Every finding on record at Phoenix of Maple Heights

Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review the facility failed to maintain an effective infection control program, failed to ensure appropriate personal protective equipment (PPE) was utilized during resident care, and failed to ensure annual Tuberculosis (TB) assessments were completed annually since the last annual survey dated 04/28/22. This had the potential to affect all 88 residents residing in the facility. Findings Include: 1. The entrance conference was held on 06/03/24 at 9:19 A.M. with the Administrator and Chief Clinical Officer (CCO) #490. The facility identified Licensed Practical Nurse (LPN) #517 as the facility's Infection Preventionist (IP). Interview with the Director of Nursing (DON) on 06/10/24 at 3:33 P.M. revealed the IP, LPN #517, had completed her testing and was certified as the IP today. CCO #490 was one acting as the IP for the facility for the last few months. Interview with CCO #490 on 06/10/24 at 3:40 P.M. revealed she has been the IP for the facility for the past eight months. She completed her certification program on 10/28/21. LPN #517 has been completing the infection control tracking each month with CCO #490 reviewing it to ensure the correct information was captured and if any trends of infection were identified. Review of the Infection Control logs for March, April, and May 2024 revealed the facility was completing tracking of infections but not providing laboratory results or x-ray results regarding the determination of what antibiotic a resident was placed on. All infections were marked as not meeting the McGreer's criteria for antibiotic treatment and had incorrect diagnoses for antibiotic use. Review of the facility's undated Infection Prevention and Control Program revealed the facility has developed and maintained an infection prevention and control program that provides a safe, sanitary, and comfortable environment to help prevent the development and transmission of infection. The infection control program will be monitored quarterly or as indicated by the Infection Prevention and Control Committee or other designated committee. A second interview with CCO #490 on 06/11/24 at 12:36 P.M. confirmed she should have been paying more attention to the infection control program than she had. CCO #490 also confirmed they do not have an infection control committee. They do a conference call between various staff to discuss what's going on in the facility related to infection control. 2. Interview with Unit Manager, LPN #453, on 06/10/24 at 5:22 P.M. revealed annual TB screening should be found under immunizations in the EMR. Review of immunizations for Residents #9, #11, #63, #72, and #81 revealed no annual screening for signs and symptoms of TB. Interview with CCO #490 on 06/11/24 at 8:55 A.M. revealed the DON keeps a binder in her office with the annual TB signs and symptoms review for the residents. The facility does not use the assessments tab in the EMR, and they do not scan it into the EMR. TB screens were provided for Resident #11 dated 03/28/23 and 03/27/24. TB screens were not provided for Residents #9, #63, #72, or #81. A second interview with CCO #490 on 06/11/24 at 12:02 P.M. revealed CCO #490 requested the DON bring the TB annual screening binder to her since the last annual survey on 04/28/22. The DON did not understand what was needed, and CCO #490 explained it was the annual screening completed each year regarding if a resident had any sign or symptoms of TB. At 12:35 P.M. CCO #490 again asked the DON to bring the TB annual screening binder to her. The binder was provided at 12:45 P.M. The TB annual screening binder only contained the screens for 2024 and not back to the last annual, 04/28/22. The DON revealed she does not know where the screens are from the previous DON. She will look through the boxes the former DON left and see if she can locate them. As far as she knows they may have not been completed. Review of the TB annual screening binder revealed the screening for Resident #92's was completed on 06/03/24, but the signs and symptoms portion was incomplete. Interview with CCO #490 at the time of the review confirmed the binder only contained screenings for 2024 and did not know why Resident #92's screening form had not been completed. Review of the medical record for Resident #92 revealed the resident was admitted to the facility on [DATE] with diagnoses of lung cancer with metastases to the brain, atrial fibrillation, high blood pressure, and opioid abuse. Review of the MAR revealed a TB test was administered on 06/03/24 and also had the result read on 06/03/24. No further information was documented regarding if anyone else had read the test result 48 to 72 hours after the test was administered. Interview with the DON on 06/11/24 at 2:05 P.M. confirmed the facility had no annual TB screening for signs and symptoms from the last annual in April 2022 through when she started in the position a year ago. The DON did not know how a copy of Resident #11's TB signs and symptoms screening was found dated 03/28/23 as she was unable to locate them. Regarding Resident #92, she was not familiar with the nurse who administered the admission TB test. The facility has hired new graduate nurses who were not yet familiar with the procedures. The DON said the test would have to be repeated as no one else appears to have read the results. 37096 3. Review of the medical record for Resident #67 revealed an admitted [DATE] with diagnoses including history of other infectious and parasitic disease, pressure ulcer of sacral region, pressure ulcer right heel, colostomy status, artificial opening of the of the urinary tract, chronic kidney disease. and malignant neoplasm of the endometrium, the uterus. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #67 had intact cognition and had an ostomy. The resident was required substantial to maximum assistance with toileting and was dependent for showering, partial to maximum assistance with rolling side to side and positioning from a sitting to a lying positioning. The resident had a stage II [NAME] ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed, without slough, may also present as an intact or open/ruptured serum filled blister) on admission and received pressure ulcer care. Review of the care plan dated 04/05/24 revealed Resident #67 had alterations in elimination related to a colostomy status, bilateral nephrostomy tubes and urostomy related to diagnoses of obstructive and reflux uropathy. Interventions included assessing abdominal distention and changing appliances as ordered. The resident was care planned for enhanced barrier precautions (EBP) to prevent the spread of infection. Interventions included assisting with hand hygiene as needed and the use EBP. Review of the physician order for June 2024 revealed the resident had an order for EBP. Observation on 06/05/24 at 8:21 A.M. of medication administration with Registered Nurse (RN) #466 to Resident #67 revealed she walked into the room with the medications and donned gloves. Resident #67 asked RN #466 to check her ostomy and colostomy bags for leakage. RN #466 did not don a gown. She lifted Resident #67's gown and began touching and lifting the colostomy and urostomy bags for leakage. RN #67 sanitized her hands, donned gloves and administered Resident #67's medications. Interview on 06/05/24 at 8:27 A.M. with RN #466 stated the facility's policy is to wear a gown and gloves when providing direct care for residents. RN #466 stated she was not required to wear gown and gloves while administering medications. RN #466 verified she did not don a gown when assessing the Resident's #67's colostomy and urostomy bags. Review of the facility policy titled Enhanced Barrier Precautions, revised 07/25/22, revealed EBP involve gown and gloves use during high-contact resident care activities for residents known to be colonized ore infected with a multidrug-resistant organisms (MDRO) as well as those at increased risk of MDRO. Review of the CDC guidelines titled Implementation of Personal Protective Equipment (PPE) use in nursing homes to prevent spread of MDRO, dated 04/02/24, stated EBP is used with resident's wounds and or indwelling medical devices regardless of MDRO colonization status during high-contact resident care including: activities dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use. wound care: any skin opening requiring a dressing.

