Every finding on record at Northwood Skilled Nursing and Rehabilitation

Based on observation, staff interviews, and policy review, the facility failed to store, prepare, and serve food in a safe and sanitary manner. This had the potential to affect all residents residing in the facility. The facility census was 69. Observation 06/14/26 at 8:58 A.M. of the walk in cooler revealed lemonade that was undated, chicken salad with a discard date of 06/11/26, and coleslaw with a discard date of 05/26/26. Interview on 06/14/26 at 8:59 A.M. with Dietary Supervisor (DS)#273 verified the lemonade did not have a date and that the chicken salad and coleslaw should have been discarded. Observation on 06/14/26 at 9:01 A.M. revealed a can of shasta cola stored under raw meats of the walk in cooler. Interview with DS #273 verified the soda should not have been stored below raw meat. Observation on 06/14/26 at 9:01 A.M. in the walk in freezer revealed homemade bread cruotons with a use by date of 06/04/26, concurrent interview with DS #273 verified that the crutons should have been discarded. Observation on 06/14/26 at 9:19 A.M. revealed two knives with missing chips on blade being stored in the knife rack. Interview with DS #273 verified that the knives had missing metal chips on the blade and he was planning on replacing them. Observation on 06/14/26 at 9:19 A.M. revealed two cans of pears with dents being stored on the can stoage rack in the dry stock area. Concurrent interview with DS #273 verified that the cans were dented and should have been discarded. Observation on 06/14/26 at 9:21 A.M. revealed a bulk bag of opened panko bread crumbs which was undated. Concurrent interview with DS #273 verified that the bag should have been dated when it was opened. Review of the facility policy titled, Food Receiving and Storage dated October 2017 revealed all food stored in the refridgerator or freezer will be covered, labeled, and dated. Uncooked and raw animal poducts will stored seperately and below ready to eat foods. Review of the facility policy titled, Sanitization dated October 2008 revealed revealed all utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seams, cracks and chipped areas.

Based on observation, staff interview, and policy review, the facility failed to maintain an effective pest control program. This had the potential to affect all residents residing in the facility. The facility census was 69.Observation on 06/14/26 at 8:56 A.M. revealed several gnats flying around near the dish machine. Interview on 06/14/26 at 9:25 A.M. with Dietary Supervisor #273 verified they have been having a problem with gnats in the dish washing area and he was planning to have the pest control company come out to treat the area. Review of the pest control reports since 02/19/26 revealed fly activity was observed in the kitchen on 02/19/26, 04/10/26, and 06/02/26. Review of the facility policy titled, Sanitization dated October 2008 revealed all kitchen areas will be kept clean and protected from rodents, roaches, flies, and other insects.

Based on record review, interview and facility policy review the facility failed to ensure a safe smoking environment when residents had their own cigarettes and lighter, this affected three residents (#32, #43, and #68), the facility also failed to maintain a smoking blanket in good condition, this had the potential affect all twenty residents ( #01, #02, #05, #06. #07, #11, #12, #16, #19, #24, #29, #32, #39, #40, #42, #43, #47, #50, #67, and #68) the facility identified as smokers , and the facility failed to accurately assess one resident (#45) for wandering/elopement. The facility census was 69.Findings include:1) Review of the medical record of Resident #32 revealed an admission date of 02/01/26 with diagnoses of ischemic cardiomyopathy, chronic kidney disease stage III, major depressive disorder recurrent, myocardial infarction, and essential hypertension. Review of the care plan dated 02/01/26 revealed Resident #32 required supervision with smoking with interventions of supervise resident per facility policy and store smoking materials per facility policy. 2) Review of the medical record of Resident #43 revealed an admission date of 01/07/26 with diagnoses of essential hypertension, intervertebral disc degeneration, lumbosacral region without mention of lumbar back pain or lower extremity pain, chronic obstructive pulmonary disease, Type II Diabetes Mellitus without complications, and heart failure. Review of the care plan dated 01/07/26 revealed Resident #43 required supervision with smoking with interventions of supervise resident per facility policy and store smoking materials per facility policy. 3) Review of the medical record of Resident #68 revealed an admission date of 12/27/22 with diagnoses of moderate persistent asthma, chronic obstructive pulmonary disease, paranoid personality disorder, other abnormalities of gait and mobility, and Type II Diabetes Mellitus with diabetic neuropathy. Review of the care plan dated 12/27/22 revealed Resident #68 required supervision with smoking with interventions of supervise resident per facility policy and store smoking materials per facility policy. Observation on 06/15/26 at 3:35 P.M. with Nurse Scheduler #280 of resident's smoking revealed nine residents smoking in the designated smoking area in the courtyard. Nurse Scheduler #280 proceeded to hand each resident one cigarette and light the cigarette for the residents with a lighter. Observation on 06/15/26 at 3:47 P.M. while multiple resident's continue to smoke, the fire blanket was located in the fire blanket box. Upon further review the fire blanket box was rusted out at the bottom of the box and fell out of the bottom of the box unto the ground. The fire blanket was noted to have an approximately 4 inch rusted area across the whole blanket. Interview on 06/15/26 at 3:49 P.M. with Nurse Scheduler #280 advised the box for the smoke blanket has been rusted out like that for quite a while. Interview on 06/15/26 at 3:55 P.M. with Director of Housekeeping #316 confirmed the smoke blanket box was rusted out at the bottom, the blanket falls out and the blanket had rust across the blanket. Interview confirmed the fire blanket and fire blanket box need replaced. Observation on 06/15/26 at 3:59 P.M. with Nurse Scheduler #280 confirmed Resident #32, #68, and #43 pulled extra cigarettes out of their shirts and Resident #32 pulled a light out of her shirt. Nurse Scheduler #280 confirmed residents go and buy cigarettes themselves or families do and they hide them, this happens all the time. Nurse Scheduler #280 also confirmed all the resident's smoking at the time were supervised smokers and were not allowed to have their own cigarettes or lighter. Review of the Smoking policy, dated July 2017 revealed the facility will establish and maintain a safe resident smoking practices. Smoking materials must be handed in to the charge nurse who will keep the materials secured. 4) Medical record review for Resident #45 revealed he was admitted to the facility 11/12/25. His diagnoses included lymphedema, chronic ulcer of right calf, essential primary hypertension, chronic kidney disease, obesity, major depressive disorder, rhabdomyolysis, Parkinson's disease, dysphagia, angina pectoris, and acute kidney disease. Review of the Minimum Data Set (MDS) assessment for Resident #45, dated 05/19/26, revealed he was cognitively intact. Resident #45 was dependent on staff for medication administration, oral hygiene, toilet use, bathing, upper body dressing, lower body dressing, and putting on shoes. Review of the progress notes for Resident #45 on 04/09/26 at 12:01 P.M. revealed Resident #45 was found at the front entrance of the facility waiting on Uber transport. The progress note revealed Resident #45 had slight confusion and was argumentative about his right to leave the facility. The facility applied a wander guard to Resident #45's right ankle. The facility documented the provider was notified with no new order. A progress note written on 01/12/26 revealed a late entry note for 1:05 P.M. on 01/12/26 revealed Resident #45 left with family on leave of absence (LOA). A note on 01/12/26 at 7:00 P.M. revealed Resident #45 returned to the facility (no other information provided). Review of the report titled, Elopement Risk Assessment, dated 05/13/26, for Resident #45 revealed the facility marked the report as Resident #45 is physically unable to leave the facility. Review of the care plans for Resident #45 revealed the facility failed to have a care plan related to the placement of Residents #45's wander guard. Review of the order summary for Resident #45 revealed an order, dated 05/18/26, monitor placement and function of wander guard to right ankle every shift. Interview with Resident #45 on 06/15/26 at 9:16 A.M. revealed Resident #45 took Uber to the Apple Store in another city and stayed until the store closed. Resident #45 revealed the store called the facility to pick him up at the store because it was about to close. The facility had the Director of Nursing (DON) pick Resident #45 up from the store. Resident #45 pointed at his ankle and revealed he was frustrated because the wander guard made him feel trapped at the facility. Interview with the Director of Nursing (DON) on 06/15/2026 at 2:49 P.M. confirmed Resident #45 required a wander guard. The DON confirmed no care plan was in place for the wander guard for Resident #45. The DON confirmed the wander guard was placed on Resident #45 after he attempted to call an Uber driver and go the bank in April 2025. The DON stated the facility felt the need to place the wander guard on Resident #45 after the incident in April 2025 because it was actually the second time Resident #45 had attempted to leave the facility with an Uber driver. The DON revealed the first incident occurred in January 2026 after Resident #45 called an Uber driver and went to another town to have his phone repaired at the Apple store. The DON revealed Registered Nurse (RN) #451 transported Resident #45 back to the facility when the store called the facility at closing time to report Resident #45 was at the store and did not have a way back to the facility. Interview with Resident #45's resident representative (RR) #501 on 06/15/26 at 5:06 P.M. confirmed the no one in the family was aware that Resident #45 called an Uber driver on 01/12/26 and went across town to the Apple store. RR #501 revealed she is frustrated with the facility and the lack of communication and updates related to Resident #45's care. RR #501 revealed RN #451 transported Resident #45 back to the facility on [DATE] and the facility told her Resident #45 was so heavily soiled when he returned to the facility that Resident #45 made a mess in RN #45's car. Interview with the previous DON, RN #450 on 06/16/2026 at 9:07 A.M. revealed Resident #45 went on leave of absence (LOA) on 01/12/26 and took an Uber to another town to get his Apple phone repaired. Resident #45 stayed until the store closed and was unable to get a ride back to the facility. The Apple store called the facility and RN #450 transported Resident #45 back to the facility in her own vehicle. RN #450 confirmed Resident #45 was very heavily soiled. Interview with Medical Doctor (MD) #500 on 06/16/26 at 10:13 A.M. confirmed he is the physician for Resident #45. MD #500 confirmed he was not aware of Resident #45 having a wander guard until a few weeks ago when Resident #45 expressed feelings of feeling like a prisoner because of wearing a wander guard. MD #500 denied any knowledge of the physician order written by MD #500 for the wander guard. MD #500 revealed the facility has him sign 12,000 orders a month and is not aware of all the orders he signs. Review of the facility policy titled, Wandering and Elopements, dated March 2019, confirmed the facility The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If the facility identified a Resident is at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.

Based on review of the menu, review of the menu spread sheet, observation, and staff interview, the facility failed to follow menus for residents with a pureed diet. This affected five (#28, #33, #37, #44, and #45) of five residents the facility identified with an order for a puree diet. The facility census was 69. Review of the menu for 06/15/26 revealed lunch was garlic herb beef pot roast, mashed potatoes, normandy vegetable blend, wheat bread, brown gravy, and oreo cookie blodies. Review of the menu spread sheet for 06/15/26 revealed residents with a puree diet should recieve pureed pot roast, mashed potatoes, pureed veggie blend, pureed bread, brown gravy, and pureed blondie. Observation on 06/15/26 12:00 P.M. revealed residents with a puree diet were not being served bread and were served apple sauce as a substitute for the cookie blondie. Interview with [NAME] #258 verified residents with a pureed diet were not being served bread or a cookie blondie. Interview on 06/15/26 at 12:05 P.M. with Dietary Supervisor #273 verified the facility had the supplies to make pureed bread and pureed cookieblondies, but the facility had not made thses food items according to the pureed menu.

Based on observation, interview, and policy review, the facility failed to residents with a dignified dining experience. This affected one (#26) of the 13 residents reviewed for dining. The facility also failed to ensure resident rights were honored. This affected one (#45) of the one reviewed for resident rights. This facility census was 69.Findings include:1) Review of the medical record revealed Resident #26 was admitted on [DATE] with diagnoses including type 2 diabetes mellitus and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #26 was cognitively intact. Resident #26 required set up and clean up assistance with eating. Observation on 06/14/26 at 12:34 P.M., revealed Dietary Aide (DA) #236 delivered food to the dining room from the kitchen and began serving the residents their meal. Observation on 06/14/26 at 12:44 P.M., revealed DA #236 delivered a second food cart from the kitchen and began serving the rest of the resident their meals. Observation on 06/14/26 at 12:47 P.M., revealed Resident #26 was at a table by herself without any food. All the other residents in the dining room were served their meal. During an interview on 06/14/26 at 12:48 P.M., Resident #26 stated it bothered her that she was the only resident that was not served a meal in the dining room. During an interview on 06/14/2026 at 12:49 P.M., Activities Director (AD) #260 stated she frequently helps in the dining room. AD #260 stated all food in the dining room was made to order. AD #260 stated the dietary aide would take all the residents orders and then notify the kitchen of the orders. AD #260 verified that Resident #26 was the only resident without a meal in the dining room. During an interview on 06/14/2026 at 12:51 P.M., DA #236 stated she took Resident #26's order at the same time as the other residents. DA#236 stated Resident #26 had ordered what was on the menu for the day and did not request a special order. DA #236 stated she had Resident #26's order ready, she just didn't have room on the cart to bring it out with the others. Observations of the kitchen on 06/14/26 at 12:54 P.M. with DA #236, revealed there was no meal made for Resident #26. DA #236 was observed plating food for Resident #26. During an interview with DA #236 at the same time, verified that the plate she was making was for Resident #26. Observation on 06/14/2026 at 12:57 P.M., revealed Resident #26 received her meal. 2) Medical record review for Resident #45 revealed he was admitted to the facility 11/12/25. Diagnoses included lymphedema, chronic ulcer of right calf, essential primary hypertension, chronic kidney disease, obesity, major depressive disorder, rhabdomyolysis, Parkinson's disease, dysphagia, angina pectoris, and acute kidney disease. Review of the progress note for Resident #45 dated 01/12/26 at 1:05 P.M., revealed the resident left with family on leave of absence (LOA). Review of the progress note for Resident #45 on 01/12/26 at 7:00 P.M., revealed Resident #45 returned to the facility. There was no other information documented. Review of the MDS assessment for Resident #45 dated 05/19/26, revealed the resident was cognitively intact. Review of the progress note for Resident #45 dated 04/09/26 at 12:01 P.M., revealed the resident was found at the front entrance of the facility waiting for an Uber ride. Resident #45 had slight confusion and was argumentative with staff about his right to leave the facility. The facility applied a Wanderguard to Resident #45's ankle and the provider was notified with no new orders. Review of an Elopement Risk Assessment for Resident #45 dated 05/13/26, revealed the Resident #45 was physically unable to leave the facility. Review of the physician's order for Resident #45 dated 05/18/26, revealed the resident was ordered to have a Wanderguard placed and the placement and function monitored twice daily. Review of the active care plans for Resident #45, revealed no care plan related to the placement of the residents Wanderguard. During an interview on 06/15/26 at 9:16 A.M., Resident #45 stated in January he took an Uber to the Apple Store in another city and stayed until the store closed. Resident #45 stated the store called the facility to pick him up because it was about to close. Resident #45 stated someone from the facility picked him from the store. Resident #45 pointed to his ankle and stated he was frustrated because the Wanderguard made him feel trapped in the facility. During an interview on 06/15/2026 at 2:49 P.M., the DON stated Resident #45 required a Wanderguard after an incident in January 2026 when the resident called an Uber and went to another town to have his phone repaired at the Apple store. The Apple store called the facility when they were closing, and a staff member had to go there and pick him up. The DON stated in April 2026, the resident called an uber to go to the bank. The DON verified there was no active care plan in place for the Wanderguard. During an interview with on 06/15/26 at 5:06 P.M., Resident#45's Representative (RR) #501 stated no one in the family was aware Resident #45 called an Uber driver on 01/12/26 and went across town to the Apple store. RR #501 stated she was frustrated with the facility and the lack of communication and updates related to Resident #45's care. RR #501 stated a staff member transported Resident #45 back to the facility on [DATE] and the resident was so heavily soiled when he returned to the facility that Resident #45 made a mess in the staff members car. During an interview on 06/16/26 at 9:07 A.M., Registered Nurse (RN) #450 stated Resident #45 went on a LOA on 01/12/26 and took an Uber to another town to get his Apple phone repaired. Resident #45 stayed until the store closed and was unable to get a ride back to the facility. The Apple store called the facility and RN #450 transported the resident back to the facility in her own vehicle. RN #450 stated Resident #45 was heavily soiled. During an interview on 06/16/26 at 10:13 A.M., Medical Doctor (MD) #500 stated he was the physician for Resident #45. MD #500 stated he was not aware of Resident #45 having a Wanderguard in place until a few weeks ago when Resident #45 expressed feelings of feeling like a prisoner because of having to wear a Wanderguard. MD #500 denied any knowledge of the physician order written by MD #500 for the wander guard. MD #500 stated he signs over 12,000 orders a month and is not aware of all the orders he signs. Review of the facility policy titled, Resident Rights dated December 2026, revealed employees shall treat all residents with kindness, respect, and dignity. Review of the facility policy titled, Wandering and Elopements, dated March 2019, confirmed the facility The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If the facility identified a Resident is at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.

