131 was started on 15 minute checks at 6:15 P.M. These checks were completed every 15 minutes by Receptionist #210 until 11:00 P.M. Review of the facility investigative timeline performed by the DON of Resident #131's elopement on 07/26/24 revealed: On 07/26/24 at 11:00 P.M. was the last documented resident check for the one-on-one by Receptionist #210. On 07/26/24 at 11:19 P.M. Registered Nurse (RN) #209 updated the DON and stated during Resident #131's one-on-one checks he was not in his room and the window was open. DON instructed RN #209 to start the elopement policy and notify police. On 07/26/24 at 11:21 P.M. the Administrator was informed. On 07/26/24 at 11:24 P.M. the Regional office was updated on the elopement and the elopement policy being implemented. On 07/26/24 at 11:29 P.M. a photo of Resident #131 was obtained for the search. On 07/26/24 between 11:30 ad 11:35 P.M. the DON arrived and staff were searching outside and throughout the local area. On 07/26/24 at approximately 11:34 P.M. facility staff located Resident #131 at a local business with the police department present. On 07/26/24 at 11:37 P.M. facility staff arrived with Resident #131 back to the facility. A full assessment was completed and he had no injuries. On 07/26/24 at 11:50 P.M. the local police department called the crisis center for assistance with Resident #131. On 07/27/24 at 12:20 A.M. the local crisis center personnel arrived and assessed Resident #131. They recommended to send him to the local emergency room . On 07/27/24 at 12:56 A.M. Resident #131's wife arrived at the facility. On 07/27/24 at 1:05 A.M. the local police as well as the crisis center escorted Resident #131 to the emergency room . Review of the police report #24-180202 dated 07/26/24 at 11:33 P.M. revealed they had received the call from the facility stating that Resident #131 eloped. He was described as a male who could be confrontational if approached. It stated that he had crawled out of his window, had a traumatic brain injury and the facility was holding him until he could get into a locked unit. The police report stated Resident #131 was found with staff at a local business and returned back to the facility at 11:53 P.M. Review of the Incident and Accident Investigation Report dated 07/27/24, by the Administrator, stated the resident had manipulated the window to meet his wife at a pre-determined location. It was noted prior to the elopement and eluding one-on-one supervision, the resident was aggressive and inappropriate with staff. Interview on 12/04/24 at 2:29 P.M. with the Administrator revealed Resident #131 was admitted on [DATE]. He stated what the facility had received on paper about Resident #131 did not match the resident they had received. He stated Resident #131 was having behaviors such as urinating in flower pots, saying sexually inappropriate statements and becoming aggressive with staff. He was also wandering and stating he was going to leave the facility. The Administrator stated they updated the wife at approximately 5:00 P.M. that he would need a different facility due to his risk of eloping. The Administrator stated on 07/26/24 at approximately 6:00 P.M. he initiated one-on-one supervision with Resident #131 with Receptionist #210 who had been educated on elopement, dementia, behaviors and communication. He stated that during the one-on-one supervision, Resident #131 became aggressive with staff, slamming the door in their faces and swearing. The Administrator stated RN #209 made the decision to allow Resident #131 to shut his door as he was becoming more agitated by being watched and felt he could calm down if the room was quiet. He stated staff performed 15-minute checks. The Administrator stated at approximately 11:19 P.M. the staff went to check on Resident #131 and his room was observed to be unoccupied and the window had been opened and the screen removed. The Administrator stated the wife of Resident #131 stated he had previously been a carpenter and knew how to take things apart. He stated the resident only opened approximately four inches but if you took the screw out, removed the locking mechanism and slid out the bracket mechanism, you could open the window all of the way. Interview on 12/09/24 at 8:35 A.M. with the Maintenance Director #208 verified he had performed elopement drills monthly. He stated he also assessed all doors daily to ensure they were working for the wanderguards. He stated he had worked at the facility for [AGE] years and never had a resident take the window apart like Resident #131 did. He stated the window has a vent lock on the side that kept the window from opening more than four inches. He stated Resident #131 had to remove the screen, open the window and remove the crank, take the crank apart and then utilize the handle to push the vent lock and pull it down. He stated Resident #131 broke the handle on the window to utilize it to move the vent lock. Attempted interviews of RN #209 and Receptionist #210 were not able to be held as calls on 12/09/24 were not returned. Review of the facility policy titled, Elopement Policy, dated 05/01/22, revealed the facility would prevent, to