Every finding on record at Orrville Pointe

Based on observations, interviews, medical record review, police reports, emergency medical services (EMS) run reports, hospital records, and review of facility Self-Reported Incidents (SRIs), the facility failed to provide adequate supervision and ensure effective systems were in place to prevent the elopement of two residents (#40 and #37) on multiple occasions, without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or negative health outcomes when on 06/27/26 at approximately 4:35 A.M., Resident #40, who had diagnoses including Alzheimer's disease and dementia, with a known history of exit seeking behaviors, exited the facility's secured/locked first floor unit through his room window without staff awareness. He walked approximately six miles and was located by local police at a gas station. Resident #40 was returned to the facility by a family member and was then transferred to the hospital for evaluation, where no injuries were identified. Upon his return to the facility, he was placed on 15-minute safety checks and was moved to the second floor secured/locked unit on 06/27/26 (room [ROOM NUMBER]) at approximately 11:58 A.M. for safety due to continued exit seeking behavior. The Immediate Jeopardy continued on 07/04/26, despite the 15-minute checks, when Resident #40 again eloped, from his second floor room by exiting through the window using a rope made from bed sheets. He fell to the ground approximately 20 feet, was assessed by facility staff, and transferred to the local emergency department. He was subsequently transferred to the main hospital for surgical intervention due to a broken ankle. Furthermore, the Immediate Jeopardy remained on-going on 07/22/26 at approximately 12:03 A.M. when Resident #37, who had diagnoses including schizoaffective disorder, delusional disorder, obsessive-compulsive personality disorder, dementia, anxiety, and impulse disorder, eloped from the facility by exiting the first floor secured/locked unit through her room window, without staff knowledge. She was located by police at her father's home approximately 13 miles from the facility. Facility staff returned Resident #37 to the facility, and she was placed on one-to-one (1:1) monitoring. This deficient practice affected two residents (#40 and #37) of three residents reviewed for elopement. The facility identified a total of 23 residents as being at risk for elopement.On 07/21/26 at 12:22 P.M., the Administrator, Interim Director of Nursing (DON) #200, [NAME] President of Operations (VPO) #202, and Clinical Manager #100 were notified Immediate Jeopardy began on 06/27/26 at 4:35 A.M., when Resident #40 exited the secured/locked first floor unit through his window without staff knowledge and was found by police 6.6 miles away from the facility. Resident #40 was returned to the facility by a family member, sent to the hospital for evaluation, and sent back to the facility the same day, placed on 15-minute checks, and had a room change to the second floor secured/locked unit for safety due to continued exit seeking behavior; however, he eloped again on 07/04/26 by exiting his second floor window using a rope made of bed sheets, sustaining an ankle injury requiring hospital treatment. Additionally, on 07/23/26 at 4:35 P.M., the Administrator, Interim DON #200, VPO #202, and Senior Administrator #199 were notified that Immediate Jeopardy remained on-going when Resident #37 eloped on 07/22/26, unknown to staff, through her window and was found by the police approximately 13 miles away from the facility at her father's home. Resident #37 was returned to the facility by staff, evaluated, and placed on 1:1 monitoring.The Immediate Jeopardy was removed on 07/27/26, when the facility implemented the following corrective actions:-On 06/27/26 at 4:45 A.M., facility staff were notified by local law enforcement Resident #40 had been located at a nearby gas station. Facility administration was notified of the elopement and immediately initiated an internal investigation. Licensed Practical Nurse (LPN) #113 completed a head count of all first floor residents, confirming all remaining residents were present and accounted for.-On 06/27/26 at 5:10 A.M., Maintenance Director #163 assessed Resident #40's room and evaluated the point of elopement.-On 06/27/26 at 5:36 A.M., EMS transported Resident #40 to a local hospital for evaluation.-On 06/27/26 at 7:00 A.M., Resident #40's Power of Attorney (POA) was notified of the elopement and immediate interventions being implemented.-On 06/27/26 at 10:00 A.M., all first floor resident room windows were secured to prevent unauthorized resident exits.-On 06/27/26 at 11:52 A.M., Resident #40 returned to the facility at baseline with no new injuries, no new treatments, and no new physician orders.-On 06/27/26 at 11:59 A.M., Resident #40 was returned to room [ROOM NUMBER], his previous room prior to being relocated to the first floor, as an immediate safety intervention. room [ROOM NUMBER] had been secured during a facility environmental safety initiative in April 2026.-On 06/29/26, a root cause analysis was completed, identifying Resident #40's leave of absence with family on this day and change in routine as potential contributing factors to the elopement.-On 06/29/26 through 07/01/26, the Interdisciplinary Team (IDT) implemented ongoing monitoring to evaluate the effectiveness of the interventions and reduce the risk of future elopement.-On 07/01/26, Resident #40's care plan was reviewed and revised to include increased supervision, environmental modifications, and ongoing behavioral monitoring.-On 07/04/26 at 11:30 P.M., Resident #40 was sent out by facility nursing staff to the local acute care hospital for assessment. Resident #40 did not return to the facility and was discharged from the facility on 07/07/26.-On 07/22/26 at 12:00 P.M., the facility implemented two levels of resident monitoring based on each resident's assessed risk and potential for a negative outcome:-Increased supervision: documented checks every 15 minutes.-Continuous supervision: one-to-one staff supervision for residents determined to be at high risk for elopement or another serious negative outcome.-On 07/22/26 at 1:00 P.M., the Resident Elopement Binder was updated by Interim DON #200.-On 07/22/26 at 1:00 P.M., Interim DON #200 completed elopement risk assessments for all Residents. A total of 23 residents were identified as being at risk for elopement (#1, #5, #9, #10, #14, #15, #16, #17, #18, #19, #22, #23, #24, #25, #28, #29, #30, #31, #32, #33, #34, #37, and #38).-On 07/22/26 at 1:00 P.M., education on Elopement Policies covering risk and response protocols was sent out to all facility employees using the online education system (OES) by the Administrator.-On 07/22/26 at 1:00 P.M., education titled Inservice Education Resident Supervision was provided to all nursing staff on the facility's two-system protocol of resident supervision; documentation requirements for 15-minute checks and one-on-one monitoring was sent out to all employees using the OES by the Administrator. As of 3:49 P.M. on 07/27/26 all 20 nursing staff assigned this education have completed said education.-On 07/22/26 at 1:00 P.M., education on Elopement Protocols was provided to the Administrator and Interim DON #200 by Senior Administrator #199.-On 07/22/26 at 2:00 P.M., education on 15-minute checks and one-on-one supervision protocol was sent out to all facility staff using the OES by the Administrator. Education included the Certified Nursing Assistant (CNA) assigned to the resident (on frequent or continuous checks) will be responsible for completing and documenting the checks. The nurse assigned to the floor will review and sign off the frequent or continuous check forms during each shift, to ensure complete documentation and compliance with the stated safety protocol(s).-On 07//22/26 by 2:00 P.M., forms for frequent (15-minute) and continuous (one-on-one) checks were updated and implemented by the Administrator.-On 07//22/26 by 2:00 P.M., baseline supervision levels for all 23 residents identified to be at risk for elopement reside on a secure unit are ensured through adequate staffing levels and building security.-On 07/22/26 by 2:00 P.M., all 23 residents at risk of elopement were assessed a second time by Interim DON #200 and no further concerns were noted.-On 07/22/26 by 2:00 P.M., Interim DON #200 verified all care plans for the 23 residents at risk for elopement reflected the current/accurate elopement risk.-Beginning 07/22/26, all resident-accessible windows will be audited weekly times (x) 4 weeks to ensure resident safety. Audits will be performed by the Administrator and/or his designee and documented accordingly, to include auditor name, date and the time the audit was performed. To ensure ongoing compliance, random window audits will continue monthly x 4 months; audits will be documented accordingly. Audits will be forwarded to the Administrator monthly for tracking, trending, and analysis. Reports will be presented to the Quality Assurance and Performance Improvement Committee (QAPI) for any follow-up measures and/or actions, as identified necessary. The Administrator will be responsible for ensuring ongoing compliance, with the support of Director of Maintenance #163.-Beginning 07/22/26, the Administrator and DON will review and sign all frequent and continuous check forms weekly x 4 weeks.-On 07/23/26, Resident #37 eloped from the facility. At 3:30 A.M., Resident #37 was returned to the facility and was placed on one-on-one supervision, assigned by Interim DON #200. One-on-one supervision would remain in place until further notice.-On 07/23/26 by 9:00 A.M., Maintenance Assistant #164 re-secured all resident accessible windows throughout the facility; 39 windows on the first floor and 67 windows on the second floor (106 total windows). Window fasteners were installed so that windows cannot be opened.-On 07/23/26 by 2:30 P.M., the Administrator physically tested and verified that the window restriction was functioning and could not be readily defeated by a resident.-On 07/23/26, Elopement Drills will be conducted by Maintenance Director #163 and the Administrator on all shifts (First, Second and Third). The drills will be documented on the facility elopement documentation form.-On 07/23/26 at 4:00 P.M., an ad hoc QAPI meeting was conducted by Senior Administrator #199. The Administrator, VPO #202, Senior Administrator #199, Interim DON #200, Human Resources (HR) #102, Social Service Director (SSD) #101, and Registered Nurse (RN) #203 were in attendance.-Starting 07/23/26 at 4:00 P.M., audits on elopement protocol and resident supervision will be completed by the Administrator and/or their designee weekly x 4 weeks. Audits will include a review of all 15-minute checks and one-on-one forms to ensure compliance.-On 07/27/26, DON #303 (from a sister facility) reviewed and updated Resident #37's care plan to include, but not limited to, her elopement event(s), and current intervention(s) to ensure safety.-On 07/27/26, all facility staff are receiving supplemental education titled Elopement and Resident Supervision Education related to the facility's elopement and prevention response program. The supplemental competency is being provided by the Administrator and Senior Leadership team. Education competency included what constitutes an elopement, recognition of exit-seeking behaviors and early warning signs, immediate staff response and intervention, resident supervision requirements, documentation requirements, actions to take when a resident cannot be located, and staff responsibilities under the facility's Elopement Policy. Staff who have not completed the education will be provided said education upon their return to work. All staff education is being administered by the Administrator and Interim DON #200 with the support of the Senior Leadership team. The Administrator is responsible for ensuring all staff education is complete and comprehensive. As of 3:27 P.M. on 07/27/26, 83 of the 91 assigned facility staff have completed the Elopement and Resident Supervision Education.-On 07/27/26, the comprehensive care plans for the 23 residents identified as at risk for elopement were reviewed by DON #303 to ensure care plans contain individualized and actionable interventions. Care plans will address, as applicable: Resident-specific triggers for exit-seeking behavior, known patterns or times when behaviors are more likely to occur, resident preferences and interests, effective approaches for redirection and de-escalation, appropriate supervision needs, and staff interventions to be implemented when exit-seeking behavior is observed. Frontline staff will be asked for input regarding residents' behaviors, preferences, triggers, and effective interventions to ensure care plans reflect the resident's current needs. Residents demonstrating new or increased exit-seeking behavior will be reassessed, and the care plan will be updated, as appropriate. Elopement care plans will be available to all staff for reference and review and will be located in the elopement binders. Binders are located on each nursing floor at the nursing stations, with a third elopement binder located at the front desk.-Starting on 07/27/26 at 4:00 P.M., audits on elopement education and resident supervision will be completed by the Administrator and/or their designee weekly x 4 weeks. Three (3) staff members will be interviewed and quizzed on Elopement Protocol and Resident supervision.-All education and audits will be referred to and reviewed by the facility Inter Disciplinary Team (IDT) and the QAPI committee. The facility IDT team meets weekly on Thursday at 12:30 P.M. The next meeting will be held on 07/30/26. Formal review will be conducted quarterly by the QAPI committee.Although the Immediate Jeopardy was removed on 07/27/26, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure ongoing compliance. 1. Review of Resident #40's closed medical record revealed an admission date of 10/04/22 and a discharge date of 07/07/26. Resident #40's diagnoses included but were not limited to Alzheimer's Disease with late onset, major depressive disorder recurrent severe with psychotic symptoms, amnestic disorder, tobacco use, impulse disorder, schizoaffective disorder, anxiety disorder, dementia with other behavioral disturbance, alcohol dependence, and pyromania. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 had severe cognitive impairment and was independent with ambulation. Review of the care plan dated 05/18/26 revealed Resident #40 was an independently mobile and resident that had an episode of leaving the facility because he thought it was time to smoke. Resident #40 was unaware of safety needs related to dementia, and history of alcoholism. Interventions initiated on 06/28/26 included the resident placed on 15-minute safety checks and on 07/01/26 (although implemented on 06/27/26) an intervention to move resident to second floor due to safety concerns. Review of Resident #40's elopement assessment dated [DATE] revealed an elopement assessment was completed for a significant change and Resident #40 was at risk for elopement. Review of the Physician orders dated 06/07/26 at 7:00 A.M. revealed an order for 15-minute safety checks every shift for one day. The medical record did not contain evidence of a significant change in the resident's status or to the reason safety checks were needed. Review of Resident #40's physician orders for June 2026 revealed an order starting 06/27/26 at 3:00 P.M. for 15-minute safety checks until further notice due to elopement. Review of the Police Report, authored by Police Officer (PO) #300, revealed on 06/27/26 at 3:50 A.M. he was assigned a call from a gas station regarding two individuals who arrived at the same location but from separate locations with altered mental status. PO #300 was enroute at 3:51 A.M. and arrived on the scene at 4:18 A.M. The male, Resident #40 was able to leave the rehabilitation facility unnoticed. Store Clerk (SC) #301 reported there was a man walking around in front of the gas station acting suspicious. PO #300 reported upon arrival Resident #40 was standing near the front doors of the gas station. PO #300 reported while speaking with Resident #40 he appeared confused, paranoid, and not able to answer his questions either fully or correctly. PO #300 was able to eventually get Resident #40's daughter's name and number and she was called and arrived on the scene. Resident #40 indicated he knows when change of shift is and after change of shift at approximately 10:00 P.M. he snuck out of his window through a screen door and then walked all the way from the nursing home to the gas station. After speaking with Resident #40, PO #300 contacted his daughter to verify what he was told. Resident #40's daughter corroborated he does reside at the nursing home, but she was very upset to find out the facility was not able to keep an eye on him and he was able to escape from the facility. PO #300 contacted the nursing facility and spoke with Licensed Practical Nurse (LPN) #113, who was the nurse on duty on the floor where Resident #40 resided. PO #300 reported when he asked if Resident #40 stayed at the nursing home, LPN #113 indicated he did and that Resident #40 was currently asleep in his bed and PO #300 informed her that was not true, he was with him at the gas station. PO #300 reported at that point, LPN #113's demeanor appeared to change on the phone, and she seemed a little nervous or scared. PO #300 informed LPN #113 Resident #40's daughter arrived on the scene and would transport him back to the nursing facility. PO #300 reported at that point LPN #113 asked him if he would have a conversation with Resident #40's daughter to try and calm her down because she knew she would be upset and arriving at the facility and the conversation would not be pleasant. PO #300 requested the case be forwarded to Adult Protective Service in hope they would follow up with Resident #40 and the nursing home to see how he was able to escape their facility and be gone for several hours without them knowing. Review of the facility SRI, revealed on 06/27/26 at approximately 4:45 A.M., Administrator was notified by staff of Resident #40's elopement. Staff reported local law enforcement had located Resident #40 at a gas station at approximately 4:35 A.M. and an investigation immediately was initiated. Resident #40 was returned to the facility by his Power of Attorney (POA)/daughter and then was sent to the local hospital for evaluation and returned to the facility on [DATE]. Upon return to facility, Resident #40 was placed on 15-minute safety checks, and his room was relocated from the first floor secured/locked unit to the second floor. Maintenance Director #163 completed an inspection of all first-floor resident room windows to verify proper function and security. Review of the EMS report dated 06/27/26 at 05:36 A.M. for Resident #40 revealed the resident escaped from the lockdown unit of a psychiatric nursing home. According to staff, they were totally unaware Resident #40 had escaped. Resident #40 was alert and able to follow commands and transported to the local hospital for evaluation. Review of the progress note dated 06/27/26 timed at 06:20 A.M. authored by LPN #113 revealed at approximately 04:45 A.M. Resident #40 had eloped from the first floor secured/locked unit after climbing out of his bedroom window and law enforcement contacted the facility and the resident stated he climbed out of his window and arrived at the gas station. Administrator and appropriate leadership staff were immediately notified, and a plan was implemented to reduce the risk of future elopement including additional window security measures and relocating Resident #40 to the second floor room upon his return from the hospital. Resident #40's POA was notified. Review of the facility document 15-Minute Surveillance Program, dated 06/27/26, revealed staff were required to record the resident's location and initial each entry. At 10:00 A.M., the form reflected Resident #40 was in his room and included staff initials. From 10:15 A.M. to 6:30 P.M., the form listed locations for the resident but contained no staff initials to verify monitoring. From 6:45 P.M. to 10:15 P.M., the form contained no documented resident locations and no initials. From 10:30 P.M. to 11:45 P.M., the form indicated RM with staff initials. The bottom of the form identified status post elopement as the reason for close observation; however, required sections for plan of care interventions, receptionist notification (for elopement risk), and documentation of the CNA (certified nursing assistant) report were left blank. Review of the progress noted dated 06/27/26 at 10:03 A.M. authored by LPN #118 revealed Resident #40 returned to the facility (from the hospital) and was alert and refusing to talk about the elopement. Resident #40 was immediately placed on 15-minute safety checks. Resident #40 was sitting in the common area, speaking to self, appeared agitated and continued to refuse to speak with staff. Resident #40's medical record lacked evidence of a reassessment for risk of elopement and additional interventions implemented to ensure resident's safety. Review of the progress note dated 06/27/26 timed at 11:05 A.M. authored by LPN #118 revealed Resident #40 had behavior to include talking to self more than usual and was agitated upon return from hospital. Review of the progress note dated 06/27/26 timed at 11:34 A.M. authored by LPN #118 revealed Resident #40 was very exit seeking at this time, was frequently asking staff to let him out of the door and walking to the doors at the end of the hallway, much redirection was given and the resident remained very agitated with staff. Review of the progress note dated 06/27/26 timed at 11:58 A.M. authored by LPN #118 revealed Resident #40 was moved to room [ROOM NUMBER] for safety due to continued exit seeking. Review of the progress note dated 06/28/26 timed at 1:48 A.M. authored by LPN #129 revealed Resident #40 continued on 15-minute frequent checks due to his elopement behavior. Review of the facility document 15-Minute Surveillance Program, dated 06/28/26, revealed from 6:00 A.M. to 6:45 A.M. Resident #40 was documented as being in his room with staff initials present. From 7:00 A.M. to 8:30 A.M., the form contained only a downward arrow with no indication of Resident #40's location or staff initials. From 8:45 A.M. to 8:45 P.M., the form listed Resident #40's location but lacked staff initials to verify monitoring. From 9:00 P.M. to 11:30 P.M., the form again contained only a downward arrow with no documented location or staff initials. At 11:45 P.M., Resident #40 was documented as being in his room with initials present. The bottom of the form listed elopement on 06/27/26 as the reason for close observation; however, required sections for plan of care interventions, receptionist notification (for elopement risk), and the CNA report were blank. Review of the progress note dated 06/28/26 timed at 9:31 A.M. authored by LPN #126 revealed Resident #40 had behaviors to include wondering the halls and in peers' rooms. Review of the facility document 15-Minute Surveillance Program, dated 06/29/26, revealed the form was labeled the same as previous days but used a different layout. From 6:00 A.M. to 6:45 A.M., Resident #40 was documented as being in his room with staff initials present. The bottom of the form listed elopement on 06/27/26 as the reason for close observation; however, the sections for plan of care interventions, receptionist notification (for elopement risk), and the CNA report were blank. Review of the progress note dated 06/29/26 timed at 10:31 A.M. authored by LPN #122 revealed Resident #40 was observed getting on the elevator by staff and trying to enter the code to operate the elevator. The resident was assisted back onto the unit by staff. Resident #40 was currently pacing the hall. The facility would continue to monitor the resident. Review of the facility document 15-Minute Surveillance Program, dated 06/30/26, revealed the bottom of the form had the section for reason for close observation left blank. Additionally, the sections for plan of care interventions, receptionist notification (for elopement risk), and the CNA report were also blank. Review of the progress note dated 06/30/26 timed at 3:06 P.M. authored by LPN #122 revealed resident remained on 15-minute safety checks and was pacing the hallways at times. Review of the facility document 15-Minute Surveillance Program, dated 07/01/26, revealed from 12:00 A.M. to 6:15 A.M. the form was blank, with no documentation of Resident #40's location or staff initials to verify 15-minute monitoring. From 6:30 A.M. to 11:45 P.M., the resident's location and staff initials were documented. The bottom of the form listed Elopement as the reason for close observation; however, the sections for plan of care interventions, receptionist notification (for elopement risk), and the CNA report were blank. Review of the facility document 15-Minute Surveillance Program, dated 07/02/26, revealed from 12:00 A.M. to 5:45 A.M. the resident's location was documented with staff initials. From 6:00 A.M. to 11:45 A.M., the resident's location was recorded but staff initials were missing. The bottom of the form was blank, including the sections for reason for close observation, plan of care interventions, receptionist notification (for elopement risk), and the CNA report. Review of the facility document 15-Minute Surveillance Program, dated 07/03/26, revealed the resident's location and staff initials were completed throughout the form. However, the bottom of the form was blank, including the sections for reason for close observation, plan of care interventions, receptionist notification (for elopement risk), and the CNA report. Review of the facility document 15-Minute Surveillance Program, dated 07/04/26, revealed from 6:45 A.M. to 6:45 P.M., the resident's location was recorded but staff initials were missing. The bottom of the form identified status post elopement as the reason for close observation; however, the remaining required sections, including plan of care interventions, receptionist notification (for elopement risk), and CNA report, were blank. Review of the EMS report dated 07/04/26 with time unknown, revealed a mutual aid EMS squad responded to nursing home of a male, Resident #40, who fell approximately 20 feet from a second story window, and advised he wanted to watch fireworks. Resident #40 had an obvious lower leg/ankle fracture, we splinted with a [NAME] splint. Review of the EMS report dated 07/04/26 at 11:15 P.M. revealed they responded to Resident #40 who had fallen from a second story window and injured his leg. Prior EMS crew already splinted his leg with a [NAME] splint and stated his leg had a deformity right above the ankle that presented as a possible fracture. Resident reported he went outside and tried to climb out his window with a bedsheet. Resident #40 was transported to the hospital. Review of the SRI revealed on 07/04/26 at approximately 10:56 P.M. Administrator was notified by CNA #144 she and CNA #102 found Resident #40 outside on the ground when taking out the trash. Immediate investigation revealed Resident #40 was on 15-minute safety checks and had tied multiple bed sheets together and lowered them from his bedroom window and used them to descend the exterior wall of the building. Resident #40 had damaged the 3-inch metal window stoppers in his room, allowing the window to open far enough for him to exit. Staff secured Resident #40, assessed for injuries and the resident complained of pain in his right ankle. LPN #127 completed the nursing assessment and notified the physician, and the resident was transported to hospital for medical evaluation. A second floor head count was done and all other residents were present. Resident #40's POA was notified. Maintenance Director #163 responded to the facility at approximately 11:20 P.M. and secured all second-floor windows. Resident #40 remained hospitalized following the incident with a fractured right ankle. Review of the hospital emergency report dated 07/04/26 at 11:35 P.M. revealed Resident #40 had a chief complaint of fall and right ankle pain. The ER note revealed Resident #40 tried to repel down the outside of his building from the second floor and fell fifteen to twenty feet onto the ground and injured his right ankle and abrasion to his left arm. EMS put on a prehospital splint and brought him to the emergency department (ED). The ankle fracture was reduced and splinted and follow up x-rays revealed bones remain poorly aligned and the hospital recommended transfer to the main hospital for orthopedic surgery. Resident #40 was transferred to the main hospital on [DATE]. Review of the hospital admission records revealed on 07/05/26 at 8:28 A.M. Resident #40 was admitted to the hospital for orthopedic surgery. Resident #40 lives in a locked secured care until he had been trying to escape and recently tied bedsheets together and climbed out of a two-story window falling resulting in a right trimalleolar ankle fracture (a severe injury where the ankle breaks in three separate places, involving the lateral malleolus, medial malleolus, and posterior malleolus) and admission to the hospital under orthopedic surgery services. He underwent surgical right spanning external fixator placement on 07/05/26. Per Resident #40's POA this is the second time he eloped from the nursing home. Review of the history and physical dated 07/05/26 at 11:27 A.M. revealed Resident #40 had a significant instability of his right ankle with large posterior malleolus fragment and recommended external fixator placement spanning his ankle. Resident #40 and the POA understood this is one of two surgeries that need done. Resident #40 was discharged on 07/10/26 at 2:41 P.M. to another nursing facility. Interview on 07/16/26 at 1:49 P.M. with Resident #40's POA confirmed she received a call on 06/27/26 around 4:30 A.M. from police informing her Resident #40 was at the gas station. Resident #40's POA reported he eloped again on 07/04/26 and broke his ankle and had to have surgery. Resident #40's POA reported the physician told her this was the first of two surgeries he will need to have, and he will have to learn to walk again, and it will be a long recovery. Interview on 07/20/26 at 3:16 P.M. with LPN #113 revealed she was the nurse assigned to Resident #40 on 06/27/26 when he eloped from the facility. LPN #113 reported she received a call from the police that he was gone. LPN #113 reported she was shocked and didn't know he was out of the facility until the police contacted her. LPN #113 reported she checked the window in Resident #40's room and it was completely wide open. LPN #113 reported she had maintenance fix the window. LPN #113 revealed nurses complete 15-minute checks, not the aides, and the checks must be completely filled out. Interview on 07/20/26 at 6:40 P.M. with DON #303 revealed she was contacted on 06/27/26 regarding Resident #40 eloping but could not remember the time they were called or the nurse that called. DON #303 instructed the nurse to move the resident to the second floor since he eloped earlier from the first floor secured/locked unit, and the second floor would be safer. Interview on 07/21/26 at 6:53 A.M. with CNA #135 confirmed for 15-minute safety checks staff are not assigned a certa