Based on medical record review and staff interview, the facility failed to notify the state mental health authority via a Pre-admission Screening and Resident Review (PASARR) process when a resident had a significant change in condition which resulted in a new diagnosed mental health condition. This affected one resident (#03) of two residents reviewed for PASARR. The facility census was 69.Findings include:Review of the medical record for Resident #03 revealed an admission date of 02/24/25 with diagnoses of pleural effusion, epilepsy and anxiety disorder. New diagnosis on 07/16/25 to include schizoaffective depressed type.Review of the Minimum Data Set (MDS) 3.0 assessment for Resident #03 dated 04/23/26, revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. Review of Resident #03's medical record on 06/16/26 at 12:30 P.M., revealed on 07/16/25 at 9:26 A.M., Resident #03 received a newly identified diagnosis of schizoaffective depressed type and no PASARR was completed to reflect the updated mental health diagnosis. During an interview on 06/16/26 at 12:34 P.M., Regional Director of Operations (RDO) #600, verified Resident #03 was diagnosed with schizoaffective depressed type on 07/16/25 and a new PASARR was not completed for the change in condition. RDO #600 stated the facility did not have a policy on the PASARR process.

Based on medical record review, staff interview, resident interview, and facility policy review the facility failed to complete comprehensive care plans for residents. This affected four Residents (#45, #02, #33, and #09) of the four residents reviewed for care plans. The facility census was 69. Findings include: 1) Medical record review for Resident #45 revealed he was admitted to the facility 11/12/25. His diagnoses included lymphedema, chronic ulcer of right calf, essential primary hypertension, chronic kidney disease, obesity, major depressive disorder, rhabdomyolysis, Parkinson's disease, dysphagia, angina pectoris, and acute kidney disease. Review of the progress note for Resident #45 dated 01/12/26 at 1:05 P.M., revealed the resident left with family on leave of absence (LOA). Review of the progress note for Resident #45 on 01/12/26 at 7:00 P.M., revealed Resident #45 returned to the facility. There was no other information documented. Review of the Minimum Data Set (MDS) assessment for Resident #45 dated 05/19/26, revealed the resident was cognitively intact. Review of the progress note for Resident #45 dated 04/09/26 at 12:01 P.M., revealed the resident was found at the front entrance of the facility waiting for an Uber ride. Resident #45 had slight confusion and was argumentative with staff about his right to leave the facility. The facility applied a Wanderguard to Resident #45's right ankle and the provider was notified with no new orders. Review of an Elopement Risk Assessment for Resident #45 dated 05/13/26, revealed the Resident #45 was unable to leave the facility. Review of the physicians order for Resident #45 dated 05/18/26, revealed the resident was ordered to have a Wanderguard placed and the placement and function monitored twice daily. During an interview on 06/15/26 at 9:16 A.M., Resident #45 pointed to his ankle and stated he was frustrated because the Wanderguard made him feel trapped in the facility. Review of the active care plans for Resident #45 on 06/15/26 at 2:45 P.M., revealed there was no comprehensive care plan related to the placement of the residents wander guard. During an interview on 06/15/2026 at 2:49 P.M., the Director of Nursing (DON) stated Resident #45 required a wander guard after an incident in January 2026 when he called an Uber and went to another town to have his phone repaired at the Apple store. The Apple store called the facility when they were closing, and a staff member had to go there and pick him up. The DON stated in April 2026, the resident called an uber to go to the bank. The DON verified there was no active care plan in place for the Wanderguard. 2) Medical record review for Resident #02 revealed she was admitted to the facility on [DATE]. Her diagnoses included essential primary hypertension, bradycardia, hyperlipidemia, congestive heart failure, diabetes mellitus (DM), adult failure to thrive, and Chronic Obstructive Pulmonary Disease (COPD). Review of the MDS assessment for Resident #02 dated 05/27/26, revealed the resident had impaired cognition. Resident #02 was dependent on staff for activities of daily living (ADL), and the resident was dependent on hemodialysis. Review of the active care plans for Resident #02 on 06/15/26 at 3:00 P.M., revealed no comprehensive care plan for the resident being on dialysis. During an interview with on 06/15/26 at 3:04 P.M., the DON confirmed the facility failed to develop a care plan for Resident #02 being on dialysis. 3) Review of the medical record for Resident #33 revealed an admissions date of 05/07/26 with diagnoses including anxiety. Review of the MDS assessment dated [DATE], revealed Resident #33 was cognitively impaired. Review of the physician orders revealed Resident #33 had an active order dated 06/02/26 for risperidone (antipsychotic) 0.5 milligrams (mg) in the evening for other specified anxiety disorders. Review of the physician orders revealed Resident #33 had an active order dated 06/08/26 for divalproex (anti- convulsant /mood stabilizer) sodium oral tablet delayed release (DR) 250 mg once a day for seizures. Review of the active care plan for Resident #33 on 06/16/26 at 4:05 P.M., revealed there was no comprehensive care plan for Resident #33's use of an antipsychotic medications or the resident's diagnosis of seizures. During an interview on 06/16/26 at 4:10 P.M., the DON verified that Resident #33 did not have a care plan for the use of antipsychotic medication. 4) Review of the medical record for Resident #09 revealed an admissions date of 03/25/26 with diagnoses including diabetes mellitus, malnutrition, and urinary tract infection. Review of the MDS assessment dated [DATE], revealed Resident #09 was cognitively intact. Review of the physician order for Resident #09 dated 04/03/26, revealed the resident #09 had an active order for an auto adjusting Continuous Positive Airway Pressure (CPAP) daily at bedtime for sleep apnea. During an interview on 06/16/26 at 5:11 P.M. Medical Director (MD) #500 stated Resident #09 had a CPAP that he used at home prior to admissions. MD #500 verified that he ordered Resident #09 a CPAP machine. Review of the active care plan for Resident #09 on 06/16/26 at 6:15 P.M., revealed there was no comprehensive care plan related to Resident #09 utilizing a CPAP machine. During an interview on 06/16/26 at 6:16 P.M., Regional Quality Assurance Nurse #320, verified Resident #09 did not have a comprehensive care plan for CPAP machine use. Review of the facility policy titles, Care Planning - Interdisciplinary Team dated September 2013, revealed the facilities care planning/interdisciplinary team was responsible for the development of an individualized comprehensive care plan for each resident. A comprehensive care plan for each resident was to be developed within seven days of completion of resident assessment (MDS). Review of the dialysis policy titled, Care of a Resident with End-Stage Renal Disease, revealed the residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Further review of the policy revealed agreements between this facility and the contracted ESRD facility include all aspects of how the resident will be managed, including: how the care plan will be developed and implemented.

Based on record review, resident and staff interview, the facility failed to ensure pain was managed as ordered, this affected one (Resident #05) out of one reviewed for pain management. The facility census was 69. Findings include:Review of the medical record of Resident #05 revealed an admission date of 04/07/26 with diagnoses of chronic obstructive pulmonary disease, Type II Diabetes Mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma, and encephalopathy.Review of the Medicare 5-Day Minimum Data Set (MDS) dated [DATE] revealed Resident #05 was cognitively intact. Resident was independent with eating, required supervision assistance with oral hygiene and wheelchair mobility, required substantial assistance with bathing, dressing, and bed mobility, and was dependent on staff assistance with toileting hygiene and transfers. Resident #05 received scheduled pain medication regimen, received as needed pain medications or was offered and declined as needed pain medication, and received non-medication intervention for pain. Further review revealed Resident #05 had pain or hurting at any time in the last 5 days, experienced pain or hurting occasionally over the last 5 days. Occasionally, over the past 5 days, pain made it hard for resident to sleep at night. Occasionally, over the past 5 days, pain limited participation in rehabilitation therapy sessions. Occasionally, over the past 5 days, pain limited day-to-day activities.Resident #05 experienced a pain intensity level of seven over the last five days.Review of the care plan dated 04/07/26 revealed Resident #05 has pain / alteration in comfort related to right below the knee amputation (RBKA) and a history of deep vein thrombosis (DVT) with interventions of administer medications as ordered and assess for effectiveness, attempt non-pharm logical interventions such as back rub, warm blanket, redirection, repositioning, monitor for effectiveness of interventions, monitor for levels of increased pain and notify physician.Review of the physician order dated 05/04/26 revealed an order for a referral to pain clinic.Interview on 06/16/26 at 1:07 P.M. with Licensed Practical Nurse (LPN) #261 confirmed the pain clinic appointment had not been made and that social services makes the appointments, but since there is not a current social worker, he would be responsible to make the appointment. Interview also confirmed he had not made the appointment for the pain clinic for Resident #05 and he is not sure which pain clinic to call.Interview on 06/16/26 at 2:08 P.M. with the Director of Nursing confirmed there was not a policy on scheduling appointments or following physician orders.

Based on record review, staff interview and policy review, the facility failed to act upon recommendations made by the pharmacist. This affected one (Resident #03) of five residents reviewed for unnecessary medications. The facility census was 69.Review of the medical record for Resident #03 revealed an admission date of 02/24/25 with diagnoses of schizoaffective depressed type, epilepsy and anxiety disorder. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Review of the medication regimen review (MRR) for Resident #03 on 10/01/25 revealed phenytoin level on next convenient laboratory (lab) day and every six months. There was no physician response or signature.Review of the MRR for Resident #03 on 12/01/25 revealed phenytoin and digoxin levels on next convenient lab day and every six months. There was no physician response or signature.Review of the MRR for Resident #03 on 02/01/26 revealed phenytoin and digoxin levels on the next convenient lab day and every six months. There was no physician response or signature. Review of the MRR for Resident #03 on 04/01/26 revealed phenytoin and digoxin levels on next convenient lab day and every six months. There was no physician response or signature.Review of the MRR for Resident #03 on 05/01/26 revealed Abnormal Involuntary Movement Scale (AIMS) test now and every six months. There was no physician response or signature.Review of the medical record for Resident #03 revealed an AIMS test was completed for Resident #03 on 06/15/26. Review of the MRR for Resident #03 on 06/01/26 revealed phenytoin and digoxin levels on net convenient lab day and every six months. Resident #03 lab results collected on 06/02/26 and revealed Resident #03 had a digoxin level of 1.00ng/mL and no level of phenytoin was detected. On 06/03/26 at 4:59 P.M. Director of Nursing #266 notified the nurse practitioner of lab levels and no new orders were received.Interview on 06/16/26 at 4:02 P.M. with Medical Director revealed Resident #03's, 06/02/26 lab results should have been followed up on at the time of results, and the repeat lab should not wait until December to be drawn. Medical Director stated he would order lab work every three to six months to check levels. Interview on 06/16/26 at 4:09 P.M. with Regional Quality Assurance Nurse confirmed pharmacy reviews for Resident #03 had not been reviewed or implemented. Review of the Medication Regimen Reviews policy, dated May 2019, revealed the pharmacists recommendations will be addressed timely by the physician.

Based on record review, resident interview, observation, staff interview, and facility policy review, the facility failed to provide Resident #1 a therapeutic diet as ordered by the physician. This had the potential to affect 16 residents that the facility had identified with an order for a therapuetic diet. The facility census was 69. Review of Resident #1's medical record revealed an admission date of 04/04/26 with diagnoses including polyneuropathy, hypokalemia, and pneumonia. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resdient #1 was cognitively intact. Review of the physician order dated 05/26/25 revealed Resident #1 was ordered a regular diet, mechanical soft texture, regular consistency with extra gravies, sauces, etc. to further moisten foods. Review of the care plan revealed Resident #1 was at risk for nutrition or hydration problems causing them to be at risk for malnutrition. Interventions included to provide and serve diet as ordered. Interview on 06/14/26 at 12:15 P.M. with Resident #1 revealed she has an order for a mechanical soft diet and that she is often given meals of the incorrect texture. Observation on 06/14/26 at 1:18 P.M. revealed Resident #1's lunch meal ticket stated that she received a regular diet. Further observation revealed Resident #1 was served a regular texture meal. Interview with Regional Quality Assurance Nurse #320 on 06/14/26 at approximatley 1:25 P.M. verified that Resident #1's meal ticket was incorrect and the resident should not have been served a regular texture meal. Interview on 06/15/26 at 7:40 A.M. with Dietary Supervisor (DS) #273 verfied that Resident #1 was served a reular diet for lunch on 06/14/26. DS #273 stated he was unaware of Resident #1 having an order for a mechanical soft diet and verified the meal ticket was not updated when she had a diet change to mechanical soft. Review of the facility policy titled, Therapeutic Diets dated October 2017 revealed therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences.

Based on medical record reviews and staff interviews, the facility failed to ensure residents signing binding arbitration agreements understood the agreement. This affected two residents (#48 and #62) of five residents reviewed for arbitration. The facility census was 69. 1.Review of the medical record for Resident #48 revealed an admission date of 11/04/25 with diagnosis of non-Alzheimer's dementia. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. Review of the Arbitration Agreement revealed the agreementwas signed by Resident #48 on 11/19/25 at 1:17 P.M. Interview on 06/16/26 at 8:25 A.M. with Admissions Director #203 confirmed Resident #48 resided in the memory care. Interview on 06/16/26 at 8:45 A.M. with Regional [NAME] President of Operations confirmed memory care residents should not be signing binding arbitration agreement. 2.Review of the medical record for Resident #62 revealed an admission date of 09/17/25 with diagnoses of non-Alzheimer's dementia and hypertension. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. Review of the Arbitration Agreement revealed the agreement was signed by Resident #62 on 09/19/25 at 4:20 P.M. Interview on 06/16/26 at 8:25 A.M. with Admissions Director #203 confirmed Resident #62 resided in memory care. Interview on 06/16/26 at 8:45 A.M. with Regional [NAME] President of Operations confirmed memory care residents should not be signing binding arbitration agreement.

