Every finding on record at Merit House LLC

Based on observations and staff interviews, the facility failed to ensure the kitchen environment was maintained in a clean and safe manner. This had the potential to affect all 82 residents who received food from the kitchen. Resident #5 received no food by mouth. The facility census was 83.Findings include:Observation on 08/03/26 at 8:20 A.M. of the kitchen revealed there was a black substance along the wall behind the juice machine and running along the floor. Interview on 08/03/26 at 8:21 A.M. with Dietary Staff (DS) #510 verified there was a black substance, thought to be mold, about six inches long down the wall under a small pipe and continuing along the floorboard for about 12 inches. DS #510 reported it had been there for a while behind the juice machine; it had previously been reported but nothing seems to have been done about it. Observation on 08/05/26 at 7:30 A.M. of the kitchen revealed the black mold area along the wall and floorboards behind the juice machine was still there. Coinciding interview with Maintenance Director (MD) #630 verified there was mold present, he was unaware of it, and it would be addressed. MD #630 took pictures of the area. This deficiency represents non-compliance investigated under Complaint Numbers 3092720 and 3071038.

Based on observation, resident interview and staff interview, the facility failed to maintain appropriate water temperatures in the shower rooms and failed to ensure resident bathrooms were maintained in good repair. This affected three (Resident #37, #51, and #66) of 29 residents reviewed for homelike environment. The facility identified 30 residents (#8, #9, #10, #11, #12, #13, #22, #29, #30, #33, #36, #37, #43, #44, #45, #49, #51, #58, #59, #61, #63, #66, #67, #69, #70, #73, #76, #77, #80, and #89) who utilized the 200-hall shower room. The facility census was 83.Findings include:1. Review of Resident #37's medical record revealed an admission date of 12/21/24. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was moderately cognitively impaired and required maximum assistance from staff with bathing.Interview on 08/03/26 at 10:43 A.M. with Resident #37 revealed he was alert and aware. Resident #37 reported he showered in the shower room on the 200-hall and the water was consistently cold. Resident #37 reported some residents would refuse showers because the water was too cold.Observation on 08/05/26 at 7:33 A.M. of the 200-hall shower room revealed the shower had just been in use. Maintenance Director (MD) #630 ran the water and found the water temperature in the shower room was 97.3 degrees Fahrenheit (F).Interview on 08/05/26 at 7:35 A.M. with MD #630 verified the water was too cold in the shower room on the 200-hall. MD #630 stated it could be due to a number of residents getting showers but he would look into it and see what could be done.The facility identified Residents #8, #9, #10, #11, #12, #13, #22, #29, #30, #33, #36, #37, #43, #44, #45, #49, #51, #58, #59, #61, #63, #66, #67, #69, #70, #73, #76, #77, #80, and #89 who utilized the 200-hall shower roomReview of the facility's Monthly Water Temperature logs revealed in April 2026 station one (the 100 hall) reached a water temperature of 99 degrees F, station two (back of the building) reached 92 degrees F, station three (near the nurse's station midway back) 102 degrees F, station four (Midway through the building) 101 degrees F, and station five (entrance and left down the hall) 101 degrees F. In May 2026, station one reached 102 degrees F, station two reached 97 degrees F, station three reached 103 degrees F, station four reached 101 degrees F and station five reached 98 degrees F. In June 2026, station one reached 100 degrees F, station two reached 98 degrees F, station three reached 102 degrees F, station four reached 99 degrees F, and station five reached 102 degrees F. In July 2026, station one reached 97 degrees F, station two reached 100 degrees F, station three reached 101 degrees F, station four reached 99 degrees F, and station five reached 100 degrees F.Review of the facility policy titled Water Temperature Regulation Policy and Procedure revised April 2026 revealed the facility would maintain water temperatures in resident areas at safe and comfortable levels. Temperature range was from a minimum of 105 degrees F to a maximum of 120 degrees F. 2. Review of Resident #51's medical record revealed an admission date of 05/07/19. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was cognitively intact and was independent with personal hygiene. Interview on 08/03/26 at 12:24 P.M. with Resident #51 reported the sink in his shared bathroom has been leaking for a while. The certified nursing aides (CNAs) put a trashcan under the sink to catch the water, but it overflows and causes the floor to be wet. Resident #51 reported he almost fell last week because the floor was wet around the sink and he has balance issues. Observation on 08/03/26 at 12:28 P.M. revealed Resident #51 had shared bathroom with Resident #66. The bathroom sink was dripping even when it was shut off and the metal pipe below the sink was leaking and dripping into a trashcan. The trashcan was full of water with approximately two inches of space remaining in the trashcan. There were white towels on the floor around the bottom of the trashcan and on the floor in front of the trashcan which were damp. Observation on 08/05/26 at 7:08 A.M. revealed Resident #51 and Resident #66's shared bathroom sink continued to leak and a bucket was placed below the pipe to catch the dripping water and a towel was placed under the trashcan. Interview on 08/05/26 at 7:11 A.M. with Maintenance Director (MD) #630 verified the sink was leaking and needed repair. MD #630 took pictures of the sink and stated it would be added to the repair list. MD #630 stated he was new in the last few weeks and was not aware of the leaking sink. This deficiency represents non-compliance investigated under Complaint Number 3071038.

