Every finding on record at Momentous Health at Richfield

Based on observation, record review, staff interview, and review of the recipe for homemade meatloaf puree, the facility failed to ensure resident meat textures were served as physician ordered. This affected one (#337) of seven residents observed for dining. The facility identified eight residents (#348, #320, #315, #302, #337, #329, #307, and #309) having a pureed diet ordered by the physician. The facility census was 55.Findings include:Review of the medical record for Resident #337 revealed an admission date of 12/12/2025. Diagnoses included Alzheimer's, hypertension, type II diabetes, and anxiety. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] for Resident #337 revealed the resident had severe cognitive impairment and required supervision or touching assistance for eating and oral hygiene. Review of current physician orders revealed a physician order dated 07/24/26 for Resident #337 to have a pureed diet.Review of the menu for 08/19/26 revealed at lunch homemade meatloaf, corn, white bread, fruited gelatin and apple juice was to be served.Observation on 08/19/26 at 12:09 P.M. of [NAME] #39 plating food for the dining room revealed that food was accurate to the menu for lunch. Observation of Resident #37 revealed the resident was sitting in the dining room at a table with another resident and an aide near the window from where the food was being served. The aide was assisting Resident #337 with eating and upon providing Resident #337 a bite of the pureed homemade meatloaf the meatloaf appeared to be lumpy. At the time of the observation a test tray was requested. Observation on 08/19/26 at 12:10 P.M. of the test tray with Dietary Supervisor #1 revealed the pureed homemade meatloaf had lumps. Sample of the pureed homemade meatloaf with Dietary Supervisor #1 found the homemade meatloaf to have clumps of meat that required one to chew. Interview on 08/19/26 at 12:11 P.M. with the Dietary Supervisor #1 confirmed the homemade meatloaf did not meet the required pureed consistency.Interview on 08/19/26 at 12:15 P.M. with [NAME] #39 revealed the cook was unaware of a recipe to puree the homemade meatloaf. Furthermore, [NAME] #39 confirmed a recipe was not followed and that [NAME] #39 just looks at the food to see if the puree is the right consistency based years of experience of being a cook. Review of the recipe for homemade meatloaf puree revealed the meat is to brought to a temperature of 165 degrees Fahrenheit (F) when reheating. Measure out the portion of food needed to puree (portions based on number of people the puree is being made for), place food in blender or processor, gradually add liquid, starting with a small amount, cover and pulse on-off until the food is coarse and puree until thin, add liquid as needed. For the homemade meatloaf puree, the portion size was 3/4 cup meat and three to five tablespoons of liquid. This deficiency represents non-compliance investigated under Master Complaint 3168300 and Complaint Number 3159911.

Based on record review and interview, the facility failed to ensure accurate documentation was recorded in the residents' medical record. This affected two residents (#14 and #57) of three residents reviewed for documentation. The facility census was 56. Findings include: 1. Review of Resident #14's medical record revealed an admission date of 01/29/26 with diagnoses including schizoaffective disorder, bipolar disorder, congestive heart failure, viral hepatitis C, and diabetes.Review of the Minimum Data Set 3.0 dated 04/01/26 revealed Resident #14 had a severe cognitive impairment and wandering behaviors.Review of the progress notes for Resident #14 dated 04/28/26 through 05/27/26 revealed no documentation of an incident that occurred on 05/18/26 when Resident #57 wandered into Resident #14's room and was found with her brief and pants around her ankles.2. Review of the medical record for Resident #57 revealed an admittance date of 04/04/25. Diagnoses included dementia with moderate behavior disturbance, type II diabetes, psychosis, and chronic obstructive pulmonary disease (COPD). The resident was discharged to another facility on 05/19/26.Review of the comprehensive Minimum Data Set 3.0 dated 03/10/26 revealed the resident had a severe cognitive impairment and verbal behaviors.Review of the psychosocial assessment dated [DATE] revealed the resident had behaviors of disorganized thinking and inattention continuously present.Review of the nursing progress notes dated 04/23/25 to 05/19/26 revealed no documentation of an incident that occurred on 05/18/26 when Resident #57 wandered into Resident #14's room and was found with her brief and pants around her ankles.Review of the facility investigation dated 05/19/26 revealed Certified Nursing Assistant (CNA)'s #212 witness statement revealed on 05/18/26 at 9:45 P.M. Resident #57 was sitting in the dining room watching television. CNA #212 provided care to another resident and noticed Resident #57 was not in the dining room. CNA #212 found Resident #57 in Resident #14's room. Resident #57 had her pants and brief pulled down around her ankles. Resident #14 was wearing no pants or underwear. CNA #212 assisted Resident #14 in getting dressed. The nurse assisted Resident #57 in getting dressed. Resident #57 became combative and was taken to her room. The investigation indicated checks were completed on Resident #14 and Resident #57 every fifteen minutes.Interview on 05/29/26 at 10:50 A.M. with the Director of Nursing (DON) verified there was no documentation in Resident #14's or Resident #57's medical record regarding the disrobing or wandering. The DON stated she would expect the nurse to document the incident in the residents' medical record.This deficiency represents non-compliance investigated under Complaint Number 3022557.

Based on record review and staff interview, the facility failed to accurately code the preadmission screen and resident review (PASRR) status on the Minimum Data Set (MDS) 3.0 assessment for Residents #7, #13, #18, #25 and #34. This affected five (Residents #7, #13, #18, #25 and #34) of five residents reviewed PASRR. The facility census was 55.Findings Include:1. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, type two diabetes and high cholesterol. Review of the PASRR level two evaluation from the state department of mental health dated 01/23/26 revealed Resident #7 had a level two mental illness.Review of section A of the MDS 3.0 assessment for Resident #7 dated 02/11/26 revealed the facility answered no to the question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability (mental retardation in federal regulation) or a related condition?2. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, type two diabetes and high cholesterol. Review of the PASRR level two evaluation from the state department of mental health dated 03/04/25 revealed Resident #13 had a level two mental illness.Review of section A of the MDS 3.0 assessment for Resident #13 dated 01/27/26 revealed the facility answered no to the question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability (mental retardation in federal regulation) or a related condition?3. Review of the medical record revealed Resident #18 was admitted to the facility on 10-10/15/25 with diagnoses that included psychosis, mood disorder and major depressive disorder. Review of the PASRR level two evaluation from the state department of mental health dated 01/23/26 revealed Resident #18 had a level two mental illness.Review of section A of the MDS 3.0 assessment for Resident #18 dated 10/28/25 revealed the facility answered no to the question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability (mental retardation in federal regulation) or a related condition?4. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses that included insomnia, schizophrenia and anxiety disorder. Review of the PASRR level two evaluation from the state department of mental health dated 09/03/25 revealed Resident #25 had a level two mental illness.Review of section A of the MDS 3.0 assessment for Resident #25 dated 10/18/25 revealed the facility answered no to the question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability (mental retardation in federal regulation) or a related condition?5. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses that included insomnia, major depressive disorder and bipolar disorder. Review of the PASRR level two evaluation from the state department of mental health dated 05/31/25 revealed Resident #34 had a level two mental illness.Review of section A of the MDS 3.0 assessment for Resident #34 dated 06/20/25 revealed the facility answered no to the question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability (mental retardation in federal regulation) or a related condition?Interview with Director of Social Service (DSS) #256 on 05/06/26 at 8:40 A.M. verified the inaccurate coding of Residents #7, #13, #18,#25 and #34's PASRR status on the MDS.

Based on record review and staff interview, the facility failed to ensure recommendations from the state Pre-admission Screening and Resident Review (PASRR) authority, the Ohio Department of Mental Health and Addiction Services, were incorporated into residents' comprehensive care plans as required. This affected four (Residents #7, #13, #18, #34) of five residents reviewed for PASRR requirements. The facility census was 55.Findings include:1. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, type II diabetes mellitus, and hyperlipidemia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #7 was severely cognitively impaired, exhibited active delusions, and required supervision with activities of daily living.Review of the PASRR Level II evaluation completed by the Ohio Department of Mental Health and Addiction Services dated 01/23/26 revealed Resident #7 met criteria for serious mental illness and included recommendations for: skills training, speech/language therapy evaluation, structured therapeutic activities, informal support from nursing facility staff, medication evaluation and monitoring by a nursing facility-designated physician, socialization and recreational activities to decrease isolation and improve peer interaction, vision evaluation, physical therapy evaluation, skin/wound evaluation, adaptive equipment evaluation, evaluation for dementia or other organic mental disorder, nutritional consult, neurological examination, dental evaluation, and occupational therapy evaluation.Review of Resident #7's current comprehensive care plan revealed the PASRR Level II recommendations had not been incorporated into the resident's plan of care.2. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, type II diabetes mellitus, and hyperlipidemia. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #13 was cognitively intact and required extensive assistance of one staff person for activities of daily living.Review of the PASRR Level II evaluation completed by the Ohio Department of Mental Health and Addiction Services dated 03/04/25 revealed Resident #13 met criteria for serious mental illness. Recommendations included obtaining a comprehensive psychiatric assessment to identify behavioral health supports and services, implementation of a crisis intervention plan, yearly or more frequent psychiatric evaluations to clarify psychiatric diagnoses and appropriate treatment, socialization and recreational activities to decrease isolation and improve mood, respiratory evaluation, skin/wound evaluation, ongoing medication review by a physician, and ongoing evaluation of the effectiveness of psychotropic medications on target symptoms.Review of Resident #13's current comprehensive care plan revealed the PASRR Level II recommendations had not been incorporated into the resident's plan of care.3.Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including psychosis, mood disorder, and major depressive disorder. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #18 was severely cognitively impaired, exhibited active delusions, and required supervision with activities of daily living.Review of the PASRR Level II evaluation completed by the Ohio Department of Mental Health and Addiction Services dated 01/23/26 revealed Resident #18 met criteria for serious mental illness. Recommendations included development of a behavior management safety plan to decrease inappropriate behaviors and ensure safety, yearly or more frequent comprehensive psychiatric evaluations, ongoing evaluation of psychotropic medication effectiveness, ongoing medication review by a psychiatrist or similarly credentialed professional, implementation of a behaviorally-based treatment plan, individual psychotherapy with a trained psychotherapist, and case management services to explore supported community living and assist with transition planning.Review of Resident #18's current comprehensive care plan revealed the PASRR Level II recommendations had not been incorporated into the resident's comprehensive care plan.4. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses that included insomnia, major depressive disorder and bipolar disorder. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #34 was severely cognitively impaired and required supervision for completing her activities of daily living.Review of the PASRR level two evaluation from the state department of mental health dated 05/31/25 revealed recommendations for treatment that included Crisis intervention plan, A behavior management safety plan to decrease inappropriate behaviors and ensure safety, yearly (or more often) comprehensive psychiatric evaluation to clarify current psychiatric diagnosis and appropriate treatments , ongoing evaluation of the effectiveness of current psychotropic medications on target symptoms, ongoing medication review by a psychiatrist or similarly-credentialed professional ,mental health counseling, behaviorally based treatment plan, individual psychotherapy with a trained psychotherapist.Interview with Director of Social Services (DSS) #256 on 05/06/26 at 8:40 A.M. verified the PASRR Level II recommendations for Residents #7, #13, #18, #34 had not been incorporated into the residents' care plans as required.

Based on observation and staff interview, the facility failed to ensure the environment remained clean, sanitary, hazard-free, and in a state of good repair. This affected 17 (Residents #1, #2, #8, #9, #10, #19, #21, #27, #33, #38, #42, #48, #52, #53, #58, #59, and #61) of 23 residents reviewed for physical environment and had the potential to affect all 55 residents residing in the facility.Findings include:Observation of the laundry area on 05/05/26 at 8:15 A.M. revealed four missing ceiling tiles directly above the area designated for clean clothing storage. The missing tiles exposed overhead structural beams and the open ceiling cavity. Interview with the Administrator during the observation confirmed the ceiling tiles were missing and had not been replaced.An environmental tour was conducted on 05/05/26 between 11:15 A.M. and 11:40 A.M. throughout resident care areas of the facility. The following multiple environmental and maintenance concerns were identified, observed, and verified with the Maintenance Director (MD) #203 at the time of discovery:- The room occupied by Resident #2 contained an electrical outlet missing its protective cover plate, leaving internal wiring components exposed and accessible. - Hallways throughout the facility, all dining room areas, and the rooms occupied by Residents #10, #21, #27, #33, #42, #58, and #59 contained numerous ceiling tiles with visible brown and yellow water stains of varying sizes. Several tiles appeared sagging and discolored, indicating prolonged or repeated water intrusion and lack of repair or replacement.- The privacy curtain utilized by Resident #9 was heavily soiled and contained multiple dark-colored visible stains throughout the fabric. The curtain appeared unclean and poorly maintained within the resident care area.- The floors in the room occupied by Residents #38 and #48 contained multiple unidentified stains and areas of discoloration scattered across the flooring surface. The stains appeared darkened and embedded, giving the flooring an unclean appearance.- The wall adjacent to the doorway in Resident #19's room contained a large visible crack extending vertically along the wall surface. - The interior portion of the ceiling light fixture located in the secured unit shower room contained seven dead insects visible beneath the light covering.- The baseboard heating unit cover located in the secured unit dining area was heavily scuffed, chipped, and deteriorated, with extensive peeling paint observed across the surface.- The ceiling vent located in the secured unit contained a thick accumulation of gray dust buildup covering the vent surface and louvers, indicating the vent had not been adequately cleaned.- Wallpaper in Resident #1's room was visibly peeling and separating away from the wall surface in multiple areas, creating a worn and poorly maintained appearance within the resident living space.- Windows in the rooms occupied by Residents #8, #52, #53, and #61 lacked privacy curtains, limiting the residents' ability to maintain visual privacy within their rooms.This deficiency represents non-compliance investigated under Complaint Number 2722919, Complaint Number 2720286, Complaint Number 2626774 and Complaint Number 2579601.

Based on record review and staff interview, the facility failed to ensure residents received proper liability notices that included required information on how to request an immediate appeal of the discontinuation of skilled services. This affected one (Resident #62) of three residents reviewed for beneficiary notices. The facility census was 55.Findings Include:Review of the medical record for Resident #62 revealed the resident received a Notice of Medicare Non-Coverage (NOMNC) dated 11/11/25. Further review of the NOMNC provided to Resident #62 revealed the notice failed to include the name of the Quality Improvement Organization (QIO) and the QIO's telephone number, which are required elements to allow the resident or responsible party to request an immediate appeal. Specifically, under the subsection titled How to ask for an immediate appeal, the notice stated: Call your QIO (Quality Improvement Organization) at (insert QIO name and toll-free number of QIO) to appeal, or if you have questions, indicating the required information had not been completed prior to issuance.Interview with the Administrator on 05/05/26 at 7:40 A.M. confirmed the QIO name and contact information were not included on the NOMNC issued to Resident #62.

THE FOLLOWING DEFICIENCY REPRESENTED AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on medical record review, review of facility investigations, staff interviews, and review of facility-initiated corrective actions, the facility failed to ensure adequate supervision and interventions were implemented to prevent resident elopement and exit-seeking behaviors. This deficient practice affected three (Residents #4, #47, and #75) of three residents reviewed for elopement risk. The facility census was 55.Findings include:1. Resident #47 was admitted to the facility on [DATE] with diagnoses including personality disorder, bipolar disorder, adjustment disorder, and adult failure to thrive. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and independent with activities of daily living. Psychiatric documentation dated 01/13/25 identified the resident as having severe impairment in judgment and insight. Review of the care plan revealed a history of significant behavioral concerns including refusal of care and medications, aggression, destruction of property, and verbal aggression toward staff.Review of nursing documentation dated 06/12/25 at 1:34 A.M. revealed staff entered Resident #47's room to administer medications and discovered the resident missing from the room with shattered glass from a broken window present. Staff confirmed the resident was not located within the room or adjoining bathroom area. Review of the facility investigation revealed the resident had last been observed at approximately 10:00 P.M. on 06/11/25 following care provided by staff. At approximately 10:45 P.M., nursing staff identified the broken window and initiated a search of the facility and surrounding grounds. The resident was ultimately located approximately one mile away from the facility and was returned to the building by local law enforcement before being transported to the emergency room for evaluation. Interview with the Administrator on 05/05/26 at 8:45 A.M. verified the circumstances surrounding the elopement incident.As a result of the incident, the facility implemented the following corrective actions by 06/12/25:- On 06/11/25 at 11:00 P.M., the police were notified that Resident #47 was missing.- On 06/11/25 at 11:05 P.M., a facility-wide resident head count was completed, and no additional missing residents were identified.- On 06/11/25 at 11:15 P.M., staff located the resident approximately one mile from the facility.- On 06/11/25 at 11:20 P.M. Licensed Practical Nurse (LPN) #223 accompanied the police back to the facility with Resident #47, and Resident #47 was transported to the emergency room for evaluation.- On 06/12/25 at 7:00 A.M. Resident #47 returned to the facility. Resident #47 was moved to a temporary room with one-on-one supervision until a bed on the facilities secured unit became available.- On 06/12/25 at 7:00 A.M. a scheduled staff meeting was held regarding the facilities policies and procedures for resident elopement.- On 06/12/25 at 8:30 A.M. the facilities Administrator attempted to interview Resident #47, however Resident #47 refused the interview, stating he only wanted his television and his bed.- On 06/12/25 at 9:00 A.M. Resident #47 was seen by the facilities Nurse Practitioner (NP).- On 06/12/25 at 9:30 A.M. Resident #47 was placed on the facilities secured unit with window opening through the secured courtyard area for added security. Every 15-minute checks were also initiated.- On 06/12/25 at 10:00 A.M. the Assistant Director of Nursing (ADON) #900 began completing elopement assessments on all residents including Resident #47. Upon completion of assessments the facilities elopement binder (book used to identify residents with high elopement risk) was updated.- On 06/12/25 at 10:00 A.M. the Director of Social Services (DSS) #256 notified all residents' responsible parties of the facilities sign in and sign out procedures.- On 06/12/25 at 11:00 A.M. a second scheduled staff meeting was held other staff who could not attend the earlier meeting for elopement education.- On 06/12/25 at 1:00 P.M. an elopement drill was conducted.- On 06/12/25 at 1:30 P.M. the Director of Maintenance (DM) #500 audited each window ensuring that each window opened to a maximum of six inches.- On 06/12/25 at 2:00 P.M. the DM # 500 inspected all exit doors and ensured alarms were in working order.- On 06/12/25 at 2:30 P.M. a quality assurance and performance improvement (QAPI) meeting was held with root cause analysis completed.- On 06/12/25 at 4:00 P.M. another staff meeting was held with all staff members regarding elopement education.- On 06/12/25 between 6:00 P.M. and 8:00 P.M. telephone education was provided by the Administrator and Human Resources Director for those who could not attend the earlier elopement educations.2. Resident #75 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury, alcohol dependence, and history of suicidal behaviors. Review of the most recent MDS assessment dated [DATE] revealed the resident was cognitively intact and independent with activities of daily living. Care plan documentation identified concerns related to impulsive behaviors and anxiety, while psychiatric documentation dated 07/07/25 identified ongoing impulsivity and safety concerns.Review of the facility timeline revealed that on 07/27/25 at approximately 9:00 P.M., Licensed Practical Nurse (LPN) #223 responded to the facility front entrance after hearing the doorbell and discovered a wheelchair positioned outside the entrance with the resident's name labeled on the chair. Staff immediately checked the resident's room and determined the resident was missing from the facility. At approximately 10:04 P.M., police located the resident approximately one-half mile from the facility and escorted him safely back to the building. During staff interview following the incident, the resident stated he had been able to leave the building because he knew the facility door access code. Interview with the Administrator on 05/06/26 at 9:30 A.M. verified the resident eloped from the facility.As a result of the incident, the facility implemented the following corrective actions by 07/28/25:- On 07/27/25 at 9:05 P.M. a head count of all residents was completed with no other missing residents.- On 07/27/25 at 10:05 P.M. the Director of Nursing (DON) arrived on site and completed and an assessment of Resident #75 with no noted concerns.- On 07/27/25 at 10:15 P.M. paramedics arrived at the facility and did not transport the resident to a hospital as they deemed the situation not an emergency situation.- On 07/28/25 at 8:30 A.M. the Administrator interviewed Resident #75. He confirmed that he knew the code to the door and was able to open the door using that code.- On 07/28/25 at 9:00 A.M. a QAPI meeting was held to develop a root cause analysis for the situation.- On 07/28/25 at 9:15 A.M. all doors that required numerical code input were changed.- On 07/28/25 at 10:00 A.M. at 10:00 A.M. Resident #75's care plan was updated to reflect an elopement risk.- On 07/28/25 at 11:00 A.M. elopement assessments were completed on all residents including Resident #75.- On 07/28/25 at 11:30 A.M. the facilities elopement binder was reviewed and updated.- On 07/28/25 at 12:00 P.M. Resident #75 was seen by the facilities NP.- On 07/28/25 at 12:30 P.M. an elopement drill was conducted.- On 07/28/25 at 1:15 P.M. all staff present were educated about the facilities elopement policy and procedure and responsibility for maintaining door code security.- On 07/28/25 between 2:00 P.M. and 4:00 P.M. staff not at facility were contacted via phone and educated on the facilities' elopement policy and procedure and responsibility for maintaining door code security.3. Resident #4 was admitted to the facility on [DATE] with diagnoses including brain cancer, hallucinogen use, and epilepsy. Review of the most recent MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired and independent with activities of daily living. Care plan documentation identified poor impulse control.Review of nursing documentation dated 02/12/26 at 6:17 P.M. revealed the resident demonstrated repeated exit-seeking behaviors, including approaching and exiting through the facility front entrance, causing activation of the door alarm on multiple occasions. Staff responded immediately each time the alarm activated and observed the resident outside the facility near the entrance area while remaining within direct staff observation. Staff provided verbal redirection and safely escorted the resident back into the building without resistance. Nursing staff completed assessments, obtained vital signs, and documented no evidence of injury, pain, or acute distress. Nursing administration and the attending provider were notified of the incidents, and due to continued wandering and exit-seeking behaviors, the facility implemented increased supervision interventions including continuous one-to-one observation. Interview with the Administrator on 05/06/26 at 9:30 A.M. verified Resident #4's exit-seeking behaviors and related incident.The deficient practice was corrected on 02/13/26 when the facility implemented the following corrective actions: - On 02/12/26 at 6:15 P.M., a call was placed to the DON and NP notifying of the incident. The NP gave orders for intramuscular (IM) Haldol (antipsychotic) injection which was refused by the resident. A message was left for Resident #4's guardian. - On 02/12/26 at 6:30 P.M., the local police arrived at facility following call from an unknown source while Resident #4 was near the road. Police ensured/confirmed safety of the resident. - On 02/12/26 at 6:40 P.M., a head count was completed by LPN #400- On 02/12/26 at 8:05 P.M., Resident #4 went to front doors and again pushed the handle allowing alarm to sound. LPN #400 heard alarm and approached the front door. She witnessed the doors release and Resident #4 proceed outside of doors. LPN #400 followed him out and after reassurance was able to redirect him back inside. - On 02/12/26 at 8:20 P.M., a call was placed to the DON and NP. Orders given for emergency transfer. Resident #4's guardian was notified of change in condition and new orders. - On 02/12/26 at 8:25 PM Head count was completed by LPN #400.- On 02/12/26 at 8:25 P.M., Resident #4 left the facility via ambulance and was taken to the local hospital.- On 2/13/26 at 9:00 A.M., a QAPI meeting was held to discuss the incident-root cause analysis determined exacerbation of psychiatric conditions causing increased behaviors in Resident #4.- On 02/13/26 at 9:15 A.M. Resident #4's care plan reviewed and updated. - On 02/13/26 at 10:00 A.M., an elopement drill was conducted.

