Every finding on record at Parkview Northwest Healthcare Center

Based on record review, staff interview and review of the facility policy, the facility failed to ensure a preadmission screening and resident review (PASARR) Level II was completed after a significant change in resident status. This affected one (Resident #14) of two residents reviewed for PASARRs. The facility census was 46 residents. Findings include: Review of the medical record for Resident #14 revealed an admitted [DATE] with diagnoses including obstructive and reflux uropathy, benign prostatic hypertrophy, gastro-esophageal reflux disease and insomnia. Review of the Minimum Data Set (MDS) assessment for Resident #14 dated 07/20/24 revealed the resident had intact cognition and required set up with activities of daily living (ADLs.) Review of the diagnosis list for Resident #14 revealed the resident had a new diagnosis of schizoaffective disorder, bipolar type added on 07/03/24 by the facility. Review of the PASARR for Resident #14 dated 03/22/21 revealed the resident was ruled out of the PASARR population because dementia was likely to be the primary focus of behavioral health treatment. Further review of the PASARR revealed the following diagnoses were ruled out while the resident was in the hospital prior to admission to the facility: bipolar disorder, depression with psychotic features, schizoaffective disorder. Interview on 09/11/24 at 11:40 A.M. with Social Worker (SW) #365 confirmed the facility should have completed a resident review and initiated a Level II PASARR for Resident #14 when the resident was diagnosed with schizoaffective disorder on 07/03/24. Review of the facility policy titled PASARR dated 01/01/20 revealed a new PASARR was to be completed any time there was a change of condition of a resident currently in a nursing facility and a change in the individual's current diagnoses, mental health treatment, functional capacity, or behavior such that, as a result of the change, the individual who did not previously have indications of a serious mental illness developed such indications.

Based on observations, medical record review, staff interview, review of the facility's investigation, review of the witness statements, review of the facilities self-reported incidents (SRIs), review of an emergency medical services (EMS) report, review of hospital records, review of emergency room (ER) notes, review of the local weather report, and review of a facility policy, the facility failed to provide adequate supervision and implement timely interventions for exit-seeking behaviors for Resident #39, who was cognitively impaired, had a history of recent exit-seeking behaviors, and who resided in a secured unit, to prevent his elopement from the facility without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death on [DATE] when Resident #39 broke the window in his room using a fire extinguisher and later returned to the room and exited the secured building by jumping out of the second story window, approximately 13 feet from the ground level. Resident #39 was missing from the facility for approximately 12 hours before staff found the resident being cared for by police and EMS six miles from the facility. This affected one (#39) of three residents reviewed for elopement risk. The facility identified twenty-seven residents (#01, #03, #04, #05, #08, #09, #10, #11, #12, #14, #15, #16, #18, #24, #25, #27, #33, #34, #36, #38, #40, #43, #44, #44, #45, #46, and #47) at risk for elopement on the secured unit. The facility census was 47. On [DATE] at 3:46 P.M., the Administrator, the Director of Nursing (DON), Regional Director of Clinical Services (RDCS) #314, and Regional Director of Operations (RDO) #315, were notified Immediate Jeopardy began on [DATE] at 6:30 A.M., when Resident #39 eloped from the facility, without staff knowledge due to the failure of the facility to provide adequate supervision. On [DATE] at 6:30 A.M., State tested Nursing Assistant (STNA) #300 discovered Resident #39 had broken out his room window with a fire extinguisher and reported it to Licensed Practical Nurse (LPN) #220. Staff then moved Resident #39 from his room to the common area. LPN #220 who was assigned to monitor Resident #39, allowed the resident to return to the room with the broken window and then left the resident's room to check on another resident. LPN #220 was aware the resident broke his window and had STNAs take him and roommate to the dining room. At 6:45 A.M., in an interview with LPN #220, she stated she observed the resident returning to his room and he refused to leave the room. LPN #220 was observing him from the door when she left to care for another resident leaving the resident unsupervised and by himself in his room. On [DATE] at 7:30 A.M., STNA # 265 could not locate Resident #39. Staff looked out Resident #39's broken window and saw the following items on the ground below: a pillow, unused gloves, wipes, a flat sheet, and a bedspread. On [DATE] at approximately 7:40 P.M., STNA #265 was off duty and observed Resident #39 with the police and EMS personnel in a heavily trafficked area approximately six miles away from the facility. Resident #39 was taken to the hospital for evaluation. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 6:30 A.M., LPN #220 was informed the window in Resident #39's room was broken. At 7:00 A.M., LPN #220 was stationed outside the resident's room to supervise and ensure the safety of Resident #39 and to prevent re-entrance and access to the resident's room. At 7:25 A.M., LPN #220 stationed outside of the resident's room responded to another resident screaming and went to check on the resident. On [DATE] At 7:30 A.M., STNA #265 checked the resident's room for the resident and noted him missing. Resident #39 was believed to have exited through the broken second floor window and landed 13 feet below on the exterior ground which consisted of grass and concrete and was unsecured. On the ground there was a pillow, unused gloves, wipes, a flat bed sheet and a bed spread. A head count was conducted immediately and there was a total of 45 residents present in-house out of a census of 47 (there was one resident on a Leave of Absence (LOA) with family and Resident #39 was unaccounted for). On [DATE] at 7:30 A.M., upon discovering the Resident #39 could not be located, STNAs #218, #217, #312, #265 and LPN # 251 began searching the facility. On [DATE] at 7:30 A.M., all other windows were checked by STNAs #216 and #312 and validated as being secured, and all exits/entrances were validated as being secured by STNA # 218. On [DATE] at 7:45 A.M., STNAs #218 and #312 searched the perimeter of the facility until 8:10 A.M. On [DATE] at approximately 8:00 A.M., LPN #293 notified the local Police Department Resident #39 was missing. Resident #39's Guardian, Psychiatric (Psych) Physician #316 and Medical Director (MD) #317 were notified by LPN #251. On [DATE] at 8:00 A.M., Maintenance Technician (MT) #318 arrived at the facility. On [DATE] at 8:10 A.M., the DON and Administrator were notified that Resident #39 could not be located. LPN #293 was placed on door watch outside of Resident #39's room to ensure the resident's room was not entered due to the broken window where she remained until the window was fixed around 10:12 A.M. by MT #318. On [DATE] at approximately 9:00 A.M., the DON, Business Office Manager (BOM) #207, Therapy Manager #258, Activities Director (AD) #305, MT #318, Administrator, RDO #315, Minimum Data Set (MDS) Coordinator #256 and Social Services Designee (SSD) #271 arrived at the facility and conducted an additional neighboring community search to locate the missing resident. On [DATE] at 9:30 A.M., calls were made to all local hospitals by SSD #271 and Resident #39 was not located. On [DATE] at approximately 10:12 A.M., the Administrator conducted a second audit of all door alarms and the elevator keypads to check for proper function and locking mechanism. No concerns were identified. On [DATE] at approximately 10:15 A.M., MT #318 conducted a second window audit to ensure all windows were secured and in proper function. There were no concerns identified. On [DATE] at 12:00 P.M., the DON and RDO #315 reviewed/completed wandering observation tools for each resident. No new residents were identified as an elopement risk. On [DATE] at 12:30 P.M., MDS Coordinator #256 reviewed/updated all care plans to identify residents who were at risk for wandering and elopement. No new residents identified. On [DATE] at approximately 1:00 P.M., the DON reviewed the elopement binder, the elopement policy, pictures, and face sheets of all at risk residents and no corrections were needed. On [DATE] at 2:30 P.M., the search for Resident #39 was concluded by the facility staff. On [DATE] at 3:00 P.M., the DON and Administrator initiated education on elopement management with all facility staff. There were 108 educated out of 108 total staff and completed by 9:00 P.M. and the facility utilized no agency staff. All 108 staff were educated electronically and any staff member not present was instructed to sign off on the education prior to the next scheduled shift. On [DATE] at approximately 3:30 P.M., education was provided to the Administrator by RDO #315 on elopement management and elopement prevention. On [DATE] at approximately 3:30 P.M., education was provided to the Administrator and DON by RDO #315 on management of potential risks and hazards to prevent accidents that include but not limited to safeguarding identified risks/hazards to avoid exposure to residents. On [DATE] at approximately 3:30 P.M., education was provided to the Administrator and DON by RDO #315 on supervision of residents when known risks or hazards are identified that include but not limited to one-on-one (1:1) supervision. On [DATE] at approximately 7:40 P.M., Resident #39 was located in a neighboring community six miles away by STNA #265 who was heading home and familiar with the area. STNA #265 observed the resident with the police and EMS. STNA #265 notified the DON Resident #39 had been located. On [DATE] at 7:55 P.M., RDO #315 was notified by the Administrator that Resident #39 had been located by STNA #265. On [DATE] at 8:08 P.M., an unknown Dispatcher at the local Police Department (PD) called the Administrator to provide an update on the status of Resident #39. The PD Dispatcher was instructed to have EMS transport Resident #39 to the local hospital for a psychological evaluation. On [DATE] at 8:12 P.M., Resident's #39's Guardian was notified by the DON and Administrator Resident #39 had been located and was being transported to the local hospital for a medical and psychological evaluation. On [DATE] at approximately 8:14 P.M., Psych Physician #316 was updated by the Administrator and DON on the status of the resident being transitioned to the hospital's Psychiatric Unit. Psych Physician #316 reported the hospital would evaluate the resident and determine if he was appropriate for a 72-hour hold (psychiatric admission). On [DATE] at 8:25 P.M., an unknown ER Nurse at the local hospital called and spoke with the Administrator and DON and informed them Resident #39 would be assessed psychologically and medically. On [DATE] at 8:59 P.M., Medical Director #317 was updated on Resident #39's status by the Administrator. On [DATE] at 9:00 A.M., the DON and Administrator reported to the Quality Assurance Performance Improvement (QAPI) committee the findings related to compliance. The QAPI committee consists of the Administrator, DON, SSD #271, RD #252, BOM #207, MDS Coordinator #256, RDO #315, Therapy Manager #258, and MD #317 (via telephone). On [DATE] at approximately 3:15 P.M., the DON called the local hospital for an update on Resident #39. The hospital noted Resident #39 was assessed, and no new discoveries or diagnoses were determined, thus the resident was set for discharge back to the facility at 5:00 P.M. On [DATE] at 5:32 P.M., an elopement drill was conducted by the DON and Administrator. No issues were identified. On [DATE] at 6:02 P.M., Resident #39 returned to the facility. The resident's Guardian and MD #317 were notified of the resident's return with no new orders given. On [DATE] at 6:02 P.M., Resident #39 was immediately placed on 1:1 observation and will remain until determined by the Interdisciplinary Team (IDT) and MD #317 that 1:1 observation was no longer required. All staff were educated on expectations of the resident being on 1:1 observation by the DON and Administrator. On [DATE] at 6:29 P.M., an admission assessment was completed (including skin, pain, and a Braden Scale) on Resident #39. A care conference with the facility's IDT and Resident #39's Guardian/mother was scheduled for [DATE] at 12:45 P.M. Beginning [DATE], to monitor for ongoing compliance, elopement drills will be completed twice weekly for four weeks, then monthly. The drills will be conducted by the DON or Administrator on day shifts and night shifts. On [DATE] at 12:45 P.M., A 72-hour care conference was held with the facility's IDT which included SSD #271, DON, Administrator, Therapy Manager #258, MD #317, RDO #315, Registered Dietitian (RD) #252, BOM #275 and Resident #39's Guardian/mother. The Guardian was okay with the new interventions of a room move, 1:1 observation, and a psychiatric consultation. A Brief Interview Mental Status (BIMS) assessment was completed on Resident #39 and noted to be a 12 which indicated the resident was cognitively intact. Resident #39's care plan was updated to show the resident eloped and new interventions include 1:1 observation, educate the resident to speak with staff if he would like to take a walk outside, provide diversionary activities, notify the physician of behavior changes, and offer additional snacks and hydration. On [DATE] 3:30 P.M., Resident #39's room change was conducted. Resident remains on 1:1 observation close to the nurse's station. On [DATE], the surveyor completed review of the medical records for residents (#03, #09, #24, and #38) identified as elopement risks and revealed no concerns related to actual elopement from the facility, elopement risk assessments were current and accurate, and care plans were initiated and updated with appropriate interventions to prevent elopement. On [DATE] from 11:00 A.M. to 12:30 P.M. and on [DATE] from 12:00 P.M. to 3:36 P.M., interviews with STNAs #216, #265, #218, Registered Nurse (RN) #210, LPNs #220 and #293, Central Supply (CS) #282, AD #215, and Activities Assistant (AA) #321, revealed all staff were educated and verbalized knowledge of the facility's elopement policies and procedures and guidelines for monitoring residents who have been placed on 1:1 supervision. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #39 revealed an admitted [DATE] with diagnoses including schizoaffective disorder, Tourette's disorder, schizophrenia, dementia, bipolar disorder, seizures, suicidality, myocardial infarction, attention deficit hyperactivity disorder (ADHD) combined type, and history of falling. Review of a Guardianship Order dated [DATE] for Resident #39 revealed the resident was assigned a guardianship due to being incompetent, and a mental disability related to schizoaffective disorder and schizophrenia. Review of the physician's order dated [DATE] for Resident #39 revealed the resident was ordered to be admitted to a secured unit. Review of a Wandering Tool Evaluation dated [DATE] for Resident #39 revealed the resident had a past history of wandering, elopement attempts, had expressed anxiety/apprehension to leave the facility, the family/responsible party voiced concerns that would indicate the resident may have wandering tendencies or try to leave, and the resident wandered without sense of purpose, i.e., confused, may enter others rooms and explore belongings. The assessment identified Resident #39 as being at risk for elopement or unsafe wandering. A follow- up evaluation was completed on [DATE] which revealed Resident #39 remained at risk for elopement and unsafe wandering. Review of the care plan dated [DATE] and revised on [DATE] for Resident #39, revealed the resident resided on a secured unit related to elopement risk, and poor cognition. Interventions included educate the resident/resident's representative of the need for a secured unit to maintain the resident's safety, notify the medical provider/resident's representative of any behavior changes, provide diversionary activities as needed and redirect when appropriate. Review of a progress note dated [DATE] at 1:04 P.M. for Resident #39, revealed the resident was seen by laundry staff trying to remove the ceiling tiles as an escape route. The resident was redirected and accompanied to the dining room for lunch. The vital signs were within normal limits, the resident denied pain, the skin was intact, and the resident was calm. Fifteen (15)-minute checks were initiated, and Resident #39 remained on 15-minute checks from [DATE] until [DATE]. Review of the quarterly MDS assessment dated [DATE] for Resident #39 revealed the resident was cognitively impaired and required supervision for activities of daily living (ADLs). Resident #39 was assessed to have the presence of wandering behaviors. Review of a progress note dated [DATE] at 8:45 A.M. for Resident #39 revealed at approximately 7:30 A.M., Resident #39 was noted to not be in his room. The Physician, DON, the resident's Guardian, and the local police were notified. Review of the EMS run report dated [DATE] revealed EMS was dispatched at 7:37 P.M. for unknown problem/person down. The report indicated the patient (Resident #39) broke out of a long care facility this morning. He has a history of mental health. There are no medical issues that he was complaining of and needs transportation back to the facility. Cincinnati Police Department (CPD) notified and responded to transport patient. The patient was turned over to law enforcement. Review of a progress note dated [DATE] at 9:00 P.M. for Resident #39 revealed the resident was located by a staff member (identified as STNA #265) earlier this evening. The police responded and EMS. The resident was transported to a psychiatric hospital for a psychological and medical evaluation. The resident was placed on 72-hour hold and the resident's Guardian was notified. The Facility Psychiatrist #316, Medical Director #317, the RDCO# 314, and RDO #315 were notified. The residents room change will be initiated prior to returning to the facility. Review of the hospital ER notes dated [DATE] at 9:40 P.M. for Resident #39 revealed the resident presented to the ER for foot pain after going missing from a nursing home. The notes revealed the nursing home found evidence that the resident had broken a window out and jumped out of the second story window around 7:30 A.M. The resident was reported to have a shuffled gait; however, refused to participate in the medical care team's examination. The resident did not express discomfort with palpation of the extremities or examination of the spine and due to history, imagining was ordered to rule out trauma. The resident had various imaging studies which were all negative for any acute fractures or abnormalities. Resident #39 was medically cleared, diagnosed with fall, schizophrenia with acute exacerbation, discharged from theER on [DATE] at 6:08 A.M. and immediately readmitted to psychiatry unit at the same hospital. The psychiatry notes indicated the resident was well known to the psychiatry team and the resident was originally placed in a Skilled Nursing Facility (SNF) due to injuries he sustained after breaking out a window at home and jumping. The resident received comprehensive psychiatric evaluation and therapeutic management in accordance Psychiatric Emergency Services (PES) guidelines for dangerous behavior while he was at his SNF. Resident #39 was monitored for 10 hours and discharged back to the SNF at 5:32 P.M. with no new orders. Review of STNA #306's written statement dated [DATE], revealed she had clocked out and was about to leave when someone said they couldn't find Resident #39 for his breakfast tray. They started looking for the resident and she stayed and waited. Review of LPN #220's undated written statement revealed the resident was walking around and acting usual. The resident didn't say or do anything unusual. Review of STNA #300's undated written statement revealed the resident was pacing until about 4:00 A.M. The resident went to his room and STNA #300 saw the window was broken and told the nurse. They checked it out and told the DON. STNA #300 helped clean up the glass. Review of SSD #271's written statement dated [DATE], revealed she called area hospitals searching for the resident and the resident was not located. SSD #271 drove around with BOM #275, and the resident was not located. Review of STNA #265's written statement dated [DATE] revealed when she arrived at work at 7:02 A.M., she was informed Resident #39 was on 15-minute checks. STNA #265 went into the resident's room at 7:15 A.M. to check on the resident and the resident was lying in bed and when she went back to check on the resident, the resident was not in the room. They all went out to check. Review of STNA #265's additional written statement dated [DATE], revealed she was heading home after work when she was driving and saw EMS who was with Resident #39. STNA #265 pulled over to let them know that Resident #39 had escaped from the facility where she worked at. STNA #265 called the DON to let her know the resident was found. Review of STNA #208's written statement dated [DATE], revealed she worked on [DATE] and noticed the window was broken along with STNA #300. During rounds, she took Resident #39 and his roommate to the dining room at 6:30 A.M. and when she left at 7:00 A.M., they were still there. Interview with the DON on [DATE] at 10:00 A.M., revealed the resident was originally admitted to the facility on [DATE] post hospitalization related to the resident jumping out of an apartment building window and fracturing both feet. The DON verified the resident was observed trying to remove ceiling tiles on [DATE] as an escape attempt and the resident was placed on fifteen-minute checks. Interview with STNA #208 on [DATE] at 1:05 P.M., revealed she was assigned to care for Resident #39 on [DATE] during the night shift (7:00 P.M. to 7:00 A.M.). STNA #208 stated during her rounds at 6:30 A.M., she discovered the window in the resident's room was broken and she reported it to LPN # 220. STNA #208 stated she did not hear glass breaking during her shift and could not be certain when the window was broken. STNA #208 stated she was instructed by the LPN #220 to remove the resident and his roommate from the room, so she placed Resident #39 and his roommate in the dining room and sat with the residents until the end of her shift at 7:00 A.M. STNA #208 stated LPN #220 was standing in the hallway near Resident #39's room to make sure no other residents entered the room as she took the residents to the dining room. Interview with LPN #220 on [DATE] at 1:32 P.M., revealed she was assigned as Resident #39's nurse on [DATE] during the night shift and into the morning of [DATE]. LPN #220 stated she was informed by STNA #208 of the broken glass in the resident's room and instructed the STNA to move the resident and his roommate to the dining room and stay with them. LPN #220 stated she did not hear breaking of any glass in the resident's room during the shift and could not be certain when the glass was broken. LPN #220 stated STNA #300 assisted her with cleaning up the glass and she remained in the hallway near Resident #39's room. LPN #220 stated at approximately 6:45 A.M. she saw Resident #39 return to his room and the resident refused to leave his room. LPN #220 stated she left the facility at approximately 7:15 A.M. when the day shift nurse, LPN #293, arrived. Interview with STNA #265 on [DATE] at 1:37 P.M., revealed she was assigned to care for Resident #39 on [DATE] during the day shift (7:00 A.M. to 7:00 P.M.). STNA #265 stated Resident #39 was on 15-minute checks and she was informed the resident's room window was broken earlier in the morning but never informed the resident was not supposed to be in his room or be on 1:1 observation. STNA #265 stated she checked on the resident at 7:15 A.M. and he was lying in his bed, and she did not want to disturb him and when she checked on him again at 7:30 A.M. the resident was not in his room. STNA #265 stated she looked out the resident's window and saw a pillow and some bed linens lying on the ground and the gate was open. STNA #265 stated she immediately informed LPN #293 and all staff started searching for the resident. STNA #265 stated after her shift at 7:00 P.M., she decided to search the neighboring community because she had heard the resident talk about the area. STNA #265 stated at approximately 7:40 P.M. she located Resident #39 with EMS and notified the Administrator. STNA #265 stated the resident was dressed in hoodie, jeans, and tennis shoes. STNA #265 left when the resident was transported to the hospital. Interview with LPN #293 on [DATE] at 1:44 P.M., revealed she was assigned to care for Resident #39 on [DATE] during the day shift. LPN #293 stated she was informed by LPN #220 that Resident #39's room window had been broken out. LPN # 293 stated she was getting report from the previous shift and did not see the resident and at 7:30 A.M., STNA #265 informed her the resident was not in his room and when she looked out the window, she saw a pillow and blankets and assumed the resident had eloped through the broken window. LPN #293 stated she initiated a head count which ended at approximately 8:15 A.M. and Resident #39 was not in the facility. LPN #293 stated she closed the door to the resident's room and stayed by the door from 8:15 A.M. until 10:12 A.M. when MT #318 repaired the window. Observation of Resident #39 on [DATE] at 1:57 P.M., revealed the resident was on a 1:1 observation by RN #210. Interview with Resident #39 at the same time, revealed the resident reported he couldn't remember what happened on [DATE] but stated he wanted to leave the facility. Telephone interview with the Administrator on [DATE] at 3:33 P.M., revealed on [DATE] at 8:00 A.M., LPN #293 notified the local police Resident #39 was missing and the police put out a statewide be on the lookout ([NAME]). The Administrator stated she was contacted by the local police on [DATE] at 8:08 P.M., that the resident had been found and asked if she wanted him held at the police station or returned to the facility. The Administrator instructed the police to take him to the hospital for a psychiatric and medical evaluation. The Administrator stated a fire extinguisher was found on the floor of the resident's room and the facility had determined he used the fire extinguisher to break the window. The Administrator stated after the resident returned to the facility on [DATE], she interviewed the resident and he stated he used the fire extinguisher to break the window and jumped out of the window because he wanted to go home. Review of the online weather report at the website https://www.wunderground.com/history/daily/us/oh/cincinnati/KCVG/date/[DATE] revealed the air temperature on [DATE] at 7:52 A.M. was 39 degrees Fahrenheit, there was no precipitation, and the wind speed was approximately twelve miles per hour. Review of the facility's undated policy titled, Elopement Management revealed failure to provide adequate supervision for cognitively impaired residents who leave the facility or safe area and are unaccounted for is considered an elopement. This deficiency represents non-compliance investigated under Complaint Number OH00153232.

