Every finding on record at Meadows of Leipsic

Based on review of facility's Legionella plan and documentation, staff interviews, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to develop and implement a comprehensive and effective infection control/water management plan to prevent the risk of Legionella. This had the possible affect all residents in the facility. The facility census was 44.Findings include:Review of the facility's Legionella Water Management Plan, updated 08/04/25, revealed Legionella could grow and spread in common areas including sinks, showers, water fountains, standing water on washing tables, spa tub and ice machines. There were no records of flushing of low-flow or dead-leg pipes by the facility. The facility had a written description of the building's water system but failed to have a flow diagram.Interview on 01/22/26 at 2:22 P.M. with the Administrator verified the facility did not document or complete flushes of the dead-leg and low flow areas. The facility did not complete a flow diagram. The Administrator stated their policy said they did not have to complete any flushes and a flow diagram was not completed because it was not written out on it.Review of the CDC guidance titled Controlling Legionella dated 03/15/24 revealed to flush low-flow plumbing runs and dead legs at least weekly. Flush infrequently used fixtures (e.g., eye wash stations, emergency showers) regularly as needed to maintain water quality parameters within control limits.

Based on record review, observation, resident interview, and staff interview, the facility failed to ensure resident requests for bed accommodations were honored. This affected one (Resident #4) of two residents reviewed for accommodation of needs. The facility census was 44. Findings Include:Review of Resident #4's medical record revealed an admission date of 10/22/24. Diagnoses included fracture of right femur (subsequent encounter) with orthopedic surgery, type I diabetes mellitus, osteoporosis, anxiety disorder, chronic pain, and muscle weakness.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was cognitively intact. Resident #4 was independent with toilet use, bed mobility, transfer, and required set up assistance with bathing. Resident #4 displayed no behaviors during the review period. Review of Resident #4's care plan revised 01/20/26 revealed supports and interventions for behaviors of hyper fixation on condition bed frame and mattress (12/09/25). Interventions included to determine the cause for inappropriate behavior, observe for triggers of inappropriate behaviors and alter environment as needed. Observation on 01/21/26 at 8:12 A.M. revealed Resident #4 was sleeping in bed on a regular mattress. Resident #4 had the head of the bed raised, her right leg straight, her left leg bent slightly and her torso twisted so she was laying partially on her left hip. The positioning did not appear to be comfortable.Interview on 01/21/26 at 9:49 A.M. with Resident #4 reported her bed was uncomfortable and it bothered her enough that it was affecting her sleep. Resident #4 explained she had a surgery to repair a broken femur and had a rod in her leg that caused her discomfort when lying in her bed. Resident #4 reported she had complained about the regular bed being uncomfortable, but they told her there was nothing wrong with it and had just given her another regular mattress or topper. Other types of mattresses had not been tried. Interview on 01/21/26 at 9:54 A.M. with Certified Nursing Assistant (CNA) #527 verified Resident #4 had reported her bed was uncomfortable and reported it dipped in the center. CNA #527 reported the concerns were passed on to the Maintenance Director but CNA #527 was not sure if another bed was provided as Resident #4 continued to have a regular bed and continued to voice concerns of being uncomfortable.Interview on 01/21/26 at 10:22 A.M. with Maintenance Director #501 revealed he was aware of Resident #4's concerns for her bed being uncomfortable. He reported this was at least the third bed she had. He reported the way she slept her butt sinks in, and the bed gets uncomfortable for her. He stated her family had even brought in toppers to try and help. The toppers worked for a while but she complained again about the bed poking her and being uncomfortable. Maintenance Director #501 reported the bed was switched out a number of times but he did not have record of when this was done. Review of maintenance log revealed it was documented Resident #4 had her bed replaced on 08/29/25 and her bed frame replaced on 12/01/25. There was no indication as to what type of bed was used as a replacement. Interview on 01/22/26 at 7:32 A.M. with the Administrator revealed Resident #4's standard mattress had been changed out a number of times. The Administrator reported the regular mattresses were evaluated, flipped or taken out when Resident #4 had complained. The regular mattresses which were removed were then used in other residents rooms and the other residents never reported any concerns. The Administrator verified there was no additional documentation or evidence to show when the mattresses were changed or if other types of mattresses were tried to improve Resident #4's comfort.Interview on 01/22/26 at 8:54 A.M. with Resident #4 reported again she had not been provided any other types of mattress to see if they would be more comfortable to her. She stated she had been provided a few different mattress toppers but not a different type of mattress. Resident #4 reported again she was uncomfortable in the regular style mattress, and she was unable to get a good nights sleep because of it. Interview on 01/22/26 at 9:19 A.M. with Licensed Social Worker (LSW) #500 revealed she was aware of Resident #4 concerns regarding her bed being uncomfortable. LSW #500 reported being aware of an air mattress being tried by Resident #4 but was unable to provide supporting evidence this trial had actually been completed.

Based on medical review, observation, and staff interviews, the facility failed to ensure the resident's bed sheets were clean and sanitary. This affected one (Resident #50) of 21 residents reviewed for clean and homelike environment. The facility census was 44.Findings include:Medical record review revealed Resident #50 was admitted on [DATE] with diagnoses including acute kidney failure with tubular necrosis, dementia, and obstructive and reflux uropathy,The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #50 had impaired cognition. Resident #50 was dependent with toileting. Observation on 01/22/26 at 10:07 A.M. of catheter care revealed Resident #50 had a bowel movement at the start of catheter care. The Director of Nursing (DON) and Certified Nursing Assistant (CNA) #584 completed incontinence care on Resident #50. There was fecal matter on the lift sheet due to CNA #584 wiping across lift sheet with fecal matter on it. Lift sheet was not changed and the soiled lift sheet remained under the resident.Interview on 01/22/26 at 10:17 A.M. with CNA #584 verified DON and CNA #584 did not change the lift shift after incontinence care and a small amount of fecal matter was on the lift sheet under Resident #50.