Based on interview and personnel file review, the facility failed to ensure an effective training program was in place before staff provided resident care upon hire. This had the potential to affect all 39 residents residing in the facility. Findings include :1. Review of Certified Nursing Assistant (CNA) #144's personnel file revealed a date of hire of 04/22/26. Online training modules for fall prevention, being with the person with dementia, assisting residents with dressing, abuse, neglect and exploitation and resident patient rights were all listed as having been over due. CNA #144's personnel file did not include an orientation skill checklist.Interview on 07/27/26 at 9:55 A.M. with Human Resources/Business Office Manager (BOM) #102 revealed employees completed their orientation training on the dates of hire and the online training should be completed within the first month. HR/BOM #103 confirmed CNA #144's personnel file did not include evidence required training was completed and did not included a skills check off list to ensure their skills had been observed by another employee to ensure competency for the tasks. During interview with HR/BOM #102, Director of Nursing (DON) #303 joined the interview and stated the skills check off list should have been completed prior to an employee performing resident care and should be kept in the employees personnel files. 2. Review of CNA #309's personnel file revealed a date of hire of 07/22/26. Online training modules for fall prevention, being with the person with dementia, assisting residents with dressing, abuse, neglect and exploitation and resident patient rights were all listed as having been over due. CNA #309's personnel file did not include an orientation skill checklist.Interview on 07/27/26 at 9:55 A.M. with Human Resources/BOM#102 revealed employees completed their orientation training on the dates of hire and the online training should be completed within the first month. HR/BOM #103 confirmed CNA #309's personnel file did not include evidence required training was completed and did not included a skills check off list to ensure their skills had been observed by another employee to ensure competency for the tasks. During interview with HR/BOM #102, DON #303 joined the interview and stated the skills check off list should have been completed prior to an employee performing resident care and should be kept in the employees personnel files. 3. Review of Licensed Practical Nurse (LPN) #123's personnel file revealed a date of hire of 06/11/26. Online training modules for fall prevention, being with the person with dementia, assisting residents with dressing, abuse, neglect and exploitation and resident patient rights were all listed as having been over due. Interview on 07/27/26 at 9:55 A.M. with Human Resources/BOM#102 revealed employees completed their orientation training on the dates of hire and the online training should be completed within the first month. HR/BOM #103 confirmed CNA #309's personnel file did not include evidence required training was completed.Review of facility policy titled On the Job Training revised November 2023 revealed on the job training is provided to train each employee in his/her respective job, department directors are responsible for on-the-job training to assure that established training schedules are followed, all training programs and classes attended by an employee are entered into his/her Employee Training Attendance Record and training records are filed in the employees personnel file.Review of the Facility Assessment Tool, dated 072026, revealed the facility's resident population consists of residents with behavior that needs interventions. Special treatments and condition include mental health with behavioral health needs. The facility lends itself very well to a slightly older resident, with an underlying cognitive deficit and/or behavioral health care need. The first floor offers a care model to support those residents that are slightly younger with an underlying behavioral baseline. The overall presentation of this resident populations' behavioral are need(s) could be described as petulant ant impulsive. Under staff training/education and competencies, training and educational topics are designed to support and/or facilitate the process of continuous quality improvement by all staff. Educational topics may be identified from an incident or event. Examples of educational topics include but were not limited to: Communication- effective communications for direct care staff members, positive behavior modification via non-verbal language, TAPS technique; resident rights .; abuse, neglect, and exploitation .; and Caring for Behavioral residents, technique for positive behavior modification. This deficiency represents non-compliance investigated under Complaint 3096332 and 3070144.

Based on interview and personnel file review, the facility failed to ensure all staff received behavioral health training. This had the potential to affect all residents residing in the facility. The facility census was 39.Findings include :1. Review of Certified Nursing Assistant (CNA) #309's personnel file revealed a date of hire of 07/22/26. The personnel file did not include evidence of behavioral health training.Interview on 07/24/26 at 10:10 A.M. with CNA #309 revealed she had not received any training on behaviors.Interview on 07/27/26 at 2:57 P.M. with Administrator confirmed staff training was not specific to behaviors. 2. Review of Licensed Practical Nurse (LPN) #123's personnel file revealed a date of hire of 06/11/26. The personnel file did not include evidence of behavioral health training.Interview on 07/23/26 at 8:42 A.M. with LPN #123 revealed he had not received any training on behavior health.Interview on 07/27/26 at 2:57 P.M. with Administrator confirmed staff training was not specific to behaviors. Review of facility policy titled On the Job Training revised November 2023 revealed on the job training is provided to train each employee in his/her respective job, department directors are responsible for on-the-job training to assure that established training schedules are followed, all training programs and classes attended by an employee are entered into his/her Employee Training Attendance Record and training records are filed in the employees personnel file.Review of the Facility Assessment Tool, dated 072026, revealed the facility's resident population consists of residents with behavior that needs interventions. Special treatments and condition include mental health with behavioral health needs. The facility lends itself very well to a slightly older resident, with an underlying cognitive deficit and/or behavioral health care need. The first floor offers a care model to support those residents that are slightly younger with an underlying behavioral baseline. The overall presentation of this resident populations' behavioral are need(s) could be described as petulant ant impulsive. Under staff training/education and competencies, training and educational topics are designed to support and/or facilitate the process of continuous quality improvement by all staff. Educational topics may be identified from an incident or event. Examples of educational topics include but were not limited to: Communication- effective communications for direct care staff members, positive behavior modification via non-verbal language, TAPS technique; resident rights .; abuse, neglect, and exploitation .; and Caring for Behavioral residents, technique for positive behavior modification. This deficiency represents non-compliance investigated under Complaint 3096332 and 3070144.

Based on observation, interview and record review the facility failed to ensure accurate and complete documentation in resident medical records. This affected three residents (Resident #9, #14 and #31) of five reviewed for accurate documentation. The facility census was 39.Findings include:1. Review of Resident #9's care plan dated 03/31/26 revealed Resident #9 was at risk for falls. Interventions included fall mats to floor beside beds, assist with all mobility, reinforce need to call for assistance.Review of Resident #9's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had impaired cognition. Resident #9 was dependent with toileting, bathing and personal hygiene. Resident #9 required maximum assistance with transfers and ambulation.Review of progress notes revealed no documentation related to a fall.Interview on 07/24/26 at 1:57 P.M. with Registered Nurse (RN) #110 revealed Certified Nursing Assistant (CNA) #309 had approached and stated Resident #9 had a large bruise to her right leg and was it was also swollen and had not been aware of how it occurred. RN #110 had then entered Resident #9's room and confirmed the right leg appeared to be swollen and had a large bruise and RN# 110 stated she had not been aware of how the injury occurred. RN #110 had then exited Resident #9's room and had re-entered a short time later and stated she had found a neurocheck sheet at the nurses station that had indicated Resident #9 may have had a fall on 07/22/26, however there had been nothing documented in Resident #9's electronic medical records. Interview on 07/24/26 at 3:20 P.M. with Administrator and Interim Director of Nursing (DON) #200 who had entered the room revealed she had found a hand written incident report for Resident #9 dated 07/22/26 that should have been documented in Resident #9's medical record as the medical record was absent of information related to an incident on 07/22/26. Review of the handwritten incident report for Resident #9 revealed a cover page titled Guidelines for Fall Documentation that included to document in the residents clinical record every seventy-two hours after the incident.2. Review of Resident #14's medical records revealed an admission date of 10/25/23. Diagnoses included dementia, bipolar and traumatic brain injuryReview of MDS assessment dated [DATE] revealed Resident #14 had impaired cognition and required moderate assistance with bathing, personal hygiene and maximum assistance with toileting and was non ambulatory.Review of Resident #14's care plan dated 07/14/26 revealed Resident #14 was at risk for injuries and often can not accurately describe what happened. Interventions included document findings and treatments in the residents medical records.Review of Resident #14's physician orders for July 2026 revealed orders clean laceration to left lower extremity with normal saline, pat dry and cover with dry dressing if needed every evening shift.Review of Treatment Administration Record (TAR) for July 2026 revealed treatments had been documented as having been completed from 07/10/26-07/26/26.Observation on 07/27/26 at 8:36 A.M. revealed Resident #14 was propelling himself in a wheelchair in the hallway and a soiled foam dressing was observed to his left leg dated 07/23/26. Interview on 07/27/26 at 12:16 P.M. with Registered Nurse (RN) #108 revealed she was unaware of Resident #14 having any skin impairments or wound care treatments. RN #108 had reviewed Resident #14's physician orders and stated he had an order to change the foam dressing daily on night shift. Observation of Resident #14 with RN #108 an time of interview confirmed the dressing date 07/23/26. Observation on 07/27/26 at 1:38 P.M. with DON #303 confirmed Resident #14's foam dressing date of 07/23/26. Review of Resident #14's medical record with DON #303 after observation confirmed the TAR was not accurate as treatments not completed were signed off as completed.3. Review of Resident #31's medical record revealed an admission date of 12/03/25. Diagnoses included Huntington's Disease, anxiety, and dementia.Review of the care plan dated 05/10/26 revealed Resident #31 had a potential for alterations in skin integrity. Interventions included provide treatments per physicians orders and weekly skin assessments.Review of the MDS assessment dated [DATE] revealed Resident #31 had impaired cognition. Resident #31 required maximum assistance with toileting, bathing and personal hygiene.Review of current physicians orders for July 2026 revealed apply a bordered foam dressing to lower lumbar to prevent skin shearing and change every three days and as needed.Review of Resident #31's TAR for July 2026 revealed treatments were documented as completed on 07/02/26, 07/05/26, 07/08/26, 07/11/26, 07/14/26, 07/17/26, 07/20/26 and 07/23/26.Observation on 07/23/26 at 8:27 A.M. revealed Resident #31 was sleeping in bed with her bare buttocks exposed to the open doorway. Further observation revealed Resident #31 had a large soiled foam bandage to her lower back that was dated 07/09/26.Observation on 07/23/26 at 8:56 A.M. with Interim DON #200 confirmed Resident #31's soiled dressing with a date of 07/09/26. Interview on 07/23/26 at 9:03 A.M. with DON in review of Resident #31's TAR for July 2026 confirmed treatments were documented as completed which was not accurate.Review of facility policy titled Charting and Documentation revised July 2017 revealed treatments or services performed and incidents or accidents were to documented in the residents medical records and documentation in the medical records was to be complete and accurate.This deficiency represents non-compliance investigated under Complaint 3070144 and continued non-compliance from the survey completed on 06/24/26.