the extent reasonably possible, the elopement of residents from the facility. The deficient practice was corrected on 07/31/2024 when the facility implemented the following corrective actions: On 07/27/24, an entire facility audit was completed by the DON of all residents for the risk of elopement. All residents who were at risk were assessed and interventions were placed if needed. On 07/27/24, all staff were educated by the Director of Nursing on the elopement policy, one-on-one supervision and resident behaviors. On 07/27/24 the facility identified the window mechanisms/function could be manipulated to open further than the regulation allowed. The windows were all observed and modified to ensure they were unable to be opened by the Administrator and maintenance department. On 07/28/24, Maintenance Director #208 emailed corporate maintenance and reviewed all windows and the mechanisms/function to ensure residents were safe at the facility. It was recommended that he remove the cranks so the windows would be inoperable. On 07/30/24 an emergency quality assurance meeting was held to discuss Resident #131's elopement. A new intervention was put into place of having staff go on-site to accept new admissions to ensure the facility was able to manage the resident's condition. Audits were performed to ensure window modification was intact and effective, twice a week with a total of 14 rooms, from 08/07/24 through 08/29/24 by the Director of Nursing for a total of four weeks. This deficiency represents non-compliance investigation under Master Complaint Number OH00160053 and Complaint Number OH00159580.

Based on record review and interview, the facility failed to ensure residents were screened for tuberculosis on admission. This affected one (Resident #63) out of three residents reviewed for tuberculosis screening. The facility census was 130. Findings include: Review of the medical record for Resident #63 revealed an admitted [DATE] with diagnoses including anxiety, depression and hypertension. Review of Resident #63's physician's orders for August 2024 revealed there were no physician's orders for tuberculosis screening. Review of Resident #63's medication administration record for August 2024 revealed staff never administered tuberculosis screening after admission. Interview on 12/09/24 at 9:45 A.M. with the Director of Nursing (DON) verified Resident #63's tuberculosis screening was not completed after her admission in August 2024. She verified Resident #63 did not have tuberculosis screening until after a readmission in October of 2024. Review of the facility policy titled, Tuberculosis Control Plan, dated 01/03/23, revealed all first-time residents would be screened for tuberculosis on admission. The screening would consist of a Mantoux testing using five units of tuberculin (liquid solution used to test for tuberculosis through skin reaction). This test would be done twice with the second test occurring one to three weeks after the first test was performed and read. This deficiency represents non-compliance investigation under Complaint Number OH00160053.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and interview, the facility failed to issue refunded monies to discharged residents in a timely manner. This affected two residents (#145 and #160) of three residents reviewed for resident refunds. The total census was 130. Findings included: 1. Closed record review revealed Resident #145 was admitted on [DATE] and was discharged on [DATE]. His payor source was Private Pay. On 06/24/24, a review of the Resident Ledger for Resident #145 revealed that a final payment was made on 03/13/24 of $19,528.00. After the facility balance was paid, Resident #145 was due a refund of $1,572.00. This was due within 30 days or by 04/13/24. The amount was approved on 05/17/24 and was paid out on 05/22/24. Interview on 06/24/24 at 1:15 P.M. with the Administrator confirmed the refund payment was issued almost six weeks late. 2. Closed record review revealed Resident #160 was admitted on [DATE] and was discharged on [DATE]. Her payor source was Private Pay. On 06/24/24, a review of the Resident Ledger for Resident #160 revealed that a final payment was made on 07/01/23 of $14,049.20. After the facility balance was paid, Resident #160 was due a refund of $8,548.60. This was due within 30 days or by 07/30/23. The amount was approved on 07/26/23 and was paid out on 08/04/23. Interview on 06/24/24 at 1:05 P.M. with the Business Office Manager (BOM) #505 confirmed the refund payment was issued late. Review of facility policy titled Resident Refund Policy and Procedure, (updated 09/22/23), revealed refunds are due to residents within 30 days of discharge. This deficiency represents non-compliance investigated under Complaint Number OH00154375. The deficient practice was corrected on 05/22/24 when the facility implemented the following corrective actions: o On 08/04/23 Resident #160's refund was paid out. o On 05/17/24 a full house audit performed with no negative findings. o On 05/22/24 Resident #145's refund was paid out. o Regional BOM increased facility visits to twice a week during facility BOM's leave.