Based on interview, record review, and policy review, the facility failed to implement an effective antibiotic stewardship program. This had the ability affect all 88 residents residing in the facility. Findings Include: Interview with the Chief Clinical Officer (CCO) #490 on 06/11/24 from 11:44 A.M. through 1:15 P.M. she has been overseeing the antibiotic stewardship program for approximately the last eight months. The facility's identified Infection Preventionist (IP) at the start of the survey process was Licensed Practical Nurse (LPN) #517. CCO #490 confirmed LPN #517 just received her IP certification on 06/10/24. LPN #517 has been tracking infections and the antibiotics used to treat the infections. LPN #517 is a full-time 7:00 P.M. to 7:00 A.M. supervisor. Every night, a report was run identifying who was on an antibiotic and why. CCO #490 said the facility received monthly reports from both the laboratory and the pharmacy regarding culture results and antibiotic use. She oversaw the program and reviewed the data tracking that LPN #517 completes. Review of the Infection Control logs from March 2024 through May 2024 revealed the tracking was not completed accurately or thoroughly. Review of the March 2024 log revealed each resident's name who had an infection. No site of infection was listed. Signs and symptoms of the infections were documented for 11 of 12 residents identified as having an infection. Resident #62 did have a site described as other. No signs or symptoms, and the infection related diagnosis was listed as an ear infection. No cultures were obtained for any of the infections except for those that were completed in the hospital. One resident had an x-ray done for pneumonia. No other residents had a diagnosis that would require an x-ray for diagnosis. The antibiotic start date was listed for all 12 residents. The antibiotic order was listed but the duration of the antibiotic was not provided. Ten of 12 residents had a date listed as the stop date when the antibiotic treatment was completed. McGreer's Criteria for antibiotic use was marked as N for all residents. One resident of the 12 required isolation precautions. Only one infection was listed as an in-house acquired infection, and that was Resident #62's ear infection. Review of the April 2024 infection control log revealed five residents were diagnosed with infection. Three residents had urinary tract infections (UTI), one was diagnosed with a yeast infection, and one diagnosis for Resident #16 the infection treated was hyponatremia (low sodium levels in the blood). The site of the infection was identified for all five residents. Signs and symptoms were identified for only two of the five residents. An infection related diagnosis was identified. Two of the five residents had cultures completed while hospitalized . Two other residents had cultures completed in the facility. No cultures were obtained for hyponatremia. No x-rays were obtained as the diagnosis was made without one. Three of the five residents had the culture organism identified as not applicable. The two in facility culture results were recorded. All five residents had an antibiotic start date listed. The antibiotic each resident was on was identified but the duration of treatment was not listed. An antibiotic stop date was listed for four of the five residents. The one resident without a stop date for the antibiotic was Resident #16. McGreer's criteria was again marked negative for four of the five residents. The fifth resident was left blank. Isolation precautions were not used for any resident, and all five residents acquired their infections in-house. Review of the May 2024 infection control log revealed eight residents were diagnosed with an infection. All eight residents had a site listed. Signs and symptoms were identified for five of eight residents. An infection related diagnosis was listed for seven of the eight residents. Six of eight residents had cultures obtained in the hospital. No x-rays were obtained for any resident. Antibiotic start dates were listed for all eight residents. The date antibiotic treatment was to end was listed for seven of the eight residents. McGreer's criteria was marked as not met for five of the eight residents, and three residents were left blank. Isolation was not required for any residents, and five of the eight residents acquired their infection in the facility and three were listed as not being acquired in the facility. Review of the facility's Antibiotic Stewardship Program program, last revised 02/21/22, revealed the facility will maintain a multi-disciplinary stewardship program that defines and provides guidance for optimal antimicrobial use. The purpose of the antibiotic stewardship program was to monitor the use of antibiotics in the facility's residents. Incidents identified under the Infection Prevention and Control Program will be recorded and corrective action will be taken and reported to the Quality Assurance and Performance Improvement (QAPI) committee. The facility uses McGreer's Definitions of Infection to determine appropriate infectious diagnoses and treatment. Staff will receive education regarding antibiotic stewardship. The training will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects residents and the overall community. The provider must include the name of the antibiotic; the dose; how often to administer the antibiotic; when it is to be started and stopped, or the number of days of therapy is to be administered; how it is to be administered; and the indication for use. Nursing staff will notify the Infection Preventionist when an infection is suspected. This will allow for early detection and management of a potential infection, as well as implementation of appropriate transmission-based precautions, if appropriate. When a culture is obtained, the results and current clinical situation will be communicated to the physician to determine if antibiotic therapy should be started, continued, modified, or discontinued. Interview with CCO #490 on 6/11/24 at 12:50 P.M. revealed she was unable to provide a reason why McGreer's criteria were marked as not being met for all three months and confirmed McGreer's criteria should be met when a resident was placed on an antibiotic and if the physician wanted the antibiotic administered despite not meeting the criteria, then the infection control committee meeting should be discussing the reason why. CCO #490 said the infection control committee does not meet on a specified date but instead they talk with the others involved over the phone. Review of the tracking logs with CCO #490 revealed Resident #19 was started on an antibiotic in March 2024 due to an elevated white blood cell count despite having no signs or symptoms of an infection. All laboratory tests were negative. The antibiotic was ordered to prevent a transfer to the emergency room for an evaluation. In April 2024 log Resident #16 was listed as being on an antibiotic for hyponatremia. CCO #490 confirmed hyponatremia is not an infection. She reviewed the resident's notes and said Resident #19 was placed on an antibiotic as it raises the resident's sodium levels and this should have been noted on the infection log. CCO #490 confirmed she should have paid more attention to the infection control tracking log.