Based on observation, interview and record review the facility failed to provide skin treatments as physician ordered. This affected two residents (Resident #14 and #31) of three reviewed for skin impairment. The facility census was 39.Findings include1. Review of Resident #14's medical record revealed an admission date of 10/25/23 with diagnoses including dementia, bipolar and traumatic brain injury.Review of Resident #14's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had impaired cognition and required moderate assistance with bathing, personal hygiene and maximum assistance with toileting and was non ambulatory.Review of the care plan dated 07/14/26 revealed Resident #14 was at risk for injuries and often can not accurately describe what happened. Interventions included document findings and treatments in the residents medical records.Review of Resident #14's physician orders for July 2026 revealed orders to clean laceration to left lower extremity with normal saline, pat dry and cover with dry dressing if needed every evening shift.Review of Treatment Administration Record (TAR) for July 2026 revealed treatments were documented as completed from 07/10/26 through 07/26/26.Observation on 07/27/26 at 8:36 A.M. revealed Resident #14 was propelling himself in a wheelchair in the hallway and a soiled foam dressing was observed to his left leg that was dated 07/23/26. Interview on 07/27/26 at 12:16 P.M. with Registered Nurse (RN) #108 revealed she was unaware of Resident #14 having any skin impairments or wound care treatments. RN #108 had reviewed Resident #14's physician orders and stated he had an order to change the foam dressing daily on night shift. Observation of Resident #14 with RN #108 an time of interview confirmed the dressing was dated 07/23/26. Observation on 07/27/26 at 1:38 P.M. with Director of Nursing (DON) #303 confirmed Resident #14's foam dressing date of 07/23/26. Review of Resident #14's medical records with DON #303 after observation confirmed TAR had been signed off as treatments being completed.2. Review of Resident #31's medical record revealed an admission date of 12/03/25 with diagnoses including Huntington's Disease, anxiety, and dementia.Review of the care plan dated 05/10/26 revealed Resident #31 had a potential for alterations in skin integrity. Interventions included provide treatments per physicians orders and weekly skin assessments. The care plan did not include activities of daily living (ADL) care.Review of MDS assessment dated [DATE] revealed Resident #31 had impaired cognition. Resident #31 required maximum assistance with toileting, bathing and personal hygiene.Review of Resident #31's current physicians orders for July 2026 revealed orders to apply a bordered foam dressing to lower lumbar to prevent skin shearing and change every three days and as needed.Review of Resident #31's TAR for July 2026 revealed treatments were documented as completed on 07/02/26, 07/05/26, 07/08/26, 07/11/26, 07/14/26, 07/17/26, 07/20/26 and 07/23/26.Observation on 07/23/26 at 8:27 A.M. revealed Resident #31 was sleeping in bed with her bare buttocks exposed to the open doorway. Further observation revealed Resident #31 had a large soiled foam bandage to her lower back that was dated 07/09/26. Resident #31 was observed to have had a strong foul odor of urine and strong body odor and her hair was severely matted and greasy.Interview on 07/23/26 at 8:42 A.M. with Licensed Practical Nurse (LPN) #123 revealed he had not provided any care for Resident #31 and was unaware of her treatment orders and stated he would need to check the physician orders. Observation of Resident #31 with LPN #123 at time of interview confirmed her soiled foam dressing and date of 07/09/26. LPN #123 had proceeded to check Resident #31's physician orders and confirmed the dressing was to be changed every three days and as needed. LPN #123 further confirmed Resident #31 odor and appearance. Resident #31 was not interviewable.Observation on 07/23/26 at 8:56 A.M. with Interim Director of Nursing (DON) #200 confirmed Resident #31's soiled dressing with a date of 07/09/26. Interim DON #200 further confirmed Resident #31's odor and appearance and stated she would instruct the aides to provide Resident #31 with a shower.Interview on 07/23/26 at 9:03 A.M. with DON in review of Resident #31 TAR for July 2026 confirmed treatments had been documented as completed but were not.Observation on 07/24/26 at 2:22 P.M. revealed Resident #31 appeared to still have severely matted and greasy hair and a strong body odor. Interviews with Certified Nursing Assistant CNA #152 and #309 at time of observation revealed they had been asked by Interim DON #200 to provide Resident #31 with a shower on 07/23/26, however they had not been able to complete it.Subsequent observations on 07/27/26 and 07/28/26 revealed Resident #31's appearance had remained the same as previous observations. Interview on 07/28/26 at 7:23 A.M. with CNA #137 confirmed Resident #31's appearance and stated she would attempt to get the residents into a shower today.Review of facility policy titled Activities of Daily Living (ADL) undated revealed residents were to be provided with care, treatment and services as appropriate to maintain activities of daily living. Appropriate care and services were to be provided to residents who were unable to carry out ADL's independently and included hygiene, bathing, and grooming.This deficiency represents non-compliance investigated under Complaint 3096332 and 3070144.

Based on observation and interview the facility failed to ensure Resident #31 was treated in a dignified manner. The affected one resident (#31) of three observed for dignified treatment. The facility census was 39. Findings includeReview of Resident #31's medical records revealed an admission date of 12/03/25 with diagnoses including Huntington's Disease, anxiety, and dementia.Review of the care plan dated 05/10/26 revealed Resident #31 had a potential for alterations in skin integrity. Interventions included provide treatments per physicians orders and weekly skin assessments. The care plan did not include activities of daily living (ADL) care.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 31 had impaired cognition. Resident #31 required maximum assistance with toileting, bathing and personal hygiene.Observation on 07/23/26 at 8:27 A.M. revealed Resident #31 was sleeping in bed with her bare buttocks exposed to the open doorway and had not been wearing an incontinence brief.Interview on 07/23/26 at 8:42 A.M. with Licensed Practical Nurse (LPN) #123 revealed he had not provided any care for Resident #123 and was not aware she had not been wearing an incontinence brief or her bare buttocks had been exposed.Observation on 07/23/26 at 8:56 A.M. with Interim Director of Nursing (DON) #200 confirmed Resident #31 had not been wearing an incontinence brief and stated she buttocks should not have been exposed to the open doorway and hall.Review of facility policy titled Resident Rights revised December 2021 revealed residents right to a dignified existence.

Based on observation and interview the facility failed to ensure linens and mattresses had been clean and sanitary and without odors. This affected one resident (Resident #31) of three observed for a clean environment. The facility census was 39.Review of Resident #31's medical record revealed an admission date of 12/03/25. Diagnoses included Huntington's Disease, anxiety, and dementia.Review of the care plan dated 05/10/26 revealed Resident #31 had a potential for alterations in skin integrity. Interventions included provide treatments per physicians orders and weekly skin assessments. the care plan did not include activities of daily living (ADL) care.Review of MDS assessment dated [DATE] revealed Resident #31 had impaired cognition. Resident #31 required maximum assistance with toileting, bathing and personal hygiene.Observation on 07/23/26 at 8:27 A.M. revealed Resident #31 was sleeping in bed with her bare buttocks exposed to the open doorway and had not been wearing an incontinence brief. A stale urine and feces odor was detected at the time of observation. Observation on 07/23/26 at 8:56 A.M. with Interim Director of Nursing (DON) confirmed Resident #31 had not been wearing an incontinence brief and her bed linens had a large urine stain and fecal matter on the bedding.This deficiency represents non-compliance investigated under Complaint 3070144.