Based on record review, observations, resident and staff interviews, and facility policy review, the facility failed to identify and incorporate known post-traumatic stress disorder (PTSD) triggers into the care plan to prevent re traumatization for one (Resident #40) of one resident reviewed for trauma-informed care. The facility census was 55.Findings include:Record review showed Resident #40 was admitted on [DATE] with diagnoses including bipolar disorder, major depressive disorder, and PTSD. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 10/15, indicating moderate cognitive impairment. The resident received Prazosin z(alpha blocker used to treat nightmares related to PTSD) 2 milligrams (mg) nightly for PTSD.The resident's psychosocial evaluation dated 8/14/24 also documented a history of being mauled by pit [NAME]. However, review of the resident's mood-focused care plan showed no inclusion of this identified trigger and no interventions to prevent exposure to dogs during facility activities. Review of the initial psychiatry initial consult dated 11/11/24 and ongoing psychotherapy notes (dated 10/15/25 through 04/08/26) identified a specific PTSD trigger: Resident #40 was attacked by three pit [NAME] in childhood and continued to experience flashbacks related to this event. Interview on 05/05/26 at 2:55 P.M. with Director of Social Services (DSS) #256 and the Resident Review Nurse (RRN) #266 confirmed that Resident #40's PTSD trigger was not care planned.During an interview on 05/05/26 at 4:00 P.M., Resident #40 stated he did not like dogs and felt bothered when therapy dogs visited. He reported staff did not keep the dogs away from him. Interview on 5/12/26 at 1:44 P.M. with Activity Director (AD) #226 revealed Resident #40 enjoyed religious activities, snack socials, live music, and pets. The facility had a musician visit once a month with two therapy dogs. The dogs stayed with the musician during the activity. Resident #40 informed AD #226 that he was bitten by dogs when he was a child. Resident #40 had attended the music activities when the dogs were present, and she informed the resident prior to the activity. She stated she had observed Resident #40 pet the dogs on occasion.Observations on 05/04/26, 05/05/26, 05/06/26, 05/07/26, 05/11/26, and 05/12/26 revealed no dogs in the building.Review of the facility's Resident Care Plans policy (05/01/22) stated that care plan interventions must address underlying sources of problems, not only symptoms or triggers.

Based on observations, staff and resident interviews, record review, and facility policy review, the facility failed to ensure a safe, clean, homelike environment by ensuring general cleanliness was maintained, water temperatures reached appropriate and homelike temperatures, and blinds, ceiling tiles, walls, and door frames were without the need for repair. This affected all residents residing in the facility. The facility census was 51. Findings include: During the onsite survey an interview on 06/04/25 at 11:07 A.M. with Chief Operating Officer (COO) revealed she was aware of physical environmental concerns that resulted in citations during the previous annual survey. She verified the physical environmental issues currently in the building, including water temperatures not reaching the appropriate and homelike temperatures, and concerns regarding the general repair and cleanliness of the room were ongoing. The COO confirmed the broken blinds, discolored and bulging ceiling tiles, gouges, and missing paint on walls and door frames, furniture in disrepair, and general housekeeping tasks were not completed by the facility's allegation of compliance date of 04/20/25 as planned in the facility's plan of correction. An interview on 06/09/25 at 1:06 P.M. with the Chief Executive Officer (CEO) confirmed the facility's physical environmental needs were not met by the deadline of 04/20/25 as stated in the facility's previous plan of correction. A follow up interview with the Administrator on 06/11/25 at 11:03 A.M. revealed the new Director of Maintenance who was due to begin employment on 06/09/25 fell through. The Administrator reported she is still in need of a new Director of Maintenance and has refreshed the advertisement for the position. The Administrator stated she had been working with the CEO to develop a revised corrective action plan. The Administrator reported the CEO will be bringing in a contractor and the goal was to go room-to-room to identify the environmental needs of each room. Review of the policy Homelike Environment dated 05/01/22 revealed residents are to be provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean, sanitary environment, adequate lighting, clean bed and bath linens that are in good condition, and pleasant and neutral scents. The following environmental concerns were identified at the time of the onsite investigation: 1. Interview on 06/02/25 at 1:47 P.M. with Resident #53 revealed her room was not being cleaned consistently and had not been cleaned for the past five days. Observation at the time of the interview revealed the floor appeared soiled with dried stains. Interview on 06/02/25 at 1:56 P.M. with Resident #49 revealed had previously requested a new mattress due to sinking in the middle several months ago but had not been addressed. Resident #49 also stated the blinds had missing pieces and the bathroom ceiling tile was bulging. Interview on 06/02/25 at 3:48 P.M. with Resident #34 stated sometimes there are no washcloths available for bathing and towels are used. Observation on 06/03/25 from 3:00 P.M. to 4:35 P.M. of a facility tour with the Administrator and Maintenance Director #218 revealed the following concerns - Resident #30's room was missing a light bulb above the sink in the resident's room. Saturated paper towels with a strong urine odor were noted on the floor at the entrance to the resident's bathroom near the bed. Resident #30's call light indicator cover was hanging and was not fully attached outside of the resident's room. - Resident #35's room was missing a bottom drawer in front of a three-drawer built-in cabinet. The floor of Resident #35's room was heavily soiled. - The flooring around the 100-hall nurse's station had a trail of various dried brown spots of an unknown substance on the floor. - Resident #49 and Resident #50's shared room had broken blinds covering the window. Ceiling tiles in the bathroom were cracked and bulging. The privacy curtain dividing the room was visibly soiled. - Resident #51's room had two stained ceiling tiles near the entrance door. - The exit door at the end of the 100-hall outside Resident #53's room revealed various loose trash debris including used gloves, napkins, condiment wrappers, lids, etc. outside of the exit door and visibly blowing around the parking lot. - Resident #53's room had multiple holes in the wall and ceiling tiles near the door. There were two stained ceiling tiles, and dried stains on the floor. The toilet paper holder in Resident #53's bathroom was empty, with two rolls of toilet paper on the back of the toilet and a partially used roll of toilet paper not easily reached on the bathroom counter. An interview at the time of observation with Resident #53 stated it was hard to reach the toilet paper, and she wished staff would replace the toilet paper on the older for her and wished staff would clean her floors. - A used glucometer test strip was on the floor outside the rooms of Residents #49, #50, #51, and #52. - Resident #40's floor was visibly soiled. Resident #40's toilet was visibly soiled with dried brown stains around the whole base of the commode. The bathroom had a strong pervasive odor, and the bathroom light was missing a cover. - The [NAME] shower room had cracked tiles to the floor and edges. - Resident #41's room contained a sink, above which were dirty dishes with the present of gnats. Resident #41's baseboards near the bathroom were loose. - Resident #42's electrical outlet between the bathroom and the bed had visible white rough spackling and dried white powder on the floor below. There were large stains on the ceiling tiles and the bathroom floor and fixtures were visibly soiled. - Resident #43 and Resident #44's shared room had a visibly dirty floor with dried brown spots around and behind the toilet. The bathroom had a strong pervasive odor. The bathroom doorframe was visible eroded from a prior leak, and dried stains were visible on the window blinds. - Resident #45's room contained two missing tiles near the sink base and the floor of the room was visibly soiled. - Resident #1 and Resident #2's shared room had two missing light bulbs in the room and no cover over the bathroom light. - Resident #3 and Resident #4's shared room floor was visibly soiled with various debris. The bathroom was wet with what appeared to be a leak. - Resident #5's bathroom had stains splattered on the blinds and walls surrounding the window. - There was a partially missing floor tile on the [NAME] hall entrance to the dining room. - There was missing wood trim pieces above the handrail outside room [ROOM NUMBER] which was vacant at the time of the survey. - Resident #6's room had a soiled privacy curtain. There were bulging ceiling tiles above the sink in Resident #6's room. The bathroom floor had wet, soiled paper towels in a pile on the floor. - Resident #7 had a stained ceiling tile above the bed and the room contained broken window blinds. - Resident #8's room had a hole in the wall next to the bed. There was a stained ceiling tile near the air conditioning unit. - Resident #9's room had peeling paint on the bathroom door, stained and bulging ceiling tiles above the bed, and a missing trim piece near the entrance door to the room. - Resident #10's room had three missing light bulbs, seven stained ceiling tiles, and six missing drawers on the bathroom cabinet. The clock in the room was non-functional. There were no paper towels in the room and the entrance door was missing the mechanism/latch for the door handle. - Resident #11's room had gouges on the wall and a visibly soiled floor. - The dining room floor in the memory care unit was peeling up. The peeling floor had previously been taped down but the tape had worn off and was not secured. - Resident #14 and Resident #15's shared room contained visibly soiled floors to the room. The bathroom contained a visibly soiled toilet seat. - Resident #17's room had a dirty privacy curtain and a bathroom with surfaces which were visibly soiled. - The East shower room had a stained ceiling tile near the vent near the entry door. - Resident #18's room contained various stains on the floor. Resident #18 was missing a drawer in the room vanity. - Resident #19's room had a stained privacy curtain that would not slide on the track. There was a brown stained sheet on the bed. The wall underneath the window had missing paint. There was a broken drawer in the dresser cabinet. The resident's bathroom was visibly soiled and had a strong pervasive odor. - Resident #21's room had a visibly dirty fan with a soiled and sticky floor. - Resident #22's room had a heavily soiled floor. - Resident #25 and Resident #26's room contained no privacy curtain. The Administrator confirmed the above findings at the time of observation during the facility environmental tour. 2. Review of the facility water temperature logs dated 04/21/25, 04/28/25, 05/05/25, 05/12/25, 05/20/25 and 05/27/25 revealed on 04/28/25 the East one shower room was recorded as 103.2 degrees Fahrenheit (F), on 05/12/25 the East two shower rooms were recorded as 103.4 degrees F and on 05/27/25 the East one shower room was recorded as 103.1 degrees F. Observation and interview on 06/02/25 at 12:00 P.M. with the Administrator conducting water temperatures revealed the shared bathroom for Resident #34 and #35's faucet was 103.1 degrees F after running the hot water for a few minutes and the hot water in the East shower room was 100.7 degrees F. The Administrator confirmed the above findings at the time of observation and confirmed the water temperatures did not meet the required minimum of 105 degrees F. Review of the 05/01/22 facility policy called Water Temperature revealed maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log. Water temperatures would not be more than 120 degrees. 3. An observation on 06/04/25 at 9:15 A.M. with Maintenance Director #218 of the shower rooms revealed the rooms contained no washcloths in the East shower room and approximately 10 washcloths in the [NAME] shower room. Maintenance Director #218 confirmed the lack of washcloths in the shower room. Observation on 06/04/25 at 9:15 A.M. with Maintenance Director #218 of the shower rooms revealed no washcloths in the east shower room and approximately 10 washcloths in the west shower room. Maintenance Director #218 confirmed the above observations. Observation on 06/04/25 at 9:22 A.M. of the laundry area with Maintenance Director #218 and Laundry Staff #229 revealed no washcloths in the clean laundry area. Laundry Staff #229 confirmed staff frequently run out of washcloths and reported more were on order but had not arrived and he was waiting for the dirty washcloths to come back to laundry to wash them for resident use. This deficiency represents non-compliance investigated under Master Complaint Number OH00165391 and Complaint Number OH00165087.

Based on observation, interview, and review of the facility menus, the facility failed to serve palatable meals at appetizing temperatures for residents' meals. This had the potential to affect all 51 residents residing in the facility. The facility indicated all residents received meals from the kitchen. The facility census was 51. Findings include: Review of the breakfast menu for 06/03/25 revealed the planned meal included a cheese omelet, two breakfast sausage links, cold or hot cereal, assorted juices, and milk of choice. Observation on 06/03/24 at 6:45 A.M. with Dietary Manager #208 revealed initial food temperatures on the steam table as follows: egg cheese omelet 166 degrees Fahrenheit (F), sausage links 181 degrees F, pureed sausage 179 degrees F, pureed eggs 169 degrees F, oatmeal 172 degrees F, mechanical sausage 173 degrees F, white milk 31 degrees F, chocolate milk 32 degrees F, and apple juice 30 degrees F. Continuous observation of the breakfast tray line on 06/03/25 beginning at 7:09 A.M. with Dietary Manager #208 revealed Dietary Manager #208 was preparing trays. Hand hygiene, proper sanitation and portions were observed during tray line. At 7:46 A.M. Dietary Manager #208 confirmed she ran out of oatmeal and needed to use cold cereal for the four remaining trays for Residents #18, #22, #23, and #25. Dietary Manager #208 also confirmed they ran out of spoons and had to use plastic spoons for the last four trays as well. Tray line finished at 7:52 A.M. A test tray was prepared and sent on the last food cart. The food cart arrived on the east unit at 7:55 A.M. and the tray pass was initiated. The last resident food tray was passed at 8:06 A.M. Interview on 06/03/25 at 8:03 A.M. with Resident #33 revealed the food was cold and the kitchen does not always have enough for meals. Interview on 06/03/25 at 8:05 A.M. with Resident #48 revealed the kitchen always runs out of food and meals are cold. A test tray was completed with Dietary Manager #208 at 8:08 A.M. which revealed the following temperatures: Cheese Omelet 118 degrees F, Sausage 109 degrees F, Sausage 109 degrees F, Pureed Sausage 112.8 degrees F, pureed egg 106 degrees F and milk 65 degrees F. Taste test with Dietary Manger #208 at the time revealed Dietary Manager #208 confirmed the food was not warm enough for preference, and the pureed omelet was bland, tasteless, and did not have a desirable flavor. Review of the Resident Council Meeting Minutes dated 05/27/25 revealed the residents reported food concerns. Residents noted the meals were repetitive at times and residents requested more fresh fruit. Review of the facility policy Food Temperatures at Point of Service dated 07/14/23 revealed best efforts will be made to present hot food hot and cold foods cold at point of service by using thermal lids and bases, heated or chilled plate and thermal pellets as necessary. Food service will monitor the palatability of food at point of service by periodic test tray evaluation and review of resident council concerns. This deficiency represents non-compliance investigated under Complaint Numbers OH00165087 and OH00164461.

Based on review of personnel files, interviews, and review of the nursing job description, the facility failed to ensure nurses providing direct care to residents maintained current cardiopulmonary resuscitation (CPR) certification. This had the potential to affect all 37 residents whose advanced directives were listed as full code (term used to signify all measures which should be taken to resuscitate, including CPR). The facility census was 51. Findings include: Review of the personnel files for three licensed practical nurses (LPNs) and the Director of Nursing (DON) revealed one LPN (LPN #215) had a hire date of [DATE] with proof of CPR certification from [DATE] through [DATE] and from [DATE] through [DATE]. There was no evidence LPN #215 had active CPR certification from [DATE] through [DATE]. Interview on [DATE] at 3:30 P.M. with Business Office Manager (BOM) #207 confirmed there was no evidence of active CPR certification for LPN #215 in the personnel file. During the interview, it was revealed that BOM #207 just started the Human Resources position the end of [DATE] and began performing personnel file audits, at which time she notified any staff whose file was noted to have missing necessary items, such as documentation of active CPR certification during their course of employment, and she had received the CPR documentation with the issue date of [DATE]. During a follow-up interview on [DATE] at 5:00 P.M., BOM #207 provided proof of ongoing, valid CPR for LPN #223 and LPN #228, whose files previously showed a gap in certification, but confirmed there was no further documentation of CPR certification from the time of the lapsed certification (expired [DATE]) and the new certification (issued [DATE]). Interview on [DATE] at 10:54 A.M. with LPN #215 confirmed there was a gap in her CPR certification and that LPN #215 was not certified in CPR from the end of [DATE] until [DATE]. Interview on [DATE] at 11:00 A.M. with the DON confirmed all facility nurses should maintain current CPR certification. A follow-up interview on [DATE] at 12:28 P.M. with the DON confirmed LPN #215 was assigned to work units per facility need and could work on any unit. Review of the job description for Licensed Practical Nurse last updated [DATE] revealed the LPN must be certified in CPR. This deficiency represents non-compliance investigated under Complaint Number OH00165087.

Based on medical record review and interview, the facility failed to ensure the power of attorney (POA) was notified of a change in condition. This affected one resident (#32) of four residents reviewed for notification of change in condition. The facility census was 51. Findings include: Review of the medical record for Resident #32 revealed an admission date of 01/31/25. Diagnoses included but were not limited to metabolic encephalopathy, acute and chronic respiratory failure, obstructive sleep apnea, congestive heart failure, and morbid obesity. Review of the banner bar of Resident #32's electronic medical record revealed special instructions which stated: POA (power of attorney) would like to be notified of any behaviors or concerns. Review of Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] for Resident #32 revealed a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. Review of activities of daily living (ADLs) revealed Resident #32 was dependent upon staff for ADLs. Review of the nursing progress note dated 04/17/25 timed 10:32 P.M. written by Registered Nurse (RN) #223 revealed upon entering Resident #32's room, Resident #32 was noted to be bleeding puddles of blood from bed onto floor. Emergency Medical Services (EMS) and Nurse Practitioner (NP) were called, and Resident #32 was sent to the hospital. No evidence was recorded that the POA was notified. Review of the nursing progress note dated 04/18/25 timed at 5:37 A.M. written by RN #223 for Resident #32 returned from the hospital and noted the NP was aware. There was no evidence the POA was notified of the resident's return. Review of the nursing progress noted dated 05/20/25 timed at 5:24 P.M. written by Licensed Practical Nurse (LPN) #215 revealed Resident #32 had worsening symptoms like shortness of breath (SOB), being extremely tired and groggy as the shift progressed. The NP was notified of Resident #32's change in condition and NP assessed Resident #32. LPN #215 was notified to have Resident #32 use his continuous positive airway pressure (CPAP) machine (a device used to treat sleep apnea and other breathing disorders. It delivers a constant stream of pressurized air through a mask to keep the airway open and prevent pauses or shallow breaths) which Resident #32 refused. Resident #32 was noted to be sent out to the hospital at approximately 4:00 P.M. for SOB and change in condition. There was no evidence the resident's POA had been notified. Review of the nursing progress note dated 05/23/25 written by LPN #204 revealed Resident #32 returned to the facility and the physician and NP were notified. No evidence was found of the POA being notified of the resident's return. Interview on 06/02/25 at 11:24 A.M. with Resident #32 revealed concerns related to his POA not being notified of changes in his condition and when he has gone to the hospital in the past few months. Interview on 06/03/25 at 11:15 A.M. with the Director of Nursing (DON) confirmed Resident #32's chart had special instructions which listed the POA would like to be notified of concerns. The DON confirmed there was no evidence of the POA being notified when Resident #32 went to the hospital on [DATE], returned on 04/18/25, went to the hospital on [DATE], or when he returned on 05/23/25. Review of the policy Change in Condition Monitoring dated 05/01/22 revealed our facility shall promptly notify the resident, his or her attending physician, and family/Power of Attorney (POA)/guardian of changes in the resident's medical status. This deficiency represents non-compliance investigated under Complaint Number OH00165009.

Based on medical record review and interview, the facility failed to ensure weights were obtained upon readmission from the hospital and refusals were consistently documented. This affected one resident (Resident #32) of four residents reviewed for weights. The facility census was 51. Findings include: Review of the medical record for Resident #32 revealed an admission date of 01/31/25. Diagnoses included but were not limited to metabolic encephalopathy, acute and chronic respiratory failure, obstructive sleep apnea, congestive heart failure, and morbid obesity. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #32 had a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. Review of activities of daily living (ADLs) indicated Resident #32 was dependent upon staff for ADLs. Review of the physician order dated 04/18/25 and discontinued on 05/22/25 for Resident #32 revealed an order for monthly weights every day shift starting on the 18th every month for screening. Review of the most recent weight recorded in the medical record for Resident #32 revealed it was on 04/18/25 with a weight of 536 pounds. Review of Resident #32's census revealed Resident #32 went to the hospital on [DATE] and returned on 05/23/25. Review of the 05/23/25 nursing admission assessment with care plan revealed under section four: dietary/nutritional status section revealed the most recent weight was 536 pounds from 04/18/25. No indication was recorded of any resident refusal. Review of the nursing progress notes dated 05/23/25 for readmission revealed no documentation of weight refusal for Resident #32. Review of the physician orders following hospitalization on 05/20/25 and readmission on [DATE] revealed no physician orders for weight monitoring frequency. Interview on 06/03/25 at 11:15 A.M. with the DON confirmed there was no readmission weight was obtained nor was a refusal documented for Resident #32 upon readmission from the hospital on [DATE] as required. Review of the policy Weight Management dated 05/01/22 revealed the nursing assistant will weigh residents within 24 hours of admission to the facility, then weekly for four weeks and then monthly thereafter. Resident's weight information is recorded and trended in the medical record by the unit manager or charge nurse. This deficiency represents non-compliance investigated under Complaint Number OH00165009.