Based on observations, medical record review, staff interview, review of the facilities investigation, review of the facilities self-reported incidents (SRIs), review of guardianship documents, review of a police report, and review of a facility policy, the facility failed to provide adequate supervision to prevent the elopement of Resident #100, who had impaired cognition, assessed with exit seeking behaviors and resided in a secured behavioral building. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death on [DATE] when Resident #100 eloped from the facility without staff knowledge. The lack of adequate supervision and timely response to interventions resulted in Resident #100 exiting the secured building at an unknown time. Resident #100 was discovered missing from the facility at 6:30 P.M. during nursing rounds and Resident #100 was discovered by fire department personnel at 7:10 P.M. when the resident walked into an apparatus bay of the local fire department which was 1.1 miles from the facility and located in a congested, highly trafficked area. This affected one resident (#100) of three residents assessed at risk for elopement in the facility. The facility census was 46. On [DATE] at 1:36 P.M., the Administrator, Regional Director of Clinical Operations (RDCO) #801, and Licensed Practical Nurse (LPN) #17 were notified Immediate Jeopardy began on [DATE] at 6:30 P.M., when Resident #100 was not provided adequate supervision and eloped from the facility, without staff knowledge. On [DATE] at 7:10 P.M., the resident was found by the fire department personnel when the resident walked into an apparatus bay of the local fire department which was 1.1 miles away and located in a congested, highly trafficked area. The fire department personnel called the local police department who responded to the fire department and transported Resident #100 back to the facility at 7:15 P.M. Observation of the facility's front door on [DATE] at 2:22 P.M. with the Administrator, revealed the front door was left unalarmed and was able to be opened with no delayed egress while there were no staff present in the area watching the door. The Administrator stated she was not aware the door was left unalarmed and verified the door was able to open without the delayed egress. The Administrator was observed to ask the nurse at the nurse's desk if she had been watching the door and the nurse stated she had no knowledge that the door was unlocked, and it was not alarmed. No other staff were in the vicinity and no staff members identified themselves as watching the door as the Administrator was attempting to find out who was watching the door while maintenance staff had the front door alarm and delayed egress turned off and were not in the vicinity of the door. Interview with the Administrator at the same time verified the front door was left unalarmed and was able to open with no delayed egress. The Administrator also verified the door was not being watched by staff and maintenance staff were not present at the door. The Immediate Jeopardy was removed [DATE] when the facility implemented the following corrective actions: On [DATE] at 6:30 P.M., LPN #17 ensured all residents were accounted for. On [DATE] at 6:45 P.M., LPN #17 completed an audit to ensure all windows and doors were secured and functioning properly. On [DATE] at 7:15 P.M., Resident #100 was returned to the facility and immediately had a head-to-toe assessment, a pain assessment, and a wandering assessment completed by former Director of Nursing (DON) #800. On [DATE] at 7:15 P.M., Resident #100 was placed on one-on-one (1:1) supervision for 24 hours. On [DATE] at 7:25 P.M., LPN #17 notified Physician #200 and new orders were written for Tylenol (over the counter pain) and Aloe Vera lotion. On [DATE] at 7:52 P.M., LPN #17 notified Resident #100's guardian. On [DATE] at 9:00 P.M., Former DON #800 and LPN #17 completed wandering and elopement assessments on all residents and no new residents were identified with elopement risks. On [DATE] at 9:00 P.M., two-hour safety checks were initiated for all residents and continued until [DATE]. On [DATE] at 9:00 P.M., RDCO #810 educated the Executive Director regarding elopement risks, secure access monitoring upon exit and entrance, and elopement prevention. On [DATE] at 9:09 P.M., Executive Director initiated education for all staff including Bridgeway (agency staff) on elopement risks, secure access monitoring upon exit and entrance, and elopement prevention. This education was completed on [DATE] at 9:00 A.M. On [DATE] at 9:30 P.M., LPN #17 reviewed and updated Resident #100's care plan to include wandering interventions to provide activities, asses for hunger, thirst and toileting needs when wondering. On [DATE], former DON #800/Designee initiated elopement drills twice weekly for two weeks, then weekly for two weeks. On [DATE] at 10:53 A.M., LPN #09 completed pain and Braden Scale skin assessments for Resident #100. On [DATE] at 11:00 A.M., the Executive Director removed the high back chairs from the front door area as an extra security measure due to Resident #100 sitting in the chairs. On [DATE] at 2:03 P.M., Therapy Manager #812 completed a Brief Interview for Mental Status (BIMS) assessment on Resident #100. On [DATE] at 5:30 P.M., Maintenance Technician #814 changed all door and elevator codes. On [DATE] at 11:00 A.M., Former DON #800 reported to the Quality Assurance and Performance Improvement (QAPI) committee the findings related to compliance. The QAPI committee consisted of former Administrator #817, Registered Dietitian (RD) #816, Licensed Social Worker (LSW) #812, Social Services Designee #818, Physician #200, and Registered Nurse (RN) #808. On [DATE] between 4:30 A.M. and 2:25 P.M., LPN #17, RN #809, STNAs #01, #02, #04, and #08 verified they were educated on resident elopement and wandering as well as responding to resident alarms. All staff members interviewed were knowledgeable of the content of each education provided by the facility. On [DATE] at 2:45 P.M., LPN #17 ensured all residents were accounted for. On [DATE] at 3:00 P.M., LPN #17 and RDCO #801 educated all staff on ensuring exit doors were closed and secured prior to walking away and that secured doors required monitoring by staff if the door was not able to be secured. On [DATE] at 3:10 P.M., Facilities Manager #809 and Maintenance Director #810 fixed the front door and ensured it was in good working order. On [DATE] at 3:30 P.M. and [DATE] at 1:00 P.M., LPN #17 and RDCO #801 completed an audit to ensure all windows and doors were secured and functioning properly. On [DATE] at 9:00 A.M., LPN #17 and RDCO #801 completed an audit of all residents at risk for elopement, reviewed the facility elopement binder for accuracy and all resident's care plans were reviewed. On [DATE] at 10:00 AM., Administrator in Training (AIT) #815 reported to the Ad hoc QAPI committee the findings related to compliance audits. On [DATE], surveyor completed review of the medical records for residents (#01, #11 and #20) identified as elopement risks and revealed no concerns related to actual elopement from the facility, elopement risk assessments were current and accurate, and care plans were initiated and updated with appropriate interventions to prevent elopement. On [DATE], to monitor ongoing compliance, Executive Director/designee will complete elopement drills twice weekly for two weeks, then once per week for two weeks. On [DATE], to monitor ongoing compliance, Maintenance Director #810 will complete an audit to ensure all windows and doors are locked and secured. Audits will be completed five times per week for two weeks, then three times per week for two weeks, then weekly for two weeks. On [DATE], Maintenance Director #810/Designee will change the door codes and elevator codes every 30 days. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #100, revealed an admitted [DATE] with diagnoses including dementia, mild intellectual disabilities (ID), schizoaffective disorder bipolar type, chronic obstructive pulmonary disease (COPD), epilepsy, and major depressive disorder. Resident #100 was discharged to another skilled nursing facility on [DATE]. Review of a guardianship order dated [DATE] for Resident #100, revealed the resident was assigned a guardianship due to mental disability related to dementia and schizoaffective disorder. Review of the physician's order dated [DATE] for Resident #100, revealed the resident was ordered to be admitted to a secured unit. Review of the progress note dated [DATE] for Resident #100, revealed Emergency Medical Services (EMS) called the facility asking about Resident #100 and stated the resident had called 911 and EMS was on their way to check out the resident. EMS was told that Resident #100 was fine, and the nurse saw him about 10 minutes ago. The nurse went to check on the resident and the resident was noted walking out of his room. The resident was asked if he called EMS and he stated yeah, I am getting out of here. Resident #100 denied any concerns and no distress was noted. Resident stated I want a pop. I know I am not supposed to call 911 but I want a coke. The last time the officer told me I could go to jail for calling too much. The nurse reminded Resident #100 that 911 was for emergencies. Review of the secured unit care plan dated [DATE] for Resident #100, revealed the resident required a secured unit for behaviors and poor cognition. Interventions included evaluate the need for a secured unit, obtain consent for the resident from resident representative, obtain a medical provider order to include the diagnosis and exhibited behaviors, notify the medical provider and resident representative of behavioral changes, provide diversionary activities as needed and redirect resident when appropriate. Review of the wandering observation tool dated [DATE] for Resident #100, revealed the resident had a history of wandering. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] for Resident #100, revealed the resident was moderately cognitively impaired, and Resident #100 required limited assistance with transfers, and toileting. Resident #100 required supervision with bed mobility, dressing, eating, and personal hygiene. Review of the secured unit follow up review assessment dated [DATE] for Resident #100, revealed the resident was agitated at times and wanted to leave and would tell staff he wanted to leave. Resident #100 also called 911 occasionally and was anxious at times. Review of the progress note dated [DATE] at 7:52 P.M. for Resident #100, revealed the resident's guardian and brother were made aware of Resident #100's unauthorized leave of absence and Resident #100's return to the facility. Review of the progress note dated [DATE] at 7:52 P.M. for Resident #100, revealed the resident left on an unauthorized leave of absence and was found at the fire station without concern. Policy and procedure were followed. Review of the police report dated [DATE], revealed the police were dispatched to the facility on [DATE] at 6:42 P.M. and arrived at the facility at 6:48 P.M. to take a report for a missing resident. Upon arrival, police met with an employee (unknown) that was waiting outside for police. After speaking with the employee, it was determined that the individual was missing from the secured part of the facility. Staff told police he was last seen at 1:30 P.M. Police gathered all the information to be able to enter him as an endangered missing person and left the scene to look for the individual. As police were entering the individual as a missing person, the fire station called at approximately 7:10 P.M. to report that a person walked into their fire house and stated he was from the facility's address. Police responded and it was the missing individual. The firehouse was a little over a mile away from the facility. Police returned the resident to the facility and to the care of the nurses. Review of the wandering observation tool dated [DATE] for Resident #100, revealed the resident had a history of wandering, had not accepted current living arrangements, the resident had expressed anxiety and apprehension to leave the facility, the resident had a history of elopement, the resident wandered without a sense of purpose and the resident had psychiatric issues. Review of LPN #802's written statement dated [DATE], revealed she last saw Resident #100 in the hall during lunch by his room around 12:30 P.M. Review of LPN #17's written statement dated [DATE], revealed she sat outside with the residents during a smoke break at 11:15 A.M. Review of STNA #803's written statement dated [DATE], revealed the last time she saw Resident #100 was in his room at 4:30 P.M. or 5:00 P.M. when the nurse administered his medications. Review of LPN #804's undated written statement, revealed she came to work on [DATE] at 2:15 P.M. She started her medication pass around 4:15 P.M. Resident #100 received medication around 4:30 P.M and she finished her medication pass around 6:15 P.M. LPN #804 got prepared for her report for the next shift and making eye contact with all of the residents when she noticed Resident #100 was missing. She contacted nursing staff and they immediately started looking for the resident. She called Resident #100's guardian and his brother, and they looked for the resident inside and outside of the building. Review of STNA #805's written statement dated [DATE], revealed she saw Resident #100 at about 4:45 P.M. in his room in his bed. Review of STNA #01's written statement dated [DATE], revealed she saw Resident #100 around 1:30 P.M. Review of STNA #11's written statement dated [DATE], revealed she saw Resident #100 at dinner time when she was passing the trays and he was laying in his bed at 5:30 P.M. Review of STNA #806's written statement dated [DATE], revealed she last saw Resident #100 at 3:15 P.M. Review of LPN #17's undated written statement revealed the temperature was 78 degrees Fahrenheit outside on [DATE] and it was somewhat cloudy due to overcast. It was not raining. Resident #100 was wearing jeans, a black T-shirt, socks, and shoes. He was dressed appropriately. Review of the facility's in-service dated [DATE], revealed staff were educated on elopement, ensuring all doors close and lock when exiting and no one follows. Staff were also educated on ensuring the elevator door closes completely when exiting. Division of Facilities Manager #809 was not listed as being educated on [DATE] and Maintenance Director #810 was not employed by the facility on [DATE]. No maintenance staff were listed as being educated on elopements. Review of the facilities SRIs from [DATE] to [DATE], revealed there were no SRIs filed in regard to any elopements from the facility. Review of the progress note dated [DATE] for Resident #100, revealed the resident discharged to another skilled nursing facility. Review of Maintenance Director #810's employment orientation education dated [DATE], revealed Maintenance Director #810 was educated that staff must ensure that all exit doors are completely closed, and the lock is engaged prior to exiting the facility and when entering the facility. Interview on [DATE] at 4:21 A.M. with STNA #02, revealed he was not present on the date of Resident #100's elopement but stated Resident #100 would make comments that he wanted to leave and go home prior to the elopement incident. Telephone interview on [DATE] at 8:43 A.M. with Resident #100's guardian, revealed Resident #100 was never authorized to go out of the facility unsupervised as he has poor safety awareness and the intellectual ability of an eight- to ten-year-old. Resident #100's guardian stated that Resident #100 eloped from the facility a few weeks ago and was found by the police at the fire department. Resident #100's guardian stated the facility notified her in the late afternoon that Resident #100 was missing from the facility, and they stated they did not know how long he had been gone. Resident #100's guardian stated the facility also notified Resident #100's brother prior to calling her and the facility did not know how he got out of the facility. Resident #100's guardian reported the facility reported that Resident #100 had a history of sitting by the door and watching the door and he likely got out from watching the doors. Resident #100's guardian stated Resident #100 had a history of attempting to leave the facility and had previously eloped from prior facilities. Resident #100's guardian reported the facility was aware of Resident #100's elopement history. Telephone interview on [DATE] at 9:52 A.M. with Police Officer #807, revealed he got a call on [DATE] at 6:42 P.M. from the facility and he responded to the call. Police Officer #807 stated staff were outside looking for Resident #100 when he arrived at the facility, and he went inside to the nurse's station. Police Officer #807 reported staff were not able to tell him when he was last seen but one staff member reported Resident #100 was last seen at 1:30 P.M. Police Officer #807 stated he asked facility staff members questions related to when Resident #100 was last seen and information about him and how he eloped several times and the responses were not consistent. Police Officer #807 reported he left and went to the shopping center across the street from the facility to search for the resident and then went back to the police department to enter Resident #100's information into their missing person systems. Police Officer #807 stated the fire department called him at 7:10 PM. and reported they had a person there that said he walked away from a nursing home. The fire house was located at 7050 Blue Ash Road Cincinnati OH 45236 which was over a mile away from the facility. Police Officer #807 stated he could not remember exactly what Resident #100 was wearing and he took Resident #100 back to the facility at 7:15 P.M. Interview on [DATE] at 10:37 A.M. with STNA #01, revealed the STNA worked on the day Resident #100 eloped from the facility, but she could not remember the time or the details. STNA #01 stated that someone told her Resident #100 eloped from the facility but could not remember who told her or what time it was but stated it might have been around dinner time. STNA #01 stated staff started looking for Resident #100 and she was not sure how he got back at the facility or what time he arrived back at the facility. Telephone interview on [DATE] at 12:48 P.M. with STNA #11, revealed the facility noticed Resident #100 was missing but she was not sure who noticed that Resident #100 was missing. STNA #11 stated she was told by another staff member that Resident #100 was missing, and they started searching the resident rooms and looking outside for Resident #100. STNA #11 stated she was not sure who called the police, when Resident #100 returned to the facility or where Resident #100 was found. Telephone interview on [DATE] at 1:13 P.M. with RN #808, revealed she did not know what time Resident #100 was last seen or when he went missing. RN #808 stated she could not remember any details of the event. RN #808 then called back on [DATE] at 1:20 P.M. and stated staff noticed Resident #100 missing at an unknown time and a head count was completed. RN #808 stated the physician and guardian were notified and Resident #100 returned to the facility at 7:15 P.M. and was not too far from the facility. Interview on [DATE] at 1:47 P.M. with the Administrator, revealed the Administrator was not the acting Administrator at the time when Resident #100 eloped from the facility on [DATE]. The Administrator stated Resident #100 was last seen at 5:30 P.M. by STNA #11 and LPN #804 noticed Resident #100 missing at 6:30 P.M. The Administrator reported staff searched all the resident rooms twice and then they went outside and checked the neighboring facility and the perimeter of the building. The Administrator stated the police were also called and the former Administrator and former DON #800 were notified. The Administrator reported the police came and the resident was assisted back to the facility by police approximately 45 minutes after he was found. The Administrator stated she was not sure where he was found as she was not working at the facility at the time of the incident but later reported he was found at the fire department. The Administrator reported the resident was wearing jeans, a black T-shirt, socks, and shoes and it was 78-degree Fahrenheit outside on [DATE]. The Administrator stated Resident #100 had a guardian and it was an unauthorized leave of absence. The Administrator stated the facility was not sure how Resident #100 got out of the facility but stated he could have followed a family member out of the building. The Administrator stated Resident #100 did not have any injuries and staff started doing resident checks every two hours, and elopement drills on [DATE]. The Administrator reported the doors and windows were checked on [DATE] and were functioning properly and the door codes were changed on [DATE]. The Administrator stated the door codes are now changed every thirty days and family are not given the codes. Observation of the facility's front door alarm on [DATE] at 1:59 P.M. with the Administrator, revealed the door was not alarming and would not open. Interview with the Administrator at the same time verified the front door was not alarming and would not open. Administrator stated she would call maintenance. Observation of the facility's front door on [DATE] at 2:22 P.M. with the Administrator, revealed the front door was left unalarmed and was able to be opened with no delayed egress while there were no staff present in the area watching the door. The Administrator stated she was not aware the door was left unalarmed and verified the door was able to open without the delayed egress. The Administrator was observed to ask the nurse at the nurse's desk if she had been watching the door and the nurse stated she had no knowledge that the door was unlocked, and it was not alarmed. No other staff were in the vicinity and no staff members identified themselves as watching the door as the Administrator was attempting to find out who was watching the door while maintenance staff had the front door alarm and delayed egress turned off and were not in the vicinity of the door. Interview with the Administrator at the same time verified the front door was left unalarmed and was able to open with no delayed egress. The Administrator also verified the door was not being watched by staff and maintenance staff were not present at the door. Telephone interview on [DATE] at 2:25 P.M. with Former DON #800, revealed she no longer worked at the facility but was in meetings at the neighboring skilled nursing facility on [DATE] when Resident #100 eloped from the facility. Former DON #800 stated that she walked over to get her stuff to go home, and the staff told her that they could not find Resident #100. Former DON #800 stated she was not sure what time it was, but staff searched the facility, and the Administrator was notified. The police were called but she was not sure who called the police and Resident #100 was later found at the fire department. Former DON #800 stated that she was not sure when Resident #100 was last seen, and stated staff recollections of events were very inconsistent. Review of LPN #17's undated witness statement, revealed the front door was fixed and was fully functioning on [DATE] at 3:10 P.M. Review of Division of Facilities Manager #809's education dated [DATE], revealed Division of Facilities Manager #809 was educated to ensure all exit doors are closed and secured prior to walking away and all exit doors require monitoring if not secured. Review of Maintenance Director #810's education dated [DATE], revealed Maintenance Director #810 was educated to ensure all exit doors are closed and secured prior to walking away and all exit doors require monitoring if not secured. Telephone interview on [DATE] at 8:58 A.M. with Firefighter/Emergency Medical Technician (EMT) #811, revealed he was working at the fire department on [DATE] when Resident #100 walked into the bay and asked if anyone was looking for him. Firefighter/EMT #811 stated that Resident #100 was wearing a black shirt, jeans, and shoes and that he was familiar with Resident #100 and knew he resided at the facility and had a history of dementia or cognitive impairment. Firefighter/EMT #811 stated the police were contacted by the fire department. Telephone interview on [DATE] at 12:53 P.M with LPN #804, revealed she was not sure when Resident #100 went missing but thought it was around 4:00 P.M. LPN #804 stated she was not sure how long Resident #100 was gone but thought it was a couple of hours. LPN #804 stated she did not know when she last saw Resident #100. LPN #804 stated she was not sure who noticed Resident #100 missing but staff started to search for him once they noticed he was missing. LPN #804 stated she was not sure who called the police. Telephone interview on [DATE] at 1:00 P.M. with LPN #802, revealed she was working at the facility on [DATE] when Resident #100 eloped from the facility. LPN #802 reported she was not sure what time she last saw Resident #100 but reported he went missing around 6:00 P.M. LPN #802 stated they checked all the rooms and then walked to the facility next door (a sister facility on the same campus) to search there. LPN #802 stated she was not sure who contacted the police and stated the police brought Resident #100 back to the facility around 7:30 P.M. and reported that Resident #100 was found at the fire station. LPN #802 stated Resident #100 was wearing a jacket with a shirt under it and long pants, but she could not recall if he was wearing shoes. LPN #802 reported she was not sure how long Resident #100 was gone or how he got out of the facility. Interview on [DATE] at 1:10 P.M. with LPN #17, revealed the front door was fixed on [DATE] at 3:10 P.M. LPN #17 stated she was in her office and watched Division of Facilities Manager #809 and Maintenance Director #810 leave the small hallway where the front door was located and walk down the hallway, but they never told her they were leaving the door unalarmed and unlocked without a delayed egress. LPN #17 stated Division of Facilities Manager #809 and Maintenance Director #810 were educated on leaving doors unalarmed and without a delayed egress without telling staff on [DATE]. Interview on [DATE] at 1:12 P.M with Division of Facilities Manager #809 and Maintenance Director #810, revealed the facility's front door was not functioning properly on [DATE] due to a sensor contact issue. Division of Facilities Manager #809 stated he and Maintenance Director #810 were working on the door on [DATE] and they left to go get tools. Division of Facilities Manager #809 reported they told LPN #17 to watch the door. Interview on [DATE] at 1:21 P.M. with LPN #17, revealed she was working in the skilled nursing facility next door on [DATE] when former DON #800 notified her that Resident #100 was missing. LPN #17 stated staff could not find Resident #100 and stated she was not sure what time it was but thought it was around 6:30 P.M. LPN #17 stated she met former DON #800 outside, and they notified the physician, guardian and Resident #100's brother. LPN #17 stated she was not sure who contacted the police and stated they continued searching for Resident #100 as staff had already done a head count of all residents. LPN #17 reported they continued to search for the resident and the police brought him back, but she was not sure where Resident #100 was located. Interview on [DATE] at 2:53 P.M. with the Administrator and LPN #17, verified Division of Facilities Manager #809 was not educated on elopements until [DATE] and Maintenance Director #810 was educated on elopements upon hire on [DATE] and on [DATE]. Email correspondence on [DATE] at 3:46 P.M. with LPN #17, verified Division of Facilities Manager #809 was covering the maintenance needs at the facility from [DATE] until [DATE] after Maintenance Technician #814 left the faciity on [DATE] and prior to Maintenance Director #810's employment at the facility. Review of the facility's undated elopement management policy revealed an elopement is defined as when a resident leaves the premises or a safe area without authorization or the necessary supervision. The facility is to immediately initiate procedures to locate any resident or patient that is unaccounted for. Notification of appropriate parties will comply with state and federal regulations. Following the location of the involved resident, the facility leadership will review prevention systems to identify performance opportunities. Failure to provide adequate supervision for cognitively impaired residents who leave the facility or safe areas and are unaccounted for is considered an elopement. Review of the facility's undated abuse, neglect and misappropriation policy revealed alleged violations of neglect, exploitation, misappropriation of resident property or mistreatment that do not result in serious bodily injury must be reported no later than 24 hours. The self-report will be made to the state survey agency if appropriate. This deficiency represents non-compliance investigated under Complaint Number OH00144202.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure resident bathrooms were maintained in a clean and sanitary manner. This affected four (Residents #16, #17, #18, and #19) of seven residents reviewed for a sanitary environment. The facility census was 47. Findings include: 1. Review of the medical record for Resident #16 revealed an admitted [DATE]. Diagnoses included unspecified dementia, Wernicke's encephalopathy, and unspecified conduct disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment, dated 05/04/23, revealed Resident #16 had severely impaired cognition. Resident #16 required supervision assistance for toileting. 2. Review of the medical record for Resident #17 revealed an admitted [DATE]. Diagnoses included Parkinson's disease, unspecified dementia, and unspecified schizophrenia. Review of the most recent MDS 3.0 assessment, dated 04/07/23, revealed Resident #17 had both long and short term memory problems. Resident #17 required extensive assistance for toileting. 3. Review of the medical record for Resident #18 revealed an admitted [DATE]. Diagnoses included unspecified schizoaffective disorder. Review of the most recent MDS 3.0 assessment, dated 05/06/23, revealed Resident #18 had severely impaired cognition and required supervision assistance for toileting. 4. Review of the medical record for Resident #19 revealed an admitted [DATE]. Diagnoses included but were not limited to schizoaffective disorder bipolar type, type two diabetes, and unspecified dementia. Review of the most recent MDS 3.0 assessment, dated 04/05/23, revealed Resident #19 was cognitively intact and was independent with toileting. Observation on 05/15/23 at 3:49 P.M. revealed the bathroom shared by Residents #16, #17, #18, and #19 had the toilet seat up, a pile of brown substance at the base of the seat/tank, and a pile of paper towels covered in a brown substance on the floor in the corner beside the toilet. Interview on 05/15/23 at 3:49 P.M. with State tested Nurse Aide (STNA) #185 verified the commode in the shared bathroom had feces and piles of feces-soiled paper towels on the floor. STNA #185 stated housekeepers had left for the day and the nursing staff was responsible to clean the unit as needed. Observation on 05/15/23 at 4:55 P.M. revealed the bathroom shared by Residents #16, #17, #18, and #19 still had a pile of brown substance at the base of the seat/tank, and a pile of paper towels covered in a brown substance on the floor in the corner beside the toilet. Interview on 05/15/23 at 4:55 P.M. with STNA #101 verified the bathroom was not clean. STNA #101 stated she was not notified that the bathroom was dirty, and stated it was the responsibility of the nursing staff to clean the unit as needed after housekeepers had left for the day. Review of policy titled Resident Rights, undated, revealed residents were treated with dignity including providing a sanitary environment and attending to needs in a timely fashion. This deficiency represents non-compliance investigated under Complaint Numbers OH00142659 and OH00141815.