Based on record review and interviews the facility failed to notify Resident #94's responsible party after a fall. This affected one resident (Resident #94) of three residents reviewed for notifications. The census was 121. Findings include: Record review of Resident #94 revealed an admitted [DATE] with diagnoses including myelodyspastic syndrome, Alzheimer's Disease and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #94 was cognitively intact. Review of the progress note dated 11/28/23 and timed at 3:34 A.M. revealed Resident #94 had a fall with no injury. A note at 10:05 A.M. revealed her hand was swollen and bruised. An x-ray was ordered. A note at 12:36 P.M. revealed there was no fracture. There was no indication the responsible party was notified. Review of the Change in Condition report titled SBAR, dated 11/28/23 revealed it was not completely filled out including notification of responsible party. Review of the post-fall evaluation dated 11/28/23 revealed it does not indicate if a responsible party or physician was notified. Interview on 12/27/23 at 12:11 P.M. with Licensed Practical Nurse (LPN) #303 revealed she did Resident #94's post-fall assessment and progress note. She stated she was not sure if the family was notified but stated she asked the Certified Nurse Practitioner (CNP) for an x-ray though it was not documented. Phone Interview on 12/27/23 at 12:29 P.M. with Registered Nurse (RN) #300 revealed she was the nurse on duty when Resident #94 had fallen. She stated she was told because the resident fell on the mat it was not considered a fall. She did start a fall investigation however it was not completed. She stated she did not notify the physician, CNP or the responsible party. Interview on 12/27/23 at 3:45 P.M. with Director of Nursing revealed any change of plane was considered a fall. DON verified there was no evidence Resident #94's family was notified of the fall. Review of the policy titled Fall Management, dated 09/22/23 revealed the licensed nurse will notify the physician and responsible party of a fall and document in the medical record. This deficiency represents non-compliance investigated under Complaint Number OH00149121.

Based on observation, record review, and policy review, the facility failed to follow infection control standards during Resident #56's pressure ulcer dressing change. This affected one resident (Resident #56) of three residents reviewed for pressure ulcers. The facility census was 119. Findings include: Resident #56 was admitted to the facility on [DATE] with diagnoses including diabetes, dementia, and high blood pressure. Review of the medical record revealed the resident had a Stage 3 pressure ulcer (a wound with full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed.) located on the coccyx which was to be treated with Triad cream and a clean dressing applied over it. Observation on 05/17/23 at 12:45 P.M. revealed Registered Nurse (RN) #315 prepared her work area and opened her dressing supplies. RN #315 then positioned Resident #56 on her right side and proceeded to unfasten the resident's incontinence brief. The resident had been incontinent of stool. RN #315 tucked the brief under the resident's hip and proceeded to clean the pressure ulcer to her coccyx. RN #315 did not remove the soiled brief from under the resident. After applying the Triad cream RN #315 attempted to put a foam dressing over the wound but contaminated the dressing with stool. RN #315 said she would redo the dressing after they provided incontinence care. Interview with RN #315 on 05/17/23 at 1:00 P.M. confirmed she should have performed incontinence care before doing the dressing change. Review of the facility's Clean Dressing Change policy, last revised 10/14/21, revealed a clean field should be used for the dressing changed.