Based on observation, medical record review, facility policy review, Centers for Disease Control (CDC) guidance on COVID-19 and interview the facility failed to provide timely and necessary intervention following changes in resident condition. Actual Harm occurred on [DATE] when Resident #18 had unwitnessed fall resulting in increased pain, decreased functional ability and inability to participate in therapy services due to pain. On [DATE] (15 days following the fall) Resident #18 was transferred to the hospital and assessed to have an acute fracture of left hemipelvis involving the left superior and inferior pubic rami extending towards the medial left acetabulum. Actual Harm occurred on [DATE] when Resident #55 was admitted to the hospital for treatment of pneumonia and was experiencing dark, tarry stools. Resident #55 had tested positive for COVID-19 in the facility on [DATE] with symptoms including dry cough, nasal congestion, nausea, vomiting, and loose stools. The lack of timely and adequate medical treatment/intervention after testing positive for COVID-19 on [DATE] contributed to Resident #55's hospitalization and subsequent death on [DATE]. Actual Harm occurred on [DATE] when Resident #31 was transferred to the hospital and admitted for treatment of acute respiratory failure secondary to COVID-19. However, Resident #31 had been experiencing symptoms including nasal congestion, cough, nausea, vomiting, and loose stools since [DATE] that were not timely or adequately treated contributing to the hospitalization . During the hospitalization , Resident #31 was also noted to have pneumonia. Resident #31 was hospitalized from [DATE] to [DATE]. This affected one resident (#18) of three residents reviewed for falls/accidents and two residents (#31 and #55) of 28 residents reviewed for quality of care and treatment. The facility census was 54 Findings include: 1. Review of the medical record for Resident #18 revealed an admitted [DATE] with diagnoses including Parkinson's disease, age-related osteoporosis, dementia, generalized muscle weakness, and dependence on wheelchair. Resident #18 was hospitalized from [DATE] to [DATE]. Review of a physician's order dated [DATE] revealed order for Acetaminophen 650 milligrams (mg) every four hours as needed. Review of a physician's order dated [DATE] revealed order for Tramadol 50 mg every six hours as needed. Review of a physician's order dated [DATE] revealed order for Acetaminophen 500 mg once daily for mild to moderate pain. Review of a nurse's note dated [DATE] at 7:35 A.M. revealed Resident #18 was found on floor by nurse aide lying flat on her back. Nurse and aide picked Resident #18 up off the floor and into her wheelchair. Resident #18 was taken to the dining room for breakfast. Resident #18 stated she got up from her recliner chair to pick something up off the floor and fell backwards. It was noted Resident #18 claimed she didn't hit her head and had no complaints of pain at this time. Review of an Orders Administration Note dated [DATE] at 5:40 P.M. revealed Resident #18 was administered as needed Acetaminophen for pain. Review of a nurse's note dated [DATE] at 6:03 P.M. revealed Resident #18 received an unspecified x-ray. Review of a Physical Therapy Summary of Daily Skilled Services note dated [DATE] at 6:43 P.M. revealed Resident #18 was noted to have had fall in morning due to ambulating on own. Unable to ensure carry over of education to wait for staff for transfers due to poor cognition. During therapy session Resident #18 was unable to use sit to stand lift or ambulate due to pain to left hip while flexing hip. Resident #18 reported moderate to severe pain. Nursing was notified. Review of Medicare Skilled Charting assessment dated [DATE] timed 6:55 P.M. revealed Resident #18 was alert and oriented to person and situation. Resident #18 had unsteady gait, impaired balance, weakness, and decreased sensation. Resident #18 required assistance for bed mobility and transfers. Resident #18 had pain to left hip/groin area status post fall and was noted to be grimacing. An x-ray was pending at time of assessment. Review of an Orders Administration Note dated [DATE] timed 9:06 P.M. revealed Resident #18 was noted to be in pain. Review of nurse's note dated [DATE] at 9:46 P.M. revealed Resident #18 complained of pain to groin and left hip to nurse. It was noted nursing staff and power of attorney (POA) argued through camera in room about Resident #18's bathing schedule. Resident #18 was noted to be upset during argument and yelled at POA. Resident #18 received a bed bath. Review of a Patient Report dated [DATE] revealed Resident #18 had one view x-ray of left hip and pelvis. X-ray showed no acute fracture or dislocation. It was noted Resident #18 had enlargement of stool within the rectal vault. Results signed by interpreting physician on [DATE] at 3:19 A.M. Review of an Orders Administration Note dated [DATE] at 9:45 A.M. revealed Resident #18 was noted to be in pain. Review of an Orders Administration Note dated [DATE] at 10:56 A.M. revealed Resident #18 was administered as needed Tramadol for hip pain. Review of an Orders Administration Note dated [DATE] at 8:26 P.M. revealed Resident #18 was administered as needed Tramadol for signs and symptoms of left hip and groin pain. Resident #18 was noted to guard areas of pain. Review of an Orders Administration Note dated [DATE] at 9:26 P.M. revealed Resident #18 was noted to be in pain. Review of an Orders Administration Note dated [DATE] at 8:08 A.M. revealed Resident #18 was administered as needed Tramadol. Review of an Orders Administration Note dated [DATE] at 8:24 P.M. revealed Resident #18 was administered as needed Tramadol for complaints of generalized hip and groin pain. Review of a nurse practitioner (NP) progress note dated [DATE] revealed on [DATE] Resident #18 complained of pain to left hip with range of motion during physical therapy. Resident #18 was status post fall on [DATE]. An x-ray was ordered and completed on [DATE] with no acute abnormalities. No new orders were obtained. Review of a nurse's note dated [DATE] at 11:28 A.M. revealed nurse aide reported Resident #18 was complaining of pain to pelvic area. The NP was contacted and stated Resident #18's x-ray was negative. Review of a nurse's note dated [DATE] at 1:00 P.M. revealed nurse aide reported Resident #18 complained of pain to pelvic area. Nurse notified Director of Nursing (DON), Assistant DON (ADON), NP and POA. Review of a Pain Tool assessment dated [DATE] at 3:28 P.M. revealed Resident #18 had pain to the pelvic area. Pain was improved by Tylenol and resting and worsened by standing. Pain affected social activities, physical activities and mobility, and emotions. Review of a nurse's note dated [DATE] at 12:56 A.M. revealed Resident #18 continued to complain of left sided pelvic pain and as needed Tramadol was administered. Review of a Physical Therapy Summary of Daily Skilled Services note dated [DATE] at 5:15 P.M. revealed Resident #18 declined to participate in transfer training due to complaints of left groin pain. Nursing aware. Review of a physician's order dated [DATE] revealed order for Norco ,d+[DATE] mg twice daily for pain management for 10 days. Review of a NP progress note dated [DATE] revealed no evaluation of continued pain. The NP noted pain regimen to be Acetaminophen 500 mg daily, Acetaminophen 650 mg every four hours as needed, Tramadol 50 mg every six hours as needed, and Norco ,d+[DATE] mg twice daily. Review of a Physical Therapy Summary of Daily Skilled Services note dated [DATE] at 5:55 P.M. revealed Resident #18 complained of pain through groin during therapy and limited participation. Nursing notified of pain present during session. Review of a Physical Therapy Summary of Daily Skilled Services note dated [DATE] timed 12:48 P.M. revealed Resident #18 continued to have intermittent pain persisting to left thigh and groin. Review of a nurse's note dated [DATE] at 5:04 P.M. revealed Resident #18 received morning scheduled pain medication. During nap time Resident #18 complained of pain to nurse aide when being adjusted in bed and Resident #18 was administered as needed Tylenol. Review of an Orders Administration Note dated [DATE] at 8:10 A.M. revealed Resident #18 complained of pain to leg and was administered Norco. Review of a NP progress note dated [DATE] revealed no evaluation of the resident's continued pain. Review of a nurse's note dated [DATE] at 1:48 P.M. revealed nurse aide reported bilateral swelling to Resident #18's lower extremities. The NP was notified, and the diuretic Lasix was ordered as needed. Review of a NP progress note dated [DATE] revealed Resident #18 had increased edema to bilateral lower extremities. The NP ordered Furosemide (Lasix) 20 milligrams (mg) for three days and as needed. The NP noted Resident #18's bilateral lower extremities were shiny and firm. Review of the Medicare Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #18 had severely impaired cognition and was dependent on staff for activities of daily living (ADLs). Review of an Orders Administration Note dated [DATE] at 7:12 P.M. revealed Resident #18 was administered an as needed suppository for constipation. Review of a Patient Report dated [DATE] revealed Resident #18 had an x-ray of the abdomen. The x-ray showed a few mildly dilated gas-filled loops of bowel, multiple non-dilated gas filled loops of bowel, and stool visualized in colon to level of hepatic flexure. Follow-up for resolution was recommended to rule out ileus or obstruction. Results signed by interpreting physician on [DATE] at 12:09 P.M. Review of a nurse's note dated [DATE] at 9:55 A.M. revealed Resident #18's abdominal x-ray results were returned. An order was received to transfer the resident to the hospital for an evaluation. Ambulance services arrived at 9:16 A.M. Review of a Hospital Medicine History and Physical dated [DATE] revealed Resident #18 presented to hospital for concern of bowel obstruction. Resident #18 had abdominal distension and stiffness. An abdominal x-ray completed prior to admission showed concern for high stool burden/obstruction. Resident #18 passed stool successfully while in hospital. While in the emergency department (ED) a cat (CT) scan was completed, and Resident #18 was noted to have a fracture of the pelvis. CT results showed acute fractures of left hemipelvis involving the left superior and inferior pubic rami extending towards the medial left acetabulum. Orthopedics were following; however, the fracture was nonsurgical. Resident #18's sister was present at hospital and reported on [DATE] Resident #18 had a fall and had been complaining of pain to left hip since. Physical examination showed edema to right lower extremity and trace edema to left hip. Resident #18 had pain to the left hip inguinal fold area and when laying on side. Review of the Hospital Discharge Summary dated [DATE] revealed diagnoses including closed nondisplaced fracture of pelvis, chronic constipation, and cellulitis of extremity. Review of a nurse's note dated [DATE] at 3:29 P.M. revealed the hospital reported Resident #18 had pelvic fracture with no surgical interventions. Resident #18 would return to facility weight bearing as tolerated. Review of a nurse's note dated [DATE] at 6:30 P.M. revealed Resident #18 returned to the facility from the hospital. Review of a NP progress note dated [DATE] revealed Resident #18 readmitted to facility from hospital with diagnoses of left pelvic fracture. The NP noted prior to admission Resident #18 was totally dependent on staff for ADL care needs. Review of the Medication Administration Record (MAR) for [DATE] revealed Resident #18 received as needed Acetaminophen 650 mg on [DATE] at 11:12 A.M. Resident #18 received as needed Tramadol 50 mg on [DATE] at 10:56 A.M. and 8:26 P.M., [DATE] at 8:08 A.M. and 8:24 P.M., and [DATE] at 12:56 P.M. Resident #18 received Norco ,d+[DATE] mg twice daily from [DATE] at 9:00 P.M. to [DATE] to 9:00 A.M. Resident #18 received routine Acetaminophen 500 mg once a day. Review of plan of care revised [DATE] revealed there was no care plan developed related to Resident #18's pain status. Interview on [DATE] at 8:00 A.M. with Resident #18's sister revealed she had made an allegation of neglect in [DATE] and had provided videos as supporting evidence to facility staff. During the interview, the resident's sister also shared Resident #18 had a fall at the beginning of [DATE]. An x-ray was completed that did not show a fracture; however, Resident #18 was in pain following the incident and was unable to advocate for herself. The resident's sister revealed around the middle of [DATE] Resident #18's stomach was hard and full for a few days and she was having edema. The sister indicated while at the hospital Resident #18 was found to have a hip fracture. Review of a family provided two minute and one second video dated [DATE] at 9:08 A.M. revealed Resident #18 was receiving incontinence care while in bed from Nurse Aide #329 and Nurse Aide #353. Resident #18 could be heard groaning when turned by the staff. During turning at the one minute and 39 second mark Resident #18 could be heard saying ouch and says ow again at the one minute and 57 second mark while staff were attempting to re-dress the resident. Review of a family provided one minute and 28 second video dated [DATE] at 11:20 A.M. revealed Resident #18 was being prepared for transfer using sit to stand lift by Nurse Aide #329 and Nurse Aide #353. At the 34 second mark Nurse Aide #329 pulls Resident #18's legs to edge of bed and the resident could be heard groaning (in pain) out loudly. Review of an email provided by Resident #18's sister dated [DATE] timed 8:35 P.M. revealed Resident #18's sister contacted the former Administrator, former DON, Social Services Designee (SSD) #355, and Ombudsman with her concerns. In the email, Resident #18's sister noted the resident fell on [DATE] and hurt her left hip and leg. The sister indicated an x-ray was taken about 6:00 P.M. on [DATE]; however, she did not receive notification of results until [DATE] at 9:45 A.M. The sister indicated it was apparent Resident #18 was in pain; however, she was not made aware of a treatment plan in place. The sister stated Resident #18 was unable to request pain medications. The sister included a series of videos in the email from a camera in Resident #18's room. The sister indicated on video Nurse Aide #329 was not gentle and did not appear to be knowledgeable of Resident #18's potentially broken left hip. The sister shared additional unrelated concerns related to the care of Resident #18 in the email. Review of a facility Self-Reported Incident (SRI) dated [DATE] at 9:30 A.M. revealed Resident #18's sister made an allegation Nurse Aide #329 was rough during incontinence care. The resident's recent fall with pain was not included on the SRI investigation. Interview on [DATE] at 11:54 A.M. with Physical Therapy Assistant (PTA) #372 confirmed Resident #18 had been complaining of pain, during walking, after her fall on [DATE]. During an interview on [DATE] at 2:04 P.M. with the Administrator and Chief Operating Officer (COO) #300, Resident #18's fall was reviewed. COO #300 indicated she was unable to remember any details of Resident #18's fall. COO #300 and the Administrator confirmed they were unable to provide any additional details related to Resident #18's fall and subsequent fracture including interventions, investigation, interdisciplinary review, or root cause analysis. Interview and review of the incident with the DON on [DATE] at 3:18 P.M. verified there was no follow-up to Resident #18's continued pain. The DON said she was not employed by the facility at the time of the incident but questioned why there wasn't another X-ray completed, since the resident was still experiencing pain. She also verified the facility was unable to locate or provide any additional information regarding the resident's fall and delay in her treatment despite concerns shared from the resident's sister and no improvement in the resident's condition. Review of facility policy Change in Condition Monitoring dated [DATE] revealed the nurse would record in the medical record information related to change in condition and notify attending physician and guardian. Review of facility policy Falls and Incident Investigation dated [DATE] revealed resident falls would be documented and investigated to determine root cause and have plan developed to prevent reoccurrence. The nurse would assess the resident and provide as needed first aide, record vital signs, initiate head injury precautions, notify supervisor, initiate incident reporting and document on incident in progress note, and notify physician and family. The DON would reassess the resident for any additional monitoring or changes to plan of care, ensure investigation occurs promptly, obtain statements from staff, and document and ensure implementation of corrective interventions. The resident would be followed on the 24-hour report and progress notes for 72 hours post-accident. The interdisciplinary team would review falls. 2. Review of the closed medical record for Resident #55 revealed an admitted [DATE] and discharge date of [DATE]. Resident #55 had diagnoses including chronic obstructive pulmonary disease, peripheral vascular disease, chronic kidney disease, dementia, and nontraumatic intracerebral hemorrhage. Review of the immunizations record revealed Resident #55 was not up to date with the COVID-19 vaccination with the last dose administered [DATE] and Resident #55 was not up to date with pneumococcal vaccinations as pneumococcal Polysaccharide Vaccine (PPSV) 23 was administered before the age of 65. Review of the physician's order dated [DATE] revealed an order for a consult to oncology for a follow up to lung mass and a repeat chest x-ray on [DATE]. Review of the nurse's note dated [DATE] revealed Resident #55 tested positive for COVID-19. Review of the physician's orders dated [DATE] revealed orders for contact and droplet precautions for five to 10 days if symptomatic, Dexamethasone six milligrams (mg) once daily, two to four liters of oxygen via nasal cannula to keep oxygen saturation above 92 percent, and vitals monitoring every shift. Review of the Orders Administration Note dated [DATE] revealed Resident #55 was unable to be administered Dexamethasone. Reason noted Medication not received by pharmacy. Review of the Nurse Practitioner (NP) progress note dated [DATE] revealed Resident #55 had nasal congestion. The NP ordered oxygen via nasal cannula to keep oxygen saturation above 92 percent, Dexamethasone six mg daily for seven days, and monitor temperature, pulse oximetry (ox), and respirations every shift for 10 days. The NP noted to continue Eliquis five mg twice per day, Acetaminophen 650 mg every six hours as needed, and Albuterol nebulizer every four hours as needed. Review of a physician's order dated [DATE] revealed an order for Resident #55 for a complete blood count with differential (CBC with diff) to be obtained on [DATE]. Further review of the medical record revealed no evidence the laboratory services (labs) were obtained as ordered. Review of the Orders Administration Note dated [DATE] revealed Resident #55 was unable to be administered Dexamethasone. Reason noted on order. Review of the physician's order dated [DATE] revealed Resident #55's chest x-ray was rescheduled to [DATE] due to current COVID-19 positive status. Review of the Orders Administration Note dated [DATE] revealed Resident #55 was unable to be administered Omeprazole. Reason noted was none in med cart. Review of the Orders Administration Note dated [DATE] revealed Resident #55 was unable to be administered Omeprazole. Reason noted was not available. Review of the Orders Administration Note dated [DATE] revealed Resident #55 required two liters of oxygen. Review of the Orders Administration Note dated [DATE] revealed Resident #55 had multiple episodes of diarrhea and as needed Polyethylene Glycol medication was held. Review of the NP progress note dated [DATE] revealed Resident #55 was having loose stools and nausea. The NP ordered Zofran four mg every six hours as needed. Resident #55's second finger on the right hand was noted to be discolored and cool to touch. The NP noted all fingers on the right hand were noted to be discolored and the NP contributed this to peripheral vascular disease. The NP ordered an ultrasound of the residents right upper extremity. Review of the Orders Administration Note dated [DATE] revealed Resident #55 was administered Acetaminophen for discomfort, headache and low-grade temperature of 99.1 degrees Fahrenheit (F). Review of the Orders Administration Note dated [DATE] revealed Resident #55 was administered Acetaminophen for stomach pain and Zofran for nausea and vomiting. Review of the NP progress note dated [DATE] revealed Resident #55 had complaints of nausea and loose stools. Stools were noted to be loose and dark tarry colored. Resident #55 reported not feeling well and not eating due to nausea and abdominal pain. Resident #55 told the nurse he was having difficulty breathing and he felt like he was dying. Resident #55 had a harsh, moist cough. The NP ordered to send Resident #55 to the emergency room for evaluation. The NP noted the ultrasound of the right upper extremity had not yet been completed. Review of the nurse's note dated [DATE] revealed Resident #55 was transported to hospital for complaints of stomach pain for a few days and black stool. Resident #55 was noted to be on a blood thinner. Review of the nurse's note dated [DATE] revealed Resident #55 was admitted to hospital for pneumonia. Review of the Ohio Department of Medicaid Facility Communication dated [DATE] revealed Resident #55 had passed away at the hospital on [DATE]. As of [DATE] the resident's death certificate was not available. Interview on [DATE] at 8:03 A.M. with the legal guardian of Resident #55 confirmed Resident #55 had passed away at the hospital. The guardian indicated she had not received the resident's death certificate yet. Additional attempts to contact the legal guardian during the survey were unsuccessful. Interview on [DATE] at 11:27 A.M. with the Administrator, COO #300, and Registered Nurse/Infection Preventionist (RN/IP) #374 revealed RN/IP #374 was not employed by the facility but had been assisting the facility with infection control in interim between IPs. Surveyor identified COVID-19 cases and Resident #55's hospitalization were reviewed with Administrator, COO #300, and RN/IP #374. The Administrator, COO #300, and RN/IP #374 were unaware of the number of COVID-19 cases that had occurred in [DATE] and were unaware Resident #55 had been hospitalized for pneumonia and subsequently passed away at hospital despite having symptoms of a change in condition since testing positive for COVID-19 on [DATE]. Interview on [DATE] at 2:13 P.M. with COO #300 revealed the facility was unable to locate evidence Resident #55 received the chest x-ray or labs as ordered. Staff present during this time period when Resident #55 experienced this change in condition were not available for interview as they either no longer worked at the facility or were agency staff. Current staff interviewed as part of the investigation including Registered Nurses (RNs) #341 and #348, Licensed Practical Nurses (LPNs) #304, #327, #369, and Certified Nurse Aides #303, #305, #326, #337, #339, #352, #353, and #357 revealed they had no knowledge of Resident #55 or the resident's change in condition that occurred from [DATE] to [DATE]. Review of facility policy Change in Condition Monitoring dated [DATE] revealed the nurse would record in the medical record information related to change in condition and notify attending physician and guardian. Review of facility policy COVID-19 Precautions and Prevention dated [DATE] revealed the facility would follow current guidelines and recommendations to ensure the facility was prepared to respond to COVID-19. A reportable outbreak was noted to be when one case had suspected or confirmed COVID-19, residents with severe respiratory infection resulting in hospitalization or death, or three or more cases of new-onset respiratory symptoms within 72 hours. Review of Centers for Disease Control (CDC) guidance on COVID-19 dated [DATE] revealed COVID-19 vaccination was recommended for prevention of severe health outcomes. Several antiviral medications were recommended including Paxlovid, Remdesivir, and Lagevriol as treatment for COVID-19 to help prevent severe illness and death. 3. Review of the medical record for Resident #31 revealed an admitted [DATE] with diagnoses including diabetes mellitus, bipolar disorder, hypothyroidism, muscle weakness, and unspecified intellectual disabilities. Resident #31 was hospitalized from [DATE] to [DATE]. Review of immunizations record revealed no evidence of Resident #31's COVID-19 or pneumococcal vaccinations status. Review of the Medicare Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #31 had severely impaired cognition and was independent for activities of daily living. The assessment revealed Resident #31 was not up to date on COVID-19 vaccinations and had not received pneumococcal vaccination. Review of Nurse Practitioner (NP) progress note dated [DATE] revealed Resident #31 complained of nasal congestion and not feeling well. The NP ordered to obtain pulse oximetry (ox), respirations, and temperature every shift for four days. There was no evidence of COVID-19 testing completed and/or any other intervention to treat the resident's symptoms at that time. Review of the NP progress note dated [DATE] revealed Resident #31 continued to have nasal congestion and a cough. Resident #31 reported cough but was unable to clear anything. The NP ordered Mucinex 600 milligrams (mg) two times per day for seven days. There was no evidence of COVID-19 testing completed at this time. Review of an NP progress note dated [DATE] revealed Resident #31 complained of not feeling well and told staff He feels like he is dying. Resident #31 observed with a dry cough and nasal congestion. Resident #31 reported an episode of vomiting. The NP ordered Vitamin C 250 milligrams daily and to continue Mucinex as needed for cough. There was no evidence of COVID-19 testing completed at this time. Review of a nurse's note dated [DATE] revealed Resident #31 was experiencing a harsh, productive cough. Lung sounds were noted to be diminished. Resident #31 had four to five episodes of watery diarrhea and reported not being able to make it to the bathroom. A COVID-19 test was completed and negative. However, there was no evidence of any additional interventions being implemented at this time to treat the resident's symptoms. Review of a NP progress note dated [DATE] revealed Resident #31 had an episode of vomiting and was ordered Zofran. Resident #31 continued to have dry cough. The NP ordered a chest x-ray and laboratory services (labs). Review of a Patient Report dated [DATE] revealed Resident #31 had chest x-ray with no acute findings. Review of a NP progress note dated [DATE] revealed Resident #31 continued to have cough and congestion. On [DATE] Resident #31 had a chest x-ray with no findings. On [DATE] Resident #31 had four to five watery stools and was ordered Loperamide two mg every six hours as needed for diarrhea. Resident #31 also complained of nausea and emesis. Labs were ordered on [DATE] and were not obtained. Resident #31's pulse ox was 92 percent on room air and the resident's heart rate was 109 (tachycardic). There was no evidence of COVID-19 testing completed. While the NP was visiting, she was alerted Resident #31 had fallen in his room. Resident #31 was trying to walk to bathroom and became dizzy causing a fall. The NP ordered Resident #31 to be sent to the emergency room for evaluation. Review of nurse's note dated [DATE] revealed Resident #31 had been admitted to the hospital with acute hypoxic respiratory failure, pneumonia, dehydration, acute kidney injury, and was positive for COVID-19. Review of a hospital note revealed Resident #31 was admitted to the step-down unit on [DATE] for acute hypoxic respiratory failure and acute kidney injury. Resident #31 was found to have COVID-19 and pneumonia. Resident #31 had episodes of oxygen desaturation and required oxygen. Resident #31 was treated with Remdesivir, steroids and antibiotics. Remdesivir had to be stopped due to Transaminitis. Resident #31 continued to have intermittent coughing while hospitalized . Review of a NP progress note dated [DATE] revealed Resident #31 had readmitted to the facility from the hospital on [DATE]. Resident #31 was diagnosed with COVID-19, pneumonia, bilateral pulmonary embolism, left leg deep vein thrombosis, and acute kidney injury. Interview on [DATE] at 4:50 P.M. with Chief Operating Officer (COO) #300 revealed the facility was unable to locate any type of facility COVID-19 tracking log or additional information related to a COVID-19 outbreak that occurred in the facility in [DATE]. Interview on [DATE] at 11:27 A.M. with Administrator, COO #300, and Registered Nurse/Infection Preventionist (RN/IP) #374 revealed RN/IP #374 was not employed by the facility but had been assisting the facility with infection control in interim between IPs. Surveyor identified COVID-19 cases and Resident #31's hospitalization were reviewed with Administrator, COO #300, and RN/IP #374. The Administrator, COO #300, and RN/IP #374 were unaware of the number of COVID-19 cases that had occurred in [DATE] and were unaware Resident #31 had been hospitalized for treatment of COVID-19 and pneumonia after the resident had been symptomatic since [DATE]. Interview on [DATE] at 12:05 P.M. with Medical Director #366 revealed when a resident was having upper respiratory infection symptoms his first step would be to test for COVID-19. Medical Director #366 indicated if a resident was having cough and nasal congestion he would test for COVID-19. Interview on [DATE] at 2:13 P.M. with COO #300 revealed the facility was unable to locate evidence Resident #31 received labs as ordered. COO #300 confirmed Resident #31 had not been COVID-19 tested prior to [DATE] despite persisting symptoms from [DATE]. Interview on [DATE] at 9:52 A.M. with Resident #31 revealed he was educated regarding the influenza and pneumococcal vaccines by the facility and he did consent to and received the vaccines, but he could not remember when he had them or when the education was. Resident #31 stated he knew he had to go to the hospital because he was sick, but he could not remember when it was, and he also could not remember any treatments or medications he was given prior to the hospitalization . He stated he had poor memory. Staff present during this time period when Resident #31 experienced this change in condition were not available for interview as they either no longer worked at the facility or were agency staff. Current staff interviewed as part of the investigation including Registered Nurses (RNs) #341 and #348, Licensed Practical Nurses (LPNs) #304, #327, #369, and Nurse Aides #303, #305, #326, #337, #339, #352, #353, and #357 revealed they had no knowledge of Resident #31 or the resident's change in condition that occurred