Based on observation, interviews, and review of the facility policy and procedure, the facility failed to ensure the residents' environment was clean, sanitary, and was in good repair. This had the potential to affect all residents residing in the facility. The census was 88. Findings include: Observations during a tour of the facility on 06/12/24 from 1:43 P.M. to 4:49 P.M. with two surveyors revealed: Residents #56 and #81's room revealed the non- skid strips on floor were coming up off the floor and the privacy curtain rod off was the track. Residents #57 and #139's room revealed the baseboard heater cover was missing, exposing the heating element. The wall outside of the locked unit revealed the baseboard heater cover was hanging off and exposing the heating element. The locked unit had a strong, malodorous smell. At 1:48 P.M. the Director of Nursing (DON) entered the unit. The DON stated there were drops of feces in the hallway, and that was the cause of the odor. The DON then went to get staff to clean up the feces on the floor. Residents #7 and #22's room revealed the floor was dirty, sticky, and there were black markings on the floor near the bed by the window. There were no curtains or blinds on the window. There was brown staining and chipped paint on the windowsill near the air conditioning (AC) unit. There was one closet door with the other door missing. The bathroom had feces on toilet, a missing toilet paper holder, a hole in the door, stains on floor, and a strong urine odor. There was a white, plastic three drawer bin that had various, dried, brown stains on it in the hallway. Residents #33 and #83's room had dirty bed linens, and the dry wall was crumbling behind the door. The bathroom had feces on back of toilet, brown stains around the toilet, and a missing toilet paper holder. This bathroom was shared with Residents #7 and #22. The dining room on the secured unit had a fan lying on the table with the feet/stand missing. The back wall was dirty with various stains, and there was moderate amount of various, dried food crumbs on the baseboard heater and floor. There was also debris on the windowsill. Residents #29 and #69's room had various dry stains on the floor, the privacy curtain was stained, and there were no curtains or blinds on the window. The bathroom had a smear of feces on toilet. Residents #40 and #72's room revealed no closet doors, and the baseboard heater cover was pulled away. Residents #36 and #54's room had missing closet doorknobs. The bathroom had missing tile, a missing toilet paper holder, a hole in wall behind the door that was five inches by five inches, and the lid to the toilet tank was chipped. This bathroom was shared with Residents #40 and #72. Residents #11 and #45's room had television hanging off wall, one closet door missing, and molding coming off the wall. The bathroom had a big chip in the counter of the sink. There was a strong odor of urine, the floor was sticky, there was a missing toilet paper holder, and a dried substance on the bathroom door. The bathroom was shared with Resident #140. The hallway had bowing ceiling tiles, and at the very end of the hallway, where the window was, there was no drywall. There was a loose piece of a board knee high, that was placed a few inches in front of this area. Behind the board was the baseboard heater with the cover off, exposing the heating element. There was also various debris and trash. Observation of the second-floor shower room revealed peeling paint above the shower, 50 or more black drain flies in the shower area and toilet, the shower curtain was heavily soiled on the bottom, and the safety strips were peeling off the floor. Residents #35 and #42's room had a missing knob on the closet door, a stained privacy curtain, and debris on the threshold in the entryway to the bathroom. The bathroom had feces in the toilet, two of the three lights were burned out, the fixture was heavily coated with dust, there was crack in the toilet base, and a dried yellowish stain down front of the base of the toilet. Residents #12 and #13's room had debris and dead bugs on the windowsill, and the baseboard was heavily stained. Residents #47 and #48's room had a missing closet door, and the windowsill was covered with dust and/or spiderwebs. The bathroom door and wall were soiled. The baseboard between the bathroom door and closet was warped. Residents #30 and #32's room had a missing closet door, debris around the bottom of the AC unit, and the baseboard cover was dirty with stains, dust, and debris. The wallpaper was peeling, and the floor mattress pushed up against the closet door was dirty. Residents #28 and #85's room had the AC unit in the window was missing the cover, hanging, and was in disrepair. Resident #66's room had a missing baseboard, one closet door was missing, paint bubbling/rusted around the top of the AC unit, peeling paint on windowsill, cracked ceiling paint above the bed by the door. The bathroom had a missing ceiling tile, the toilet paper holder was broken, stained tile on the floor near toilet, and two of three lights were burned out. The wall in doorway to the resident's room had chipped paint, and the baseboard was coming off wall. This bathroom was shared with Residents #41 and #49. Residents #41 and #49's room had an electrical outlet hanging off the wall near the bed by the door, black dirt and debris on the floor under the bathroom door, the windowsill paint was chipping, a missing closet door, a cable cord cover broken between the beds, the floors dirty with various crumbs throughout, and a dirty floor mat. Residents #2 and #21's room revealed the closet doors had worn paint and were not on the track, the windowsill paint was peeling, there was a small hole in wall behind the door, and the baseboard heating cover was pulled away from the unit. Residents #71 and #190's room had an odor of urine, the floor was sticky with various crumbs and debris, one closet door was missing a knob, missing paneling at the bottom of the closet door, and the knob on the second closet door was chipped leaving a sharp edge. Residents #10 and #46's room had a closet door missing a knob, the baseboard between the closet and the bathroom door was heavily soiled. The bathroom doors had worn paint. This bathroom was shared with Residents #16 and #189. Residents #16 and #189's room had no closet doors, there was duct tape around the AC unit, a missing piece of the baseboard near the bed by the window, the baseboard near the door was coming off the wall, the nightstand top drawer was missing a knob/handle, the privacy curtain in front of the bed by the window was hanging off the track, and silver tape on the threshold of the floor under the bathroom door. Residents #51 and #79's room had water spots on the ceiling tile outside of the room, a missing frame and rusting around the AC unit, and two of the three light bulbs were burned out in the bathroom. Resident #18's room revealed the wall near the closet was in disrepair, the baseboard was coming off the wall, a hole in the wall by the bathroom door, a missing closet door, brown staining on ceiling above the AC unit, peeled paint on the walls near the bathroom. The curtain was off track. The bathroom toilet paper holder was off the wall, there was large brown stain on the ceiling tile in the left corner near the toilet, a tile broken off the wall under the sink near the trash can. Residents #60 and #72's room revealed no closet doors, broken window blinds, the privacy curtain was hanging off the track, and there was a missing ceiling tile in the bathroom. Residents #9 and #63's room had no closet doors and broken window blinds. The bathroom had missing ceiling tiles, the light fixture was hanging not affixed to the wall giving dim lighting in the bathroom. This bathroom was shared with Residents #62 and #82. Residents #19 and #47's room had no closet doors, a hole in the wall, missing baseboards, a hole in the bathroom door, and the lower part of the wall was cracked and rusted where the AC unit was located. The bathroom had a toilet paper holder, cracked/chipped sink counter leaving a jagged/rough edge, a hole in wall underneath the sink, and two of three light bulbs were burned out. The hallway near Residents #62 and 82's room had a loose handrail. Residents #50 and #53's room had missing closet doors, a missing baseboard near the closet, and the drywall was pulled away from the wall near the bathroom door. The bathroom had missing ceiling tiles exposing the sprinkler head, and there were black markings across the lower part of the bathroom door. Residents #5 and #55's room revealed the bed rail was loose and hanging off of Resident #55 bed, a missing closet door, and a missing knob on the other closet door. Interview on 06/03/24 at 3:59 P.M. with State tested Nurse Aide (STNA) #502 verified the bed rail was very loose. Residents #17 and #59's room had no closet doors and a soiled privacy curtain that was also partially off the track. The bathroom had plaster patches needing to be painted, two of three light bulbs were burned out, two water stained ceiling tiles, and there was a missing wood piece in the door jamb that was approximately six inches long. Residents #4 and #69's room revealed the cable covers between the beds were missing and broken, there was a missing threshold strip under bathroom door, a tannish substance was observed along this area, rusting on the baseboard heater unit, and missing closet doors. Observation of the first-floor shower room revealed it was cluttered, the shower curtain was torn, there was missing tile in the shower, three of six lights were not working above the sink, the floor was dirty, and there was a spider web in corner behind the door. Residents #31 and #70's room had crumbs on floor. The bathroom floor was dirty with brown stains and debris, and there were three cracked ceiling tiles. Residents #44 and #75's room had a missing doorknob on the closet door, and half of the second closet door was missing. Residents #15 and #74's room revealed the over the bed light cover was missing, there was a small hole in bathroom door, the closet doors were missing, the bathroom floor was dirty with brownish stains, odor, and one of three light bulbs was burned out. Residents #1 and #27's room had a missing closet door, a dirty wall with brown stains near the bathroom door, and one of three light bulbs was burned out in the bathroom. Resident #92's room revealed the baseboard heating cover was hanging off and was rusted near the AC unit. Residents #61 and #86's room had no knobs on the closet doors, and the window blinds were broken. The bathroom toilet paper holder was broken, there was a brown spot on the ceiling tile above the toilet, and one of three light bulbs was burned out. Resident #26's room revealed peeling paint around the AC unit, the baseboard was rusty, there were no closet doors, there was no cover on the light over the bed by window, the backing on the wall/wall protector was peeling off the wall behind the bed by the door, there was a hole in the bathroom door, the door jamb was in disrepair, there was a missing piece of wood and black markings on the doors. The bathroom ceiling tile was brown and bowing above the toilet, there was peeling paint near the light fixture, one of three light bulbs was burned out, the counter of the sink was chipped/broken, and there was a missing threshold strip between the room and the bathroom. Residents #24 and #84's room had missing closet doors. Residents #34 and #76's room had no closet doors, soiled privacy curtains, missing tile above toilet, the toilet tank was dirty with a brown, dried substance on the floor around the toilet, and the toilet paper holder was missing. This bathroom was shared with Residents #6 and #64. Residents #65 and #77's room revealed closet doors were off the tracks, and the window blinds were broken with a crocheted blanket covering the window. The bathroom had missing tile near the toilet, and two of three light bulbs were burned out. This bathroom was shared with Residents #14 and #20. Interview at this time with Resident #65 stated the blind had been broken for about a week, and she put her crocheted blanket over the window so no one could look in. Resident #65 stated she wanted the blinds fixed so she could take her blanket down. Residents #14 and #20's room had missing closet doors, and the door handle to the room was very loose, slightly hanging, and not affixed to the door. Resident #67's room had a missing closet door. The bathroom had two water-stained ceiling tiles, stool in the toilet, and the toilet tank lid was off with no water in the tank. Interview on 06/03/24 at 11:31 A.M. with Resident #62 stated her bathroom flooded about one month ago, and the wall was torn down around sink area. Resident #62 stated it's been that way now for one month. Interview on 06/04/24 at 9:56 A.M. with Resident #77 stated her only concern was that her closet doors would not stay on track. Interview on 06/04/24 at 10:06 A.M. with Resident #4 stated he did not have closet doors when he moved into his room. Interview on 06/05/24 at 8:58 A.M. with Housekeeper (HSK) #458 stated Resident #62's bathroom had a leak and looked that way for about two weeks. HSK #458 stated that bathroom was scary looking to her. Interview on 06/05/24 at 9:03 A.M. with Registered Nurse (RN) #466 stated she felt they could invest more in the building. Interview on 06/05/24 at 10:03 A.M. with Interim Maintenance Director (IDM) #497 revealed he was only interim for this week, and the facility had not been without maintenance staff. IMD #497 stated the last maintenance director was terminated on 06/03/24. Tour of the facility on 06/05/24 from 10:13 A.M. to 12:06 P.M. with IMD #497 the strip along the entryway onto the elevator was heavily worn down, uneven, and missing pieces. During the tour, IMD #497 verified the above identified findings. IMD #407 stated things needed to be done, some things sooner than later. IMD #497 stated he would help the new maintenance man get it all done. Interview on 06/05/24 at 1:21 P.M with Resident #73 stated she had difficulty getting out of the elevator due to the flooring having a missing part. Resident #73 stated she almost fell three times in the elevator because of the ripped out piece of flooring. Interview on 06/06/24 at 11:05 A.M. with Housekeeping/Laundry Director (HLD) #512 stated the turnover for both housekeeping and maintenance had been horrible. HLD #512 stated housekeeping staff were fully staffed at this time. HLD #512 stated resident rooms and common areas were cleaned daily. HLD #512 stated when staff reported concerns, she would fix what she could, but they did not have a steady maintenance director. HLD #512 stated the last maintenance director was lazy and stayed for only three weeks. HLD #512 stated the one before him stayed for about one year and left because he was overwhelmed. HLD #512 stated the maintenance director from 2020 took down all the closet doors in the residents' rooms because he thought it looked better. HLD #512 stated the Administrator had been trying to get in a maintenance director. Observation on 06/06/24 at 3:10 P.M. of Resident #140's room revealed no curtain or window blinds. There was also no curtain rod. Interview at this time with STNA #420 verified the observation and stated the rod had been hanging, and the resident removed it from off the wall. STNA #420 stated Resident #140 was walking around with it, and he had taken it from the resident. STNA #420 stated Resident #140 didn't try to hit anyone with it but was just walking around with it. Review of the facility policy titled Environmental Cleaning and Disinfecting, dated 11/19/20, revealed housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when surfaces are visibly soiled. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. This deficiency represents noncompliance investigated under Master Complaint Number OH00154790.

Based on record review and staff interview the facility failed to maintain the services of a registered nurse for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 88 residents currently residing in the facility. Findings include: Review of the Payroll Based Journal (PBJ) staffing data report for quarter 1 (10/01/23 - 12/31/23) revealed six identified dates (10/07/23, 10/21/23, 11/18/23, 11/19/23, 12/17/23, and 12/31/23) that had no registered nurse coverage. Review of the following staffing dates on 06/05/24 at 7:46 A.M. with State tested Nurse Aide (STNA) #492 using the staffing tool worksheet revealed: 10/07/23 (listed as 12/26/23), 10/21/23 (Listed as 12/27/23), 11/18/23 (listed as 12/28/23), 11/19/23 (listed as 12/29/23), 12/17/23 (listed as 12/30/23), 12/31/23 (listed as 12/31/23) and 01/01/24 (listed as 01/01/24) did not have a registered nurse working during the 24 hours for each of the identified dates. Interview on 06/05/24 at 8:33 A.M. with STNA #492 confirmed the above listed dates there were no registered nurses working as direct care staff during the 24-hour periods. Review of the staffing schedules and Benefits Improvement and Protection Act (BIPA) for 05/01/24 - 05/31/24, and 06/03/24 - 06/05/24, revealed 05/23/24 was also identified as not having a RN scheduled. Interview on 06/06/24 at 12:35 P.M. with the Director of Nursing (DON) confirmed she worked on 05/23/24 but did not work on the floor providing resident care. The DON asked if her scheduled management working hours counted towards the required eight hours for a registered nurse. The DON also confirmed there were no scheduled registered nurses working the floor to provide direct care on 10/07/23, 10/21/23, 11/18/23, 11/19/23, 12/17/23, and 12/31/23. Interview on 06/10/24 at 11:42 A.M. with STNA #492 confirmed she was not aware that a registered nurse was required for at least eight hours every day doing resident direct care.

Based on record review and staff interview, the facility failed to ensure the medical director was an active participant of the Quality Assessment and Assurance (QAA) committee. This had the potential to affect all residents. The facility census was 88. Findings include: Review of the facility sign-in sheets for the QAA meeting minutes for the meetings dated 07/06/23 through 05/01/24 revealed no evidence the medical director attended the meetings. Interview on 06/11/24 at 12:54 P.M. with the Administrator verified the medical director's signature was not on any of the sign-in sheets for the QAA meetings. The Administrator stated the medical director would at times attend the meetings via phone but was unable to indicate which meetings the medical director attended via phone.