Based on medical record review, staff interview, and policy review, the facility failed to ensure residents were free from significant medication errors. This affected one (Resident #50) out of four residents reviewed for medication administration. The facility census was 47. Findings include: Review of the medical record for Resident #50 revealed an admitted [DATE] and a discharge date of [DATE]. Resident #50's diagnoses included Parkinson's disease, type two diabetes, and unspecified Alzheimer's disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment, dated 02/22/23, revealed Resident #50 had severely impaired cognition. Review of Resident #50's physician orders revealed an order, dated 04/05/23, for Rocephin (antibiotic) one gram solution, inject one gram intramuscularly daily in the afternoon. Review of Resident #50's progress notes revealed on 04/05/23 at 4:13 P.M. the Rocephin one gram solution was not administered to Resident #50 because it was on order. Review of the Medication Administration Record, dated April 2023, revealed Resident #50 did not receive any doses of the Rocephin one gram solution on 04/05/23 and 04/06/23. Interview on 05/15/23 at 5:40 P.M. with the Former Director of Nursing #25 verified Resident #50's Rocephin one gram solution was not available in the facility emergency drug supply, and there was no evidence the medication was administered to Resident #50 as ordered. Review of policy titled Medication Administration, undated, revealed medications were administered as prescribed by the provider. Medications that were not given were documented, and critical medications were followed up with physician contact. This deficiency represents non-compliance investigated under Complaint Number OH00141815 and is an example of continued noncompliance from the survey dated 03/30/23.

Based on medical record review, staff interview, and policy review, the facility failed to ensure the physician was notified when antibiotic medication was not available for multiple administrations. This affected one (Resident #50) out of four residents reviewed for notifications. The facility census was 47. Findings include: Review of the medical record for Resident #50 revealed an admitted [DATE] and a discharge date of [DATE]. Resident #50's diagnoses included Parkinson's disease, type two diabetes, and unspecified Alzheimer's disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment, dated 02/22/23, revealed Resident #50 had severely impaired cognition. Review of Resident #50's physician orders revealed an order, dated 04/05/23, for Rocephin (antibiotic) one gram solution, inject one gram intramuscularly daily in the afternoon. Review of Resident #50's progress notes revealed on 04/05/23 at 4:13 P.M. Rocephin one gram solution was not administered to Resident #50 because it was on order. Review of the Medication Administration Record, dated April 2023, revealed Resident #50 did not receive any doses of the Rocephin one gram solution on 04/05/23 and 04/06/23. Review of Resident #50's medical record revealed no documentation regarding the physician having been notified that Resident #50's Rocephin one gram solution was not available or administered. Interview on 05/15/23 at 5:40 P.M. with the Former Director of Nursing #25 verified Resident #50's Rocephin one gram solution was not available in the facility emergency drug supply and there was no evidence of the physician having been notified the Rocephin was not available or administered to Resident #50. Review of the policy titled Notification of Change in Condition, undated, revealed circumstances which required notification included circumstances that required the need to alter treatment.