Based on observation, record review, facility policy review, and interview, the facility failed to implement an adequate and effective pressure ulcer prevention program to promote healing and to ensure Resident #49, who was cognitively impaired, dependent on staff for activity of daily living care and incontinent of bowel and bladder, received timely and necessary pressure ulcer prevent and treatment. Additionally, the facility failed to ensure accurate and comprehensive weekly skin assessments for Resident #11's in-house acquired pressure ulcer. This affected two residents (#49 and #11) of two residents reviewed for pressure ulcers. The facility census was 54. Actual Harm occurred beginning on 01/31/25 when nursing staff failed to comprehensively assess, implement effective interventions and provide timely and necessary treatment to prevent an open area to Resident #49's coccyx/buttocks area from deteriorating to a Stage III (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) pressure ulcer. Findings include: Review of the medical record for Resident #49 revealed an admitted [DATE] with diagnoses including heart failure, chronic respiratory failure, kidney failure, obesity and cirrhosis of the liver. Review of the five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 was cognitively impaired, had no behaviors, was always incontinent of bowel and bladder and was dependent on staff for toileting hygiene, rolling and transfers. There were no pressure ulcers/sores documented, however, the assessment noted the resident was at risk for developing one. Review of the Nursing Admission Assessment with Care Plan dated 01/31/25 revealed Resident #49 was alert, was always incontinent of bowel and bladder, had skin tears to the right and left knees and was a smoker. There was no initial care plan for skin integrity or skin impairment for the resident. Review of a nursing progress note for Resident #49 revealed on 01/31/25 at 3:00 P.M. the resident arrived at the facility with skin tears to his knees, maceration to his abdominal folds and an open area to the coccyx. The progress note did not include any additional information related to the area on the coccyx, including staging or a description of the ulcer. In addition, there was no evidence pressure ulcer prevention measures/interventions were implemented at this time. Review of the head-to-toe assessments for Resident #49 revealed on 01/31/25 there were skin tears noted to his right and left knees. On 02/01/25, Nurse Practitioner (NP) #363 assessed Resident #49 and documented the resident had skin issues on admission with treatments in place. There was no documentation of the actual pressure ulcers by NP #363 in the resident's nursing progress notes. Review of the admission MDS 3.0 assessment dated [DATE] revealed the resident had no skin conditions, no pressure ulcers, no turning and repositioning program and no pressure reducing devices for the chair or bed. The head-to-toe assessment dated [DATE] included there was a pressure ulcer to the coccyx. However, there was no description or stage of the ulcer. Review of the physician's orders for Resident #49 revealed pressure relieving interventions and wound treatments were not initiated until 02/10/25. In addition, an order dated 02/10/25 revealed head-to-toe skin check to be completed every night shift on Monday, Wednesday and Thursday was ordered. The head-to-toe assessment on 02/13/25 included there was left elbow bruising and a pressure ulcer to the coccyx. Again, there was no description or staging of the coccyx ulcer. On 02/18/25 a note at the bottom of the head-to-toe assessment revealed previously documented pressure sore to left buttock with treatment recommendations in place, no new areas noted. On 02/21/25 a note at the bottom of the head-to-toe assessment revealed impaired skin on left buttocks, previously mentioned. There was a note that included resident was non-compliant with turning and repositioning. However, no additional care plan or documentation to support the non-compliance as it pertained to the impaired skin integrity. On 02/26/25 at 7:05 P.M., nursing staff documented they did not have time to do a skin assessment during the shift. Review of a Weekly Wound Healing Record for Resident #49 dated 02/26/25 revealed the resident had a Stage III pressure ulcer to the right medial buttock that was acquired on 01/31/25 when the resident was admitted to the facility. The pressure ulcer measured 2.0 centimeters in length by 2.0 centimeters width with 0.2 centimeters depth with granulation tissue and a small amount of bloody drainage. There was odor present to the wound. Treatment was initiated with Triad Paste and the wound progress was noted to be unchanged. On 02/26/25 a treatment order was obtained for Triad Hydrophilic Wound Dress External Paste, apply to buttock topically two times a day for wound. Review of a Weekly Wound Healing Record for Resident #49 dated 03/05/25 revealed the Stage III pressure ulcer to the right medial buttock was improving. The ulcer measured 2.0 centimeters by 2.0 centimeters by 0.1 centimeters. There was no change in treatment. On 03/07/25 pressure relieving interventions were ordered to float the heels, have a pressure reducing mattress, utilize a pressure relieving cushion to wheelchair and turning and repositioning every two hours every shift. The medication administration record and treatment administration record corresponded to these orders for Resident #49. Review of the care plan for Resident #49 dated 03/07/25 revealed the resident had potential/actual impairment to skin integrity of the right medial buttock related to fragile skin. Interventions included to encourage good nutrition and hydration, observe and document the location of skin impairment, and weekly treatment documentation to include measuring of each area of the skin breakdown's width, length, depth, type of tissue exudate and any other notable changes or observations. Interview on 03/12/25 at 2:33 P.M. with NP #364 (the wound nurse) revealed she was at the facility weekly or biweekly. She stated she did not measure Resident #49's wounds and stated it was the responsibility of the facility staff to keep the measurements and document on pressure ulcers. NP #364 revealed Resident #49 had a Stage III pressure ulcer to his right medial buttock. Interview on 03/12/25 at 3:40 P.M. with the Director of Nursing (DON) verified Resident #49 had no pressure ulcers documented on his 01/31/25 head-to-toe assessment. She verified the only documentation that revealed an open area to his coccyx was on a nursing progress note on 01/31/25. The DON revealed on Resident #49's head-to-toe assessment on 02/10/25 the Stage III pressure ulcer to his coccyx was documented the first time without measurements. She stated she started at the facility on 02/17/25 and initially saw Resident #49's pressure ulcer on 02/26/25. She stated the coccyx Stage III pressure ulcer was more to the right medial buttock with measurements of 2.0 centimeters by 2.0 centimeters by 0.2 centimeters. The DON stated she was the first person to document Resident #49's Stage III pressure as the facility had not been measuring/assessing it prior. Interview on 03/17/25 at 2:29 P.M. with NP #363 revealed she was not aware the facility was not measuring any resident wounds. Interview on 03/18/25 at 10:09 A.M. with the DON verified Resident #49 did not have a wound care plan until 03/07/25 for potential interventions to his coccyx/right buttock pressure ulcer. She also verified Resident #49 did not have any wound documentation by NP #364 from 01/31/25 through 02/26/25. Observation on 03/12/25 at 2:33 P.M. of wound care to Resident #49 with NP #364 and the DON revealed the resident had a Stage III pressure ulcer measuring 1.6 centimeters by 1.0 centimeters by 0.1 centimeters. NP #364 stated the pressure ulcer was more to the right buttock than the coccyx. Review of the facility policy titled, Wound Care, dated 05/01/22 revealed it was the policy of the facility to ensure that all residents skin conditions were properly tracked and cared for. The nursing staff would assess and document the resident's significant risk factors for developing pressure ulcers as well as the nurse would document a full assessment including location, stage, length, width, depth and presence of exudates or necrotic tissue. During resident visits, the physician would evaluate and document the progress of wound healing. The physician would help the staff review and modify the care plan as appropriate, especially when wounds were not healing as anticipated or new wounds developed despite existing interventions. During monitoring, the physician would also evaluate and document the progress of the wound. 38522 2. Review of Resident #11's medical record revealed an admitted [DATE] with diagnoses including vitamin D deficiency, depression, repeated falls, dysphagia, dementia with mood disturbance and urinary and fecal incontinence. Review of Resident #11's quarterly MDS 3.0 assessment dated [DATE] revealed Resident #11 was cognitively impaired and dependent on staff for eating, toileting, lower body dressing and required substantial/maximal staff assistance to roll left and right. Resident #11 was noted to have a Stage III pressure ulcer, not present on admission. Review of Resident #11's physician's orders revealed an order dated 08/01/24 to admit to hospice for end-stage cerebral infarction; an order dated 11/23/24 for ProSource oral liquid (nutritional supplement) 30 milliliters (ml) by mouth twice daily; an order dated 11/24/24 for pressure reduction boots as tolerated, when in bed; an order dated 11/24/24 for air mattress; an order dated 11/26/24 for hospice to change wound dressings on Tuesday and Thursday only every night shift for wound; an order dated 11/26/24 for monitor erythema to right foot, notify physician and hospice for signs/symptoms of infection, edema or drainage and discontinue when resolved. No as-needed (PRN) wound care orders were available on Resident #11's physician's orders list. Review of an interdisciplinary team post-wound investigation summary for Resident #11 dated 11/23/24 at 10:33 (morning or evening not specified) and authored by Registered Nurse (RN) #313, who was the facility's previous DON, revealed aide (not named) informed nurse (not named) of suspected new area to the right foot. When assessed, new open areas were identified to the right shin, right lateral foot, and right pinky toe. The right foot peri-wound skin was reddened and edematous. No drainage or foul odors were noted upon assessment. Contributing factors included hospice client, limited physical activity, risk for impaired skin integrity and non-compliance with hygiene and refusals of care. Wound management completed by wound nurse practitioner, orders obtained and in place for daily treatment of wounds. Review of a weekly wound healing record-wound care nurse assessment dated [DATE] revealed Resident #11 had a facility-acquired venous ulcer to his right lateral foot measuring 3.0 centimeters (cm) length by 2.5 cm width by 0.0 cm depth with a scab noted. The assessment indicated it was the first observation of the wound, and no odor or drainage was present. Prophylactic antibiotics (Augmentin) initiated for suspected cellulitis. Cleanse the area with normal saline, pat dry. Apply calcium alginate to the wound bed. Cover with an abdominal (ABD) pad and Kerlix gauze daily and as needed. Review of the next available weekly wound healing record-wound care nurse assessment dated [DATE] revealed Resident #11 had a facility-acquired pressure ulcer to right lateral foot as of 12/18/24 that was originally a Stage III pressure ulcer and remained at that stage. The wound was unchanged, had a dry scab area and had no drainage or odor. The area measured 0 cm by 0 cm by 0 cm. Comments at the bottom indicated the wound nurse did not measure the area, leave area open to air. Treatment changed this date to Skin Prep (forms a film to protect the skin by reducing friction) to the scabbed area once daily. Review of the weekly wound healing record-wound care nurse assessment dated [DATE] revealed Resident #11 had an improving Stage III pressure area to right lateral foot. No wound measurements were included on this assessment. Review of the weekly wound healing record-wound care nurse assessment dated [DATE] revealed Resident #11 had an improving Stage III pressure area to the right lateral foot. No drainage or odor was noted. The wound measured 3.2 cm by 1.0 cm by 0.0 cm. The current treatment plan was listed as Skin Prep with ABD and Kerlix gauze change daily and PRN. Review of Resident #11's nurses' notes from November 2024 through March 2025 revealed no wound measurements. Review of Resident #11's plan of care for skin/pressure areas dated 02/03/17 listed an intervention dated 11/03/19 for monitor/document/report to physician PRN changes in skin status: appearance, color, wound healing, signs/symptoms of infection, wound size (length by width by depth) and stage. Interview on 03/11/25 at 11:48 A.M. with the DON revealed the wound nurse practitioner saw Resident #11 weekly and shared Certified Nurse practitioner (CNP) #364 told her she does not measure wounds in the facility. The DON verified she had no further wound tracking for Resident #11 as the wound started in November 2024, which was before she started her employment with the facility three weeks ago. The DON confirmed she began tracking all in-house wounds two weeks ago and indicated Resident #11's Stage III pressure ulcer on his foot was a scab and was improving. The DON verified Resident #11 did not have a PRN order for wound care in case the dressing needed to be changed in between the scheduled times and verified he should have had such an order. The DON also verified hospice completed Resident #11's wound dressing Tuesdays and Thursdays on night shift as ordered by the physician. Interview on 03/12/25 at 2:33 P.M. with CNP #364 revealed she came to the facility weekly and sometimes every other week. CNP #364 verified she did not put wound measurements in her assessments as it was the responsibility of the facility to measure the wounds. CNP #364 indicated Resident #11's Stage III pressure wound to the foot had been improving and was now a scab. Review of the facility policy, Wound Care, dated 05/01/22, revealed all residents' skin conditions would be properly tracked and cared for. The nursing staff and attending physician will assess and document and individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss and a history of pressure ulcer(s). In addition, the nurse shall describe and document/report the following: a) full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; pain assessment; resident's mobility status; current treatments including support surfaces and all active diagnoses. The staff will examine the skin of a new admission for ulcerations or alterations in skin. The physician will authorize pertinent orders related to wound treatments, including would cleansing and debridement approaches, dressings (occlusive, absorptive, etc.) and application of topical agent if indicated for type of skin alteration .during resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive or non-healing wounds. The physician will help the staff review and modify the care plan as appropriate.

Based on observations, staff and resident interviews, and facility policy review, the facility failed to ensure a safe, clean, homelike environment by ensuring water temperatures reached appropriate and homelike temperatures, and blinds, ceiling tiles, walls, door frames, and hand rails were without the need for repair. This affected all residents residing in the facility. The facility census was 54. Findings include: 1. Interview on 03/10/25 at 10:01 A.M. with Resident #48 revealed the water was cold and the water pressure was low. Resident #48 indicated the shower room was broken. Interview on 03/10/25 at 10:29 A.M. with Resident #203 revealed the shower was broken and he had been unable to get a shower. Observation and interview on 03/10/25 at 10:29 A.M. with Resident #23 revealed her toilet had not been working for a week and Resident #23 reported the shower room was broken. Observation of Resident #23's toilet revealed it was not secured to the floor. Resident #23 reported hot water was also an issue, stating it was either too hot or too cold. Observation and interview on 03/10/25 at 12:01 P.M. with Resident #27 revealed the resident had asked where she could use the bathroom and stated her toilet did not work. Housekeeper #311 was nearby and indicated she could use the one in her room. Housekeeper #311 went into Resident #27's bathroom in her room and confirmed the toilet was not secured to the floor and was not working appropriately. The bathroom was shared between two rooms, including Resident #23. Resident #27 was assisted by staff to a bathroom down the hall. Observations on 03/10/25 from 12:18 P.M. to 12:55 P.M. revealed a sign on the west side shower room indicating Do not use shower. Out of order. Interview on 03/10/25 at 12:22 P.M. with Resident #22 revealed the shower room had not been working all weekend and he was unable to get a shower. Resident #22 stated the backed up water leaked out into the hallway. Interview on 03/10/25 at 12:49 P.M. with Resident #44 revealed she could get showers, but the water was cold. Follow up tour on 03/10/25 from 1:00 P.M. to 1:10 P.M. with the Administrator revealed the shower room had been fixed and it had been out of order since 03/07/25. Interview on 03/11/25 at 1:08 P.M. with the Administrator revealed she was unable to find any logged water temperatures or maintenance records for the last 12 months. Follow up tour on 03/12/25 from 9:45 A.M. to 10:05 A.M. with Housekeeping and Maintenance Supervisor (HMS) #306 revealed most residents shared a bathroom between two rooms, but there were a few with private bathrooms. HMS #306 indicated there were no showers in resident rooms, and there were two shower rooms in the facility. Observation of water temperatures on 03/12/25 from 11:16 A.M. to 12:19 P.M. with HMS #306 using the facility's digital thermometer revealed the following: Resident #18's sink water temperature was 101.5 degrees Fahrenheit (F). Resident #49's sink water temperature was 99.1 degrees F. Resident #48 and #203's sink water temperature was 101.9 degrees F. Resident #31 and Resident #45's sink water temperature was 96.1 degrees F. Resident #20's sink water temperature was 77.0 degrees F. Resident #5's sink water temperature was 90.5 degrees F. Resident #15's sink water temperature was 102.6 degrees F. Resident #14's sink water temperature was 98.4 degrees F. Resident #104's sink water temperature was 101.5 degrees F. Resident #205's sink water temperature was 81.7 degrees F. The [NAME] side shower room shower was 81.0 degrees F. The East side shower room shower was 97.3 degrees F. Interview during the observation of water temperatures on 03/12/25 from 11:16 A.M. to 12:19 P.M. with Resident #49 revealed the water was never hot. Interview during the observation of water temperatures on 03/12/25 from 11:16 A.M. to 12:19 P.M. with Resident #5 revealed the water did not get hot no matter how long it ran. Interview on 03/12/25 at 11:42 A.M. with HMS #306 confirmed the water temperatures throughout the building were not within a comfortable range. HMS #306 indicated he had recently taken over the maintenance supervisor position and was unsure how to adjust the water temperatures. HMS #306 indicated the water was heated by a boiler system. HMS #306 indicated this was the first time he had taken water temperatures. Review of the facility policy titled Water Temperature dated 05/01/22 revealed maintenance was responsible for checking temperature controls of water in the facility and recording the checks in a maintenance log. Water temperatures would be no more than 120 degrees. 2. Observations on 03/10/25 from 12:18 P.M. to 12:55 P.M. revealed Resident #8, Resident #34 and Resident #46 were observed with broken blinds in their rooms. Interview on 03/10/25 at 12:50 P.M. with Resident #46 revealed the blinds in his room had been broken since he moved in. Follow up tour on 03/10/25 from 1:00 P.M. to 1:10 P.M. with the Administrator confirmed the environmental findings for Resident #8, #34, and #46. Follow up interview and tour on 03/12/25 from 9:45 A.M. to 10:05 A.M. with HMS #306 revealed Resident #38's room had broken mini blinds. The observations were confirmed with HMS #306 at the time of the observation. Observation on 03/12/25 from 11:16 A.M. to 12:19 P.M. with HMS #306 revealed Resident #104's mini blinds were broken in their room and Resident #5's mini blinds were broken in their room. Interview during the observation on 03/12/25 from 11:16 A.M. to 12:19 P.M. with HMS #306 confirmed findings in Resident #5's room and Resident #104's room. 3. Observations on 03/10/25 from 12:18 P.M. to 12:55 P.M. revealed multiple discolored ceiling tiles observed across from the west side nursing station, in the hallway outside Resident #21 and Resident #15's room, in the east side shower room, and in hallway outside Resident #14's room. There were multiple patched and unpainted dents in walls on the memory care unit. The paint was chipped on the door frame leading to the 100 hallway, and there was paint chipped off the doors of Resident #37, Resident #33, Resident #8, Resident #1, Resident #23, and Resident #19's rooms. Resident #38's room had dented and paint chipped walls. There was a piece of plywood leaning against the wall in the occupied room. Resident #40's room had numerous white unpainted patches on the walls and there was blue painters' tape around cabinets, door frames, and lights. Interview on 03/10/25 at 12:45 P.M. with Certified Nursing Assistant (CNA) #317 reported there was not a maintenance person currently and there was no one to report issues to. CNA #317 indicated if there was some kind of emergency she would report it to housekeeping. Follow up tour on 03/10/25 from 1:00 P.M. to 1:10 P.M. with the Administrator confirmed the above environmental findings. The Administrator indicated there were some ceiling leaks when the ice was melting with the temperature changes. Interview on 03/11/25 at 1:08 P.M. with the Administrator revealed she was unable to find any maintenance records for the last 12 months, including maintenance records regarding the discolored ceiling tiles, dents on the memory care walls, paint chipping from the doorway in the 100 hall, and paint chipping from the residents doors. Follow up tour on 03/12/25 from 9:45 A.M. to 10:05 A.M. with HMS #306 revealed Resident #38's room also had two discolored and sagging ceiling tiles. Resident #1 and Resident #23's shared room was observed with a vanity with a missing drawer and mirror and it had two cabinet doors hanging off the hinges. The observations were confirmed with HMS #306 at the time of the observation. Observation on 03/12/25 from 11:16 A.M. to 12:19 P.M. with HMS #306 revealed large holes were observed in the wall behind Resident #5's headboard. Interview during the observation on 03/12/25 from 11:16 A.M. to 12:19 P.M. with HMS #306 confirmed the findings in Resident #5's room. 4. Observations on 03/10/25 from 12:18 P.M. to 12:55 P.M. revealed the handrail extending between rooms #13 and #14 was loose on the wall, the handrail extending between rooms #36 and #37 was loose on the wall, and the handrail extending from the east side shower room door to the corner of the wall was loose. Interview on 03/10/25 at 12:45 P.M. with Certified Nursing Assistant (CNA) #317 reported there was not a maintenance person currently and there was no one to report issues to. CNA #317 indicated if there was some kind of emergency she would report it to housekeeping. Follow up tour on 03/10/25 from 1:00 P.M. to 1:10 P.M. with Administrator confirmed the above findings. Interview on 03/11/25 at 1:08 P.M. with Administrator revealed she was unable to find any maintenance records for the last 12 months. This deficiency represents non-compliance investigated under Complaint Number OH00162361.