Based on medical record review, observation, interview, and policy review, the facility failed to ensure residents had a functioning call system. This affected 18 (Resident #7,#13,#19,#15,#10,#26,#43,#32,#6,#4,#63,#57,#64,#33,#73,#5,#14,#31) out of 18 residents who resided on the 400 and 500 hallway. Additionally, the facility failed to provide timely care to residents who did not have a functioning call system. This affected one (Resident #33) of three reviewed for timely care. The facility census was 73.Findings Included:1. Review of the medical record for Resident #33 revealed an admission on [DATE]. Diagnoses included cerebral infarction, muscle spasms of back, and muscle weakness.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 05. Additional review of the MDS revealed Resident #33 had impairment on one side, used a wheelchair, and required substantial assistance with toileting.Review of the care plan dated 06/13/26 revealed Resident #33 was at risk for Activities of Daily Living (ADL) self-care performance deficit related to cerebral vascular accident. Interventions included one assist for toileting and transfers. Further review of the care plan revealed Resident #33 was at risk for falls. Interventions included ensuring call light was in reach, Resident #33 required prompt response to all requests for assistance.Review of the Fall Scale dated 02/20/26 revealed Resident #33 was at high risk for falls.Observation on 06/16/26 at 10:40 A.M. revealed Resident #33 yelling out for help from the bathroom. Resident #33 did not have a functional call system in the bathroom.Interview on 06/16/26 at 10:40 A.M. with Certified Nursing Assistant (CNA) #100 revealed she was unsure how long Resident #33 had been on the toilet or who placed him on the toilet. CNA #100 stated Resident #33 most likely transferred himself. CNA #100 stated Resident #33 was a one assist and required assistance on and off the toilet. CNA #100 further verified Resident #33's call light was not functioning properly.2.Observation on 06/16/26 at 10:20 A.M. of the 400 and 500 hallways revealed no visible call lights outside of the resident's bedrooms.Observation on 06/16/26 at 10:25 A.M. revealed Residents #7,#13,#19,#15,#10,#26,#43,#32,#6,#4,#63,#57,#64,#33,#73,#5,#14,and #31 did not have a functional call system.Interview on 06/16/26 at 10:25 A.M. with CNA #100 revealed the 400 and 500 hallway residents had call buttons that they wore around their necks and could press when they needed assistance. CNA #100 further stated that the staff had applications on their personal cell phones that the call system came through on. CNA #100 stated that there was no alert that came through the phones, and that she personally did not have the application on her phone. CNA #100 further stated that the call buttons also came through on the computers at the nurse's station, however you had to login to the system each time to see if there were call lights on. CNA #100 stated that the call system was currently not working, so staff were instructed by the Director of Nursing (DON) to just check on the residents more frequently. CNA #100 verified Residents #7,#13,#19,#15,#10,#26,#43,#32,#6,#4,#63,#57,#64,#33,#73,#5,#14,and #31 did not have functional call systems, or an alternative way to call for assistance.Interview on 06/16/26 at 11:08 A.M. with the DON revealed the call system had been working on and off intermittently. The DON further stated staff were supposed to be checking on residents more frequently on the 400 and 500 hallways. The DON stated some staff do not have the applications on their phones for the call system and were supposed to check the computers at the nurse's station. The DON verified the residents should have an alternative way to call for help and verified they had not provided the residents with any alternatives.Review of the policy titled Call Light Protocol, dated 01/2022 revealed staff are to respond to resident needs by answering the call light in a reasonable amount of time and assist residents as needed to a comfortable position with call light within reach.Review of the policy titled Personal Care Needs, dated 01/2024 revealed the facility would promote a healthy environment by assisting residents with ADLs which included toileting, and transfers.This deficiency represents non-compliance investigated under Complaint Number 3013691.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on review of electronic mail (email) correspondence, staff interview and review of the facility investigation, the facility failed to ensure Minimum Data Set (MDS) assessments were certified by qualified staff. This affected 40 (#43, #66, #74, #63, #75, #44, #77, #15, #80, #81, #82, #83, #84, #85, #86, #87, #88, #89, #90, #91, #92, #93, #94, #95, #96, #97, #98, #99, #100, #101, #102, #103, #104, #105, #106, #107, #108, #109, #110, and #111) residents identified by the facility as having MDS assessments completed by an unqualified staff. The facility census was 78.Findings include:Review of email correspondence from 01/12/26 through 01/29/26 between the Administrator and the Ohio Board of Nursing (OBN) revealed the facility identified that former Licensed Practical Nurse (LPN) #825 certified 64 MDS assessments as the Registered Nurse (RN) MDS Coordinator. Interview on 04/23/26 at 9:26 A.M. with the Administrator revealed in January 2026, she noticed LPN #825 certified an MDS assessment as the RN MDS Coordinator when she printed an MDS for a resident. The Administrator stated she was aware LPN #825 was not qualified to certify the MDS assessments and she initiated an audit and subsequently reported the concern to the OBN. The Administrator stated her audit identified a total of 64 MDS assessments involving 40 (#43, #66, #74, #63, #75, #44, #77, #15, #80, #81, #82, #83, #84, #85, #86, #87, #88, #89, #90, #91, #92, #93, #94, #95, #96, #97, #98, #99, #100, #101, #102, #103, #104, #105, #106, #107, #108, #109, #110, and #111) residents that were certified by LPN #825 over the course of two separate tenures as a nurse in the facility between July 2022 and December 2025. The Administrator stated she audited approximately 1,500 MDS assessments and there was no pattern or reasoning for LPN #825 to have certified the MDS assessments. The Administrator stated there was always an RN MDS Coordinator or the Director of Nursing (DON) available to review and certify the assessments so she did not know why LPN #825 certified the 64 MDS assessments. Additionally, the Administrator reported the previous RN MDS Coordinator was no longer employed at the facility so she could not verify what process she followed to ensure she completed the review and certification of the MDS assessment. The Administrator confirmed only a RN was completing MDS assessments at the facility now.The deficient practice was corrected on 01/21/26 when the facility implemented the following corrective actions:-On 01/05/26, the Administrator discovered former LPN #825 certified an MDS assessment as the RN MDS Coordinator.-By 01/11/26, the Administrator completed an audit of 1,591 current and discharged residents' records in the electronic medical record (EMR) system for MDS assessments completed during LPN #825's employment from 07/28/22 through 11/20/23 and a second tenure from 02/04/25 through 11/20/25, when LPN #825 no longer worked in the facility. LPN #825 participated in the MDS assessment process for 351 residents and signed as the RN MDS coordinator on 64 assessments.-On 01/12/26, the Administrator notified the OBN that LPN #825 signed and certified 64 MDS assessments that he was not qualified to sign and certify.-On 01/12/26, the Administrator educated the Director of Nursing (DON), RN MDS Coordinator #440, Assistant Director of Nursing (ADON) #170 and LPN #150 on the qualifications required to verify MDS assessment completion, RN MDS Coordinator attestation of MDS completion, and an LPN can only sign the completion of an Entry Tracking or a Death in Facility tracking form.-On 01/21/26, the Quality Assurance and Performance Improvement (QAPI) committee met to review the concern and ensure corrective action was implemented. In attendance were the Administrator, DON, ADON #170, Social Worker (SW) #625, RN MDS Coordinator #440, Medical Director (MD) #815, Therapy Director (TD) #810, Medical Records Clerk (MRC) #460, Registered Dietitian (RD) #820, LPN #150, Infection Preventionist (IP) #640 and Activities Director (AD) #565.-By 01/24/26, RN MDS Coordinator #440 completed and submitted corrected MDS assessments for the 64 MDS assessments signed by LPN #825 as the RN MDS Coordinator.-Review of the audits for January 2026, February 2026, March 2026, and April 2026 confirmed the facility completed audits with no additional concerns identified.-Interviews on 04/23/26 with the Director of Nursing (DON) and RN MDS Coordinator #440 confirmed education was received related to qualified staff to complete and certify MDS assessments.-Review of three (#74, #66 and #43) open resident medical records, reviewed for MDS assessments signed by LPN #825 as the RN MDS Coordinator, verified the MDS assessments were corrected and submitted. Additionally, review of current MDS assessments confirmed the assessments were certified by RN MDS Coordinator #440.This deficiency represents non-compliance investigated under Complaint Number 2734168.

Based on observation, staff interview, personnel file review, and policy review revealed the facility failed to ensure personnel obtained the proper registry. This affected one (#101) of four Certified Nursing Assistant personnel files reviewed. This had the ability to affect all residents. The facility census was 84.Findings include:Observation on 01/27/26 at 11:07 A.M. revealed Certified Nursing Assistant (CNA) #101 was assisting Resident #15 in morning care which involved dressing and positioning in the wheelchair.Review of CNA #101's personnel file revealed a hire date of 08/22/25.Review of CNA #101's Nurse Aide Training and Competency Evaluation Program was completed on 06/13/25. Review of CNA #101's personnel file and the State of Ohio State Tested Nursing Assistant website revealed it was absent of proof of State Registry.Review of the facility staffing schedule revealed CNA #101 worked as a CNA on 01/27/26 and 01/28/26. Interview with CNA #101 on 01/27/26 at 11:52 A.M. revealed she was employed at a CNA and was caring for residents that day.Interview with the Administrator on 01/27/26 at 4:10 P.M. revealed CNA #101 had been employed longer than four months since her completion of a CNA program. The Administrator stated that CNA #101 failed to pass her first registry test and was scheduled to take it again. The Administrator further verified CNA #110 should not be working as a CNA providing resident care without having passed the registry examination and stated CNA #110 was moved to the position of hospitality aide until the registration was completed.In Ohio, an individual can work as a nurse aide for a maximum of four months (approximately 120 days) from their date of hire without being on the state registry. During this grace period, they must complete an approved training program and pass the state competency exam to continue working.Review of the facility policy titled Test Ready CNA undated revealed certain positions within the facility require state mandated certification or licensing. Any employee whose position requires certification or licensing is expected to maintain and fulfill any requirements of the individual certification or license. Failure to maintain a valid license required of a specific position may result in termination of employment and a formal report to the licensing board.This deficiency represents non-compliance investigated under Master Complaint Number 2701102 and Complaint Number 2694213.