Based on medical record review, observations, staff interviews, and policy review, the facility failed to have functioning call lights in resident's room. This affected seven residents (#3, #5, #6, #7, #8, #10, and #22) out of the six rooms observed for functioning call lights. The facility census was 46. Finding include: Review of medical record for Resident #3 revealed the resident was admitted on [DATE] with diagnosis including schizoaffective disorder, hypertension, hypothyroidism, chronic pain, obesity, delusional disorder, impulsiveness, paranoid personality disorder, dyspepsia, violent behaviors, insomnia, and brachial plexus disorders. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 had moderately impaired cognition. Review of medical record for Resident #5 revealed the resident was admitted on [DATE] with diagnosis including schizophrenia, depression, psychosis, anxiety, and bipolar. Review of the MDS assessment dated [DATE], revealed Resident #5 was cognitively intact. Review of medical record for Resident #6 revealed the resident was admitted on [DATE] with diagnosis including paraplegia, depression, anxiety, chronic pain, pressure ulcers, hepatitis B, and contact dermatitis. Review of the MDS assessment dated [DATE], revealed Resident #6 was cognitively intact. Review of medical record for Resident #7 revealed the resident was admitted on [DATE] with diagnosis including schizophrenia, asthma, hernia, bulimia nervosa, bipolar, psychosis, chest pain, intellectual disabilities, and antisocial behavior. Review of the MDS assessment dated [DATE], revealed Resident #7 was cognitively intact. Review of medical record for Resident #8 revealed the resident was admitted on [DATE] with diagnosis including Parkinson's disease, chronic obstructive pulmonary disease, diabetes, schizophrenia, hypertension, and dysphagia. Review of the MDS assessment dated [DATE], revealed Resident #8 had moderately impaired cognition. intact. Review of medical record for Resident #10 revealed the resident was admitted on [DATE] with diagnosis including schizophrenia, intellectual disabilities, slurred speech, schizoaffective disorder, bipolar, insomnia, sexual disorders, anxiety, and impulse disorder. Review of the MDS assessment dated [DATE], revealed Resident #10 was cognitively intact. Review of medical record for Resident #22 revealed the resident was admitted on [DATE] with diagnosis including atrial fibrillation, psychosis, hypotension, dementia, liver disease, alcohol use, traumatic brain injury, and joint pain. Review of the MDS assessment dated [DATE], revealed Resident #22 was cognitively intact. During observations on 03/02/23 at 9:55 A.M. with State tested Nursing Assistant (STNA) #40 revealed room [ROOM NUMBER] with two residents (#10 and #22), room [ROOM NUMBER] with two residents (#3 and #7), and room [ROOM NUMBER] with one resident (#5), the resident's call lights were not functioning. Additionally, in room [ROOM NUMBER], Resident #6's bathroom call light was not functioning, and in room [ROOM NUMBER], with Resident #8, there was no call light for resident to use. Interview at same time with STNA #40, verified the above findings. Review of the undated Maintenance Work Request System Policy revealed corrective maintenance can be defined as those actions required to restore equipment, buildings, and grounds to normal condition and operation. This represents non-compliance investigated under Complaint Number OH00140248.

Based on medical record review, observations, staff interviews, and policy review, the facility failed to ensure a residents antiseizure medication was administered resulting in a significant medication error. This affected one resident (#1) out of four residents observed for medication administration. The facility census was 46. Findings include: Review of medical record for Resident #1 revealed the resident was admitted on [DATE]. Diagnosis included, but not limited to, epilepsy, hypertension, schizophrenia, coronary artery disease, antisocial personality disorder, chronic obstructive pulmonary disease (COPD), angina, anxiety, bipolar disorder, peripheral vascular disease, and chronic pain. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact. Review of the active March 2023 physician orders for Resident #1 revealed the resident was ordered to receive Keppra 1,000 milligrams (mg) in the morning and 1,500 mg nightly for seizures. Observation of the medication administration on 03/02/23 at 7:50 A.M. with Licensed Practical Nurse (LPN) #38, revealed the LPN prepared the following medications for Resident #1: Geodon (antipsychotic) 80 mg, Cogentin (antipsychotic) 1 mg, Tegretol (antiseizure) 200 mg, Clonidine (blood pressure) 0.2 mg, Ferrous Sulfate (iron supplement) 325 mg, Haldol (antipsychotic) 10 mg, Protonix (reduce stomach acid) 40 mg, Phenobarbital (antiseizure) 64.8 mg, Senna (laxative) 8.6 mg two tabs and a Fluticasone inhaler (respiratory). During continued observation of medication administration and directly before LPN #38 was about to administer medications to Resident #1, LPN #38 was asked to stop the medication administration to verify the medications in the cup. LPN #38 verified the medications in cup. During medication reconciliation with LPN #38, she verified she had omitted the following medications: Toprol 25 mg, Norvasc 10 mg, Hydralazine 100 mg, Losartan 100 mg, and Keppra 1,000 mg. During a follow up interview on 03/02/23 at 10:54 A.M. with LPN #38, verified she omitted Resident #1's Keppra 1,000 mg during the morning medication administration. Review of an undated facility policy titled Medication Administration revealed medications shall be administered as prescribed by the provider safely and in a timely manner. This deficiency represents non-compliance investigated under Complaint Number OH00140248.

Based on medical record review, observations, and staff interviews, the facility failed to ensure medication error rates did not exceed five percent (%). Medication error rate was 20.0 percent (%). This affected one resident (#1) out of three residents observed for medication administration. The facility census was 46. Findings include: Review of medical record for Resident #1 revealed the resident was admitted on [DATE]. Diagnosis included, but not limited to, epilepsy, hypertension, schizophrenia, coronary artery disease, antisocial personality disorder, chronic obstructive pulmonary disease (COPD), angina, anxiety, bipolar disorder, peripheral vascular disease, and chronic pain. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact. Review of the active March 2023 physician orders for Resident #1, revealed the resident was ordered to receive Geodon 80 milligrams (mg) (antipsychotic) twice daily at 8:00 A.M. and 4:00 P.M., Cogentin 1 mg (antipsychotic/anti-tremor) one tablet daily at 9:00 A.M., Tegretol 200 mg (antiseizure) three times daily at 9:00 A.M. 1:00 P.M. and 9:00 P.M., Clonidine 0.2 mg (blood pressure) twice daily at 9:00 A.M. and 9:00 P.M., Ferrous Sulfate 325 mg (iron supplement) twice daily at 9:00 A.M. and 9:00 P.M., Haldol 10 mg (antipsychotic) twice daily at 9:00 A.M. and 9:00 P.M., Fluticasone-Salmeterol Aerosol powder 250-50 micrograms (mcg) inhaler one puff twice daily at 8:00 A.M. and 9:00 P.M., Protonix 40 mg (proton pump inhibitor) daily at 9:00 A.M., Phenobarbital 64.8 mg (anti-seizure) three times daily at 9:00 A.M., 1:00 P.M. and 900 P.M., Senna 8.6 mg two tabs (laxative) two tablets daily at 9:00 A.M., Toprol XL extended release (ER) 25 mg (blood pressure) daily at 8:00 A.M., Norvasc 10 mg (blood pressure) daily at 8:00 A.M., Hydralazine 100 mg (blood pressure) four times daily at 8:00 A.M, 12:00 P.M. 6:00 P.M. and 9:00 P.M., Losartan 100 mg (blood pressure) daily at 8:00 A.M., and Keppra 1,000mg (anti-seizure) daily at 8:00 A.M. and 1,500 mg nightly. An observation of medication administration on 03/02/23 at 7:50 A.M. with Licensed Practical Nurse (LPN) #38 revealed the LPN prepared the following medications for Resident #1. Geodon 80 mg, Cogentin 1 mg, Tegretol 200 mg, Clonidine 0.2 mg, Ferrous Sulfate 325 mg, Haldol 10 mg, Protonix 40 mg, Phenobarbital 64.8 mg, senna 8.6 mg two tabs and a Fluticasone inhaler. During continued observation of medication administration and directly before LPN #38 was about to administer medications to Resident #1, LPN #38 was asked to stop the medication administration to verify the medications in the cup. LPN #38 verified the medications in cup. During medication reconciliation with LPN #38, she verified she had omitted the following medications: Toprol 25 mg, Norvasc 10 mg, Hydralazine 100 mg, Losartan 100 mg, and Keppra 1,000 mg. During a follow up interview on 03/02/23 at 10:54 A.M. with LPN #38, verified she omitted Resident #1's Toprol 25 mg, Norvasc 10 mg, Hydralazine 100 mg, Losartan 100 mg, and Keppra 1,000 mg during morning medication administration. Review of an undated facility policy titled Medication Administration revealed medications shall be administered as prescribed by the provider safely and in a timely manner. This deficiency represents non-compliance investigated under Complaint Number OH00140248.

Based on observation, staff interview, review of the facility assessment, and policy review, the facility failed to ensure the facility had an emergency three day supply of food for the residents. This had the potential to affect all residents at the facility. The facility census was 47. Findings include: Observation during the tour of the facility kitchen on 07/27/22 at 1:00 P.M. with the Dietary Manager (DM) #52 revealed the facility dry food storage contained many empty shelves and a low supply of food. Observation in the walk in refrigerator area of the kitchen revealed many open shelves and a low supply of food. Interview with the DM #52 at the time of the tour on 07/27/22 at 1:00 P.M., confirmed the facility had a very low level of food on hand. DM #52 confirmed the facility had failed to have a three day emergency supply of food on hand in the case of an emergency. DM#52 stated he had just received his weekly order that day from the food supply company and he was sure he would run out of food prior to the next shipment. Interview on 08/04/22 at 11:32 A.M., with the Administrator confirmed the facility received a food delivery one time per week. He confirmed the delivery day was every Tuesday. Review of the facility policy titled Dining Services Director-Emergency Responsibilities, undated, the policy stated the Dining Services Director is responsible for feeding residents and staff in an emergency. Further review of the policy stated, obtain and store all food and supplies that may be needed in an emergency situation. Review of the facility assessment dated [DATE] through July 2021 revealed the lack of information related to emergency food storage. This deficiency substantiates Master Complaint Number OH 237.

Based on medical record review, staff interview, review of the notice of transfer and discharge form, and policy review, the facility failed to ensure appropriate discharged notices were issued. This affected two residents (#10 and #14) out of two residents reviewed for discharge notification. The facility census was 47. Findings included. 1. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #10 was listed as his own responsible party. Review of Resident #10's quarterly minimum data set assessment (MDS) dated [DATE] revealed he was cognitively intact. The resident required extensive assistance from staff with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Review of the nursing progress notes for Resident #10 revealed no information regarding the issuance of a thrifty day discharge notice from the facility. Review of the notice of transfer and discharge form dated 06/23/22 for Resident #10 revealed a copy of the letter would be hand delivered, and mailed via certified mail. Further review of the discharge notice for Resident #10 revealed the reason for discharge was listed as, unable to meet the resident's need. A line was listed for the Resident/and or Resident Representative to sign, however the line was blank. 2. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE] revealed Resident #14 was cognitively impaired. The resident required extensive assistance from staff with bed mobility, transfers, eating, and toilet use and limited assistance from staff with dressing. Resident #14 required supervision from staff with personal hygiene. Review of the nursing progress notes for Resident #14 revealed no information regarding the issuance of a discharge notice from the facility. Review of the notice of transfer and discharge form dated 06/23/22 for Resident #14 revealed a copy of the letter would be hand delivered, and mailed via certified mail. Further review of the discharge notice for Resident #14 revealed the reason for discharge was listed as, unable to meet the resident's need. A line was listed for the Resident/and or Resident Representative to sign, however the line was blank. Interview on 08/04/22 at 9:00 A.M., with the Administrator confirmed the discharge notices issued to Resident #10 and #14 were not signed by the resident and/or resident representatives. The Administrator confirmed the facility had been unable to find placement for either resident following the discharge notices being issued. The Administrator confirmed Resident #10 and #14 have no documented evidence of a discharge notice being issued in the resident records. The Administrator stated Resident #10 was issued a discharge notice related to increased aggression. The Administrator stated Resident #14 was issued a discharge notice related to suicidal ideation. The Administrator confirmed the receiving facility listed on the discharge notice denied admission for Resident #10 and Resident #14. Interview with the Regional Director (RD) #65 on 08/04/22 at 9:38 A.M., revealed the facility had a hearing with the Ohio Department of Health regarding an improper discharge for Resident #10 and Resident #14. RD #65 confirmed the reason Resident #10, #14 remain at the facility was because the facility lost the hearing regarding discharge. Review of the facility policy titled Transfer and Discharge Policy, dated 03/10/17 revealed the facility has documentation requirements for involuntary discharge. 1. Take steps to ensure that the transfer or discharge is documented in the resident's medical record. B. Documentation in the resident's medical chart must include, 1. The basis for transfer or discharge 2. The specific resident needs that cannot be met. 3. The facility attempts to meet the residents needs. 4. The service available at the receiving facility to meet the need(s). This deficiency substantiates Complaint Number OH 927.

Based on observation, interview and policy review, the facility failed to ensure staff wore face masks while providing care to residents. This had the potential to affect all residents residing in the facility. The facility census was 43. Findings include: During observation on 06/22/22 at 8:22 A.M. upon entrance to the facility, one Licensed Practical Nurse (LPN) #9, and four State tested Nursing Assistants (STNA) #14, #18, #19, and #20 did not have any mask or shield in place while assisting residents with the breakfast meal. During observation LPN #9 yelled loudly down the hall; Hey everyone the state lady is coming up here put on your masks and shields. During interview on 06/22/22 at 8:23 A.M., LPN #9 reported that she though it was ok not to wear the masks because all the staff and all the residents were vaccinated. During interview on 06/22/22 at 9:15 A.M., the Director of Nursing (DON) verified that staff should have been wearing the masks and shields. Review of the guidance for COVID mitigation revealed [NAME] County transmission rate was low, last updated 06/16/22. Review of the policy titled Use Of Personal Protection Equipment, dated 03/02/22, revealed employees must wear a surgical mask at all times, this includes all departments (nursing, housekeeping, dietary, maintenance, business office, medial records, human resources, and central supply).