Based on interview, record review, and policy review, the facility failed to have an Infection Preventionist providing qualified oversight of the facility's infection control. This had the ability to affect all 88 residents residing in the facility. The facility census was 88. Findings Include: The entrance conference was held on 06/03/24 at 9:19 A.M. with the Administrator and Chief Clinical Officer (CCO) #490. The facility identified Licensed Practical Nurse (LPN) #517 as the facility's Infection Preventionist (IP). Interview with the Director of Nursing (DON) on 06/10/24 at 3:33 P.M. revealed the IP, LPN #517, had completed her testing and was certified as the IP today. CCO #490 was the person acting as the IP for the facility for the last few months. Interview with CCO #490 on 06/10/24 at 3:40 P.M. revealed she has been the IP for the facility for the past eight months. She completed her certification program on 10/28/21. LPN #517 has been completing the infection control tracking each month with CCO #490 reviewing it to ensure the correct information was captured and if any trends of infection were identified. Review of immunizations for Residents #9, #63, #72, and #81 revealed no annual screening for signs and symptoms of TB. Review of the Infection Control logs for March, April, and May 2024 revealed the facility was completing tracking of infections but not providing laboratory results or x-ray results regarding the determination of what antibiotic a resident was placed on. All infections were marked as not meeting the McGreer's criteria for antibiotic treatment, and had incorrect diagnoses for antibiotic use. Review of the facility's undated Infection Prevention and Control Program revealed the facility has developed and maintained an infection prevention and control program that provides a safe, sanitary, and comfortable environment to help prevent the development and transmission of infection. The infection control program will be monitored quarterly or as indicated by the IP and Control Committee or other designated committee. Interview with CCO #490 on 06/11/24 at 8:55 A.M. revealed the DON keeps a binder in her office with the annual TB signs and symptoms review for the residents. The facility does not use the assessments tab in the electronic medical record (EMR), and they do not scan the information to the EMR. TB screens were provided for Resident #11 dated 03/28/23 and 03/27/24. TB screens were not provided for Residents #9, #63. #72, or #81. Review of the TB annual screening binder revealed residents were screened for signs and symptoms of TB for the past year; however, no information was found from the last annual survey dated 04/28/22. Interview with the DON on 06/11/24 at 12:45 P.M. revealed she did not know if the annual TB screens were completed by the former DON. She would look through the boxes of things left by the former DON and see if she was able to find them. Interview with the DON on 06/11/24 at 2:05 P.M. confirmed the facility had no annual TB screening for signs and symptoms from the last annual in April 2022 through when she started in the position a year ago. Review of the Infection Control logs from March 2024 through May 2024 revealed the tracking was not completed accurately or thoroughly. Signs and symptoms were not documented for all residents with infections, lab work and/or radiology testing were not completed on all residents when they were symptomatic, McGreer's criteria was marked as not met for any of the infections reviewed. Review of the facility's undated Infection Prevention and Control Program revealed the facility has developed and maintained an infection prevention and control program that provides a safe, sanitary, and comfortable environment to help prevent the development and transmission of infection. The infection control program will be monitored quarterly or as indicated by the Infection Prevention and Control Committee or other designated committee. Review of the facility's Antibiotic Stewardship Program program, last revised 02/21/22, revealed the facility will maintain a multi-disciplinary stewardship program that defines and provides guidance for optimal antimicrobial use. The purpose of the antibiotic stewardship program is to monitor the use of antibiotics in the facility's residents. Incidents identified under the Infection Prevention and Control Program will be recorded and corrective action will be taken and reported to the Quality Assurance and Performance Improvement (QAPI) committee. The facility uses McGreer's Definitions of Infection to determine appropriate infectious diagnoses and treatment. Staff will receive education regarding antibiotic stewardship. The training will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects residents and the overall community. The provider must include the name of the antibiotic; the dose; how often to administer the antibiotic; when it is to be started and stopped, or the number of days of therapy is to be administered; how it is to be administered; and the indication for use. Nursing staff will notify the Infection Preventionist when an infection is suspected. This will allow for early detection and management of a potential infection, as well as implementation of appropriate transmission-based precautions, if appropriate. When a culture is obtained, the results and current clinical situation will be communicated to the physician to determine if antibiotic therapy should be started, continued, modified, or discontinued. Interview with CCO #490 on 6/11/24 at 12:50 P.M. revealed she was unable to provide a reason why McGreer's criteria were marked as not being met for all three months and confirmed McGreer's criteria should be met when a resident was placed on an antibiotic, and if the physician wanted the antibiotic administered despite not meeting the criteria, then the infection control committee meeting should be discussing the reason why. CCO #490 confirmed she should have paid more attention to the infection control tracking log and increased her supervision of the infection control process.

Based on record review, staff interview, and facility policy review the facility failed to ensure physician orders for psychotropic medications included the diagnosis for each medication for Residents #11, #15, #16, and #62. The facility also failed to ensure monitoring of behaviors and adverse side effects from the use of psychotropic medications affecting for Residents #16 and #62. This affected four residents (#11, #15, #16, and #62) of five residents reviewed for unnecessary medications. The facility census was 88. Findings include: Review of the medical record for Resident #62 revealed an initial admitted [DATE]. Diagnoses included schizoaffective disorder, bipolar type, major depressive disorder, persistent mood [affective] disorder, psychotic disorder with delusions, personality disorder, manic episode, severe with psychotic symptoms, bipolar disorder, and post-traumatic stress disorder. Review of the care plan revised on 06/12/23 revealed Resident #62 was at risk for adverse effects of antipsychotic medication and antidepressant medication. Resident #62 received Klonopin for a diagnosis of schizoaffective disorder, bipolar type. Interventions included monitoring for side effects of psychotropic such as nausea, vomiting, and diarrhea, dry mouth, blurred vision, and change in appetite, weight etc. Notify the physician. Monitor adverse reactions to medications: headaches, abdominal pain, constipation, flatulence, esophageal ulcer, vomiting, dysphagia, abdominal discomfort, gastritis, taste perversion, and musculoskeletal pain. Monitor for side effects sedation, hypotension, extrapyramidal symptoms (EPS), anticholinergic signs, headache, insomnia, anorexia, and constipation. Report changes in mood or behavior. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 had intact cognition, had moods that included little interest, feeling, trouble falling asleep, feeling tired, poor appetite, feeling bad, trouble concentrating 12 to 14 days of the look back period. The assessment indicated the resident had behaviors that included hallucinations, delusions, other behaviors that occurred daily, and rejection of care daily. The resident also received antipsychotic, antianxiety, and antidepressant medications. Review of the June 2024 physician orders revealed active orders for: KlonoPIN (antianxiety) oral tablet one milligram (mg) (Clonazepam). Give one mg by mouth two times a day with a start date of 11/22/23. Aristada (antipsychotic) Intramuscular Prefilled Syringe 882 mg/3.2 milliliters (ml) (Aripiprazole Lauroxil). Inject 3.2 ml intramuscularly one time a day every four weeks on Monday with a start date of 11/27/23. Further review of the physician orders revealed no orders to monitor for behaviors or for side effects from the use of antipsychotic medications and no diagnoses listed for the medications. Interview on 06/10/24 at 1:29 P.M. with the Director of Nursing (DON) verified the above findings. 45442 2. Review of the medical record for Resident #15 revealed an admitted [DATE]. Diagnoses included but were not limited to unspecified convulsion, type II diabetes mellitus, major depressive disorder, sleep apnea, multiple sclerosis, conversion disorder with seizures or convulsion, and anxiety disorder. Review of the 05/24/24 quarterly MDS assessment for Resident #15 revealed intact cognition, an antipsychotic and antidepressant medication were noted to being received and no behaviors were noted. Review of the physician's orders for Resident #15 revealed: An order dated 04/05/24 for Olanzapine oral table five mg. Give five mg by mouth one time a day for antipsychotic. No diagnosis was listed. An order dated 02/24/24 for Sertraline HCL Oral tablet 50 mg. Give one tablet by mouth one time a day for antidepressant. No diagnosis was listed. Interview on 06/10/24 at 1:28 P.M. with the DON confirmed the above listed concerns related to the appropriate diagnoses not being listed on the physician orders. Review of the 08/2020 facility policy titled; Medication Management revealed under procedures section f: number one and two stated; The dose, route of administration, duration and monitoring are in agreement with current clinical practice, clinical guidelines, and/or manufacturer's specifications for use. A written diagnosis, an indication and/or documented objective findings support each medication. 37096 3. Review of the medical record for Resident #16 revealed an admitted [DATE] with diagnoses including history of other infectious psychotic disorder with delusions, type II diabetes, Alzheimer's disease, Parkinson's disease, anxiety, insomnia, chronic kidney disease, depression, polydipsia, and paranoid schizophrenia. There were no diagnoses related to seizures or genitourinary. Review of the quarterly MDS assessment dated [DATE] revealed Resident #16 had intact cognition and behaviors that included inattention and disorganized thinking that fluctuated. The resident was receiving an antipsychotic, an antibiotic, antiplatelet, and hypoglycemic medications. Review of the progress notes revealed Resident #16 had no documented behaviors. Review of the care plan dated 04/15/24 revealed a behavior plan with assisting Resident #16 with activities of daily living and Resident #16 had delusions, wore multiple layers of clothing, and exhibited manic behavior at times related to diagnoses of schizophrenia and psychotic disorder. Review of the physician orders for June 2024 revealed the following medications had classes of medication listed instead of diagnoses: Desvenlafaxine 50 milligram (mg) for antidepressant Olanzapine 10 mg for antimanic There were no orders to monitor behaviors. Interview on 06/10/24 at 1:46 P.M. with the DON verified the medications had incorrect diagnoses and stated the facility was in the process of reviewing medications for correct diagnoses. The DON stated some residents have behaviors documented in the medication administration record (MAR) or the treatment administration record (TAR) and the progress notes. However, behaviors should be documented in MARS and TARS. Review of the facility policy titled Medication Management. dated August 2020, revealed in order to optimize the therapeutic benefit of medication therapy and minimize prevent potential adverse consequences, the facility, the attending physician, and the consultant pharmacist will perform ongoing monitoring for appropriate, effective and safe medication use. In addition, when the resident receives a new medication, the medication should include a written diagnosis, an indication, or documented objective findings supporting each medication. 32650 4. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, disorganized schizophrenia, psychosis, paranoid schizophrenia, anxiety, cannabis dependence, insomnia, nicotine dependence, chronic viral hepatitis C, and chronic obstructive pulmonary disease. Review of the physician's orders for Resident #11 revealed the following medications were ordered for the associated diagnosis: Lithium 600 milligrams (mg) orally every morning and 300 mg orally every evening for behaviors Depakote (a medication used to treat seizures) 500 mg orally two times a day for anticonvulsant. The resident does not have a diagnosis of seizures or convulsions. Provera (a medication used to prevent pregnancy) 30 mg orally three times a day for hormone Haloperidol Decanoate (an antipsychotic used to treat mental illness) 50 mg/milliliter (ml) give 1 ml intramuscularly every 14 days for psych Benadryl (an antihistamine) 25 mg orally every eight hours for agitation as needed Interview with the DON on 06/06/24 at 4:30 P.M. confirmed the diagnoses and their associated medications were accurate. The DON said she would speak with the psychiatric nurse practitioner and obtain appropriate diagnoses for Resident #11's medications.