Based on medical record review, observation, interview, and policy review, the facility failed to ensure residents with enhanced barrier precautions (EBP) had clear signage or instruction indicating required personal protective equipment (PPE) and care activities that require what PPE. Additionally, the facility failed to ensure staff have awareness of the EBP policy. This affected 11 (#02, #05, #06, #10, #12, #19, #34, #36, #56, #68 and #73) of 11 residents reviewed for EBP. Additionally, the facility failed to clean and disinfect durable medical equipment (DME) between residents. This affected two residents (#14 and #78) of three reviewed. The facility also failed to ensure gloves were changed in between residents and hands were washed in-between resident care and after resident care. This affected one (#72) of three resident reviewed for incontinence care. The facility census was 76. Findings include:Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure residents with enhanced barrier precautions (EBP) had clear signage or instruction indicating required personal protective equipment (PPE) and care activities that require what PPE. Additionally, the facility failed to ensure staff have awareness of the EBP policy. This affected 11 (#02, #05, #06, #10, #12, #19, #34, #36, #56, #68 and #73) of 11 residents reviewed for EBP. Additionally, the facility failed to clean and disinfect durable medical equipment (DME) between residents. This affected two residents (#14 and #78) of three reviewed. The facility also failed to ensure gloves were changed between residents and hands were washed in-between resident care and after resident care. This affected one (#72) of three residents reviewed for incontinence care. The facility census was 76. Findings include: 1.Review of the medical record revealed Resident #19 was admitted to the facility on [DATE]. Diagnoses included major depressive disorder, chronic obstructive pulmonary disorder, and paranoid schizophrenia. Review of the care plan dated 04/11/24 revealed Resident #19 required enhanced barrier precautions due to suprapubic catheter. Interventions included educating staff on enhanced barrier precautions and enhanced barrier precautions will be maintained by staff per policy.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 was cognitively intact, had no behaviors, uses a walker for mobility, independent with eating, substantial assistance with toileting, and bathing. Review of Resident #19 physician orders revealed no orders for EBP. 2.Review of the medical record revealed Resident #56 was admitted to the facility on [DATE]. Diagnoses included anemia, aneurysm of the ascending aorta, and depression. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #56 had moderately impaired cognition, had behaviors, independent with mobility, set up for eating, and supervision with toileting and bathing. Review of the care plan dated 10/12/25 revealed Resident #56 had no EBP documented in the care plan.Review of the medical record revealed Resident #56 did not have an order for EBP. 3.Review of the medical record revealed Resident #68 was admitted to the facility on [DATE]. Diagnoses included gastroesophageal disease, generalized anxiety disorder, and bipolar disorder. Review of the care plan dated 08/18/25 revealed Resident #68 had enhanced barrier precautions due to complex wound/wound care with interventions including EBP will be maintained per policy.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #68 was cognitively intact, had no behaviors, used wheelchair for mobility, and set up for eating and bathing. Review of the medical record revealed Resident #68 did not have an order for EBP. 4. Review of the medical record revealed Resident #73 was admitted to the facility on [DATE]. Diagnoses included paraplegia, generalized anxiety disorder, and anxiety disorder. Review of the care plan dated 01/10/25 revealed Resident #73 requiring enhanced barrier precautions due to complex wound condition with interventions including educating staff on EBP and EBP will be maintained by staff per policy.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #73 was cognitively intact, had no behaviors, uses wheelchair for mobility, and was independent with eating and bathing. Review of the medical record revealed Resident #73 did not have an order for EBP. Observations and interview with the Director of Nursing (DON) on 11/18/25 from 12:25 P.M. to 12:45 P.M revealed residents (#02, #05, #06, #10, #12, #19, #34, #36, #56, #68 and #73) rooms had a magnetic square with EP written on the magnetic square and no other information was available on the status which was verified by the DON. Interview on 11/18/25 at 11:54 A.M. with Licensed Practical Nurse (LPN) #57 revealed residents have EBP when they have open wounds and catheters. The LPN #57 revealed they put on all PPE when providing any care to residents. Interview on 11/18/25 at 12:20 P.M. with Certified Nursing Assistant (CNA) #100 revealed they were aware of what to put on for residents in EBP because CNA #100 knows all the residents. CNA #100 stated if there was a new resident that went into EBP would ask the nurse or the DON what to put on for any resident care. Interview on 11/18/25 at 10:48 A.M. with Registered Nurse (RN) #101 revealed not aware of what the EP on the doors stand for and what to do if care must be provided in those resident rooms labeled with EP. Interview on 11/18/25 at 12:09 P.M. with CNA #102 revealed unsure of what PPE to wear when providing care to residents with EP on the door and would have to ask a nurse. Interview on 11/18/25 at 12:25 P.M. to 12:45 P.M. with the DON revealed staff were educated on putting full PPE on for any high contact care for residents with EBP. The DON revealed the staff are trained on EBP monthly at staff meetings and when newly hired. The DON also stated if a staff does not know what to put on or to do for EBP they can ask a nurse in the building. The DON confirmed the PPE cart is placed inside the room or outside the room depending on resident preference and there is no distinction at the door for which resident in the room is in EBP. The DON confirmed there is no additional signage at the door for a resident in EBP, staff would look in the resident chart if they needed to know. The DON stated there was no order for EBP, it was only documented in the resident care plan. Interview on 11/19/25 at 7:17 A.M. with CNA #82 revealed if the resident is in EBP there is usually a letter outside of the resident rooms to let the staff know what to wear for resident care. Interview and observation on 11/19/25 from 7:55 A.M. to 8:00 A.M. with Nurse Practitioner (NP) #110 revealed NP#110 walked into resident #73's room, which was labeled to be EBP, to do a dressing change. Observed the NP #110 walk out of the resident #73's room with no gown, door was open the entire time, the NP #110 stated does not wear a gown to remove the old wound dressing on any resident, even in EBP, and confirmed only wears a gown when applying the new wound dressing. Interview 11/20/25 at 8:50 A.M. with the DON revealed full PPE must be worn if any staff are providing wound care, including gloves, gown and masks. Review of the facility policy titled, Enhanced Barrier Precautions, dated 08/2022 revealed, staff are trained prior to caring for residents on EBP's and signs are posted on the door or wall outside the resident room to alert staff the resident requires EBP. EBP's employ targeted gown and glove use during high contact resident care activities. 5. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE]. Diagnoses included essential hypertension, altered mental status, unspecified, and chronic obstructive pulmonary disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #14 had moderately impaired cognition, partial assistance needed for mobility, set up for eating and set up for bathing. 6. Review of the medical record revealed Resident #78 was admitted to the facility on [DATE]. Diagnoses included essential hypertension, anxiety disorder, and chronic obstructive pulmonary disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #78 was cognitively intact, had no behaviors, set up for eating, partial assistance for toileting and set up for bathing. Observation on 11/19/25 from 8:00 A.M. to 8:15 A.M. of Licensed Practical Nurse (LPN) #77 obtained vital signs in Resident #78's room including the durable medical equipment (DME) (reusable medical equipment), finger pulse oximeter, blood pressure cuff and a forehead thermometer. Continued observation of LPN #77 walked out of Resident #78's room and put the DME supplies onto the medication cart. Observed Resident #14 walk up to medication cart to LPN #77 and requested medication. The LPN #77 used the same DME, finger pulse oximeter, blood pressure cuff and forehead thermometer on Resident #14 without any cleaning or disinfecting of the equipment prior to use. Interview on 11/19/25 at 8:15 A.M. with LPN #77 confirmed there was no cleaning of the DME between Resident #14 and Resident #78. LPN #77 confirmed the policy is to clean DME between resident use, but LPN #77 confirmed it was not done.Interview on 11/20/25 at 8:50 A.M. with the DON revealed all DME is to be cleaned per policy between each resident use. Review of the policy titled, Cleaning and Disinfection of Resident Care Items and Equipment dated 10/2018 revealed, reusable items are cleaned and disinfected or sterilized between resident. DME must be cleaned and disinfected before reused by another resident. 7. Medical record review for Resident #72 revealed an admission date of 07/27/21. Medical diagnoses included disorganized schizophrenia, heart failure, Alzheimer's disease, and cerebrovascular accident. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #72 was severely cognitively impaired. Her functional status was set up or clean-up assistance with eating, dependent for toileting and transfers. She was substantial/maximal for bed mobility. She was frequently incontinent for bladder and always incontinent for bowel. 8. Medical record review for Resident #55 revealed an admission date of 11/17/24. Medical diagnoses included after care for a fracture of the left femur. Review of the quarterly MDS dated [DATE] revealed Resident #55 was severely cognitively impaired. Her functional status was substantial/maximal assistance for eating, toileting, bed mobility, and transfers. She was always incontinent of bowel and bladder. During an observation on 11/19/25 at 6:16 A.M. CNA #117 revealed she had on two pairs of gloves and had finished incontinence care for Resident #55. The aide placed the covers back over the resident and then went to Resident #72's side of the room. CNA #33 had prepared the water for incontinence care for Resident #72. CNA #117 wiped the face and neck of Resident #72 and removed her shirt and washed under her breasts and armpits. She continued with the same gloves and provided incontinent care for the resident and removed the first pair of gloves on her hands. CNA #117 continued to dress Resident #72. She emptied the basin of water and put things away in the room. Right before she was ready to walk out into the hallway the Director of Nursing (DON), who was observing the interaction reminded the aide to take off her gloves before leaving the room and had not washed her hands before leaving the room and walked down the hall to the shower room to dispose of the dirty items from Resident #72's room. Interview with CNA #117 on 11/19/25 at 6:40 A.M. confirmed she had not changed her gloves in between residents and had not washed her hands in between residents or before leaving the room. She stated that was not her normal practice and should have changed her gloves and washed her hands. Review of policy titled Handwashing and Hand Hygiene dated 08/01/19 revealed to use an alcohol-based hand rub containing at least 62% alcohol, an approved non-alcohol-based hand sanitizer or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a. Before and after coming on duty.b. Before and after direct contact with residents.c. After contact with a resident's intact skin.d. After contact with blood or bodily fluids.e. After removing gloves. This deficiency represents non-compliance investigated under Complaint Number 2642540.

Based on medical record review, staff and resident interview and policy review, the facility failed to ensure they were free from significant medication errors when the nurse failed to administer medications according to the physician orders. This affected six (#39, #05, #49, #10, #40, #75) of seven residents reviewed for late medications. The census was 76. Findings include:1.Medical record review for Resident #75 revealed an admission date of 09/05/25. Medical diagnoses included acidosis, coronary artery disease, heart failure, and renal insufficiency. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #75 was cognitively intact. Review of the Medication Administration Audit Report dated 11/18/25 revealed the following medications were prescribed at 9:00 P.M., Pregabalin (anticonvulsant medication) capsule 25 milligrams (mg) to give one capsule two times a day, Atorvastatin (a cholesterol medication) Calcium Oral Tablet 40 mg to give one tablet at bedtime, Budesonide-Formoterol Fumarate (an asthma medication) Inhalation Aerosol 160-4.5 micrograms (mcg) to give two puffs a day, Trazadone (antidepressant medication) 150 mg to give one tablet, Lorazepam (a benzodiazepine medication) 0.5 mg. to give one tablet by mouth two times a day, Bupropion (antidepressant medication) 75 mg to give one tablet by mouth twice a day, Metformin (a medication to control blood sugar levels) 1000 mg to give twice a day. The above medication were given at 10:29 P.M.Interview with Resident #75 on 11/19/25 at 11:03 A.M. revealed her medications were late last night, 11/18/25, and would prefer them to be given on time.2.Medical record review for Resident #48 revealed an admission date of 07/12/25. Medical diagnoses included chronic obstructive pulmonary disease, heart failure, and diabetes. Review of the admission MDS dated [DATE] revealed Resident #48 was cognitively intact.Review of the Medication Administration Audit Report dated 11/18/25 revealed the following medications were prescribed at 9:00 P.M. Atorvastatin 20 mg to give one and was given at 11:20 P.M. Divalproex (anticonvulsant medication) extended release give one tablet was given at 11:25 P.M. Lantus (insulin medication) give 30 units was given at 12:02 A.M. Haldol (antipsychotic medication) 10 mg give one two times a day and was given at 11:25 P.M. Gabapentin (anticonvulsant medication) 300 mg give three times a day was given at 11:25 P.M. Buspirone (antianxiety medication)15 mg give three times a day was given at 11:20 P.M. Melatonin (a supplement) three mg give two tablets was given at 11:26 P.M. Interview with Resident #48 on 11/20/25 at 11:28 A.M. revealed she would like to get her medications around 9:00 P.M., but lately it has been more like 11:30 P.M. to 12:00 A.M. and she didn't like that. 3.Medical record review for Resident #10 revealed an admission date of 04/02/25. Medical diagnoses included dementia, heart failure, hypertension, and psychotic disorder.Review of the quarterly MDS dated [DATE] revealed Resident #10 was cognitively intact. Review of the Medication Administration Audit Report dated 11/18/25 revealed the following medications were prescribed at 9:00 P.M., Gabapentin 100 mg give one two times a day and Melatonin three mg give two tablets were given at 11:25 P.M. Interview with Resident #10 on 11/18/25 at 11:06 A.M. revealed at times his medications were late and he would like them on time. 4.Medical record review for Resident #49 revealed an admission date of 08/08/24. Medical diagnoses included acute respiratory failure with hypoxia, diabetes, bipolar disease and psychotic disorder. Review of the quarterly MDS dated [DATE] revealed Resident #49 was cognitively intact. Review of Medication Administration Audit Report dated 11/18/25 for medications prescribed for 9:00 P.M. revealed Depakote 500 mg give once a day was given at 11:20 P.M. Lantus give 30 units subcutaneously was given at 12:02 A.M. Haldol (antipsychotic medication) give one tablet twice a day was given at 11:25 P.M. 5.Medical record for Resident #05 revealed an admission date of 03/07/25. Review of diagnoses included spondylolisthesis lumbar region, cancer, renal insufficiency and neurogenic bladder. Review of the quarterly MDS dated [DATE] revealed Resident #5 was moderately cognitively impaired.Review of the Medication Administration Audit Report dated 11/18/25 revealed the following medications were prescribed for 9:00 P.M., Pregabalin 75 mg twice a day, Metoprolol (blood pressure medication) 25 mg two times a day and Hydroxyzine (antihistamine medication)10 mg one twice a day were given at 12:06 A.M. on 11/19/25. 6.Medical record review for Resident #39 revealed an admission date of 02/11/20. Medical diagnoses included dementia, peripheral vascular disease, and multiple sclerosis. Review of the quarterly MDS dated [DATE] revealed Resident #39 was severely cognitively impaired.Review of Medication Administration Audit Report dated 11/18/25 revealed the following medications prescribed for 9:00 P.M. Seroquel (antipsychotic medication) 150 mg two times a day, Melatonin 5 mg one tablet, Mirtazapine (antidepressant medication) 7.5 mg, Depakote 125 mg give three tablets twice a day were given at 10:34 P.M. Interview with Licensed Practical Nurse (LPN) #116 on 11/19/25 at 6:50 A.M. revealed she was late with giving her medications last night, 11/18/25, because she had two falls. She stated she had not ask for help from anyone because there was not a unit manager and the other nursing staff had their own medications to pass. Interview with the Nurse Practitioner (NP) #115 on 11/19/25 at 12:11 P.M. revealed she had not received a call from the facility last night, 11/18/25, concerning late medications and confirmed while she was at the facility she was not informed of any late medications for last night. Review of the policy titled Administering Medications dated 04/01/19 revealed medications are to be administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medications are to be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).This deficiency represents non-compliance investigated under Complaint Number 2642540 and 2642363.

Based on medical record review, observation and staff interview, the facility failed to ensure timely incontinence care was provided. This affected one (#72) of three residents reviewed for incontinence. The census was 76. Findings include:Medical record review for Resident #72 revealed an admission date of 07/27/21. Medical diagnoses included disorganized schizophrenia, heart failure, Alzheimer's disease, and cerebrovascular accident. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #72 was severely cognitively impaired. Her functional status was set up or clean-up assistance with eating, dependent for toileting and transfers. She was substantial/maximal assistance for bed mobility. She was frequently incontinent for bladder and always incontinent for bowel. Observation of incontinence care for Resident #72 on 11/19/25 at 6:16 A.M. with Certified Nursing Assistant (CNA) #56 revealed the resident's brief was saturated and had leaked a small amount onto the incontinence pad she was lying on. The odor was pungent. Interview with the CNA #56 on 11/19/25 at 6:30 A.M. verified the brief was saturated and leaked onto the pad under the resident. She said she changed the resident at 2:15 A.M. and didn't know why she would be so wet. She confirmed the resident should be changed every two hours. This deficiency represents non-compliance discovered under Complaint Number 2642540.

Based on medical record review, observation, staff interview, review of the water temperature logs, and review of a plumbing invoice, the facility failed to ensure water temperatures were within normal limits. This affected one (#72) of three residents reviewed for water temperatures. The census was 76. Findings include:Medical record review for Resident #72 revealed an admission date of 07/27/21. Medical diagnoses included disorganized schizophrenia, heart failure, Alzheimer's disease, and cerebrovascular accident. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #72 was severely cognitively impaired. Her functional status was set up or clean-up assistance with eating, dependent for toileting and transfers. She was substantial/maximal assistance for bed mobility. She was frequently incontinent of bladder and always incontinent for bowel. Review of an invoice from a plumbing company dated 11/11/25 revealed the mixing valve from the hot water had to be replaced. Review of the temperatures for the water for the 200-hall dated 11/18/25 revealed they were within normal limits. Review of the invoice dated 11/19/25 after the incontinence care revealed there was a new mixing valve replaced due malfunction of the one placed on 11/11/25. During an observation of incontinence care on 11/19/25 at 6:16 A.M. with Certified Nursing Assistant (CNA) #117 and CNA #33 revealed CNA #33 went into the bathroom to prepare water for the care but had to leave the room to go to another room to get water that was warm and came back into the room. During the care resident #72 was uncomfortable with the water temperature and she would pull away from the washcloth when the aides tried to wash under her arms, face and peri-care. The aides acknowledged the resident was cold from the cold water they were washing her with and continued with the care. Observation of the water temperature on 11/19/25 at 6:30 A.M. revealed the water temperature was taken by the Director of Nursing (DON) and the thermometer read 93.7 degrees Fahrenheit. The DON confirmed the water was too cold. Interview with CNA #33 on 11/19/25 at 6:35 A.M. revealed the water temperature had been a problem lately and the facility had someone out to fix it and it worked for a while and now it was not working anymore. She stated she tried to get warmer water by leaving the room, but it was only lukewarm. There wasn't a policy to review and the Administrator said they follow the regulatory guidelines.