Based on review of the personnel files, review of the facility assessment and interview, the facility failed to ensure Certified Nursing Assistants (CNAs) #305 and #329 received annual performance reviews. This affected two of two CNA's personnel files reviewed and had the potential to affect all 54 residents residing in the facility. Findings include: 1. Review of the personnel file for CNA #305 revealed there were no annual performance evaluations in her file or 12 hours of in-services as required. Interview on 03/18/25 at 3:10 P.M. with the Chief Operating Officer (COO) #300 verified CNA #305 did not have an annual performance evaluation in her personnel file. She stated the facility was unable to provide evidence of CNA #305 receiving 12 hours of in-services as required annually. Review of the facility assessment dated [DATE], revealed the facility would address areas of weakness as determined in nurse aide performance reviews during training and in-services. The facility assessment also stated training topics for staff would include communication, resident rights, abuse, infection control, culture change and dementia management. 2. Review of the personnel file for CNA #329 revealed there were no annual performance evaluations in her file or 12 hours of in-services as required. Interview on 03/18/25 at 3:10 P.M. with the Chief Operating Officer (COO) #300 verified CNA #305 did not have an annual performance evaluation in her personnel file. She stated the facility was unable to provide evidence of CNA #329 receiving 12 hours of in-services as required annually. Review of the facility assessment dated [DATE], revealed the facility would address areas of weakness as determined in nurse aide performance reviews during training and in-services. The facility assessment also stated training topics for staff would include communication, resident rights, abuse, infection control, culture change and dementia management.

Based on observation, interview, record review and review of the facility policy, the facility failed to follow the menu spreadsheets as written to ensure proper portion sizes were served to the residents. This affected 53 residents receiving food from the kitchen as Resident #10 was ordered nothing by mouth (NPO). Facility census was 54. Findings include: Review of the facility menu corresponding to Tuesday, 03/11/25 revealed a lunch meal consisting of smothered and covered pork chop (one each), seasoned rice (four ounces), Price [NAME] vegetable blend (four ounces), yellow cake with frosting (one slice) and beverage of choice (four ounces). Review of the facility production sheet for lunch on 03/11/25 revealed those receiving a mechanical-soft diet received a #10-scoop (three ounces) of ground pork and those on a low-concentrated sweets (LCS) diet were to have a half-portion of yellow cake with frosting. Review of the facility's diet list as of 03/10/25 revealed Resident #10 was NPO, eight residents were ordered mechanical soft diets (Residents #7, #8, #16, #28, #32, #33, #35 and #204) and eight residents were ordered LCS diets (Residents #5, #20, #21, #29, #31, #36, #37 and #44). Observation on 03/11/25 starting at 11:23 A.M. revealed [NAME] #315 was taking temperatures of the foods to be served using the facility's self-calibrating electronic thermometer and putting serving utensils in each pan on the steam table. The rice was noted to have a green #12-scoop (serving 2.66 ounces) and the ground pork had a blue #16-scoop (serving two ounces). Trayline began at 11:34 A.M. Clear plastic and colored plastic bowls with cake in them were noted on the individual trays and all of the portions of cake appeared to be the same size. Interview on 03/10/25 at 10:36 A.M. with Resident #22 revealed the food at the facility was inadequate and he bought his own food because it is so bad. Interview on 03/11/25 at 11:43 P.M. with Dietary Manager (DM) #361 verified all the portions of cake for this meal were the same size. Interview on 03/11/25 at 12:09 P.M. with [NAME] #315 verified the mechanical soft pork had a #16-scoop which did not follow the spreadsheet as written. Interview on 03/11/25 at 12:15 P.M. with DM #361 verified the rice had a #12-scoop which did not follow the spreadsheet as written. During a follow-up interview on 03/11/25 at 12:40 P.M. DM #361 was made aware the facility did not follow the portion sizes for the LCS diets as a full piece of cake was provided, did not follow the portion sizes for the mechanical soft diets as too small of a scoop was used and did not follow the portion size for the rice as too small of a scoop was used and DM #361 did not disagree. Review of the facility policy, Portion Control, no date, revealed a specific portion size shall be established for all menu items. A serving utensil that will yield the designated portion will be specified for each menu item. Review of the facility policy, Portion Sizes, no date, revealed menu items shall be served according to pre-determined portion size. The standard portion is a level measure using the appropriate serving utensil, which is used to accurately serve the designated portion size. This deficiency represents noncompliance investigated under Complaint Number OH00162361.

Based on observation, interview and review of the menu, the facility failed to serve palatable meals at appetizing temperatures. This had potential to affect all 53 residents receiving meals from the kitchen as Resident #10 was ordered nothing-by-mouth. The facility census was 54. Findings include: Review of the facility menu corresponding to Tuesday, 03/11/25 revealed a lunch meal consisting of smothered and covered pork chop, seasoned rice, Prince [NAME] vegetable blend, yellow cake with frosting and beverage of choice. Interview on 03/10/25 at 10:20 A.M. with Resident #48 revealed the hot food was served cold and terrible. Interview on 03/10/25 at 10:36 A.M. with Resident #22 revealed the food at the facility was inadequate and he bought his own food because it is so bad and the hot food was really cold. Interview on 03/10/25 at 1:23 P.M. with Resident #42 revealed the food at the facility was terrible as it was cold, tasted awful and was a low quality of food. Observation on 03/11/25 starting at 11:23 A.M. revealed [NAME] #315 was taking temperatures of the foods to be served using the facility's self-calibrating electronic thermometer and putting serving utensils in each pan on the steam table. Temperatures of the foods to be served were as follows: pork chop, 173 degrees Fahrenheit (F); vegetable blend, 177 degrees F; rice, 172 degrees F and cake, room temperature (not taken). Trayline began at 11:34 A.M. The east cart began at 12:09 P.M. and a test tray was requested. The test tray was made at 12:21 P.M., on the cart at 12:22 P.M., and was on the unit at 12:23 P.M. Nursing staff began passing trays from the cart immediately after its arrival. The test tray was sampled at 12:40 P.M. with Dietary Manager (DM) #361 and temperatures obtained at that time with the facility's self-calibrating electronic thermometer were as follows: pork, 116 degrees F; rice, 112 degrees F; milk, 45 degrees F; vegetable, 115 degrees F. The foods sampled were lukewarm and not palatable at the current temperatures. Interview on 03/11/25 at 12:40 P.M. with DM #361 confirmed the test tray was lukewarm and the hot foods were not at appropriate temperatures during the sampling of the test tray thus were not palatable. DM #361 stated hot foods were to be at 145 degrees F minimum at point of service. This deficiency represents noncompliance investigated under Complaint Number OH00162361.

Based on observation, interview, review of the facility policy and record review the facility failed to ensure foods were labeled, dated and not retained when expired. This had the potential to affect 53 residents receiving meals from the kitchen as Resident #10 was ordered nothing-by-mouth (NPO). The facility census was 54. Findings include: Observation of the kitchen on [DATE] from 9:20 A.M. to 9:54 A.M. with Dietary Manager (DM) #361 revealed the following areas of concern: In the walk-in cooler, there were two expired cartons of cream dated [DATE] and [DATE], a package of bologna that did not have a date nor a label, two expired bags of salad lettuce dated [DATE] and expired coleslaw dated [DATE]. In the dry stock room, there were nine expired cartons of thickened dairy beverage dated [DATE] that were in between rows of thickened beverages that still had appropriate dates. Interviews with DM #361 verified the above findings at the time of observation. DM #361 stated the first shift cook was responsible for checking for expired food and this was documented on the cleaning sheets. DM #361 confirmed foods were to be labeled and dated. Review of the supplied cleaning schedules revealed the morning cook was responsible for removing out-of-date items from the refrigerator at the beginning of their shift. This was not documented as completed on [DATE] and [DATE], with [DATE] being the last day this task was marked as completed. Review of the facility policy, Labeling and Dating Foods, dated [DATE] revealed to decrease the risk of foodborne illness and to provide the highest quality, foods are labeled with the date received. If the product does not have an expiration date, the product is labeled with a discard or use by date. Review of the facility policy, First In, First Out (FIFO), no date, revealed food products are used by the expiration date, if not, food items are discarded. Do not use any item that for which the manufacturers' suggested use by date has passed.