Based on observation, staff interview and policy review, the facility failed to maintain a clean and sanitary kitchen area and failed to properly label/date foods to ensure food safety. This had the potential to affect all 46 residents residing in the facility. Facility census was 46. Findings include: Observation on 05/13/22 at 09:25 A.M. during the tour of the kitchen with the Administrator revealed a large refrigerator that contained refrigerated items. The refrigerator contained two large bags of lettuce. The bags of lettuce were brown and green and contain a large amount of brown slimy substance. A large white bucket containing an unknown yellow substance and was dated 12/08/21. A large pan of a brown substance was observed under a foil cover with no label or date. A large metal pan of what appeared to be hot dogs with foil over the pan was observed to have no date or label. A white cup of apple juice was observed to be sitting on a shelf in the refrigerator. A tray with 14 bowls of salads with lids were observed to be undated and unlabeled. A large pan of pudding dated 04/29/22 was observed. A large pan of applesauce was dated 04/29/22. A large container of dried pineapple bits was observed with no label or date. 15 pudding cups with what appeared to be pudding was located inside the refrigerator with no date or label. A large amount of what appeared to be lunch meat was wrapped in plastic wrap with no date or label. Further observation of the kitchen revealed the tops of the counters and appliance contained food debris, and dirt build up. Dried spills, splashes and dirt build up was observed on the outside doors of the appliances. Food debris, dried spills, and brown dirt build-up were observed on surfaces and in corners and crevices, and on the sides of cabinets and appliances. The floor in the dry storage room was observed to have numerous large spots of dirt build-up and food debris underneath the food storage racks, including trash and debris thrown about. A bottle of soda was observed in the window over the sink. Interview on 05/13/22 at 09:30 A.M. with the Administrator confirmed the findings in the refrigerator. The Administrator confirmed she is not sure if the brown substance was chicken or Tuna salad. The Administrator stated the dietary manager quit her position over a week ago. The Administrator stated the kitchen has not been organized since dietary manager quit. The Administrator confirmed the kitchen area was not clean or sanitary. The Administrator confirmed all 46 residents residing in the facility receive their meals from the facility kitchen. Review of the facility policy titled, Environment, dated 09/2017, revealed all food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. Review of the facility policy titled, Food: Preparation, undated, revealed all Time/Temperature Control for Safety (TCS) foods that are to be held for more than 24 hours at a temperature of 41 degrees Fahrenheit (F) or less, will be labeled and dated with a prepared date (Day 1) and a use by date (Day 7). This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, review of self-reported incidents (SRI's), staff interview and policy review, the facility failed to thoroughly investigate an allegation of resident-to-resident sexual abuse. This affected one (#02) of four residents reviewed for abuse. The facility census was 46. Findings include: Record review for Resident #02 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the discharge and return anticipated minimum data set (MDS) assessment, dated 02/02/22, revealed Resident #02 had impaired cognition as evidenced by his brief interview for mental status (BIMS) score of 99. Further review of the MDS assessment revealed Resident #02 required extensive assistance from staff with bed mobility, transfer, dressing, toilet use, personal hygiene eating and bathing. Review of the nursing progress notes for Resident #02 dated, 05/09/22 revealed resident was complaining of increased pain in the right shoulder and left pelvis. Further review of the nurse's progress notes revealed Resident #02 was assessed by the facility nurse practitioner (NP) #200 on 05/10/22 for a comprehensive assessment for management of chronic medical conditions. Resident #02 was receiving Hospice Services. NP #200 placed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review for Resident # 26 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #26's five- day MDS assessment revealed the facility was unable to determine his cognitive level as based on a BIMS score of 00. Further review of the MDS assessment revealed Resident #26 required limited assistance from staff with personal hygiene, eating, and extensive assistance from staff with toilet use. However, Resident #26 required only required supervision from staff with dressing. Review of the nursing progress notes for Resident #26, dated 05/06/22, revealed he was urinating and defecating in resident rooms. Further review of the nurse's notes revealed, resident attempted to pull blankets off another resident. Staff intervened and redirected resident prior to any physical contact. He was placed on a one-on-one observation. Resident #26 refused to be transported to the hospital on 05/06/22 after several attempts and he remained at the facility. Review of the psychiatric physician visit notes for Resident #26, dated 05/12/22, revealed the resident is, barely alert to self . Further review of the physician assessment revealed Resident #26 had ongoing psychotic symptoms, poor memory and his prognosis is limited. The physician is recommending a hospice consultation. Interview on 05/13/22 at 02:24 P.M. with State tested Nurse Aide (STNA) #101 regarding the alleged incident on 05/06/22 confirmed the incident happened after dinner on 05/06/22. STNA #101 did not witness Resident #26 touch Resident #02. STNA #101 confirmed Resident #26 was not in the room at the time Resident #02 alleged the incident happened. STNA #101 stated Resident #02 was upset and yelling out regarding Resident #26 and stated he tried to have intercourse with him. STNA #101 confirmed Resident #02 was wet all over and smelled of urine. STNA #101 stated she informed Licensed Practical Nurse (LPN) #100 and notified the Director of Nursing (DON) of the situation. STNA #101 confirmed Resident #02 never named the perpetrator by name however Resident #02 did say it was his roommate. Interview on 05/13/2203:08 P.M. with LPN #100 confirmed the alleged incident with Residents #02 and #26 took place on Friday, May 6, 2022, after dinner. LPN #100 stated STNA #101 informed her that Resident #02 reported Resident #26 had urinated on him (Resident #02) and was pulling on him in the bed. LPN #100 stated she immediately told the DON because LPN #100 worked as a DON at another facility and knew this needed to be reported/investigated. LPN #100 stated the DON told her not to document anything because the DON will do the documentation for her. LPN #100 stated Resident #02 was wet all over and smelled of urine. LPN #100 stated she was told by the DON that Resident #26 will be placed on a one on one supervision until he was sent to the hospital for evaluation. LPN #100 stated the DON told her she will request an x-ray for Resident #02's shoulder. LPN #100 reported she was comfortable leaving for the evening knowing Resident #02 was safe. LPN #100 stated Resident #02 is unable to make complete sentences however he can speak single words and answer with yes or no answers. Interview on 05/13/22 at 1:15 P.M. with STNA #110 confirmed the date of the incident involving Resident #26 and #02 was 05/06/22 after dinner. STNA #110 stated she heard Resident #02 yelling behind a closed door of his room. STNA #110 stated Resident #02 was soaked all over and smelled of urine. STNA #110 stated Resident #02 was yelling and stated his roommate was trying to have sex with him. STNA #110 stated she knows Resident #26 has urinated on Resident #02 in the past, however, she cannot say when and denied ever witnessing the event. STNA #110 stated Resident #02's roommate (Resident #26) was under the cover in his own bed at the time of the alleged incident. STNA #110 could not say if he was dressed or not. STNA #110 stated she reported this to her nurse and STNA #101 sent a message to the DON regarding the event. Interview on 05/13/22 at 3:30 P.M. with the DON revealed she received a report from LPN #100 that Resident #26 had urinated on Resident #02 and tried to take his covers. DON stated the only reason she told LPN #100 that she would complete the documentation was so that LPN #100 could leave for the evening. The DON confirmed she did report the incident as a SRI and did not complete an investigation because the facility did not consider the incident abuse. However, the DON further confirmed that Resident #02 was alleging that Resident #26 was trying to have intercourse with him. The DON stated she wanted to place Resident #26 on a one on one supervision because she felt this was a change of condition and did not want the matter to escalate further. However, the DON stated Resident #26 refused to go to the hospital, so he remained on a one on one until Monday, 05/10/22 when he was assessed by the psychiatrist. The DON denied being notified of the incident by anyone other than LPN #100. Review of facility SRI's revealed there was no incident involving Resident #02 and Resident #26 on 05/06/22. Additionally, there was no evidence of an investigation being completed regarding Resident #02's allegation. Review of facility policy titled, Ohio Abuse, Neglect, and Misappropriation, dated 04/01/19, revealed each occurrence of resident incident, bruise, abrasion, or injury of unknown source or report of alleged abuse, neglect or misappropriation of funds will be identified and reported to the supervisor and to the Administrator immediately. The facility will then submit a SRI to ODH. The policy also indicated that allegations of abuse would be investigated by executive leadership. This deficiency substantiates Complaint Number OH 593.

Based on medical record review, review of self-reported incidents (SRI's), staff interview and policy review, the facility failed to report an allegation of resident-to-resident sexual abuse to the Ohio Department of Health (ODH). This affected one (#02) of four residents reviewed for abuse. The facility census was 46. Findings include: Record review for Resident #02 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the discharge and return anticipated minimum data set (MDS) assessment, dated 02/02/22, revealed Resident #02 had impaired cognition as evidenced by his brief interview for mental status (BIMS) score of 99. Further review of the MDS assessment revealed Resident #02 required extensive assistance from staff with bed mobility, transfer, dressing, toilet use, personal hygiene eating and bathing. Review of the nursing progress notes for Resident #02 dated, 05/09/22 revealed resident was complaining of increased pain in the right shoulder and left pelvis. Further review of the nurse's progress notes revealed Resident #02 was assessed by the facility nurse practitioner (NP) #200 on 05/10/22 for a comprehensive assessment for management of chronic medical conditions. Resident #02 was receiving Hospice Services. NP #200 placed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review for Resident # 26 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #26's five- day MDS assessment revealed the facility was unable to determine his cognitive level as based on a BIMS score of 00. Further review of the MDS assessment revealed Resident #26 required limited assistance from staff with personal hygiene, eating, and extensive assistance from staff with toilet use. However, Resident #26 required only required supervision from staff with dressing. Review of the nursing progress notes for Resident #26, dated 05/06/22, revealed he was urinating and defecating in resident rooms. Further review of the nurse's notes revealed, resident attempted to pull blankets off another resident. Staff intervened and redirected resident prior to any physical contact. He was placed on a one-on-one observation. Resident #26 refused to be transported to the hospital on 05/06/22 after several attempts and he remained at the facility. Review of the psychiatric physician visit notes for Resident #26, dated 05/12/22, revealed the resident is, barely alert to self . Further review of the physician assessment revealed Resident #26 had ongoing psychotic symptoms, poor memory and his prognosis is limited. The physician is recommending a hospice consultation. Interview on 05/13/22 at 02:24 P.M. with State tested Nurse Aide (STNA) #101 regarding the alleged incident on 05/06/22 confirmed the incident happened after dinner on 05/06/22. STNA #101 did not witness Resident #26 touch Resident #02. STNA #101 confirmed Resident #26 was not in the room at the time Resident #02 alleged the incident happened. STNA #101 stated Resident #02 was upset and yelling out regarding Resident #26 and stated he tried to have intercourse with him. STNA #101 confirmed Resident #02 was wet all over and smelled of urine. STNA #101 stated she informed Licensed Practical Nurse (LPN) #100 and notified the Director of Nursing (DON) of the situation. STNA #101 confirmed Resident #02 never named the perpetrator by name however Resident #02 did say it was his roommate. Interview on 05/13/2203:08 P.M. with LPN #100 confirmed the alleged incident with Residents #02 and #26 took place on Friday, May 6, 2022, after dinner. LPN #100 stated STNA #101 informed her that Resident #02 reported Resident #26 had urinated on him (Resident #02) and was pulling on him in the bed. LPN #100 stated she immediately told the DON because LPN #100 worked as a DON at another facility and knew this needed to be reported/investigated. LPN #100 stated the DON told her not to document anything because the DON will do the documentation for her. LPN #100 stated Resident #02 was wet all over and smelled of urine. LPN #100 stated she was told by the DON that Resident #26 will be placed on a one on one supervision until he was sent to the hospital for evaluation. LPN #100 stated the DON told her she will request an x-ray for Resident #02's shoulder. LPN #100 reported she was comfortable leaving for the evening knowing Resident #02 was safe. LPN #100 stated Resident #02 is unable to make complete sentences however he can speak single words and answer with yes or no answers. Interview on 05/13/22 at 1:15 P.M. with STNA #110 confirmed the date of the incident involving Resident #26 and #02 was 05/06/22 after dinner. STNA #110 stated she heard Resident #02 yelling behind a closed door of his room. STNA #110 stated Resident #02 was soaked all over and smelled of urine. STNA #110 stated Resident #02 was yelling and stated his roommate was trying to have sex with him. STNA #110 stated she knows Resident #26 has urinated on Resident #02 in the past, however, she cannot say when and denied ever witnessing the event. STNA #110 stated Resident #02's roommate (Resident #26) was under the cover in his own bed at the time of the alleged incident. STNA #110 could not say if he was dressed or not. STNA #110 stated she reported this to her nurse and STNA #101 sent a message to the DON regarding the event. Interview on 05/13/22 at 3:30 P.M. with the DON revealed she received a report from LPN #100 that Resident #26 had urinated on Resident #02 and tried to take his covers. DON stated the only reason she told LPN #100 that she would complete the documentation was so that LPN #100 could leave for the evening. The DON confirmed she did report the incident as a SRI and did not complete an investigation because the facility did not consider the incident abuse. However, the DON further confirmed that Resident #02 was alleging that Resident #26 was trying to have intercourse with him. The DON stated she wanted to place Resident #26 on a one on one supervision because she felt this was a change of condition and did not want the matter to escalate further. However, the DON stated Resident #26 refused to go to the hospital, so he remained on a one on one until Monday, 05/10/22 when he was assessed by the psychiatrist. The DON denied being notified of the incident by anyone other than LPN #100. Review of facility SRI's revealed there was no incident involving Resident #02 and Resident #26 on 05/06/22. Additionally, there was no evidence of an investigation being completed regarding Resident #02's allegation. Review of facility policy titled, Ohio Abuse, Neglect, and Misappropriation, dated 04/01/19, revealed each occurrence of resident incident, bruise, abrasion, or injury of unknown source or report of alleged abuse, neglect or misappropriation of funds will be identified and reported to the supervisor and to the Administrator immediately. The facility will then submit a SRI to ODH. The policy also indicated that allegations of abuse would be investigated by executive leadership. This deficiency substantiates Complaint Number OH 593.

Based on review of the nursing staffing schedules, staff interviews and review of the staff roster, the facility failed to have a Registered Nurse (RN) in the facility for at least eight hours a day, seven days a week and failed to have a full time Director of Nursing (DON) employed at the facility. This had the potential to affect all 27 residents residing at the facility. Facility census was 27. Findings include: 1. Review of the facility nurse staffing schedules for 08/21/21 and 08/22/21 revealed there was not an RN scheduled to work in the facility. Interview with RN #100 on 08/25/21 at 11:00 A.M. verified there was not an RN present in the facility on 08/21/21 or 08/22/21. 2. Interview with the DON on 08/25/21 at 11:20 A.M. revealed she was the DON for the facility as well as the facility located next door and was the only DON employed at both facilities. The DON stated she worked approximately 50 hours per week and split the time between the two facilities. Review of the facility staff roster revealed the DON was the only RN employed as a DON at the facility.

Based on observation, staff interview, review of online resources per the Centers for Disease Control (CDC) and the Center for Medicare and Medicaid Studies (CMS), and review of facility policy, the facility failed to ensure staff wore eye protection in resident areas. This had the potential to affect all residents residing in the facility. The facility failed to ensure staff wore appropriate personal protective equipment (PPE) which affected one (Resident #172) of one facility-identified residents on transmission based precautions. The facility also failed to properly sanitize blood glucose meters which affected one (Resident #173) out of two facility-identified residents with physician orders for finger stick blood sugar testing. The census was 27. Findings include: 1. Observation on 08/23/21 at 8:10 A.M. of Licensed Practical Nurse (LPN) #16, at 8:15 A.M. of State tested Nursing Assistant (STNA) #104, and at 8:20 A.M. of STNA #13, revealed staff were working in resident care areas and were not wearing eye protection. Interviews on 08/23/21 at 8:10 A.M. of LPN #16 at 8:15 A.M. of State tested Nursing Assistant (STNA) #104, and at 8:20 A.M. of STNA #13 confirmed they were working in resident care areas and were not wearing eye protection. Interview on 08/25/21 at 11:20 A.M. with Registered Nurse (RN) #100, the facility's Infection Preventionist (IP), confirmed eye protection was required if the facility was in outbreak mode. The interview further revealed she was not aware the county positivity rate had any bearing on the facility's requirement for staff to wear eye protection in resident areas. Interview on 08/25/21 at 11:21 A.M. with Regional RN #99, confirmed the county in which the facility was situated was experiencing a moderate spread of COVID-19 positivity and staff were required to wear eye protection in resident care areas. Review of facility policy titled Criteria for COVID-19 Isolation, dated 06/22/21, revealed eye protection is not required in the resident units if the county positivity rate was less than 5 percent (%). Review of an online resource from CMS titled COVID-19 Nursing Home Data found at https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data-Test-Positivity-Rates/q5r5-gjyu/ revealed the county in which the facility was situated was experiencing a moderate spread of COVID 19 with a positivity rate of 8.8% for the week ending in 08/17/21. Review of an online resource from the CDC titled Infection Control Guidance for Healthcare Professionals about Coronavirus (COVID-19) found at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html revealed the use of eye protection in healthcare facilities is recommended in areas with moderate to substantial community transmission and staff should don eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area. 2. Review of the medical record for Resident #172 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #172's coronavirus (COVID19) care plan dated 08/23/21, revealed Resident #172 was at risk for COVID19 related to potential exposure with his recent hospitalization and admission from the community. Interventions included droplet isolation precautions per physician's orders, determine appropriate barriers to apply based on isolation precautions, arrange supplies and equipment in resident's room, and explain the purpose of isolation and precautions necessary to the resident and family. Review of Resident #172's droplet precautions care plan dated 08/24/21, revealed Resident #172 was on droplet precautions. Interventions included implement droplet isolation precautions, explain the purpose for isolation, and arrange supplies and equipment. Review of Resident #172's physicians order dated 08/21/21 revealed Resident #172 was ordered to be in droplet precautions. Observation of Resident #172's room on 08/23/21 at 10:05 A.M. revealed State tested Nurse Aide (STNA) #13 was getting items out of Resident #172's dresser and collected Resident #172's finished breakfast tray. Resident #172 was in his bed at the time of the observation. STNA #13 was observed wearing a surgical mask but was not wearing gloves or an isolation gown. There was no signage observed on Resident #172's door but Resident #172 was observed to have a set of drawers with personal protective equipment (PPE) outside of his room. Interview with STNA #13 on 08/23/21 at 10:05 A.M., verified she wore only a surgical mask into Resident #172's room, and she collected Resident #172's finished breakfast tray without donning gloves or an isolation gown. STNA #13 verified Resident #172 was on droplet precautions but did not have any droplet precautions signage on his door. Observation of Resident #172's room on 08/23/21 at 10:10 A.M. revealed Licensed Practical Nurse (LPN) #102 and Registered Nurse (RN) #15 were placing droplet precautions signage on the inside and outside of Resident #172's room. LPN #102 was observed to enter Resident #173's room and was observed to hang a droplet precautions sign on the wall inside of his room while only wearing a surgical mask. LPN #102 was not wearing an N-95 respirator, isolation gown, or gloves. Resident #172 was observed in his room at the time of the observation. Interview with LPN #102 and RN #15 on 08/23/21 at 10:10 A.M. verified they were hanging droplet precautions signage inside and outside Resident #172's room. LPN #102 verified she entered Resident #172's room and hung a droplet precautions sign on the wall while only wearing a surgical mask. LPN #102 verified she was not wearing a N-95 respirator, gloves, or an isolation gown. Observation of Resident #172 on 08/23/21 at 10:49 A.M., revealed Housekeeper #101 was cleaning Resident #172's room while only wearing gloves and a surgical mask. Resident #172 was observed to be present in the room at the time of the observation. Interview with Housekeeper #101 on 08/23/21 at 10:49 A.M. verified she was in Resident #172's room while only wearing a surgical mask and gloves. Housekeeper #101 verified she was not wearing an N-95 respirator or an isolation gown. Review of the facility's policy titled Criteria for COVID-19 isolation, dated 04/05/21, revealed all new admissions who are not fully vaccinated will be on the at risk unit and will have appropriate signage on or around their resident room door. An N-95 and eye protection will be required when working in the general area of the unit and full personal protective equipment (PPE) will be required when entering a resident room. Full PPE consists of an N95 respirator, face shield, isolation gown, and gloves. 3. An observation of the medication administration with Licensed Practical Nurse (LPN) #16 on 08/23/21 at 7:50 A.M., revealed LPN #16 obtained Resident #173's blood glucose. LPN #16 placed the glucometer on the bedside table without a barrier. After obtaining the blood glucose level, LPN #116 cleaned the glucometer with an alcohol wipe and placed it on top of the medication cart. An interview with LPN #116 at 8:01 A.M. confirmed that she did not use a barrier to lay the glucometer on the bedside table. LPN #116 also confirmed that the alcohol wipe used to clean the glucometer was not an acceptable cleaning agent for glucometer and was not the policy/procedure. Review of the facility policy titled Cleaning and Disinfection of Glucose Meter, revised on 10/08/18, revealed that one glucose meter may be in use while the other meter was undergoing disinfection with the high-level antimicrobial wipe for wet-contact time per the manufactures recommendation. The suggested method to obtain proper disinfection times for wet-contact is to wrap the machine in the wipe ensuring that all surfaces remain wet during contact time period. Place the wrapped meter in a clean cup on the med cart for the appropriate length of time and allow the meter to air dry prior to use.