Based on medical record review, observation, staff interviews, review of a facility investigation, and review of facility policy, the facility failed to ensure staff provided adequate supervision and intervention to prevent Resident #01, who had impaired cognition, was at risk for elopement, was housed on a secured memory care unit and who had a history of eloping from his bedroom window, from leaving the facility unsupervised. This resulted in Immediate Jeopardy when one resident (#01) was placed at potential risk for serious life-threatening harm and/or injury when the resident was displaying a change of condition and was observed pacing near the nurse's station and the resident was noted to be observing Licensed Practical Nurse (LPN) #110 closely. Resident #01 eloped from his bedroom window without staff knowledge and was found 2.3 miles from the facility, leaving a Dollar General store in a very busy area of town. This affected one (#01) of six residents reviewed for risk for elopement. The facility census was 71. On 06/12/24 at 3:03 P.M., the Administrator, Director of Nursing (DON), Regional Quality Assurance Nurse (RQAN) #403, Director of Clinical Services #401, Regional Director of Operations (RDO) #402 and Assistant Director of Nursing (ADON) #405 were notified that Immediate Jeopardy began on 06/09/24 at an unknown time, when Resident #01 exited the facility without staff knowledge. Resident #01 was seen pacing near the nurse's station on 06/09/24 at approximately 4:00 A.M. when LPN #110 provided the resident with water in the common area of the memory care unit. LPN #110 reported Resident #01 was observing her closely. State tested Nursing Assistant (STNA) #76 reports seeing Resident #01 on 06/09/24 at 5:00 A.M. when he asks her for a cup of ice water. On 06/09/24 at 5:50 A.M., LPN #110 went to Resident #01's room to administer his morning medication, when she noticed the resident was not in his room and noticed the bedroom window was partially raised with the screen removed and it was lying on the ground outside. The staff immediately conducted a head count which revealed Resident #01 was missing. The staff initiated their elopement plan and all staff started searching for Resident #01. The Police Department was contacted on 06/09/24 at 6:13 A.M. to help with the search. On 06/09/24 at 11:47 A.M., Director of Rehabilitation (DOR) #85 located Resident #01 leaving the Dollar General store approximately 2.3 miles from the facility and in a very busy area. Resident #01 continued to walk down the street and cross the middle of the street until he reached the Sunoco Gas Station which was 2.4 miles from the facility. On 06/09/24 at 12:03 P.M., nine-one-one (911) was called to assess Resident #01 and the resident refused care. On 06/09/24 at 12:20 P.M., Resident #01 was returned to the facility by emergency medical services (EMS). A head-to-toe assessment was completed and found Resident #01 to be free of any pain or distress. Resident #01 did have abrasions on both knees. Resident #01 had a previous elopement in May 2023 from the same room where he eloped from his bedroom window. The Immediate Jeopardy was removed on 06/09/24 when the facility implemented the following corrective actions: On 06/09/24 at approximately 5:45 A.M., LPN #110 identified Resident #01 was not in his room and the facility began searching for the resident. On 06/09/24 at 11:41 A.M., DOR #85 located Resident #01 at a Dollar General Store and the facility was notified. On 06/09/24 at 12:20 P.M., Resident #01 was returned to the facility by [NAME] EMS, accompanied by the [NAME] Police Department. ADON #405 initiated one to one safety supervision for Resident #01. At 12:30 P.M., Registered Nurse (RN) #109 completed a head-to-toe assessment on Resident #01 and the resident was free from any pain or psychosocial distress related to the incident. Resident #01 did have an abrasion noted to his bilateral knees. On 06/09/24, RQAN #403 reviewed progress notes for the last 30 days for all current facility residents for any like behaviors and no other concerns were identified. On 06/09/24, the Administrator installed metal L Brackets and additional upgraded hardware to prevent Resident #01's window from opening more than six inches or wide enough to prevent the resident from exiting the window. On 06/09/24, the Administrator audited all resident accessible windows and upgraded securement hardware throughout the facility. All windows were noted to be secured without any identified concerns. On 06/09/24, Unit Manager (UM) #134 completed elopement risk assessments for all current facility residents. There were no identified concerns from prior elopement assessments. On 06/09/24, Clinical Operations Specialist (COS) #121 completed wander risk assessments for all current facility residents. There were no identified concerns noted from the prior assessments. On 06/09/24, the Administrator audited all egress doors, alarm panels and the facility wander guard system to ensure proper alarm and functioning. There were no identified concerns noted. On 06/09/24, COS #121 audited all current facility residents with physician orders for wander guards. All wander guards were placed properly, functioning and within required expiration. No identified concerns were noted. On 06/09/24, UM #134 audited all current facility residents at risk of elopement, to ensure all those at risk have a care plan with appropriate interventions in place. There were no identified concerns in the audit. On 06/09/24, COS #121 audited to ensure all current facility residents with a wander guard were appropriately assessed for placement as ordered, had a physicians order and had a care plan in place. There were no identified concerns noted. On 06/09/24, UM #122, Dietary Manager #400, DOR #85, Environmental Services Director #450 and Nursing Administrative Assistant #79 began educating all current facility staff in person, on the missing resident procedure and the facility Abuse/Neglect policy and all remaining staff via phone. The education was completed on 06/09/24. On 06/09/24, the Administrator held an elopement drill in person with staff on dayshift and night shift. Staff response was immediate and appropriate. There were no identified concerns noted. On 06/09/24, the facility held a Quality Assessment and Performance Improvement (QAPI) meeting with the Administrator, RQAN #403, ADON #405, UM #134, UM #122, COS #121, RDO #402 and Medical Director #501. Resident #01's elopement and the facilities corrective action plan was discussed. The facilities corrective action plan was approved by the QAPI committee. Maintenance Director #130 or designee will conduct elopement drills on each shift, twice weekly for a period of four weeks to ensure staff respond accordingly with the first elopement drill being conducted on 06/09/24. All variances will be corrected upon discovery and additional education/follow-up will be provided as deemed necessary. All findings will be reported to the facility's QAPI committee. Maintenance Director #130 or designee will conduct checks of exit doors/wander guard system once weekly, for a period of four weeks to ensure proper functioning with the first one being conducted on 06/09/24. All variances will be corrected upon discovery and education/follow-up will be provided as deemed necessary. Ongoing compliance will be further maintained through audits as dictated by the facility's QAPI committee. The DON or designee will complete elopement risk and wandering risk assessments on current residents weekly for a period of four weeks, to ensure no changes in behavior patterns are present, placing residents at risk for elopement and ensuring that appropriate and effective interventions are in place with the first one being conducted on 06/09/24. All variances will be corrected upon discovery and additional education/follow-up will be provided as deemed necessary. The DON or designee will review current resident progress notes in the clinical operations meeting five times weekly for a period of four weeks to monitor acute changes in behavior patterns that require further intervention with the first one being conducted on 06/09/24. All variances will be corrected upon discovery and additional education and follow-up will be provided as deemed necessary. The DON or designee will audit all current facility residents with physician's order for wander guard five times a week, for a period of four weeks to ensure proper functioning, placement and devices within stated expiration with the first one being conducted on 06/09/24. All variances will be corrected upon discovery and additional education/follow-up will be provided as deemed necessary. All findings will be reported to the facility's QAPI committee. The Administrator or designee will conduct checks of window securement hardware, three times a week for a period of four weeks to ensure windows are secure and safety latches remain intact with the first one being conducted on 06/09/24. All variances will be corrected upon discovery and education/follow-up will be provided as deemed necessary. Further continued ongoing compliance will be further maintained through audits as dictated by the facility quality assurance committee. RDO #402 will review all audits weekly for a period of four weeks to ensure completion and compliance. All variances will be corrected immediately upon discovery and additional follow-up and education will be provided as deemed necessary. The DON or designee will educate new hires and/or agency staff working in the facility prior to working their shift on the Wandering elopement procedure and Abuse/Neglect policy for four weeks. All variances will be corrected upon discovery and additional education and follow-up will be provided as deemed necessary. Although the Immediate Jeopardy was removed on 06/09/24, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimum harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #01's medical record revealed he was admitted to the facility on [DATE]. Diagnoses include hyperlipidemia, tinnitus, major depressive disorder, essential primary hypertension, vascular dementia, and encephalopathy. Review of Resident #01's care plan dated 03/31/23, revealed the resident was at risk of elopement related to cognitive dysfunction, lack of capacity, poor judgment and decision making. Further review of the care plan revealed Resident #01 was at a moderate risk for wandering. Review of Resident #01's care plan revealed there was no specific care planned interventions addressing the resident's previous elopement from his window on 05/21/23. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/28/24, revealed Resident #01 had a brief interview for mental status (BIMS) score of 10 out of 15 indicating the resident had moderate cognitive impairment. Resident #01 was dependent on staff for medication administration and set up assistance with eating, dressing, oral hygiene, and putting on or taking off shoes. Resident #01 required supervision from staff with toileting, showering, and personal hygiene. Review of Resident #01's nursing progress notes revealed on 05/22/23 (late entry for 05/21/23) the resident's window was observed to be broken and the screen out in the courtyard. Resident #01 exited the facility through his window. Resident #01 was documented to be returned to the facility by the staff. Review of Resident #01's assessment titled, Wandering Assessment, dated 05/24/24, revealed the resident was determined to be a moderate risk for elopement. Review of Resident #01's assessment titled, Elopement Risk, dated 05/24/24, revealed the resident was capable of leaving the facility and had a history of elopement. Resident #01 resides on a locked unit with alarms. Review of Resident #01's progress notes revealed a late entry note, dated 06/09/24 at 12:20 P.M., which documented the resident exited the facility from his room after breaking and opening the window. Resident #01 returned to the facility accompanied by EMS and facility staff. The progress note documented Resident #01 was free of pain and distress and placed on a one-on-one supervision. On 06/10/24 at 2:50 P.M., the progress notes identified Resident #01 had abrasions on both knees. Interview on 06/12/24 at 8:12 A.M. with STNA #76 revealed she was pulled from the memory care unit on 06/08/24 at approximately 11:00 P.M. and worked on another unit. STNA #76 stated this left one nurse (LPN #110) and one STNA (#78) to work the floor with a total of twenty-three memory care residents. STNA #76 confirmed one other STNA (#129) was assigned to work on the memory care unit on a one-on-one with Resident #20. STNA #76 confirmed the memory care unit is hard to work when it is only one nurse and one aide assigned to the unit. STNA #76 stated there are times that several residents are exit seeking and pushing on the doors. During an interview on 06/12/24 at 8:23 A.M. with LPN #110, who was the nurse for Resident #01 on the day of the elopement from the facility on 06/09/24, she stated she started her shift at 7:00 P.M. on 06/08/24 on another hallway. LPN #110 stated after competing her assignment, she took over the assignment on the memory care unit. LPN #110 stated she began her shift with two STNA's assigned to the memory care unit to work with her (STNA #76 and STNA #78). LPN #110 explained another STNA #129 was assigned to the memory care unit; however, she was assigned to provide one-on-one care for Resident #20 because this resident had eloped from the facility on 06/08/24. LPN #110 stated STNA #76 was pulled from the memory care unit to work on another hallway for the rest of the shift. LPN #110 confirmed this left one STNA (#78) providing care along with herself (LPN #110) for a total of twenty-three memory care residents. LPN #110 stated on 06/09/24 at 4:00 A.M. Resident #01 asked her for a drink of water. LPN #110 stated it was not unusual for Resident #01 to be up at 4:00 A.M. LPN #110 further stated looking back on the incident, Resident #01 was observed to be pacing back and forth by the nurse's station and he was keeping a close eye on her. LPN #110 stated she began her medication pass on 06/09/24 at 5:00 A.M. and arrived at Resident #01's room on 06/09/24 at approximately 5:50 A.M. when she identified Resident #01 was not in his room and the window was open wide. LPN #110 stated she did not notice it at first but later identified a piece of wood on the floor along with a metal screw which were a part of the window. LPN #110 stated she immediately began a headcount and Resident #01 was the only resident not accounted for. LPN #110 stated she contacted the management team on 06/09/24 at 5:55 P.M. LPN #110 confirmed STNA #129 remained on her one-on-one assignment for Resident #20, and STNA #78 was providing care to another resident down the hallway. Interview on 06/12/24 at 11:51 A.M. with DOR #85 stated he was assisting with searching for Resident #01 after his elopement on 06/09/24. DOR #85 stated he was driving down the streets and searching for Resident #01 and thought he may have passed Resident #01, but he was not sure. DOR #85 stated he observed Resident #01 enter a nearby store and DOR #85 parked his car and walked into the store. DOR #85 confirmed he saw who he thought was Resident #01 and asked what his name was. DOR #85 asks the cashier to contact the police as DOR #85 followed Resident #01 out the door of the store. DOR #85 confirmed he was unable to redirect Resident #01, so he followed him. DOR #85 confirmed Resident #01 crossed a busy road and did not use the crosswalk and walked into a gas station. DOR #85 stated the police arrived with other staff members and later the squad arrived and took Resident #01 back to the facility. DOR #85 could not say for sure but thought this was around noon on 06/09/24. Interview on 06/12/24 at 12:23 P.M. with the Administrator revealed he stated he was not aware of Resident #01's previous elopement in May 2023 and could not provide any information related to that elopement. Interview on 06/12/24 at 2:32 P.M. with STNA #78 revealed two aides were assigned to work on the memory care unit on 06/08/24 until they pulled STNA #76 to work on another unit. STNA #78 stated it was not unusual for a STNA to be pulled from the memory care unit. STNA #78 confirmed it was herself and LPN #110 to provide care for twenty-three memory care residents. STNA #78 confirmed STNA #129 was assigned to provide one-on-one care supervision to Resident #20 because the resident eloped from the facility on 06/08/24. STNA #78 stated management was at the facility late on 06/08/24 and completed an elopement drill and education because Resident #20 had exited one of the memory care doors. STNA #78 confirmed she saw Resident #01 on 06/09/24 at 5:00 A.M. when he asked her for a cup of ice water. STNA #78 thought she must have woken Resident #01 when she turned on the light to provide care to his roommate. STNA #78 stated on 06/09/24 at around 5:30 A.M. LPN #110 told her that she could not find Resident #01. STNA #78 told LPN #110 she would help search for Resident #01 after she completed personal care on another resident. STNA #78 stated LPN #110 noticed the window in Resident #01's room was open wide, and Resident #01 was missing. A subsequent interview and observation on 06/13/24 at 12:30 P.M. with the Administrator confirmed the type of stop previously located in Resident #01's room was similar to the one in the conference room. The Administrator pointed at a small block of wood about two inches long with a metal screw on the face inside of the conference room window frame. The Administrator stated he replaced the pieces of wood and screws on Resident #01's window with metal L shaped brackets. Review of the facility policy titled, Wandering and Elopements, dated March 2019, revealed the facility will identify residents who are at risk for unsafe wandering and strive to prevent harm while maintaining a least restrictive life. Further review of the policy revealed the facility will provide strategies and interventions to maintain resident's safety. This deficiency represents non-compliance investigated under Complaint Number OH00154691.