Based on observation, record review, and resident and staff interview, the facility failed to timely assess and obtain a physician order to treat the resident's wounds. This affected one (Resident #21) of three residents reviewed for skin conditions. The facility census was 44. Findings include:Review of Resident #21's medical record revealed an admission date of 11/10/23. Diagnoses included heart failure, sepsis, obesity, acquired absence of right leg above the knee, convulsions, depression, type II diabetes, and peripheral vascular disease. Review of Resident #21's care plan revised 11/30/25 revealed supports and interventions for self-care deficit, risk for excessive bleeding and bruising related to medications, risk for injury related to seizures, pain, and risk for skin breakdown. Interventions for risk for skin breakdown included weekly skin assessments, keep linens clean and dry, and avoid shearing skin during positioning, turning and transferring. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was cognitively intact. Resident #21 had no skin concerns at the time of the review and displayed no behaviors.Review of Resident #21's physician orders revealed an order dated 12/29/25 and discontinued 01/20/26 to wrap left lower leg daily off at night. There were was no assessment of any wounds on Resident #21's left lower leg nor a physician order to treat any wounds on Resident #21's left lower leg prior to 01/20/26. Observation and interview on 01/20/26 at 9:56 A.M. revealed Resident #21 had three two inch by two inch white bandages on his left lower leg. There were no initials or dates on the dressings indicating when the dressings were applied. The bandage on the left lower extremity on the left side of the lower leg had dried blood with yellow fluid on it and was partially separating from Resident #21's skin. Resident #21 verified he had a weeping wounds and the one on the side of his leg needed the dressing to be changed. Interview on 01/20/26 at 10:21 A.M. with Registered Nurse (RN) #543 reviewed Resident #21's physician orders and verified there were no orders in place for dressing changes to be done to Resident #21's left lower leg. There was just an order for wrapping the left lower leg at night,.Observation and interview on 01/20/26 at 10:25 A.M. of Resident #21's left lower extremity with RN #543 verified Resident #21 had three undated bandages in place on his left lower extremity. RN #543 stated the dressings should have been dated when applied. Resident #21 reported he thought they were put on sometime yesterday and restated to RN #543 there were areas that were weeping. RN #543 removed the bandages and there were red areas on Resident #21's leg where the adhesive came in contact with his skin. RN #543 stated she would talk with the physician and get an order put in place for the areas.

Based on observation, staff interview, and policy review, the facility failed to ensure dietary staff were provided beard protectors while working in the kitchen. This affected all 39 residents who resided in the facility and received food from the kitchen. The facility census was 39. Findings include: Observation on 05/30/23 at 8:27 A.M. revealed Cook #205 had a full beard and mustache approximately one inch long and was working in the kitchen. The Cook was not wearing a beard protector. Interview with Cook #205 on 05/30/23 at 8:32 A.M. verified that he did not wear a beard protector while working as they were not provided for staff. Interview with the Director of Food Services on 05/30/23 at 8:35 A.M. revealed the facility did not have beard protectors in stock and she would look into purchasing. Review of the facility policy titled, Hair Restraint, dated 11/30/21 revealed food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles.

Based on medical record review, review of the meal ticket, review of the menu, observation, and staff interview, the facility failed to ensure diets were provided as ordered. This affected one (Resident #1) of one resident reviewed for nutrition. The facility census was 39. Findings include: Review of the medical record revealed Resident #1 was admitted on [DATE]. Diagnoses included chronic kidney disease stage 4, acute kidney failure, hypertensive heart disease with heart failure, hyperlipidemia, and essential (primary) hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired. Review of Resident #1's care plan dated 08/16/21 revealed interventions in place to follow diet as ordered by physician as protein, sodium, potassium and phosphorous intake may need to be regulated based on kidney function. Review of the dietician progress note dated 05/17/23 revealed Resident #1 continued on a regular, regular/thin diet with double portion protein. Intakes mostly 76-100%, decreased at times with no significant changes in weight. Review of dietary orders dated 04/27/22 revealed Resident #1's diet was prescribed as regular, regular texture, and thin liquids. Special instructions included double protein at mealtimes. Review of Resident #1's weights dated the last six months revealed no significant weight fluctuations. Review of the lunch menu dated 05/31/21 revealed the menu included fried chicken sandwich, tater tots, California vegetable blend, tossed salad, and dessert. Observation on 05/31/23 at 1:52 P.M. of Resident #1's lunch tray included one serving of the protein (one chicken sandwich). Review of the meal ticket dated lunch 06/01/23 revealed Resident #1 was to be provided with double protein/double portions. Observation on 06/01/23 at 12:10 P.M. of Resident #1's lunch tray revealed one portion of protein (chili), one grilled cheese sandwich, and tossed salad. Interview on 06/01/23 at 12:14 P.M. with Licensed Practical Nurse (LPN) #278 verified Resident #1 only received one portion of protein at the lunch meal.

Based on medical record review, observation, and staff interview, with facility failed to ensure residents received adequate and timely assistance with grooming. This affected one (Resident #1) of two residents reviewed for activities of daily living. The facility census was 39. Findings include: Review of the medical record revealed Resident #1 was admitted on [DATE]. Diagnoses included chronic kidney disease stage 4, acute kidney failure, hypertensive heart disease with heart failure, contracture left and right hand, hypothyroidism, and essential (primary) hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was moderately cognitively impaired. Resident #1 required total dependence for personal hygiene. Review of the care plan dated 02/13/17 revealed Resident #1 needed support of staff for activities of daily living (ADLs) completion and interventions included to provide assistance for ADLs. Further review of the medical record revealed no documentation showing Resident #1 had his nails trimmed. Observation on 05/30/23 at 10:51 A.M. revealed Resident #1's fingernails were long, jagged, and dirty with dark discoloring underneath the nail. Observation on 05/31/23 at 1:45 P.M. revealed Resident #1's fingernails were long, jagged, and dirty with dark discoloring underneath the nail. Interview on 05/31/23 at 9:20 A.M. with State tested Nursing Assistant (STNA) #230 revealed Resident #1 required assistance with personal hygiene. Interview on 05/31/23 at 1:48 P.M. with the Administrator verified Resident #1's nails were long, dirty, and required trimming.

Based on medical record review, observation, and staff interview, the facility failed to apply hand splints as ordered and failed to implement interventions for a resident with bilateral hand contracture's. This affected one (Resident #15) of one resident observed for the use of hand splints. The facility's census was 39. Findings include: Review of Resident #15's medical record revealed an admitted [DATE]. Diagnoses included cerebral palsy, intellectual disabilities, and phalanax fracture. Review of Resident #15's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was rarely understood and had impairments of the bilateral upper extremities. Review of Resident #15's most recent care plan revealed interventions to follow physical therapy and occupation therapy orders. Resident #15 was to have rolled up washcloths (one washcloth for each hand) in each palm/hand to decrease tightness and skin breakdown. The resident was to use washcloths when in bed (at night and during any naps during the day) due to a diagnosis of cerebral palsy. Review of Resident #15's physician order dated 03/28/19 revealed the resident required bilateral resting hand splints should be applied he was in the wheelchair. The splints should be off when in bed. Review of of Resident #15's Occupational Therapy Plan of Care notes dated 03/01/19 revealed the resident had bilateral resting hand splints due to increased risk of contracture's from stiffness and tone. Observation on 05/30/23 at 8:45 A.M. revealed Resident #15 was sitting in his wheelchair in his room watching television. The resident had no splints nor washcloths in place. Observation on 05/30/23 at 11:02 A.M. revealed Resident #15 did not have hand splints nor washcloths applied. Interview on 05/30/23 at 11:07 A.M. with Registered Nurse #221 verified Resident #15 failed to have the physician ordered hand splints in place and the splints were available and located in the resident's room. Further observation on 06/01/23 at 9:02 A.M. revealed Resident #15 still did not have hand splints nor washcloths applied.