Based on observation, interview, and record review, the facility failed to ensure fall interventions were in place per the plan of care for Resident #100. This affected one (#100) of three residents reviewed for falls. The facility census was 119. Findings include: Review of the medical record for Resident #100 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, dementia, fracture around internal prosthetic right hip joint (03/14/23), age related physical debility, difficulty in walking, and unsteadiness on feet. Review of the care plan dated 11/16/22 revealed Resident #100 was at-risk for falls due to deconditioning, Alzheimer's, hypertension, congestive heart failure, and debility. Interventions included educate resident and family about safety reminders and what to do if a fall occurs, encourage resident to rest when they feel fatigued, provide assistive devices as needed, anti-rollbacks to wheelchair, bed in low position, mat to floor beside bed, and call light touch pad within reach. Review of the comprehensive nursing evaluation dated 02/07/23 revealed Resident #100 was at-risk for falls due to a history of falls, fear of falling, urinary urgency, impaired cognition, and taking medications the increased potential for falls. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #100 had one fall with major injury since the last assessment. Review of the significant change MDS assessment dated [DATE] revealed Resident #100 had severe cognitive impairment and required extensive assistance from staff for bed mobility and transfers. The assessment indicated Resident #100 had one fall with no injury since the last assessment. Review of the incident log revealed Resident #100 experienced falls on 01/31/23, 02/01/23, 03/10/23, and 04/06/23. Review of the progress note dated 03/10/23 at 6:34 P.M. revealed Resident #100 was found on the floor in her bedroom after attempting to self-ambulate and her wheelchair was located on her roommates side of the room with the brakes not engaged. A note dated 03/10/23 at 6:42 P.M. indicated Resident #100 was laying on her back on the floor with her legs out in front of her. A note dated 03/10/23 at 8:38 A.M. revealed Resident #100 was complaining of pain to her right thigh. A noted dated 03/11/23 at 12:56 P.M. revealed Resident #100 had a periprosthetic fracture of the right femoral shaft. A note dated 03/11/23 at 1:15 P.M. revealed Resident #100 was sent to the hospital for evaluation. Review of the fall investigation dated 03/10/23 revealed Resident #100 was found laying on her back on the floor and had no obvious injuries at the time of the fall. On 03/11/23, Resident #100 was complaining of right leg pain and a fracture was identified. At the time of the fall, there were anti-rollbacks to her wheelchair and her wheelchair brakes were not engaged. New interventions implemented after the fall included education on call light use and a fall mat beside the bed. Review of the progress note dated 04/06/23 at 3:00 P.M. revealed Resident #100 was found laying on her left side on the floor after attempting to self-transfer to bed. Resident #100 had gripper socks on and her wheelchair was beside her with brakes unlocked. No documentation of fall mat in place beside bed. Review of the fall investigation dated 04/06/23 revealed Resident #100 was found on the floor on her left side and Resident #100 stated she was attempting to lay down in bed. At the time of the fall, her wheelchair brakes were not engaged and she had gripper socks on. There was no evidence a fall mat was in place at the time of the fall. New interventions included offering to put to bed between lunch and dinner. On 05/16/23 at 9:16 A.M., observation of Resident #100 revealed she was laying in bed and there was no fall mat in place beside the bed. On 05/16/23 at 9:42 A.M., interview with Licensed Practical Nurse (LPN) #418 verified the fall mat was not beside the bed. Upon further observation of the room, LPN #418 located the fall mat propped vertically between two cupboards in Resident #100's room. On 05/17/23 at 10:11 A.M., interview with the Director of Nursing verified the fall investigation dated 04/06/23 indicated Resident #100 was laying on the floor and not on a fall mat. She also stated that on the evening of 05/16/23, Resident #100's fall mat was underneath her bed rather than beside it. Review of facility policy titled Fall Management, dated 08/18/22, revealed falls would be reviewed within 24 to 72 hours after a fall and the plan of care would be revised to minimize repeat falls.