Based on observations, staff interview, and facility policy review, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect all 71 residents who reside at the facility. The facility census was 71. Findings include: An interview and observation during the initial tour of the kitchen on 06/11/24 at 10:26 A.M. with the Kitchen Supervisor (KS) #300 revealed the three compartment sink did not contain sanitizing solution to sanitize the dishes. KS #300 confirmed the facility has been out of sanitizer for the three compartment sink for several days. KS #300 confirmed the dirt, food debris, and black substance under [NAME] the three compartment sink and all along the walls throughout the kitchen and behind the equipment. KS #300 confirmed the cove base covering was tore off the wall under [NAME] the three compartment sink as well as a missing tile. KS #300 confirmed the trash cans in the kitchen have food debris and splattered substance running down the trash cans. KS #300 confirmed the unknown splatter and debris running down the front of the dishwasher and food debris along the top of the dishwasher. KS #300 confirmed the water dripping from the dishwasher into a large bucket underneath the dishwasher. The facility confirmed all 71 residents residing in the facility receive their meals/food from the kitchen. Interview with Regional Dietary Director (RDD) #400 on 06/11/24 at 11:47 A.M. revealed he had a work order request for the leaking dishwasher machine. RDD #400 confirmed the three compartment sink was out of sanitizing solution. Interview on 06/11/24 at 2:11 P.M. with the Customer Service Representative (CSR) #600 who completes the dishwasher maintenance and supplies the facility with sanitization confirmed the facility did not have sanitizer in their three compartment sink. CSR #600 confirmed the dishwasher does not have the correct seal and is allowing water to leak into a bucket placed underneath the leaking areas. Review of the facility policy titled, Sanitization, dated October 2008, confirmed the facility shall be maintained in a clean and sanitary manner. All equipment shall be washed to remove or completely loosen soils with hot water and sanitizing solutions. Kitchen waste shall be kept in clean leakproof tightly closed containers. If a sink is used for washing utensils, cooking equipment or dishes, it will be cleaned between uses with an approved sanitizing agent. This deficiency represents non-compliance investigated under Complaint Number OH00153481.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, observation, resident interview, staff interview, review of the facility's Self-Reported Incident (SRI) and investigation, review the National Weather Forecast, and review of facility policy, the facility failed to provide adequate supervision to ensure a cognitively impaired resident, assessed to be at moderate risk for elopement from the facility and had previous attempts to elope, did not elope from the facility. This resulted in Immediate Jeopardy when Resident #26 was placed at risk for potential serious harm and/or injury when the resident eloped from the facility without staff knowledge and exited through the front door. The resident was missing for approximately six hours before being found approximately 3.9 miles from the facility, after accepting a ride from a neighbor of the facility, riding public transportation, accessing funds from the bank, and located walking along a main downtown street with variances of two to four lanes. This affected one (#26) of six residents (#26, #45, #66, #84, #91 and #96) reviewed for elopement. The facility identified four residents (#26, #45, #84, and #91) to be at risk for elopement. The facility census was 71. On 11/08/23 at 3:34 P.M., the Administrator was notified Immediate Jeopardy began on 10/20/23 at 7:00 A.M. when State tested Nurse Aide (STNA) #556, assigned to provide one-to-one supervision for Resident #26, left at the end of her shift without ensuring another staff member assumed supervision of the resident. Subsequently, Resident #26 cut off his wander guard bracelet from his left ankle with a pair of nail clippers and exited from the facility through the front door without staff knowledge. Resident #26 was located approximately six hours later by facility staff as the resident was walking down a main downtown street, approximately 3.9 miles away from the facility. The ambient air temperature outside on 10/20/23 was a low of 50 degrees Fahrenheit (F) to a high of 54 F. Resident #26 was placed at potential risk of being hit by a car while walking through areas that had two to four lane roads of traffic, traveled by city bus, procured a ride from a facility neighbor, withdrew funds from the bank, and gave money to a friend. At the time of discovery, Resident #26 was transported to the hospital for evaluation and found to have no injuries. The Immediate Jeopardy was removed, and the deficient practice corrected on 10/21/23 when the facility implemented the following corrective actions: On 10/20/23 at approximately 8:10 A.M., Registered Nurse (RN) #521 discovered Resident #26 was not in his room and initiated a head count of facility residents. All residents were accounted for, except Resident #26. On 10/20/23 at 8:26 A.M., Unit Manager (UM) #643 called a code and alerted all available staff to conduct a thorough search inside the facility and assigned additional staff to search immediately outside of the facility. On 10/20/23, Regional Quality Assurance Nurse (RQAN) #651 notified the assisted living facility on campus to conduct a thorough search of their facility and grounds. On 10/20/23 at 8:30 A.M., the Administrator began organizing a search team to conduct a thorough search of external facility grounds and adjacent areas outside the facility. The search team disseminated photographs and physical description of Resident #26 and conducted an on-going search for Resident #26. On 10/20/23 at 8:41 A.M., the Administrator notified the police department Resident #26 exited the facility unsupervised and was unable to be located. On 10/20/23 at 8:47 A.M., RQAN #651 notified the Medical Director and Social Service Designee (SSD) #510 notified the emergency contact of Resident #26's elopement from the facility. On 10/20/23 from 10:20 A.M. to 10:50 A.M., Regional Clinical Resource Specialist (RCRS) #654 assessed all facility residents with physician orders for wander guards to ensure they were properly placed, functioning, and within expiration dates. Additionally, all residents with a wander guard were assessed to ensure use was appropriate and care plans were in place related to the use of a wander guard. On 10/20/23 between 10:25 A.M. and 10:50 A.M., RCRS #654 and Director of Clinical Reimbursement (DCR) #650 searched the rooms for all residents currently ordered a wander guard for objects that could potentially impair the integrity of a wander guard strap. No concerns were identified. On 10/20/23 between 10:45 A.M. and 11:00 A.M., RCRS #654 audited to ensure all current facility residents identified at risk for elopement had a care plan with appropriate interventions in place. There were no variances identified in the audit. On 10/20/23 between 10:45 A.M. and 12:40 P.M., Minimum Data Set (MDS) Nurse #538 assessed all current facility residents for elopement risk. There were no variances noted from prior assessment. On 10/20/23 between 10:50 A.M. and 2:30 P.M., UM #525 assessed all facility residents for risk of wandering. There were no variances noted from prior assessment. On 10/20/23 between 10:51 A.M. and 11:00 P.M., the Administrator educated Assistant Director of Nursing (ADON) #619, DCR #650, Medicaid Specialist (MS) #551, Medical Records Coordinator (MRC) #642, and Director of Rehabilitation (DR) #540 on the missing resident/Wandering and Elopement Procedure, expectations of one-to-one safety supervision, ensuring residents with wander guards did not have sharp objects in room, and the facility Abuse/Neglect policy. On 10/20/23 from 11:00 A.M. to 8:40 P.M., ADON #619, DCR #650, MS #551, MRC #642, and DR #540 educated all working agency staff and current facility staff in person on the missing resident/Wandering and Elopement procedure, expectations of one-to-one safety supervision, ensuring residents who had wander guards did not have sharp objects in room and the facility Abuse/Neglect policy. Staff not working were educated by phone. One hundred percent of facility staff were educated by 8:40 P.M. On 10/20/23 at 1:51 P.M., Resident #26 was located approximately 3.9 miles away from the facility, walking down the street, by UM #643. The resident was free of any injury, pain, or indicators of psychosocial distress. UM #643 called 911 and Emergency Medical Services (EMS) transported Resident #26 to the hospital to be assessed as a precaution. On 10/20/23 between 2:25 P.M. and 8:40 P.M., Senior Administrator (SA) #653 held an elopement drill with in-person staff on day shift. Staff response was immediate and appropriate. On 10/20/23 between 2:40 P.M. and 5:00 P.M., SA #653, Director of Business Development (DBD) #554, Director of Clinical Services (DCS) #550, and RCRS #654 reviewed progress notes for the past 90 days for all facility residents for any like behaviors without any variances identified. On 10/20/23 between 3:52 P.M. and 3:59 P.M., [NAME] President of Operation (VPO) #555 and RQAN #651 interviewed STNA #556 via phone. STNA #556 verified leaving her one-to-one safety assignment with Resident #26 without handing-off supervision to another responsible person at 7:00 A.M. STNA #556 was suspended and removed from the nursing schedule. Beginning on 10/20/23, the Director of Nursing (DON) or designee completed elopement and wandering risk assessments on current residents five times weekly for two weeks, then three times weekly for two weeks to ensure no changes in behavior patterns were present placing residents at risk for elopement and ensuring that appropriate and effective interventions were in place. Evidence was received verifying monitoring was completed on 10/20/23, 10/21/23, 10/22/23, 10/23/23, 10/24/23, 10/25/23, 10/26/23, 10/27/23, 10/28/23, 10/29/23, 10/30/23, 10/31/23, 11/01/23, 11/02/23, 11/03/23, 11/04/23, 11/05/23, 11/06/23, 11/07/23, 11/08/23, 11/09/23, 11/10/23, 11/12/23, and 11/13/23. Beginning on 10/20/23, the DON or designee audited the resident activities room five times weekly for four weeks to ensure residents did not have unsupervised access to sharp objects, such as scissors. Any variances were corrected upon discovery and additional education and follow-up provided as deemed necessary. Evidence was provided verifying monitoring was completed on 10/20/23, 10/21/23, 10/22/23, 10/23/23, 10/24/23, 10/25/23, 10/26/23, 10/27/23, 10/28/23, 10/29/23, 10/30/23, 10/31/23, 11/01/23, 11/02/23, 11/03/23, 11/04/23, 11/05/23, 11/06/23, 11/07/23, 11/08/23, 11/09/23, 11/10/23, 11/12/23, and 11/13/23. Beginning on 10/20/23, the DON or designee verified each shift for four weeks that one-on-one supervision was provided for Resident #26 and staff had full understanding of the requirement for providing one-on-one supervision. Evidence was provided verifying this was completed on 10/20/23, 10/21/23, 10/22/23, 10/23/23, 10/24/23, 10/25/23, 10/26/23, 10/27/23, 10/28/23, 10/29/23, 10/30/23, 10/31/23, 11/01/23, 11/02/23, 11/03/23, 11/04/23, 11/05/23, 11/06/23, 11/07/23, 11/08/23, 11/09/23, 11/10/23, 11/12/23, and 11/13/23. Beginning on 10/20/23, the DON or designee reviewed current residents' progress notes in the clinical record five times weekly for four weeks to monitor for acute changes in behavior patterns that required further intervention. Evidence was provided verifying this was completed on 10/20/23, 10/21/23, 10/22/23, 10/23/23, 10/24/23, 10/25/23, 10/26/23, 10/27/23, 10/28/23, 10/29/23, 10/30/23, 10/31/23, 11/01/23, 11/02/23, 11/03/23, 11/04/23, 11/05/23, 11/06/23, 11/07/23, 11/08/23, 11/09/23, 11/10/23, 11/12/23, and 11/13/23. Beginning on 10/20/23, the DON or designee audited all current facility residents with physician order for wander guards five times weekly for four weeks to ensure proper functioning, placement and devices were within the stated expiration date. Evidence was provided to verify audits were completed on 10/20/23, 10/21/23, 10/22/23, 10/23/23, 10/24/23, 10/25/23, 10/26/23, 10/27/23, 10/28/23, 10/29/23, 10/30/23, 10/31/23, 11/01/23, 11/02/23, 11/03/23, 11/04/23, 11/05/23, 11/06/23, 11/07/23, 11/08/23, 11/09/23, 11/10/23, 11/12/23, and 11/13/23. Beginning on 10/20/23, the DON or designee interviewed five staff members five times weekly for four weeks to ensure understanding of one-to-one education provided on supervision and elopement and one-to-one supervision was to continue for Resident #26, without exception, until it is discontinued. Evidence was provided to verify this was completed on 10/20/23, 10/21/23, 10/22/23, 10/23/23, 10/24/23, 10/25/23, 10/26/23, 10/27/23, 10/28/23, 10/29/23, 10/30/23, 10/31/23, 11/01/23, 11/02/23, 11/03/23, 11/04/23, 11/05/23, 11/06/23, 11/07/23, 11/08/23, 11/09/23, 11/10/23, 11/12/23, and 11/13/23. Beginning on 10/20/23, the Administrator or designee audited, via observation, each resident room with a physician order for a wander guard to ensure the room was free from sharp items that may impair the integrity of a wander guard strap five times weekly for four weeks. Evidence was provided verifying this was completed on 10/20/23, 10/21/23, 10/22/23, 10/23/23, 10/24/23, 10/25/23, 10/26/23, 10/27/23, 10/28/23, 10/29/23, 10/30/23, 10/31/23, 11/01/23, 11/02/23, 11/03/23, 11/04/23, 11/05/23, 11/06/23, 11/07/23, 11/08/23, 11/09/23, 11/10/23, 11/12/23, and 11/13/23. Beginning on 10/20/23, MD #622 or designee conducted elopement drills on two shifts five times a week for two weeks, then three times a week for two weeks to ensure staff respond accordingly. Evidence was provided to verify elopement drills were completed on 10/20/23, 10/21/23, 10/22/23, 10/23/23, 10/24/23, 10/25/23, 10/26/23, 10/27/23, 10/28/23, 10/29/23, 10/30/23, 10/31/23, 11/01/23, 11/02/23, 11/03/23, 11/04/23, 11/05/23, 11/06/23, 11/07/23, 11/08/23, 11/09/23, 11/10/23, 11/12/23, and 11/13/23. Beginning on 10/20/23, MD #622 or designee conducted checks on exit doors/wander guard system five times a week for four weeks to ensure proper functioning. Evidence was provided to verify the checks were completed on 10/20/23, 10/21/23, 10/22/23, 10/23/23, 10/24/23, 10/25/23, 10/26/23, 10/27/23, 10/28/23, 10/29/23, 10/30/23, 10/31/23, 11/01/23, 11/02/23, 11/03/23, 11/04/23, 11/05/23, 11/06/23, 11/07/23, 11/08/23, 11/09/23, 11/10/23, 11/12/23, and 11/13/23. On 10/20/23 at 8:42 P.M., an ad hoc (unplanned) Quality Assurance and Performance Improvement (QAPI) meeting was held to review the corrective action plan. The plan was approved by the committee, including ongoing monitoring to ensure compliance. On 10/20/23 at approximately 10:00 P.M., Resident #26 returned to the facility via EMS transport. A wander guard was placed to the resident's right ankle by UM #643. Resident #26 was free of any injury or complaints. STNA #656 was assigned to provide one-to-one safety supervision for Resident #26. On 10/23/23, STNA #556 was terminated for failing to provide one-to-one as required and leaving the premises without supervisor's permission or knowledge. On 11/01/23, the physician completed a competency evaluation and the facility submitted to probate court to obtain a legal guardian for Resident #26. On 11/06/23 at 3:42 P.M., observation of exit doors revealed all doors functioned properly and staff responded to alarms. On 11/06/23, 11/07/23, 11/08/23 and 11/13/23, observations throughout the day of Resident #26 confirmed one-to-one safety supervision was in place. On 11/08/23, interviews with MRC #642, Accounts Manager (AM) #655, MDS Nurse #538, and Activities Assistant (AA) #548 verified they were educated on elopement, Abuse, and one-to-one supervision on 10/20/23. All verified they have participated in elopement drills. Review of five (#45, #66, #84, #91, #96) additional open resident records, reviewed for elopement, revealed no concerns. Findings include: Review of medical record for Resident #26 revealed an admitted [DATE]. Diagnoses included, but not limited to, sepsis, type II diabetes, pseudocyst of pancreas, alcohol dependence, bipolar II disorder, schizoaffective disorder, and metabolic encephalopathy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had moderately impaired cognition for daily decision making, inattention and disorganized thinking, and required extensive assistance of one for Activities of Daily Living (ADL's). Review of the plan of care dated 10/02/23 revealed Resident #26 was at risk for elopement/wandering related to impaired cognition and unaware of safety needs. Interventions included one-to-one supervision as needed, orient to new surroundings, psychoactive medication as ordered, remind resident not to leave facility without notifying staff, wander guard to left ankle, check placement and function every shift, assess for risk factors per facility procedures, follow facility elopement procedures, monitor/report changes in behavior (restlessness and pacing), monitor medication side effects, provide diversional activities of interest as needed, and redirect as needed. Review of a Wandering Risk assessment dated [DATE] revealed Resident #26 was disoriented, combative/severely agitated, did not understand surroundings, disturbed by environmental noise levels, loss of self-control, and experienced of anger/fear of abandonment. Resident #26 was independent for mobility and was taking antipsychotics. Resident #26 scored 09 on the assessment, indicating a moderate risk for wandering. Review of a Social Service Note dated 10/17/23 at 11:50 A.M. revealed Resident #26 attempted to exit the facility, accompanied by staff. The resident's emergency contact and physician were notified. The wander guard was replaced to the resident's ankle and Resident #26 was placed on one-to-one safety supervision. Review of a statement dated 10/17/23, from UM #643, revealed Resident #26 was noted to have removed his wander guard and attempted to leave the facility through the front door. Staff were present at the time the resident attempted to leave the facility and followed immediately behind resident, walking beside him while he exited the facility. The resident was redirected into the facility without difficulty. Review of a Health Status Update Note dated 10/18/23 at 11:18 A.M. revealed Interdisciplinary Team (IDT) spoke with Resident #26's emergency contact in regard to having an apartment in the community. Emergency contact was unaware of the whereabouts of an apartment in the community, stating Resident #26 was homeless prior to arriving. The physician was notified to schedule a competency evaluation as the resident did not have a responsible party and the emergency contact did not wish to make decisions for Resident #26. Review of the Health Status Update Note dated 10/20/23 at 8:10 A.M. revealed Resident #26 exited the facility unsupervised by staff. Wander guard and nail clippers observed on bedside table. The note did not indicate what time the resident exited the facility. Review of the facility's Self-Reported Incident (SRI) dated 10/20/23 revealed STNA #556 had knowledge Resident #26 required one-to-one assistance to ensure his safety and well-being. STNA #556, on her own accord, chose to leave her safety assignment with Resident #26 without securing one-to-one supervision. STNA #556 left Resident #26, absent of the necessary supervision to ensure his safety, had the appropriate knowledge in respect of the need for continued one-to-one supervision for Resident #26, and chose to leave him unattended and left the facility without any staff having knowledge of her doing so. The facility substantiated STNA #556's neglect of Resident #26. The facility understands the potential severity of such instances and implemented extensive staff education and monitoring to ensure the safety of all residents as it relates to exiting the facility unsafely. STNA #556's employment was terminated. Resident #26 continues to reside within the facility absent of any indicators of psychosocial and physical distress. Resident #26's plan of care will be updated as necessary to reflect his highest practicable psychosocial/physical well-being and safety. Resident #26 reports he will not be exiting the facility again, however, continues to remain on one-to-one supervision at this time. Review of a statement dated 10/20/23 at 8:39 A.M. from the former Administrator revealed the facility was notified by a vendor that at approximately 8:10 A.M. to 8:15 A.M., Resident #26 was standing outside in front of the facility wearing a black hoodie (sweatshirt) and blue sweatpants. Review of a statement from STNA #556, dated 10/20/23 at 3:52 P.M., obtained by VPO #555 and RQAN #651, revealed STNA #556 reported leaving her one-on-one safety assignment with Resident #26 without handing-off to another responsible person at 7:00 A.M. Interview on 11/08/23 at 10:50 A.M. with Resident #26 revealed on 10/20/23 a neighbor of the facility gave him a ride to a local fast-food restaurant and then he walked to the bank. From the bank, Resident #26 stated he went to a local grocery store and caught the city bus to go to a restaurant downtown. Resident #26 confirmed he removed his wander guard before leaving the facility and was eventually located by facility staff while walking in the downtown area. Interview on 11/08/23 at 12:00 P.M. with DCS #550 revealed upon admission, Resident #26 had encephalopathy and was confused. On 10/17/23, Resident #26 cut off his wander guard and attempted to leave the facility and one-to-one supervision was initiated as an intervention. Following that incident, the facility requested the physician complete a competency evaluation for guardianship as there was no responsible party willing to make decisions for the resident. DCS #550 stated one-to-one supervision would continue until a court appointed guardian was in place. Telephone interview on 11/15/23 at 2:50 P.M. with the DON and DCS #550 verified on 10/20/23, STNA #556 left her assignment of one-to-one supervision for Resident #26 without handing-off responsibility for supervision and without notifying any facility staff she was leaving, which the DON and DCS #550 confirmed should have occurred. Subsequently, Resident #26 was left without the supervision level identified by the facility to ensure his safety, resulting in the resident leaving the facility unsupervised. The DON and DCS #550 verified Resident #26 was missing from the facility for approximately six hours before being located by facility staff. DCS #550 verified, based on physician evaluation, Resident #26 was not capable of making safe decisions for himself due to mental illness. Review of AccuWeather data, located at https://www.accuweather.com, for 10/20/23 revealed the ambient air temperatures were a low of 50 degrees Fahrenheit (F) and a high temperature of 54 F. Review of facility policy titled Wandering and Elopements, revised March 2019, revealed the facility will identify residents at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Additionally, if identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. This deficiency represents non-compliance investigated under Complaint Number OH00147915 and Complaint Number OH00147452.