Based on medical record review, review of an emergency medical services (EMS) run report, review of hospital records, staff and family interviews, and facility policy review, the facility failed to ensure medications were appropriately secured and inaccessible to residents. This resulted in Immediate Jeopardy and serious life-threatening harm and negative health outcomes on 06/05/26 at approximately 9:00 A.M. when Resident #46 was observed to have multiple empty medication cards (packaged by pharmacy and provided specific labeling including the resident's name, medication name and dosage, and administration times) of Keppra (an anticonvulsant medication used to treat seizures) and Baclofen (a skeletal muscle relaxant and antispasmodic) each which had an original quantity of 30 and belonged Resident #11. Facility staff notified the physician who instructed staff to monitor the resident throughout the day. At approximately 7:45 P.M., while outside at a smoke break, Resident #46 experienced a change in condition and began vomiting a white, liquid substance. The physician was contacted and instructed staff to send Resident #46 to a local emergency department (ED) where she was evaluated and observed to have altered level of consciousness and required intubation and admission to the medical intensive care unit (MICU). Resident #46 remained in the MICU where she required mechanical ventilation, frequent monitoring, and intravenous (IV) hydration to address her medication overdose until she returned to the facility on the evening of 06/09/26. This affected one (#46) of three residents observed and reviewed for medication administration and storage. The facility identified 14 residents (#1, #2, #3, #5, #6, #9, #10, #11, #13, #14, #16, #17, #18 and #46) who were cognitively impaired and independently ambulatory on the secured unit. The facility census was 45. On 06/11/26 at 2:09 P.M., the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) #100, Licensed Practical Nurse (LPN)/Clinical Manager (CM) #101, Corporate Registered Nurse (RN)/DON #192, and Corporate Minimum Data Set (MDS) Nurse #193 were notified the Immediate Jeopardy began on 06/05/26 at 9:00 A.M. when Resident #46 was found to have multiple empty medication cards of Baclofen and Keppra belonging to Resident #11 in her room. At approximately 7:45 P.M., Resident #46 was observed to have been vomiting a white substance, was lethargic and pale and was ordered to be sent to the hospital. Resident #46 was admitted for a drug overdose and admitted to the MICU and was intubated, received mechanical ventilation and IV fluids. Resident #46 was returned to the facility on [DATE]. The Immediate Jeopardy was removed on 06/06/26, when the facility implemented the following corrective actions: -On 06/05/26 at 3:27 P.M., LPN/CM #101 educated the facility's licensed nursing staff, which included eight RNs and 16 LPNs, via text message on medication storage safety requirements including maintaining medication cart security at all times, securing medication deliveries immediately upon receipt, preventing unauthorized resident access to medications, and reporting any medication security concerns immediately to facility leadership. All nursing staff replied to or acknowledged receipt of the education on 06/05/26. -On 06/06/26, an audit was completed by LPN/CM #101 of all locations where medications are stored and received within the facility and included the first-floor medication cart, the first-floor medication room, the second-floor medication cart, and the second-floor medication room. Additionally, the medication delivery totes and medication receiving process was reviewed with no concerns for medication storage identified. -On 06/06/26 at 9:00 A.M., LPN/CM #101 placed signage at the nurse's station reminding staff to lock medication carts when not in use, to appropriately store medication bins from pharmacy, and to not leave medications unattended in resident rooms. -On 06/06/26 at 9:00 A.M., all residents residing on the first floor (secured unit) underwent personal assessments to evaluate the residents' functional and behavior and room sweeps to look for any unsecured medications. No concerns were identified in the room sweeps; and no concerns were identified that residents had acquired medications that were not prescribed to them. All residents were assessed for deviations of functional and behavioral baselines. No concerns were identified. These assessments and room sweeps were conducted by LPN/CM #101. -On 06/06/26, the Administrator and DON implemented additional medication security, and the first-floor medication cart was to be locked in the first-floor medication room behind the nurses' station when not in use. This began on 06/06/26. -On 06/06/26, the Administrator and DON implemented additional medication security, and the second-floor medication cart was secured in a locked room (room [ROOM NUMBER]) when not in use. Maintenance applied a lock to room [ROOM NUMBER] on the morning of 06/06/26 with the on-duty floor nurse as the only nurse with access to the room. This began on 06/06/26. -Beginning on 06/06/26, the facility implemented ongoing audits of medication storage and security practices to include medication cart security observations, medication room security observations, medication delivery and receiving practices, and verification that medications are appropriately stored and secured when not in use. The DON or designee is responsible for completion of the audits. Audits were to be completed every shift (twice daily) for seven days, then three times weekly for one week, twice weekly for two weeks, and then once weekly for one week. The results of the ongoing audits would be reviewed in the facility's Quality Assurance and Performance Improvement (QAPI) program for further recommendations. -On 06/09/26, upon return from the hospital, Resident #46 was comprehensively assessed by LPN #129 and Resident # 46 was placed on facility-initiated 15-minute safety checks upon her return. The 15-minute checks are open-ended with no end date. -On 06/09/26, the Administrator coordinated a QAPI meeting to discuss and review the incident with Resident #46, the interventions in place, on-going systems for medication storage to prevent re-occurrence, reviewed the completed staff training and education, and how the staff believed the incident occurred. In attendance were the Administrator, DON, LPN/CM #101, Corporate MDS Nurse #193, Corporate RN/DON #192, Social Services Designee #102, Maintenance Director #157, and Business Office Manager (BOM) #103. -On 06/11/26, Resident #46's care plan was updated by Corporate MDS Nurse #193 to include the resident had a history of drug seeking behaviors and a history of taking medications that were not hers, stashing them in her clothing and in her room, and special care was needed when Resident #46 was around medication carts or where she could potentially have access to medications. Although the Immediate Jeopardy was removed on 06/06/26, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include:Review of Resident #46's medical record revealed an admission date of 09/01/25. Diagnoses included schizoaffective disorder, obsessive compulsive disorder (OCD), anxiety, impulse disorder, Attention-Deficit/Hyperactivity Disorder (ADHD), psychoactive substance abuse in remission, and delusional disorder. Review of the care plan dated 03/26/26 revealed Resident #46 exhibited behavioral symptoms that were not easily altered and were potentially harmful to herself and others including wandering with no discernable rational purpose, socially inappropriate/disruptive behaviors, non-compliance with ordered fluid restrictions, attempts to get others to get drinks for her, drinks her own urine, and drinks water out of the toilet. Care planned interventions included for staff to administer medications as ordered, monitor for adverse reactions to medications, monitor the resident's mood, affect and behaviors, encourage Resident #46 to verbalize feelings, and consult psychological services as needed. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 had a Brief Interview for Mental Status (BIMS) score of a 5, indicating severely impaired cognition. Resident #46 was noted to have hallucinations and delusions. Resident #46 was independent with eating, toileting, ambulation, and transfers. Review of Resident #46's current physician orders for June 2026 revealed her medication regimen did not include medication orders for Baclofen or Keppra. Review of a progress note dated 06/05/26 timed 9:41 A.M. authored by Registered Nurse (RN) #109 revealed multiple cards of an (unspecified) peer's medication were located in Resident #46's room, including one empty card of Baclofen and one empty card of Keppra. The note indicated the nurse was unable to determine if Resident #46 had taken the medications and Resident #46 denied taking the medications. Resident #46 was without signs/symptoms of distress, and a physical and mental assessment had been performed with no abnormal findings. The physician was notified and orders were received for a STAT (immediate) Keppra level. Review of a progress note dated 06/05/26 timed 10:50 A.M. authored by RN #109 revealed the laboratory called and stated they were unable to perform the STAT Keppra levels at that time and a Keppra level could only be completed on a routine laboratory day. The physician was notified. Review of progress note dated 06/05/26 timed 8:00 P.M. authored by RN #109 revealed that during smoke break Resident #46 vomited a white, liquid emesis. Resident #46 was returned to her room and was noted to be more lethargic than her baseline, difficult to arouse, and pale in color. The progress notes included Resident #46's vital signs were stable, she denied pain, nausea and denied taking any medications not prescribed to her. The note referenced the prior nurse (unspecified by name) had just administered her evening medications prior to her vomiting. The physician was notified and orders were received to send Resident #46 to the hospital for evaluation. Review of an EMS run report dated 06/05/26 revealed call received at 8:09 P.M. for poisoning/drug ingestion with a chief complaint of lethargy from a possible overdose of medication. The EMS narrative included EMS personnel were dispatched to the facility for a possible overdose on medication. Upon arrival, Resident #46 was found lying in bed alert to voice. Resident #46 had altered mental status and was observed to be pale. Staff reported to EMS that a room search had been done, and staff had found empty cards of Keppra and Baclofen and it was unknown the amount of each Resident #46 had taken. Staff reported to EMS personnel that during the morning Resident #46 seemed slightly off from her normal. EMS report further noted Resident #46 had altered mental status and was pale. EMS personnel transported Resident #46 to a local ED for evaluation. Review of a local hospital ED report dated 06/05/26 revealed Resident #46 was brought to the ED for a possible drug overdose after being found with multiple cards of medications from other patients. Upon arrival at the ED, Resident #46 was vomiting profusely and had a Glasgow Coma Scale (GSC, a scale used to objectively measure a person's level of consciousness in the three key areas of eye opening, verbal response, and motor response with a max score of 15 indicating normal alertness and orientation) score of eight, indicating a severe neurological emergency. The ED report indicated the resident was not alert, oriented, or answering questions appropriately. Resident #46 did not open her eyes to verbal or painful stimuli and could not state her name. ED staff called the facility to inquire about the medications Resident #46 potentially consumed, and facility staff reported to ED staff the two medications Resident #46 ingested were Keppra 750 milligrams (mg) extended release (ER) and Baclofen 10 mg tablets. After ED staff determined the resident consumed extended-release doses of Keppra, the ED physician called and spoke with poison control who indicated significant concern for Baclofen overdose, indicating the maximum daily dose is 80 mg, and Resident #46 potentially consumed 300 mg. Poison control indicated patients with a Baclofen overdose almost always required intubation and patients can exhibit signs that look like brain death for several days which include coma and flaccidity. Poison control indicated with a Keppra overdose the patient will likely have a lot of vomiting and central nervous system (CNS) depression making her at high risk for aspiration. During the ED evaluation, Resident #46 became combative with ED staff and due to concerns the resident could not safely maintain her airway, the decision was made to intubate the resident. Just prior to intubation, the resident was not responding to stimuli and her GCS score decreased down to a 7, indicating a continued neurological emergency. Resident #46 was intubated and sedated and mechanical ventilation was initiated. The ED report indicated there were no antidotes to the medications she consumed, and the resident would require intensive care unit (ICU) admission while she metabolized the medications. Resident #46 was transferred to another hospital with MICU availability in the early morning hours of 06/06/26. Review of hospital paperwork dated 06/06/26 to 06/09/26 revealed Resident #46 was admitted to the hospital from an affiliated ED with diagnoses including drug overdose on Keppra and Baclofen, acute toxic encephalopathy related to a drug overdose, and acute respiratory failure on mechanical ventilation. From 06/06/26 to 06/08/26, Resident #46 required mechanical ventilation and MICU care, including frequent monitoring, laboratory testing every six hours, and IV hydration. Resident #46 was extubated on 06/08/26 and monitored for another day. The records indicated Resident #46 saw a psychiatry provider who recommended she return to her locked facility on discharge. Hospital records dated 06/09/26 revealed Resident #46 denied recollection of the incident and was transferred back to the facility on the evening of 06/09/26. Interview on 06/09/26 at 7:20 A.M. with LPN #118 revealed she had been informed Resident #46 had multiple empty medication cards in her room, one was Keppra and the other was Baclofen that had belonged to Resident #11. LPN #118 stated the staff had performed routine random room sweeps of Resident #46's room because she had hoarding behaviors and had been known to take items and hide things. LPN #118 stated Resident #46 was ambulatory and would pace quickly in the halls throughout the day and night. LPN #118 stated that on 06/05/26 during the evening smoke break, Resident #46 had thrown up and was sent to the hospital but was unsure why Resident #46 had not been sent to the hospital sooner. LPN #118 stated she was unsure how Resident #46 had obtained the medications; however, Resident #46 was sneaky and would take anything that was out. Interview on 06/09/26 at 7:46 A.M. with Behavioral Specialist (BS) #191 revealed she was present at the facility on 06/05/26 when, at approximately 9:00 A.M., Certified Nursing Assistant (CNA) #132 had informed her of finding an empty medication card in Resident #46's room. BS #191 stated she immediately went into Resident #46's room and she had also observed an additional empty medication card of Keppra on the nightstand. BS #191 stated she had also observed two other medication cards that the top portions were ripped off that would have included the medication and the residents name, and due to the information missing she was unable to state what the two additional medication cards were. BS #191 stated she had concerns later that morning regarding how high Resident #46 had looked and stated she had taken a picture of Resident #46 at that time. Observation of the picture she had taken of Resident #46 at time of interview revealed the photo was taken on 06/05/26 at 10:39 A.M. and Resident #46 had glassy eyes that were half open and the resident appeared disheveled and appeared to be under the influence. BS #191 stated the picture was not how Resident #46 normally appeared. BS #191 stated she had informed RN #109 at that time and stated there was no administrative staff present in the facility to further inform. Interview on 06/09/26 at 10:34 A.M. with CNA #132 revealed she had done a random room search of Resident #46's room on 06/05/26 at approximately 9:00 A.M. and stated she had observed Resident #46's blankets looked weird on her bed. CNA #132 stated as she removed the blankets, she observed an empty medication card of Baclofen along with some loose pills. CNA #132 stated she had alerted BS #191, who then entered Resident #46's room and an additional empty medication card was found; however, she was unsure what the additional medication card was. CNA #132 stated she had observed the dispense date of the Baclofen card of 06/01/26 and the other medication card had a dispense date of 05/28/26. CNA #132 stated BS #191 had informed RN #109. CNA #132 stated later that morning she had noticed that Resident #46 had been walking slower than normal and her pupils were huge. CNA #132 stated BS #191 noticed changes with Resident #46 as well and had taken a picture of her. CNA #132 stated Resident #46 was definitely altered and stated she had asked RN #109 about sending Resident #46 out [to the hospital] and RN #109 had not provided her with a response. Telephone interview on 06/09/26 at 11:07 A.M. with RN #109 revealed she was Resident #46's assigned nurse on the morning of 06/05/26 at approximately 9:00 A.M. when BS #191 informed her of the multiple empty medication cards found in Resident #46's room. RN #109 stated Resident #46 had denied she had taken the medications and stated she had performed an assessment and Resident #46 was within her normal baseline. RN #109 stated BS #191 had shown her the photograph she had taken that morning; however, Resident #46 had appeared normal to her. RN #109 stated she had left the facility at approximately 1:00 P.M. and had returned at 8:00 P.M. During the smoke break at approximately 8:00 P.M., a (unspecified) CNA had told her Resident #46 was outside throwing up. RN #109 stated she had called the physician who had given her orders to send Resident #46 to the hospital. Interview on 06/09/26 at 11:25 A.M. with LPN/CM #101 revealed she worked at the facility on 06/05/26 from approximately 4:00 A.M. to 9:00 A.M. LPN/CM #101 stated she had administered Resident #46 her morning medications at approximately 6:00 A.M. with no concerns. LPN/CM #101 stated after she had left the facility, she had received calls from BOM #103 and BS #191 between 9:13 A.M. and 9:15 A.M. LPN/CM #101 stated she had returned the call to BOM #103 and had been informed of the medication cards found in Resident #46's room. LPN/CM #101 stated she returned to the facility at approximately 11:00 A.M. following the call with BOM #103. LPN CM #101 stated once she returned to the facility, she observed the medication cards and stated she had attempted to reach the Administrator, who had not answered and stated she called DON #192 from their sister facility. LPN/CM #101 stated she had assessed Resident #46, and she was within her normal baseline. LPN/CM #101 stated she had kept an eye on Resident #46 all throughout the day with no concerns. LPN/CM #101 stated during the day (couldn't recall timeframe) staff had reported Resident #46 wasn't acting normal and had slurred speech; however, when she assessed Resident #46, she had not observed any concerns and stated sometimes the aides overreact. LPN/CM #101 stated she had obtained vital signs and neurological checks throughout the day, and all were within normal limits, however she had not documented the findings in the electronic medical record system. LPN/CM #101 stated she was unsure how Resident #46 had obtained the medications and speculated the medication cart had been left unlocked. LPN/CM #101 had further stated she had spoken with the Administrator at 10:10 A.M. and had informed her of the situation and was advised to conduct a room search and call the physician and to keep her updated on the situation. LPN/CM #101 stated during the evening smoke break between 7:45 P.M. and 8:00 P.M., the CNAs had informed her Resident #46 had thrown up and stated she had advised RN #109 to obtain vital signs and assess Resident #46. LPN/CM #101 stated she had assisted with assessing Resident #46 at that time and Resident #46 was not speaking clearly, mumbling, and was having difficulty keeping her eyes open. LPN/CM #101 stated she had then called the physician who advised the nurse to send Resident #46 to the hospital. Interview on 06/09/26 at 12:30 P.M. with DON #192 revealed she worked for a sister facility and had received a call from LPN/CM #101 on the morning of 06/05/26 (couldn't recall the time) and had been informed two empty medication cards had been found in Resident #46's room. DON #192 stated she had advised staff to perform a room sweep, a full assessment, and call the physician and Resident #46's guardian. DON #192 stated she was not made aware how Resident #46 had obtained the medications and she had not been informed of any abnormal behaviors. DON #192 stated she had received a call later that evening around 8:00 P.M. that Resident #46 was vomiting after she received her evening medications and DON #192 had agreed it was appropriate to have Resident #46 taken to the hospital. Interview on 06/09/26 at 12:50 P.M. with BOM #103 revealed at approximately 9:00 A.M. on 06/05/26, BS #191 had brought her multiple empty medication cards of Baclofen and Keppra. BOM #103 stated she had immediately called the Administrator, the DON (who had not answered), and DON #192 who had advised calling the physician, have the staff do an assessment, contact the physician, and have the staff perform a medication error report. BOM #103 stated once LPN/CM #101 had arrived she had given the medication cards to her and had told her what DON #192 had advised. BOM #103 stated she saw Resident #46 during the morning, and she appeared more tired than normal and was groggy. Interview on 06/09/26 at 3:22 P.M. with the DON revealed he had worked the morning of 06/05/26 until approximately 4:00 A.M. and had not observed any concerns with Resident #46. The DON stated he had left the facility and had gone home to sleep and when he woke up (couldn't recall time) he had a text message from LPN/CM #101 and the Administrator but did not have any record he responded. The DON stated he had returned to the facility on [DATE] and an investigation had been started that was still ongoing. The DON stated the facility was unable to state how Resident #46 had obtained the medications and stated it was likely from the medication cart having been unlocked or the medications possibly having been left on top of the cart. Interview on 06/10/26 at 7:49 A.M. with ADON #100 and LPN/CM #101 revealed ADON #100 stated she had received a text message from LPN/CM #101 on 06/05/26 at 8:46 P.M. that stated, I need to tell you something. ADON #100 stated she then called LPN/CM #101, who advised her that Resident #46 was found with multiple empty medication cards in her room and that Resident #46 was being taken to the hospital. ADON #100 did not provide any additional information. Observation on 06/10/26 at 9:24 A.M. revealed Resident #46 was seated in a reclining chair in a common area. She was observed to quickly stand up and began pacing the hallways. Interview with Resident #46 at the time of the interview revealed non-sensical phrases and when asked why she was recently at the hospital, she was unable to respond and continued to pace the hallways. Telephone interview on 06/10/26 at 11:05 A.M. with Physician #194 revealed he had received a call from the facility and had been informed staff found multiple empty medication cards in Resident #46's room that had belonged to another resident. Physician #194 stated he had advised the staff to perform frequent vitals (every three hours), obtain STAT Keppra levels, and to keep an eye on the resident. Physician #194 stated he had asked facility staff how Resident #46 had obtained the medication cards and he had been told they were still investigating. Physician #194 stated he had received a call later that evening around approximately 8:00 P.M. that Resident #46 had a change in mental status and advised staff to send Resident #46 to the hospital. Physician #194 stated he had been caring for Resident #46 for several years and stated she was sneaky and slick and would make a great pick pocket. Physician #194 stated symptoms of an overdose of Baclofen may not present from 6-8 hours after ingestion and stated Keppra may take a little longer as it was a long-acting medication, and stated signs of an overdose would likely include a change in mental status. Physician #194 stated he had not been made aware of the outcome of the investigation and stated he did not expect the investigation to have taken this long to complete. Interview on 06/10/26 at 2:30 P.M. with the DON revealed the investigation was still ongoing, and they had not been able to determine how Resident #46 had obtained the medication cards. The DON reported so far, he had only gathered staff statements and had not yet followed up with Physician #194 as the investigation was ongoing. Interview on 06/10/26 at 2:51 P.M. with LPN/CM #101 revealed she had sent a text message to the nursing staff on 06/05/26 at 3:27 P.M. regarding the securing of medication carts. Interview on 06/10/26 at 4:01 P.M. with LPN #118 revealed she had spoken with Resident #46 on the afternoon of 06/10/26, and Resident #46 informed her of how she had obtained the medications. LPN #118 stated Resident #46 had stated when the DON and CNA #195 had been working she had taken the pills from the unlocked medication cart and stated she wanted vitamins. Interview on 06/10/26 at 4:10 P.M. with CNA #195 revealed she had spoken with Resident #46 on 06/10/26 during the 3:00 P.M. smoke break and Resident #46 stated she had taken the medication from the medication cart while she and the DON were sitting at the nurses' station. CNA #195 stated she had worked with the DON on the evening of 06/04/26 from 2:30 P.M. to 10:30 P.M. CNA #195 stated on 06/04/26, she had searched Resident #46's room at approximately 5:00 P.M. as she was helping Resident #46 look for her missing vape and she had not found any medications. CNA #195 stated she asked Resident #46 how she had gotten the medications and Resident #46 had stated the medication cart was unlocked and she just took them. Interview on 06/11/26 at 9:00 A.M. with LPN/CM #101 revealed she had performed cart audits on 06/05/26, and posted signs at the nurses' station to remind nurses to ensure medications carts were always secured. LPN/CM #101 stated staff had not spoken with Resident #46 since her return from the hospital and stated ADON #100 had a better rapport with Resident #46, and she would speak with her. Observation of an interview on 06/11/26 at 9:24 A.M. revealed ADON #100 and LPN/CM #101 interviewed Resident #46 in her room. ADON #100 asked Resident #46 how she had gotten the medications and Resident #46 was heard stating, I was quiet as a mouse. Resident #46 additionally stated the medication cart was unlocked and she needed vitamins. Follow up interview on 06/11/26 at 9:37 A.M. with ADON #100 and LPN/CM #101 regarding their interview with Resident #46 revealed Resident #46 had stated while the DON and CNA #195 were at the nurses station the cart was unlocked and she was quiet as a mouse and took the medications from the bottom drawer of the unlocked medication cart because she know staff did not get in there all the time. At the time of the interview, the DON entered and stated he had just been made aware of Resident #46's account of how she obtained the medications. The DON stated he had worked with CNA #195 on the evening of 06/04/26 until about 10:30 P.M. and stated he recalled having sat at the nurses' station with CNA #195 during that evening. The DON stated he could not state if the medication cart had been left unlocked and stated the medication cart usually was placed outside of the nurses' station. The DON denied seeing Resident #46 approach the medication cart during the evening of 06/04/26. Follow up interview on 06/11/26 at 11:39 A.M. with CNA #195 revealed she had again spoken with Resident #46 about the situation later in the evening of 06/10/26 and Resident #46 had provided additional information that included Resident #46 stated to CNA #195 that she was observant and she watches staff. CNA #195 further stated Resident #46 had told her she kept the medications in her jacket's double liner. Interview on 06/11/26 at 1:27 P.M. with Resident #46's Guardian revealed she had just completed a care conference with the DON, Administrator, ADON #100, and LPN/CM #101 who informed her of the follow-up regarding the incident on 06/05/26. The Guardian stated in the meeting, the DON indicated he may have left his medication cart unlocked and Resident #46 had obtained the medication without his knowledge. Review of the facility policy titled Storage of Medications revised November 2020, revealed drugs and biologics were to be stored in a locked compartment and only persons authorized to prepare and administer medications were to have access to locked medications. Compartments containing drugs and biologicals are to be locked when not in use and unlocked medication carts are not to be left unattended. This deficiency represents non-compliance investigated under Complaint Number 3036496.

Based on interview, record review, and facility policy review, the facility failed to protect Resident #31 from abuse and mistreatment on 06/11/26 at approximately 10:00 P.M. when Registered Nurse (RN) #107 forced a spoonful of applesauce and medications into Resident #31's mouth as she was unresponsive. This affected one Resident (#31) of three residents reviewed for abuse. The facility census was 45. Findings include: Review of the medical record for Resident #31 revealed an admission date of 11/30/24. Diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus, and chronic respiratory failure with hypoxia. Resident #31 passed away at the facility on 06/13/26. Review of the care plan dated 04/20/26 revealed Resident #31 was experiencing a significant decline in health status related to terminal illness. Interventions included to administer all medications as ordered and provide a supportive, private environment for resident and family.Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had a severe cognitive impairment with a memory problem and required extensive assistance for all activities of daily living. Review of the physician's orders dated 06/11/26 revealed orders to administer Morphine (an opioid analgesic commonly used for end-of-life comfort measures) 20 milligrams (mg)/5 milliliters (ml), administer 5 mg (0.25 ml) every four hours routine for respiratory distress, and an additional order for Morphine 5 mg (0.25 ml) every two hours as needed for respiratory distress. Resident #31 had an additional order dated 03/06/26 for Lorazepam (also known as Ativan, an antianxiety medication commonly used for end-of-life restlessness) 0.5 mg one tablet by mouth every 4 hours as needed for agitation, restlessness, or anxiety. Review of the outside hospice nursing note dated 06/11/26 authored by Hospice Nurse #210 revealed a facility nurse attempted to administer medications to Resident #31 crushed in applesauce. Resident #31 was unresponsive at the time with deep shallow respirations. Her respiration rate was 27 breaths per minute. Hospice Nurse #210 asked the facility nurse not to continue to attempt to administer oral medications as Resident #31 was no longer responsive and may aspirate the applesauce as she was mouth breathing. The facility nurse proceeded to place the applesauce in Resident #31's mouth when Resident #31's daughter verbally requested the nurse leave the room. The facility nurse handed Hospice Nurse #210 the Morphine syringe and told her to give it then. Hospice Nurse #210 administered Resident #31's Morphine dose at 10:00 P.M. and attempted to remove the applesauce out of Resident #31's mouth as she was not swallowing it and continued mouth-breathing. Hospice Nurse #210 then left Resident #31's room and went to speak to the facility nurse who was placing her cart in the closet stating she was leaving the facility. A follow up note authored by Hospice Nurse #210 revealed the facility nurse locked her keys in her cart and left the building. Interview on 06/16/26 at 9:26 A.M. with Resident #31's daughter reported on 06/11/26 at approximately 10:00 P.M., RN #107 brought Resident #31's medication (Ativan) into the room crushed and mixed with applesauce. Hospice Nurse #210 informed RN #107 not to administer the Ativan to Resident #31 because she was unresponsive and no longer able to swallow. RN #107 proceeded to ignore Hospice Nurse #210 and forced her mother's lips open and shoved the medication/applesauce mixture into Resident #31's mouth. At that point, Resident #31's daughter reported she screamed for RN #107to leave her mother's room. RN #107 began screaming at Hospice Nurse #210 and her and stated, well then who is going to administer this Morphine. Hospice Nurse #210 reached for the Morphine and RN #107 exited the room. The daughter and Hospice Nurse #210 then began removing the applesauce from Resident #31's mouth and Hospice Nurse #210 administered the Morphine to Resident #31. The daughter confirmed she believed this treatment by RN #107 to be abusive and they notified all administration of the incident. Resident #31's daughter reported she, Hospice Nurse #210, and Resident #31's son were all in the room, witnessed the behavior, and all felt it was abusive. Resident #31's daughter indicated Resident #31's son indicated he would contact the authorities for investigation into potential criminal charges if the facility did not investigate the incident with RN #107. Interview on 06/16/26 at 1:38 P.M. with the Administrator, Assistant Director of Nursing (ADON) #100, and Licensed Practical Nurse (LPN)/Clinical Manager (CM) #101 revealed the Administrator reported she got a call around 10:00 P.M. [on 06/11/26] that Resident #31's family was very upset about the care RN #107 was providing. She reported she then reached out to her clinical staff and ADON #100 reached out to RN #107and informed her to go administer the Morphine to Resident #31. Around 12:00 A.M., LPN/CM #101 then received messages that RN #107 could not be located in the facility. LPN/CM #101 reported she got dressed and went to the facility and began reaching out to RN #107 who would only respond by text message. RN #107 informed LPN/CM #101 that she had counted the medications with the other nurse working the first floor and locked the medication carts along with the keys in the second-floor medication room. The Administrator, LPN/CM #101, and ADON #100 all confirmed Resident #31's family and Hospice Nurse #210 reported that RN #107 attempted to shove medication in applesauce into Resident #31's mouth when she was unresponsive. They reported they did not think of it as abuse and did not feel the need to report the incident to the state agency nor investigate the incident since RN #107 left the facility shortly after the incident occurred.Telephone interview on 06/16/26 at 3:43 P.M. with RN #107 confirmed she was very busy the night that Residents #31 was passing away. She reported that evening (06/11/26) she had been dealing with emergencies, so she administered nighttime medications to other residents late and they were upset so she did not want that to happen again. When Resident #31's family asked to have her 7:30 P.M. Morphine and Ativan administered she informed them they would have to wait. She then administered the medications to Resident #31 around 8:00 P.M. and at that time Resident #31 was able to swallow medications. When Resident #31 was due for her at 10:00 P.M. Ativan and Morphine, she prepared the Ativan in some applesauce and entered the room to administer it. Hospice Nurse #210 told her not to put the applesauce in Resident #31's mouth because she was no longer coherent and would not swallow it. RN #107 confirmed she told her she was still placing the Ativan into her mouth and used a spoon to place the Ativan in applesauce in her cheek. At that point, Resident #31's daughter screamed at RN #107 and informed her to leave the room. She left the Morphine syringe with Hospice Nurse #210 and exited the room, counted her narcotic drawers with the nurse from the first floor, clocked out of the facility, and left the facility around 11:30 P.M. She reported Resident #31 was able to swallow at 8:00 P.M. and her mouth was open when she entered the room but could not answer questions related to the resident's cognitive status or her level of alertness when she returned for the 10:00 P.M. dose.Review of the facility policy Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, revised April 2021, revealed residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraints not required to treat the resident's symptoms. The facility must identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source, the Administrator is responsible for determining what actions are needed for the protection of residents. All allegations are thoroughly investigated. The Administrator initiates investigations. This deficiency represents non-compliance investigated under Complaint Number 3044559.