Based on medical record review, staff interview, review of disciplinary documents, and review of written statements, the facility failed to ensure resident care and services were provided in a respectful and dignified manner. This affected two (#7 and #8) of three residents reviewed for dignity. The census was 41. Findings include: 1. Review of Resident #7's medical record revealed an admitted [DATE]. Diagnoses included aphasia following cerebral infarction, dysphagia, diabetes mellitus type II, major depression, weakness, and abnormal posture. Review of the most recently completed Minimum Data Set (MDS) assessment completed 10/22/22 revealed Resident #7 was assessed with severely impaired cognitive skills for daily decision making. Review of nursing progress notes dated between 12/16/22 and 01/31/22 revealed Resident #7 had no change in condition or adverse changes in behavior. 2. Review of Resident #8's medical record revealed an admitted [DATE]. Diagnoses included cerebral palsy, anxiety, major depression, lack of coordination, history of falling, and hyperlipidemia. Review of the most recently completed MDS assessment dated [DATE] revealed Resident #8 was assessed with modified independence for daily decision making and had long term memory problems. Review of nursing progress notes dated between 12/16/22 and 01/31/22 revealed Resident #8 had no change in condition or adverse changes in behavior. Review of a written statement completed by the Administrator on 12/16/22 revealed she and Director of Nursing (DON) #1 were in the facility in third third shift on 12/16/22 to observe the night shift's routine. The Administrator documented she and DON #1 walked outside and heard a conversation through Resident #7's and Resident #8's bedroom window between Nurse Aide (NA) #330 and State tested Nurse Aide (STNA) #800. The Administrator documented she heard Resident #7 grunting and then NA #330 decided to repeat the grunting noises back to Resident #7 several times. The Administrator documented she then heard NA #330 and STNA #800 talking to each other and STNA #800 stated two curse words during the conversation all while providing care for Resident #7 and Resident #8 in their bedroom. The Administrator stated throughout the conversation between NA #330 and STNA #800 she could hear everything that was said. The Administrator documented she and DON #1 talked to STNA #800 and she admitted to using vulgar words in Resident #7 and Resident #8's bedroom, but indicated it was not directed at either resident. Observation on 02/03/23 at 10:15 A.M., revealed Resident #7 and Resident #8 in there bedroom with no signs or symptoms of distress or behaviors observed. An interview was attempted with Resident #7 on 02/03/23 at 10:16 A.M. with Resident #7, and an interview was attempted at 10:18 A.M. with Resident #8 and both residents did not respond verbally to questioning. Interview on 02/03/23 at 10:48 A.M., with the Administrator and Director of Nursing (DON) #1 stated they heard NA #330 and STNA #800 talking in Resident #7's and Resident #8's bedroom on 12/16/22 during the night shift. Both staff members verified they heard STNA #800 using curse words while providing care in Resident #7's and Resident #8's bedroom and both staff members stated they heard NA #330 grunting in the room when Resident #7 was grunting but could not tell if the grunting was in response to Resident #7's grunting at that time. Further interview with the Administrator verified she documented in her written statement dated 12/16/22 that she heard Resident #7 grunting and then NA #330 repeated grunting noises back to Resident #7 several times. The Administrator also verified STNA #800 admitted to using curse words during resident care in Resident #7's and Resident #8's bedroom. DON #1 stated Resident #7 made grunting noises because he was not able to talk. DON #1 verified she assessed both Resident #7 and Resident #8 after the incident on 12/16/22 and both residents had no change in condition. Further interview with both staff members stated staff members using curse words and staff members communicating with residents using grunting noises was not something the facility educated the staff on using as an accepted practice and stated that type of activity would not be tolerated. DON #1 stated NA #330 did not provided direct care to either residnet and was a staff memeber for the assited living. Review of NA #330's written statement dated 12/16/22 revealed the events that happened on 12/16/22 were heard and taken out of context but documented no specifics related to the incidents on 12/16/22. Review of STNA #800's written statement dated 12/16/22 revealed she was in Resident #7's and Resident #8's bedroom and told NA #330 a story. STNA #800 documented she told NA #330, She dug her nails into me and I told her to get her dirty (expletive) nails out of my arm. STNA #800 documented she should not have been talking about that matter or using that language in front of residents and indicated the story being told was not about a resident. Review of disciplinary action documents dated 12/19/22 revealed both NA #330 and STNA #800 were terminated from employment for gross misconduct. This deficiency represents an incidental finding discovered during the investigation for Complaint Number OH00139412.

Based on medical record review, staff interview, review of personnel files, review of a self-reported incident, and review of written statements, the facility failed to ensure staff members providing direct resident care were appropriately licensed or certified. This affected one (#1) of three residents reviewed for abuse. The census was 41. Findings include: Review of Resident #1's medical record revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, dementia without behavioral disturbances, dysphagia, muscle weakness, hyperlipidemia, altered mental status, cognitive communication deficit. Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was assessed with severely impaired cognitive skills for daily decision making. Review of a self-reported incident (SRI) dated 12/16/22 revealed an allegation of verbal abuse involving Resident #1 and Nurse Aide (NA) #330. Further review of the SRI revealed on 12/16/22 at approximately 4:30 A.M. Director of Nursing (DON) #1 overheard NA #330 speaking in a loud tone in Resident #1's bedroom. The facility thoroughly investigated the allegation and unsubstantiated resident abuse. Review of a nursing progress note dated 12/16/22 at 5:43 A.M. revealed Resident #1 was in bed sleeping quietly with no signs or symptoms of distress. A full body assessment was completed on Resident #1 with no abnormalities noted. Resident #1's skin was clean and dry. Review of the Administrator's written statement dated 12/16/22, as part of the SRI investigation, revealed NA #330 was observed on 12/16/22 leaving Resident #1's bedroom with a soiled incontinence brief in her hand. The Administrator documented NA #330 was not a certified state tested nurses aide, was not allowed to provide resident care in the skilled nursing facility, and should have been in the assisted living facility completing resident rounds. The Administrator documented NA #330 was interviewed and she denied being verbally abusive to Resident #1, but did admit to providing resident care to Resident #1 and NA #330 indicated she knew she was not allowed to perform resident care in the skilled nursing facility. Observation on 02/03/23 at 8:05 A.M. revealed Resident #1 sitting in the common area in her wheelchair. Resident #1 was calm and free from distress with no care concerns identified. An interview was attempted with Resident #1 on 02/03/23 at 8:07 A.M., however, Resident #1 did not respond verbally to questions, rather she just smiled and nodded her head. Interview on 02/03/23 at 10:48 A.M. with the Administrator and Director of Nursing (DON) #1 stated they observed NA #330 enter Resident #1's bedroom on 12/16/22 during third shift. Both staff members stated they could not see what NA #330 doing in Resident #1's bedroom but heard NA #330 speaking to Resident #1. Further interview with the Administrator verified she documented NA #330 admitted to performing care for Resident #1 on 12/16/22 and the Administrator confirmed she was not allowed to provide resident care in the skilled nursing facility. Further interview with DON #1 stated Resident #1 was the only resident NA #330 provided direct resident care to on 12/16/22. Review of NA #330's personnel file revealed a hire date of 10/12/20 and a document indicating she completed the temporary COVID-19 nurse aide training on 11/17/20, however, there was no documentation she complete the necessary testing to become certified. Review of a personnel action form dated 12/19/22 revealed NA #330 was terminated from employment for gross misconduct. Review of an employee disciplinary action document for Licensed Practical Nurse (LPN) #750 dated 12/19/22 revealed LPN #750 received a verbal and written warning that included LPN #750 allowed a nurse aide under her supervision to work and provide resident care in the skilled nursing facility without a certification. This deficiency represents an incidental finding discovered during the investigation for Complaint Number OH00139412.