Based on observation, medical record review, resident interview, and staff interview the facility failed to ensure residents were transported to appointments as scheduled. This affected one (#11) of three residents reviewed for transportation to outside appointments. The facility census was 84.Findings include:Review of Resident #11's medical record revealed an admission date of 01/16/26. Diagnoses included nondisplaced fracture of right humerus subsequent encounter, morbid obesity, fall subsequent encounter, fracture of first and second lumbar vertebra, anxiety disorder, and alcohol use.Review of Resident #11's Minimum Data Set (MDS) revealed an admission MDS was in progress.Review of Resident #11's Baseline Care Plan dated 01/17/26 revealed the resident was alert and aware. Resident #11's plan was to complete physical and occupational therapy to increase strength and stamina and discharge home. While at the facility the nursing staff would provide nursing care as ordered to reach optimal health status, therapy would provide therapy services as ordered to reach optimal function, and social services would coordinate services to achieve discharge goals. Resident #11 was non-weight bearing on affected extremity. Staff were to encourage him to participate in his activities of daily living (ADLs) to the fullest extent possible. Resident #11 had a nondisplaced fracture of his right humerus, lumbar spine (L) fractures at L1 and L2 with a traumatic subdural hematoma from subsequent falls. Review of Resident #11's physician orders revealed an order written 01/17/26 for an appointment scheduled 01/27/26 at 8:50 A.M. for an orthopedic follow-up. Further review found an order dated 01/27/26 for an appointment dated 02/03/26 for orthopedic follow-up. Observation on 01/27/26 at 8:39 A.M. of Resident #11 found him standing in the doorway of his room with his right arm in a black sling, the resident was holding papers in his hand. Resident #11 had his shoes on and was looking up and down the hallway.Interview on 01/27/26 at 8:43 A.M. with Resident #11 found him to be alert and aware. Resident #11 reported he was admitted to the facility a week ago Friday and was to have a follow up appointment with his orthopedic doctor today at 8:50 A.M. Resident #11 reported he had a fall before he came to the facility and broke his arm so he had to wear the sling until he was healed. Resident #11 stated his arm and sling were bothering him and he wanted to go today to get it checked out. Resident #11 stated no one had come to get him yet.Observation on 01/27/26 at 10:56 A.M. of Resident #11 found he was still in his room, arm in a sling, shoes on, and his appointment papers were on the bedside table. Coinciding interview with Resident #11 revealed no one ever came and got him and he missed his appointment with his orthopedic doctor. He stated he was told his appointment would be rescheduled. Review of the appointment paperwork on Resident #11's bedside table found on 1/27/26 at 8:50 A.M. Resident #11 was to have had an orthopedic follow-up. The appointment had been scheduled 01/17/26 and required staff accompaniment and the staff needed to be medically trained.Interview on 01/27/25 at 11:03 A.M. with Registered Nurse (RN) #152 verified Resident #11 had not been transported to his orthopedic appointment scheduled for today. RN #152 reported there was some miscommunication with the doctors office and Resident #11 had missed his scheduled appointment. RN #152 stated the appointment was going to be rescheduled. This deficiency represents non-compliance investigated under Complaint Number 2694213.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure narcotic pain medications were administered as ordered. This affected one (#11) of three residents reviewed for narcotic pain medication use. The facility census was 84. Findings include:Review of Resident #11's medical record revealed an admission date of 01/16/26. Diagnoses included nondisplaced fracture of right humerus subsequent encounter, morbid obesity, fall subsequent encounter, fracture of first and second lumbar vertebra, anxiety disorder, and alcohol use.Review of Resident #11's Minimum Data Set (MDS) revealed an admission MDS was in progress.Review of Resident #11's Baseline Care Plan dated 01/17/26 revealed was alert and aware. Resident #11 plan was to complete physical and occupational therapy to increase strength and stamina and discharge home. While at the facility the nursing staff would provide nursing care as ordered to reach optimal health status. Resident #11 had indicators of pain and a goal was in place for adequate pain control. Review of Resident #11's physician orders revealed an order dated 01/16/26 and discontinued 01/19/26 for acetaminophen 500 milligrams (mg) every six hours as needed for mild to moderate pain. The acetaminophen 500 mg was reordered 01/19/26 and still active for every six hours as needed for mild to moderate pain with no more than four tablets per day. Further review of Resident #11's physician orders revealed an order dated 01/16/26 and discontinued 01/22/26 for Roxicodone oral tablet 5 milligrams (mg) (Oxycodone HCl) give one tablet by mouth every six hours as needed for severe pain for seven days. Severe pain was noted to be a pain level of eight to ten on a scale of one to ten. On 01/17/26 Resident #11 was administered his as needed (PRN) Roxicodone for a pain level of seven, on 01/18/26 he was administered his PRN pain medication twice for pain levels of seven. On 01/20/26 Resident #11 received his pain medication for a documented pain level of zero and again on 01/20/26 for a pain level of seven. On 01/21/26 Resident #11 was administered his PRN pain medications for pain levels of seven and six. Eight administrations were provided when Resident #11's pain was below ordered parameters.Additionally, Resident #11's order was refilled on 01/22/26 for Roxicodone oral Tablet 5 milligrams (mg) (Oxycodone HCl) give one tablet by mouth every six hours as needed for severe pain. On 01/27/26 Resident #11 was administered his PRN pain medication for a pain level of seven which also was a pain level below the required parameters for administration. Interview on 01/27/26 at 1:33 P.M. with Licensed Practical Nurse (LPN) #130 and Registered Nurse (RN) #180 verified Resident #11's PRN pain medications were administered outside of parameters, when Resident #11 pain level was below eight. RN #180 verified there were eight administrations with the first order when Resident #11's pain level was below eight and administered once under the second order with a pain level of seven. Follow up interview on 01/27/26 at 2:32 P.M. with LPN #130 verified Resident #11 had an order for acetaminophen 500 mg for mild or moderate pain every six hours as needed which should have been administered when Resident #11's pain levels were below eight. Review of the facility policy titled Administering Medications, revised 10/03/24 revealed medications were to be administered in a safe and timely manner and as prescribed. This deficiency represents non-compliance investigated under Complaint Number 2695906.

Based on observation, staff interview, and review of a facility policy, the facility failed to ensure medications were stored in a safe and secure manner. This had the potential to affect all 81 residents residing in the facility. The facility census was 81.Findings include:Observation on 12/02/25 at 7:55 A.M. revealed an unattended and unlocked medication cart located in the hallway outside of room [ROOM NUMBER].Interview on 12/02/25 at 7:56 A.M. with Licensed Practical Nurse (LPN) #126 confirmed the medication cart was unattended and unlocked. Continued interview with LPN #126 stated the medication cart should be locked when no staff are attending the cart.Review of an undated facility policy titled, Storage of Medications, revealed medications would be stored in locked compartments.

Based on resident interview, medical record review, staff interview and review of facility policy, the facility failed to ensure residents were provided opportunities and assistance with voting. This affected three (#4, #7 and #47) of three residents reviewed for voting, with the potential to affect all residents except one (#69) identified by the facility as voting by absentee ballot. The facility census was 91. Findings include: 1. Review of the medical record for Resident #4 revealed an admitted [DATE]. Diagnoses included Parkinson's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was cognitively intact. Interview on 01/27/25 at 3:21 P.M. with Resident #4 revealed the facility did not provide assistance or opportunities for her to vote in recent elections and it was important to her to vote. 2. Review of the medical record for Resident #7 revealed an admitted [DATE]. Diagnoses included diabetes mellitus, hypertension, and cerebral vascular accident (CVA). Review of the quarterly MDS assessment dated [DATE] revealed Resident #7 was cognitively intact. Interview on 01/27/25 at 3:50 P.M. with Resident #7 revealed voting was important to her and the facility did not provide assistance or opportunities for with voting in recent elections. 3. Review of the medical record for Resident #47 revealed an admitted [DATE]. Diagnoses included diabetes mellitus, hypertension, heart failure, and chronic obstructive pulmonary disease (COPD). Review of the annual MDS assessment dated [DATE] revealed Resident #47 was cognitively intact. Interview on 01/27/25 at 8:36 A.M. with Resident #47 revealed voting was important to her and the facility did not offer assistance or provide opportunities for voting in recent elections. Interview on 01/27/25 at 12:27 P.M. with Activity Coordinator (AC) #500 verified residents were not assisted or offered the opportunity to vote in recent elections. AC #500 reported she was unaware providing assistance to residents with voting was her duty and further stated she did not know the facility policy related to voting. Interview on 01/27/25 at 4:14 P.M. with AC #510 revealed an individual came to the facility in approximately September 2024 and requested entrance to assist residents with voting. The individual had credentials from the board of elections. AC #510 stated she was not sure if a non-employee could just walk around the building, so she discussed the situation with the previous facility Administrator, who denied the individual entrance into the facility. AC #510 confirmed residents were not provided any assistance or opportunities to vote, with the exception of one resident who sought out assistance with an absentee ballot. Review of the facility policy titled Federal and Ohio Residents Rights and Facility Responsibilities, dated October 2019, revealed residents had the right to exercise their civil rights and arrangements must be made to allow the residents to exercise their right to vote. This deficiency represents non-compliance investigated under Complaint Number OH00161624.