Based on interview, record review, review of the Ohio Department of Health's Certification and Licensure System, and facility policy review, the facility failed to ensure an allegation of staff to resident abuse was reported to the State Agency as required. This affected one resident (#31) of three residents reviewed for abuse. The facility census was 45. Findings include: Review of the medical record for Resident #31 revealed an admission date of 11/30/24. Diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus, and chronic respiratory failure with hypoxia. Resident #31 passed away at the facility on 06/13/26. Review of the care plan dated 04/20/26 revealed Resident #31 was experiencing a significant decline in health status related to terminal illness. Interventions included to administer all medications as ordered and provide a supportive, private environment for resident and family.Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had a severe cognitive impairment with a memory problem and required extensive assistance for all activities of daily living. Review of the physician's orders dated 06/11/26 revealed orders to administer Morphine (an opioid analgesic commonly used for end-of-life comfort measures) 20 milligrams (mg)/5 milliliters (ml), administer 5 mg (0.25 ml) every four hours routine for respiratory distress, and an additional order for Morphine 5 mg (0.25 ml) every two hours as needed for respiratory distress. Resident #31 had an additional order dated 03/06/26 for Lorazepam (also known as Ativan, an antianxiety medication commonly used for end-of-life restlessness) 0.5 mg one tablet by mouth every 4 hours as needed for agitation, restlessness, or anxiety. Review of the outside hospice nursing note dated 06/11/26 authored by Hospice Nurse #210 revealed a facility nurse attempted to administer medications to Resident #31 crushed in applesauce. Resident #31 was unresponsive at the time with deep shallow respirations. Her respiration rate was 27 breaths per minute. Hospice Nurse #210 asked the facility nurse not to continue to attempt to administer oral medications as Resident #31 was no longer responsive and may aspirate the applesauce as she was mouth breathing. The facility nurse proceeded to place the applesauce in Resident #31's mouth when Resident #31's daughter verbally requested the nurse leave the room. The facility nurse handed Hospice Nurse #210 the Morphine syringe and told her to give it then. Hospice Nurse #210 administered Resident #31's Morphine dose at 10:00 P.M. and attempted to remove the applesauce out of Resident #31's mouth as she was not swallowing it and continued mouth-breathing. Hospice Nurse #210 then left Resident #31's room and went to speak to the facility nurse who was placing her cart in the closet stating she was leaving the facility. Review of the Ohio Department of Health's (ODH) Certification and Licensure System (CALS) record of self-reported incidents (SRI) on 06/16/26 at 9:00 A.M. revealed no SRI had been reported involving Resident #31 on or around 06/11/26. Interview on 06/16/26 at 9:26 A.M. with Resident #31's daughter reported on 06/11/26 at approximately 10:00 P.M., RN #107 brought Resident #31's medication (Ativan) into the room crushed and mixed with applesauce. Hospice Nurse #210 informed RN #107 not to administer the Ativan to Resident #31 because she was unresponsive and no longer able to swallow. RN #107 proceeded to ignore Hospice Nurse #210 and forced her mother's lips open and shoved the medication/applesauce mixture into Resident #31's mouth. At that point, Resident #31's daughter reported she screamed for RN #107to leave her mother's room. RN #107 began screaming at Hospice Nurse #210 and her and stated, well then who is going to administer this Morphine. Hospice Nurse #210 reached for the Morphine and RN #107 exited the room. The daughter and Hospice Nurse #210 then began removing the applesauce from Resident #31's mouth and Hospice Nurse #210 administered the Morphine to Resident #31. The daughter confirmed she believed this treatment by RN #107 to be abusive and they notified all administration of the incident. Resident #31's daughter reported she, Hospice Nurse #210, and Resident #31's son were all in the room, witnessed the behavior, and all felt it was abusive. Resident #31's daughter indicated Resident #31's son indicated he would contact the authorities for investigation into potential criminal charges if the facility did not investigate the incident with RN #107. Interview on 06/16/26 at 1:38 P.M. with the Administrator, Assistant Director of Nursing (ADON) #100, and Licensed Practical Nurse (LPN)/Clinical Manager (CM) #101 revealed the Administrator reported she got a call around 10:00 P.M. [on 06/11/26] that Resident #31's family was very upset about the care RN #107 was providing. She reported she then reached out to her clinical staff and ADON #100 reached out to RN #107and informed her to go administer the Morphine to Resident #31. Around 12:00 A.M., LPN/CM #101 then received messages that RN #107 could not be located in the facility. LPN/CM #101 reported she got dressed and went to the facility and began reaching out to RN #107 who would only respond by text message. RN #107 informed LPN/CM #101 that she had counted the medications with the other nurse working the first floor and locked the medication carts along with the keys in the second-floor medication room. The Administrator, LPN/CM #101, and ADON #100 all confirmed Resident #31's family and Hospice Nurse #210 reported that RN #107 attempted to shove medication in applesauce into Resident #31's mouth when she was unresponsive. They reported they did not think of it as abuse and did not feel the need to report the incident to the state agency nor investigate the incident since RN #107 left the facility shortly after the incident occurred.Further review of the ODH CALS system revealed a SRI for possible staff to resident physical abuse was initiated on 06/16/26 at 2:05 P.M. The nursing staff involved was not named or listed as an alleged perpetrator. The SRI was completed on 06/19/26 at 1:17 P.M. and unsubstantiated the allegation of abuse as the evidence was inconclusive. The SRI summary noted the involved nurse is no longer employed by the facility and had not returned the facility's phone call for a first-hand statement. The root cause analysis referenced in the summary suggested the inappropriate administration was related to the nurse being overwhelmed with her tasks and duties but that did not negate her actions. The facility indicated the medication administration itself did not reflect abusive intent but the nurse later left the facility and her duties without ensuring adequate coverage for her tasks or obtaining approval to do so and the facility was pursuing action with her appropriate licensing board. Telephone interview on 06/16/26 at 3:43 P.M. with RN #107 confirmed she was very busy the night that Residents #31 was passing away. She reported that evening (06/11/26) she had been dealing with emergencies, so she administered nighttime medications to other residents late and they were upset so she did not want that to happen again. When Resident #31's family asked to have her 7:30 P.M. Morphine and Ativan administered she informed them they would have to wait. She then administered the medications to Resident #31 around 8:00 P.M. and at that time Resident #31 was able to swallow medications. When Resident #31 was due for her at 10:00 P.M. Ativan and Morphine, she prepared the Ativan in some applesauce and entered the room to administer it. Hospice Nurse #210 told her not to put the applesauce in Resident #31's mouth because she was no longer coherent and would not swallow it. RN #107 confirmed she told her she was still placing the Ativan into her mouth and used a spoon to place the Ativan in applesauce in her cheek. At that point, Resident #31's daughter screamed at RN #107 and informed her to leave the room. She left the Morphine syringe with Hospice Nurse #210 and exited the room, counted her narcotic drawers with the nurse from the first floor, clocked out of the facility, and left the facility around 11:30 P.M. She reported Resident #31 was able to swallow at 8:00 P.M. and her mouth was open when she entered the room but could not answer questions related to the resident's cognitive status or her level of alertness when she returned for the 10:00 P.M. dose.Review of the facility policy Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, revised April 2021, revealed residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraints not required to treat the resident's symptoms. The facility must identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source, the Administrator is responsible for determining what actions are needed for the protection of residents. All allegations are thoroughly investigated. The Administrator initiates investigations. This deficiency represents non-compliance investigated under Complaint Number 3044559.

Based on interview, record review, review of the Ohio Department of Health's Certification and Licensure System, and facility policy review, the facility failed to ensure an investigation into alleged of staff to resident abuse was timely and thoroughly investigated. This affected one Resident (#31) of three residents reviewed for abuse. The facility census was 45. Findings include: Review of the medical record for Resident #31 revealed an admission date of 11/30/24. Diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus, and chronic respiratory failure with hypoxia. Resident #31 passed away at the facility on 06/13/26. Review of the care plan dated 04/20/26 revealed Resident #31 was experiencing a significant decline in health status related to terminal illness. Interventions included to administer all medications as ordered and provide a supportive, private environment for resident and family.Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had a severe cognitive impairment with a memory problem and required extensive assistance for all activities of daily living. Review of the physician's orders dated 06/11/26 revealed orders to administer Morphine (an opioid analgesic commonly used for end-of-life comfort measures) 20 milligrams (mg)/5 milliliters (ml), administer 5 mg (0.25 ml) every four hours routine for respiratory distress, and an additional order for Morphine 5 mg (0.25 ml) every two hours as needed for respiratory distress. Resident #31 had an additional order dated 03/06/26 for Lorazepam (also known as Ativan, an antianxiety medication commonly used for end-of-life restlessness) 0.5 mg one tablet by mouth every 4 hours as needed for agitation, restlessness, or anxiety. Review of the outside hospice nursing note dated 06/11/26 authored by Hospice Nurse #210 revealed a facility nurse attempted to administer medications to Resident #31 crushed in applesauce. Resident #31 was unresponsive at the time with deep shallow respirations. Her respiration rate was 27 breaths per minute. Hospice Nurse #210 asked the facility nurse not to continue to attempt to administer oral medications as Resident #31 was no longer responsive and may aspirate the applesauce as she was mouth breathing. The facility nurse proceeded to place the applesauce in Resident #31's mouth when Resident #31's daughter verbally requested the nurse leave the room. The facility nurse handed Hospice Nurse #210 the Morphine syringe and told her to give it then. Hospice Nurse #210 administered Resident #31's Morphine dose at 10:00 P.M. and attempted to remove the applesauce out of Resident #31's mouth as she was not swallowing it and continued mouth-breathing. Hospice Nurse #210 then left Resident #31's room and went to speak to the facility nurse who was placing her cart in the closet stating she was leaving the facility. Review of the Ohio Department of Health's (ODH) Certification and Licensure System (CALS) record of self-reported incidents (SRI) on 06/16/26 at 9:00 A.M. revealed no SRI had been reported involving Resident #31 on or around 06/11/26. Interview on 06/16/26 at 9:26 A.M. with Resident #31's daughter reported on 06/11/26 at approximately 10:00 P.M., RN #107 brought Resident #31's medication (Ativan) into the room crushed and mixed with applesauce. Hospice Nurse #210 informed RN #107 not to administer the Ativan to Resident #31 because she was unresponsive and no longer able to swallow. RN #107 proceeded to ignore Hospice Nurse #210 and forced her mother's lips open and shoved the medication/applesauce mixture into Resident #31's mouth. At that point, Resident #31's daughter reported she screamed for RN #107to leave her mother's room. RN #107 began screaming at Hospice Nurse #210 and her and stated, well then who is going to administer this Morphine. Hospice Nurse #210 reached for the Morphine and RN #107 exited the room. The daughter and Hospice Nurse #210 then began removing the applesauce from Resident #31's mouth and Hospice Nurse #210 administered the Morphine to Resident #31. The daughter confirmed she believed this treatment by RN #107 to be abusive and they notified all administration of the incident. Resident #31's daughter reported she, Hospice Nurse #210, and Resident #31's son were all in the room, witnessed the behavior, and all felt it was abusive. Resident #31's daughter indicated Resident #31's son indicated he would contact the authorities for investigation into potential criminal charges if the facility did not investigate the incident with RN #107. Interview on 06/16/26 at 1:38 P.M. with the Administrator, Assistant Director of Nursing (ADON) #100, and Licensed Practical Nurse (LPN)/Clinical Manager (CM) #101 revealed the Administrator reported she got a call around 10:00 P.M. [on 06/11/26] that Resident #31's family was very upset about the care RN #107 was providing. She reported she then reached out to her clinical staff and ADON #100 reached out to RN #107and informed her to go administer the Morphine to Resident #31. Around 12:00 A.M., LPN/CM #101 then received messages that RN #107 could not be located in the facility. LPN/CM #101 reported she got dressed and went to the facility and began reaching out to RN #107 who would only respond by text message. RN #107 informed LPN/CM #101 that she had counted the medications with the other nurse working the first floor and locked the medication carts along with the keys in the second-floor medication room. The Administrator, LPN/CM #101, and ADON #100 all confirmed Resident #31's family and Hospice Nurse #210 reported that RN #107 attempted to shove medication in applesauce into Resident #31's mouth when she was unresponsive. They reported they did not think of it as abuse and did not feel the need to report the incident to the state agency nor investigate the incident since RN #107 left the facility shortly after the incident occurred.Further review of the ODH CALS system revealed a SRI for possible staff to resident physical abuse was initiated on 06/16/26 at 2:05 P.M. The nursing staff involved was not named or listed as an alleged perpetrator. The SRI was completed on 06/19/26 at 1:17 P.M. and unsubstantiated the allegation of abuse as the evidence was inconclusive. The SRI summary noted the involved nurse is no longer employed by the facility and had not returned the facility's phone call for a first-hand statement. The root cause analysis referenced in the summary suggested the inappropriate administration was related to the nurse being overwhelmed with her tasks and duties but that did not negate her actions. The facility indicated the medication administration itself did not reflect abusive intent but the nurse later left the facility and her duties without ensuring adequate coverage for her tasks or obtaining approval to do so and the facility was pursuing action with her appropriate licensing board. Telephone interview on 06/16/26 at 3:43 P.M. with RN #107 confirmed she was very busy the night that Residents #31 was passing away. She reported that evening (06/11/26) she had been dealing with emergencies, so she administered nighttime medications to other residents late and they were upset so she did not want that to happen again. When Resident #31's family asked to have her 7:30 P.M. Morphine and Ativan administered she informed them they would have to wait. She then administered the medications to Resident #31 around 8:00 P.M. and at that time Resident #31 was able to swallow medications. When Resident #31 was due for her at 10:00 P.M. Ativan and Morphine, she prepared the Ativan in some applesauce and entered the room to administer it. Hospice Nurse #210 told her not to put the applesauce in Resident #31's mouth because she was no longer coherent and would not swallow it. RN #107 confirmed she told her she was still placing the Ativan into her mouth and used a spoon to place the Ativan in applesauce in her cheek. At that point, Resident #31's daughter screamed at RN #107 and informed her to leave the room. She left the Morphine syringe with Hospice Nurse #210 and exited the room, counted her narcotic drawers with the nurse from the first floor, clocked out of the facility, and left the facility around 11:30 P.M. She reported Resident #31 was able to swallow at 8:00 P.M. and her mouth was open when she entered the room but could not answer questions related to the resident's cognitive status or her level of alertness when she returned for the 10:00 P.M. dose.Review of the facility policy Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, revised April 2021, revealed residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraints not required to treat the resident's symptoms. The facility must identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source, the Administrator is responsible for determining what actions are needed for the protection of residents. All allegations are thoroughly investigated. The Administrator initiates investigations. This deficiency represents non-compliance investigated under Complaint Number 3044559.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure medications were administered per physician orders. This affected one Resident (#25) of three residents observed and reviewed for medication administration. The facility census was 45.Findings include: Review of Resident #25's medical record revealed an admission date of 01/04/23. Diagnoses included paranoid schizophrenia, dementia, depression, Alzheimer's disease, impulse disorder, and delusions.Review of a care plan dated 02/24/26 revealed Resident #25 required Clozaril (antipsychotic medication) therapy due to severe schizophrenia. Interventions included to monitor and document the resident's response to Clozaril therapy and monitor the resident during medication administration to assure they are not pocketing medication.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had impaired cognition. Resident #25 was dependent with toileting, transfers, and mobility.Review of the current physician orders for June 2026 revealed Resident #25 was ordered Clozaril 50 milligrams (mg) by mouth in the morning and Clozaril 100 mg by mouth at bedtime.Observation of medication administration on 06/11/26 at 7:35 A.M. with Licensed Practical Nurse (LPN) #124 for Resident #25 revealed she had obtained Resident #25's Clozaril medication card and the top of medication card indicated 100 mg was to be given at bedtime. LPN #124 proceeded to administer Resident #25's medications, which included administration of Clozaril 100 mg tablet.Follow up interview on 06/11/26 at 7:58 A.M. with LPN #124 and was asked to provide the medication card used to administer Resident #25's Clozaril. LPN #124 retrieved the medication card and confirmed the card was for Clozaril 100 mg and was to be administered at bedtime. LPN #124 was asked to check Resident #25's physicians orders and she then verified Resident #25's physician orders were to administer Clozaril 50 mg in the morning and Clozaril 100 mg at bedtime. LPN #124 confirmed the error and stated she had not noticed the top of the medication card was the 100 mg dose and was intended to be given at bedtime. Review of facility policy titled Administering Medications revised April 2019 revealed medications were to be administered in accordance with prescribers orders, medication errors were to be documented, reported, and reviewed by the Quality Assurance Performance Improvement (QAPI) committee and the individual administering the medication was to check the dosage.This deficiency represents non-compliance investigated under Complaint Number 3036496.