Based on medical record review, observation, staff interviews, and facility policy review, the facility failed to ensure appropriate signage was placed on the door of one Resident (#20) in quarantine status, and failed to ensure one Resident (#13) remained in quarantine status. This had the potential to affect all 43 residents of the facility. Findings include: 1. Review of Resident #20's medical record revealed an admitted [DATE]. The resident had a hospital stay from 04/17/21 through 04/24/21. Observation on 04/26/21 at 11:59 A.M. revealed there was no sign on the resident's door to indicate transmission-based precautions. Interview on 04/26/21 at 12:05 P.M. with Registered Nurse (RN) #401 verified Resident #20 had been on transmission-based precautions due to having a hospital stay and the resident's door did not have signage. Review of facility policy titled COVID-19 Guidelines for Contact/Droplet Precautions, dated 07/29/20, revealed when a resident is on contact/droplet precautions a sign is posted on the resident's door alerting of precautions. 2. Review of Resident #13's medical record revealed an admitted [DATE]. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 04/26/21 at 12:08 P.M. revealed Resident #13 was sitting in the lounge area with other residents. Interview at the time of the observation with RN #403 verified Resident #13 had been on isolation precautions for influenza and should be in her room. Review of facility policy titled, Guidelines for Droplet Precautions, dated 03/19/20, revealed a resident under droplet precautions should be placed in a private room if possible. Limit the movement of the resident from the room to essential purposes only.

Based on medical record review, observation, staff interview, and facility policy review, the facility failed to ensure a resident's call light was within reach. This affected one Resident (#23) of 14 observed for call lights. The facility census was 43. Findings include: Review of the medical record for Resident #23 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #23's care plan dated 05/23/20 revealed Resident #23 had impaired ability to perform Activities of Daily Living (ADLs) tasks and needed staff support to complete. Resident #23 was at risk for falling related weakness, impaired safety awareness, and use of medication. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #23 had mild cognitive impairment. The resident was noted to require a one person physical assist with bed mobility, extensive assistance with one person physical assist for dressing and toilet use, as well as an extensive assist with two person physical assist for personal hygiene. Observation on 04/26/21 at 11:08 A.M. revealed Resident #23 was sitting in his recliner and his call light was lying at the foot of his bed, not within his reach. Observation on 04/28/21 at 4:00 P.M. revealed Resident #23's call light was lying at the foot of his bed , not within his reach. Interview on 04/28/21 at 4:01 P.M. with the Director of Health Services (DHS) verified Resident #23's call light was not within his reach. Review of the facility policy titled, Guidelines for Answering Call Lights, dated 05/11/16, revealed; 2. Ensure the call light is plugged securely to the outlet and in reach of the resident.

Based on medical record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure one Resident (#15) of one reviewed was provided proper interventions to potentially prevent constipation. The facility's census was 43. Findings include: Medical record review for Resident #15 revealed an admission of 11/17/20. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #15's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #15's orders revealed orders for [MEDICATION(S)] 17 grams, once per day, as needed (PRN) with a start date of 11/17/20, [MEDICATION(S)] 100 milligrams (mg) two times a day with a start date of 02/12/21, and [MEDICATION(S)] 17 grams once per day with a start date of 03/25/21. Review of Resident #15's Bowel and Bladder by Shift Chart revealed from 02/06/21 to 02/11/21 (six days) Resident #15 had no bowel movement documented. Review of Resident #15's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #15's Bowel and Bladder by Shift Chart revealed from 03/06/21 to 03/10/21 (five days) Resident #15 had no bowel movement documented. Review of Resident #15's MAR March 2021 revealed PRN order for [MEDICATION(S)] was not administered the whole month of March 2021. Interview on 04/26/21 at 4:15 P.M. with Resident #15 revealed he was once constipated for a week and he told staff, however they did not provide him with any relief. Interview on 04/28/21 at 4:11 P.M. with the Director of Nursing (DON) verified all of Resident #15's bowel movements should be documented on the Bowel and Bladder by Shift Chart. The DON verified lack of bowel movements from 02/06/21 to 02/11/21 and from 03/06/21 to 03/10/21. The DON further verified Resident #15's PRN orders for [MEDICATION(S)] was not initiated or administered the whole month of February 2021 and March 2021. Review of facility policy titled, Bowel Protocol Guidelines, revised 11/09/17 revealed the facility would use bowel stimulants for residents with constipation and an Ineffective Bowel Pattern Event should be initiated for any resident not having a bowel movement within 72 hours.

Based on medical record review, resident interview, and staff interview, the facility failed to ensure one resident was free from falls when personal care was provided by one staff member, instead of the required two. This affected one Resident (#10) of three reviewed for falls. The facility census was 43. Findings include: Medical record review for Resident #10 revealed an admitted [DATE] with diagnoses including, type II diabetes, [CONDITION(S)] (COPD), and [CONDITION(S)]. Review of Resident #10's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Resident #10 required extensive assistance of two staff for bed mobility and toileting. Interview on 04/26/21 at 11:18 A.M. with Resident #10 revealed she had a fall during incontinence care. Resident #10 revealed a State tested Nursing Assistant (STNA) rolled her to the side to perform care and she fell out of bed. Resident #10 could not recall the date of when the incident happened. Interview on 04/28/21 at 4:44 P.M. with Resident #10 revealed STNA #500 was the aide providing incontinence care when she rolled out of the bed. Resident #10 revealed she will not allow staff to provide incontinence care unless there are two staff members present since the fall. Interview on 04/29/21 at 10:24 A.M. with STNA #500 verified there was an incident that happened in February 2021, however she could not recall the exact date. STNA revealed Resident #10 was wedged between her bed and the wall, however did not fall to the floor. The STNA revealed she was providing incontinence care to Resident #10 by herself and when rolled Resident #10 over, she got wedged between her bed and wall. She revealed four additional staff members came to assist to get the resident back in bed. Interview on 04/29/21 at 10:26 A.M. with the Assistant Director of Nursing (ADON) verified she was not aware Resident #10 had been wedged between her bed and wall while one STNA was providing personal care. Interview on 04/29/21 at 11:42 A.M. with Licensed Practical Nurse (LPN) #511 verified there was an incident where Resident #10 was wedged between her bed and wall. She revealed it happened either towards the end of February 2021 or beginning of March 2021. She further revealed she was not the residents nurse, however came to help assist the resident back in bed. Interview on 04/29/21 at 1:13 P.M. with LPN #533 verified there was an incident where Resident #10 became stuck in-between her bed and the wall. LPN #533 revealed she was Resident #10's nurse at time of the incident and Resident #10 voiced no concerns after the incident. Interview on 04/29/21 at 4:00 P.M. with STNA #555 verified Resident #10 required two staff person to assist with incontinence care and she had always required assistance of two staff members.