Based on observation, staff interview and review of facility policy, the facility failed to maintain a dignified dining experience for the residents by serving meals on disposable dishware. This had the potential to affect 79 of 81 residents who received meals from the kitchen. The facility identified two residents (#2 and #34) who received no food from the kitchen. The facility census was 81. Findings include: Observation on 12/26/24 at 1:15 P.M. of lunch trays being picked up by Certified Nursing Assistant (CNA) #502 revealed desserts for all of the trays were served in a Styrofoam bowl. Interview at the time of the observation with CNA #502 verified the desserts were served in a Styrofoam bowl. Further interview with CNA #501 revealed meals were sometimes served in Styrofoam containers. Observation on 12/26/24 at 4:54 P.M. of the dinner meal service revealed the meal was served to residents in a disposable, clear and green, carryout container. Interview on 12/26/24 at 4:55 P.M. with [NAME] #425 verified dinner was served in disposable carryout containers and further stated she decided to serve the meals in disposable containers as she did not want to dirty the dishes. Interview on 12/26/24 at 5:00 P.M. with Resident #10 revealed it bothered her when meals were served on disposable dishware instead of on regular plates. Interview on 12/30/24 at 4:50 P.M. with the Administrator revealed two (#2 and #34) residents were identified as NPO and did not receive meals from the kitchen. Interview on 12/31/24 at 12:10 P.M. with Dietary Technician (DT) #501 revealed she had observed residents being served meals on disposable dishware. Review of the facility policy titled Dignity, revised February 2021, revealed each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. This deficiency represents non-compliance investigated under Complaint Number OH00160314.

Based on observation, staff interview, review of the facility menu and review of facility policy, the facility failed to follow established menus and further failed to maintain a substitution log. This had the potential to affect 79 of 81 residents who received food from the kitchen. The facility identified two residents (#2 and #34) who received no nutrition from the kitchen. The facility census was 81. Findings include: 1. Review of the facility menu cycle revealed the facility was on a five-week rotation for the winter menu. Further review of the menu revealed for week five, day five (12/26/24), the menu for breakfast was choice of cereal, scrambled eggs, bacon, wheat toast, jelly, butter, juice of choice, milk, and coffee or tea. Observation on 12/26/24 at 7:48 A.M. of the breakfast trayline revealed the meal consisted of two slices of french toast, two sausage links and hot cereal. The cereal was served from a white handled scoop. Concurrent interview with [NAME] #471 verified the breakfast served was french toast, sausage links, cereal of choice and beverage of choice and not the meal identified on the menu. [NAME] #471 was uncertain of the serving size of the white handled scoop used for serving the hot cereal. Further review of the menu for week one, day three (12/31/24), revealed lunch was maple mustard glazed pork tenderloin, baked potato with butter/sour cream/chives, carrots, choice of roll, angel food cake, and coffee/tea. Observation on 12/31/24 at 12:00 P.M. of the lunch trayline revealed the meal consisted of spaghetti, green beans, dinner roll, ice cream and beverage of choice. Coinciding interview with [NAME] # 471 verified the lunch meal served was spaghetti, green beans, dinner roll, and ice cream. [NAME] #471 stated she had to cook the meat that was defrosted and she sometimes made up her own menu. [NAME] #471 verified the lunch meal served was not what was on the menu and was a meal she made up on her own. Continued observation revealed the spaghetti was served using a white handled scoop. Further interview with [NAME] #471 revealed she was not able to identify the portion size of the spaghetti served from the white handled scoop but she stated she knew she needed three ounces of meet and approximately four to six ounces of noodles and, since it was spaghetti, the white handled scoop is what she used. [NAME] #471 confirmed she served four ounces of green beans, one dinner roll and one container of ice cream. Interview on 12/31/24 at 12:05 P.M. with Dietary Manager (DM) #455 confirmed the facility was on week one of the five week menu rotation and further verified the lunch meal served was not the planned menu meal. Interview on 12/31/24 at 12:10 P.M. with Dietary Technician (DT) #501 verified the menu for the day was not followed and, since the meal was not on the menu, she could not verify the serving sizes to be correct. Review of the facility policy titled Menu and Planning, undated, revealed nutritional needs of individuals would be provided in accordance with established national standards, adjusted for age, gender, activity level and disability, through nourishing well balanced diets, unless contraindicated by medical needs. Review of the facility policy titled Standardized Recipes undated, revealed standardized recipes will be used when preparing menu items. 2. Review of the facility menu for week one, day three (12/31/24) revealed the lunch meal was maple mustard glazed pork tenderloin, baked potato with butter/sour cream/chives, carrots, choice of roll, angel food cake, and coffee/tea. Observation on 12/31/24 at 12:00 P.M. of the lunch trayline revealed the meal served consisted of spaghetti, green beans, dinner roll, ice cream and beverage of choice. Concurrent interview with [NAME] # 471 verified the meal served was spaghetti, green beans, roll and ice cream and not the planned lunch menu meal. [NAME] #471 confirmed she made up the meal served on her own as she needed to use the meat that was defrosted. Interview on 12/31/24 at 12:05 P.M. with Dietary Manager #455 confirmed the lunch menu was to be maple mustard glazed pork tenderloin, baked potato with butter/sour cream/chives, carrots, choice of roll, angel food cake, and coffee/tea and verified the meal served was spaghetti, green beans, and ice cream. DM #455 further stated sometimes we have substitutes. When asked by the surveyor for the substitution log, DM #455 stated, I don't know what you're talking about. I have never filled out a log about substitutes. Interview on 12/31/24 at 12:10 P.M. with Dietary Technician (DT) #501 confirmed the menu for the day was not followed and a substitute meal was served. Further interview with DT #501 verified the facility did not maintain a substitution log. Review of the facility policy titled Menu Substitutions, undated, revealed all changes to the menu would be recorded. Records of menu substitutions should be retained for a period of time based on state regulations. This deficiency represents non-compliance investigated under Complaint Number OH00160314.

Based on resident interview, observation, medical record review, staff interview and review of facility policy, the facility failed to complete dressing changes according to physician orders. This affected one (#30) of three residents reviewed for wound care. The facility census was 81. Findings include: Review of the medical record for Resident #30 revealed an admitted [DATE]. Diagnoses included status post cardiac arrest, respiratory arrest, chronic obstructive pulmonary disease (COPD), diabetes mellitus type two, and congestive heart failure. Review of the admission Minimum Data Set (MDS) assessment, dated 12/12/24, revealed Resident #30 was cognitively intact and was admitted with no unhealed pressure or vascular ulcers. Review of a nursing progress note dated 12/27/24 revealed Resident #30 had an intact purple area noted to the right heel during her shower. A physician order was obtained to apply skin prep to the right heel, cover with abdominal (ABD) pad and wrap with kerlix for protection, to be done twice daily and as needed, and apply offloading heel boot. Review of the physician order dated 12/27/24 revealed Resident #30 had an order to apply skin prep to the right heel, let dry, cover with ABD pad and wrap with kerlix twice daily and as needed. Interview on 12/30/24 at 4:32 P.M. with Resident #30 revealed had a spot on her right heel and no dressing change had been completed for about a week. Resident #30 further stated she was not aware how she got the spot, it just showed up. Resident #30 stated she had been involved in therapy services and ambulating, with a goal to discharge home. Concurrent observation of Resident #30's right heel wound dressing revealed the dressing was dated 12/27/24. Interview on 12/30/24 at 4:36 P.M. with Registered Nurse (RN) #308 verified Resident #30's right heel dressing was dated 12/27/24. RN #308 further stated she placed that dressing on 12/27/24. Coinciding review of the Treatment Administration Record (TAR) for December 2024 revealed Resident #30's right heel wound treatment was documented as completed twice daily, per physician order, including 12/28/24 and 12/29/24. Further interview with RN #308 verified the physician order written for Resident #30's right heel was for twice daily dressing changes and further confirmed the TAR reflected the treatment had been signed off as being completed by the weekend nurse; however, the treatment had not been completed since 12/27/24. Interview on 12/31/24 at 10:20 A.M. with wound care RN #321 confirmed Resident #30's original physician order was for twice daily dressing changes for a suspected right heel deep tissue injury. RN #321 stated on 12/30/24, the order was changed to once daily as the usual treatment for this type of wound was daily, not twice daily. RN #321 stated she was made aware Resident #30's right heel dressing changes were not completed as ordered on 12/28/24 and 12/29/24. Review of the facility policy titled Wound Care, revised October 2010, revealed the purpose of the procedure was to provide guidelines for the care of wounds to promote healing. This deficiency represents non-compliance investigated under Complaint Number OH00160314.