Based on record review, interview, and facility policy review, the facility failed to prevent a significant medication error for Resident #31, when routine and as-needed medications for end-of-life comfort were unavailable for administration. This affected one Resident (#31) of five residents reviewed for medication administration. The facility census was 45.Findings include: Review of the medical record for Resident #31 revealed an admission date of 11/30/24. Diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus, and chronic respiratory failure with hypoxia. Resident #31 passed away at the facility on 06/13/26. Review of the care plan dated 04/20/26 revealed Resident #31 was experiencing a significant decline in health status related to terminal illness. Interventions included to administer all medications as ordered and provide a supportive, private environment for resident and family. Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had a severe cognitive impairment with a memory problem and required extensive assistance for all activities of daily living. Review of the physician's orders dated 06/11/26 revealed orders to administer Morphine (an opioid analgesic commonly used for end-of-life comfort measures) 20 milligrams (mg)/5 milliliters (ml), administer 5 mg (0.25 ml) every four hours routine (scheduled for 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M.) for respiratory distress, and an additional order for Morphine 5 mg (0.25 ml) every two hours as needed for respiratory distress. Resident #31 had an additional order dated 03/06/26 for Lorazepam (also known as Ativan, an antianxiety medication commonly used for end-of-life restlessness) 0.5 mg one tablet by mouth every 4 hours as needed for agitation, restlessness, or anxiety. Review of the outside hospice nursing note dated 06/11/26 authored by Hospice Nurse #210 revealed a facility nurse attempted to administer medications to Resident #31 crushed in applesauce. Resident #31 was unresponsive at the time with deep shallow respirations. Her respiration rate was 27 breaths per minute. Hospice Nurse #210 asked the facility nurse not to continue to attempt to administer oral medications as Resident #31 was no longer responsive and may aspirate the applesauce as she was mouth breathing. The facility nurse proceeded to place the applesauce in Resident #31's mouth when Resident #31's daughter verbally requested the nurse leave the room. The facility nurse handed Hospice Nurse #210 the Morphine syringe and told her to give it then. Hospice Nurse #210 administered Resident #31's Morphine dose at 10:00 P.M. and attempted to remove the applesauce out of Resident #31's mouth as she was not swallowing it and continued mouth-breathing. Hospice Nurse #210 then left Resident #31's room and went to speak to the facility nurse who was placing her cart in the closet stating she was leaving the facility. A follow up note authored by Hospice Nurse #210 revealed the facility nurse locked her keys in her cart and left the building. Resident #31's daughter had notified the Director of Nursing (DON). Hospice Nurse #210 indicated hospice staff would stay with Resident #31 until management staff arrived. Review of Resident #31's Medication Administration Record (MAR) for June 2026 revealed the routine dose of Morphine due at 06/12/26 at 12:00 A.M. was marked as not administered. Review of an outside hospice notes dated 06/12/25 at 2:43 A.M., 3:00 A.M., and 4:00 A.M. authored by Hospice Nurse #225 revealed Hospice Nurse #225 took over care and was at Resident #31's bedside. The note referenced a locksmith arrived to the facility and gained entry to the medication cart at 2:52 A.M. The note referenced the DON and Licensed Practical Nurse (LPN)/Clinical Manager (CM) #101 was present in the facility working to obtain the resident's Morphine and Ativan. A subsequent note timed 3:00 A.M. revealed LPN CM #101 medicated Resident #31 with doses of Morphine and Ativan [on 06/12/26] at 3:00 A.M. for comfort and dyspnea. The note referenced after administration [on 06/12/26] at 3:30 A.M., Resident #31's respirations were now 16 (breaths per minute) and accessory muscle usage (the use of extra muscles in the neck, chest, and/or stomach to help with breathing; accessory muscle use indicates your primary breathing muscles such as the diaphragm are fatigued and signals the body is struggling to take in enough oxygen) had decreased. The note referenced Resident #31's family members remained at bedside and voiced concern regarding the patient's breathing pattern. Hospice Nurse #225 provided family education that it may take a few consistent doses of Morphine and Ativan for accessory [muscle] use to resolve, as Resident #31 went several hours without medications due to events in the facility earlier in the evening. Interview on 06/16/26 at 1:38 P.M. with the Administrator, Assistant Director of Nursing (ADON) #100, and LPN CM #101 revealed the Administrator reported she got a call around 10:00 P.M. [on 06/11/26] that Resident #31's family was very upset about the care RN #107 was providing. She reported she then reached out to her clinical staff and ADON #100 reached out to RN #107and informed her to go administer the Morphine to Resident #31. Around 12:00 A.M., LPN/CM #101 then received messages that RN #107 could not be located in the facility. LPN/CM #101 reported she got dressed and went to the facility and began reaching out to RN #107 who would only respond by text message. RN #107 informed LPN/CM #101 that she had counted the medications with the other nurse working the first floor and locked the medication carts along with the keys in the second-floor medication room and left the facility. When MDS Nurse #100 arrived at the facility she had no keys to unlock the medication room. She notified the maintenance supervisor who then came to the facility around 1:00 A.M. He was able to unlock the medication room, but they could not unlock the medication carts. They reached out to the pharmacy who stated they could not send someone until the morning, so the staff reached out to a 24-hour locksmith who arrived at the facility around 2:30 A.M. He was able to get the medication carts unlocked around 3:10 A.M. and then they were able to administer medications to Resident #31. LPN CM #101 confirmed Resident #31 who was actively dying in hospice care did not receive their routine dose of Morphine due 06/12/26 at 12:00 A.M., nor any additional as-needed doses of any medications as no medications were available. Review of the facility policy titled Storage of Medications revised November 2020, revealed drugs and biologics were to be stored in a locked compartment and only persons authorized to prepare and administer medications were to have access to locked medications. Review of facility policy titled Administering Medications revised April 2019 revealed medications were to be administered in accordance with prescribers orders, medication errors were to be documented, reported, and reviewed by the Quality Assurance Performance Improvement (QAPI) committee and the individual administering the medication was to check the dosage. This deficiency represents non-compliance investigated under Complaint Number 3044559.

Based on interview and record review the facility failed to maintain an accurate and complete medical records which included documentation of resident to resident altercations. This affected two residents (#6 and #47) of three residents reviewed for abuse. The facility census was 45. Findings include: 1.Review of Resident #6's medical record revealed an admission date of 12/22/25. Diagnoses included depression, bipolar disorder, and mood disorder.Review of a care plan dated 01/16/26 revealed Resident #6 was prone to anger and aggression and had poor coping skins and due to serious mental illness and underdeveloped coping skills, anger is often misplaced on others. Interventions included be attentive to angry and aggressive behaviors, use appropriate word choices and tone of voice, set limits on specific behavior, document all behaviors and their responses to interventions. Resident #6 was at risk for behaviors that can be physically or emotionally harmful to self or others that included physical altercations with others. Interventions included intervene early to calm resident and defuse potential incident. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had intact cognition. Resident #6 required supervision with eating, toileting, bathing and was independent with ambulation.Review of Resident #6's progress notes from 06/08/26-06/22/26 revealed no documentation indicating the resident had been involved in any resident to resident altercations.2. Review of Resident #47's medical records revealed an admission date of 06/16/26. Diagnoses included post traumatic stress disorder, anxiety, and schizophrenia.Review of a care plan dated 06/16/26 revealed Resident #47 had behavioral symptoms not easily altered and potential harmful to others and had false ideas and had become agitated at times with staff and residents. Interventions included offer non-pharmacological interventions including calming touch, 1:1 distraction and removing from overstimulating environments. Review medications with the physician to ensure the resident is at behavioral baseline, administer medications as ordered, monitor mood and behaviors, and monitor for increased stimulation that may trigger agitation.Review of the MDS assessment dated [DATE] revealed Resident #47 had intact cognition. Resident #47 was recorded to have verbal and physical behaviors and delusions. Resident #47 required supervision with toileting, bathing and ambulation.Review of Resident #47's progress notes from 06/16/26-06/21/26 revealed no documentation indicating the resident had been involved in any resident to resident altercations.Telephone interview on 06/22/26 at 9:10 A.M. with Certified Nursing Assistant (CNA) #132 revealed on the evening of 06/13/26 between approximately 6:30 P.M. and 7:30 P.M., Licensed Practical Nurse (LPN) # 125 had made her aware Resident #47 had punched Resident #6 in the head with her fist. CNA #132 stated she had not witnessed the altercation and she had not observed any injuries to Resident #6. Interview on 06/22/26 at 11:18 A.M. with LPN/Clinical Manager (CM) #101 revealed she had not been made aware of an altercation between Resident #6 and Resident #47. LPN/CM #101 stated if an altercation would have occurred, a progress note should have been written that included information regarding the incident and notification to the physician and family/guardian. LPN/CM #101 had reviewed Resident #6's and #47's medical records and confirmed no documentation regarding any altercations was in either record. LPN/CM #101 further stated if an altercation would have occurred, a risk assessment should have been completed. LPN/CM #101 had reviewed the risk assessments and had located one created on 06/13/26 (untimed) by LPN #125. LPN/CM #101 confirmed the risk assessment was not complete and had not included any information of the alleged incident.Interview on 06/22/26 at 11:33 A.M. with the Director of Nursing (DON) revealed he had not been made aware of any altercations involving Resident #6 and #47 on 06/13/26. DON stated if a resident to resident altercation had occurred, there should have been a progress note written regarding the incident and notification to the physician and family/guardians. The DON further confirmed the risk assessment dated [DATE] completed by LPN #125 was not complete and had not included any specific information or notification to the physician or guardian. Interview on 06/22/26 at 12:50 P.M. with Resident #6 revealed a few weeks ago as she was ambulating in the hallway Resident #47 had punched her in the face. Resident #6 stated no staff were present to witness the altercation, however she had told an (unspecified) aide a little while after about what had occurred.This deficiency represents non-compliance investigated under Complaint Number 3047818.