Based on record review, observation, staff interview and review of facility policy, the facility failed to ensure controlled substance medications were properly counted. This had the potential to affect five (#10, #19, #122, #172, #273) of five residents with controlled substances being stored in Cart 2. The census was 27. Findings include: 1. Review of the controlled substance count sheet for Cart 2 revealed the nurse had not signed the count sheet at the beginning of her shift, 7:00 A.M. on 08/23/21. Interview on 08/23/21 at 3:14 P.M. with Licensed Practical Nurse (LPN) #16 confirmed she had not signed the count sheet for the controlled substances at the beginning of her shift on 08/23/21. 2. Review of the medical record for Resident #122 revealed an admitted [DATE] with a diagnosis of encounter for orthopedic aftercare and a discharge date of [DATE]. Review of the physician orders for Resident #122 revealed an order dated 05/12/21 for oxycodone five milligrams. Review of the controlled substance record for Resident #122 revealed resident had six oxycodone tablets remaining. Observation on 08/23/21 at 3:15 P.M. of the controlled substance storage for Resident #122 revealed there was a card of oxycodone for resident with six tablets remaining. Interview on 08/23/21 at 3:15 P.M. with Licensed Practical Nurse (LPN) #16 confirmed there was a controlled substance sheet for Resident #122's oxycodone indicating six tablets remained and the controlled substance storage in Cart 2 included a card with six oxycodone tablets for Resident #122. LPN #16 confirmed Resident #122 was discharged from the facility in June 2021 but his oxycodone had not been removed from Cart 2. The facility confirmed there are five (#10, #19, #122, #172, #273) residents with controlled substances being stored in Cart 2. Review of the facility policy titled Medication Controlled Drugs and Security dated 07/25/18 revealed the controlled drug record must be signed by the nurse coming on duty and going off duty to verify that the count of all controlled drugs is correct after the count has been completed. Further review of the policy revealed when the prescribed drug was discontinued or the resident discharged , the container and the control sheet must be removed for drug destruction within five (5) days.

Based on record review, staff interview, and review of facility policy, the facility failed to ensure a pharmacist completed a monthly drug regimen review as required and failed to ensure pharmacist recommendations were reviewed and acted upon in a timely manner by the physician. This affected six (#4, #5, #10, #16, #17 and #20) of six residents reviewed for unnecessary medications. The census was 27. Findings include: 1. Review of the medical record for Resident #4 revealed resident was admitted on [DATE] with a diagnosis of early onset Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment for Resident #4 dated 05/10/21 revealed resident was cognitively impaired and was totally dependent on assistance of one to two staff with activities of daily living (ADL's). Review of August 2021 Medication Administration Record (MAR) for Resident #4 revealed resident had an order dated 12/01/20 for [MEDICATION(S)] as needed every four hours for agitation and an order dated 03/28/21 for [MEDICATION(S)] 500 mg three times daily. Further review of MAR revealed resident received as needed doses of [MEDICATION(S)] on 08/08/21 and 08/18/21 and resident received routine [MEDICATION(S)] as ordered. Review of the pharmacy recommendation for Resident #4 for July 2021 revealed resident was ordered [MEDICATION(S)] one milligram (mg) every four hours as needed for agitation. Further review recommendation revealed this was an order for an as needed [CONDITION(S)] medication without a stop date and the State Operations Manual (SOM) required an assessment to continue an as needed [CONDITION(S)] medication beyond 14 days. Recommendations included the following: prescriber to reassess the as needed [CONDITION(S)] order, prescribe to update the order to include the duration and rationale for extending the order, consider if discontinuing the [MEDICATION(S)] order was appropriate. Further review of the pharmacy recommendation revealed it had not been reviewed by the physician or prescriber. Review of the pharmacy recommendation for Resident #4 for July 2021 revealed resident had an order for [MEDICATION(S)] 500 mg three times daily since March. Recommendation was for prescriber to re-evaluate the use of [MEDICATION(S)] and consider discontinuing or if medication was to be continued to update indication of use. Further review of the pharmacy recommendation revealed it had not been reviewed by the physician or prescriber. Interview on 08/25/21 at 9:00 A.M. with Regional Registered Nurse (RN) #99 confirmed the July 2021 pharmacy recommendations for Resident #4 regarding [MEDICATION(S)] and [MEDICATION(S)] had not been reviewed or addressed by the physician. 2. Review of the medical record for Resident #17 revealed an admitted [DATE] with diagnoses including dementia with behavioral disturbance, unspecified [CONDITION(S)], and mood disorder. Review of the MDS assessment for Resident #17 dated 07/22/21 revealed resident was cognitively impaired and required supervision and set up help of one staff with activities of daily living. Review of the August 2021 MAR for Resident # 17 revealed an order dated 04/14/21 for [MEDICATION(S)] as needed at bedtime. Review of the pharmacy recommendation for Resident #17 for July 2021 revealed resident had an as needed order for [MEDICATION(S)] for anxiety and recommendations were to reassess the resident and determine if the order should be updated or discontinued. Further review of the pharmacy recommendation revealed it had not been reviewed by the physician or prescriber. Interview on 08/25/21 at 9:00 A.M. with Regional RN #99 confirmed the July 2021 pharmacy recommendations for Resident #17 regarding [MEDICATION(S)] had not been reviewed or addressed by the physician. Review of facility policy titled Medication Regimen Review dated 09/23/19 revealed the resident's attending physician must document in the medical record that the identified irregularity has been reviewed, and what, if any action has been taken to address it. 3. Review of the medical record for Resident #16 revealed an admitted [DATE] with diagnosis including depressive disorder with psychotic symptoms, mood disorder, unspecified [CONDITION(S)] and [CONDITION(S)] disorder. Review of the quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact and received antipsychotic and antidepressant medications. Review of the physician orders for 08/21 revealed Resident #16 was taking [MEDICATION(S)] one milligram (mg) by mouth daily for mood disorder, [MEDICATION(S)] extended release 75 mg by mouth-take three tablets to equal 225 mg-daily for mood disorder and [MEDICATION(S)] extended release 300 mg by mouth every 12 hours for mood disorder. Review of the 07/21 pharmacy recommendations and note to the attending physician/prescriber revealed the pharmacy recommended obtaining a [MEDICATION(S)] level now and every three months, a basic metabolic panel every every three moths, and a [CONDITION(S)]-stimulating hormone level every six months. The recommendations were not reviewed or signed by the physician. Interview with the Regional RN #99 on 08/25/21 at 9:54 A.M. confirmed the pharmacy recommendations for Resident #16 were not acted upon by the physician. 4. Review of the medical record for Resident #20 revealed an admitted [DATE] with diagnosis including [CONDITION(S)], [CONDITION(S)] and depression. Review of the quarterly MDS assessment dated [DATE] revealed the resident was cognitively impaired with symptoms of depression and received antidepressant medication. Review of the physician orders for 08/21 revealed Resident #20 was taking [MEDICATION(S)] [MEDICATION(S)] 75 mg by mouth two times daily for major depressive disorder, [MEDICATION(S)] extended release 250 mg by mouth three times daily for [CONDITION(S)], Sertrailne [MEDICATION(S)] 100 mg by mouth daily for major depressive disorder and Trazadone [MEDICATION(S)] 50 mg by mouth at bedtime for [CONDITION(S)]. Review of the 07/21 pharmacy recommendations and note to attending physician/prescriber revealed the pharmacy stated the resident currently had an active order for [MEDICATION(S)] 250 mg three times daily for [CONDITION(S)]. However, [CONDITION(S)] was not listed as a current medical diagnosis. The recommendations were not reviewed or signed by the physician. Interview with the Regional RN on 08/25/21 at 9:54 A.M. confirmed the pharmacy recommendations for Resident #20 was not acted upon by the physician. 5. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Coronavirus Disease 2019 (COVID-19), cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, type two diabetes mellitus without complications, major depressive disorder, moderate protein calorie malnutrition, anxiety disorder and heart failure. Review of Resident #5's quarterly MDS assessment dated [DATE] revealed the resident to be severely cognitively impaired and required extensive with transfers, bed mobility, dressing, toileting, and personal hygiene. Resident #5 also required supervision with eating. Resident #5 was reported to be on a routine antipsychotic, antianxiety, antidepressant and anticoagulant. Review of Resident #5's care plan dated 12/30/19 revealed Resident #5 had potential side effects of [CONDITION(S)] medications due to antianxiety use, antidepressant use and antipsychotic use. Interventions included administer [CONDITION(S)] medications as ordered, monitor side effects, approach in a non judgmental manner, assess for boredom, assess for pain, call light in reach and consult with the pharmacy and the physician to consider dosage reduction when clinically appropriate. Review of Resident #5's physician orders dated 08/24/21 revealed Resident #5 was prescribed [MEDICATION(S)] 100 milligrams (mg) give one tablet by mouth one time a day for major depressive disorder on 03/29/20, [MEDICATION(S)] five mg give one tablet by mouth at bedtime for anxiety disorder on 02/11/20, [MEDICATION(S)] tablet delayed release 250 mg give one tablet by mouth every morning and bedtime related to anxiety disorder on 01/09/20, and [MEDICATION(S)] 15 mg give one tablet by mouth three times a day for anxiety disorder on 05/07/21. Review of Resident #5's chart from 08/23/20 to 08/23/21 revealed there were no monthly regimen reviews in Resident #5's chart. Interview with Regional RN #99 on 08/24/21 at 3:08 P.M. verified Resident #5 did not have monthly regimen reviews from 08/23/20 to 08/23/21. Review of the facility's medication regimen review policy dated 09/23/19 revealed the consultant pharmacist shall conduct a monthly medication regimen review for each resident in the facility. The Director of Nursing (DON) or designee will be responsible for addressing all medication irregularity reports with the attending physicians in a manner that meets the needs of the resident. 6. Record review for Resident #10 revealed an admitted [DATE] with the following diagnoses: type two diabetes mellitus, dementia, COVID-19, [CONDITION(S)], depression, anxiety, and suicidal ideation's. This resident had allergies to [MEDICATION(S)] and [MEDICATION(S)]. Review of the Admission MDS assessment, dated 05/26/21, revealed this resident had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of nine. This resident was assessed to require supervision with set-up assistance for bed mobility, transfers, and toileting. Review of the August 2021 MAR for Resident #10 revealed an order for [MEDICATION(S)] every 12 hours as needed. Further review of the MAR revealed Resident #10 had received an as needed dose of the [MEDICATION(S)] on 08/03/21. Review of the pharmacy recommendation for Resident #17 for July 2021 revealed resident had an as needed order for [MEDICATION(S)] for anxiety and recommendations were to reassess the resident and determine if the order should be updated or discontinued. Further review of the pharmacy recommendation revealed it had not been reviewed by the physician or prescriber. Interview on 08/25/21 at 9:00 A.M. with Regional RN #99 confirmed the July 2021 pharmacy recommendations for Resident #10 regarding [MEDICATION(S)] had not been reviewed or addressed by the physician. Review of facility policy titled Medication Regimen Review dated 09/23/19 revealed the resident's attending physician must document in the medical record that the identified irregularity has been reviewed, and what, if any action has been taken to address it.

Based on medical record review, staff interview, review of online resource Medscape, and review of facility policy, the facility failed to ensure as needed [CONDITION(S)] medications had a stop date, antipsychotic medications were given for appropriate indication, gradual dose reduction (GDR) was addressed as appropriate for antipsychotic medication and failed to obtain appropriate laboratory testing for [CONDITION(S)] medications. This affected six (#4, #5, #10, #16, #17, and #72) of six residents reviewed for unnecessary medications. The census was 27. Findings include: 1. Review of the medical record for Resident #4 revealed resident was admitted on [DATE] with a diagnosis of early onset Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment for Resident #4 dated 05/10/21 revealed resident was cognitively impaired and was totally dependent on assistance of one to two staff with activities of daily living (ADL's). Review of the August 2021 physician orders for Resident #4 revealed an order dated 12/01/20 for resident to receive [MEDICATION(S)], an antipsychotic medication on a routine basis. Further review of the record for Resident #4 revealed an order dated 08/10/21 for Resident #4 to receive an additional routine antipsychotic medication, [MEDICATION(S)]. Review of the nurse progress notes for Resident #4 dated 08/01/21 through 08/25/21 revealed the notes contained no documentation regarding any behavioral symptoms or indications for the use of antipsychotic medications. Review of the diagnosis list for Resident #4 revealed resident did not have an appropriate diagnosis to justify the use of antipsychotic medication. Review of the August 2021 physician orders for Resident #4 revealed an order dated 12/01/20 for resident to receive an as needed [MEDICATION(S)] with no stop date or duration for the order. Interview on 08/23/21 at 3:20 P.M. with Licensed Practical Nurse (LPN) #16 confirmed there was no indication for Resident #4 to receive antipsychotic medications and Resident #4's [MEDICATION(S)] order did not include a stop date. Review of the online resource Medscape revealed [MEDICATION(S)] and [MEDICATION(S)] had black box warnings indicating the medication placed elderly patients with dementia related [CONDITION(S)] at increased risk of mortality and neither medication was not approved for the treatment of patients with dementia-related [CONDITION(S)]. Review of the facility policy titled Medication Management dated 08/2020 revealed when a resident received medications from the same class or with similar therapeutic benefits (duplicate therapy), the clinical rationale and benefit should be documented in the resident's active record. 2. Review of the medical record for Resident #17 revealed an admitted [DATE] with diagnoses including dementia with behavioral disturbance, unspecified [CONDITION(S)], and mood disorder. Review of the MDS assessment for Resident #17 dated 07/22/21 revealed resident was cognitively impaired and required supervision and set up help of one staff with activities of daily living. Review of the August 2021 MAR for Resident # 17 revealed an order dated 04/14/21 for [MEDICATION(S)] as needed at bedtime. Interview on 08/23/21 at 3:20 P.M. with Licensed Practical Nurse (LPN) #16 confirmed Resident #17's [MEDICATION(S)] order did not include a stop date. 3. Review of Resident #72 medical record revealed an admission order of 07/29/21. Diagnoses included [CONDITION(S)], and anxiety. Review of the most recent five-day MDS assessment revealed Resident #72 was cognitively impaired. Review of the physicians orders dated on 07/29/21 and 08/01/21 revealed an order for an antianxiety medication ([MEDICATION(S)]) 0.5 mg (milligrams) to be given every six hours as needed. The medication did not have a stop date. Review of the 08/21 Medication Administration Record (MAR) revealed the resident received one dose on 08/22/21. Observations of Resident #72 on 08/23/21 and 08/24/21 at random times noted the resident was usually in the dining room with his head on the table asleep. Interview with Registered Nurse #99 on 08/24/21 at 4:30 P.M. verified there was no stop date for the medication, and it should not have went through without clarification for a stop date. 4. Review of the medical record for Resident #16 revealed an admitted [DATE] with diagnosis including depressive disorder with psychotic symptoms, mood disorder, unspecified [CONDITION(S)] and [CONDITION(S)] disorder. Review of the quarterly Minimum Data Set 3.0 (MDS) dated [DATE] revealed the resident was cognitively intact and received antipsychotic and antidepressant medications. Review of the physician orders for 08/21 revealed Resident #16 was taking [MEDICATION(S)] extended release 300 mg by mouth every 12 hours for mood disorder. Review of the 07/21 pharmacy recommendations and note to the attending physician/prescriber revealed the pharmacy recommended obtaining a [MEDICATION(S)] level now and every three months, a basic metabolic panel every every three moths, and a [CONDITION(S)]-stimulating hormone level every six months. The recommendations were not reviewed or signed by the physician. Review of the laboratory test results for Resident #16 revealed no laboratory studies were completed to monitor the [MEDICATION(S)] level. Interview with the Regional Nurse #99 on 08/25/21 at 9:54 A.M. confirmed there was not a [MEDICATION(S)] level obtained for Resident #16 since his admission on 03/23/21. 5. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Coronavirus Disease 2019 (COVID-19), cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, type two diabetes mellitus without complications, major depressive disorder, moderate protein calorie malnutrition, anxiety disorder and heart failure. Review of Resident #5's quarterly MDS assessment dated [DATE] revealed the resident to be severely cognitively impaired and required extensive with transfers, bed mobility, dressing, toileting, and personal hygiene. Resident #5 also required supervision with eating. Resident #5 was reported to be on a routine antipsychotic, antianxiety, antidepressant and anticoagulant. Review of Resident #5's care plan dated 12/30/19 revealed Resident #5 had potential side effects of [CONDITION(S)] medications due to antianxiety use, antidepressant use and antipsychotic use. Interventions included administer [CONDITION(S)] medications as ordered, monitor side effects, approach in a non judgmental manner, assess for boredom, assess for pain, call light in reach and consult with the pharmacy and the physician to consider dosage reduction when clinically appropriate. Review of Resident #5's physician orders dated 08/24/21 revealed Resident #5 was prescribed [MEDICATION(S)] 100 milligrams (mg) give one tablet by mouth one time a day for major depressive disorder on 03/29/20, [MEDICATION(S)] five mg give one tablet by mouth at bedtime for anxiety disorder on 02/11/20, [MEDICATION(S)] tablet delayed release 250 mg give one tablet by mouth every morning and bedtime related to anxiety disorder on 01/09/20, and [MEDICATION(S)] 15 mg give one tablet by mouth three times a day for anxiety disorder on 05/07/21. Review of Resident #5's chart from 08/23/20 to 08/23/21 revealed there were no monthly regimen reviews in Resident #5's chart. There was also no indication that Resident #5's medications were contraindicated. Review of Resident #5's physician's visits dated 07/22/20, 09/27/20, 11/17/20, 01/20/21, 03/21/21, and 05/18/21 revealed there were no gradual dose reductions or documentation of contraindications of a gradual dose reduction for Resident #5's [MEDICATION(S)] 100 milligrams (mg) give one tablet by mouth one time a day for major depressive disorder on 03/29/20, [MEDICATION(S)] five mg give one tablet by mouth at bedtime for anxiety disorder on 02/11/20, [MEDICATION(S)] tablet delayed release 250 mg give one tablet by mouth every morning and bedtime related to anxiety disorder on 01/09/20, and [MEDICATION(S)] 15 mg give one tablet by mouth three times a day for anxiety disorder on 05/07/21. Interview with Director of Social Services #11 on 08/24/21 at 12:59 P.M. reported Resident #5 had not received any psychiatric services from 08/23/20 to 08/24/21. Interview with Regional Registered Nurse (RN) #99 on 08/25/21 at 9:54 A.M. verified Resident #5 did not have any contraindications or gradual dose reductions for his [MEDICATION(S)] 100 milligrams (mg) give one tablet by mouth one time a day for major depressive disorder on 03/29/20, [MEDICATION(S)] five mg give one tablet by mouth at bedtime for anxiety disorder on 02/11/20, [MEDICATION(S)] tablet delayed release 250 mg give one tablet by mouth every morning and bedtime related to anxiety disorder on 01/09/20, and [MEDICATION(S)] 15 mg give one tablet by mouth three times a day for anxiety disorder on 05/07/21. 6. Review of the medical record for Resident #10 revealed an admitted [DATE] with the following diagnoses: type two diabetes mellitus, dementia, COVID-19, [CONDITION(S)], depression, anxiety, and suicidal ideation's. Review of the Admission MDS assessment for Resident #10 revealed this resident had moderately impaired cognition evidenced by a BIMS score of nine. This resident was assessed to require supervision and set-up assistance for transfers, bed mobility, and toileting. Review of the August 2021 MAR for Resident #10 revealed an order dated 05/19/21 for [MEDICATION(S)] every 12 hours as needed. Resident #10's [MEDICATION(S)] order did not contain a stop date. Interview on 08/23/21 at 3:20 P.M. with LPN #16 confirmed Resident #10's [MEDICATION(S)] order did not include a stop date.