Based on observation, staff interview and review of the facility policy, the facility failed to ensure soiled bedpans were cleaned and disinfected timely. This affected one (#22) of one resident reviewed for bedpan use. The facility identified eight additional residents who utilized bedpans. The facility census was 81. Findings include: Review of the medical record for Resident #22 revealed an admitted [DATE]. Diagnoses included spinal stenosis, congestive heart failure (CHF), atrial fibrillation, and hypertension with heart disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/07/24, revealed Resident #22 was frequently incontinent and was staff dependent for toileting. Review of the Certified Nursing Assistant (CNA) documentation for the past 30 days revealed Resident #22 was both continent and incontinent. Observation on 12/26/24 at 8:45 A.M. of Resident #22's bathroom revealed a soiled bedpan on the floor of the bathroom. There was a pink substance on the bottom of the bedpan and the bedpan was left, uncovered, in the open. Concurrent interview with Resident #22 revealed she was both continent and incontinent and sometimes used the bedpan. Observation on 12/26/24 at 3:22 P.M. of Resident #22's bathroom revealed the soiled bedpan remained uncovered on the floor. Interview on 12/26/24 at 3:49 P.M. with Registered Nurse (RN) #420 verified the soiled and uncovered bedpan on Resident #22's bathroom floor. Review of the facility policy titled Infection Control, revised October 2018, revealed the infection control policies and practices were intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.

Based on observation, medical record review, staff interview, review of the emergency medication box (E-box) inventory and review of facility policy, the facility failed to administer medications per physician order. This affected one (#100) of three residents reviewed for medication administration. The facility census was 81. Findings include: Review of the medical record for Resident #100 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), emphysema, and anxiety. Review of the admission Minimum Data Set (MDS) assessment, dated 12/13/24, revealed Resident #100 was cognitively intact. Review of the admission orders for Resident #100 revealed he was ordered Zithromax (antibiotic) 250 milligrams (mg) to give two tablets on day one for acute exacerbation of COPD and prednisone (oral steroid used to decrease inflammation) 20 mg to give one and a half tablets (30 mg total) for acute exacerbation of COPD. Review of the Medication Administration Record (MAR) for December 2024 revealed on 12/07/24 a code five, followed by the nurse's initials, was entered into the MAR for the administration of both Zithromax 250 mg two tablets and prednisone 20 mg one and a half tablets. Further review of the MAR revealed code five indicated a note was made in the nursing progress notes for any infraction of the medication administration. Review of the nursing progress note dated 12/07/24 at 3:37 A.M. for Resident #100 revealed the Zithromax 250 mg two tablets was not administered due to awaiting pharmacy. Review of the nursing progress notes dated 12/07/24 at 12:16 P.M. for Resident #100 revealed the prednisone 20 mg one and a half tablets was not administered due to meds (medication) on order. Interview on 12/26/24 at 4:46 P.M. with Licensed Practical Nurse (LPN) #327 revealed the facility had an E-box that common medications could be pulled from for immediate use. LPN #327 further stated the E-box did not have all medications, but a select variety to get the resident started, such as antibiotics, some insulin and some narcotic medications that would be needed. Further interview with LPN #327 revealed the contracted pharmacy was responsible for maintaining the E-box. Review of the undated E-box inventory sheet provided by the facility revealed Zithromax 250 mg (total of six tablets) and and prednisone (four 20 mg tablets and four five mg tablets) were available in the E-box for administration. Interview on 12/30/24 at 8:47 A.M. with the Director of Nursing (DON) revealed just because the facility had an E-box that did not mean the medication was in stock in the E-box. The DON declined to verify Resident #100's medications were available and not administered as ordered based on the documentation. The DON further stated she was not working as the floor nurse and could not determine if the medications were available in the E-box for administration. Interview on 12/20/24 at 10:57 A.M. with pharmacy Processing Manager (PM) #500 revealed the pharmacy contract provided an E-box of medications for use for new orders and newly admitted residents. Further interview with PM #500 revealed the pharmacy conducted an in-house audit on 12/04/24 the facility E-box and verified Zithromax 250 mg, prednisone 20 mg and prednisone five mg was fully stocked and available for use. PM #500 further verified there were no requests submitted to the pharmacy from 12/04/24, following the in-house audit, and 12/07/24 for the use of Zithromax 250 mg or prednisone for any resident, so the facility had a full stock available of Zithromax (six tablets) and prednisone (four 20 mg and four five mg tablets). PM #500 further confirmed no submission forms were sent to the pharmacy regarding any medications used from the E-box for Resident #100. Review of facility policy titled Administering Medications, revised April 2019, revealed medications were administered per prescriber orders, including any required time frame. This deficiency represents non-compliance investigated under Complaint Number OH00160314 and continued non-compliance to the surveys dated 09/23/24 and 11/06/24.

Based on observation, resident interview, medical record review, staff interview and review of facility policy, the facility failed to obtain a physician order for administration of oxygen therapy. This affected one (#30) of three residents reviewed for oxygen therapy. The facility identified 18 residents who received oxygen therapy. The facility census was 81. Findings include: Review of the medical record for Resident #30 revealed an admitted [DATE]. Diagnoses included status post cardiac arrest, respiratory arrest, chronic obstructive pulmonary disease (COPD), and congestive heart failure. Review of the admission Minimum Data Set (MDS) assessment, dated 12/12/24, revealed Resident #30 was cognitively intact and received oxygen therapy. Review of the physician orders for December 2024 revealed no order for oxygen therapy. Observation on 12/30/24 at 4:32 P.M. of Resident #30 revealed she was wearing oxygen via nasal cannula, running at two liters per minute (lpm). Concurrent interview with Resident #30 revealed she had been receiving oxygen therapy since admission. Resident #30 further stated she was on oxygen therapy at home, prior to her admission to the facility. Interview on 12/30/24 at 4:36 P.M. with Registered Nurse (RN) #308 confirmed Resident #30 had been on oxygen since her admission. RN #308 verified there was no physician order for Resident #30's oxygen therapy, despite having it since her admission on 12/06/24. RN #308 further verified from the hospital referral records that Resident #30 should have had an order for oxygen therapy, as it was on the referral paperwork, and it must have been missed. Interview on 12/31/24 at 12:32 P.M. with the Administrator verified a physician order was not written until 12/30/24 for Resident #30's oxygen therapy. Review of the facility policy titled Oxygen Administration, revised October 2010, revealed to verify there was a physician order for this procedure and . Review the physician's order or the facility protocol for oxygen administration. This deficiency is an incidental finding discovered during the complaint investigation.