Based on observations, medical record review, resident and staff interview, and policy review, the facility failed to ensure a call light was in place for a resident. This affected one (#68) of 24 residents reviewed for call light placement. The facility census was 76. Findings included: Medical record review for Resident #68 revealed an admitted [DATE]. Diagnoses included dementia, hypertension, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #68 was cognitively intact. Observations of the call light for Resident #68 on 10/03/23 at 9:14 A.M. and on 10/04/23 at 3:14 P.M. revealed the call light cord was hanging wrapped around the call light outlet and out of reach of the resident. At the time of the observations, Resident #68 said she didn't know where her call light was. Interview with State tested Nursing Aide (STNA) #307 on 10/04/23 at 3:27 P.M. confirmed the call light wasn't within reach for Resident #68. Review of the policy titled Call Light-Resident, dated 09/01/22, revealed residents will be provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. Each resident will be provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

Based on medical record review and staff interview, the facility failed to complete an accurate Pre-Admission Screen and Resident Review (PASARR) for Resident #62. This affected one (Resident #62) of two residents reviewed for PASARR. The facility census was 76. Findings include: Review of Resident #62's medical record revealed an admitted [DATE]. Diagnoses included catatonic schizophrenia (diagnosis upon admission on 03/14/23), major depressive disorder, psychosis, and dementia with behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was moderately cognitively impaired. Review of Resident #62's PASARR dated 06/20/23 revealed the PASARR had only mood disorder marked as a serious mental disorder. The PASARR did not include Resident #62's diagnosis of catanoic schizophrenia, which Resident #62 had the diagnosis since admission on 03/14/23. Interview with Certified Operations Specialist #249 on 10/03/23 at 3:35 P.M. verified Resident #62 had a catatonic schizophrenia diagnosis and it was not coded on the PASARR dated 06/20/23.

Based on medical record review, staff interview, review of the outside provider cardiologist notes, and policy review, the facility failed to ensure ordered oxygen was applied prior to transporting a resident, who required continuous oxygen, to an outside appointment. This resulted in Actual Harm when Resident #01 was sent to an outside provider appointment without ordered continuous oxygen, suffered hypoxemia (low oxygen levels in the blood), difficulty breathing and required supplemental oxygen prior to the resident being transported back to the facility. This affected one resident (#01) out of three residents reviewed who required oxygen. The census was 80. Findings include: Review of the medical record revealed Resident #01 was admitted to the facility on [DATE]. Diagnoses included acute respiratory failure, pulmonary embolism, heart disease, protein-malnutrition, atrial fibrillation, and hypotension. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #01 had impaired cognition, required supplemental oxygen, and was a one-person assist for Activities of Daily (ADL). Review of Resident #01's care plans dated 05/31/23 revealed a focus for respiratory function related to respiratory failure, history of pulmonary embolism, and oxygen use. Resident #01 would remove his oxygen at times. Interventions included administer oxygen per order, encourage compliance, medications per order, monitor blood oxygen levels, and observe for signs of shortness of breath. Review of Resident #01's physician orders dated 06/01/23 revealed the resident was ordered two liters of oxygen via nasal cannula continuously. Review of the cardiologist's office documentation dated 06/13/23 revealed Resident #01's chief complaint was shortness of breath. Per the document, the patient presented without nasal cannula oxygen. The patient was hypoxic with 66 percent oxygen saturation and breathing very hard. Further review of the physician documentation revealed no explanation of Resident #01 provided oxygen prior to leaving to return to the facility. Review of Resident #01's vital signs documented in the facility's medical records revealed the nurse assessed the resident upon their return to the facility on [DATE] at 4:54 P.M. and the resident's oxygen saturation was 97 percent on two liters via a nasal cannula. Interview on 06/21/23 at 2:30 P.M. with the Administrator revealed on 06/13/23 he received a call from Resident #01's physician office stating the resident was in respiratory distress upon arriving at the facility due to having no oxygen tank on his wheelchair. The Administrator verified Resident #01 was ordered by the physician to have continuous supply of oxygen. The Administrator stated he retrieved an oxygen tank and nasal cannula from the supply and drove the oxygen supplies to the physician's office and gave them to the nurse at the office. The Administrator stated he did not assess or observe Resident #01 at the office. Interview on 06/22/23 at 11:22 A.M., with Registered Nurse (RN) #200 revealed on 06/13/23 in the afternoon the nurse had prepared all Resident #01's transportation paperwork for the resident which stated the resident required supplemental oxygen during transport. RN #200 stated Resident #01's physician appointment was scheduled for 3:15 P.M. and transportation was scheduled to pick him up at 3:00 P.M., the physician's office was a 10 minute drive from facility. Per RN #200, State tested Nurse Aide (STNA) #300 was told to get the resident ready for his appointment. RN #200 stated she checked on the resident around 2:30 P.M. and saw him sitting in his wheelchair with oxygen being supplied by the concentrator. RN #200 stated she informed STNA #300 the resident would need a supplemental oxygen tank put on his wheelchair prior to leaving the facility. RN #200 stated she was not made aware the transport company came early to pick up Resident #01 and the resident left the facility without an oxygen tank on his wheelchair. RN #200 stated STNA #300 was scheduled to attend the appointment with Resident #01 but due to another resident needing assistance another staff member attended the office visit with Resident #01. RN #200 stated she had no knowledge the resident had no oxygen applied when he left the facility and stated the transport company staff did not collect the resident's information paperwork to be transported with him Interview on 06/22/23 at 2:45 P.M with Regional Registered Nurse (RRN) #500 revealed when Resident #01 was being dressed and prepared for his physician appointment and the aide assigned to him put him on a concentrator for oxygen supply and not a travel tank. RRN #500 stated the nurse and aide were unaware the transporter came into Resident #01's room and took the resident onto the van without any travel oxygen on his wheelchair. RRN #500 verified due to a scheduling conflict the aide who was originally scheduled to attend Resident #01's appointment had to attend to another resident so the Activity Director (AD) #501 volunteered to attend Resident #01's appointment. RRN #500 stated the AD #501 does not have any medical training and did not know the resident required oxygen. RRN #500 verified Resident #01 suffered hypoxemia and heavy breathing per the nurse's notes during his office visit and stated the doctor's office had to supply oxygen to the resident during the visit. RRN #500 stated the resident returned to the facility with the travel oxygen supplied by the Administrator and the facility was taking action to ensure the incident would not occur again. Review of the policy titled Oxygen Policy, dated 10/2010 revealed all residents are to receive supplemental oxygen per physician order at all times. This citations is an example of non-compliance relating to Complaint Number OH00143747.

Based on medical record review, observation, staff interviews, police interview, review of the facility's self-reported incident and review of the facility drug storage policy, the facility failed to ensure medications were properly secured and supervised. This resulted in Immediate Jeopardy, serious life-threatening harm, for one cognitively intact resident with a history of drug abuse (Resident #1) when Agency Licensed Practical Nurse (ALPN) #50 left the medication cart, including the narcotic box located on the skilled unit, unlocked. Actual life threatening harm occurred when Resident #1 removed 23 [MEDICATION NAME] (narcotic pain medication) pills from the medication cart, consumed suspected 19 [MEDICATION NAME] pills resulting in an opioid overdose that required the use of [MEDICATION NAME] (medication to treat narcotic overdose in an emergency situation) in the emergency room and subsequent hospitalization . This affected two of two residents (Resident #1 and #8) reviewed for accident hazards. The facility census was 70. On 12/28/17 at 3:20 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 12/10/17, when ALPN #50 failed to properly secure the medication cart including the narcotic box. Resident #8 admitted he assisted Resident #1 in stealing 23 [MEDICATION NAME] pills from the medication cart. Resident #1 and Resident #8 consumed the [MEDICATION NAME] pills. Resident #1 had a change in condition on 12/10/17, was sent to the emergency roiagnom on [DATE] and was diagnosed with [REDACTED]. The Immediate Jeopardy was removed on 12/28/17 at 6:00 P.M. when the facility took the following corrective actions: · On 12/10/17, Unit Manger (UM) #100 began educating nursing staff on medication cart security and ensuring medication carts were properly secured. All facility nursing staff education was completed by the DON and UM #100 by 12/28/17 at 3:59 P.M. · On 12/11/17 at 1:10 A.M. Resident #1 was sent to the emergency room , was admitted with an opioid overdose and remained hospitalized as of 12/29/17. · On 12/11/17 at approximately 10:00 A.M. an unidentified pharmacy technician completed a medication cart functionality assessment on the two carts located on the front and back carts located on the skilled unit. The assessment stated that both carts were in working order. However, it was noted the back hall skilled cart narcotic box was unable to lock securely when the narcotic caddy was slid to the front of the medication cart. · On 12/11/17, Regional Nurse Consultant #350 initiated medication cart lock audits one to two times per day, five days per week to be completed by the DON and/or designee. · On 12/13/17 at 8:30 A.M. the DON began educating the facility nursing staff on the facility's malfunctioning equipment protocol. All nurses were educated by 12/28/17 at 3:59 P.M. · On 12/27/17 at 8:30 P.M. a Contracted Emergency Pharmacy technician completed medication cart functionality assessments on the two medication carts located on the skilled unit and changed the medication cart keys for both medication carts including the narcotic boxes on the skilled unit. This allowed the narcotic boxes to lock securely. · On 12/28/17 and 12/29/17 surveyor observations revealed all medications carts were properly secured. · On 12/28/17, the facility immediately initiated that all agency nursing staff as well as new hires would be educated by the DON or DON designee on medication cart security and the facility's medication cart malfunction protocol prior to the beginning of each shift. · On 12/28/17, the facility implemented preventative maintenance to be completed by a pharmacist which will be completed monthly to ensure proper medication cart security and functionality. · Interview with Registered Nurse (RN) #11, Licensed Practical Nurse (LPN) #31 and LPN #32 on 12/29/17 at approximately 1:30 P.M. revealed they knew to immediately put the medication cart in a locked medication room and notify the DON of any malfunctions immediately. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #1 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of the plan of care dated 11/13/17 revealed Resident #1 was at risk for nutrition and dehydration related to [DIAGNOSES REDACTED]. Review of Resident #8's closed medical record revealed the resident was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the resident's comprehensive MDS 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of the Self-Reported Incident (SRI) # 3 dated 12/10/17 revealed at 7:03 A.M. the Administrator received a call from UM #100 stating there was a discovery, by ALPN #50, that two narcotic medication cards, one card containing six [MEDICATION NAME] five milligrams (mg.) and one card containing 17 [MEDICATION NAME] five mg were missing from the skilled hall medication cart. The Administrator along with UM #100 began an investigation immediately upon notification of the allegation. An empty medication sleeve was found in the garbage of Resident #1 when the resident allowed for the room search to be conducted. Resident #8 was acting unusually lethargic and was sent to the hospital. Upon return from the hospital that same day on 12/10/17, Resident #8 came forward and confessed that he was involved in distracting the nurse in order for Resident #1 to pull the medication from the drawer of the medication cart. Resident #1 was asked multiple times by facility staff to go to the hospital as he was also noted to be lethargic. He refused every time. At approximately 1:10 A.M. on 12/11/17, emergency number 9-1-1 was called for Resident #1. Upon their arrival, Resident #1 continued to refuse to go with the responders to the hospital. At that time, the Administrator and UM #100 went in the room while paramedics and a Police Officer were present to encourage the resident to go out for medical attention. The resident continued to refuse, but then consented to go, at which time he was taken to a local hospital. Resident #1 was hospitalized for [REDACTED]. The facility notified the police department and substantiated the SRI. Review of the ALPN #50's statement dated 12/10/17 revealed she was the nurse assigned to the back skilled and memory care unit for night shift scheduled 12/09/17 from 7:00 P.M. through 7:00 A.M. on 12/10/17. On 12/09/17 at approximately 10:00 P.M., the nurse finished passing medications to the residents on the back skilled hallway and left to go to the memory care unit. On 12/11/17 at approximately 2:00 A.M. to 2:20 A.M. a State tested Nurse Aide (STNA) from the skilled unit informed her that an unspecified resident on the back skilled unit was requesting a pain pill. On 12/11/17 at approximately 2:30 A.M. the nurse attempted to open the back hall skilled unit medication cart to retrieve medications for that resident but the key would not turn and was sticking. She revealed she was wiggling the key in the lock and pushing on the drawers to the cart and noticed one drawer was not completely closed and was slightly ajar. She tried to push the drawer closed but it would not close, so she pulled on the drawer and the drawer and the lock both popped open. The key was then able to turn in the lock with ease. She also noticed the lock box for the controlled substances had not latched completely and was slightly ajar. She revealed she shut the lock box completely. She said when she finished getting the resident's medications she pushed each drawer closed tightly to ensure they were closed and locked the cart. No other staff or resident were present in the hallway at that time. Around 4:00 A.M. she returned to the skilled unit hall to put away the medications she received from the pharmacy and she also had some residents in the hallway asking for as needed (PRN) medications. While attempting to give one of the residents his [MEDICATION NAME] she noted there was a card of 17 [MEDICATION NAME] five mg. pills missing. She then went through the lock box to verify medications with the log book and saw there was one other card missing of six [MEDICATION NAME] five mg. pills. This totaled 23 [MEDICATION NAME] 5 mg. pills missing from the narcotic box. She stated she got the other nurse and told her what was going on and asked her to verify the medications with her and to help her look through the cart to be certain. They verified the two cards with a total of 23 pills were missing from the cart. The aides had told us that Resident #1 and #8 had been up all night and had been acting strange and Resident #8 had removed several small bags of trash from both their rooms. RN #10 and herself decided to check the trash that was removed from the unit. One of the missing cards was retrieved from a bag of trash that was removed from Resident #1's room. Review of RN #10 statement dated 12/12/17 revealed Resident #8 told the nurse that Resident #1 stole two cards of [MEDICATION NAME] pills. Resident #8 stated Resident #1 came to him on 12/10/17 during the night and Resident #1 stated that he noticed the back hall skilled unit medication cart did not lock all the way. Around 2:00 A.M., Resident #1 told Resident #8 again that the medication cart was not locked all the way and he planned to steal some pain medications. Resident #8 stated that he blocked an STNA's view while Resident #1 stole the pain medications and he saw Resident #1 take two cards of [MEDICATION NAME] pills. Resident #8 stated that Resident #1 gave him four [MEDICATION NAME] pills. A few hours later Resident #8 asked Resident #1 for more pills and Resident #1 stated that there were not any pills left and Resident #1 stated he took them all. Resident #8 stated he felt he needed to tell the truth to staff because he was concerned about how sick Resident #1 looked and was worried about him. Review of the hospital report dated 12/11/17 revealed Resident #1 was diagnosed with [REDACTED]. The hospital report indicated the resident had received a dose of [MEDICATION NAME] during transportation to the emergency room (ER) and upon arrival to the ER the resident received another four mg. intravenous (IV) [MEDICATION NAME] and his pupils were consistent with opioid overdose. It was noted the IV [MEDICATION NAME] administration had a positive effect on the resident's health. Review of the pharmacy's invoice dated 12/11/17 revealed both carts were in working order. Back skilled cart narcotic box had a problem when the narcotic medication card was slid to the front of the narcotic box. Interview with RN #10 on 12/27/17 at 11:18 A.M. revealed Resident #8, upon returning from the hospital, told her he noticed Resident #1 was not looking too good so he decided to tell the truth to the RN that Resident #1 took those pills. Resident #8 had revealed Resident #1 told him that he noticed the lock on the medication cart was not fully engaged and that was how he was going to steal the narcotics. Resident #8 admitted to consuming four of the [MEDICATION NAME] pills that Resident #1 stole from the medication cart. Interview with UM #100 on 12/27/17 at 11:45 A.M. revealed at approximately 6:00 A.M. she received a call from ALPN #50 who was working for the facility on 12/10/17 regarding missing medications from the medication cart for the back hall skilled unit. The ALPN stated the medication cart must not have been secured properly because it didn't appear the cart had been tampered with or that a forced entry into the cart had occurred. The UM advised the ALPN that no one was to leave the building. The nurses and STNAs that worked on the skilled unit were drug tested prior to leaving the facility and they all came back as negative findings for any opioids in their systems. Interview with Police Detective #400 on 12/28/17 at 10:03 A.M. confirmed charges were being made against Resident #1 and Resident #8. She also revealed Resident #1 remained at the hospital. Interview with RN #10 on 12/28/17 at 11:00 A.M. revealed the bottom drawer of the back hall skilled unit medication cart did not always close all the way. She revealed if you did not push that bottom drawer in all the way, it would still look like the cart was locked. However, the cart would not be locked as the lock was able to be pulled back out. RN #10 also revealed she had told her unit manager (UM #100) in passing about this concern but there was never a formal report made. Interview with Contract Pharmacy Agent (CPA) #200 on 12/28/17 at 11:40 A.M. revealed he received a phone call from this facility on 12/27/17 at 7:00 P.M. stating they had an issue with a medication cart lock and the narcotic box inside the medication cart and the locks were sticking. He revealed at approximately 8:30 P.M. the same day he dispatched a technician out to the facility and he replaced the core key elements in the narcotic box and on the skilled unit medication cart. Interview with ALPN #50 on 12/28/17 at 4:30 P.M. confirmed her statement of events on 12/10/17. She stated she did not get any orientation and was not told anything about how to work the skilled unit medication cart. She stated the cart and even the narcotic box did jam. ALPN #50 stated if she would have known about it she would have made sure to lock it properly. She stated that you had to push down completely for it to catch and lock properly and noticed the key got jammed during her shift that night on 12/09/17; stated that she had to yank both drawer and narcotic box to get it opened. She confirmed that she did not feel the medication cart appeared to be tampered with. She revealed RN #10 came on the next morning and revealed she had the same issues with the medication cart. ALPN #50 stated again that she wished that RN #10 would have told her that when she had started her shift. She revealed ultimately it was her mistake and that she was ultimately responsible to ensure the cart was locked. Review of the facility policy titled Storage and Expiration of Medications, Biologicals, Syringes and Needles dated 12/01/07 revealed the facility did not follow their policy. The facility policy stated the facility was to ensure that all medications and biologicals, including treatment items, were securely stored in a locked cabinet/cart or locked medication room that was inaccessible by residents and visitors. This deficiency substantiates Master Complaint Number OH 257 and Control Number OH 108.