Based on review of medical records, review of hospital documentation, review of a Police Report, review of a Paramedic Report, observations, staff interviews, Police Officer interview, Emergency Medical Personnel interview, review of the facility policy, review of the facility investigation, review of facility video surveillance footage and review of local weather reports, the facility failed to ensure staff provided adequate supervision to prevent a cognitively impaired resident from leaving the facility unsupervised. This resulted in Immediate Jeopardy when one resident (#5) was placed at risk for serious harm and injury when she eloped from the facility without staff knowledge, was missing for approximately nine hours, was found on the floor in a locked office within a vacant building and required emergency medical services. This affected one (#5) of six residents reviewed for risk of elopement. The facility identified eight residents at risk for elopement. The facility census was 53. On 12/07/16 at 10:05 A.M., the Administrator, the Director of Nursing (DON), the Corporate DON, the Vice President of Operations (VPO), and the Corporate Compliance Officer (CCO) were notified Immediate Jeopardy began on 12/03/16 at 10:11 P.M. when Resident #5, who was care planned as a risk for elopement and required a secured dementia unit, exited the facility, unsupervised and without staff knowledge, through an alarmed door which initiated an audible alarm. At 11:00 P.M., State tested Nursing Assistant (STNA) #62 turned off and reset the door alarm, notified a co-worker and Licensed Practical Nurse (LPN) #81 that the sounding door alarm had been reset and returned to her job duties. On 12/04/16, between 12:00 A.M. and 12:30 A.M., STNA #62 realized Resident #5 was missing, two hours after the door alarm sounded, and notified LPN #81. Staff searched the facility, the building grounds, and a vacant building next to and attached to the facility; however, the staff could not locate Resident #5. LPN #81 attempted to notify Registered Nurse (RN) Supervisor #90 but he could not be located. At 3:30 A.M., RN Supervisor #90 was located and informed Resident #5 was missing at which time the police were notified, over five hours after the resident left the facility and three hours after the resident was discovered missing by staff. The facility interior, the building grounds, and the vacant building next to and attached to the facility which had been a prior dialysis center with laundry facilities in the basement, were once again searched with the Police. The vacant building was attached to the facility by a door that lead to an enclosed breezeway which had alarmed earlier. The Police discovered numerous doors inside this vacant building were locked and unable to be accessed as staff did not have the keys or codes to these areas so they were unable to be searched. Law enforcement was informed these areas were secured prior to Resident #5 going missing and that Resident #5 could not have accessed the areas. The staff insisted Resident #5 had to have been outside. Resident #5 was found on 12/04/16 at 7:05 A.M., approximately nine hours after leaving the facility, by LPN #65 in a locked area in the vacant building, visible through a window in a door. Staff was unable to obtain access to the room where Resident #5 was seen as the staff did not have keys or the code to access the locked door. The staff called 911, the Police reported to the vacant building and broke through the door to gain access to Resident #5. Resident #5 was found lying on the floor shivering, clothed only in a hospital gown without socks or shoes. The paramedics arrived and assessed Resident #5. Resident #5 was shivering due to exposure to a less temperature controlled building for several hours, the residents' skin was pale, cool and dry. Resident #5 complained of left hip pain. Hot packs were applied to Residents #5's feet and chest to initiate active warming and the resident's body temperature was obtained as 96.8 degrees Fahrenheit (F) tympanic. Intravenous access was unsuccessful in an attempt to administer warmed fluid bolus and the resident was started on oxygen. Subsequently, Resident #5 was sent to the emergency room for evaluation and treatment and was admitted for a hip injury, hypothermia and observation. The Immediate Jeopardy was removed on 12/07/16 at 8:17 A.M. when the facility implemented the following corrective actions: · On 12/04/16 at 7:25 A.M., Resident #5 was found and emergency medical personnel arrived and transported Resident #5 to the hospital for evaluation and treatment. · On 12/04/16 at 8:30 A.M., day shift nursing staff were in-serviced by the Administrator on the elopement policy and procedure and notification of Administration during the event of an elopement. Nursing staff began completing elopement assessments on all residents currently residing in the facility. · On 12/04/16 at 6:00 P.M., the DON and VPO in-serviced day shift and night shift nursing staff on the elopement policy and procedure, abuse policies and procedures, notification of Administration during the event of an elopement, and location of Administration contact information. An elopement drill was conducted as part of the in-service. · On 12/04/16 at 7:01 P.M., LPN #81 was suspended pending the investigation of Resident #5's elopement from the facility. · On 12/04/16 at 7:12 P.M., the DON and VPO conducted an elopement drill with night shift nursing staff. The night shift nursing staff were also in-serviced on the elopement policy and procedure, contacting Administration during the event of an elopement and location of the Administration contact information. · On 12/05/16 at 8:00 A.M., the DON conducted an elopement drill with all staff on duty. Education was provided on elopement and abuse policies and procedures and location of Administration contact information. · On 12/05/16 at 8:30 P.M., the DON conducted an elopement drill with all staff on duty. Education was provided on elopement and abuse policies and procedures and location of Administration contact information. · On 12/06/16 at 8:00 A.M., nursing staff completed the elopement assessments for all residents residing in the facility and the assessments were reviewed by the DON. · On 12/06/16 at 2:45 P.M., all staff education had been completed regarding the elopement and abuse policies and procedures, notification of Administration during the event of an elopement, and location of Administration contact information. · On 12/06/16 at 6:30 P.M., all resident's elopement assessments were reviewed by CCO and the DON for appropriateness of placement. · On 12/06/16 at 7:20 P.M., the DON reviewed the care plans of all residents in the facility and updated them as appropriate regarding elopement risk and interventions. · On 12/07/16 at 7:30 A.M., maintenance personnel placed a keyed lock on the door to the therapy room and the exit door to the breezeway which is connected to the vacant building. Keys were placed on the medication cart key rings to ensure access to these locked areas. · On 12/07/16 at 8:17 A.M., the Administrator in-serviced all therapy staff regarding the therapy door remaining locked upon leaving the therapy room and the key to the door must remain on their person at all times. · On 12/07/16 at 11:22 A.M., observations of the exit door to the breezeway in the therapy room confirmed a keyed lock was in place. The door was also alarmed. · On 12/07/16 between 11:38 A.M. and 4:33 P.M., LPN #65, LPN #91, LPN #98, STNA #85, STNA #84 and STNA #164 were interviewed. All the staff verbalized an understanding of the facilities elopement policy and procedure. The staff also verbalized an understanding of the location of Administrative contact numbers and situations that would require Administrative contact. · On 12/07/16, six (#3, #6, #7, #9, #18 and #25) additional resident's medical records were reviewed and revealed no concerns regarding supervision or elopements. Although the Immediate Jeopardy was removed, the deficiency remains out of compliance at Severity Level 2 (no actual harm with potential for more that minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective actions to ensure monitoring for on-going compliance. Findings include: Medical record review revealed Resident #5 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the comprehensive admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely impaired with her cognitive skills for daily decision making, required limited assistance with transfers, extensive assistance with personal hygiene, and a walker and wheelchair were utilized for mobility. There was no elopement assessment in Resident #5's medical record. Review of the care plan dated 10/19/16 revealed Resident #5 required a secured unit for dementia, the resident was at risk for injury related to wandering and elopement, the resident lacked safety awareness, wandered daily and had a history of [REDACTED]. Interventions included one-on-one attention during times of agitation, structured activities, and pleasant diversions such as food, television, and conversation. Review of a nursing progress note dated 12/04/16 at 8:50 A.M. revealed around 12:30 A.M. an STNA reported Resident #5 was not in her room. Staff searched the facility, the building grounds, and the vacant dialysis building but were unable to locate the resident. The nurse supervisor was notified and contacted the Police. All areas were searched again with the police but Resident #5 was not found. Around 7:00 A.M., the oncoming LPN (#65) was notified about the missing resident and between 7:00 A.M. and 7:15 A.M., an oncoming unidentified STNA reported the missing resident had been found in the old dialysis building. Upon responding to the building where the resident was located, staff were unable to get to Resident #5 as all the doors were locked. Nine-one-one was called and transported the resident to the hospital. It was unknown how the resident got into the old building. Review of the Police Report dated 12/04/16 revealed at 4:01 A.M. the Police were advised of a possible missing resident at the facility. Upon arrival at the facility, RN Supervisor #90 reported Resident #5 had been missing since approximately 10:00 P.M. on 12/03/16 and had serious medical issues including dementia, depression, chronic pain, diabetes, and was on numerous medications. When RN Supervisor #90 was questioned as to the reason the Police were not contacted earlier he reported because he was unable to contact anyone from Administration. The building where Resident #5 resided was a semi-locked down building with key codes and door alarms (not a secured unit). LPN #81 reported Resident #5 was last seen at 10:00 P.M. on 12/03/16 wearing a hospital gown without shoes or socks and was discovered missing around 11:00 P.M. LPN #81 reported Police were not contacted earlier as staff had been looking for the resident. LPN #81 reported a door alarm went off on 12/03/16 around 11:30 P.M. but staff checked the door and nobody was around. A search was conducted of the facility and the grounds including the vacant building located behind the facility. Numerous locked doors were noted within the vacant building which staff reported they did not have keys too and the resident would not have been able to access these rooms since they had been locked. Staff was instructed to contact Administration for keys. RN Supervisor #90 reported numerous attempts to contact Administration were unsuccessful. Staff were instructed to continue searching for Resident #5. Staff assured the Police they had checked every possible place they could within the buildings. At this point, the officer was faced with a critical elderly missing report, in which the person had been missing for approximately five to six hours by the time police were notified. Resident #5 was entered into a data system as an endangered critical missing person, an all-county broadcast was conducted immediately and every hour, additional units from the Police Department were called in, other units checked the perimeter of the facility, a canine perimeter search was conducted, local hospitals were contacted and attempts were made to contact Administration of the facility. Resident #5's daughter was contacted for information and reported she was not contacted or informed that the resident was missing from the facility. Resident #5's daughter reported the resident was not very mobile, used a walker, took small steps and moved slowly, was legally blind, had dementia, and was placed at the facility due to the need for a secured unit as she walked at the doors at her previous facility. A search was focused within a one mile radius of the facility. On 12/04/16 at 7:25 A.M., the Police were dispatched to the facility as Resident #5 had been located by staff members outside of the alarmed doors, locked inside the old dialysis building, which no one had keys to. The Police Officers forced entry by kicking in the door. Resident #5 was found shivering from the cold and lying on the ground. The building did not appear to be heated. From the location where Resident #5 was found, she would have had to go out a set of alarmed doors, cross a cat walk, go through another set of doors and enter the old dialysis doors which were locked at the time she was discovered. Resident #5 was transported to the hospital. Review of the Paramedic Patient Care Report dated 12/04/16 revealed paramedics were dispatched to the facility on [DATE] at 7:27 A.M. for an injury related to a fall. The narrative documented Resident #5 lying on her abdomen in a vacant building after escaping a secured dementia wing of the facility and not being seen or heard from for approximately six hours, per nursing staff. Resident #5 was alert, but not oriented to self, location, or event due to advanced dementia. Resident #5 was shivering due to exposure to a less temperature controlled building for several hours, skin was pale, cool and dry. Resident #5 also complained of left hip pain. Nursing staff reported they had last seen the Resident on 12/03/16 at 11:00 P.M., approximately eight hours prior to Resident #5 being found. Hot packs were applied to Resident #5's feet and chest to initiate active warming and the resident's tympanic temperature was obtained as 96.8 degrees Fahrenheit (F). Intravenous access was unsuccessful in an attempt to administer warmed fluid bolus. Resident #5 was placed on five liters per minute of oxygen via nasal cannula for comfort and to correct a low oxygen saturation reading of 94 percent (%) that was likely related to the resident's lowered skin temperature. Resident #5 was transported to the hospital for a hip injury and hypothermia. Review of Resident #5's hospital admission history and physical dated 12/04/16 revealed the resident had a history of [REDACTED].#5 was admitted to the hospital after she escaped from a locked down unit at an extended care facility and went missing for approximately five and a half hours. Resident #5 went missing on 12/03/16 at around 11:30 P.M.; however, the facility did not call the Police for assistance until 4:00 A.M. Resident #5 was found on facility grounds in an old dialysis building. Resident #5 was cold with scattered bruising. She was admitted to the hospital for observation related to a fall at the nursing facility, dementia and adult neglect or abandonment. Review of the hospital discharge summary dated 12/06/16 revealed Resident #5 was medically stable, had dementia and was unable to recall reasons for hospitalization . Resident #5 was hospitalized for [REDACTED]. Resident #5 was discharged to another extended care facility on 12/06/16. Review of the facility's investigation revealed LPN #81 contacted RN Supervisor #90 on 12/04/16 at 3:30 A.M. to inform the supervisor Resident #5 was missing. LPN #81 also reported an alarm was silenced earlier in the shift by STNA #62. The police were contacted and attempts were made to contact management without any response. Observations during the facility tour on 12/06/16 at 9:33 A.M. with CCO and Maintenance Assistant #519 revealed an unsecured open door to a therapy room at the rear of the facility on the main floor. At the rear of the therapy room was a door with a sign push until alarm sounds, door can be opened in 15 seconds and a numbered key pad was located on the wall beside the door. Upon touching the handle to the door an alarm sounded. When the door was opened, an alarm sounded and a code was required to be entered into the numbered key pad on the wall to silence the alarm. The door led to a one story elevated enclosed breezeway which was approximately 20 feet in length and led to the top, second floor of an adjacent vacant building which used to be utilized as a dialysis center. The door from the breezeway to this vacant building was unlocked and did not have any locking mechanism. Upon entrance to this vacant building there was a door directly to the right which was unlocked. The door did not have any locking mechanism and led to two flights of concrete steps. There was an elevator in the center of the entrance which was operational, without a code needed to access, and a door with a window on each side of the elevator. The door to the right had a push number code which had to be entered to access and the door to the right had a key lock. Each door led to a hallway and connected at the rear of the building. This area contained three vacant offices which included an electrical room, a mechanical room, and a water treatment room with exposed wires, a medication room and two closets. All rooms, except one closet, were unsecured. The temperature was obtained by Maintenance Assistant #519 and measured 70 degrees F in the breezeway and 65 degrees F in the vacant building. An interview during the observation with the CCO reported Resident #5 was located in the back office and was visible from the window in the door to the left of the elevator. The CCO stated it was assumed that this door was not latched completely and then latched and automatically locked once the resident went through the door. Resident #5's legs were seen by staff as she was lying on the floor when she was found. There were no cameras in the vacant building and Administration was attempting to gain access to the videos in the facility from the previous company. During a telephone interview with LPN #81 on 12/06/16 at 1:05 P.M. he reported he administered medications to Resident #5 on 12/03/16 between 9:00 P.M. and 10:00 P.M. Around 12:30 A.M., STNA #62 reported she was unable to find Resident #5. STNA #62 had reported hearing a door alarm earlier in the shift but had checked the door and everything was okay at that time. LPN #81 stated staff searched inside and outside of the facility and the vacant dialysis building but could not locate Resident #5. LPN #81 reported he attempted to contact RN Supervisor #90 but could not locate him as he did not have telephone numbers to contact the new Administration whom took over the facility on 12/01/16. Around 2:00 A.M. or 3:00 A.M., RN Supervisor #90 was located and informed Resident #5 was the missing. The Police came to the facility about 20 to 30 minutes later, assisted with the search and notified Resident #5's family. An interview on 12/06/16 at 2:24 P.M. with the CCO revealed the main floor of the facility was not a secured unit but was equipped with alarms to doors and wander guard mechanisms; however, no wander guards were utilized for any residents on this floor. Access to video footage had been obtained and revealed Resident #5 entered the therapy room on 12/03/16 at 10:08 P.M. and exited the facility through the rear door that led to the breezeway at 10:11 P.M. Resident #5 was observed to be wearing a hospital gown. The alarm to the door sounded for 49 minutes until 11:00 P.M. at which time it was silenced by STNA #62. An interview on 12/06/16 at 4:22 P.M. with Emergency Medical Service (EMS) Chief #400 reported he had been contacted by the Police sometime around 4:00 A.M. on 12/04/16. EMS Chief #400 stated the Police inquired if they had transported Resident #5 to the hospital. Around 8:00 A.M. that same morning their services were contacted again to transport Resident #5 to the hospital. A telephone interview on 12/06/16 at 4:40 P.M. with STNA #62 revealed she was assigned to care for Resident #5 and had seen her in bed on 12/03/16 at 8:30 P.M. STNA #62 reported she was a new STNA and kept hearing this noise (the audible door alarming) but didn't know what it was so around 10:30 P.M. she followed the noise which was coming from the rear door in the therapy room which led to an adjacent vacant building. STNA #62 reported she silenced the alarm, looked around and didn't see anything unusual, then informed LPN #81 and returned to her job duties. Around 12:30 A.M. on 12/04/16, STNA #62 reported she noticed Resident #5 was missing and informed LPN #81. All staff searched for Resident #5 including a search of the vacant building; however, nobody had keys to the locked doors within the vacant building so staff knocked on the doors and called Resident #5's name. STNA #62 stated management was unable to be contacted because they were new and nobody had their phone numbers. A telephone interview on 12/06/16 at 5:25 P.M. with Police Officer #710 revealed the facility contacted the Police on 12/04/16 at 4:00 A.M. that Resident #5 was missing. Police Officer #710 stated Resident #5 has numerous chronic illnesses including dementia, diabetes, chronic pain and was also legally blind. Police Officer #710 stated Resident #5 ambulated slowly with a walker and had previously eloped from another facility. The facility reported a door alarm had sounded earlier in the shift and then Resident #5 was discovered missing at 11:30 P.M. Police Officer #710 reported he questioned the nurses as to the reasons they waited over four hours to notify the Police about a critically missing person and was told the delay was because there had been a recent change in Administration and they were unable to get in touch with anyone for instructions. There were only a few ways Resident #5 could have exited the building through the fire egress system. The building was searched upon arrival. Police Officer #710 stated the vacant building next to the facility had numerous locked doors which staff did not have keys to so these areas could not be accessed and searched but staff reported these areas were locked prior to Resident #5 going missing so she couldn't have accessed these areas. Due to the delay in contacting law enforcement of a critically missing person, the low temperatures outside, and staff insisting Resident #5 had to be outside, Police Officer #710 reported he was concerned that the resident was seriously injured or dead. Police Officer #710 stated twenty different agencies were contacted, a critically missing person alert was issued, and dogs were utilized to search a one mile radius of the facility in efforts to locate Resident #5; however, she was not found. Police Officer #710 stated at 7:00 A.M., Resident #5 was found by staff in a locked area of the vacant building next to the facility. The staff was unable to access this area as they did not have a key to the door so the door was kicked in to gain access to Resident #5. Police Officer #710 stated Resident #5 was lying on the floor shivering within this room, she was wearing only a hospital gown, without socks or shoes, it was freezing in the building and the building was without heat. Resident #5 was transported to the hospital for further evaluation by the paramedics. Police Officer #710 stated this case was referred to the prosecutor's office due to the staff delay in reporting a critically missing person timely. An interview on 12/07/16 at 9:22 A.M. with the Administrator and the CCO reported it was approximately 60 feet from Resident 5's bedroom to the therapy exit door. The Administrator reported her contact information was located at the nursing station but staff was confused on whom to contact at the time of Resident #5's elopement due to recent changes in Administration. Resident #5 previously resided on a secured unit at the sister facility, on the same property, with a shared parking lot prior to being transferred to this facility. The Administrator stated Resident #5's physician was contacted on 12/04/16 at 7:47 A.M. and notified of the elopement and the situation. An interview on 12/07/16 at 11:38 A.M. with LPN #65 revealed upon arrival to work for the day shift on 12/04/16, LPN #81 informed her Resident #5 was missing. LPN #65 proceeded to search the facility and the old vacant dialysis building in an effort to locate Resident #5. LPN #65 looked through the key locked door window to the left of the elevator in the vacant building and could see Resident #5's buttocks, legs and hand on her leg in the doorway of the office at the end of the hallway. LPN #65 reported the lights were on in the hallway but she was unable to access the area as the doors to the room were locked. LPN #65 stated the Administrator was called for the combination for the push number lock to the other door and she was unaware of the situation and did not have the code. LPN #65 then called 911. LPN #65 stated the Police arrived and kicked in the door. Resident #5 was cold and was only wearing a hospital gown. A blanket was applied to Resident #5 and the paramedics transported her to the hospital for evaluation. Observation on 12/07/16 at 12:33 P.M. of video footage with the CCO revealed Resident #5 walked into the therapy room on 12/03/16 at 10:08 P.M. and exited the rear alarmed door into the breezeway at 10:11 P.M. STNA 62 entered the therapy room and silenced the door alarm at 11:00 P.M., 49 minutes after the alarm was activated. On 12/04/16 at 1:44 A.M., numerous staff were observed looking in the therapy room and exiting through the breezeway. Staff continued to search the area. On 12/04/16 at 4:19 A.M., a Police Officer was observed in the therapy room and exited the door into the breezeway. On 12/04/16 at 7:05 A.M., LPN #65 exited the door into the breezeway. Review of the facility's policy titled, Elopements and Wandering Residents, dated 07/01/13, revealed residents would be assessed for elopement risk on admission and throughout their stay. The facility was equipped with door locks/alarms to help avoid elopements. Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol. Facility staff will look for the resident. If the resident is not located in the building or on the grounds, the Administrator or designee will notify the police department and serve as the designated liaison between the facility and the police department. The DON or designee shall notify the physician and family. According to the history report on Weather Underground, the local weather forecast, the outside temperature in the area on 12/04/16 at 2:53 A.M. was 36 degrees F. This deficiency substantiates Master Complaint Number OH 297 and Complaint Numbers OH 266 and OH 264. This deficiency is an example on continued non-compliance from the survey completed on 11/18/16.