Based on medical record review, staff interview, and policy review, the facility failed to ensure medications were administered as ordered. This affected one (#93) of three residents reviewed for medications. The facility census was 83. Findings included: Review of Resident #93's medical record revealed an admission ate of 10/02/24. Diagnoses included cellulitis of the left lower extremity, diabetes mellitus, ulcerative colitis, and schizophrenia. The resident was discharged on [DATE]. Review of Resident #93's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had an intact cognitive function and was independent of most activities of daily living (ADLs). Review of Resident #93's nursing progress note dated 10/02/24 revealed the resident arrived to the facility at 2:00 P.M. from a local hospital. The resident's medications were reviewed and confirmed with the physician. Review of Resident #93's physician orders while in the facility included orders dated 10/02/24 for atorvastatin calcium tablet 40 milligrams (mg) one table by mouth at bedtime for hyperlipidemia, the antipsychotic medication quetiapine furnarate (Seroquel) oral tablet 150 mg at bedtime for schizophrenia, doxycycline monohydrate (antibiotic) 100 mg to be administered by mouth twice daily for a right toe infection/cellulitis for seven days, Fluticasone-Salmetrerol inhalation aerosol powder breath activated 150-50 micrograms to be administered twice daily for chronic obstructive pulmonary disease, and memantine five (5) mg to be administered twice daily for Alzheimer's disease. Review of Resident #93's medical record revealed a physician order dated 10/03/24 for mesalamine delayed release tablet 1.2 grams to be administered once daily for ulcerative colitis. Review of Resident #93's medical record revealed a physician order dated 10/04/24 for the anticoagulant warfarin sodium 10 mg to be administered every evening on Monday, Wednesday, Friday, Saturday, and Sunday. Review of Resident #93's medication administration record (MAR) for October 2024 revealed on 10/02/24 the resident was not administered atorvastatin calcium and Seroquel as ordered. Further review revealed Resident #93 was not administered Fluticasone-Salmeterol on 10/02/24 at 7:00 P.M. or 10/03/24 for the morning dose as ordered. On 10/03/24 and 10/05/24, mesalamine was not administered as ordered, on 10/05/24 warfarin was not administered as ordered, on 10/06/24 doxycycline monohydrate was not administered as ordered for the 8:00 A.M. dose, and on 10/02/24 at 7:00 P.M. and on 10/06/24 (the morning dose) memantine was not administered as ordered. Review of Resident #93's nursing progress notes dated 10/02/24 revealed the ordered memantine was not available. Review of subsequent nursing progress notes revealed Resident #93's Fluticasone-Salmeterol was not available on 10/03/24, mesalamine was not available on 10/04/24, warfarin was not available on 10/04/24 and 10/05/24, and doxycycline monohydrate was not available on 10/06/24. Interview on 11/06/24 at 8:16 A.M. with the Director of Nursing (DON) confirmed the missing doses of medication documented on the October 2024 MAR were not administer as ordered to Resident #93. The DON stated the medications were in the facility, but were not given to the resident. Review of the facility policy titled, Administering Medications, dated 10/03/24, revealed medications are administered in accordance with prescribers' orders, including any required time frame. This deficiency represents non-compliance investigated under Complaint Number OH00158933 and represents continued non-compliance from the survey dated 09/23/24.

Based on record review, staff interview, review of exterminator documents, and policy review, the facility failed maintain a pest free environment. This affected one (#84) of two residents reviewed for environmental concerns. The facility census was 83. Findings included: Review of Resident #84's medical record revealed an admitted [DATE]. Diagnoses included mild intellectual disabilities, congestive heart failure, and diabetes mellitus. Review of Resident #84's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had an intact cognition and was at risk for skin impairment related to weakness. Review of Resident #84's nursing progress note dated 10/08/24 revealed the resident was showered and staff noticed small bug bites all over the resident's legs and arms. The nurse practitioner was notified. Review of Resident #84's nursing progress note dated 10/11/24 revealed the resident was showered with assistance from a nurse aide and bite marks on her bilateral upper and lower extremities were found. Review of the exterminator service record and related documentation dated 10/10/24 revealed a lot of dead bed bugs were found in Resident #84's room on the mattress. Staff bagged everything so the exterminator could treat the room and bed bugs were vacuumed off the mattress and chair. The mattress, chair, dresser drawers, armoire, and perimeter baseboards were treated. Interview with the Director of Nursing on 11/06/24 at 9:52 A.M. verified Resident #84 suffered bed bug bites due to an infestation. Review of the undated facility policy titled, Preventing and Managing Infestations of Bed Bugs, revealed staff will employ infection control strategies to prevent and manage infestation of bed bugs. This deficiency represents non-compliance investigated under Complaint Number OH00158774.

Based on observation, review of a facility investigation, staff interview, and policy review, the facility failed to maintain a safe environment free from an outdoor fire. This had the potential to affect 11 residents (#5, #9, #14, #34, #38, #42, #46, #54, #61, #77, #181) with rooms in proximity to where the fire occurred. The facility census was 85. Findings include Review of an incident summary dated 09/13/24 about 3:50 P.M. by the Administrator revealed a nurse stated there was smoke outside of the 200 Hall lounge exit door on the sidewalk. When the Administrator arrived, there was a small flowerpot under a chair that staff put dirt and water on because it was smoking. There were no residents or staff witnessed sitting in the chair which had a hole. The Administrator reviewed the camera footage but the area was not in view of the camera. Observation on 09/16/24 at 3:15 P.M., with the Director of Maintenance (DM) #416 revealed a red fabric patio chair near the southwest doorway of the interior courtyard with a burn hole in the seat of the chair approximately six inches by four inches. There was black soot staining on the wall behind the chair which extended upward to approximately 18 inches below the vinyl soffit. Also on the wall were small pieces of burnt plastic. On the ground below the chair there was black potting soil intermixed with numerous cigarette butts. Interview on 09/16/24 at 3:15 P.M., DM #416 verified the burn hole in the chair and the black soot staining on the wall and the cigarette butts in the potting soil. During further interview, DM #416 revealed they believed the fire started when staff put out a cigarette in the flower planter. Interview on 09/18/24 at 2:41 P.M., Licensed Practical Nurse (LPN) #445 revealed there was a small fire in a flowerpot in the courtyard. LPN #445 revealed no staff or residents were in the courtyard at the time. LPN #445 revealed herself and another staff member threw potting soil on top of the fire. Review of the policy, Safety and Supervision of Residents, last revised 07/2017, revealed the facility would stive to make the environment as free from accident hazards as possible. Resident safety, supervision, and assistance to prevent accidents were facility-wide priorities. This deficiency represents noncompliance investigated under Complaint Number OH00157910.

Based on medical record review, staff interview, review of facility Self-Reported Incidents (SRIs), review of staff schedules, and review of the facility policy, the facility failed to thoroughly investigate an allegation of verbal abuse and failed to protect residents from potential abuse. This affected three (Resident #9, #42, and #54) of three residents reviewed for abuse. The facility census was 85. Findings include: 1. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE]. Diagnoses included schizophrenia, depression, anxiety, bipolar disorder, and muscle weakness. Review of the quarterly Minimum Data Set assessment dated [DATE] identified the resident as cognitively impaired. The resident required substantial/maximal assistance from staff for a majority of the activities of daily living. Review of the medical record revealed no evidence regarding an allegation of abuse. 2. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE]. Diagnoses included cardiomyopathy, depression, hypertension, and facial weakness. Review of the quarterly Minimum Data Set assessment dated [DATE] identified the resident as cognitively impaired. The resident was dependent on staff for a majority of the activities of daily living. Review of the medical record revealed no evidence regarding an allegation of abuse. 3. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE]. Diagnoses included dementia, hypertension, unsteadiness on feet, heart failure, anxiety, and depression. Review of the significant change Minimum Data Set assessment dated [DATE] identified Resident #54 was cognitively impaired. The resident received hospice services and was dependent on staff for a majority of the activities of daily living. Review of the medical record revealed no evidence regarding an allegation of abuse. Interview on 09/18/24 at 3:54 P.M. with State tested Nurse Aide (STNA) #474 revealed that approximately 10 days prior, STNA #464 had threatened to hit Resident #42 and #54. STNA #474 stated the allegation was reported to management. Interview on 09/18/24 at 4:41 P.M. with the Director of Nursing (DON) revealed it was reported to them that STNA #464 had threatened to hit Resident #9 and #54. The DON reported completing an investigation and providing the investigative documentation to the previous Administrator. The DON reported having no evidence regarding investigative documentation. Interview on 09/19/24 at 11:33 A.M. with Administrator #2 revealed the facility was unable to provide any investigative documentation related to the allegation. Review of the facility SRIs revealed there were no reports filed for the allegation of verbal abuse. Review of nursing staff schedules for 09/05/24 to 09/19/24 revealed STNA #464 worked at the facility on 09/05/24, 09/06/24, 09/07/24, 09/08/24, 09/10/24, 09/13/24, 09/16/24, 09/17/24, and 09/19/24. A follow-up interview on 09/19/24 at 12:45 P.M. with Administrator #2 revealed STNA #464 was sent home on 09/19/24 and was not allowed to return until the investigation was complete. Review of the facility policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, revised June 2017, revealed staff should report all incidents/allegations immediately to the Administrator or designee. The policy also stated documentation in the nursing notes should include the results of the resident's assessment, notification of the physician and the resident representative, and any treatment provided. The policy also stated if a staff member was accused or suspected, the facility should immediately remove the staff member from the facility and the schedule pending the outcome of the investigation. The policy further stated once the Administrator and state agency were notified of the allegation, and investigation would be conducted and would include: interviewing the resident, the accused and all witnesses; obtaining statements from the resident, if possible, the accused, and each witness; reviewing the resident's record; if the accused was an employee, reviewing their employment records.