Based on closed record review, policy and procedure review and interview, the facility failed to timely identify, provide timely medical intervention and notify Resident #42's physician and power of attorney (POA) of an acute change in condition/altered mental status. This affected one resident (#42) of three residents reviewed for change of condition. The facility census was 39. Actual Harm occurred beginning on 08/27/23 at 1:46 A.M. when facility staff failed to timely identify and provide medical intervention for an acute change in condition (including lethargy, pain, decreased oxygen level) for Resident #42. The resident was noted to have a change in condition with no evidence, from 08/27/23 through 08/31/23 the resident's physician or power of attorney (POA) were notified. On 08/31/23 at 9:36 P.M. per family request, 911 was called and Resident #42 was transported via Emergency Medical Services (EMS) to the local Emergency Department. Resident #42 was admitted to the hospital with a urinary tract infection and possible sepsis. The resident did not return to the facility. Findings include: Review of Resident #42's medical record revealed an admitted [DATE] with diagnoses including malignant neoplasm of meninges, malignant neoplasm of prostate, and displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with malunion, and anemia in neoplastic disease. Resident #42 was transported to the hospital Emergency Department on 08/31/23, admitted to the hospital and was discharged from the hospital on 09/21/23 to a different Skilled Nursing Facility. Review of Resident #42's Clinical Admission Evaluation dated 06/29/23 included Resident #42 obeyed commands, and denied weakness, tremors, numbness, or tingling. Resident #42's mood was pleasant, and no unwanted behaviors were witnessed. Resident #42 was confused, speech was clear, had the ability to understand others, and made himself understood. Review of Resident #42's Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #42 required extensive assistance of two staff for bed mobility, transfers, and required total dependence of two staff for toilet use. Resident #42 was always incontinent of urine and bowel. Resident #42 required limited assistance of staff for eating. Review of Resident #42's care plan dated 07/09/23 included Resident #42's power of attorney (POA) consented for all physician recommended medical or surgical treatments. Resident #42's POA's wishes would be honored through the next review date. Interventions included to communicate any change of condition with Resident #42 and his POA, explain any medical or surgical treatments being recommended by the physician and how they pertain to Resident #42's quality of life, report any change of condition to the nurse or social worker. Review of Resident #42's progress notes dated 08/26/23 at 10:28 P.M. revealed Resident #42 was congested, had thick mucus coming from his nose, and had a moist cough. Vital signs included a temperature of 98.2 degrees Fahrenheit, respirations 22 per minute, blood pressure 111/54, pulse 70 beats per minute, and 93 percent oxygen saturation level on room air. Resident #42 was administered Levsin (gut antispasmodic) for secretions. Review of Resident #42's progress noted dated 08/27/23 at 1:46 A.M. revealed hospice was notified and arrived at the facility to evaluate Resident #42. As a result of the visit, the facility nurse was told to monitor Resident #42 and if any changes took place to call hospice. Review of Resident #42's Hospice Assessment notes dated 08/27/23 at 2:20 A.M. revealed an unidentified facility nurse called and reported Resident #42 was congested with a moist cough, thick mucus, and secretions. Respirations were 24 per minute with no shortness of breath or labored breathing. The medication Levsin used for secretions was effective. The facility nurse was advised to call the hospice agency if Resident #42 had a change in status. Review of Resident #42's progress notes from 08/27/23 at 1:46 A.M. through 08/30/23 at 9:31 P.M. revealed no documented evidence Resident #42 was monitored for a change of condition. There was no documented evidence Resident #42's mental status or vital signs were checked during this time period. There was no documented evidence Resident #42's POA, the hospice nurse, or Resident #42's physician were notified of any issues for Resident #42's during this time period. Review of Resident #42's progress notes dated 08/30/23 at 6:44 A.M. revealed the anti-anxiety medication, Ativan 0.5 milligrams (mg) (which could be administered every four hours as needed for anxiety) was administered. Review of Resident #42's progress notes dated 08/30/23 at 6:48 A.M. revealed Morphine sulfate oral solution (opioid pain medication) 10 mg/5 milliliter (ml), 0.5 ml (which could be administered every two hours as needed for pain and shortness of breath) was administered for the resident crying and screaming. Review of Resident #42's Hospice Assessment note dated 08/30/23 at 8:31 P.M. revealed an emergent visit for lethargy noted by family. Family stated this was not Resident #42's baseline and he was found by them freezing, cold, and unresponsive. Family stated Resident #42 was cold due to anemia and they encouraged the facility to put extra layers on him. At the time of the visit, Resident #42 was cool to touch, pulses were palpable, and skin was pale. Resident #42 was minimally responsive to verbal and painful stimuli. Per facility nurse Resident #42 was restless and crying out in pain and was medicated with Roxanol (Morphine) and Ativan at 6:50 A.M. and since then Resident #42 was minimally responsive. The plan was to hold pain medication and hope Resident #42's lethargy wore off and was due to poor excretion due to age and body. The facility nurses were instructed to hold nighttime antipsychotic medication and all as needed medications until morning and the hospice nurse could reassess Resident #42's level of consciousness. Family and facility nurses agreeable to the plan. Review of Resident #42's Hospice Assessment note dated 08/31/23 at 10:21 A.M. revealed emergent visit for lethargy noted by family. Resident #42 was curled on his right side in bed. Resident #42 was oriented to self, was minimally verbal with garbled speech, and followed commands. Resident #42's skin was warm, dry, with no edema and not mottling. Resident #42 had left over food in his mouth which was gently removed. Resident #42 was changed to a pureed diet. The resident's lungs were clear to auscultation, respirations shallow from pain, no shortness of breath. Resident #42 was notably lethargic and had not been out of bed since 08/30/23. Coordinated care with facility staff, educated facility nurse to give as needed Morphine for pain. Resident #42 was to be a daily watch at this time. Review of Resident #42's Hospice Assessment note dated 08/31/23 at 11:11 A.M. included Hospice Nurse (HN) #318 spoke with POA #340, and POA #340 was very upset regarding Resident #42's care at the facility. POA #340 stated she did not believe Resident #42 was declining, rather she believed there was something wrong that needs to be treated. POA #340 demanded a laboratory testing (a complete blood count (CBC) and Depakote level draw and wants everything to find out what's wrong. POA #340 was educated on limitations of treatment, tests when a resident was on hospice and Resident #42 could be discharged from hospice for seeking treatment. POA #340 stated she wanted hospitalization and treatment for Resident #42 until cardiac arrest. POA #340 verbalized understanding about possible discharge from hospice. CBC and Depakote draw requested from the hospice physician at this time. Review of Resident #42's Hospice Assessment note dated 08/31/23 at 2:33 P.M. revealed POA #340 called HN #318 and expressed concern about Resident #42's hydration status. POA #340 stated Resident #42 got dehydrated and developed urinary tract infections (UTIs) frequently and wanted him tested for a UTI and specific gravity. Permission was given for a urine test for infection, but a specific gravity would not be covered. POA #340 verbalized understanding but still wanted a urine test for infection and a specific gravity. POA #340 and HN #318 discussed hospitalization for fluid resuscitation, and HN #318 reminded POA #340 hospice patients could not be admitted to the hospital for treatment or they would be discharged from services. POA #340 verbalized understanding. Review of Resident #42's Hospice Assessment note dated 08/31/23 at 2:42 P.M. revealed the facility was called and Resident #42's lab order was placed with Licensed Practical Nurse (LPN) #309. Review of Resident #42's progress notes dated 08/31/23 at 6:59 P.M. written by LPN #309 revealed new orders for STAT (immediate) labs from Hospice Nurse #318 for a CBC, Depakote level, urine culture and sensitivity and specific gravity would be passed onto oncoming nurse. Review of Resident #42's Hospice Assessment note dated 08/31/23 at 9:15 P.M. included POA #340 called and was very upset and wished for Resident #42 to be sent to the hospital. POA #340 reported Resident #42's oxygen saturation level was 85 percent and he was pocketing food. POA #340 indicated she went to the facility on [DATE] and Resident #42 was sitting in his wheelchair underneath an air conditioner in the hall. POA #42 stated Resident #42 was very lethargic, his temperature was 95 degrees Fahrenheit, and she warmed him up with blankets. POA #340 stated she requested lab work and a urinalysis for culture and sensitivity earlier in the day (08/31/23) because she believed Resident #42 was anemic and possibly dehydrated with a UTI. POA #340 stated the facility left these labs for the night nurse and the results would not be back until next week due to the holiday weekend. POA #340 demanded Resident #42 to be transported via squad to the local hospital Emergency Department. Hospice Nurse (HN) #341 advised POA #340 she would contact the facility for more information. Review of Resident #42's Pre-hospital Care Report Summary dated 08/31/23 included a call was received on 08/31/23 at 9:36 P.M. and Emergency Medical Services (EMS) were on scene at 9:40 P.M. The dispatch reason was respiratory distress. At 9:59 P.M. Resident #42's oxygen saturation level was 88 percent and oxygen was initiated at four liters nasal cannula. The POA told the facility to withhold all comfort care medications and to run diagnostic testing for illness. The POA requested transport to the Emergency Department for more diagnostic procedures. Patient contact was delayed due to fire department consultation with Med Control. Review of Resident #42's Hospice Assessment note dated 08/31/23 at 9:39 P.M. included HN #341 spoke with the facility and was told POA #340 demanded Resident #42 be transported to the local hospital. HN #341 stated it was POA #340's wish that Resident #42 was transported to the local Emergency Department and the wishes must be followed. Review of Resident #42's progress note dated 08/31/23 at 11:21 P.M. written by Licensed Practical Nurse (LPN) #313 included when LPN #313 arrived for work it was reported to her Resident #42 needed STAT (immediate) labs and a urine test completed. Lab work was ordered, and Resident #42 was catheterized to obtain a urine specimen. When LPN #313 entered Resident #42's room to administer bedtime medications she observed Resident #42 grimacing in pain and white thick secretions coming from his mouth. Resident #42's temperature was 98.7 degrees Fahrenheit, respirations were 16 per minute, pulse was 75, blood pressure was 148/55, and oxygen saturation level was 86 percent on room air. LPN #313 informed POA #340 of Resident #42's condition and that she would keep Resident #42 comfortable and administer oxygen to assist with his oxygen saturation level. POA #340 wanted Resident #42 to be sent to the Emergency Department to be evaluated. POA #340 stated she understood this could revoke Resident #42's hospice order. POA #340 wanted Resident #42 sent to the Emergency Department via 911 and Emergency Medical Services (EMS). LPN #313 called 911 and Resident #42 was transported to the local Emergency Department. Resident #42's POA, Director of Nursing, and the hospice nurse were updated. Review of Resident #42's progress note dated 09/01/23 at 1:15 A.M. included Resident #42 was admitted to the local hospital with a diagnosis of UTI with possible sepsis. Resident #42 was removed from hospice status. Interview on 09/20/23 at 11:29 A.M. with Resident #42's POA #340 revealed she wanted all life saving measures done for Resident #42 up until extreme measures would be implemented like intubation, chest compressions. POA #340 stated if Resident #42 needed medicine she wanted him to have it. POA #340 stated Resident #42 had a fractured right hip, surgery was not recommended due to his brain tumor, and he started receiving hospice services in 07/2023. POA #340 stated the main reason Resident #42 started receiving hospice services was because it was not known how fast his brain tumor would progress and communication with the facility was challenging due to new owners and administration. POA #340 stated she did not receive a call from the facility informing her Resident #42's mental status changed and when she came in for a visit on 08/30/23 and found him cold and freezing and not responding well. POA #340 stated the nurse and State tested Nursing Assistant (STNA) #315 assigned to care for Resident #42 were regular facility staff, knew Resident #42 and should have known his baseline and realized something was off. POA #340 stated she told Hospice Nurse #318 that Resident #42 had a UTI, as she could almost guarantee it. POA #340 stated Resident #42 needed medicine to clear his infection, and she wanted him to have fluids and antibiotics. POA #340 stated she wanted Resident #42 to have blood work and a urine test, and Hospice Nurse (HN) #318 requested a urine test and blood work through the facility. POA #340 stated on 08/31/23 at 9:00 P.M. she received a call from the resident's facility nurse, she did not remember her name, and the nurse told her she was preparing to have Resident #42's urine test completed and blood work drawn. POA #340 stated she thought the facility nurse was calling to give her the results because the urine test and blood work should have been done in the morning. The nurse also told POA #340 Resident #42's oxygen saturation was 85 percent, and POA #340 indicated she insisted Resident #42 was sent to the hospital via a 911 call and transported by EMS. POA #340 stated Resident #42 laid in bed all day on 08/31/23 and was not responsive. Interview on 09/20/23 at 3:31 P.M. of LPN #309 revealed she had just started working at the facility around 08/31/23 and did not remember Resident #42 or any details regarding his care. Interview on 09/20/23 at 4:02 P.M. with LPN #313 revealed when she arrived for work on 08/31/23 at 6:30 P.M., LPN #309 reported to her Resident #42 needed a urine sample and blood work drawn STAT. LPN #313 stated Registered Nurse (RN) #316 assisted her, placed a Foley catheter to obtain the urine specimen, and checked Resident #42's vital signs. LPN #313 stated Resident #42 did not look well and was grimacing in pain. LPN #313 stated she called POA #340 and informed her of Resident #42's low oxygen level, and she could make Resident #42 comfortable with oxygen and pain medication. LPN #313 indicated POA #340 wanted Resident #42 sent to the hospital and asked if Resident #42's STAT labs and urine test were back because the order was written early in the day. LPN #313 indicated a urine specimen was collected and placed in the specimen area but would not be picked up until the morning. LPN #313 stated the urine specimen was not sent and blood work was not drawn because Resident #42 was transported to the Emergency Department. Interview on 09/20/23 at 4:14 P.M. with RN #316 revealed on 08/31/23 Resident #42 was lethargic and she thought he was passing. RN #316 stated she obtained Resident #42's urine specimen via a Foley catheter, and it was supposed to be sent the next morning, but he was sent to the hospital and the urine was not sent. RN #316 stated Resident #42's urine was orange in color and was darker than it should have been. RN #316 stated she did not know why the urine and lab work were not done on the day shift. RN #316 stated Resident #42 was usually alert, but the day he was sent to the hospital he was lethargic, sleeping a lot, and it was a change from how he usually was. Interview on 09/21/23 at 8:15 A.M. with STNA #315 revealed Resident #42 could answer questions and say things like good morning, and how are you, but could not carry-on long conversations. STNA #315 stated Resident #42's nurse told him the day before he went to the hospital that Resident #42 was in pain and trying to get out of his chair and she gave him something to calm down and help him relax. STNA #315 stated after Resident #42 received the medication he was less sleepy and talkative. STNA #315 stated the resident was a lot sleepy the day he went to the hospital, and STNA #315 thought it was because Resident #42 did not sleep well. The nurse told me Resident #42's family was concerned because he was not his normal self which was alert. Interview on 09/21/23 at 8:29 A.M. with STNA #317 revealed Resident #42 was generally alert and not sleepy or lethargic. Interview on 09/21/23 at 1:23 P.M. with Hospice Nurse (HN) #318 and Hospice Supervisor (HS) #320 revealed HN #318 visited Resident #42 once a week, but the last few days he was lethargic and he was visited two days in a row. Resident #42 received a hospice emergent visit for lethargy on 08/30/23 (Hospice Nurse #342) and 08/31/23. HN #318 stated on 08/31/23 Resident #42 was lethargic and POA #340 was concerned about the lethargy, concerned because Resident #42 was not eating and POA #340 was also worried the resident might have a UTI. HN #318 stated she had not visited Resident #42 since 08/23/23 but did not receive any calls 08/27/23 through 08/31/23 from the facility regarding Resident #42's status. HN #318 stated on 08/27/23 the facility called to let the hospice nurses know they were using Levsin for secretions. HS #320 stated they would expect to get a call if Resident #42 was lethargic or had a change in condition in case they needed to make a visit to make Resident #42 more comfortable. HN #318 stated she called LPN #309 on 08/31/23 at 2:42 P.M. and gave orders for lab work and a urine specimen to be completed for Resident #42. HN #318 stated Resident #42 had lethargy and increased pain on 08/31/23 and this was a change from 08/23/23. Interview on 09/21/23 at 2:57 P.M. with the Director of Nursing (DON) revealed an actual physician order was not written on 08/31/23 for the urine specimen and lab work to be completed per hospice. The DON also stated even with the resident's advance directives for Do Not Resuscitate (regardless of a DNRCCA or DNR no intubation) would require staff to perform all life saving measures to be done for Resident #42 up until the point of cardiac respiratory arrest. Review of the facility policy titled Change in Condition Monitoring, dated 05/01/22, revealed the facility should promptly notify the resident, his or her attending physician, and the family, guardian, POA of changes in the resident's medical, mental condition and, or status. The nurse would notify the resident's attending physician or physician on call when there had been a significant change in the resident's physical, emotional, or mental condition. A significant change of condition was a major decline or improvement in the resident's status that would not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, impacted more than one area of the resident's health status, and required interdisciplinary review and or revision to the care plan. Prior to notifying the physician or healthcare provider, the nurse would make detailed observations and gather relevant and pertinent information for the provider. Unless otherwise instructed by the resident a nurse would notify the resident's representative when there was a significant change in the resident's physical, mental or psychosocial status. Except in medical emergencies, notifications would be made within twenty-four hours of a change occurring in the resident's medical, mental, condition or status. The nurse would record in the resident's medical record information relative to changes in the resident's medical, mental condition or status. This deficiency represents non-compliance investigated under Complaint Numbers OH00146368 and OH00146399.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated [DATE], Nursing Home Guidance from the Centers for Disease Control (CDC), review of the facility's infection control policies and procedures, review of the facility's Coronavirus (Covid-19) occurrences, observations, medical record review, staff interview and review of staff COVID 19 screenings, the facility failed to implement effective and recommended infection control practices. This resulted in Immediate Jeopardy when the facility failed to isolate residents who tested positive for Covid-19 from the general population, failed to monitor COVID 19 test results and implement procedures including notifying the staff who tested positive and the local health department, as well as not permitting them to provide resident care, monitor screening procedures and implement appropriate isolation and quarantine procedures to prevent COVID 19. The facility's lack of current effective infection control practices during a COVID-19 outbreak in the facility placed all 46 residents at risk for the likelihood of harm, complications and/or death. On [DATE] at 1:10 P.M. the Administrator and Director of Nursing were notified Immediate Jeopardy began on [DATE] when the laboratory sent email confirmation that Registered Nurse (RN) #50 had tested positive for COVID 19 and RN #50 continued to work in the facility in both the COVID 19 unit and non-COVID 19 unit through [DATE]. On [DATE] the laboratory sent an email confirmation that State tested Nurse Aide (STNA) #64 tested positive for COVID 19 and STNA #64 continued to work in the facility through [DATE]. The facility failed to monitor test results leading to a delay in notification of the local health department to immediately initiate contact tracing. The facility failed to consistently screen staff prior to beginning work, failed to implement transmission-based precautions for new admissions, re-admissions and residents displaying respiratory symptoms associated with COVID 19. This likely contributed to an outbreak that spread throughout the facility infecting 23 residents (Resident #'s #1, #2, #4, #5, #6, #7, #8, #10, #17, #28, #29, #31, #32, #33, #35, #36, #37, #38, #40, #42, #43, #44 and #48) including four hospitalization s (Resident #'s #1, #10, #32 and #35) and one death (Resident #28). The Immediate Jeopardy was removed on [DATE] at 5:00 P.M. when the facility implemented the following corrective action: · On [DATE] at 11:29 A.M. signs were posted to identify the zones. The Red zone was the COVID 19 unit, the Yellow zone was for persons under investigation (PUI) and the Green zone was for the general population. The facility was no longer cohorting Covid-19 positive and negative residents. · On [DATE] at 4:15 P.M. the administrator, Director of Nursing (DON), activities/social service designee, human resources, business office manager, scheduler and environmental services and on [DATE] by 1:30 P.M. assessment nurse, therapy and dietary services were educated by the Director of Clinical Operations regarding preparing for COVID 19 in Nursing Homes, COVID 19 testing for staff and residents, managing new and re-admissions for COVID 19 and criteria for healthcare personnel with [DIAGNOSES REDACTED] CoV-2 to return to work, discontinuation of transmission-based precautions and disposition of residents with COVID 19. · On [DATE] at 5:00 P.M. all staff, including agency staff, will be trained in person or via telephone on policies and practices of the COVID 19 unit as it pertains to housing residents in accordance with CDC (Centers for Disease Control) guidelines. · Appropriate signs were posted at the entrance to the unit where COVID 19/presumptive positive/symptomatic residents reside and to the unit where residents have been exposed and/or a Person Under Investigation (PUI) on [DATE] at 3:00 P.M. The director or nursing or the administrator will ensure signs remain posted during daily rounds. · Beginning on [DATE] at 11:00 A.M. the administrator will notify the Director of Clinical Operations of any new presumptive or positive residents/staff. The DON will utilize the Long-Term Care Respiratory Surveillance Line List, a template for data collection and active monitoring of both residents and staff Monday through Friday via telephone to verify accuracy and CDC guidelines were being followed. · The receptionist's hours will be adjusted to 7:00 A.M. beginning on [DATE] to ensure day shift staff were screened upon entering the facility. The administrator will assign a department head team on a rotating basis to ensure evening shift staff were screened upon entering the facility. The charge nurse will ensure screening of weekend staff for day and evening shift. The administrator will review the daily screening logs Monday through Friday with Saturday and Sunday logs reviewed on Monday morning during the clinical meeting to verify staff were screened appropriately. · Beginning on [DATE] the facility will begin utilizing the Abbot Rapid POC to test residents and staff so there will be no delay in getting test results or placing residents/staff in appropriate precautions according to the CDC guidelines. The administrator will review the CDC COVID 19 data for county positivity rate weekly to verify the current positivity rate. · Audits/logs will be reviewed during monthly Quality Assurance and Performance Improvement meetings. Although the Immediate Jeopardy was removed on [DATE], 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 was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Observations during the tour of the facility on [DATE] beginning at 8:05 A.M. revealed Resident's #31 and #32 shared a room, and Resident #6 was in a private room. All were on droplet isolation. The facility had one wing cordoned off by a plastic zippered wall for residents under observations/quarantine for possible COVID 19 and another section for residents who were positive for COVID 19. There was one resident (Resident #48) in the COVID 19 unit and no residents on the observation/quarantine unit. Observation of Resident #6 on [DATE] at 10:33 A.M. revealed he was in a private room, lying in bed wearing oxygen. The door was wide open, and he was coughing. The posted sign indicated he was on droplet isolation. Interview with Resident #6 on [DATE] at 10:33 A.M. revealed he was waiting to go to the hospital because he had a cough. On [DATE] at 12:30 P.M., Resident #6 was seated in his wheelchair in his room coughing and wearing oxygen. Interview with Resident #6 at that time reported he had been coughing for four days, his chest was tight, and he was sweaty but did not have an elevated temperature. He normally wore oxygen only when in bed but needed it now when out of bed. He had tested positive for COVID 19 on [DATE] at 4:20 P.M. and was placed on droplet isolation. Interviews with RN #50 and Licensed Practical Nurse (LPN) #51 on [DATE] between 8:05 A.M. and 8:54 A.M. revealed the facility had one resident positive for COVID 19 (Resident #48) who resided in the COVID 19 unit. They reported no residents were in the observation/quarantine unit which was set up for new admissions, re-admissions and those with respiratory symptoms associated with COVID 19. The nurses reported Resident's #6, #31 and #35 were experiencing respiratory symptoms. Resident #31 and #35 shared rooms with other residents with no respiratory symptoms. They also reported Resident #13 and #25 were newly admitted to the facility and not isolated. RN #50 reported new admissions or re-admission were to be quarantined for 14-days to monitor for signs and symptoms of COVID 19, but the facility was not following the guidelines. RN #50 was working the COVID 19 and non-COVID 19 units while she was positive for COVID 19 unbeknownst to her. Interview with the administrator and DON on [DATE] at 11:30 A.M. reported Resident #25 was not considered a readmission because he was only at the hospital for 11 hours. She did not consider this resident as requiring observation for respiratory symptoms associated with COVID 19. Resident #45 was admitted on [DATE] and was removed from isolation on [DATE] after seven days. The DON reported it was an independent decision by the night nurse, not herself, to put Resident's #6, #31 and #32 on droplet isolation. She verified Resident #31 was experiencing signs and symptoms related to COVID 19 and shared a room with Resident #32 who did not have signs or symptoms of COVID 19. The director of nursing confirmed staff were tested on e time per week despite the recommended testing cadence by the Centers for Disease Control (CDC). The DON reported she was the infection control preventionist and monitored the CDC and CMS websites; however, there was no evidence of monitoring. Further interview with the DON on [DATE] at 12:47 P.M. revealed when she began testing staff, she was not wearing personal protective equipment but now does. The DON reported she notified all staff about staff or residents who tested positive by phone or in person. Interview with RN #57 on [DATE] at 11:43 A.M. reported multiple residents were not residing in the COVID 19 unit after testing positive for [MEDICAL CONDITION] in the past few days. Resident's #1, #2, #6, #8, #17, #29, #32, #33, #40, #43, #44 and #48 were identified as testing positive for COVID 19 and have been placed on the expanded COVID 19 unit, but some of the roommates where displaying signs and symptoms associated with COVID 19 including Resident #7, #15 #16, #28, #31, #41 and #42. RN #57 expressed concerns for residents in the secured unit because three residents (Resident's #7, #14 and #15) were displaying signs and symptoms of COVID 19, and they wandered throughout the unit and did not understand mask wearing. RN #57 reported she suspended all smoking privileges due to the increase in positive cases at the facility. RN #57 reported staff light the cigarette for a resident, but they immediately blew smoke and potentially COVID 19 into the staff's face. Interviews with RN #50, LPN #51, State tested Nurse Aides (STNA's) #52, #53, #54 and #55 on [DATE] between 8:05 A.M. and 12:30 P.M. and RN's #57 and #60, STNA's #58, #59 and #61 on [DATE] between 11:43 A.M. to 12:30 P.M. revealed they were tested on e time per week on Wednesdays. Four of 11 staff interviewed reported they were asked to pre-date their testing vials. Four of the 11 staff interviewed reported not being notified of staff or residents with positive COVID 19 results. Review of medical records revealed there were three rooms where one resident in each room (Resident's #8, #31 and #35) showed signs and symptoms associated with COVID 19 and the roommate was not (Resident's #7, #32 and #36). According to the census report dated [DATE] there were five residents (Resident's #3, #30, #34, #39 and #41) on the person under investigation (PUI/quarantine) unit and 18 residents (Resident's #2, #4, #5, #6, #7, #8, #17, #29, #31, #33, #36, #37, #38, #40, #42, #43, #44 and #48) in the COVID 19 unit. On [DATE] at 9:25 A.M. upon entry into the facility, no staff offered to screen the surveyor. Upon inquiry regarding screening, the receptionist who had been the screener had tested positive for COVID 19 and was on leave. The DON indicated staff were expected to self-screen. There were no signs posted to indicate staff, visitors or vendors should self-screen upon entry into the facility. The tour of the facility with the administrator revealed plastic zippered walls that had been expanded since [DATE]. There were no signs posted regarding the areas that were cordoned off and no instructions on any precautions to take upon entry to those areas. The administrator reported Resident's #3, #30, #34, #39 and #41 were PUI (persons under investigation) for COVID 19 and Resident's #2, #4, #5, #6, #7, #8, #17, #29, #31, #33, #36, #37, #38, #40, #42, #43, #44 and #48 were in the COVID 19 unit. There was also a zippered plastic wall between the common dining room and Rooms ,[DATE]. The administrator indicated the wall was put up just in case they needed to expand. The wall was zippered closed, and no signs were posted to indicate what type of unit existed beyond the plastic zippered wall. Interview with the DON/infection control preventionist on [DATE] beginning at 10:15 A.M. verified she failed to review the emails sent by the laboratory to review COVID 19 test results. The DON indicated the emails were lengthy and not easy to review. The DON reported RN #50 approached her requesting to see the results of her COVID 19 test. When the DON reviewed the test results it revealed RN #50 had tested positive on [DATE] and had been working both the COVID 19 section and non-COVID 19 section of the west side of the facility through [DATE]. The DON said it was a night nurse that found STNA #64 had tested positive for COVID 19 on [DATE] and she worked through [DATE]. Review of the screening log compared with the staffing schedules for [DATE] through [DATE] with the DON verified the following: [DATE] eight direct care staff were not screened prior to their shift, [DATE] four direct care staff were not screened prior to their shift, [DATE] four direct care staff were not screened prior to their shift, [DATE] five direct care staff were not screened prior to their shift, [DATE] two direct care staff were not screened prior to their shift, [DATE] five direct care staff were not screened prior to their shift and on [DATE] for the first shift three staff were not screened prior to their shift. Review of additional medical records on [DATE] revealed Resident's #28 and #29 shared a room. Review of the progress notes revealed Resident #29 displayed respiratory symptoms associated with COVID 19 on [DATE] at 10:37 A.M. and tested positive for COVID 19 on [DATE]. This was the first COVID-19 test Resident #29 had after experiencing symptoms beginning on [DATE]. On [DATE] Resident #29 was moved to the isolation unit. Review of the progress notes revealed Resident #28 indicated on [DATE] she was in contact with and suspected exposure to COVID 19 and was placed in droplet precautions for 14 days. Review of the progress notes revealed Resident #28 had to be reminded not to go through the zipped off areas. On [DATE] at 2:14 P.M. the resident (Resident #28) was pale and sweating. Her temperature was 96.4 degrees Fahrenheit. Her code status was checked, 911 was called and she was found not breathing. Cardio-pulmonary resuscitation was initiated. Resident #28 was transferred to the hospital where she expired. Resident #31 and #32 shared a room. On [DATE] at 8:25 P.M. Resident #31 developed symptoms associated with COVID 19. Droplet precautions were initiated, but Resident #31 continued to remain in the room with Resident #32. On [DATE] Resident #31 was tested for COVID 19 and positive results were reported on [DATE] at 11:45 A.M. and isolation was initiated at that time. The roommate, Resident #32 received a rapid [MEDICATION NAME] COVID 10 test on [DATE] at 8:30 A.M., four days after the roommate became symptomatic, and was positive for COVID 19. On [DATE] it was noted Resident #32 was in a private room. On [DATE] at 10:30 P.M. Resident #32 was lethargic, short of breath, labored breathing and upon auscultation crackles and audible wheezing was noted in the right lower lobe. A cough was present. Resident #32's pulse oxygen level was 78% on 2 liters of oxygen. The resident was transferred to the hospital. Record review revealed Residents #7 and #8 shared a room. Review of the progress notes revealed on [DATE] at 2:58 P.M. the physician was notified Resident #8 displayed signs and symptoms associated with COVID 19 but tested negative. Resident #8 was not isolated at that time. On [DATE] at 6:27 P.M., the physician was notified of a positive rapid [MEDICATION NAME] COVID 19 test for Resident #8. An immediate chest X-ray was ordered. Labored breathing was noted. on [DATE] at 6:35 A.M. Resident #8 remained on room isolation for COVID precautions for positive rapid result. On [DATE] at 6:27 P.M. the daughter was notified Resident #8 was moved to the isolation unit due to positive COVID 19 results. On [DATE] at 6:22 A.M. Resident #8 had a wet sounding cough and was lethargic at times. Review of the progress notes dated [DATE] at 4:59 P.M. revealed Resident #7 was positive for COVID 19 and presented with a dry cough. It was noted she was at risk for complications related to hypertension, heart failure, history of pneumonia and sedentary lifestyle. On [DATE] at 12:51 A.M. Resident #7 was noted with tachypnea, dry cough, lungs diminished throughout, pulse oxygen level was 85% on room air. Resting [MEDICAL CONDITION] 101. Oxygen initiated and a chest X-ray was ordered. On [DATE] at 7:46 A.M. the chest X-ray results indicated she had a right lower lobe infiltrate and antibiotics were ordered. CMS Survey and Certification memoranda, guidance, clarifications and instructions to State Survey Agencies issued QSO-,[DATE] memo, dated [DATE], revealed tables of a symptomatic individual identified an outbreak as any new case arises in the facility. Staff with signs and symptoms must be tested , test all staff that previously tested negative until no new cases are identified. Residents with signs and symptoms must be tested . Test all residents that previously tested negative until no new cases are identified. For outbreak testing, all staff and residents should be tested , and all staff and residents that tested negative should be retested every three days to seven days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. While test results are pending, residents with signs or symptoms should be placed on transmission-based precautions (TBP) in accordance with CDC guidance. Once test results are obtained, the facility must take the appropriate actions based on the results. An outbreak is defined as a new COVID-19 infection in any healthcare personnel (HCP) or any nursing home-onset COVID-19 infection in a resident. In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further [MEDICAL CONDITION] transmission. A resident who is admitted to the facility with COVID-19 does not constitute a facility outbreak. Upon identification of a single new case of COVID-19 infection in any staff or residents, all staff and residents should be tested , and all staff and residents that tested negative should be retested every three days to seven days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. See CDC guidance Testing Guidelines for Nursing Homes section Non-diagnostic testing of symptomatic residents without known or suspected exposure to an individual infected with [DIAGNOSES REDACTED]-CoV-2. For individuals who test positive for COVID-19, repeat testing is not recommended. A symptom-based strategy is intended to replace the need for repeated testing. Facilities should follow the CDC guidance Test-Based Strategy for Discontinuing Transmission-Based Precautions Discontinuing Transmission-Based Precautions for residents and Criteria for Return to Work for Healthcare Personnel with [DIAGNOSES REDACTED]-CoV2 Infection. According to the CMS.gov website the county prevalence color for the facility has been red since [DATE] which indicated testing should occur twice a week. Review of the facility policy titled preparing for COVID 19 in nursing homes, dated [DATE]. indicated to identify a dedicated space to monitor and care for residents who were COVID 19 positive. Plan how a resident positive with COVID 19 would be handled i.e. transfer to a single room and implement transmission-based precautions. For new admissions, status unknown, place the resident in a private room and observe for 14 days. Review of the facility policy titled discontinuation of transmission-based precautions, dated [DATE], indicated for severe critical illness to isolate for ,[DATE] days after onset of symptoms. For symptom-based strategy obtain two negative tests. The test-based strategy was no longer recommended. This deficiency substantiates Master Complaint Number OH 688 and Complaint Numbers OH 686, OH 585, OH 533 and OH 114.