Based on observations, staff interview, record review, and facility policy review, the facility failed to ensure their infection control prevention policy for COVID-19 was implemented to prevent the potential spread of COVID-19. This had the potential to affect all residents. The facility census was 115. Findings include: 1. Initial tour of the facility on 06/23/22 at 10:44 A.M. revealed Housekeeper (HSK) #507 in Resident #107's room wearing a face shield and a surgical mask. HSK #507 was observed putting something in a bag for Resident #107 and talking with Resident #107. Further observation revealed a bin of personal protective equipment (PPE) and a sign that read to see nurse before entering located outside of Resident #107's door. Interview on 06/23/22 at 10:44 A.M. with HSK #507 verified the observation and stated she wasn't sure why Resident #107 was on isolation but Resident #107 was being discharged today (06/23/22). HSK #507 stated she believed Resident #107 was off isolation even though the sign and PPE bin had not been removed. HSK #507 stated if the resident was in isolation, she should be wearing a gown, gloves, N95 mask, and face shield. HSK #507 stated when exiting the room, she would clean her face shield if it was dirty. Interview on 06/23/22 at 10:47 A.M. with Infection Control Preventionist (ICP) #550 revealed Resident #107 was in isolation for exposure to someone positive with COVID-19. After looking in the electronic health record, ICP #550 stated Resident #107 was on isolation until 06/27/22. ICP #550 stated the expectation was for the staff to don full PPE which included gown, gloves, N95 mask, and face shield prior to entering Resident #107's room. Review of the medical record for Resident #107 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #107 had intact cognition. Review of the June 2022 physician orders revealed orders for contact and droplet isolation (transmission-based precautions [TBP]) related to COVID-19 every day and night shift until 06/27/22. 2. A follow up tour of the facility on 06/23/22 from 1:30 P.M. to 1:58 P.M. with ICP #550 revealed Resident #110's room did not have signage indicating Resident #110 was in isolation but there was a PPE bin outside of the door. ICP #550 verified the observation and obtained a sign that read stop and see the nurse before entering, from the drawer of the PPE bin and placed the sign outside the door of Resident #110's room. Observation on 06/23/22 at 1:38 P.M. revealed Registered Nurse (RN) #510 on the 200-hall standing at the medication cart in front of the nurses' station with his N95 face mask pulled below his chin and a face shield positioned on top of his head. At this time RN #510 verified the observation and confirmed his mask should be covering his mouth and nose and the face shield covering his face. ICP #550 stated the 200 hall was the exposure hall, all residents were on isolation, and RN #510 should have had his face mask and face shield on properly. Continued tour and observations revealed the rooms of Residents #48, #49, #56, #79 and #80 were the only rooms that had signs posted indicating to see nurse before entering the room. Review of the floor plan indicated Residents #47, #59, #64, #72, #73, and #76 were identified as residents that were positive with COVID-19 and should have had signage indicating to see nurse prior to entering the room. Further observation revealed the rooms for Residents #1 through #44 located on the 100 hall, which ICP #550 identified as isolation rooms, did not have signage to indicate the residents were in isolation. Interview on 06/23/22 between 1:30 P.M. to 1:58 P.M. with ICP #550 verified the observations. Review of the CDC Covid-19 Data tracker on 06/23/22 revealed the county in which the facility was located had a high community transmission rate. Review of the facility policy titled Coronavirus (COVID 19), revised 06/02/22, revealed under the section of core principles of COVID-19, infection prevention, instructional signage throughout the facility and proper visitor education on COVID-19 signs and symptoms, infection control precautions, and other applicable facility practices. Under the section of personal protective equipment, transmission-based precautions revealed use of PPE included if a resident was in isolation use of N95 mask or equivalent or higher, face shield or goggles, gown, and gloves should be worn when entering the room and during all care. Also, under this section revealed healthcare personnel (HCP) working in facilities located in areas with substantial or high transmission or high community transmission were more likely to encounter asymptomatic or pre-symptomatic residents with [CONDITION(S)]-CoV-2 infection. If [CONDITION(S)]-CoV-2 infection was not suspected in a resident (based on symptom and exposure history and resident is not on TBP) a surgical mask or higher-level mask and eye protection (face shield or goggles) should be worn during resident care encounters (to ensure the eyes were also always protected from exposure to respiratory secretions) and while in the facility. This deficiency substantiates Complaint number OH 533.