Based on medical record review, resident interview, staff interview, and facility policy review, the facility failed to accurately document an incident/fall in a resident's medical record. This affected one Resident (#10) of one reviewed for accurate documentation. The facility census was 43. Findings include: Medical record review for Resident #10 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #10's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Resident #10 required extensive assistance of two staff for bed mobility and toileting. Review of Resident #10's progress notes for February 2021 and March 2021 revealed no evidence of any documentation of incidents or falls. Interview on 04/26/21 at 11:18 A.M. with Resident #10 revealed a State tested Nursing Assistant (STNA) rolled her to the side to perform care and she fell out of bed. Resident #10 could not recall the date of when the incident happened. Interview on 04/28/21 at 4:44 P.M. with Resident #10 revealed STNA #500 was the aide providing incontinence care when she rolled out of the bed. Resident #10 revealed she will not allow staff to provide incontinence care unless there are two staff members present since the incident. Interview on 04/29/21 at 10:24 A.M. with STNA #500 verified there was an incident that happened in February 2021, however she could not recall the exact date. STNA revealed she was providing incontinence care to Resident #10 by herself and when rolled Resident #10 over, she got wedged between her bed and wall. She revealed four additional staff members came to assist to get the resident back in bed. Interview on 04/29/21 at 11:42 A.M. with Licensed Practical Nurse (LPN) #511 verified there was an incident where Resident #10 was wedged between her bed and wall. She revealed it happened either towards the end of February 2021 or beginning of March 2021. She further revealed she was not the resident's nurse, however came to help assist the resident back in bed. Interview on 04/29/21 at 1:13 P.M. with LPN #533 verified there was an incident where Resident #10 became stuck in-between her bed and the wall. LPN #533 revealed she was Resident #10's nurse at time of the incident. LPN #533 stated Resident #10 voiced no concerns after the incident took place. She could not recall if she documented the incident/fall in the resident's record. Interview on 04/29/21 at 10:26 A.M. the Assistant Director of Nursing (ADON) verified there was no documentation in Resident #10's medical record of the incident/fall.

Based on medical record review, observation., staff interview, and review of facility policy, the facility failed to ensure proper maintenance was completed on a wheelchair being used by one Resident (#16) of one observed. The facility census was 43. Findings include: Review of Resident #16's medical record revealed an admitted [DATE] with diagnoses including unspecified [CONDITION(S)] disease (stroke), heart failure, and history of falling. Observation on 04/27/21 at 11:51 A.M. revealed Resident #16 was sitting in her wheelchair. There were two screws exposed on the right arm rest of the wheelchair protruding through the foam padding. The exposed screws were approximately one inch long. Interview on 04/27/21 at 11:55 A.M. with Registered Nurse (RN) #405 verified Resident #16's wheelchair had exposed protruding screws on the right arm rest of the wheelchair. Review of facility policy titled, Guidelines for General Use of Equipment, dated 08/01/16 revealed, the facility provides and maintains routine equipment for the general use for the resident population.