Based on medical record review, observation, resident interview, and staff interview, the facility failed to ensure residents received the necessary services to maintain a dignified appearance. This affected one (Resident #62) of three residents reviewed for dignity. The facility census was 85. Findings include: Review of the medical record revealed Resident #62 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, chronic kidney disease, heart failure, gout, hypertension, and type II diabetes mellitus. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #62 had a moderate cognitive impairment. The resident was dependent on staff assistance for dressing and personal hygiene. Review of the physician progress notes dated 01/17/24 and 03/12/24 revealed Resident #62's right breast was surgically absent and an order for a prosthetic bra per patient request. Review of the social service progress notes dated 03/14/24 revealed Resident #62 mentioned her insurance previously covered two bras on a yearly basis and social services would check to see if the resident would qualify for two free bras. Review of the physician progress notes dated 04/03/24, 05/28/24 07/10/24, and 07/30/24 revealed Resident #62's right breast was surgically absent and an order for a prosthetic bra per patient request. Further review of the medical record revealed no evidence Resident #62's request for a prosthetic bra was followed up on. An interview on 09/16/24 at 9:30 A.M. with Resident #62 revealed the resident had a breast removed and needed a special bra. The resident reported the facility was aware she needed a bra but that she had not heard anything regarding this. Resident #62 reported she sometimes felt ashamed to go out due to not having an appropriate bra. An observation at the time of interview verified Resident #62 did not have a prosthetic bra. An interview on 09/17/24 at 4:01 P.M. with Licensed Social Worker #478 verified Resident #62's request for a prosthetic bra had not been followed up on.