Based on record review, review of the Self-Reported Incident (SRI), interviews and review of facility policy, the facility failed to ensure that Resident #41 was adequately supervised to prevent elopement and risk of accident hazards. This affected one resident (#41) out of three residents reviewed for accident hazards. The facility census was 44.Findings include:Review of the medical record for Resident #41 revealed an admission date of 09/01/25 with pertinent diagnoses including schizoaffective disorder bipolar type, delusional disorder, obsessive compulsive disorder, auditory hallucinations, unspecified dementia moderate with other behavioral disturbance, generalized anxiety disorder, homicidal ideations, and attention deficit hyperactivity disorder.Review of Resident #41's care plan, initiated on 09/09/25, revealed Resident #41 exhibited symptoms that were not easily altered and potentially harmful to the resident or others and wandered with no discernable, rational purpose. Goals included staff will be aware of resident's whereabouts at all times, and resident will not wander from unit. Interventions included giving medications per physician order; monitor mood, affect, and behaviors with all hands-on care and contacts; encourage to verbalize feelings. Give positive, realistic feedback; take resident on supervised walks inside or outside the facility weather permitting; allow the resident to utilize enclosed patio, garden, outdoor walking path weather permitting; and psych services as needed.Review of Resident #41's modified quarterly Minimum Data Set (MDS) assessment, dated 02/10/26, revealed the resident was severely impaired cognitively; exhibited fluctuating inattention and disorganized behaviors; had hallucinations and delusions; exhibited other behavioral symptoms not directed toward others on a daily basis; wandered daily; and was independent for mobility, which included being able to walk 150 feet without any assistive devices. Further review of Resident #41's medical record revealed a progress note dated 03/31/26 and time stamped 8:30 P.M. which stated while out in the courtyard smoking, resident walked up to the gate and pushed it open and ran. CNA (Certified Nursing Assistant) ran after her. The resident ran and made it to the sidewalk by the street until the CNA yelled stop! Resident turned around quickly and put her fists up. CNA talked to the resident and said it was not safe. Resident #41 had stated, I don't want to be here anymore let's go play in traffic, its ok you can go with me, we can go together and be free. The resident was then able to be brought safely back into the building.Review of Resident #41's progress note dated 04/18/26 and time stamped 4:33 P.M. revealed Resident #41 was taken out to smoke break by an Activities Aide at 1:15 P.M. At 1:37 P.M. a CNA (name removed) had went to lunch break and noted Resident #41 walking down Market Street. The CNA immediately called the facility and spoke with the nurse. The CNA attempted to get Resident #41 to stop and get in the car with her to keep her safe and back to facility. Resident #41 refused and started running. Nurse arrived, police were called, and EMS (Emergency Medical Services) called. Resident #41 became aggressive with the CNA and nurse while they were trying to stop her from running. The resident picked up rocks, was hitting staff, biting, punching, broke nurse and CNAs' glasses, and was trying to stab the nurse with a pen. The nurse had to restrain the resident for residents own safety until police arrived and handcuffed resident. Resident #41 had been wrestling with staff and running barefoot, down the road, over gravel, and through a junk yard. Police met EMS at the facility and the resident was transferred to [NAME] Orrville for evaluation and treatment. The guardian, administrator, and MD (Doctor of Medicine) were all notified of the incident. A new order was received from the MD for lorazepam (an anti-anxiety medication) one milligram (mg) three times a day (TID) as needed (PRN), and 15min checks upon return until further notice.Review of Resident #41's progress notes dated 04/18/26 and time stamped 5:30 P.M. revealed the facility had received a call from a nurse at the hospital. After an evaluation of Resident #41, there were no signs or symptoms of distress, and all evaluations were negative. An order has been placed for Resident #41 to be transported back to the facility from the hospital.Review of the facility's April 2026 Incident Tracking Log revealed on 04/18/26 Resident #41 had an elopement from the facility.Review of the Ohio Department of Health's Application Gateway website revealed the facility had created a Self-Reported Incident (SRI) number 273478 on 04/18/26 at 2:18 P.M. and completed on 04/21/26 for an allegation/suspicion of neglect/mistreatment abuse, which stated on 4/18/26 at approximately 1:30 P.M. it was reported that Resident #41 left facility property after a scheduled, sanctioned smoke break. Activities Aide (AA) #377 who monitored the smoke break had successfully escorted all 10 first-floor smoking residents back inside the facility, into their locked unit. Headcounts were completed by AA #377 before taking the residents outside to smoke and completed upon bringing them back inside on the unit; both counts accounting for all 10 smoking residents. After all 10 smoking residents were back on their unit, AA #377 left the unit, stating that no residents were by the door when she left, and then went back upstairs to continue to complete her assigned activities aide tasks. The first-floor unit was a locked unit, with the door at-the-time automatically locking after 30 seconds of entering the code. Within that 30 second timeframe, Resident #41 was able to exit the first-floor unit without any alarms sounding and allegedly walked out of the front door and out onto the street sidewalk. From there, CNA #335 witnessed Resident #41 walking down [NAME] Market Street and attempted to persuade Resident #41 to go to McDonald's with her. At 1:37 P.M, CNA #335 placed a call to the facility to notify the nurse on duty that Resident #41 was located and to request assistance to bring the resident back to the facility. LPN #324 left the facility to assist CNA #335, where they both followed and monitored Resident #41. LPN #324 exited her vehicle and ran after Resident #41, while attempting to persuade her to go back to the facility with her. CNA #335 proceeded to follow LPN #324's lead and exit her vehicle as well, attempting to bring Resident #41 back to the facility safely. Resident #41 was noncompliant with LPN #324 requests, continuously looking back at LPN #324, and running further away. Resident #41 then became physically combative with both staff members; breaking both of their eye glasses and hitting, biting, and kicking LPN #324. At 1:48 P.M., CNA #335 called Orrville Police for assistance, who quickly arrived at their location, detained Resident #41, and escorted her safely back to the facility. The facility then called EMS to have her taken out to the hospital and evaluated. Resident #41 was evaluated and returned the same day with no new orders given and no injuries noted. Resident #41's legal guardian and medical director were both notified about the incident involving the resident. Medication orders were updated and implemented as ordered. ADON #317 interviewed Resident #41 regarding the incident upon return to the facility on 4/18/26. The resident stated that she was apologetic for what had happened and thought peers didn't want her in the facility because she perceived them as not looking at her during their scheduled smoke break. Resident #41 was reported at baseline and denied any pain, discomfort, or stress. On 4/20/26, the Administrator interviewed Resident #41 to which resident stated that she wanted to stay in the rain outside and that her book was calling to her to leave the facility. Resident stated that she felt as if Administrator was present with her during the entire incident and was just leaving to get her book from her old home in [NAME] and bring it back. Resident mentioned her father, whom the court ordered she was not allowed to visit, resided at the [NAME] home she was attempting to get to. Resident stated she did not want to leave the facility and that she felt good and was noted to be at baseline with no signs of visible injury or distress. Further review of the SRI revealed the facility had unsubstantiated the allegation since evidence had not indicated abuse, neglect, or misappropriation had occurred.Review of Resident #41's elopement risk assessment, dated 04/18/26, revealed the resident was at risk for elopement since the resident has a history of wandering/elopement; verbalized a strong desire to leave; had a diagnosis of dementia; and exhibited high level of anger or frustration. An interview on 05/01/26 at 9:38 A.M. with AA #377 revealed she normally did the smoke breaks while she was working at the facility. The normal procedure for smoke breaks was to gather the residents and tell them it was smoke time. She would then line the residents up who go and smoke, take them to the courtyard where they smoked, and hand the residents a cigarette and then light it for them. Smoke breaks normally last 10 to 15 minutes depending on how long it takes residents to smoke their cigarette, and then she would line them back up to take back to their unit. She normally counted the residents before and after the smoke breaks. On 04/18/26 she lined everyone up after they were done smoking. She thought she had counted ten residents. After she brought them all in, she counted ten residents. The smoke break had started at 1:15 P.M. and she brought them back maybe around 1:30 P.M. She counted everyone when they came in from that same break and then left the unit to go grab the cart for snacks. When she got back to the unit, that was when they noticed Resident #41 was gone. She assumed Resident #41 was in the line and taken back to the unit, but she hadn't seen her exit the courtyard. She confirmed she hadn't waited to make sure the keypad from the door from the unit to the hallway had turned red to ensure the lock had reset until she left the door to the unit to go and get the snack cart. AA #377 stated Resident #41 could have gotten out through that door before the door had locked and went through the front door. Since the incident, AA#377 stated the facility now has two staff members observe smoke breaks, and one of the staff stands by the gate of the courtyard.An interview with Guardian #400 on 05/01/26 at 10:11 A.M. revealed Resident #41 had escaped from a previous facility she had been residing at in Akron.An interview with LPN #324 on 05/01/26 at 10:25 A.M. revealed a couple weeks prior to the elopement incident Resident #41 had escaped from a fence door in the courtyard. The aide was able to redirect and get Resident #41 back into courtyard and bring her back to facility. When she talked to maintenance about putting a lock on the fence after that happened, he said he couldn't lock the gate to the courtyard but could put a code on it. LPN #324 stated no changes came after that incident on 03/31/26. Prior to the 1:15 P.M. smoke break on 04/18/26, the resident had asked to use a phone. She dialed number and said she was talking to her sister. The resident got off the phone and lined up and went to smoke. LPN #324 saw them counting on the way out. At 1:37 P.M. on 04/18/26 the phone rang and it was CNA #335 telling her that Resident #41 was off the facility property and was close to Market and [NAME] Street. When LPN #324 had gotten the call from CNA #335, LPN #324 told CNA #338 to contact the upstairs nurse that she was leaving facility and to call the police and that someone escaped and the approximate area where that resident had been found. LPN #324 then called CNA #335 to see what area they were in and jumped into her car and drove to Terminal and Elm streets. Resident #41 was in the yard of a house. LPN #324 stated she parked along the road and tried to persuade Resident #41 to take a ride with the CNA #335. At that point she got closer to the resident and then the resident took off running. LPN #324 ran after her, and CNA #335 was still in her car. Resident #41 ran into a junk yard. LPN #324 followed her into junk yard. It was cold and rain poured down and the resident had no shoes on. LPN #324 stated she didn't know where the resident's shoes went. At that point, CNA #335 was also now running after the resident. Resident #41 then hit CNA #335 in the face and twisted her glasses. LPN #324 was then able to bear hug her, but the resident then bit her. They then went down to the ground, and the nurses pens fell out of her pocket, and the resident tried to grab one of the pens to possibly use as a weapon. The resident was picking up rocks and was trying to hit her. The resident's safety was LPN #324s' first concern. CNA #335 and LPN #324 were able to contain her until the cop pulled in. When the resident saw the cop, the fight went out of her; she said hi; and then held hands out for him to cuff her. The cop took her back to the facility and then EMS took her for evaluation at the hospital. The resident came back the same day. The next day LPN #324 worked, the resident gave her a hug and apologized. LPN #324 asked her how she got out and the resident told LPN ##24 that she got out of fenced gate during smoking and denied ever coming back from smoke break. LPN #324 stated the resident does talk off the wall at times but other times she was with it and it depended on who you are if she makes sense. Resident #41 vaped and went out during smoke breaks to vape. Since the incident, two staff members have to observe smoke breaks, staff were educated to ensure they making sure door locks are reset before walking away from the doors, and the time it takes to reset the door lock once the code was put in for the door leaving the first floor unit to the hallway was decreased from 30 seconds to 10 seconds.An interview on 05/01/26 on 11:05 A.M. with CNA #335 on 04/18/26 revealed the CNA was working on 04/18/26 and went out at approximately 1:30 P.M. for her lunch break. At that time, it was down pouring rain, and she sat in her car for a couple minutes waiting for the rain to die down. She then exited the parking lot and turned right onto Crownhill Street and right again on Market Street. Resident #41 has a noticeable walking gait, and the CNA saw her from behind. When she passed the resident in her car, Resident #41 was bare foot and had short shorts, a tank top and a cardigan. When the CNA saw her, she pulled into a driveway and said, Hey girl lets go get McDonalds, Resident #41 screamed no and ran down a side street. The CNA then pulled into random driveways and Resident #41 went down Mohican Street and threw her cardigan into a random yard. The resident was snaking through houses running up driveways and then behind houses. They ended up on Terminal Street. The CNA had called the facility when she was on Market Street to alert them, and that was when LPN #324 came out in her vehicle and caught up with them on Terminal Street. There was a house with a car port and chain link fence which cornered the resident. The CNA and LPN tried to talk to her and she screamed and ran again. LPN #324 followed on foot and the CNA followed in car and they ended up in a junk yard where there were dumpsters with jagged sheet metal pieces on the ground and gravel. Resident #41 and LPN #324 traveled straight and the CNA went the opposite direction around the dumpsters. They met in the middle and Resident #41 came after her with both fists. CNA #335 caught the resident's fists and then Resident #41 grabbed CNA #335 's glasses off of her face, crunched them, and held them between her legs. That was when LPN #324 came from behind and bear hugged her. Everyone ended up on the ground. LPN #324 was able to get control of the resident, and the CNA ran to a phone and called 911. The facility had already called 911. While on phone with 911, Resident #41 was grabbing gravel and trying to smash the gravel into LPN #324's face. The CNA grabbed the resident's hands so she couldn't hit LPN #324 in the face. Within two to three minutes of LPN #324 and CNA #335 having control of the resident, the officer showed up. At that point the resident completely relaxed, and the officer then took over. Resident #41 told LPN #324 and CNA #335 the next day that she slipped out the smoking gate. The resident said she got out right when they first went out to smoke. CNA #335 stated she was leaving the unit as they were lining inside the hallway to come into the unit when she left for her break, and not everyone was in the building yet from the smoke break. The CNA hadn't noticed if Resident #41 had been in that line. CNA #335 stated Lord knows where she would have ended up if I hadn't seen her. Since the incident, the facility has alerted staff to be more vigilant with the doors of the unit, two staff members now monitor smoke breaks with one standing in front of the gate in the courtyard, and the timer on the one door got changed from 30 to 10 seconds.An interview with the Administrator via phone on 05/01/26 at 12:27 P.M. revealed she had unsubstantiated the allegation since the facility had found the resident pretty quickly and Resident #41 hadn't shown any injury or emotional distress from the incident. The Administrator verified Resident #41 snuck out the door from the unit to the hallway after coming back from a smoke break before the secure door was reset. Review of the facility document titled Smoking Headcount log on 05/01/26 at 1:44 PM with the Director of Nursing (DON) revealed the document had vertical columns for date, time, # 'R' out and #'R' in . On 04/18/26, there was no documentation for any of the smoke breaks that day, which included the 1:30 P.M. smoke break. The DON confirmed at the time of the review, there was no proof that the residents had been counted upon return from the 1:30 P.M. smoke break on 04/18/26.Review of the facility policy titled Smoking Policy, revised April 2024, revealed it was the policy of the facility to ensure a safe living environment for all residents and all residents will be supervised and monitored by facility staff while smoking during facility designated smoking times. The use of a vape pen was limited to the length of the smoking session in the dedicated area and would be returned to staff prior to reentering the facility.This deficiency represents noncompliance investigated under Complaint Incident Number 2988942.

Based on interviews, review of the facility assessment, and staff schedule review the facility failed to ensure a full time Director of Nursing (DON) was employed by the facility and involved in direct oversight of nursing services. This had the potential to affect all residents in the facility. The facility census was 44.Findings include: Review of the staff schedule from 04/06/26 through 04/12/26 revealed the interim DON, Registered Nurse/DON #450, was in the facility for 11 hours on 04/07/26.An interview on 04/13/26 at 8:34 A.M. with the Assistant Director of Nursing (ADON) (a Licensed Practical Nurse) revealed DON #500 was terminated in February for a bunch of different reasons. DON #450 was the DON at another building but came to the facility once or twice a week to assist the ADON. Clinical Registered Nurse (RN) #104 was the RN in the building for eight hours Monday through Friday. There were RNs that were weekend workers to ensure there were RNs seven days a week, but none were the facility DON. Interview on 04/14/26 at 10:25 A.M. with DON #450 revealed she was in the facility one to two days a week since the last DON was terminated on 02/09/26. She reported the plan was for the ADON to take over as the full time DON once she finished nursing school next year.Interview on 04/14/26 at 11:46 A.M. with the Licensed Nursing Home Administrator (LNHA) verified the facility did not have a full-time DON. She reported the plan was to move the ADON into the DON position when she finished school (RN degree) next year. The LNHA also verified there were no company job descriptions for positions held in the facility.Interview on 04/15/26 at 8:45 A.M. with Licensed Practical Nurse (LPN) #120 revealed the facility did not have a full-time DON. The current/interim DON was in the facility one to two times a week. She reported if issues arose she contacted the Assistant DON.Interview on 04/15/26 at 9:00 A.M. with LPN #112 revealed the facility did not have full-time DON. The current DON (DON #450) was in the facility one to two times a week. She reported if issues arose she contacted the Assistant Director of Nursing (ADON) who was a Licensed Practical Nurse (LPN).An interview on 04/15/26 at 9:36 A.M. with Registered Nurse (RN) #104 confirmed he was not the facility DON, interim DON or functioned in the DON capacity.The facility did not have a job description for the Director of Nursing or Assistant Director of Nursing.Review of the facility assessment with the most recent update of 03/2026 and the assessment was reviewed in Quality Assurance Performance Improvement/QAPI was 03/26/26 revealed no DON listed as persons involved in completing the assessment. Further review revealed the interdisciplinary team (IDT) consisted of the Director of Nursing (DON) who assisted in the review of all referrals to the facility and the IDT members must agree that the resident's placement is appropriate on that the facility has access to and/or the available resources required to ensure the care needs and expectations for the standard of can be reasonably met. Under facility resources needed to provide competent support and care for our resident population every day and during emergencies the facility agreement expressed the facility did not use any agency staff nor does it carry any staffing waivers. All direct care and/or supportive staff are employed directly by the facility (this does not include contracted services such as hospice). At a minimum, the facility will provide staff to ensure care needs are met, the physical plant is maintained in a safe and sanitary manner, food is appropriately prepared, managed and served, psychosocial needs are addressed and daily administrative operational tasks are accomplished. Staff classification necessary to meet the aforementioned task(s) are as follows: Administrator and administrative support personnel (business office and general reception); DON; Infection Preventionist; MDS Coordinator; Social Service Designee; Environmental Services, RN, LPN, Certified Nursing Assistants (CNA); Culinary Personnel; Activities Staff; Therapy Staff; Registered Dietician and Contracted Staff (Medical Control, Pharmacy Services, Hospice and ancillary providers).This deficiency represents non-compliance investigated under Complaint Number 2565095.

Based on personnel record review, and interview, the facility failed to be effectively and efficiently administered in a manner that allowed all residents to attain or maintain their highest level of well-being when the administrator failed to ensure concerns regarding Director of Nursing (DON) #500's (who was part of the facility administration) performance and allegations of DON #500 working under the influence of alcohol were thoroughly investigated and timely and necessary protective measures were implemented to safeguard the residents. This had the potential to affect all 44 residents who resided in the facility.Findings include: Review of the personnel file for Director of Nursing (DON) #500 revealed she was hired on 04/30/25 and terminated on 02/09/26. The personnel file revealed no evidence of reference checks being completed. In addition, there was no written job description for the Director of Nursing (DON) in the employee's file nor was a job description available to review during the onsite survey. Record review revealed there were no termination documents located in the personnel file and no written information related to the reason for DON's termination was provided during the onsite survey.Review of DON #500's personnel file revealed an associate performance appraisal was completed by the Administrator on 09/19/25 (a three month evaluation). Goals and/or projects included ensuring the schedule was done properly, keeping reaching out to support systems when there were questions, continuing to want to learn and improve, staying up to date with State Survey Agency regulations and documentation for survey, and continuing to work on staffing/retention. The evaluation noted, as the DON, you have a challenging group to manage, keep your open-door policy. How your department performs reflects your leadership. Record review revealed no indication for how the DON's performance would be monitored for these goals and/or projects following the evaluation period.A typed statement dated 01/13/26 by Social Service Designee (SSD) #116 to the Administrator revealed over the last couple of months there had been a lack of communication, support, and attendance by DON #500. SSD #116 had to answer challenging questions and step up to manage residents' medical questions/concerns. DON #500's lack of communication and follow through with issues/concerns with family members was concerning because it showed more of the disconnect in the facility. The past couple months had been challenging with lack of communication. SSD #116 had been transparent with the lack of communication for clinical matters including falls, specifically for the fall screens for the therapy department. There had been no fall reports for the last couple of months. In addition, the statement revealed on 12/30/25, DON #500 had a stench of alcohol and showed up for work at 11:00 A.M. The typed statement continued indicating there was so much SSD #116 could go on about with orders, advanced directives, and concerns brought to DON #500's attention that were ignored. DON #500 stated she was too busy to deal with situations. There was a big concern with staff because tenured staff were leaving because they could not get their concerns handled. New nurses reported they were unable to get ahold of DON #500 when there were concerns about the residents. DON #500 lied about things being done and being at the facility but leaving early or coming in late. It had come to the point where residents reported that nursing staff refused to give showers. SSD #116 gave showers to decrease the residents' stress. When SSD #116 reported showers were not being given, she was blown off (by DON #500) and told it was a nursing concern and would be handled. Residents were reporting they never saw or knew who DON #500 was. Record review revealed there was no further information regarding specific incidents, residents interviewed or details about the DON's leaving early or coming to work late. In addition, there was no evidence concerns identified on 12/30/25 related to DON #500 were investigated and/or addressed. Review of an undated typed statement from Behavioral Health #325 to the Administrator revealed Behavioral Health #325 was writing to formally express ongoing concerns with DON #500 based on observations and experiences over the past several months. Behavioral Health #325 witnessed a consistent lack of attendance and significant breakdown in communication with staff. As an outside contracted provider, effective and timely communication with the DON was essential to perform Behavioral Health #325's role and ensure appropriate care for the residents. Unfortunately, this had not been possible. I (Behavioral Health #325) personally observed behavior that raises serious concern, including smelling alcohol on DON #500's breath on multiple occasions. The statement included I clearly recall smelling it on 12/30/25. Recently an aide informed me that staff were instructed not to speak to me regarding residents. When I asked who gave this instruction, the aide stated it was DON #500. The statement included as a contracted outside provider, I must be able to communicate with facility staff to fulfill my responsibilities effectively and ethically. (My) residents come first, and any restriction on appropriate communication interfered with their care. Based on my observations, there were serious concerns regarding professionalism, reliability, and the overall work environment. I do not feel I can communicate effectively with DON #500 nor do I feel confident in her availability or conduct. The situation had made it increasingly difficult for me to do my job appropriately within the facility. Record review revealed there was no administrative follow-up provided related to this statement to include dates and/or evidence these ongoing concerns with DON #500 had been investigated or addressed. A typed statement dated 01/15/26 by the Assistant Director of Nursing (ADON) revealed that since stepping into the ADON role there had been a lot of issues. Some of the issues involved DON #500. On the first day of being ADON, DON #500 did not show up. When the Administrator was on vacation, DON #500 was rarely in the building. When DON #500 was at the facility, there were constant breaks to go smoke, lack of follow up, and lack of addressing concerns. When I took this position, I was told I would not be on call. My phone rings at all hours of the day and night because staff are unable to get ahold of DON #500. DON #500 has left the building knowing there were not enough staff. Yesterday, the nurses had called me upset because they were short staffed. DON #500 came in for an hour and a half and then left. We are short again today, it is 10:00 A.M. and DON #500 is not here. Several of the nurses were new and had expressed concern and frustration that if something happens, they cannot get ahold of their leader, the one who was supposed to guide them. DON #500 takes the day off, comes in late, or complains about working the weekend but does not work the weekend. Record review revealed there was no additional information provided regarding additional nurse or staff interviews to identify specific concerns the staff had or dates of reported occurrences. The facility did not have any investigation to provide as requested related to the DON's performance.A performance improvement/reset plan signed by Corporate Human Resource Director, the Administrator and DON #500 on 01/15/26 revealed the following concerns had been substantiated through reports, observation, and leadership feedback: failure to meet state-mandated Registered Nurse (RN) coverage requirements, unreliable physical presence in the building during assigned work hours, removal of self from on-call responsibilities without approval, unprofessional conduct toward staff, including yelling, swearing, and refusal to assist during staffing shortages, creating unsafe staffing conditions resulting in staff working excessive hours, allegations of reporting to work smelling of alcohol, dishonesty and misrepresentation of work activities, retaliation against employees who raise concerns, undermining the chain of command resulting in Certified Nursing Assistant (CNA) insubordination, breakdown in communication with leadership and staff, and loss of nursing staff and risk of additional resignations. Record review revealed following the identification and development of this improvement plan, there was no evidence the Administrator and/or Corporate Human Resource staff implemented a plan to monitor DON #500's performance and/or behavior. An interview on 04/13/26 at 2:01 P.M. Certified Nursing Assistant (CNA) #139 revealed the CNA had smelled alcohol on DON #500 several times. CNA #139 stated if you reported anything about the DON, you could be written up or fired. The CNA stated staff were afraid of the DON. An interview on 04/14/26 at 7:37 A.M. SSD #116 revealed concerns with DON #500 being at work and smelling like alcohol which had been previously reported to the Administrator and Corporate staff. SSD #116 revealed most recently (in December 2025) this concern was reported Corporate Human Resource Director (the Administrator was on vacation). SSD #116 revealed both she and MDS Coordinator #122 noted the smell of alcohol on DON #500. SSD #116 revealed she was performing resident showers because the staff were not doing scheduled showers. SSD #116 stated there were a lot of things DON #500 did not report, including falls. The nurses could leave medications in resident rooms and cut corners on care and DON #500 would not address the infractions. SSD #116 stated DON #500 came to the facility initially as the ADON. DON #500 was friends with the person who was the DON at that time. That DON left and DON #500 became the facility DON. SSD #116 stated she believed the Administrator had reached out to corporate staff for guidance on how to address the concerns with DON #500. SSD #116 revealed the DON would terminate staff or not schedule them to work if anything negative was said about the DON. The SSD revealed staff were afraid of the DON. An interview on 04/14/26 at 10:17 A.M. with CNA #152 revealed they noticed an odor of alcohol on DON #500 when she was passing medications. However, CNA #152 could not recall the date or time of this incident. An interview on 04/14/26 at 2:42 P.M. with LPN #122 revealed she saw DON #500 daily and DON #500 smelled of alcohol whenever the Administrator was not at the facility. LPN #122 stated she reported the concerns to the Administrator. She stated she was told it was a serious accusation to make without proof. LPN #122 stated DON #500 kept missing work and coming in late. On 12/30/25, DON #500 came into work around 11:00 A.M., was slurring her words, and the odor of alcohol could be smelled without being next to DON #500. The Administrator was on vacation and Corporate Human Resource Director was notified but DON #500 left before anyone could request DON #500 go to the hospital for drug/alcohol testing. LPN #122 stated in January 2026 DON #500 was still erratic and the concerns were again reported. However, the LPN did not feel Corporate Human Resource Director did much to help the Administrator with handling the situation. LPN #122 stated DON #500 had a driving under the influence charge but had driving privileges for work. People in the community were referring to the facility as the place with the drunk DON. Sometime after the incident was reported in December, DON #500 left the facility for two hours and returned smelling of alcohol. DON #500 would go sit in her car and smoke for long periods of time. DON #500 would smell of alcohol after smoke breaks. Interview on 04/14/26 at 3:05 P.M. with the Administrator revealed she got statements from SSD #116, MDS Coordinator #122, and Behavioral Health #325 who had concerns about DON #500 in December 2025 but not from any other staff. A reset was discussed with DON #500. However, there was no evidence an investigation was completed or evidence of the DON's performance/behaviors being monitored during this time. During the interview the Administrator revealed DON #500 did not follow the performance improvement plan/reset in various ways, so DON #500 was terminated. The Administrator verified there was no follow up about concerns with DON #500's attendance, clocking in and out, conduct and retaliation towards staff, aggressive behavior, and being free from any impairing substances. The Administrator revealed there were no audits of time punches, schedules, staffing, documentation, or interviews with staff and residents about DON #500 and concerns about her presentation or performance. Record review revealed no evidence the Administrator implemented timely and necessary protective measures to safeguard the residents related to concerns/allegations being made against DON #500.An interview on 04/16/26 at 11:34 A.M. with the Corporate Human Resources Director (CHRD) revealed she received phone call before Christmas that DON #500 reeked of alcohol. SSD #116 and MDS Coordinator #122 were asking for assistance with how to handle the situation since the Administrator was on vacation. CHRD stated she was one and half hours away and it was not feasible for her to drive to the facility. CHRD instructed SSD #116 and MDS Coordinator #122 to send DON #500 and/or have the DON get tested for alcohol if there were signs of impairment. However, MDS Coordinator #122 called the CHRD back and said DON #500 had left the facility before the staff could take DON #500 for testing or offer to drive her home. The CHRD stated she then talked to the Administrator about the incident (after return from vacation) and the Administrator said all she had from staff were rumors (please note, there was no documented investigation or additional follow up with residents or staff regarding the concerns from the staff as noted above). There was no additional information provided from the Administrator regarding increased monitoring of the DON or discussion with the DON regarding concerns until the improvement plan was created. The CHRD stated staff were interviewed and she had a long conversation with the Administrator; however, there was no documentation of this provided as part of the onsite survey investigation. The CHRD revealed DON #500 was ultimately terminated because she did not meet the expectations that were put in place which included lack of performance and profession conduct. This deficiency represents non-compliance investigated under Complaint Numbers 2572467 and 2565095