Based on medical record review, review of employee personnel files, staff interview, review of the facility's Advance Directive Policy and review of the facility investigation, the facility failed to provide the necessary care and services for Resident #200 who was found without vital signs and was a full code status, when staff did not implement cardiopulmonary resuscitation (CPR). This resulted in Immediate Jeopardy for one of six residents (Resident #200) reviewed for advanced directives and provision of emergency measures. Additionally, the facility failed to provide the necessary care and services in regards to pain management for one resident (Resident #33) observed during a dressing change to a Stage IV pressure ulcer. This affected one of three residents reviewed for pressure ulcers. The facility census was 108. On [DATE] at 2:30 P.M. the administrator, director of nursing (DON) and Corporate Registered Nurse (RN) #44 were notified of Immediate Jeopardy which began on [DATE] at 5:45 A.M. when Resident #200 was found in bed without vital signs by Licensed Practical Nurse (LPN) #34 and CPR was not initiated. Resident #200 had a signed advance directive form dated [DATE] indicating she desired CPR. The Immediate Jeopardy was removed on [DATE] when the facility initiated the following measures: ? On [DATE] an in-service was conducted by the director of nurses for the facility's 10 registered nurse and 22 licensed practical nurses entitled CPR policy with a post test. This in-service was a review of the facility's current CPR policy dated August, 2011. ? On [DATE] LPN #34 was counseled by the DON regarding the failure to administer CPR. ? On [DATE] LPN #34 was terminated. ? On [DATE] record review was completed for four residents who had expired in the facility between August, 2014 and October, 2014 with no concerns identified with regard to following advance directives. ? On [DATE] and [DATE] interviews with licensed nurses and state tested nurse aides revealed they were knowledgeable of CPR and following advance directives. Although the Immediate Jeopardy was removed, the deficient practice remained at a severity level two, (potential harm that is not Immediate Jeopardy), when the facility failed to adequately assess Resident #33 for pain and provide the care and services that was directed by the plan of care. Findings include: 1. Review of the closed medical record for Resident #200 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Summary of Assessment form dated [DATE], indicated Resident #200 had no cognitive impairment. The assessment included an Emergency Response Directive Status dated [DATE] identifying Resident #200 desired "Full Resuscitation". Review of the nurses note dated [DATE] timed 5:45 A.M. documented LPN #34 entered the room of Resident #200 for morning care and found Resident #200 "cold and pale to touch". The nurses note indicated Resident #200 was absent of vital signs. The medical record contained no other documentation of the condition of Resident #200 upon discovery and no documentation CPR was initiated. Review of a written statement by the DON dated [DATE], (untimed) indicated she spoke with LPN #34 who stated she entered Resident #200's room at 5:45 A.M. and the resident was without vital signs, cold, pale and had fixed pupils. LPN #34 indicated she called the doctor and verified she did not initiate CPR as "it would not have brought her back." Review of an undated handwritten statement by LPN #34 indicated the following timeline of events: ? Approximately 12:15 A.M., the resident's blood sugar was checked, medication was given via peg tube and flushed, sliding scale coverage was administered and aerosol treatment was given. The resident was alert and oriented. ? 1:00 A.M. A State-tested nurse aide (STNA) answered the call light to put the resident on a bed pan per her request. ? 3:45 A.M. Sensory alarm was going off down the short hall, STNA doing room checks, resident resting without any concerns. ? 5:45 A.M. Nurse entered the resident room and resident was absent of vital signs, MD notified. ? 6:45 A.M. Notified primary contact, and he was to contact the facility with where to release the body. He was unsure at this time. An interview with the DON on [DATE] at 9:34 A.M. verified she had no additional information regarding Resident #200 and stated if she remembered correctly the resident was "really, really dead". The DON stated LPN #34 was no longer employed by the facility. She indicated LPN #34 had obtained her registered nursing license and had "moved on". The DON verified the advance directive for Resident #200 indicated a full code status. Interview with Registered Nurse (RN) #35 on [DATE] at 10:15 A.M, who worked first shift, indicated she would begin CPR if a resident was a full code status. RN #35 stated there was no situation when she would not initiate CPR on a resident that was a full code status. Interview with LPN #36, who worked first shift, on [DATE] at 10:25 P.M. revealed if she found a resident who was not breathing she would immediately determine the code status and, if