Based on record reviews, interviews, and facility policy review the facility failed to ensure all medications had an appropriate diagnosis for Residents #1, #15, #16, and #62. This affected four residents (#1, #15, #16, and #62) of five residents reviewed for unnecessary medications. The facility census was 88. Findings include: 1. Review of the medical record for Resident #1 revealed an admitted [DATE]. Diagnoses included but were not limited to human immunodeficiency virus (HIV), acute and chronic respiratory failure, schizophrenia, dementia with agitation, bipolar disorder, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had intact cognition, antidepressants were being administered, and no behaviors were noted. Review of the physician orders for Resident #1 revealed the following medications listed the class of medication instead of the diagnosis: An order dated 01/04/24 for Omeprazole 20 milligram (mg) capsule delayed release (proton pump inhibitor to treat gastroesophageal reflux disease). Give one capsule by mouth one time a day. No diagnosis was listed. Interview on 06/10/24 at 1:28 P.M. with the Director of Nursing (DON) confirmed the above-listed concerns related to the appropriate diagnoses not being listed on the physician orders. 2. Review of the medical record for Resident #15 revealed an admitted [DATE]. Diagnoses included but were not limited to unspecified convulsion, type II diabetes mellitus, major depressive disorder, sleep apnea, multiple sclerosis, conversion disorder with seizures or convulsion, and anxiety disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #15 had intact cognition, an antipsychotic and antidepressant were administered, and no behaviors were noted. Review of the physician's orders for Resident #15 revealed the following medications listed the class of medication instead of the diagnosis: An order dated 02/24/24 for Losartan Potassium Oral Table 50 mg (antihypertensive). Give one tablet once a day for antihypertensive. No diagnosis of hypertension was listed. An order dated 02/24/24 for Prednisone Oral Tablet 20 mg (steroid). Give one tablet by mouth two times a day for corticosteroid. No diagnosis was listed. An order dated 04/05/24 for Olanzapine oral table five mg (antipsychotic) by mouth one time a day for antipsychotic. No diagnosis was listed. An order dated 02/24/24 for Montelukast Sodium Oral Tablet 10 mg (anti-inflammatory). Give one tablet by mouth at bedtime for anti-asthmatic. No diagnosis was listed. Interview on 06/10/24 at 1:28 P.M. with the DON confirmed the above-listed concerns related to the appropriate diagnoses not being listed on the physician orders. 39969 3. Review of the medical record for Resident #62 revealed an initial admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), hypothyroidism, atherosclerotic heart disease of native coronary artery without angina pectoris, type II diabetes mellitus, acute bronchitis, hypertension, atrial fibrillation, convulsions, and vitamin d deficiency. Review of the physician orders for June 2024 revealed the following medications listed the class of medication instead of the diagnosis: Insulin Glargine Subcutaneous Solution 100 UNIT/ milliliters (ml) (Insulin Glargine). Inject 30 units subcutaneously two times a day for itching. Ergocalciferol (vitamin D) Oral Tablet 50 MCG (2000 UT). Give 2000 micrograms (mcg) by mouth one time a day. Claritin (antihistamine) Oral Tablet 10 MG (Loratadine). Give 10 milligrams (mg) by mouth one time a day. Thera-M Oral Tablet (Multiple Vitamins w/ Minerals). Give 400 mcg by mouth one time a day. Mirabegron ER Oral Tablet Extended Release 24 Hour 25 mg (medication to treat overactive bladder). Give one tablet by mouth one time a day. Metformin (antidiabetic) HCl Oral Tablet 1000 mg (Metformin HCl). Give one tablet by mouth two times a day. Cozaar (antihypertensive) Oral Tablet 50 mg (Losartan Potassium). Give 50 mg enterally one time a day. Levothyroxine Sodium (thyroid product) Oral Tablet (Levothyroxine Sodium). Give 150 mcg by mouth one time a day. HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro). Inject 8 units subcutaneously with meals. Furosemide (diuretic) Oral Tablet 20 mg (Furosemide). Give one tablet by mouth one time a day. Apixaban (anticoagulant) Oral Tablet 5 MG (Apixaban). Give 5 mg by mouth two times a day. Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate). Two puffs inhale orally every 4 hours as needed for pain. rOPINIRole HCl (anti-Parkinson) Oral Tablet 1 MG (Ropinirole Hydrochloride). Give one tablet by mouth at bedtime. rOPINIRole HCl Oral Tablet 0.5 MG (Ropinirole Hydrochloride). Give 1 tablet by mouth two times a day. Interview on 06/10/24 at 1:29 P.M. with the DON verified the orders for the medication did not include the diagnoses. The DON also verified the diagnoses listed for the Insulin Glargine Subcutaneous Solution 100 UNIT/ml and the Albuterol Sulfate HFA Inhalation Aerosol Solution were inaccurate for those medications. 37096 4. Review of the medical record for Resident #16 revealed an admitted [DATE] with diagnoses including psychotic disorder with delusions, type II diabetes Alzheimer's disease, Parkinson's disease, anxiety, insomnia, chronic kidney disease, depression, polydipsia, and paranoid schizophrenia. There were no diagnosis seizures or genitourinary. Review of the quarterly MDS assessment dated [DATE] revealed Resident #16 had intact cognition and behaviors that included inattention and disorganized thinking that fluctuated. The resident was receiving an antipsychotic, an antibiotic, antiplatelet, and hypoglycemic medications. Review of the physician orders for June 2024 revealed the following medications listed the class of medication instead of the diagnosis: Cholecalciferol 5000 units on daily for vitamin. Divalproex sodium 500 mg for anticonvulsants. Flomax 0.4 mg daily for genitourinary. Oxcarbazepine 150 mg for anticonvulsant. Sodium chloride 1gram (gm) for electrolyte. Interview on 06/10/24 at 1:46 P.M. with the DON verified the medications had incorrect diagnosis, and the facility was in the process of reviewing medications for correct diagnosis. Review of the facility policy titled Medication Management, dated August 2020, revealed when the resident receives a new medication, the medication should include a written diagnosis, an indication, or documented objective findings supporting each medication.

Based on observation and interview the facility failed to ensure a medication cart remained locked when the nurse was not in attendance. This affected one of two medication carts located on the second floor and had the potential to affect all residents except for 14 residents (#7, #11, #22, #25, #29, #33, #36, #40, #45, #54, #72, #78, #83, and #140) located on the secure unit. The facility census was 88. Findings include: Observation of medication cart located in front of the wall between rooms [ROOM NUMBERS] on 06/03/24 at 12:06 P.M. revealed the cart was unlocked, no nurse was in sight, and residents were in the hallway heading to lunch. A housekeeper was in the hallway and said she would locate the nurse. A staff member walked up to the cart and stood there. When asked who she was, the employee identified herself as Licensed Practical Nurse (LPN) #517. Interview with LPN #517 at 06/03/24 at 12:08 P.M. revealed LPN #517 did not realize what was wrong with the cart and was unable to identify the cart was unlocked. LPN #517 replied oh when informed the medication cart was unlocked but did not move to lock it. When questioned if she was going to lock it, LPN #517 replied she needed to get into the cart. Interview with the Administrator on 06/03/24 at 12:15 P.M. confirmed the medication cart should be locked when the nurse is away from it. The facility store is located on the second floor, and residents from both floors, except for the secured unit, would have potentially had access to the cart. The facility was a psychiatric facility for residents with behavior problems.