Based on observation, resident and staff interview, medical record review, review of facility investigation, and review of the facility Elopement Management Policy, and Pine Valley Window Security Audit Policy, the facility failed to provide adequate supervision of one resident (Resident #96) to prevent elopement from the facility. This resulted in Immediate Jeopardy when Resident #96, who had a history of [REDACTED].#43 walking along a heavily trafficked two lane road. This resulted in the likelihood of serious injury, harm, impairment, or death as Resident #96 had [DIAGNOSES REDACTED]. Resident #96 had a history of [REDACTED]. This affected one of three residents reviewed (Resident #96) for exit seeking behaviors in the secured unit. The facility identified ten additional residents (Residents #32, #60, #62, #64, #65, #70, #77, #79, #81 and #84) who were ambulatory or independently mobile and assessed as being at risk for wandering and elopement and exhibited exit seeking behaviors. On 10/27/16 at 3:00 P.M., the Director of Nursing (DON), the Administrator and Regional Nurse #75 were notified Immediate Jeopardy began on 10/25/16 at 4:30 P.M. when Resident #96, who was cognitively impaired with known exit seeking behaviors, crawled out of a window in the secured unit of the facility and was found walking along a busy two lane road 0.5 miles from the facility. The Immediate Jeopardy was removed on 10/28/16 when the facility implemented the following corrective actions: · On 10/25/16 at 4:50 P.M., Resident #96 was returned to the facility by LPN #43 and assessed to have no injury, except for being cold. The resident was placed on one to one monitoring and her care plan was updated to reflect the intervention · On 10/25/16 at 5:15 P.M., the window from which Resident #96 eloped was secured by Maintenance Director (MD) #47. · On 10/26/16 at 10:30 A.M., 11 LPNs, one registered nurse (RN) and 30 state tested nursing assistants (STNA) in the facility were provided with education to verify location of residents on an hourly basis and make continuous walking rounds to ensure resident safety. All staff were in serviced except for six staff members (one LPN, one RN and 4 STNAs) who worked as needed (PRN) and would be in serviced prior to their next scheduled shift. Staff were to sign the census sheet hourly to verify the resident had been observed, or a notation made to indicate the resident had been taken off the unit, as for therapy. One STNA would remain in the sunroom (dining/activity room) at all times, with other STNAs assigned to the unit designated to make the continuous walking rounds. During meal times, when STNA staff is in the dining room feeding or assisting residents, the nurse assigned to the unit would be observing residents not in the dining room. This procedure provided an hourly head count of the residents in the secured unit, including Residents #32, #64, #65, #70, #77, #79 and #96, who were assessed as having exit seeking behavior. · On 10/27/16 at 8:30 A.M., all windows and doors in resident areas were checked by MD #47 to ensure they were not able to be opened and that securing hardware was in place. A new policy, Pine Valley Window Security Audit Policy, was put in place on 10/27/16 to ensure all windows in resident rooms and resident common areas would be audited on a weekly basis by the maintenance director or designee to ensure all windows were not able to be opened and all securing hardware was in place. · On 10/27/16 by 1:00 P.M. Unit Manager, LPN #43 and Regional Nurse #46 assessed or reassessed all residents for potential exit seeking behaviors. Residents #32, #60, #62, #64, #65, #70, #77, #79, #81 and #84 who were ambulatory or independently mobile, were assessed as being at risk for wandering and elopement and exhibited exit seeking behaviors. These residents had these behaviors already care planned and with interventions in place. No new residents with exit seeking behaviors were identified as a result of the assessment/reassessment. · On 10/27/16 at 7:00 P.M. the Director of Nursing (DON) completed in-service education with 77 of 93 facility staff members on supervision of residents, elopement policy, identifying escalating resident behaviors and hourly verification of residents. Three additional staff members were in serviced by the DON on 10/28/16. The remaining thirteen staff members will be in serviced when they return to active work status. · On 10/28/16 at 10:00 A.M., hourly checks were instituted for Residents #60, #62, #81 and #84, who exhibited exit seeking behaviors but did not reside on the secured unit. These residents also had Wander Guards in place. · On 10/28/16 from 11:00 A.M. to 2:00 P.M., interviews revealed Housekeeper #50, Culinary Director #51, Therapist #52, STNAs # 44 and #45, LPN #48, Activity Director #49, RN #46 and MD #47 had all been in serviced on supervision of residents, the elopement policy, identifying escalating resident behaviors and hourly verification of residents. Although the Immediate Jeopardy was removed, the deficiency remained at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing ongoing monitoring of the corrective actions and continuing staff education. Findings include: Review of the medical record revealed Resident #96 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the elopement risk assessment ( Wandering Observation Tool ) dated 10/14/16 revealed Resident #96 was at risk for wandering based on [DIAGNOSES REDACTED]. The tool indicated Resident #96 ' s family had expressed concerns the resident had wandering tendencies, had expressed anxiety or apprehension to leave the facility, packed personal belongings, paced with no course of action or direction and attempted to exit doors. Resident #96 was assessed as at risk for elopement, was ordered a Wander Guard and resided on the secured unit. Review of a nursing note dated 10/15/16 at 4:32 P.M. revealed Resident #96 was asking for someone to open the locked doors for her, and was unable to be redirected. A nursing note on 10/18/16 at 5:41 P.M. revealed Resident #96 goes in and out of others ' room, hangs around the exterior doors of the memory unit looking to go through doors and asking how to leave and get through the doors. A nursing note on 10/19/16 at 9:21 A.M. revealed she was at the door banging and yelling at staff to let her out. Nursing notes on 10/21/16 at 2:21 A.M. and 1:34 P.M. both indicated the resident stayed close to unit doors and tried to leave when staff went out the locked doors. A nursing note on 10/22/16 at 2:22 A.M, revealed the resident was grabbing clothes and begging staff to let her through the doors, and was agitated when redirected. She was going in all rooms and trying to take other residents out exit doors. A nursing note on 10/22/16 at 4:43 P.M. revealed Resident #96 was repeatedly going towards the exit doors stating I want to go home . Review of Resident #96 ' s care plan for elopement risk dated 10/24/16 revealed the resident was at risk due to disorientation, history of attempts to leave the facility unattended, impaired safety awareness and aimless wandering. The interventions dated 10/24/16 included assess for fall risk and distract the resident from wandering by offering pleasant diversion, structured activities, food, conversation, television programs or books. Review of a nursing note on 10/25/16 at 6:07 P.M. written by LPN #48 revealed the nurse had last seen the resident around 4:25 P.M. lying on her bed. The note indicated the resident was unable to be found and an elopement alert was initiated. The note indicated a search was started outside the building and Resident #96 was found on the road and was brought back to the facility by a staff member. The resident ' s Wander Guard was noted in place on return. The note indicated a window was the apparent way the resident left the building and the window was repaired by maintenance. The note indicated Resident #96 ' s physician and power of attorney were notified. Review of a note by the DON dated 10/25/16 at 6:09 P.M. revealed she was notified at 4:45 P.M. the resident was not in the facility. The note indicated a staff member (LPN #43) left the grounds in his car and located the resident on the road returning with her at 4:50 P.M. The resident was dressed for the weather with coat, shoes and socks, long pants and long sleeve shirt. The resident stated she climbed out a window and was headed for home. The resident was not injured. The window identified by the resident as the one she opened and climbed out was observed and was able to be opened despite having screws in place to prevent opening. The window was secured by MD #47 and all other windows in the facility were checked. The note indicated an STNA revealed at 4:30 P.M. the resident was up and pacing in the hallway and was in and out of the sunroom. The note indicated it was found that blinds in the other rooms in the hall were partially lifted suggesting the resident attempted other windows but was unable to gain access to the outside. The note indicated the resident ' s son was contacted and stated she had successfully navigated her way home from her previous facility. Review of the investigation revealed the DON received a text and phone call from an acquaintance that had driven by the building and knew she (the DON) was employed there. The text/phone call on 10/25/16 at 4:45 P.M. revealed the caller asked if a resident might have left the facility, as someone was noted walking along the road. The DON sent the unit manager out in his car to look for the person who was walking, to determine if the person was a resident of the facility. The DON also facilitated an immediate accounting of all residents and started a search of the building. An interview with the DON and Regional RN #55 on 10/27/16 at 11:30 A.M. verified Resident #96 climbed out of a window on the secured unit on 10/25/16 sometime after 4:30 P.M. The DON stated a friend of hers, who was driving by the facility texted and called her on that day at 4:45 P.M. to say she had noted a female walking along the highway. The DON said her friend said she may want to check if all of the residents in the facility were present. She said she sent a unit manager (LPN #43) out in his car to look for the unknown female and began a head count in the building. Resident #96 was noted to be missing and she called LPN #43 about the same time the resident was observed walking along the road. An interview on 10/27/16 at 11:45 A.M. with the unit manager (LPN #43) revealed he left in his car when asked by the DON to look for someone. Resident #96 was found walking along the road about a half mile from the facility. He stated she was hitch hiking, (had her thumb out to signal she wanted a ride.) He said when he stopped his car, the resident got in and said You are a sweetheart for picking me up, it ' s cold out here. LPN #43 stated the resident did not realize he was from the facility until he started to drive back toward the facility. She then said, You are taking me back, aren ' t you? He said he asked the resident how she got out of the building and she told him she went out a window and she was going to her home and car, just up the hill. All windows on the secured unit were examined with MD #47 on 10/28/16 at 8:05 A.M. All resident rooms had double-hung windows, of which only the lower window had opening capability. The windows were secured with four screws: two on the top portion of the lower window, and two to the front side sections of the lower window. All screws were tightly secured. Interview with MD #47 confirmed physical checks for window security had been added to the weekly preventative maintenance program, which incorporates date/time check-list initials for accountability. There were additional rooms with windows on the secured unit used for ancillary services (therapy, beauty shop, employee break room) which had unsecured windows; however, these rooms have locked entry doors and can only be accessed by facility personnel. The resident sitting room on the secured unit had two windows, one of which was functional; however, windows from this room lead to a fully-enclosed courtyard with no exit. An interview with the DON and the regional nurse, RN #46, on 10/28/16 at 9:45 A.M. revealed the facility did not have a policy or procedure for every 15 minute checks for residents. They stated Resident #96 was ordered to have one to one supervision by a staff member from the time she returned to the facility on [DATE] at 4:50 P.M. The one to one supervision would continue until the resident ' s exit seeking behaviors deescalated or resolved or until the resident was transferred to a more appropriate facility. The DON said the documented hour checks would account for all residents on the unit, including eight residents on the unit who had exit seeking behaviors. She said the newly instituted rounding procedure would be a continuous check of the residents to monitor for escalation of behaviors, which would then be redirected with a resident centered activity. If the resident centered behavior was unsuccessful, the resident would be placed on one to one monitoring. An interview with STNA #45 on 10/28/16 at 11:30 A.M. revealed she had worked on 10/25/16. She said she saw Resident #96 pacing in the hall around 4:30 P.M. and the resident asked her about the next smoking break. She told the resident the next break was after dinner and the resident continued pacing. She then helped another resident to the bathroom and did not see Resident #96 again until she was returned to the facility. An interview with Resident #96 was attempted on 10/28/16 at 12:10 P.M. She was sitting in the dining room area of the locked unit. She denied concerns when approached by the surveyor and initially stated she did not remember leaving the facility. When questioned further, she again could not describe any circumstances regarding the incident on 10/25/16, but when asked about her time at the facility, she said she did not like being here because she likes to be in control and she would like to go back to her home. An interview with LPN #48 on 10/28/16 at 12:15 P.M. revealed he was working on 10/25/16. He stated he had last seen the resident lying down in her room about 4:25 P.M. He said he was told by the Administrator about 4:45 P.M. to check for any resident that may have left the building. He stated he and the other staff were unable to locate Resident #96. LPN #48 said he called a facility wide code to enable a full search. He then heard Resident #96 had been found walking along the road that was in front of the facility. He said she was uninjured when she returned but indicated he heard she started walking back to the facility because she was cold. LPN #48 said he saw the window Resident #96 had opened to leave the building. He said from the door, it was difficult to see it was open, but when he approached, the window was tipped in slightly and he was able to pull the bottom section of the window down. The window was secured by maintenance and the resident was started on one to one supervision. Interview with MD #47 on 10/28/16 at 12:43 P.M. revealed he visited every room every day to check for concerns related to plumbing, lighting or other issues. He said the windows in the facility were secured with four screws. He said the top screws were in place to prevent the releases from moving toward the center, which would allow the window to be raised or tipped in for cleaning. The screws on the sides of the bottom half of the window prevent it from tipping in or rising up. MD #47 stated the room in which the resident opened the window was a room that residents liked to look out, as it had two windows, one looking toward the road, and another opening toward the street. He stated he had been in the room on 10/24/16 but he did not observe concerns with the window on that day. MD #47 stated he observed the window after the resident was returned to the facility on [DATE]. He said the upper left screw was missing and it looked as if someone had forced the window open, despite two screws on the top of the bottom section and two screws on the side of the bottom section about midway down. He said he was unsure how the resident opened the window or how far she was able to open it to get out of the building. Elopement drills had been conducted on 10/26/16 at 10:30 A.M. and 10/27/16 at 6:22 A.M. to ensure staff recognized the absence of a resident from the secured unit and instituted the proper procedures. On 10/28/16 at 2:55 P.M., Regional Nurse, RN #55 said plans were being made to transfer Resident #96 to a different facility later in the day on 10/28/16. Review of the facility policy Behavior Management: Elopement Preventative Guidelines, dated 06/17/14, revealed the facility would follow preventative measures to deter cognitively impaired residents from the center and/or grounds without proper supervision. The policy indicated the facility would address interventions to distract and/or prevent elopement, interventions would be individualized based on the resident ' s interests, capabilities and physical and cognitive status and the facility would account for the resident ' s presence every two hours and at shift change-more often if need be.