Based on record review, staff interviews, incident report review, and policy review, the facility failed to ensure Resident #37 received medication labeled with Resident #37's name. This affected one (Resident #37) of three residents reviewed for medication administration. The facility census was 44.Findings include: Review of the medical record revealed Resident #37 was admitted on [DATE] with diagnoses that included dementia with behavioral disturbance, metabolic encephalopathy, mood disorder, history of traumatic brain injury, and catatonic disorder. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #37 had severe cognitive impairment. Review of physician orders revealed Resident #37 was ordered clonazepam (benzodiazepine) one milligram (mg) at 6:00 P.M. and 12:00 A.M. Resident #37 was also ordered clonazepam 0.5 mg at 12:00 P.M. A nursing progress note dated 03/24/26 at 9:24 P.M. revealed Resident #37 received clonazepam one mg instead of 0.5 mg as ordered. Review of the facility investigation of Med Error: Wrong dose dated 03/24/26 revealed Resident #37 received clonazepam one mg dose instead of a 0.5 mg dose as ordered. An interview on 04/15/26 at 9:31 A.M. Assistant Director of Nursing (ADON) verified Registered Nurse (RN) #104 administered clonazepam one mg to Resident #37 as ordered but the clonazepam was taken from Resident #31's controlled medication card. An interview on 04/15/26 at 9:36 A.M. RN #104 stated he did not make a medication error because Resident #37 received the correct dose of clonazepam. RN #104 stated at first he thought it was a medication error because Resident #37 was ordered clonazepam 0.5 mg at 12:00 P.M. RN #104 verified he administered clonazepam one mg at 6:00 P.M. as ordered but took the clonazepam one mg from Resident #31's supply of controlled medications. RN #104 stated the error was caught at shift change when the controlled medication count was incorrect for Resident #31 and #37. RN #104 verified the five rights of medication administration included the right resident and the right medication. Administering Medications policy (no date) revealed the individual administering medications verify the resident's identity before giving the resident their medication. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method before giving the medication. This deficiency represents non-compliance investigated under Complaint Numbers 2565095 and 1399215.

Based on record review and interview, the facility failed to ensure a skin alteration was comprehensively assessed, monitored and a treatment was ordered after a fall. This affected one (Resident #45) of three residents reviewed for falls. Facility census was 44.Findings include: Review of the medical record revealed former Resident #45 was admitted on [DATE] with diagnoses that included chronic kidney disease, dysphagia, disorders. Resident #45 expired on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #45 had severe cognitive impairment.A nursing progress note dated [DATE] at 4:46 P.M. revealed Resident #45 was observed lying on the floor in front of her bed. The resident stated she rolled out of bed. Resident #45's right elbow was bleeding. The resident's elbow was cleansed with normal saline and steri-strips were applied and covered with dry clean dressing. Review of the treatment administration record (TAR) for June and July revealed no evidence of treatments being completed to Resident #45's right elbow. Review of the progress notes revealed no further documentation of the skin tear to the resident's right elbow. An interview on [DATE] at 10:12 A.M. the Assistant Director of Nursing (ADON) verified there were no treatments ordered or documented after Resident #45 received the skin tear on [DATE]. The ADON also verified there was no documentation of the size of the skin tear or any monitoring of the skin tear. This deficiency represents non-compliance investigated under Complaint Numbers 2572467 and 1399215.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and staff interview, the facility failed to maintain registered nurse (RN) coverage in the facility at least eight consecutive hours a day seven days a week as required. This had the potential to affect all 45 residents who reside in the facility. Findings include: Review of the nursing staff punch detail, nursing staff schedule, and payroll based journal (PBJ) submission for 12/22/23, 12/23/23, and 12/25/24 revealed no registered nurses were present working in the facility. Interview on 09/05/24 at 10:39 A.M. with Human Resources (HR) #105 verified the identified findings. The deficient practice was corrected on 04/01/24 when the facility implemented the following corrective actions: Beginning 03/01/24 Director of Nursing (DON)/Designee reviewed the current number of RN's employed by the facility and update the roster intermittently. Beginning 03/01/24 the facility would advertise for RN's on job recruitment sites and review daily. Beginning 03/01/24 the facility would audit daily scheduling sheets to ensure 8-hour RN covered was provided. Beginning 03/01/24 the DON would provided the 8 hour coverage in the event there was a call off to ensure the facility met state and federal regulation.

Based on observations, review of the medical record, facility investigation reports, facility policy and staff and resident interviews, the facility failed to provide adequate supervision to prevent elopement of one cognitively impaired resident (Resident #6). This resulted in Immediate Jeopardy when Resident #6 eloped from the facility on 08/16/18. The likelihood of serious harm or injury occurred when the resident was found outside the facility on the road in his wheelchair by State tested Nursing Assistant (STNA) #526 and Resident #28 at 7:45 P.M. on 08/16/18. This affected one of one resident reviewed for elopement. The facility identified five residents as at risk for elopement, (Resident #6, Resident #5, Resident #37, Resident #14 and Resident #19). The facility census was 40. On 09/06/18 at 3:04 P.M., the Licensed Nursing Home Administrator (LNHA) was notified that Immediate Jeopardy began on 08/16/18 at 6:30 P.M. when Resident #6, who had previously eloped from the facility on 08/07/18, was last seen and exited the facility without staff knowledge. The Immediate Jeopardy was removed on 09/07/18 when the facility implemented the following corrective actions: · On 08/16/18 at 7:45 P.M. STNA #526 and Resident #28 found Resident #6 outside of the facility in his wheelchair, on the road, and returned Resident #6 to the facility unharmed. · On 08/17/18 at 1:46 P.M., Resident #6 was moved to a new room on the second floor where he is unable to operate the elevator and would no longer be able to leave the facility unsupervised. · On 08/17/18, the LNHA provided verbal education to all facility staff related to resident safety and building security. · On 09/04/18, an elopement drill was conducted with seven staff members in the facility participating and signing the evaluation sheet. · On 09/07/18 at 8:30 A.M., the LNHA confirmed all 40 residents in the facility were reassessed for wandering and elopement risk on 09/06/18 with nine residents being identified as at risk for wandering and elopement. Of the nine residents identified, Resident #5, Resident #37, and Resident #14 resided on the first floor and had care plans reflecting wandering and possible risk of elopement. These residents had no documented exit seeking behaviors. · On 09/07/18 at 8:30 A.M., the LNHA confirmed staff education was completed with 83 out of 91 staff regarding the revised procedure for completing wandering/elopement risk assessment and messages were left for the remaining eight staff members. · On 09/07/18 at 8:30 A.M., the LNHA confirmed the facility's Travel Club book, the notebook used by the facility containing a list of residents identified as at risk for wandering and/or elopement, had been updated. A copy of this notebook was placed at the receptionist desk and the nurse's stations on the first and second floors. · On 09/07/18 at 10:00 A.M., the updated Travel Club notebooks were observed at the nurse's stations and at the receptionist desk. · On 09/07/18 between 9:30 A.M. and 11:45 A.M. the following staff from various shifts were interviewed and acknowledged being in-serviced and educated regarding the revised procedure for the elopement and wandering risk assessments, identifying residents at risk, and what to do if a resident elopes: STNA #509, STNA #507, STNA #528, STNA #505, Culinary Manager #523, Social Services #522, LPN #500, Business Office Manager #520, Therapy Director #502, LPN #503, LPN #506, Housekeeper #518, Housekeeper #529, Dietary Aide (DA) #530, DA #514, DA #512, Activity Aide (AA) #511, AA #531, Physical Therapy Assistant (PTA) #524, Maintenance Director #501, and Housekeeper #516. · On 09/07/18 at 11:52 A.M. STNA #532 was interviewed by telephone and acknowledged being in-serviced and educated regarding elopement and wandering risk assessments, identifying residents at risk, and what to do if a resident elopes. · On 09/07/18 at 12:09 P.M., the LNHA stated 87 total staff members had been educated regarding the revised procedure for the wandering/elopement risk assessments. 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 still in the process of implementing their corrective action plan including conducting in services for as needed staff and monitoring to ensure on-going compliance. Findings include: Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #6's quarterly Minimum Data Set (MDS) 3.0 assessment with an Assessment Reference Date (ARD) of 06/05/18 revealed Resident #6 had severe cognitive impairment with continuous inattention and disorganized thinking and fluctuating altered level of consciousness. Resident #6 also rejected care daily and wandered four to six days during the seven-day look back period. This assessment indicated Resident #6 required extensive assistance of one staff person for ambulation. Resident #6's care plan, which did not have an initiation date, had a target date of 09/13/18 and indicated Resident #6 was mobile in a wheelchair and expressed a desire to leave the facility unattended, had poor cognition, and was at risk for elopement and injury. Interventions in place included staff to post a sign in Resident #6's room reminding him not to leave the unit unsupervised, for staff to redirect him from the administration hallway, which was near the front entrance, throughout the day, to deter the desire to wander off the unit and go outside, for staff to attempt to find causative factors proceeding resident's attempts to leave and to eliminate/reduce these factors if possible, staff to escort him on walks outside or within facility, divert his attention if possible when he becomes insistent on leaving, do not agitate, find activities of interest to the resident, and schedule or provide equipment/supplies to him to prevent prolonged periods of idle time. A nursing progress note dated 07/12/18 at 10:01 P.M., authored by LPN #525, indicated Resident #6 exited a door which led into the enclosed facility courtyard. This was the first documented attempt Resident #6 made to leave the facility unsupervised, although it was into the courtyard. Facility staff found Resident #6 in the courtyard prior to the scheduled smoking time at 8:00 P.M. No new interventions were put into place to prevent Resident #6 from exiting any doors and he was not reassessed after this incident. Resident #6 eloped from the facility and was found outside the front of the facility near the busy two-lane road on 08/07/18. The posted speed limit for this road is 45 miles per hour. The nursing progress note dated 08/07/18 at 7:30 P.M., authored by LPN #525, revealed Resident #6 had wandered and was increasingly agitated when repeatedly assisted onto the unit. Resident #6's vital signs were normal with a heart rate of 87, respirations of 20, temperature of 98.0 and an oxygen level of 94%. Resident #6 refused to have his blood pressure taken. According to Accuweather.com the outdoor temperature was 84 degrees on 08/07/18. Review of the facility general incident investigation for Resident #6's elopement on 08/07/18, revealed the following time line: Resident #6 ate dinner between 5:00 P.M. and 5:30 P.M. and participated in the supervised smoke break at 6:00 P.M. At 7:00 P.M., STNA #527 received a phone call from an unknown source and was told Resident #6 was in front of the facility on the road in his wheelchair. STNA #527 went out and brought Resident #6 back into the facility where he was assessed with [REDACTED]. Staff interview with LPN #525 on 09/05/18 at 5:00 P.M. verified Resident #6's elopement on 08/07/18. LPN #525 further stated Resident #6 was in his wheelchair when he eloped from the facility and stated Resident #6 was agitated upon return into the facility and required antianxiety medication. STNA #527 no longer worked at the facility. A telephone interview was attempted on 09/05/18 at 3:33 P.M., however the number had been disconnected. Interventions put into place after the elopement on 08/07/18 included a sign posted in Resident #6's room reminding him not to leave the unit unsupervised and to redirect the resident from the administrative hallway throughout the day to deter his desire to wander off unit and go outside. Resident #6 eloped from the facility a second time and was found outside near the road on 08/16/18. The nursing progress note dated 08/16/18 at 11:45 P.M., authored by LPN #525, revealed Resident #6 had wandered and was increasingly agitated when assisted onto the unit and repeatedly tried to leave. According to Accuweather.com the outdoor temperature was 76 degrees on 08/16/18. Review of the facility general incident investigation report for the elopement, dated 08/16/18, revealed the following time line: Resident #6 participated in the supervised smoke break at 3:30 P.M. and ate dinner between 5:00 P.M. and 5:30 P.M. Resident #6 was assisted with toileting between 6:00 P.M. and 6:30 P.M. At 7:40 P.M., STNA #526 gathered residents for the 8:00 P.M. smoke break and Resident #6 was not with the group who normally smokes. STNA #526 began a search for Resident #6. At 7:45 P.M., STNA #526 and Resident #28 found Resident #6 in his wheelchair on the road outside of the facility and brought Resident #6 back into the facility. Staff interview with STNA #526 on 09/05/18 at 3:55 P.M. verified Resident #6's elopement on 08/16/18. Staff interview with LPN #525 on 09/05/18 at 5:00 P.M. verified Resident #6's elopement from the facility and confirmed Resident #6 was agitated upon return into the facility and required antianxiety medication. Interview with Resident #28 on 09/06/18 at 9:20 A.M. verified Resident #6's elopement on 08/16/18. Resident #28 further stated Resident #6 was on the road and was easily redirected into the facility by STNA #526. Interventions put into place after Resident #6's elopement on 08/16/18 included Resident #6 being moved to the second floor of the facility on 08/17/18. The second floor of the facility requires the residents to utilize an elevator with a door and a gate, Resident #6 is unable to cognitively or physically maneuver these actions to gain access to the elevator. Review of the facility policy titled, Wandering, Unsafe Resident, revised (MONTH) (YEAR), stated the facility would assess at-risk individuals for potentially correctable risk factors related to unsafe wandering and then the resident's care plan would be updated to include interventions to maintain safety. This deficiency is an incidental finding identified during the complaint survey completed on 09/10/18.