Based on medical record review, ancillary services appointment lists, interviews, and facility policy review the facility failed to ensure dental services were provided to Resident #26 as needed. This affected one resident (#26) of one resident reviewed for dental services. The facility census was 88. Findings include: Review of the medical record for Resident #26 revealed an admitted [DATE]. Diagnoses included but were not limited to delusional disorders, depression, vascular dementia, osteoarthritis, morbid obesity, gastro esophageal reflux disorder, and schizoaffective disorder. Resident #26 was noted to be cognitively intact and require supervision for eating and oral hygiene. No evidence was found related to a dental care plan to address dental issues. Review of the facility resident dental list for the past twelve months revealed Resident #26's last dental visit was on 06/27/23. Review of the 06/27/23 dental summary report for Resident #26 revealed partial dentition, and multiple root tips needed to be extracted. An oral surgery referral was noted to be written to a local dental institute for evaluation and treatment. Follow-up was to occur after oral surgery has been completed. Review of Resident #26's nursing progress notes from 06/27/23 to 06/10/24 revealed no indication of follow-up for a dental consult for Resident #26 following his 06/27/23 appointment. Interview on 06/03/24 at 3:55 P.M. with Resident #26 revealed he desired a dental appointment, was unsure of his last appointment, had some broken teeth, and was experiencing pain. Interview on 06/05/24 at 1:16 P.M. with the Administrator, who is the facility social worker, confirmed Resident #26 had a chip in the root tips per the 06/27/23 consult. The Administrator confirmed she was unable to provide any additional documentation as to why no follow-up had occurred for dental concerns for Resident #26 since 06/27/23. Review of the facility policy titled Dental Services, dated 04/12/16, revealed routine and emergency dental services are provided to our residents. Nursing services is to notify social services of a resident's need for dental services. Social services personnel will be responsible for assisting the resident/family in making dental appointments and transportation arrangements as necessary.

Based on record review, observation, interview, and facility policy review the facility failed to ensure call lights were functional and in reach for Residents #5, #12, and #13. This affected three residents (#5, #12 and Resident #13) of 88 residents reviewed for call lights. The facility census was 88. Findings include: 1. Review of the medical record for Resident #12 revealed an admitted [DATE] with diagnoses including acute kidney failure, dementia, and abnormalities of gait and mobility. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #12 had impaired cognition and required substantial to maximal assistance for transfers, hygiene, and dressing. The resident was dependent for transferring. Review of the care plan dated 03/12/24 revealed Resident #12 had a self-care deficit related to weakness and behaviors. Interventions included one staff for assistance with dressing, eating, and toileting. 2. Review of the medical record for Resident #13 revealed an admitted [DATE] with diagnoses including dementia, malnutrition, and vertigo. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #13 had memory problems, disorganized thinking, and inattention. The resident required partial to moderate assistance with eating, toileting, showering, and dressing. The resident was incontinent of bowel and bladder. Review of the care plan dated 05/16/24 revealed Resident #13 had a self-care deficit related to cognitive impairment and confusion. Interventions included encouraging the resident to participate while performing activities of daily living, and to monitor and report a decline to the physician. Observation on 06/03/24 at 11:23 A.M. of Resident #12's room revealed she was sitting in her wheelchair next to her bed. There was no call light in reach. Resident #12's roommate, Resident #13, was lying in her bed resting. There was no call light in reach. The call light system located on the wall had the face plate that was pulled away from the wall and hanging. There were no call light cords attached to the call light system. Interview at this time with Resident #12 revealed the call light system in the room was not functioning and has not been functioning for a long time. Resident #12 stated there was no other way to contact staff. Interview with Resident #13 at this time, stated she was able to use her call light if she had one. Interview with on 06/03/24 at 11:30 A.M. with Licensed Practical Nurse (LPN) #517 verified Resident #12 and Resident #13's call lights were not functioning. LPN #517 revealed the call light system in this room had issues for several weeks. The room was located close to the nurses' station. Resident #12 would yell if she needed help, and Resident #13 would come to the nurses' station if she needed help. LPN #517 stated she would have maintenance fix the call lights. Further observation on 06/03/24 at 2:20 P.M. of Resident 12's room revealed Resident #12 was yelling for help. Resident #12 was sitting in her wheelchair next to her bed. There was no call light in reach. Resident #12's roommate, Resident #13, was lying in her bed resting. There was no call light in reach. The call light cords were plugged into the call light system on the wall. Interview at this time with Resident #12 stated her call light was not within her reach, and she needed the state tested nursing assistant (STNA). Interview on 06/03/24 at 2:25 P.M. with Registered Nurse (RN) #439 verified Resident #12 and Resident #13's call lights were not within reach. RN # 439 stated the maintenance man was in prior fixing the call light system. The maintenance probably forgot to put the call lights in reach of the residents. 39969 3. Review medical record for Resident #5 revealed an initial admitted [DATE]. Diagnoses included schizoaffective disorder, bipolar type, muscle weakness, low back pain, and unsteadiness on feet. Review of the quarterly MDS assessment dated [DATE] revealed Resident #5 had impaired cognition, used a wheelchair, and required partial/moderate assistance from staff for transfers from the bed or chair to the chair and for toileting. Observation on 06/03/24 at 3:54 P.M. of Resident #5 in bed sleeping, and the call light was on the floor not within reach. Interview on 06/03/24 at 3:59 P.M. with STNA #502 verified the call light was not within the resident's reach. Observation at this time of STNA #502 pick the call light up off the floor and place it within reach of Resident #5. Interview on 06/04/24 at 11:02 A.M., Resident #5 stated she was able to use her call light, and that she used her call light when she needed assistance from staff. Review of the facility policy titled Call Light, Use Of, revised 10/20/19, revealed assure call system is in working order, report to maintenance defective call lights with exact location, and be sure all call lights are placed within reach of the resident at all times.

Based on record review and staff interview the facility failed to notify the appropriate state agency (The Ohio Department of Mental Health) of a significant change in Resident #26's mental health condition as required. This affected one resident (#26) of one resident reviewed for preadmission screening and resident review (PASARR). The facility census was 88. Findings include: Review of the medical record for Resident #26 revealed an admitted [DATE]. Diagnoses included but were not limited to delusional disorder, depression, vascular dementia, and mood disorder. Review of the 12/29/2017 facility PASARR Identification Screen for Resident #26 revealed it was the most recent PASARR completed. Under section D indications of serious mental illness revealed a diagnosis of delusional (paranoid) disorder and psychiatric services had been utilized within the past two years due to mental disorder. Review of Resident #26's medical diagnoses revealed a diagnosis of schizoaffective disorder on 03/30/21 was added. Review of both the electronic and paper chart revealed no evidence the appropriate state agency (The Ohio Department of Mental Health) was notified of the new diagnosis for PASARR. Interview on 06/05/24 at 1:16 P.M. with the Administrator confirmed the last PASARR for Resident #26 was completed on 12/19/17 and a new one should have been completed following the new diagnosis of schizoaffective disorder on 03/30/21.

Based on medical record review, observation, interview, and facility policy review the facility failed to ensure comprehensive care plans were created for Resident #26, #63, and #72. This affected three residents (#26, #63, and #72) of three residents reviewed for care plans. The facility census was 88. Findings include: 1. Review of the medical record for Resident #26 revealed an admitted [DATE]. Diagnoses included but were not limited to delusional disorders, depression, vascular dementia, osteoarthritis, morbid obesity, gastro esophageal reflux disorder, and schizoaffective disorder. Resident #26 was noted to be cognitively intact and require supervision for eating and oral hygiene. No evidence was found related to a dental care plan to address dental issues. Review of the facility resident dental list for the past twelve months revealed Resident #26's last dental visit was 06/27/23. Review of the 6/27/23 dental summary report for Resident #26 revealed partial dentition, and multiple root tips needed to be extracted. Oral Surgery referral was noted to be written to a local dental institute for evaluation and treatment. Follow-up was to occur after oral surgery has been completed. Review of Resident #26's nursing progress notes from 06/27/23 to 06/10/24 revealed no indication of the follow-up for a dental consult for Resident #26 following his 06/27/23 appointment. Interview on 06/03/24 at 3:55 P.M. with Resident #26 revealed he desired a dental appointment, was unsure of his last appointment, had some broken teeth, and was experiencing pain. Interview on 06/10/24 at 10:30 A.M. with Minimum Data Set (MDS) Coordinator #523 confirmed there was no dental care plan to address dental concerns and/or the ordered dental follow-up for Resident #26. 2. Review of the medical record for Resident #63 revealed an admitted [DATE]. Diagnoses included but were not limited to end stage renal disease, dependence on renal dialysis, congestive heart failure, and moderate protein-calorie malnutrition. Review of Resident #63's care plan initiated on 08/19/23 revealed monitor fistula for bruit and thrill and to weigh resident the same time every day. No updates were noted since admission. No evidence was found as to what to do if bleeding was observed at the site or whether meals were to be given prior to dialysis or were to be sent with the resident. Review of Resident #63's physician orders dated 10/04/23 for monthly weights and an order dated 11/21/23 revealed to check dialysis catheter on left chest every shift. Interview on 06/06/24 at 12:20 P.M. with Licensed Practical Nurse (LPN) #425 confirmed there was no evidence of a dialysis care plan in the paper chart for the facility or the dialysis center. Interview on 06/06/24 at 12:27 P.M. with the Director of Nursing (DON) confirmed Resident #63's care plan had not been updated to reflect having a port rather than a checking for bruit and thrill, did not address how meals were being provided, did not identify transportation needs, the correct frequency to monitor weights, or to complete pre and post dialysis assessments. Interview on 06/10/24 at 10:30 A.M. with MDS Coordinator #523 confirmed the care plan had not been updated since admission, did not give clear instructions as to what to do if there was bleeding at the dialysis port site, did not reflect discontinuation of checking for bruit and thrill since Resident #63 had a dialysis port, did not reflect the frequency of weight monitoring change, and did not give instructions as to ensure Resident #63 was provided meals consistently with dialysis. Review of the facility policy titled; Care Planning, dated 11/13/20, revealed the facility care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. A comprehensive care plan for each resident is developed within seven days of completion of the resident assessment. 32650 3. Review of the medical record revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including psychosis, schizoaffective disorder, bipolar disorder, factitious disorder (a condition in which a patient intentionally falsifies medical or psychiatric symptoms and can be self-induced or fabricated), and mood disorder. Review of the quarterly comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #72 was cognitively intact. Review of the progress notes for Resident #72 revealed he refused all medications daily, refused to see the psychiatric nurse practitioner at each visit, and had numerous disruptive behaviors. Review of Resident #72's care plans (undated) revealed a behavior care plan for the diagnosis of factitious disorder, medication noncompliance, refusing care, and lying in bed with no clothes on and with a towel across him at times. The goals were to have a decrease in noncompliance and not have any negative outcomes related to noncompliance. The interventions to achieve the goal were to document education attempts made with the resident regarding compliance, educate regarding the negative outcomes which could occur due to noncompliance, and explain all procedures to the resident. No interventions were initiated on ways to deal with the resident's behaviors and were not resident centered. Observation on 06/03/24 at 11:58 A.M. through 12:15 P.M. revealed Resident #72 was sitting in a wheelchair in the hallway wearing only a T-shirt. The bottom of the shirt rested on the resident's upper thighs. No briefs or underwear were worn. Resident #72's genitals were exposed and visible to anyone in the hallway. Residents and staff were observed in the hallway during the time span of the observation. Staff did not intervene or redirect the resident at any time during the observation. Interview with MDS Coordinator #522 on 06/10/24 at 12:35 P.M. revealed she was unaware of Resident #72's behavior of exposing his genitals in the hallway and did not realize there were no interventions for his preference of wearing no clothes.