Based on observation, record review, and staff interview the facility failed to ensure interventions were in place for residents who were at risk for pressure ulcers. This affected two Residents (#55 and #46) of three reviewed for pressure ulcers of 28 Stage II residents reviewed. This resulted in actual harm to Resident #55 who acquired multiple Stage II pressure ulcers without any interventions put into place. The total facility census was 52. Findings include: Review of Resident #55's medical record revealed the resident was admitted from a sister facility on the same property with a shared parking lot on 09/26/16 with [DIAGNOSES REDACTED]. weakness, [MEDICAL CONDITION],and lack of coordination. The resident's diet order was for a regular diet with mechanical soft food consistency and nectar thick liquids. The resident also received supplements of boost, a frozen nutritional treat and house supplement two times a day. Review of the State tested Nursing Assistant (STNA) Kardex revealed the resident was to have a cushion to his wheel chair that was initiated on 09/30/16. Review of the admission Minimum Data Set ((MDS) dated [DATE] for Resident #55 revealed the resident was coded as being severely cognitively impaired, the resident required extensive assistance of one care giver for bed mobility, transfers, walking in the corridor, locomotion on the unit, and toilet use. The resident was coded as being dependent on staff for locomotion off the unit, personal hygiene, and bathing. The MDS noted the resident utilized a walker and wheelchair as mobility devices. Resident #55 was coded as occasionally incontinent of bowel and bladder but was not on a toileting program. The MDS noted the resident was at risk for developing pressure ulcers, but the resident did not have any pressure ulcers at the time of the admission MDS. The MDS indicated the resident was to have a pressure reducing device for bed, but no other pressure reducing devices were noted to be used in the care of the resident during the review period for the admission MDS. Review of the comprehensive care plan revealed the resident was at risk for skin breakdown due to his occasional incontinence, decreased mobility [MEDICAL CONDITION] and dementia. The goal for the resident dated 10/12/16 was to have red areas identified promptly and treatment put in place to minimize the risk for breakdown. Interventions included weekly skin assessments per policy and observe skin integrity daily with care and report any changes to the physician. Review of the resident's progress note dated 11/12/16 at 1:18 A.M. revealed the resident was found in his room crawling around on his hands and knees with his pants down. It was noted upon assessment by the nurse that the resident was noted to have open areas to his buttock and penis. The medical record was silent to any interventions or treatments put in place for the treatment. Review of the residents physician orders [REDACTED]. Review of STNA documentation revealed the resident was being provided care daily that included toileting assistance, and incontinent care where the change in his skin should have been identified prior to the areas being noted. During an interview on 11/14/16 at 10:47 A.M., Licensed Practical (LPN) #3 indicated Resident #55 had no pressure ulcers at the present time. During an interview on 11/17/16 at 10:00 A.M., LPN # 8 verified there were no notifications made to the family or the physician about the multiple Stage II pressure ulcers that were identified on Resident #55's buttock. LPN #8 stated the nurses note was the only place the pressure ulcers were mentioned. LPN #8 indicated management was unaware of the presence of the pressure ulcers until 11/17/16 when they were informed by the surveyor of the progress note from 11/12/16. LPN #8 verified there were no ordered treatments or interventions put in place regarding the multiple newly identified pressure ulcers to Resident #55's buttock. During an observation of Resident #55's peri and buttock region on 11/17/16 at approximately 11:30 A.M. it was noted the resident had four open areas to his right buttock, one open area to the left of his coccyx and one open area to his left buttock. The presence of these areas were verified by State tested Nursing Assistant (STNA) #50 and Registered Nurse (RN) #70. At the time of the observation RN #70 staged all the areas as Stage II and measured the areas as follows: Right lateral buttock 0.6 centimeters (cm) x 0.6 cm x 0.2 cm Right middle buttock 0.6 cm x 1.2 cm x 0.2 cm Right medial buttock 0.5 cm x 0.5 cm x 0.2 cm Right distal buttock 1.7 cm x 0.5 cm x 0.2 cm Left distal buttock 0.5 cm x 0.6 cm x 0.2 cm Left medial buttock 0.9 cm x 0.8 cm x 0.2 cm. During an interview on 11/17/16 at 5:05 P.M., the Director of Nursing (DON) revealed if a new skin condition is identified the nurse is to note the skin condition in the progress notes after the area has been assessed. The documentation should describe a description of the area and the nurse should call the physician with the findings, obtain treatment orders and notify the family of the area and the new orders. The DON stated the nurse should also implement an acute care plan and the area should be monitored daily unit it is healed. The DON verified the STNA's do not complete a shower sheet with the residents showers, but the nurses do complete a weekly skin assessment on each resident. The DON stated the unit manager (UM) and the Assistant Director of Nursing (ADON) are responsible for monitoring that weekly skin assessments are completed for all residents. The DON stated there was an unusual skin occurrence form that should be filled out with all new skin areas. The DON verified there was no unusual skin occurrence form completed for the multiple areas to the resident's buttock that were identified on 11/12/16. The DON verified once an unusual skin occurrence form is filled out it goes to the management team, which would include the ADON who is responsible for all skin issues, the UM and the DON. Lastly the DON revealed the staff are bad about filling out the required paperwork the facility has in place. The DON stated he was not aware of the new multiple Stage II pressure ulcers to Resident #55's buttock which were initially identified in a progress note written on 11/12/16 until today (11/17/16). Observation of Resident #55 on 11/18/16 at 8:06 A.M. revealed the resident was sitting in a wheel chair in the dining area waiting on his breakfast. Upon inspection it was noted there was no cushion in the wheel chair the resident was sitting on. During an interview with Licensed Practical Nurse (LPN) #12 on 11/18/16 at 8:11 A.M. it was verified Resident #55 did not have a cushion to his wheel chair that he was sitting in. During an interview with LPN # 17 on 11/18/16 at 11:31 A.M. it was verified Resident #55 was sitting in his room in a wheel chair that did not have a cushion in the wheel chair and additionally that the resident mattress that was on the resident's bed was a regular mattress and not a speciality mattress. LPN #17 verified that Resident #55 has multiple stage II pressure ulcer to his buttock region. Observation of Resident #55 on 11/18/16 at 11:25 A.M. revealed the resident was sitting in his room in a wheelchair that continued to not have a cushion in the wheel chair. Review of the unusual skin occurrences investigation form the facility utilized revealed the information included: Resident name, date of discovery, time of discovery and if the injury was witnessed and if yes by whom. Description of the injury, staff interview, and the resident's description of how the injury occurred. Risk factors for skin injuries present, environmental assessment and resident mobility description. Review of the policy titled Oak Ridge Nursing and Rehabilitation Skin Assessments (no date noted on policy) revealed skin will be assessed on each new admission and readmission, and on a weekly basis. The ADON is to be notified of any new skin issues and time appropriate measures will be taken to implement a plan of care and treatments as necessary. Prevention: 1: all residents who use a wheel chair will have a pressure reduction pad in the wheel chair at all times. 2: all residents will receive a dietary supplement if needed 3: any residents who are immobile will be assessed for specialty mattress if needed. 4: Moisture barrier cream will be ordered for any incontinent resident or anyone with periods of incontinence. 5: Any resident with skin issues will be seen by wound care specialist who visits the facility on a weekly basis. Treatment : 1: All residents will be treated according to the Medical Doctor (MD) orders and wound care consultants recommendations. 2. Resident #46 was admitted to the facility on [DATE] from another nursing facility, with [DIAGNOSES REDACTED]. The facility completed an admission comprehensive assessment (MDS 3.0) of the resident's cognitive and functional status dated 10/20/16. The 10/20/16 assessment identified the resident had short and long term memory impairment with severely impaired cognitive skills for daily decision making, and required the physical assistance of at least one staff person for all activities of daily living, except for eating for which she required only supervision. The resident required the physical assistance of two staff persons for bed mobility and transfer. Resident #46 was assessed as having no pressure ulcers on admission to the facility, although she was assessed as being at risk for the development of pressure ulcers. The resident was receiving hospice services for end-stage [MEDICAL CONDITION]. Review of Resident #46's physician's orders [REDACTED]. Review of the Resident #46's nursing progress notes revealed the resident was found with an open area to her left buttock on 11/09/16. A nurse first noted in the medical record the resident had an open area to her left buttock on 11/09/16, and was unable to observe/measure the open area due to the resident being combative. The resident's physician was notified on 11/09/16 and a treatment for [REDACTED]. There was no documentation evident to support the resident's responsible family member was notified of the presence of the pressure ulcer, or the treatment ordered. Resident #46 was observed lying in bed on 11/17/16 at 9:12 A.M. The resident was on a special low air loss mattress for pressure ulcer prevention and treatment. The resident was alert to herself and basic needs, but otherwise confused and disoriented. When asked if she every got out of bed, she responded that why should she, her bed was comfortable and she didn't want to. Resident #46 was again observed, and the resident's responsible family member interviewed, on 11/17/16 at 12:30 P.M. The resident's low air loss mattress was not operational, had no power, and was deflated at the time of the observation. The family member was questioned about the resident's care and services provided by the facility related to her skin. The family member stated that she did not think that nursing staff cleaned her up very well after being incontinent as the resident seems to have little white areas on her bottom. She reported that nursing staff told her they do clean her up well in the morning. The responsible family member of Resident #46 denied that any facility staff person had called or reported to her about the resident having any skin problems or breakdown. RN #70 was alerted and asked by the surveyor to check the low air loss mattress. RN #70 viewed and verified the low air loss mattress was not working, and found that it was not securely plugged into the wall; and plugged the mattress in. At that time the ADON RN RN #70 also asked permission from the resident and family member to complete a treatment to the open area on the resident's buttock. The responsible family member stated to RN #70, in front of the surveyor, she was not informed Resident #46 had an open area on her bottom. On 11/17/16 at 3:54 P.M. Resident #46 was observed in her room lying on the low air loss mattress. The mattress was not operational, had no power, and was flat. The mattress was unplugged from the wall. On 11/17/16, at 4:04 P.M., LPN #17 came to the resident's room at the surveyors request to view the low air loss mattress. LPN #17 viewed and verified the mattress was not working, as it was unplugged. She plugged in the mattress and stated she thought the bed being too close to the wall was the problem. On 11/17/16 at 4:16 P.M., RN #70 reported the measurements for the pressure ulcer to the resident's left buttock. She stated the wound measured 4 cm by 2 cm by 0.3 cm deep. There was no odor, some slough, and mostly granulation tissue. RN #70 stated it would be categorized as a Stage 3 pressure ulcer. RN #70 affirmed at that time, there was no documentation evident in the medical record to support the family of the resident was notified regarding the presence of the pressure ulcer on 11/09/16. On 11/18/16 at 9:44 A.M., RN #70 agreed the placement of Resident #46's bed against the wall where the outlets were located was potentially causing the low air loss mattress to become unplugged when observed on 11/17/16. In addition, during interview RN #70 was questioned as to what information/guidance the facility was using to ensure the resident's low air loss mattress was operating at the correct setting for the resident. She stated that she was no aware of any specific manufacture's information related to properly setting the low air loss mattress based on the resident's weight and needs, and shared the mattress was the property of the facility. This deficiency substantiates Complaint Number OH 919.