Based on medical record review, staff interview, physician interview and policy review, the facility failed to timely and adequately respond to Resident #85's increased extremity [MEDICAL CONDITION] (swelling) and severe weight loss. This resulted in actual harm when Resident #85 experienced a weight gain of 28.2 pounds or 20.58 percent (%) in less than two months and the resident was subsequently hospitalized for [REDACTED].#85) out of three residents reviewed for [MEDICAL CONDITION]. The facility identified 18 residents with significant [MEDICAL CONDITION]. Facility census was 77. Findings included: Record review for Resident #85 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the most recent 30 day minimum data set (MDS), dated [DATE] revealed Resident #85 was moderately impaired cognitively. He required limited assistance with bed mobility, transfers, locomotion, toilet use and personal hygiene. He required extensive assistance with dressing and bathing. He was supervised with meals. He was occasionally incontinent. The MDS also revealed Resident #85 has experienced a weight gain of 5% or more in the last month or 10% or more in the last six months and the resident does not receive diuretics. According to a discharge MDS Resident #85 was discharged to the hospital on [DATE]. Review of Resident #85's care plan written on 03/01/17 revealed the resident has short of breath, [MEDICAL CONDITION] and on oxygen therapy. Resident is at risk for fluid overload. A nursing note, dated 03/31/17 at 10:00 A.M. revealed Resident #85 was up in the wheelchair. He was short of breath. His oxygen sat was 91%. The physician was notified and ordered labs, a chest x-ray and [MEDICATION NAME] due to pneumonia. The chest x-ray revealed moderate right lower lobe and moderate left lower lob pneumonia. There was also slight pleural effusion. The blood count revealed a red blood count of 2.98, hemoglobin of 7.0 and hematocrit of 22.9. Resident #85 was transfused with a blood product. A nursing note written on 04/02/17 at 5:20 P.M. revealed Resident #85's son called stating the resident called him indicating he needed to go to the hospital due to difficulty breathing. The nurse gave medications and a Nebulizer. Resident educated on taking off his oxygen and smoking. A nursing note dated 04/11/17 at 10:20 A.M. revealed Resident #85 had two plus (2+) [MEDICAL CONDITION] in his lower extremities with weeping and increase in girth. The physician was notified and labs were ordered. Daughter and resident was notified. The nursing note, dated 04/17/17 at 3:00 A.M. revealed [MEDICAL CONDITION] was noted to bilateral lower extremities, elevated while in bed. Will continue to monitor. There were only two nursing notes written related to the [MEDICAL CONDITION]. The next nursing note was written on 04/19/17 at 7:00 P.M. which simply said hospital. There were no further documentation. Review of the resident's physician orders [REDACTED]. The physician note dated 03/28/17 did not address the [MEDICAL CONDITION]. The note stated breath sounds were distant with scant rhonchi. Further review of the dietary progress notes revealed on 03/29/17, the thirty-day review, Resident #85's current weight was 150.2 pounds which reflected a significant weight gain of 8.1% since admission weight on 03/07/17 of 139 pounds. Weight gain at that time was listed as desirable due to increased intakes and supplements. The note on 03/31/17 stated per the nurse, the resident had swelling to legs contributing to weight gain. On 04/05/17 the Registered Dietician (RD) documented the April weight was 156.2 pounds on 04/04/17. This reflected a significant weight gain of 12.4% in thirty days. Weight gain was related to fluid. On 04/14/17, the RD documented the current weight reflects further weight gain with weight of 167.6 pounds and significant weight gain of 22.4 pounds and 15.4% in thirty days. Per the dietary progress notes the RD requested a re- weigh which was not obtained. Intakes over the last week were poor at 25%. Discussed with the Director of Nursing (DON). The DON stated the increase was from fluids; however, there was no documentation and/ or communication with the physician regarding the weight gain. Review of the medical record also revealed the family was not notified regarding Resident #85's weight gain. Review of an emergency room (ER) history and physical dated 04/18/17 revealed Resident #85 was seen in the ER for reports of worsening shortness of breath in the last few weeks with worsening on exertion and improvement with rest. The resident has [MEDICAL CONDITION] as well as [MEDICAL CONDITION] and uses oxygen. Resident #85 also was noted with 2+ [MEDICAL CONDITION] in the extremities. According to the assessment and plan Resident #85 has acute on chronic systolic heart failure with no plan for intravenous fluids as the resident has fluid overload. Resident #85 was given [MEDICATION NAME] (diuretic to remove fluid), his symptoms are improving and he was admitted for further evaluation and care. An interview with the Assistant DON (ADON) on 05/04/17 at 2:00 P.M. revealed he made the rounds with the physician and the Certified Nurse Practitioner (CNP). According to the ADON he remembers talking about the increasing [MEDICAL CONDITION] and was told to continue to monitor. The resident was seen by the either the physician or the CNP on 02/28/17, 03/03/17, 03/07/17, 03/10/17, and 03/28/17. The physician and CNP progress notes did not address Resident #85's weight gain or the [MEDICAL CONDITION]. An interview with the DON on 05/04/17 at 4:00 P.M. confirmed there was no documentation that Resident #85's physician and family were notified regarding the change of condition and the subsequent hospitalization . An interview with the DON by telephone on 05/08/17 at 1:59 P.M. revealed Resident #85 was admitted to hospital on [DATE] due to shortness of breath from [MEDICAL CONDITION]. The DON stated a liter of fluid was removed from the resident in the emergency room with [MEDICATION NAME]. She confirmed the weight gain was not adequately monitored and timely addressed to prevent the hospitalization . An interview with Resident #85's attending physician on 05/08/17 at 3:41 P.M. revealed he was called by the staff about the resident's shortness of breath, wheezing and [MEDICAL CONDITION] on 04/11/17 and he ordered labs and chest x-ray which unremarkable; however, the staff did not address the resident weight gain. The nurse called later and stated the resident was doing better and he also stated to council the resident about his smoking. He said he was to see Resident #85 on 04/18/17 but the resident was in the hospital related to the significant weight gain/ [MEDICAL CONDITION]. He stated he has been the medical director of the facility for less than one month and the previous physician group was providing the care to the resident. An interview with the DON on 05/08/17 at 4:11 P.M. revealed she was told by the social worker that Resident #85 had a liter of fluid removed by [MEDICATION NAME] in the emergency room . The chest x-ray in the ER showed [MEDICAL CONDITION] vascular congestion. She stated the facility had a weight change policy but it was mainly for weight loss. A facility policy titled Clinical Change in Condition dated 02/2016 was reviewed. According to the policy the interdisciplinary team strives to identify and manage all resident's that are experiencing changes in a resident that requires further investigation. Daily observations includes but is not limited to changes in the physical assessment (i.e.: cardiovascular, respiratory, mental status, neurological). Clinical care management includes routine assessment, evaluation, response to changes in clinical condition and communication with residents and/ or family/ responsible parties. Procedure includes but is not limited to assessing the resident, reviewing the medical record, review the condition with a Registered Nurse, contacting the physician and provide clinical date and information about the resident condition, documenting the notification and physician response in the resident medical record, initiating any new physician orders [REDACTED]. The policy did not specifically address weight gain as a change of condition. This deficiency substantiates Complaint Number OH 854.

Based on observation, review of medical record, staff interviews and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to provide preventative skin breakdown care, failed to provide physician ordered wound treatments and provided continuous monitoring of pressure ulcers. This resulted in actual harm when a pressure ulcer to the coccyx increased from a stage two to an unstageable ulcer when the facility failed to implement physician ordered treatments and provide continuous monitoring of the pressure ulcer. This also resulted in actual harm when a pressure ulcer to the right heel was not monitored for approximately two months resulting in an unstageable pressure ulcer to the right heel. This affected one (#33) of two residents reviewed for pressure ulcers. The facility identified five residents currently with pressure ulcers. The facility census was 81. Findings include: Review of Resident #33's medical record revealed an admission a date of 03/01/13, with [DIAGNOSES REDACTED]. Resident #33's brief interview for mental status score (BIMS) was 4, indicating severe cognitive impairment. 1. Review of facility wound documents titled Weekly Pressure Injury Report Worksheet dated 09/04/16, revealed a stage two pressure ulcer to the coccyx was first identified and measured 2.5 centimeters (cm) x 3.0 cm x 0.1 cm on 09/07/16 and was documented as being in-house acquired. On 10/01/16 through 10/08/16 the coccyx wound was documented as a stage two measuring 1.2 cm x 1 x 0.1 cm. On 10/09/16 through 10/15/16 the pressure ulcer was a stage two measuring 3 cm x 2 cm x 0.1 cm. On 11/14/16 through 11/20/16, the pressure ulcer was documented as being unstageable due to slough and had a small amount of foul smelling drainage. The pressure ulcer now measured 4 cm x 2 cm x 0.4 cm. Review of a facility document titled Skin Grid for Pressure Injury dated 12/13/16 documented the pressure ulcer to the coccyx as being a stage three and measured 3 cm x 2 cm x 0.6 cm. On 12/20/16, the pressure ulcer was documented as being stage three, measuring 2.4 cm x 2 cm x 0.1 cm. Review of a physician order [REDACTED]. Review of a physician order [REDACTED]. No documentation of the dressing being changed on 10/23/16, 10/26/16, 11/07/16, 11/10/16, 11/16/16 was in these TAR's. Review of a new physician order [REDACTED]. Review of the TAR for November and December 2016 was completed. There was no documentation for this treatment being completed on 11/21/16, 11/22/16, 11/23/16, 11/24/16, 11/25/16, 11/28/16, 12/04/16, 12/08/16, 12/09/16 and 12/11/16 was in these TAR's. Review of a new physician order [REDACTED]. Review of the TAR for December 2016 was completed. There was no documentation of the treatment being completed was documented on 12/141/6 and 12/16/16. The treatment was documented as being completed only once a day on the following dates: 12/15/16, 12/17/16, 12/18/16, 12/19/16 and 12/20/16. 2. Review of the wound document titled Weekly Pressure Injury Report dated 10/09/16 though 10/15/16 revealed a pressure ulcer to the right heel. The pressure ulcer measured 3 cm x 2.5 cm x 0.3 cm. There was no documentation of a date identified, stage or acquired status. There was no additional documentation in the medical record of this wound until 12/13/16. Review of the wound document titled Skin Grid for Pressure Injury dated 12/13/16, revealed the pressure ulcer to the right heel was documented as first being identified 12/13/16, measuring 1.2 cm x 3.8 cm and unstageable due to necrotic tissue. The pressure ulcer to the right heel was documented 12/20/16 as increasing in size to 2.5 cm x 3.5 cm and being unstageable due to necrosis. Review of a physician order [REDACTED]. Review of a physician order [REDACTED]. Review of the TAR for December 2016 was completed. There was no documentation of the treatment being completed on 12/14/16 and 12/16/16. The treatment was documented as being completed only once a day rather than twice daily as ordered on the following dates: 12/15/16, 12/17/16, 12/18/16, 12/19/16 and 12/20/16. Review of a physician order [REDACTED]. There was no documentation of the treatment being completed on 12/14/16 and 12/16/16. The treatment was documented as being completed once a day rather than twice daily as ordered on the following dates: 12/15/16, 12/17/16, 12/18/16, 12/19/16 and 12/20/16. Interview on 12/20/16 at 8:15 A.M. with Registered Nurse (RN) #4 verified the dates listed above did not have the treatments completed as the physician order. RN #4 stated she changed the dressing on 12/15/16, she initialed and dated the dressing. When RN #4 returned to work on 12/17/16 and changed the dressing, it was still the dressing she had placed on 12/15/16 with her initials and date. Observations on 12/20/16 at 2:07 P.M. revealed RN #4 and RN #49 were providing wound care for Resident #33. Observation of the right heel pressure ulcer revealed a necrotic wound bed and dry skin flap was observed. RN #49 measured the wound as 2.5 cm x 3.3 cm with no depth. RN #49 identified the wound as unstageable. A coccyx wound was observed to be a red wound bed and measured 2.4 cm x 2 cm x 0.1 cm. RN #49 identified the wound as a stage three. Treatments were completed as ordered. Observation on 12/21/16 at 9:57 A.M. of Resident #33, revealed he was in bed, awake, without moon boots on bilateral feet. The moon boots were observed on the bedside table. Interview on 12/21/16 at 10:05 A.M. with the Director of Nursing (DON) verified Resident #33 did not have the moon boots. The DON verified the presence of moon boots at the bedside. The DON also confirmed during this interview that wound treatments were not being completed as ordered for Resident #33. The DON verified Resident #33's coccyx wound and the right heel wounds both increased in stages and size. Information from the NPUAP (www.npuap.org) was reviewed. According to the NPUAP pressure ulcers should be assessed initially and re-assessed at least weekly which should include the location of the wound, stage, size, tissue type, color, periwound condition, wound edges, sinus tracts, undermining, tunneling, exudate and odor. The NPUAP indicates the pressure ulcer should be managed on a regular basis. The NPUAP defined a Stage 2 pressure ulcer as a partial- thickness loss of skin with exposed dermis, the wound bed is viable, pink or red, moist, and adipose (fat) tissue is not visible and deeper tissues are not visible. A Stage 3 pressure ulcer is defined as full- thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/ or eschar, undermining and tunneling may be visible or present with Stage 3 pressure ulcers; however, if slough or eschar obscures the extent of tissue loss the pressure ulcer should be classified as an Unstageable Pressure Ulcer. An Unstageable Pressure Ulcer is defined by the NPUAP as obscured full- thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If the slough or eschar is removed from the Unstageable Pressure Ulcer, a Stage 3 or Stage 3 pressure ulcer will be revealed. This citation substantiates Master Complaint Number OH 495.