Based on record review, interview, and facility policy review the facility failed to ensure Resident #67 had orders to care for a urostomy and failed to ensure supplies were available. This affected one resident (#67) of one resident who received ileostomy and colostomy care. The facility census was 88. Findings include: Review of the medical record for Resident #67 revealed an admitted [DATE] with diagnoses including history of other infectious and parasitic disease, pressure ulcer of sacral region, pressure ulcer right heel, colostomy status, artificial opening of the of the urinary tract, chronic kidney disease, and malignant neoplasm of the endometrium, the lining of the uterus. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #67 had intact cognition and had an ostomy. The resident was required substantial to maximum assistance with toileting. Review of the care plan dated 04/05/24 revealed Resident #67 had alterations in elimination related to a colostomy status, bilateral nephrostomy tubes, and urostomy related to diagnoses of obstructive and reflux uropathy. Interventions included assessing abdominal distention and changing appliances as ordered. Review of the nurses note dated 05/19/24 at 6:34 A.M. written by Licensed Practical Nurse (LPN) # 415 revealed the nurse changed Resident #67's left side colostomy bag. The residents urostomy bag on the right side was leaking. This nurse attempted to change the urostomy bag but was unable to locate any supplies and temporarily covered the bag with a towel. The supervisor was notified, and they searched the supply room, cabinet, and resident's room. The urostomy bag will need to be replaced and will pass on the information to the oncoming A.M. staff. Resident #67 was very verbally aggressive and argumentative towards staff. Review of the physicians' order for June 2024 revealed and order to change the colostomy bag every seven days, empty urostomy bag when half full, and to flush bilateral nephrostomy tubes weekly. There was no order to change the urostomy bag. Interview on 06/05/24 at 4:36 P.M. with LPN #415 revealed on 05/19/24 at approximately 10:00 P.M., she went into the room to check the Resident #67's urostomy bag, and it was leaking. LPN #415 notified the nursing supervisor, LPN #446, she needed to replace the urostomy bag and could not find one. Both searched for supplies; however, none were located. In the meantime, LPN #415 used a towel to absorb the liquid. The resident got the bag changed when the day supervisor came in the next day. LPN #415 stated Resident #67 was very upset that supplies were not available, and she had to calm her down. Interview on 6/06/24 at 10:22 A.M. with Resident #67 stated she feels the staff does not use the same technique or the same supplies that the hospital used. Many times, the nurses have put on the wrong size bag that causes it to overflow and leak. Resident #67 stated she ordered her urostomy supplies to ensure her urostomy and colostomy bags were maintained. Interview on 06/06/24 at 10:50 A.M. with State tested Nursing Assistant (STNA) #492, central supply person, regarding the incident on 05/19/24 revealed Resident #67 had two urostomy bags located in the closet in her room. The nurse did not look in the closet, there were two bags left. The day shift nurse located and replaced the urostomy bag. STNA #492 stated the resident was picky with her supplies. The urostomy and colostomy bags were standard and could be cut to ensure proper fit. She now ensures supplies were ordered, and there were supplies available for staff prior to leaving her shift. Interview on 06/06/24 at 4:28 P.M. with the Director of Nursing (DON) verified that there were no orders for urostomy bags to be changed. Review of the facility policy titled Colostomy and Ileostomy site care, dated 11/13/22, revealed the purpose of the policy is to prevent infection and skin irritation.

Based on observation, interview, record review, and facility policy review the facility failed to ensure Resident #12 had current oxygen orders and an oxygen care plan and failed to ensure portable oxygen tanks were secured. This affected one resident (#12) of ten residents receiving oxygen. The facility census was 88. Findings include: Review of the medical record for Resident #12 revealed an admitted [DATE] with diagnoses including acute kidney failure, dementia, and abnormalities of gait and mobility. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #12 had impaired cognition and required substantial to maximal assistance for transfers, hygiene, and dressing. The assessment stated the resident was not receiving oxygen therapy. Review of the care plan dated 03/12/24 revealed Resident #12 did not have an oxygen care plan. Review of the profile computer tab revealed a picture of Resident #12 wearing a nasal canula for oxygen. Review of the physician orders for June 2024 revealed there were no oxygen orders and/or orders to change oxygen tubing. Observation on 06/03/24 at 11:23 A.M. revealed Resident #12 was sitting in her wheelchair next to her bed and receiving oxygen by nasal canula through a concentrator unit. There were three portable oxygen tanks located next to the window. One was secured in a stand and two were unsecured. Interview on 06/03/24 at 11:30 A.M. with Licensed Practical Nurse (LPN) #517 verified the resident had three portable tanks and two were unsecured. LPN #517 stated every morning staff ensures all empty tanks are taken out of the room. Interview on 06/06/24 at 1:53 P.M. with the MDS Nurse #522 stated at the time of the MDS assessment on 3/12/24, Resident #12 was not on oxygen. MDS Nurse #522 stated she checks the medication administration and treatment records for verifications. MDS #522 stated she had no idea why nursing put the resident on oxygen. Interview on 06/06/24 2:35 P.M. with LPN #49 verified there was no current oxygen order; however, there was a discontinued oxygen order in December 2023. Interview on 06/06/24 at 2:57 P.M. with the Director of Nursing (DON) verified there were no current oxygen orders and/or orders to change oxygen tubing. In addition, there was no oxygen care plan. The DON stated Resident #12 was sent out the hospital and all orders were discontinued. Upon arrival back at the facility, the nurse had to re-enter all the orders and forgot to input the oxygen order. Review of the facility policy titled Oxygen Safety, dated 11/19/21, revealed cylinders are secured either by a chain or strap or supported by cylinder base or cart designed not to tip over. Review of the facility policy titled Care Planning, dated 11/13/20, revealed the interdisciplinary team is responsible for the development of a comprehensive care plan for each resident.

Based on record review, interview, and facility policy review the facility failed to ensure monitoring prior to and following dialysis treatments for Resident #63. This affected one resident (#63) of one resident residing at the facility receiving dialysis. The facility census was 88. Findings include: Review of the medical record for Resident #63 revealed an admitted [DATE]. Diagnoses included but were not limited to end stage renal disease, dependence on renal dialysis, congestive heart failure, and moderate protein-calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 was receiving dialysis treatments. Review of the facility pre and post dialysis assessments for Resident #63 for the month of April, May, and June of 2024 revealed no documented evidence of pre and post assessments for 04/01/24, 04/03/24, 04/05/24, 04/08/24, 04/10/24, 04/12/24, 04/15/24, 04/17/24, 04/19/24, 05/01/24, 05/08/24, 05/10/24, 05/13/24; no documented evidence of pre-dialysis assessments for 04/22/24, 04/26/24, 04/29/24, and 05/20/24; and no documented evidence of post dialysis assessments for 04/24/24, 05/06/24, 05/15/24, 05/22/24, 05/27/24, 05/29/24, 05/31/24, and 06/03/24. Interview on 06/06/24 at 12:20 P.M. with Licensed Practical Nurse (LPN) #425 confirmed when Resident #63 goes to dialysis, there was no communication form sent with him or any information that comes back with him, and LPN #425 was not aware of any email communication with the dialysis center. LPN #425 also confirmed there was no additional dialysis communication information in the paper chart. Interview on 06/06/24 at 12:47 P.M. with the Director of Nursing (DON) confirmed staff were to complete a pre and post dialysis assessment and send the pre-dialysis assessment with Resident #63 when he goes. The DON confirmed there was no documented evidence of pre and post dialysis assessment dates listed above. The DON also confirmed since the pre and post dialysis assessments were not being consistently completed, weights as ordered by the physician were also not being monitored consistently. Interview on 06/10/24 at 8:37 A.M. with the DON confirmed the facility did not have a copy of the short-term care plan and/or the long-term care plan as stated in the facility dialysis contract under collaboration of care. Review of the facility policy titled Long Term Care Facility Outpatient Dialysis Services Coordination Agreement revealed the facility will provide for the interchange of information useful or necessary for the care of the end stage renal dialysis (ESRD) residents including a contact person at the Long-Term Care Facility (LTCF) whose responsibilities include assisting with the coordination of Renal Dialysis Services for ESRD residents. Under Mutual Obligations under Collaboration of Care revealed both parties shall ensure that there is documented evidence of collaboration of care and communication between the Long-Term Care Facility and ESRD Dialysis unit. Documentation shall include, but not be limited to, participation, as members of the interdisciplinary team, in care conferences, continual quality improvements program, annual review of infection control of policies and procedures, and the signatures of team members from both parties on a short-term care plan (STCP) and Long-term care plan (LTCP). Team members shall include the physician, nurse, social worker, and dietitian from the ESRD Dialysis Unit and a representative from LTCF. The LTCF shall maintain a copy of the STCP and LTCP. Review of the facility policy titled; Hemodialysis Policy and Procedure, dated 03/23/19, revealed all residents receiving dialysis must have a pre and post dialysis assessment completed in the electronic medical record by a licensed nurse.