Based on medical record review, observations, staff interview, review of the facility ' s elopement risk policy, review of the facility Self-Reported Incident (SRI) investigation, and the "Weather Underground" report, the facility failed to provide adequate supervision for one (#1) of five residents identified and reviewed for potential elopement. This resulted in Immediate Jeopardy for one (#1) cognitively impaired resident, identified at risk for elopement, who successfully eloped from the facility without staff knowledge, fell from her wheelchair onto a concrete pad, and suffered a fractured right knee. Additionally, two residents (#2 and #3) were placed at risk for more than minimal harm that is not Immediate Jeopardy due to failure of the facility to ensure Wander-guard devices were utilized according to physician orders and plans of care, and failure to follow the facility ' s policy to complete elopement risk assessments quarterly. However, these residents were not observed to exhibit wandering behaviors and had no documented instances of attempted elopement. The facility identified a total of five residents assessed at risk for potential elopement. On 04/01/15 at 4:00 P.M., the Administrator, and Director of Nursing (DON) were notified Immediate Jeopardy began on 03/24/15 at approximately 5:45 P.M. when Resident #1 propelled her wheelchair through an unoccupied section of the building and exited the facility through an alarmed exit door, which only sounded in the unoccupied area of the building. The facility was not aware Resident #1 was missing until approximately 6:10 P.M. when an unidentified tenant of the neighboring apartment community alerted staff Resident #1 was lying on the ground, next to a wheelchair, near the driveway to the facility. According to the history report on "Weather Underground," the local weather forecast, the outside temperature in the area on 03/24/15 at 5:53 P.M. was 35.1 degrees Fahrenheit (F), with a wind chill of 27.9 degrees F. Resident #1 was subsequently taken to the hospital for evaluation and discovered to have sustained a right patellar (knee) fracture. The Immediate Jeopardy was removed on 04/02/15 at 2:20 P.M. when the facility implemented the following corrective actions: · On 03/26/15 at 6:30 P.M., Resident #1 was returned to the facility with orders for physical therapy. · On 04/01/15 at 4:34 P.M., Licensed Practical Nurse (LPN) #1 re-assessed all residents in the facility for elopement risk. The plans of care for all residents assessed to be at risk for elopement were reviewed for accuracy. · On 04/01/15, the facility began implementation of a new policy titled " Merit House Elopement, Door Policy. " This policy indicated door alarms will be placed on the doorways accessing the unoccupied area of the facility. These door alarms will be activated during non-business hours, as management personnel are present to supervise this area during business hours. A second set of doors past the office area, which leads to the laundry department, will be alarmed on a continual basis. Between the hours of 8:00 P.M. and 9:00 P.M., the second shift charge nurse will be responsible for physically checking the functioning of all door alarms. This monitoring is to be documented on a log located at the nurses ' station. · On 04/02/15 at 9:30 A.M., audible alarms were placed on all doors that accessed the unoccupied area of the facility. · Between 04/01/15 at 4:00 P.M. and 04/02/15 at 2:20 P.M., the Administrator and DON completed an all staff in-service for each shift, including nursing, activities, dietary, housekeeping, and maintenance on the facility elopement policy and the utilization of the alarms installed on the doors which access the unoccupied area, as well as the policy regarding these doors. · On 04/02/15 at 6:45 A.M. and 2:40 P.M., interviews with State tested Nursing Assistant (STNA) #1, #44, #55, #56 and #57, and Housekeeper #4 revealed they were able to describe in detail the facility ' s " Merit House Elopement, Door Policy, " and procedure. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing the new policy regarding the monitoring of exit doors, the monitoring of door alarms, and assessing the appropriateness of staff response to this newly developed policy. Findings Include: 1. Review of Resident #1 ' s medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment, completed on 03/10/15, identified the resident had visual impairment, moderately impaired cognition, and experienced hallucinations and delusions. The resident required extensive physical assistance of one person for the completion of activities of daily living, which included transfers, and utilized a wheelchair or walker for ambulation. The assessment identified the resident had an unsteady balance while standing without staff assistance. Review of physician ' s orders dated 05/08/14 revealed the physician ordered a Wander-guard bracelet (device which causes specific door alarms to sound and/or door to lock) to the left leg. Staff were to check placement and function every shift. Review of Resident #1 ' s plan of care, dated 06/24/14, revealed the resident was at risk for elopement and injury. The resident was identified to wander as evidenced by difficulty to redirect, unaware of safety needs, and cognitive deficits. Interventions included observe the resident to see if she is attempting to meet physical needs and meet these needs for the resident, monitoring the Wander-guard bracelet placement and functioning per facility protocol, and placing the resident ' s picture in the Medication Administration Record (MAR). Review of the elopement risk assessment completed on 03/10/15 identified Resident #1 to be at moderate risk of elopement. Review of physician ' s orders revealed on 03/24/15 at 6:30 P.M., a physician ' s order was written to send the resident to the emergency room for evaluation and treatment, due to the resident complaining of nose, right hand, knee and right leg pain from a fall. Review of the patient transfer form, dated 03/24/15, revealed the resident complained of nose, right hand, and right lower leg pain after a fall. Review of nurses notes, dated 03/24/15 at 9:08 P.M., documented Resident #1 was found on the ground at the front of the building. A visitor had found the resident outside and reported the situation to staff. Staff responded to the resident at the location where she was found. The physician and family were immediately notified of the incident. The physician ordered the resident sent to the emergency room (ER) for evaluation due to complaints of pain in the nose, right hand, right knee and right lower leg. Review of the facility SRI investigation, dated 03/25/15, noted Resident #1 was found on the ground. The resident was assessed for any injury by staff. The resident complained of knee pain and was sent to the hospital for an evaluation. The resident was discovered to have a right patella fracture. Review of an X-Ray of the right knee, dated 03/25/15, revealed Resident #1 had a minimal displaced transverse fracture through the patella, associated with joint effusion. Review of the hospital community referral form dated 03/26/15, documented the resident sustained [REDACTED]. Physician ' s orders on the community referral included physical therapy orders which included toe touch weight bearing to the right leg for transfers only. Interview on 03/31/15 at 3:00 P.M. with the DON revealed during the change of shift on 03/24/15, Resident #1 was looking for a family member. After asking staff numerous times, and being told the family member was not present in the facility, the resident propelled her wheelchair through several doors and out a door equipped with a Wander-guard bracelet/magnetic locking device. The DON stated a visitor informed the facility a resident in a wheelchair was lying in the parking lot. Staff responded to the resident ' s location. The resident sustained [REDACTED]. The DON stated the resident was brought back into the facility, was assessed, and the physician was contacted. The resident was sent to the hospital for an evaluation and was found to have a broken patella. After the incident it was noted the door alarm was sounding and the resident had a Wander-guard bracelet in use as she was an elopement risk. During an Interview on 03/31/15 at 4:00 P.M. with Maintenance Director (MD) #1 he stated he checks the operation of the alarming doors weekly, with the exception of the one Wander-guard door at the main lobby. Nursing staff are responsible for monitoring the operation and function of this door. Interview on 03/31/15 at 4:30 P.M. with the Administrator revealed no other elopements had occurred at the facility. As a result of the incident, Registered Nurse (RN) #11 was terminated and MD #1 was instructed to perform an additional check of all delayed egress doors. All doors were noted to be operational and functional as designed. No additional action was taken to in-service staff. Observation on 03/31/15 at 4:50 P.M., noted Resident #1 was sitting in a wheelchair with a personal safety alarm to the back of the seat. The Wander-guard bracelet was observed in place on the left ankle. The resident was unable to answer questions pertaining to the incident, only stating she fell from her wheelchair outside and hit her head. During an Interview on 03/31/15 at 5:15 P.M., RN #55 verified the Wander-guard door was checked by the designated nurse for operation each shift. Interview on 04/01/15 at 10:40 A.M. with RN #22 revealed she last observed Resident #1 on 03/24/15 at 4:30 P.M. following a blood sugar check. At 6:10 P.M., a man came running to the nursing station and said a resident had fallen out of her wheelchair up by the road. RN #22 stated she was the first staff to reach Resident #1. The resident was observed by the northeast door, lying on a concrete landing, at the foot of a two stair step in the sidewalk. Blood was coming from the bridge of her nose and the resident was complaining of pain to the right leg. RN #22 stated she assessed the resident and with assistance of additional staff, placed the resident into the wheelchair. Interview on 04/01/15 at 10: 51 A.M. with LPN #23 revealed Resident #1 was last observed on 03/24/15 at 5:15 P.M. in her room when she placed tennis shoes on the resident ' s feet. The resident then proceeded out of her room, propelling towards the dining room. At approximately 6:05 P.M., a man came to the nurse ' s station and reported a resident had fallen out of the wheelchair by the street. LPN #23 went out to the resident ' s reported location with additional nursing staff and found the resident at the foot of the steps with blood coming from her forehead and stating her leg hurt. LPN #23 asked RN #11 and LPN #33 if they heard a door alarm or alarm panel at the nursing station sound and none of the alarms were reported as having been activated. RN #11 informed LPN #23 she used the code pad to turn off a door alarm near the location where Resident #1 was found. Additionally, LPN #23 stated none of the door alarm panels at the nursing stations were illuminated or sounding. Observation on 04/01/15 at 11:20 A.M. with MD #1 and the Administrator revealed the exit pathway Resident #1 would have taken to exit at the door where she was discovered would have required the resident to have propelled her wheelchair through several sets of closed doors through an unoccupied area of the facility. The distance traveled was noted to measure approximately 286 feet from the door of the occupied section of the facility, through the unoccupied section of the building, through the exterior exit door, down the sidewalk and two concrete steps, to a concrete slab where the resident was discovered. This sidewalk led to a driveway shared by the nursing facility and the apartment units next door. The driveway led to a heavily traveled two lane road. Observation of the exit door at the walkway, where the resident was discovered, revealed the door was equipped with an audible alarm which sounded when the exit door was opened. Upon activation of the door alarm, no notification or alarming device registered at any of the nurse ' s stations or within the occupied section of the building. Observation of three additional exit doors in the unoccupied section of the facility revealed the doors all had an alarm which activated when the door was opened. None of the doors in the unoccupied area were audible in the occupied area of the facility to alert staff of any person exiting the building. The only exit door equipped with a Wander-guard alarm was the main lobby exit, which when activated by a Wander-guard bracelet, sounded an alarm. MD #1 indicated he was unaware the alarming doors installed inside the unoccupied section of the building did not sound or illuminate inside the occupied section of the facility to alert staff of the door being opened. During an interview on 04/01/15 at 3:05 P.M., STNA #1 stated she had observed Resident #1 on occasion to enter unoccupied areas of the facility. She stated on 03/24/15 at 5:45 P.M., Resident #1 was observed in the dining room. At approximately 6:10 P.M, a man from the apartment next door entered the facility stating a resident had fallen out of the wheelchair by the driveway. STNA #1 and additional staff went out to assist the resident. The resident was observed on the ground at the bottom of a two stair step in the walkway. STNA #1 stated she heard no alarms, but was told the door at the top of the exit pathway had been sounding and RN #11 turned the audible alarm off. Interview with the Administrator on 04/01/15 at 3:30 P.M. verified Resident #1 was last observed on 03/24/15 at approximately 5:45 P.M. by STNA #1 in the dining room. The facility was made aware of the resident ' s status by a tenant of the neighboring apartment community on 03/24/15 at approximately 6:05 P.M. The Administrator verified the door alarms inside the unoccupied section of the building do not sound or illuminate inside the occupied section of the facility to alert staff of the door being opened. 2. Review of the medical record for Resident #2 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] identified the resident with moderately impaired cognition, and dependent on staff for the completion of activities of daily living. Additionally, the assessment indicated the resident experienced wandering behaviors within the last one to three days. Review of physician ' s orders revealed an order dated 03/26/14 for a Wander-guard to the left ankle due to exit seeking behavior. The Wander-guard was to be checked for function and placement every shift. Review of the elopement risk assessment completed on 05/28/14 identified the resident at serious risk for elopement due to risk factors of dementia diagnosis, wandering behaviors, and expressing a desire to go home. Review of a nursing plan of care dated 08/05/14 revealed the resident was at risk for elopement and injury, as evidenced by wandering at times, difficult to redirect, unaware of safety needs, and exit seeking behaviors. Interventions included the use of the Wander-guard bracelet with staff to check placement and functioning per facility protocol. Observation on 04/01/15 at 7:55 A.M. of STNA #90 providing Resident #2 with morning care, revealed no Wander-guard was applied to the resident ' s ankle. Review of MAR ' s on 04/01/15 at 8:10 A.M. with LPN #102, who was identified to have worked with the resident during the third shift, noted initials indicating the Wander-guard was in place. Observation and interview with LPN #102 on 04/01/15 8:10 A.M. verified the Wander-guard was not applied to the resident ' s ankle. Review of the facility policy titled " Elopement Risk, " dated 10/11, indicated elopement assessments are to be completed on admission, re-admission, significant change, and quarterly. During an interview on 04/01/15 at 3:30 P.M. with the MDS nurse, LPN #303 verified Resident #2's elopement risk assessment was last conducted on 05/28/14. She verified the facility had not conducted quarterly assessments as per the policy. 3. Review of the medical record for Resident #3 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] identified the resident to have moderately impaired cognition, and dependent on staff for the completion of activities of daily living. Review of the elopement risk assessment, completed on 02/26/14, identified Resident #3 to be a moderate risk for elopement due to risk factors of dementia diagnosis, cognitive impairment, and poor decision making skills. Review of a nursing plan of care dated 03/07/14 revealed the resident was at risk for elopement and injury, as evidenced by unaware of safety needs, exit seeking behaviors, and cognitive deficits. Interventions included the use of the Wander-guard bracelet with staff to check placement and functioning per facility protocol. Observation on 04/01/15 at 9:20 A.M. with RN #90 revealed Resident #3 did not have the Wander- guard in place, as identified on the plan of care. Interview with RN #90 at the time of the observation revealed she was unaware the Wander-guard was not applied to the resident. During an interview on 04/01/15 at 3:30 P.M. with the MDS nurse, LPN #303 verified Resident #3's elopement risk assessment had not been completed since 02/26/14. She verified the facility had not conducted quarterly assessments as per the policy. Review of the facility policy titled " Elopement Risk, " dated 10/11, indicated elopement assessments are to be completed on admission, re-admission, significant change, and quarterly. This Deficiency Substantiates Complaint Number OH 477.