Based on observation, staff interview, review of the manufacturer's instructions and review of the Centers for Disease Control and Prevention (CDC) recommendations, the facility failed to store their reused N95 masks in a designated storage area while not in use and failed to disinfect surfaces properly to prevent the potential spread of COVID-19. This had the potential to affect all 36 residents residing in the facility. Findings include: 1. Interview on 11/18/20 at 8:57 A.M. with Registered Nurse (RN) #302 revealed there were no COVID-19 positive residents in the building. The facility had three residents on 14-day monitoring in the yellow zone. RN #302 reported staff in the facility wore N95 respirators with face shields when working with residents in the yellow zone. Observation on 11/18/20 at 9:00 A.M. of the 500-hallway found three residents resided in the yellow zone on 14-day monitoring quarantine. Isolation carts were observed outside their doors. No paper bags, hooks, or storage for N95 masks were found. Interview and observations on 11/18/20 at 11:05 A.M. with State tested Nursing Assistant (STNA) #186 and STNA #187 revealed both STNAs worked with the three residents in the yellow zone. STNA #186 and STNA #187 were observed wearing ear loop surgical masks and face shields. STNA #186 and STNA #187 reported N95 masks were provided to them each day they worked, and they disposed of their N95 masks at the end of their shift. STNA #186 stated they changed out of their surgical masks and put on their N95 mask when they worked with the residents in the yellow zone. When they were done with the yellow zone residents, they changed back into a surgical mask. STNA #186 was observed pulling an N95 respirator out of the front right pocket of her scrub pants. STNA #186 reported the N95 masks were stored in their pockets between uses. STNA #187 agreed and verified there were no storage options, hooks, or bags in or around the yellow zone to store their N95s between uses. STNA #186 was then observed putting the N95 respirator back into the front right pocket of her scrub pants. Review of the Center for Disease Control (CDC) recommendations titled, Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Settings, revealed reused referred to the practice of using the same N95 respirator for multiple encounters with patients but removing it ('doffing') after each encounter. The respirator was to be stored in between encounters to be put on again ('donned') prior to the next encounter with a patient. If reuse of N95 respirators was permitted, respiratory protection program administrators should ensure adherence to administrative and engineering controls to limit potential N95 respirator surface contamination and consider additional training and/or reminders for staff to reinforce the need to minimize unnecessary contact with the respirator surface, strict adherence to hand hygiene practices. Used respirators were to be hung in a designated storage area or keep them in a clean, breathable container such as a paper bag between uses. To minimize potential cross-contamination, store respirators so that they do not touch each other and the person using the respirator was clearly identified. Storage containers should be disposed of or cleaned regularly. 2. Observation on 11/18/20 at 9:39 A.M. of the dining room found Dining Services Staff (DSS) #185 sprayed the counter tops by the drink dispenser with cleaning spray and immediately wiped the solution off. The counter tops were found to be dry after they were wiped. Interview on 11/18/20 at 9:41 A.M. with DSS #185 revealed she was using 3M Disinfectant Cleaner spray to clean and disinfect the counter tops. DSS #185 was not aware of how long the disinfectant needed to remain on the surface to be effective. DSS #185 verified she wiped the counter top immediately after spraying the solution. Review of the 3M Disinfectant Cleaner spray bottle revealed the disinfectant was to remain on the surface for 60 seconds (one minute) to be effective. Review of the manufacturer's instructions for 3M Disinfectant Cleaner Concentrate 40A and 40L revealed for disinfection the solution was to be applied to hard surfaces thoroughly wetting the surface with a sprayer. Treated surfaces must remain wet for the contact time indicated on the label (60 seconds). Wipe dry with a cloth, sponge, mop or allow to air dry.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, observation, staff interviews, review of the facility submitted Self-Reported Incident (SRI), review of an Emergency Medical Squad (E[CONDITION]) report, review of an employee personnel file, review of the facility's Guidelines for Elopement/Missing Resident policy, review of the witness statements, review of Weather Underground computerized environmental temperatures website, and review of in-service records regarding responding to door alarms, the facility failed to provide adequate supervision to ensure a resident with intermittent cognitive impairment did not elope from the facility. This resulted in Immediate Jeopardy and placed the resident at risk for potential serious life-threatening harm and/or injuries, when Resident #01 left the facility without staff knowledge and was found by the police officers at 2:45 A.M. at a private residence, sitting on the porch, dressed in a thick top and bottom pajama set, a bath robe and fuzzy hard sole slippers. The resident had walked down a two-lane state highway approximately 0.25 miles from the facility in 32-degree Fahrenheit weather looking for her church. This affected one (#01) of three (#01, #02 and #03) residents reviewed for being at risk for elopement. The facility identified ten current residents who were assessed as being at risk for elopement. The facility census was 45. On 02/20/20 at 3:40 P.M., the Administrator, Corporate Registered Nurse (CRN) #01, and the Director of Health Services (DHS) was notified the Immediate Jeopardy began on 01/31/20 at 1:30 A.M., when Resident #01 left the facility through an alarming door on the 500-hall, without staff's knowledge. State tested Nursing Assistant (STNA) #06 stated she heard the 500-hall door alarm go off around 1:30 A.M., so she looked out the door and did not see anything. STNA #06 stated she informed Charge Nurse #21 that the alarm had gone off, but did not receive further instructions. STNA #10 stated she was on the unit at the time the alarm went off. She stated she briefly looked outside and did not see anything and she reset the door alarm using a code for the keypad. On 01/31/20 between 2:00 A.M. and 2:20 A.M., STNA #06 stated she was passing ice water with STNA #22 in Resident #01's room and noticed the resident was not there. STNA #22 went to inform the nurse and an internal and outside perimeter search was initiated. During the facility's search for the resident, at approximately 2:50 A.M., a call was received by the dispatcher from the police department that the resident had been found sitting outside at a neighborhood residence's home. The resident was placed at potential risk of being hit by a vehicle or development of hypothermia while walking down a state highway at 1:30 A.M., in night clothes with temperatures listed as 32 degrees Fahrenheit and remaining outdoors until discovered at 2:45 A.M. The staff were alerted by the alarm that a resident may have potentially left the facility and did not begin an internal and external check for residents; therefore, not following the facility's procedures for responding to an activated door alarm. The Immediate Jeopardy was removed on 02/02/20 at 2:30 P.M., when the facility placed Resident #01 on 15-minute observations with a wander guard alarm in place, an audit was performed on all residents at risk for eloping, and staff education about responding to door alarms was completed. The deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 02/18/20 when the facility implemented the following corrective actions: · On 01/31/20 at 2:37A.M., a physical head count was performed for all residents. Resident #01 was not accounted for. An internal and outside perimeter check was initiated by facility staff. · On 01/31/20 at approximately 2:50 A.M., the facility was notified by the local police dispatcher that Resident #01 had been found sitting outside a home on the porch. Two facility staff were sent to the resident's location. · On 01/31/20 at 2:51 A.M., the Administrator was notified of the situation. · On 01/31/20 at 3:50 A.M., Resident #01's responsible party was notified. · On 1/31/20, the Director of Health Services (DHS) was notified at 3:52 A.M. · On 01/31/20 at 3:55 A.M., Resident #01was returned to the facility per E[CONDITION]. The resident was assessed for injuries by the E[CONDITION] and Charge Nurse #21. No injuries were apparent. The resident was placed on 15-minute observations. · On 01/31/20 at 5:25 A.M., a physician order was obtained for a wander guard secure bracelet to be applied for resident safety. Consent was obtained from the responsible party and the bracelet was applied. The resident's care plan was updated to include exit seeking behavior and the use of the wander guard bracelet. · On 01/31/20 beginning at 5:25 A.M., elopement education, including the Guidelines for Elopement/Missing Resident for all employees was initiated by the DHS. An additional 66 current staff members were trained by the DHS and LPN #35 was completed at 2:30 P.M. On 02/02/20, 11 remaining staff members were in-serviced by the DHS and LPN #35 at 2:30 P.M. · On 01/31/20 at approximately 8:00 A.M., all exit door alarms, and wander guard sensors were checked and were found functional by Maintenance Director #12. · On 01/31/20 at 8:00 A.M., Charge Nurse #21 was suspended and did not return to work as she ended employment on her own. · On 01/31/20 beginning at 8:00 A.M. and concluding at 2:30 P.M., all residents were assessed for accurate and up to date elopement risks by the DHS and Licensed Practical Nurse (LPN) #35. Residents found to be at risk for elopement had orders verified for wander guard bracelets which included the bracelet to be checked for placement each shift and functioning daily. All residents who were found to be at risk for elopement had their care plans reviewed to ensure they were accurate and up to date. · On 01/31/20 at 9:38 A.M., the facility submitted the initial SRI to the State Agency for potential neglect. · On 01/31/20 at 1:30 P.M., an elopement drill was conducted and evaluated for effectiveness. There were no concerns identified. · On 01/31/20, a Quality Assurance meeting was held with the Medical Director, DHS, LPN #35 and the Administrator via phone to inform of the incident, interventions and audits implemented and allow the opportunity for the Medical Director to make suggestions. · On 01/31/20, Resident ' #01s name, picture and information were added to the Elopement book. · On 02/01/20, the DHS and LPN #35 implemented random employee interviews and audits to determine awareness of the elopement policy. Additional interviews and audits were conducted by the DHS and LPN #35 on 02/03/20, [DATE], 02/05/20, [DATE], 02/10/20, 02/11/20,0[DATE], [DATE], 0[DATE] and 02/18/20. · On 02/20/20 between 5:30 A.M. and 2:00 P.M., interviews with STNA #04, #05, #06, #10, #11, Registered Nurses (RNs) #08 and #09, LPN #07, and Maintenance Director #12, revealed they had been in serviced and were able to verbalize what to do in case of an elopement. · Review of the medical records of Residents #02 and #03 were reviewed with appropriate assessments and plans of care in place. There were no other identified elopement events. Findings include: Review of the medical record for Resident #01 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a nursing admission assessment dated [DATE] revealed the resident was alert and oriented to person, place, time and situation. The resident used a walker and wheelchair and had minimal limited mobility. The resident was assessed for elopement risk and found not to be at risk. Review of a 48-hour baseline care plan dated 01/26/20 revealed the resident was alert and oriented, required assistance for transfers, bed mobility, toileting and activities of daily living, was at risk for falls and had no history of wandering. Review of progress notes dated 0[DATE] at 8:32 P.M., revealed Resident #01 was up walking, pushing the