the resident was a full code, she would initiate CPR. Interviews with State tested Nurse Aides (STNA) #37, #38, and #39, all who worked first shift, on [DATE] between 10:30 A.M. and 10:45 A.M. verified they checked residents every two hours and as needed for care. Each indicated if they found a resident unresponsive and not breathing they would get the nurse immediately. Interviews on [DATE] between 9:20 A.M. and 9:35 A.M. with LPN #42, LPN #43 and STNA #41, who worked the night shift revealed they were knowledgeable of residents' code status and the procedure to be followed to initiate CPR. Review of the personnel record of LPN #34 revealed a hire date of [DATE] and termination on [DATE]. LPN #34 had received a disciplinary action on [DATE] for a medication error of "significant magnitude". The termination on [DATE] did not specify the reason. There was no evidence LPN #34 had been reported to the State Board of Nursing. Interview with the DON on [DATE] at 12:15 P.M. verified LPN #34 had worked her normal shift on [DATE] and [DATE] following the incident of [DATE]. The DON stated LPN #34 had been terminated on [DATE] for her lack of knowledge regarding the failure to initiate CPR for Resident #200 despite her individual counseling on [DATE]. Record review was completed for four residents, Residents #155, #182, #227 and #240, who had expired in the facility between August, 2014 and October, 2014. No concerns were identified with the advance directives and the residents' deaths. Review of the four resident records had the code status clearly delineated inside the front cover of the chart and under the Advance Directive tab. The facility identified no residents that required CPR since their last annual survey. Review of the undated facility policy entitled Advance Directives, revealed all executed advance directives would be requested by Social Services so that a copy could be made of the original and placed in the guest's current medical record. The directive identified the facility would honor the advance directive of the resident. 2. Resident #33 was admitted [DATE] with [DIAGNOSES REDACTED]. A Stage IV pressure wound is defined as (full thickness skin loss with exposed bone, tendon or muscle. Slough or eschar (necrotic tissue) may be present on some parts of the wound bed. It often includes undermining and tunneling). Review of the Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #33 had short and long term memory problems with severely impaired decision making skills. An observation of the wound dressing change was completed on [DATE] at 10:00 A.M. STNA #49 explained to Resident #33 he would assist her to turn on her side so LPN #48 could change the wound dressing. Resident #33 became tearful and STNA #49 offered verbal support. STNA #49 and STNA #50 assisted Resident #33 to turn onto her right side. During the turn, Resident #33 moaned and called out for her husband. LPN #48 reassured the resident that her husband would be visiting later. LPN #48, STNA #49 and STNA #50 did not question the resident regarding pain. During the dressing change, the resident was observed to intermittently moan and call out. Interview with LPN #48 verified Resident #33 was not pre-medicated prior to the extensive dressing change to the coccyx. The resident stated she was in pain. LPN #48 stopped the dressing change at that point and medicated the resident with the 'as needed' Tylenol for pain, as there were no other physician orders [REDACTED]. LPN #48 said Resident #33 had exhibited the same behaviors previously but the nurse assessed the behaviors as anxiety rather than pain. LPN #48 said Resident #33 feared falling out of bed when being turned and repositioned. LPN #48 verified Resident #33 received no medication for anxiety and only had an order for [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the MAR from [DATE] through [DATE], revealed Resident #33 received 12 pressure ulcer treatments and no pain medication was documented as administered. Review of the plan of care dated [DATE] related to the pressure ulcer and pain revealed the following interventions: ? Observe for signs of discomfort with dressing changes and administer pain medications, as ordered. ? Administer pain medications prior to dressing changes. ? If unable to scale pain (,[DATE]) observe for nonverbal signs such as, grimacing, yelling, crying, moaning, or guarding. Report these to the nurse. ? Administer medication for pain and observe for effectiveness/side effects and report ineffectiveness to the physician. Review of the Pain Management Program dated ,[DATE] indicated the Pain Management Program will provide the nursing staff with a structured approach for developing an appropriate care plan for pain management, and/or to evaluate the effectiveness of the current regimen. Situations when guests may be evaluated for pain include, but are not limited to: guest has pressure ulcers, surgical wounds, casts, splints etc. The licensed nurse will evaluate the guest's mental status and if cognitive and physical impairments alter the guest's ability to verify or rate pain.