Based on medical record review, review of a death certificate, staff interview, physician interview, nephrologist interview, and review of a facility policy, the facility failed to appropriately monitor and seek timely medical attention when a resident experienced a significant change in condition. This resulted in Immediate Jeopardy when facility staff failed to provide emergent medical intervention for Resident #20 who began experiencing shortness of breath as evidenced by the use of accessory muscles to breathe and exhibited abnormal vital signs which included an elevated blood pressure, pulse, and respirations. Subsequently, Resident #20 was found without a pulse and respirations, the resident did not respond to resuscitative measures, and was pronounced dead at the facility. This affected one (#20) of ten residents reviewed for deaths. The facility identified ten residents who passed away in the past six months that were not receiving Hospice services. The facility census was 78. On [DATE] at 4:55 P.M., the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Registered Nurse (RN) Corporate Director of Nursing Services #100 were notified Immediate Jeopardy began on [DATE] at 1:00 A.M. when Resident #20 experienced respiratory distress and received no medical intervention. Resident #20's physician was paged and the nurse was awaiting a return call from the physician on [DATE] at 1:00 A.M. Resident #20 was assessed on [DATE] at 2:00 A.M. and 3:30 A.M. with continued signs of distress as the resident continued to use accessory muscles for breathing. The physician did not return the phone page and subsequently Resident #20 was found on the floor without a pulse or respirations on [DATE] at 6:55 A.M. Resident #20 was provided with cardiopulmonary resuscitation (CPR); however, the resident did not respond to the CPR and was pronounced dead at the facility. The Immediate Jeopardy was removed on [DATE] when the facility completed all staff in-service training regarding appropriate response to a change in a resident's condition and implemented the following corrective actions: · On [DATE] at 7:00 P.M. the DON, RN #111 and Minimum Data Set (MDS) Nurse #114 began immediate in-service training for all departments regarding the appropriate response when a resident demonstrates a change in condition. The in-service included the following: assessments, observations, appropriate intervention, physician notification, obtaining emergent care, calling 911 for emergency medical conditions, documentation of the condition change and intervention, tracking laboratory (lab) values, physician notification of lab values, and obtaining physician follow-up when a resident exhibits a significant change in condition. The in-service training was completed on [DATE] at 7:00 P.M. with all staff. · On [DATE] at 8:00 P.M., the DON implemented medical record audits regarding the timeliness of physician notification for residents with a change in condition in the past 30 days including appropriate intervention and documentation. The audits were completed on [DATE] at 5:45 P.M. and there were no identified concerns. · On [DATE], the DON/designee implemented medical record audits during the morning clinical meeting for any resident with a change in condition or lab draw. The interdisciplinary team (IDT) will discuss and follow-up with any intervention as needed. Any concerns will be forwarded to the Quality/Assurance and Performance Improvement (QAPI) committee and the Medical Director for immediate follow-up. These medical record audits will be completed three times a week for four weeks, then randomly thereafter, to ensure timely and thorough follow through as well as documentation. · On [DATE] at 5:45 P.M., the DON implemented medical record audits for any death of a resident or critical lab values since [DATE]. This audit was completed on [DATE] at 5:00 P.M. and there were no identified concerns. · On [DATE] at 7:00 A.M., the DON implemented a daily tracking system to track labs in the morning clinical meeting to ensure timely completion and follow through, including documentation of physician notification. · During interviews on [DATE] between 11:50 A.M. and 2:06 P.M., Licensed Practical Nurse (LPN) #101, #102, and #110 verified they had received training prior to working on [DATE] regarding notification of change, contacting 911 for emergent resident conditions when the physician could not be reached, and appropriate documentation. · During interviews on [DATE] between 1:17 P.M. and 1:51 P.M., LPN #109, #110, and #115 verified they had received training prior to working on [DATE] regarding critical lab processing and documentation of physician response. · On [DATE], review of the medical records of nine residents (#1, #12, #13, #14, #15, #16, #17, #18 and #21) additional non-Hospice related deaths revealed facility staff had responded appropriately and physician notification was timely. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan to ensure on-going compliance. Findings include: Review of Resident #20's medical record revealed an admission date of [DATE] after an acute hospital stay status [REDACTED]. [DIAGNOSES REDACTED]. The medical record revealed Resident #20 was a Full Code resuscitative status. Review of Resident #20's admitting physician's orders [REDACTED]. Review of Resident #20's admission MDS dated [DATE] revealed the resident had no impairment in cognition. According to the MDS, Resident #20 required limited assistance for bed mobility, transferring, walking, locomotion on the unit, dressing, and toileting and the resident required extensive assistance for locomotion off the unit and personal hygiene. The MDS documented the resident was not experiencing any shortness of breath and did not have a condition or chronic disease that may have resulted in a life expectancy of less than six months. Furthermore, the MDS documented Resident #20 was participating in physical therapy and occupational therapy, and the resident was expected to be discharged to the community. Review of the medical record revealed Resident #20 was seen by Nephrologist #112 on [DATE] at 10:45 A.M. for follow up of [MEDICAL CONDITION] stage five with some nausea. Resident #20 returned to the facility on [DATE] at 11:35 A.M. with various lab orders that were previously ordered prior to the appointment and included a basic metabolic profile (BMP) and a complete blood count with differential (CBC). Review of the lab results revealed Resident #20 had a BMP and CBC drawn on [DATE] at 8:15 A.M. prior to the appointment with Nephrologist #112. The lab results were completed on [DATE] at 3:35 P.M.; however, the labs were not finalized and reported to the facility until [DATE] at 4:06 P.M. via facsimile (fax) timestamp. The BMP and CBC results showed a critically low carbon [MEDICATION NAME] level of seven (normal ,[DATE]), critically low calcium of 5.8 (normal 8XXX,[DATE].2), critically high blood urea nitrogen (BUN) of 127 (normal ,[DATE]), and critically high creatinine of 20.8 (normal 0XXX,[DATE].3). The bottom of the laboratory slip was initialed on [DATE]. Interview with the DON on [DATE] at 3:00 P.M. revealed the initials belonged to a Nurse Practitioner. Review of the nursing notes revealed an untimed note dated [DATE] indicating RN #113 called Medical Director #107 and informed him of the resident's critical lab values. Medical Director #107 instructed RN #113 to fax the results to Nephrologist #112 (the ordering physician). According to the nursing notes RN #113 documented, done. Review of the medical record revealed no fax confirmation indicating Nephrologist #112 received the lab results and there was no documentation indicating orders were received indicating how to proceed with the care of Resident #20 in response to the critical lab values. Review of nursing notes dated [DATE] at 1:00 A.M. documented Resident #20 was complaining of shortness of breath, the resident denied chest pain and had a blood pressure of ,[DATE] millimeters of mercury (mm Hg), pulse rate was 103 beats per minute, respirations were 28 breaths per minute, and a pulse oximetry (a non-invasive test used to measure the oxygen level or oxygen saturation of the blood) reading of 100% on room air. Resident #20 was using accessory muscles to breath, lungs were clear throughout, and one-on-one with breathing exercises were ineffective. The physician was paged and the nurse was awaiting a call back from the physician. The next nursing note dated [DATE] at 2:00 A.M. documented the resident was asked how he was feeling, and the resident stated, A little better. The nurse encouraged pursed lip breathing at that time. At 2:00 A.M., Resident #20's blood pressure was ,[DATE] (mm Hg), pulse rate was 91 beats per minute, and respirations remained at 28 breaths per minute. Resident #20 continued to use accessory muscles to breath and a pulse oximetry was documented at 99% on room air. The nursing note documented the staff would continue to monitor. The next entry at 3:30 A.M. indicated the resident was sitting on the edge of the bed, leaned over the bedside table, and when Resident #20 was asked how he was feeling he stated I feel a little better, but still sick. At 3:30 A.M. Resident #20's blood pressure was ,[DATE] (mm Hg), pulse rate was 81 beats per minute, respirations were 22 breaths per minute, and a pulse oximetry was documented at 99% on room air. According to the nursing notes, Resident #20 continued to use accessory muscles to breathe at 3:30 A.M., and the staff would continue to monitor. Review of the medical record revealed there was no documentation regarding administration of Resident #20's as needed [MEDICATION NAME] nebulizer to treat the resident ' s shortness of breath or another attempt to contact the physician. There were no further nursing notes until [DATE] at 6:55 A.M. when State tested Nursing Assistant (STNA) #120 called for the nurse to come to Resident #20's room where he was observed lying on the floor on his left side with no respirations and no pulse. The nurse began chest compressions and the STNA called 911. At 7:08 A.M., the emergency medical squad (EMS) arrived and ran a cardiac rhythm strip which indicated Resident #20 was in asystole (without a heartbeat). On [DATE] at 7:11 A.M. the paramedic stated Resident #20's time of death was 7:11 A.M. and the next of kin and physician were notified. Review of Resident #20's death certificate dated [DATE] revealed the resident's immediate cause of death was acute [MEDICAL CONDITION] infarction. The death certificate listed subsequent conditions including [MEDICAL CONDITION] and [MEDICAL CONDITION]. Telephone interview with LPN #108 on [DATE] at 2:49 P.M. revealed she was Resident #20's nurse on [DATE]. LPN #108 stated the resident started complaining of feeling funny and not being able to catch his breath around 1:00 A.M. She stated the resident was really anxious. She could not recall if she gave the resident a breathing treatment. She also stated Resident #20 had been sick and unable to keep anything down. She further stated Resident #20 was so shaky and nervous, that she paged the on call physician which was Medical Director #107. LPN #108 stated she called the paging service twice and left two messages marked as urgent and the physician did not call back. LPN #108 stated Resident #20 was found on the floor in his room at shift change (approximately 7:00 A.M.) with no pulse and no respirations. LPN #108 stated the physician did call the facility on [DATE] at around 7:30 A.M.; however, the resident had already expired. LPN #108 stated she did not send Resident #20 to the emergency room because she did not have a physician's orders [REDACTED]. LPN #108 stated she was not sure if she could send a resident to the emergency room without a physician's orders [REDACTED].#20's change in condition. LPN #108 stated she was the supervisor that night and the resident did state he was feeling a little better and she thought he might have been having a panic attack. LPN #108 stated she really wishes she had called 911 and sent the resident to the emergency room and in the future she will always call 911 if she feels it is necessary and she has not received a call back from a physician. Telephone interview with Nephrologist #112 on [DATE] at 4:30 P.M. revealed he was not in the office and he could not remember specifically if he had received the results from Resident #20's blood work. Nephrologist #112 stated he had not signed any lab values with a carbon [MEDICATION NAME] level of seven (Resident #20's value on [DATE]). Nephrologist #112 stated Resident #20's carbon [MEDICATION NAME] level had been chronically low as he had not had [MEDICAL TREATMENT] for at least two months. When Nephrologist #112 was asked if he would have kept Resident #20 at the nursing home with the knowledge of the resident's critical lab values, he stated a carbon [MEDICATION NAME] level of seven would have made him nervous and he would have advised the facility to send the resident to the emergency room if he was having any symptoms, especially tachypnea (increased respirations greater than 20), to dialyze (the process of removing waste products and excess fluid from the body, which is necessary when the kidneys are not able to adequately filter the blood) the resident. Interview with RN #113 on [DATE] at 9:15 A.M. revealed she called Medical Director #107 to inform him of Resident #20's critical lab values. Medical Director #107 instructed her to fax the critical lab results to Nephrologist #112, as he ordered the labs. RN #113 stated she did fax the critical labs to Nephrologist #112 and she received a response the fax machine was busy and she then refaxed the labs. RN #113 verified she does not have confirmation the fax was transmitted and received by Nephrologist #112. RN #113 stated she did not speak with Nephrologist #112 and she received no further orders regarding Resident #20's critical lab values. Interview with Medical Director #107 on [DATE] at 11:22 A.M. verified he did receive a page from the facility the night of [DATE]; however, he was unable to determine if he called back to the facility or not. Medical Director #107 stated he would have called from his home phone that night and therefore does not have a record of the call. Medical Director #107 stated the nurses do have the latitude to call 911 if they feel it is necessary, even without a physician's orders [REDACTED]. If a nurse cannot reach one, they should call the other person on call. Medical Director #107 stated the facility will be working with the staff to ensure they are aware of what to do if they do not receive a call back from a physician in a timely manner. During a follow-up interview with Medical Director #107 on [DATE] at 11:58 A.M. revealed he had just spoken with Nephrologist #112. Medical Director #107 stated Nephrologist #112 reported he had looked for Resident #20's labs from [DATE] and was unable to locate them. Medical Director #107 indicated Nephrologist #112 stated he has had problems receiving labs from nursing homes. Medical Director #107 stated the facility wants to make some changes and improve processes, including ensuring Nephrologist #112's office has the same electronic access to labs as the facility, and Medical Director #107's practice does. Interview with the DON on [DATE] at 4:03 P.M. verified the facility did not have a specific lab policy, but referred to the Clinical Change in Condition Management policy for abnormal lab values. Review of a facility policy titled Clinical Change in Condition Management, dated ,[DATE], revealed a resident who is experiencing a change in condition should be assessed clinically and the resident's medical record should be reviewed including but not limited to: primary [DIAGNOSES REDACTED]. The physician should be contacted and provided with clinical data and information about the resident's condition. The policy further directs to document notification, and physician response in the resident's medical record.