wheelchair, had her coat on and stated she was going home. The resident was able to be redirected back to her recliner and was given medication for pain. Further review of progress notes dated 0[DATE] through 01/31/20 revealed no indication of the resident exit seeking or verbalizing her desire to leave the facility. Review of an Observation Detail List Report - Room/Roommate Notification dated 01/28/20 at 10:50 A.M., revealed the resident was transferred from her room on the 300-hall to a room on the 500-hall, per her request for a private room. Review of a comprehensive admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had moderate cognitive deficits, no abnormal behaviors and had wandering during one to three days which did place the resident at significant risk of getting to a potentially dangerous place. The resident required limited assistance with bed mobility, transfers, walking, locomotion and extensive assistance with dressing, toileting and personal hygiene. Review of the facility SRI for Neglect with a discovery date of 01/31/20 revealed on 01/31/20 at 1:30 A.M., staff heard a door alarm sounding from the 500 halls. The staff looked out the door and windows and shut off the alarm. At 2:30 A.M., STNA #06 was passing ice water and upon entering the room of Resident #01 discovered the resident was not there. Charge Nurse #21 was notified, a head count was completed, and a search of the building and perimeter was started. The resident could not be located, and the Administrator and DHS were notified. At 2:55 A.M. a phone call was received from the sheriff's office stating they had found the resident, who was located 0.25 miles from the campus and that E[CONDITION] would be bringing her back. The resident returned to the campus at 3:25 A.M. and was assessed to have no concerns. The resident was wearing floral flannel pajamas, ted hose, a pink fleece robe and brown fleece lined slippers. The resident was placed on observation and a wander guard was placed on the resident's right wrist. The resident's cognition was assessed and was noted to be cognitively intact. When asked where she was going, the resident stated she was going to a church she had not been to in a while. As a result of the investigation, the facility reassessed all independently mobile residents with confusion for elopement risk and care plans were reviewed. The elopement book was updated with Resident #01's picture and profile. Staff were educated on the facility policy for elopement. Review of the facility resident head count on 01/31/20 at 2:37 A.M. revealed Resident #01 was missing. All other residents were accounted for. Review of an E[CONDITION] report dated 01/31/20 revealed they received a call at 2:45 A.M. for a person with cold exposure. The resident was found outside sitting on the porch. The local police department wanted the resident checked out. The resident lives at the nursing home and wondered off approximately 30 minutes prior to the call. The squad arrived on scene to find the nursing home staff with the resident. The resident appeared fine and no transport to the hospital was needed. There were no signs of hypothermia. The resident was released to facility staff. The resident did have a history of dementia. The resident was alert and oriented to the event and person. Review of Episodic Event/Past Non-Compliance form dated 01/31/20, revealed the resident exited the campus and was found across the road from the campus. The resident was assessed, and no injuries were noted. A wander guard was placed to the residents ' right wrist and was also placed on a one on one observations for safety. The resident was confused and was looking for the Zion church. The resident had been previously assessed on 01/26/20 and was not determined to be an elopement risk at that time. All independently mobile confused residents were re-assessed for elopement risk and care plans were reviewed. All residents with wander guards were reviewed and wander guards were checked for placement and functioning properly. Staff were to be in-serviced on elopements and the campus was to complete random audits four times weekly to ensure staff was aware of the policy for elopements and missing residents. This was to be completed by 02/28/20. Review of the audits revealed four staff members were audited for week one and week two of the plan, with week three in progress at this time. Review of a Checklist for Post Elopement, dated 01/31/20, revealed the facility followed their policy on assessing, notifying and documenting on Resident #01 after the elopement in a timely manner. It did not address the hour time span between the door alarming and staff noticing the resident was missing. The report documented a wander guard was applied when the resident was returned. The 500-hall door alarm that was sounding was a 15 second release door and not a wander guard door. Review of a Facility Elopement Drill Form dated 01/31/20 at 1:30 P.M., revealed a drill was conducted after the resident elopement with seven staff in attendance. Review of a witness statement from STNA #20 dated 01/31/20 (no time indicated) revealed she had been in to see the resident on 01/30/20 at 10:20 P.M. and the resident was sleeping. She stated at 3:00 A.M. she was exiting a resident's room and was notified by the nurse and another STNA, that the Resident was missing, and they had received a phone call with her location and was asked to meet the resident there. She stated STNA #22 and herself went to meet the resident at a neighborhood home. The E[CONDITION] was there and checked the resident and returned her back to the facility. She stated the staff was informed the resident was to be checked on every 15 minutes. Review of a witness statement dated 01/31/20 by Charge Nurse #21 revealed around 2:45 A.M., STNA #06 notified her, while doing rounds, she did not see the resident in bed. A search was initiated in the health care area and then outside on the grounds of the facility. Before the outside inspection could be completed, Charge Nurse #21 stated the sheriff's office called and stated they had found the resident at a neighborhood home. She stated she sent two staff to help with the resident and the resident was returned to the facility by the E[CONDITION]. She stated the resident was not in distress and was wearing flannel pajamas and a thick fuzzy bathrobe with wooly slippers. Further statements by Charge Nurse #21 at 8:38 A.M. revealed at 1:30 A.M., she was completing care of another resident on the 300 hall and was informed of the door alarm going off. She did look out windows but did not complete a head count. Review of a witness statement from STNA #10 dated 01/31/20 at 5:25 A.M. revealed she was in the room with another resident around 2:45 A.M. and was informed Resident #01 was missing. She stated she started looking in each room on the 300 and 400 halls while others went outside to look. She stated around 2:55 A.M., the facility phone rang, and the facility was informed the sheriffs had found the resident. Further statements by STNA #10 at 8:52 A.M., documented by corporate staff, revealed she heard a door alarm sounding around 1:30 A.M. and initially thought it was coming from the front door, then realized it was the 500-hall. The report documented STNA #10 went to the alarming door, opened the door and shut it, thinking the wind may have blown it open. STNA #10 then reset the alarm. She looked out the windows and did not see anything or anyone. The statement indicated there was no head count completed on the residents and the nurse had been notified. Review of a witness statement from STNA #06 dated 01/31/20 (no time indicated) revealed she had seen the resident at midnight that night and she was sleeping on her bed. STNA #06 stated after that she was passing water with STNA #22 and the resident was not on the bed or in the room. Charge Nurse #21 was informed, and they started looking for the resident but were unable to find the resident. Further statements dated 01/31/20 at 8:58 A.M., documented she had seen the resident at midnight, and she was sleeping. At 2:30 A.M., she and STNA #22 were passing ice water and discovered the resident was not in her room and began to look for the resident. She did not remember what time the door had alarmed earlier but they had not completed a head count on residents at that time. Review of a witness statement from STNA #22 dated 01/31/20 (no time indicated) revealed she was assisting to pass ice water and STNA #06 came out of Resident #01's room and stated she was not there. Charge Nurse #21 was notified, and all rooms and closets were checked. STNA #22 stated she went outside with Charge Nurse #21 and was checking the backyard and they got a call the resident had been found by the police. Review of an Elopement Risk Re-assessment dated [DATE] revealed all residents were assessed for elopement risk. Nine residents were identified at risk. Care plans for those residents had been reviewed for accuracy. Interview with STNA #10 on 02/20/20 at 9:30 A.M., revealed she was working on the 300 hall the night of 01/31/20. She stated rounds had been done at midnight and there were no concerns. She stated around 1:15 A.M. she was notified by STNA #06 there was an alarm going off, so she went with her. She stated she opened the door and looked out and should have looked further, but she didn ' t. She stated she knew the code to the door, so she reset the alarm. She stated the nurse had been notified the alarm was going off, but she didn ' t check on the door or ask for anything to be done. She stated around 2:00 A.M. she found out the resident was missing and went outside to search. A call was received during the search that the resident had been found. On 02/20/20 between 5:30 A.M. and 2:00 P.M., interviews with STNAs #04, #05, #06, #10, #11, RNs #08 and #09, LPN #07, and Maintenance Director #12 revealed they had been in serviced and were able to verbalize what to do in case of an elopement. Observation of Resident #01 on 02/20/20 between 5:00 A.M. and 3:30 P.M. revealed a wander guard was in place on her right wrist. The resident was tearful at times throughout the day but had no attempts of exit seeing behavior. The resident was able to propel herself in her wheelchair and was not observed to be ambulating. Review of the employee file for Charge Nurse #21 revealed a hire date of 10/09/18. The nurse had an active license. Elopement training had been provided on 04/26/19. There were no concerns revealed regarding performance or background checks. The nurse had been promoted to the Assistant DHS on 01/13/20. The record documented the nurse had resigned on 02/20/20 on her own and the resignation had been accepted by the home office. The nurse was not eligible for rehire. Review of the Weather Underground computerized environmental temperatures on 01/31/20 revealed between 1:30 A.M. and 2:45 A.M., the outside temperature was 32 degrees Fahrenheit, cloudy with 61% humidity, and no winds. Review of the facility policy Guidelines for Elopement/Missing Resident dated 03/20/17, documented all personnel were to report any resident suspected of being missing to the charge nurse as soon as practical. For a Door Alarm Sounding/Missing Resident, staff were to respond promptly to the sounding door alarm. The charge nurse was to call staff to a central area and designate the following: A staff person to perform a facility head count to determine who may be missing, two additional staff members to exit the alarming doorway and go in opposite directions around the building perimeter until they met each other and return to the central area of the facility, a staff member to review the Sign out Log to determine if the resident was out of the facility with the responsible party, and one or more staff members to make a thorough search of the facility to include all resident rooms, bathrooms, storage areas, offices, closets and kitchen. All areas were to be searched regardless if they were locked or not. If necessary, one or more staff members were to expand the search to the facility premises and check buildings, storage sheds and hedges and bushes. If the resident was not found at the campus, one of the staff members was to notify the local police department, attending physician and responsible party. This deficiency substantiates Complaint Number OH 051.