Based on observation, medical record review, staff interview, review of facility incident reports, review of a police report, and review of the facility Elopement Management policy and standard procedures, the facility failed to provide adequate supervision to prevent the elopement of Resident #33 and Resident #32, who were severely cognitively impaired, independently mobile and assessed as being at a moderate risk for elopement and wandering. This resulted in Immediate Jeopardy on 03/29/16 at 7:30 P.M. when Residents #32 and #33 were last seen in the facility prior to exiting the facility unsupervised. The potential for serious harm occurred when the residents exited the secured dementia unit through a door with a key pad lock, walked through an electrical room and through the maintenance work shop where multiple biohazard materials were stored and out the back door. This affected two of 20 residents assessed as being at risk for elopement. On 07/22/16 at 12:37 P.M. the administrator, director of nursing (DON) and Corporate Registered Nurse (CRN) #1 were notified that Immediate Jeopardy began on 03/29/16 at 7:30 P.M. when Residents #33 and #32 exited the secured dementia unit unsupervised and Resident #33 was subsequently found by the police wandering approximately 3/4 mile away from the facility. The Immediate Jeopardy was removed and corrected on 07/25/16 when the facility implemented the following corrective measures: · On 04/21/16 an outside vendor completed installation for a single door Wandering Resident system to the laundry/maintenance door. · On 07/22/16 all residents in the facility were re-assessed for their wandering /elopement risk by the registered nurse (RN) unit managers; the care plans of all residents identified at risk for wandering/elopement were updated to include measurable goals and individualized interventions; all Wanderguard bracelets (signaling device that alarms when an attempt is made to go through a monitored doorway) were checked for placement, function and expiration date by Licensed Practical Nurse (LPN) #50; maintenance verified the functioning of Wanderguard sensors on all doors, and the facility conducted a quality assurance (QA) meeting to discuss the elopements, interventions, and communication with the direct care staff. All department heads attended the QA meeting. · On 07/23/16 all facility staff had been re-inserviced by the administrator, DON, CRN #1 and the dietary manager regarding the facility ' s policy and procedure for elopement. This training included the definition of elopement and unsafe wandering, the Elopement Prevention Management Program, and environmental modifications to promote safe mobility, with monitoring for effectiveness. · On 07/23/16 at 1:30 P.M. audits were initiated by the administrator and dietary manager which included random checks of the Wanderguard protected doors to be continued five times a week for four weeks. Results of all audits would be forwarded to the quality assurance committee for further review and recommendations. · Elopement drills were completed on 07/23/16 at 9:22 A.M., 07/24/16 at 10:18 A.M. and a third drill was scheduled to be completed on 07/25/16 on third shift. All staff on duty participated in the drills. The drills were monitored and evaluated by the administrator and dietary manager. · On 07/23/16 at 7:25 A.M an interview with LPN #44 revealed she was knowledgeable regarding the Wanderguard system and the elopement/missing resident protocol. · On 07/25/16 a picture of each resident identified at risk for elopement was placed in books and placed in easily accessible areas at the reception desk and two nursing units. · On 07/25/16 between 10:09 A.M. and 10:59 A.M., interviews with staff representing all shifts including State tested Nurse Aide (STNA) #48, Speech Therapist #1, Certified Occupational Therapists #2 and #3, STNA #4, STNA #5, RN #6, STNA #7, Dietary Aide #9, Housekeeper #10, Laundry Aide #11 and Receptionist #12 revealed all were knowledgeable regarding the facility ' s procedures for elopement and their roles in an elopement situation. Findings include: 1. Review of Resident #33's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] indicated Resident #33 was severely cognitively impaired and required supervision with walking in the room, on the unit and the corridors. Physician orders [REDACTED]. Review of an elopement assessment dated [DATE] revealed Resident #33 was a moderate risk for elopement. Review of Resident #33's plan of care with initiation date of 03/19/16 revealed Resident #33 was a moderate risk for elopement due to wandering aimlessly. Care planned interventions included apply Wanderguard to the left lower extremity, check function every shift, assess for hunger, thirst, or toileting needs when found attempting to exit. Review of a progress note dated 03/29/16 timed 8:00 P.M. and logged as a late entry, revealed staff alerted the nurse Resident #33 could not be located on the unit at approximately 8:10 P.M. Staff were alerted to search the secure unit and the rest of the building. The elopement protocol was initiated and staff searched routes on foot outside the building. The DON was notified and emergency medical services (911) were called. The 911 operator notified the nurse the local police department had picked up Resident #33 on the road approximately 1/2 mile from the facility after someone in the community called to report a suspicious person walking in the area. The progress note indicated the police returned Resident #33 to the facility but the time of the resident ' s return was not included. A head to toe skin assessment was completed with no injuries noted. Resident #33 had a Wanderguard on the left lower leg which was functioning properly. After investigation on the unit, the staff suspected the resident exited through the back of building, near the laundry and may have entered the key code to open the door. Resident #33 said he was at a movie all afternoon and tried getting back to Cleveland. Review of an undated witness statement provided by STNA #41 revealed she had last seen Residents #32 and #33 between 7:30 P.M. and 7:45 P.M. in the hallway near the laundry room door. At around 8:00 P.M. a nurse from the West side of the facility escorted Resident #32 to the secured dementia unit after he was found in the kitchen. No alarms had sounded to alert staff he had exited the secured unit. A few minutes after Resident #32 was returned, STNA #41 notified staff Resident #33 was missing and a search was initiated. On 03/29/16 at 7:51 P.M. Resident #33 was found by the local police department and subsequently returned to the facility at an undocumented time. Review of a witness statement dated 03/29/16 provided by STNA #42 revealed she had seen Resident #32 at approximately 6:50 P.M. by his room and Resident #33 at 7:15 P.M. in the hallway. Review of a witness statement dated 03/29/16 provided by STNA #43 revealed she had last seen both Resident #32 and Resident #33 at approximately 7:30 P.M. while passing out snacks. STNA #43 indicated at that time Resident #32 had gone to lie down in his room and Resident #33 had walked towards the sunroom. The next time she saw Resident #32 he was being escorted into the unit by a nurse who said the resident had re-entered the facility through the back door of the kitchen. The nurse was paged and STNA #43 continued to pass snacks. When STNA #43 reached Resident #33's room he was not there. STNA #43 started to search resident rooms, working her way back to the nurse ' s station where the other STNAs and the nurse were. At that time she notified them Resident #33 was missing. A head count was completed confirming Resident #33 was not in the secure dementia unit. The administrator and the DON were notified and the elopement protocol was initiated. No other witness statements were provided related to the incident. Review of the police report dated 03/29/16 revealed Resident #33 was picked up by the local police department at 7:51 P.M., following a call from an anonymous source of a suspicious person walking in the area. The police report indicated Resident #33 was found approximately 3/4 mile from the facility and was taken to the police department because the officer felt Resident #33 was confused. At 8:01 P.M. the facility called the police department to report a missing resident. After confirmation of the identity of Resident #33 he was transported back to the facility. Review of the historical temperature recorded by Underground Weather revealed a temperature of 42 degrees Fahrenheit on 03/29/16 and sunset at 7:48 P.M. Interview with LPN #50 on 07/22/16 at 11:48 A.M. revealed Residents #32 and #33 had eloped from the facility together on 03/29/16 sometime between 7:30 P.M. and 8:00 P.M. LPN #50 was not present at the time, but showed the route the two residents were believed to have taken out of the secured dementia unit. LPN #50 said the residents walked down the hallway to the laundry door. After walking through the door they travelled through the electrical room and maintenance workshop where they exited the back of the building. LPN #50 said Resident #32 re-entered through the kitchen and Resident #33 continued around the building and off the premises. Staff were unaware Resident #33 was missing until after a staff member passing snacks observed he was not in his room or the common areas. An interview with the administrator on 07/22/16 at 3:10 P.M. confirmed the facility investigation did not include any other witness statements. Interview with the DON on 07/25/16 at 7:56 A.M. revealed the residents that left the building on 03/29/16 (Residents #32 and #33) knew the key code to the door in which they exited. When asked how a resident with severe cognitive impairment could remember the key code the DON said Resident #33 told them he knew the code from watching other people. The DON explained Resident #32 followed Resident #33 out the door. They exited via the laundry housekeeping area which was the door staff used to exit the building to smoke. Residents did not use the exit, only staff. Both residents were wearing Wanderguards at the time they exited the facility; however the door was not Wanderguard protected. The DON was notified Resident #32 had exited and re-entered the facility and was returned to the nursing unit by dietary staff. At the time of this notification it was not known Resident #33 was missing. The DON instructed staff to complete a head count. Staff called him back later (unsure of time) to tell him Resident #33 was gone. When the DON arrived at the facility (time unknown, maybe around 10:00 P.M.) Resident #33 had been returned to the facility by the police. Interview with RN #50 on 07/25/16 at 11:14 A.M. revealed she was the nursing supervisor on 03/29/16 when Resident #32 and #33 exited the facility. She said it was the worse day of her nursing career because she was so worried about Resident #33's safety. A little bit before 8:00 P.M. the kitchen staff called the nurse from the West hall indicating they had a resident in the kitchen. The nurse went back to the kitchen and found Resident #32. That nurse alerted RN #50 and staff went to the kitchen and returned him to the secured dementia unit. Because no doors had alarmed when Resident #32 exited the facility, RN #50 and the other staff came to the conclusion Resident #32 went out via the door that led to the laundry housekeeping area which was not Wanderguard protected. RN #50 said although Resident #32 had dementia, he was not a dummy . He could have watched someone else put the code in the door and then entered the code himself, or somebody came in or out of the door and he slipped out. RN #50 then said she did not believe Resident #32 could remember a four digit code. About 15 minutes after Resident #32 was returned a STNA said they could not find Resident #33. RN #50 called the police and the DON and then initiated the elopement protocol. RN #50 said it was cold and dark outside. Upon his return Resident #33 was wearing jeans, a long sleeve shirt and shoes. He was not wearing a coat. The resident was in a good mood, he said he was going to the movies but could not find the way. Resident #33 wanted to know why he was with the police. RN #50 described Resident #33 ' s safety awareness as not too great, he did not make good decisions, and was not aware of his limitations. Observation and interview with Resident #33 on 07/25/16 at 11:30 A.M. revealed he had clear speech. Resident #33 revealed he liked to walk. He had no memory of leaving the facility. Resident #33 was observed to have a very slow steady gait with a stride of about one foot. Interview with STNA #51 on 07/25/16 at 11:46 A.M. revealed she was not sure of the time but it was near the beginning of the shift which began at 7:00 P.M. when the West side nurse brought Resident #32 back from the kitchen. No alarm sounded to alert the staff a resident had exited the secured dementia unit. Staff did not realize Resident #33 was gone until after a head count was completed. After the head count the elopement protocol was initiated. They guessed Resident #33 went out the laundry room door, slipping out when staff either entered or exited that same door. STNA #51 said it was a very busy door which all staff used because it led to the laundry and staff smoking area. It was also the only door which was not alarmed. Resident #33 was wearing, a shirt, shoes, pants but no coat when he returned. It was cold and dark outside. By the time the nurse called the police they already had him in custody. The police had received a suspicious person alert. 2. Review of Resident #32's medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission MDS 3.0 assessment dated [DATE] indicated Resident #32 had severe cognitive impairment and required supervision walking in the room, on the unit and the corridors. An elopement assessment dated [DATE] indicated Resident #32 was a moderate risk for elopement. A physician order [REDACTED]. Review of Resident #32's plan of care dated 03/19/16 and revised on 04/01/16 related to an elopement revealed Resident #32 was an elopement risk /wanderer as evidenced by aimless wandering. Interventions included assessing for fall risk, direct resident from wandering by offering pleasant diversions, structured activities, food, conversation, diversional activities, identify patterns of wandering, intervene as appropriate, monitor for fatigue and weight loss, plastic utensils to prevent potential removal of Wanderguard. A physician's orders [REDACTED].#32 required the secured dementia unit due to dementia with behavioral disturbances. Review of a progress note dated 03/29/16 at 7:40 P.M. logged as a late entry revealed staff alerted the nurse that the kitchen staff had reported a resident wandered into the back door of the kitchen. The nurse assisted Resident #32 back to the secured dementia unit. Resident #32 was unable to verbalize how he exited the unit. A head to toe skin assessment was completed with no injury noted. The progress note indicated Resident #32 had a Wanderguard in place and functioning to his lower extremity. The staff suspected Resident #32 left the unit through a door leading to the laundry area. Review of a progress note dated 06/23/16 at 4:00 P.M. revealed Resident #32 was observed by staff sitting outside at the front door on the bench. Resident #32 had removed the Wanderguard that was placed on his left ankle. Review of a 06/24/16 interdepartmental team meeting review of the above incident revealed on 06/23/16 at 4:00 P.M. Resident #32 was immediately redirected to the secure dementia unit after being found on the front porch. The Wanderguard device had been in place earlier in the day; however, at the time the resident was observed on the porch, the Wanderguard was missing. Staff had not removed the Wanderguard. A new Wanderguard was placed to the left ankle. A new care planned intervention to prevent further exit from the facility without supervision included using plastic utensils to prevent potential removal of Wanderguard device with a metal utensil. Review of a progress noted dated 07/15/16 at 7:32 A.M. logged as a late entry revealed Resident #32 took a chair onto the enclosed patio and attempted to climb over the fence. The Resident had placed a towel on top of the fence and had his upper body over the side of fence. The nurse was notified by another resident in the dining room and assisted Resident #32 down to the chair and back inside the unit. The chair was placed back in the dining room. Resident #32 was monitored by staff and redirected away from the patio door several more times. Review of a progress note dated 07/17/16 at 6:32 P.M. revealed the unit manager (LPN #50) reported Resident #32 was sitting at the front of the entrance to the building, on a bench looking through the ashtray for cigarettes. A progress noted dated 07/17/16 at 6:35 P.M. revealed the unit manager went out to the enclosed courtyard on the memory unit and removed the chair that was up against the fence which Resident #32 had used to climb over the fence and then walk to the front entrance to look for cigarettes. LPN #50 then secured the doors to the patio. Observation and interview with Resident #32 on 07/23/16 at 10:04 A.M. revealed Resident #32 had a steady gait. An attempt to interview Resident #32 was unsuccessful; he just smiled and danced in place in response to questions. Observation on 07/25/16 at 8:30 A.M. revealed the doors leading to the patio enclosed by the fenced off the sunroom, where Resident #32 had exited the facility on 07/15/16 and 07/17/16, were locked and could not be opened. There was a small metal plate with bolts in place to the bottom of the double doors. There were no chairs or tables on the patio. Interview with Maintenance Man #1 on 07/25/16 at 8:42 A.M. revealed on 07/22/16 he had the Wanderguard company come out after a resident (Resident #32) exited through a set of doors leading to a patio enclosed by a fence. The resident climbed the fence and wandered about the property ending up seated on a bench at the front entrance of the facility. Those doors were now Wanderguard protected. Review of the Policy and Procedure Elopement Prevention and Management Overview dated 07/01/2016 revealed elopement was defined as a resident/patient leaving the premises or a safe area without authorization and/or any necessary supervision and places the resident at harm or injury. Unsafe wandering was defined as a resident/patient entering an area that was physically hazardous or contained potential safety hazards. This deficiency substantiates Complaint Number OH 646.

Based on observation, record review and interview the facility failed to ensure Resident #28 received proper and timely dental care and services to address the condition of his teeth and increased pain. Harm occurred when Resident #28 complained of increased mouth/tooth pain, rated a 10 and above on a scale of one to ten with ten being the most severe without evidence dental services were arranged or provided to the resident. This affected one resident (Resident #28) of two residents reviewed for dental concerns. Findings include: Review of Resident #28's medical record revealed an admission date of [DATE] with reentry date of 05/11/15. The resident had a [DIAGNOSES REDACTED]. Review of Resident #28's plan of care, initiated on 05/08/15 with a focus of pain revealed an intervention to identify, record, and treat existing conditions which may increase pain and or discomfort. Review of Resident #28's dietary nutritional assessment dated [DATE] revealed Resident #28 had missing teeth with no other abnormalities noted. Review of Resident #28's admission Minimum Data Set (MDS) 3.0 assessment, dated 05/20/15 revealed Resident #28 had mouth or facial pain, discomfort, or difficulty chewing. Review of the medication administration note, dated 05/26/15 at 9:11 A.M. revealed one 325 milligram of Tylenol was administered for tooth, shoulder and back pain. Review of the New Admission Observation Tool, number two dated 05/30/15 revealed Resident #28 had obvious or likely cavity or broken natural teeth. Review of the medication administration note, dated 06/05/15 at 10:17 P.M. revealed [MEDICATION NAME] (Tylenol) tablet of 325 milligrams was given for complaints of a toothache with pain noted to be a level four on a scale with 10 being the highest. The note indicated that a quiet environment and medication were ineffective to relieve the pain. Review of the quarterly MDS assessment, dated 06/07/15 revealed no evidence of any dental concerns. The MDS indicated Resident #28 had a brief interview of mental status score of 14 indicating the resident was cognitively intact. Review of the medication administration note dated 06/11/15 at 11:11 P.M. revealed Resident #28 complained of pain in a loose tooth in the left lower jaw. The tooth was broken off at the gum line. The note indicated one tablet of [MEDICATION NAME] was given for pain. Review of Resident #28's plan of care revealed no evidence of a plan of care related to dental concerns or pain related to dental problems. Review of the medical record revealed no evidence of Resident #28's guardians consent for ancillary services including the dentist. There was no evidence in the medical record related to physician or guardian notification related to Resident #28's tooth/mouth pain or concerns. Review of the most recent dental visit list dated 06/26/15 revealed no evidence Resident #28 was seen by the dentist. Interview on 07/14/15 at 4:39 P.M. with Resident #28 revealed the resident had dental problems. Resident #28 indicated he was actively having a toothache that was above a 10 on a scale of one to ten with ten being the highest level. Resident #28 stated that the toothache had been going on for so long that he must just tolerate the pain. Resident #28 stated that his teeth were rotten and he needed all new teeth. Resident #28 indicated he was not satisfied with the facility treatment related to his dentition. Resident #28 stated he did not think a dentist came to the facility and he would need to either find one on the street or go to the hospital to get further care for his dental issues. Observation on 07/14/15 at 4:39 P.M. revealed Resident #28 with multiple broken teeth with multiple black areas and gums swollen. There were only two to four teeth that were noted above the gum line. All the other teeth were broken off, missing or noted to be black at the gum line. Interview on 07/15/15 at 4:33 P.M. with Licensed Social Worker (LSW) #11 revealed Resident #28 was a fairly new resident and had a legal guardian. Resident #28 indicated the consents for ancillary treatment, including for the resident to see the dentist had been previously sent to the guardian but were not returned through this date. LSW #11 stated that Resident #11 has not seen the dentist since being admitted to the facility and LSW #11 was not aware of Resident #28 having any dental problems. Interview on 07/16/15 at 9:06 A.M. with Registered Nurse (RN) #10 stated Resident #28 was a newer resident. RN #10 verified Resident #28 does not have a plan of care related to dental issues and indicated the Resident #28 did not have any issues with his teeth. Interview on 07/16/15 at 10:12 A.M. with RN #10 confirmed the MDS on 06/07/15 did not capture Resident #28's mouth pain and confirmed the resident has poor dentition. Interview on 07/16/15 at 9:14 A.M. with LSW #11 revealed Resident #28 receives Medicaid and would be able to receive ancillary services with funding from Medicaid. Interview on 07/15/15 at 6:34 P.M. with Licensed Practical Nurse (LPN) #12 revealed Resident #28 told LPN #12 on one occasion that his teeth were hurting. LPN #12 stated that Resident #28 does not complain every time that she works with the resident of tooth pain. LPN #12 stated she did not assess Resident #28's teeth at the time the pain was noted because Resident #28 only complained once. LPN #12 stated she was unaware of any problems with Resident #28's teeth. LPN #12 stated no other staff members have communicated to her that Resident #28 had tooth pain. Interview on 07/16/15 at 10:36 A.M. with LPN #13 indicated that on two occasions Resident #28 complained of pain in the mouth. LPN #13 stated she gave Resident #28 Tylenol and it was well over a month ago since the last time Resident #28 complained of tooth pain. LPN #13 indicated it was when she was working night shift that Resident #28 had complaints of pain. LPN #13 stated that she did look in his mouth which was positive for broken carious teeth. LPN #13 stated to her knowledge Resident #28 has had poor dentition since admission and it was a preexisting issue. LPN #13 stated Resident #28 eats at his own leisure and no concerns have been identified while eating. LPN #13 stated that she did talk to the morning nurse in report that Resident #28 complained of pain but did not notify anyone else of the pain. Interview on 07/16/15 at 10:47 A.M. with Resident #28 revealed the resident was sad because of his muscle spasms in his right shoulder and teeth pain. Resident #28 stated the nursing staff does ask if he has pain. Resident #28 tells them he is and they give him a Tylenol and tell him to go lay down. During the interview the resident stated the Tylenol was ineffective for pain. Resident #28 stated his pain level was always over 10 on a 1-10 scale with 10 being the highest. Resident #28 stated the staff do not come back and ask him if the medication is effective. Resident #28 stated he takes the Tylenol because he doesn't want to get in trouble for refusing the Tylenol that is offered to him. Resident #28 stated he did have poor dentition when he was admitted to the facility. Resident #28 stated his teeth break off all the time. Resident #28 stated since residing in this facility two teeth have broken. Resident #28 stated he has trouble eating solid food due to his dentition but did not want a diet change and was able to eat his current diet. Observation on 07/16/15 at 10:55 A.M. with LPN #13 and Registered Nurse (RN) #14 revealed at least 12 teeth were noted to be broken with some down to the gum line. LPN #13 stated while looking in Resident #28's mouth that Resident #28 had a lot of broken teeth. At this time Resident #28 told LPN #13 and RN #14 that the Tylenol was ineffective and has never been effective for the pain. Interview on 07/16/15 at 5:00 P.M. with Physician #15 revealed he was unaware until this date of any pain or dental concerns with Resident #28. Interview on 07/17/15 at 10:53 A.M. with LSW #11 revealed she had spoken with the resident's guardian on 06/02/15 regarding another issue, but did not notify the guardian of any dental concerns because she was unaware of them. LSW #11 stated that if a resident was having an acute problem telephone consent could be obtained to receive care. LSW stated if a resident is in pain and needs care I would do everything possible to get consent for care.

The following survey finding pertains to an incident of past non-compliance that was subsequently corrected on January 31, 2012, prior to this survey. Based on observation, interview and record review, the facility did not ensure timely assessment and treatment of [REDACTED].#15's right arm. This affected one of two sampled residents (Resident #15) in a facility census of 70. Findings include: Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/7/11 a [DIAGNOSES REDACTED]. The facility filed a self reported incident form with the state agency on 01/14/12 that indicated the date of the injury of unknown origin was discovered 01/14/12 under the category of "Injury of unknown source" with an unknown perpetrator. The initial source of the allegation/suspicion was the resident victim and the visitor family. Interview with the resident's daughter via telephone on 02/02/13 at 3:36 P.M. confirmed a statement from the resident's daughter dated 01/16/12 which revealed the following regarding Resident #15. The resident admitted on [DATE] and needed to be kept safe. She was independent in dressing, walking, feeding and using the bathroom. The resident had no judgment. The resident fell on [DATE] and fractured the right hip. She was admitted to hospital on [DATE] and returned to the facility on [DATE]. The resident developed pneumonia on 10/13/11. After the pneumonia, Resident #15 was dependent in all areas for activities of daily living (ADL). On 01/01/12, Resident #15 could move all four extremities but on 01/02/12 the resident could not move her right arm. Over the next two weeks, the resident's daughter addressed these concerns with multiple members of the staff. Further review of the daughter's statement revealed when she went to visit Resident #15 on 1/02/12 at lunch time, the resident was sitting in the wheelchair with her head tilted to the right. When she examined the resident, she realize her right arm did not work and it was painful when she lifted it. She informed the nurse and two nurses came into the room and said they would give her something for pain and check her later. The resident's daughter further stated that the orthopedic surgeon saw Resident #15 on 01/17/12 and indicated he could not repair the two week old dislocation without surgery, but the resident was not a good candidate for surgery at [AGE] years old. The interview ended at 3:39 P.M. on 02/02/12. Review of the resident's printout of electronic clinical notes report provided by the facility revealed a note dated 01/02/12 from 5:33 P.M. to 5:56 P.M. by the licence practical nurse (LPN #81) which stated "pain medication administered as per prn order at 1:30 P.M. for c/o right arm pain, effective." Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. on 01/02/12. The facility could provide no documentation in the resident's record that the resident had been assessed for range of motion or that a physician had been notified of this significant change in the resident's condition. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"as needed" [MEDICATION NAME] during the entire month. This was confirmed via interview with the director of nursing on 02/02/12. Although clinical notes and hospice care notes reflect pain and disuse of Resident #15's right arm as well as concerns expressed by the family, the facility did not have the resident assessed by a physician or other qualified health practitioner. On 01/13/12, a friend of the resident's daughter who was a nurse practitioner examined the resident and suggested an x-ray as she thought the resident had an injury. A telephone physician's orders [REDACTED]. A clinical note dated 1/14/12 at 6:30 P.M. by LPN #81 revealed the x-ray results indicated an anterior dislocation and the physician, director of nursing, hospice and the family were notified by LPN #81. A physician's note dated 01/16/12 confirmed the right shoulder dislocation and that [MEDICATION NAME] (a narcotic pain reliever) had been added to Resident #15's medication regimen. The facility could provide no evidence that the physician had seen the resident since 12/26/11. On 02/02/12 at 8:35 A.M., Resident #15 was observed in a full "Broda" chair with her feet elevated on a footrest. She was transported into room [ROOM NUMBER] for restorative dining by a state tested nursing assistant (STNA #82). The resident leaned to the right with her left leg crossed over her right. Her right arm and shoulder were unable to be visualized as they were under a blanket. The resident had to be fed by STNA #82. She was very lethargic and not responding to prompts. Interview with STNA #82 on 02/02/12 at 9:12 A.M. revealed Resident #15 used to be able to stand and transfer with two people assisting her but now she used a mechanical lift. STNA #82 indicated the resident had a change "because her arm was hurting." At 9:24 A.M., STNA #82 began to transport Resident #15 out of room [ROOM NUMBER]. STNA #82 pulled down the blanket to reveal the resident's right arm. The forearm was covered with a clean dressing and the arm was resting on the resident's abdomen. STNA #82 indicated she did not put a sling on the resident's arm as she had used a mechanical lift to transfer her from her bed to her chair. At 10:47 A.M. STNA #82 and the Hospice Aide (HA #83) were observed transferring Resident #15 from her bed to a reclining shower chair. The resident leaned to the right and STNA #82 retrieved and rolled two bath blankets to position the resident in the chair more comfortably. The resident's arm was kept close to her torso during and after the transfer. At 12:25 P.M., Resident #15 was observed in her room in a Broda chair with her granddaughter and HA #83 dressing her. When HA #83 left the room, interview with the resident's granddaughter revealed the resident was walking and talking when she entered the facility last July. She encouraged a call to the resident's daughter as the family was moving the resident to another facility on Monday. She indicated the facility did not get an x-ray for the resident until two weeks after her mother had expressed concerns of severe pain and loss of movement in Resident #15's right arm. The interview ended at 12:40 P.M. Interview with the director of nursing on 02/02/12 at 3:00 P.M. revealed she did not know there was an injury until Resident#15's x-ray result was reported to her on 01/14/12. She began her investigation and staff education on the same day. Review of the facility's corrective action reveals the following were implemented prior to this complaint survey. On 01/14/12, a physician's orders [REDACTED]. On 01/14/12, LPN #81 was educated related to notifying physicians and treating residents on comfort care and hospice care and unusual occurrences. On 01/17/12, the facility began educating staff on transfers and the use of gait belts. On 01/18/12 and 01/19/12, other facility nursing staff were educated as above. On 01/23/12, nursing staff were provided an in-service training on Level of Care for Hospice residents. On 01/27/12, when an injury of unknown origin was discovered with Resident #64 who was also on hospice, the facility notified the physician, completed an assessment and investigation in a timely manner. On 01/31/12, the facility educated STNA's and nurses on Documentation, Change in Condition, Risk Triggers, and Hospice. This citation substantiates Complaint Number OH 105