Based on review of the facility's Legionella policy and staff interview, the facility failed to develop a facility water risk assessment for Legionella. This had the potential to affect all 42 residents residing in the facility. Findings include: Review of an undated facility document titled Legionella and Other Opportunistic Pathogens revealed the Director of Plant Operations (DPO) will maintain documentation that describes the facility's water system. A risk assessment of water system components will be conducted to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems. The risk assessment will be completed by facility leadership and the infection preventionist with collaboration from other facility team members such as maintenance employees, safety officers, risk and quality management staff, and the Director of Nursing. Based on the risk assessment, control measures will be established to address potential hazards. Further review of the facility Legionella documentation revealed the facility did not complete a risk assessment of water system components. Interview with the Administrator on 02/28/19 at 3:32 P.M. verified the facility had not completed a risk assessment of the water system to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system.

Based on medical record review, review of the facility infection control log, staff interview, and review of a facility policy, the facility failed to ensure the antibiotic stewardship program was implemented when a resident did not have adequate indication for antibiotic usage. This affected one (Resident #11) of seven residents reviewed during the antibiotic stewardship program review. The had the potential to affect all 42 residents residing in the facility. Findings include: Review of Resident #11's medical record revealed the resident was admitted [DATE]. Medical [DIAGNOSES REDACTED]. Continued review of the resident's medical record revealed [REDACTED]. coli). The resident was treated with [MEDICATION NAME] (antibiotic) until 10/20/18. On 11/29/18, the resident was diagnosed with [REDACTED]. faecalis). The resident was treated with [MEDICATION NAME] (antibiotic) until 12/04/18. Further review of the resident's medical record revealed [REDACTED]. She stated if the facility medical director would not order the [MEDICATION NAME] antibiotic, she would switch to a different physician. Continued review revealed no evidence the resident or resident's family was educated regarding the use of [MEDICATION NAME] antibiotics. The resident remained on [MEDICATION NAME]. Review of a pharmacy recommendation dated 01/14/19 revealed the pharmacist requested additional information regarding the use of [MEDICATION NAME] for Resident #11. The recommendation indicated the use of antibiotics should be limited to confirmed or suspected bacterial infection based on the presence of symptoms. [MEDICATION NAME] use of any antibiotic was discouraged due to risk of side effects and bacterial resistance. If the current therapy was to be continued, please document the reasoning below, and that the risks versus benefits have been considered. On 01/21/19, the physician responded due to recurrent urinary tract infections, risks/benefits reviewed. Review of a facility fax to the physician dated 02/20/19 revealed the Director of Nursing (DON) stated the resident was still on [MEDICATION NAME] 250 milligrams (mg.) daily since 12/14/18. The resident's chest x-ray dated 12/14/18 was negative. Resident was asymptomatic of respiratory concerns. Centers for Medicare & Medicaid Services (CMS) guidelines for long term care facility for antibiotic use requires positive lab cultures or positive chest x-ray. She asked if the facility could discontinue [MEDICATION NAME]. Then stated if you would like to continue [MEDICATION NAME] use of [MEDICATION NAME] please provide [DIAGNOSES REDACTED]. She has been on it long term for [MEDICATION NAME]. Interview with the DON on 02/28/19 at 12:35 P.M. verified Resident #11 was on a [MEDICATION NAME] antibiotic for a urinary tract infection. She verified there was no clinical indication for the use of the [MEDICATION NAME] long term. She verified there was no documentation indicating Resident #11's family was educated regarding the use of [MEDICATION NAME] antibiotics. She stated the facility medical director would not order the [MEDICATION NAME] antibiotic, so the resident's family obtained a different physician. Review of the (MONTH) facility infection control log revealed Resident #11 received [MEDICATION NAME] (antibiotic medication) 250 milligrams (mg.) orally once daily since 12/14/18. The infection type and organism were listed as not applicable (N/A). The antibiotic was identified as a [MEDICATION NAME] antibiotic and the end date was listed as indefinite. Review of a facility policy titled Antibiotic Stewardship effective 11/10/17 revealed the purpose of the policy was to optimize the treatment of [REDACTED]. Reduce the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use.