Based on observation, interview, and record review, the facility failed to monitor resident behaviors, develop resident centered care plans with interventions specific for the resident's behaviors, or implement interventions when behaviors occurred for Resident #72. This affected one resident (#72) of two residents reviewed for behavioral health. The facility census was 88. Findings Include: Review of the medical record revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including psychosis, schizoaffective disorder, bipolar disorder, factitious disorder (a condition in which a patient intentionally falsifies medical or psychiatric symptoms and can be self-induced or fabricated), and mood disorder. Review of the physician's orders for Resident #72 dated 06/23/23 was an order to document resident's behaviors every shift. Review of the Medication Administration Record (MAR) for April, May, and June 2024 for Resident #72 revealed the resident refused all medications every day. Behavior monitoring was also located on the MAR and was to be assessed each shift. A Y indicated the resident had demonstrated behaviors and a nurse's note was to be documented as to what the behavior was. Review of the progress notes for Resident #72 revealed he refused all medications daily, refused to see the psychiatric nurse practitioner at each visit, and had numerous disruptive behaviors. On 04/25/24 the Administrator, who is also the facility's social worker, summarized the resident's behaviors as being aggressive, targeting certain employees, leaving threatening emails for staff in the facility as well as the community, and noncompliance with care. On 04/30/24 the resident shoved another resident and claimed the other resident punched him in the chest. The MAR behavior tracking for Resident #72 during the quarterly MDS look back period revealed the resident exhibited behaviors on 04/24/24 during the 7:00 A.M. to 7:00 P.M. shift and on the 04/28/24 7:00 P.M. to 7:00 A.M. shift but no associated nursing documentation was found in the nurses' progress notes. Review of the quarterly comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #72 was cognitively intact and had delusions but exhibited no behaviors during the seven-day look back period of the assessment time frame. Review of Resident #72's care plans (undated) revealed a behavior care plan for the diagnosis of factitious disorder, medication noncompliance, refusing care, and lying in bed with no clothes on and with a towel across him at times. The goals were to have a decrease in noncompliance and not have any negative outcomes related to noncompliance. The interventions to achieve the goal were to educate the resident upon refusing care and the potential consequences of the refusal and to document the education provided. No interventions were provided on ways to deal with the resident's behavior of exposing his genitals and were not resident centered. Observation on 06/03/24 at 11:58 A.M. through 12:15 P.M. revealed Resident #72 was sitting in a wheelchair in the hallway wearing only a T-shirt. The bottom of the shirt rested on the resident's upper thighs. No briefs or underwear were worn. Resident #72's genitals were exposed and visible to anyone in the hallway. Residents and staff were observed in the hallway during the time span of the observation. Staff did not intervene or redirect the resident at any time during the observation. Review of the June 2024 MAR indicated behaviors had occurred, but no associated documentation of the incident was located. Interview with MDS Coordinator #522 on 06/10/24 at 10:32 A.M. revealed she bases her decision on how frequently a resident exhibited behaviors and what type of behavior was exhibited by reviewing the nursing documentation, the aide's documentation, and through staff interviews. A second interview on 06/10/24 at 12:35 P.M. revealed she was unaware of Resident #72's behavior of exposing his genitals in the hallway and did not realize there were no interventions for his preference of wearing no clothes.

Based on observation, interview, record review, and facility policy review facility failed to prevent public indecency to ensure residents were treated with dignity at all times. This affected one resident (#72) of three residents reviewed for dignity and had the potential to affect all residents that may have witnessed Resident #72's public indecency. The facility census was 88. Findings include: Review of the medical record revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including psychosis, schizoaffective disorder, bipolar disorder, factitious disorder (a condition in which a patient intentionally falsifies medical or psychiatric symptoms and can be self-induced or fabricated), and mood disorder. Review of the quarterly comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #72 was cognitively intact. Observation on 06/03/24 at 11:58 A.M. through 12:15 P.M. revealed Resident #72 was sitting in a wheelchair in the hallway wearing only a T-shirt. The bottom of the shirt rested on the resident's upper thighs. No briefs or underwear were worn. Resident #72's genitals were exposed and visible to anyone in the hallway. Residents and staff were observed in the hallway during the time span of the observation. Interview with Resident #72 revealed no information related to the observation. Staff did not intervene or redirect the resident at any time during the observation. Interview with the Director of Nursing (DON) on 06/11/24 at 2:45 P.M. revealed Resident #72 always refused to wear pants or underwear whenever staff requested that he put them on. Review of the facility's dignity policy revealed the facility provided a copy of the document from the Ohio Revised Code Section 3721.13 titled Residents' Rights. Right (2) stated the resident has the right to be treated at all times with courtesy, respect, and full recognition of dignity and individuality. This deficiency represents noncompliance investigated under Master Complaint Number OH00154790 and Complaint Number OH00153937.

Based on facility assessment review and staff interview, the facility failed to ensure its facility assessment contained the necessary required information related to contracted nurses and state tested nurse aides. This had the potential to affect all 88 residents residing at the facility. Findings include: Interview on 06/06/24 at 12:35 P.M. with the Director of Nursing (DON) confirmed the facility does use agency when needed for staffing shortages. Interview on 06/10/24 at 10:17 A.M. with the Administrator confirmed the facility utilizes agency for staffing when needed and confirmed the facility assessment stated under the contracts section, the facility utilizes contractors for emergencies when they need staff. Interview on 06/10/24 at 11:42 A.M. with State tested Nurse Aide (STNA) #492, who is the facility scheduler, confirmed the facility uses agency usually at least a couple times a week. STNA #492 also confirmed on 10/07/23, two agency Licensed Practical Nurses (LPNs) were used, on 10/21/23 one agency LPN was used, on 11/18/23 one agency STNA was used, on 12/31/23 one agency LPN was used, and on 05/23/24 one agency STNA was used to fill call offs in the staffing schedule. Review of the Facility assessment dated [DATE] revealed the facility staffing is based on resident population and acuity. Under section E called; Contracts/Memorandum/Agreements with Third Parties for Services section revealed the Medical Director, physicians, pharmacy, hospice providers, nurse practitioners, dietitian, ambulance company, hospital transfer agreement, language translation services, information technology (IT), snow removal, repair, laundry, transportation, lab services, service provider under contract for emergencies (e.g. HVAC,) etc. No evidence was found for contracted direct care providers such as registered nurses (RNs), LPNs, or STNAs. Review of the facility contract agency Client Staffing Service Agreement, dated 01/06/22, revealed under terms of contract; the agency will assign employees to the client on an as needed basis to supplement the client's own work force.

Based on facility employee file review and interview, the facility failed to ensure two State tested Nurse Aides (STNAs) #494 and #498 of four STNAs reviewed received the required 12 hours annually of continuing education credits. This had the potential to affect all 88 residents residing at the facility. Findings include: Review of the staff education for STNA #494 revealed evidence of four one-hour education in-services (06/08/23, 12/27/23, 01/31/24, and 04/26/24) in the past 12 months. Review of the staff education for STNA #498 revealed evidence of nine one-hour education in-services (07/26/23, 08/30/23, 10/25/23, 11/29/23, 01/31/24, 02/28/24, 03/21/24, 04/26/24, and 05/29/24) in the past 12 months. Review of the facility education in-service sign in sheets from the past 12 months revealed STNAs #494 and #498 were not listed on all 12 months to meet the required 12 hours of education annually for staff. Interview on 06/11/24 at 9:07 A.M. with Chief Clinical Officer #490 and the Administrator confirmed they were unable to produce proof of 12 education credits for STNAs #494 and #498 for the past twelve months as required.

Based on interview, record review, and facility policy review, the facility failed to ensure timely interventions were implemented and failed to timely address signs and symptoms of a stroke for Resident #32. Actual harm occurred on 04/06/21 when Resident #32 experienced a significant change in condition including slurred speech, facial droop, right sided weakness and difficulty with ambulation. Resident #32 was subsequently admitted to the hospital on 04/14/21 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 81. Findings include: Review of the medical record for Resident #32 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/31/21, prior to hospitalization on [DATE], revealed Resident #32 had severely impaired cognition. The resident required supervision with one staff assist for walking in room, extensive assistance with one staff for locomotion on unit, supervision with set-up only for walking in corridor and locomotion off unit. Review of the progress note dated 04/06/21 at 3:03 P.M. revealed Resident #32 was noted to be dragging his right leg during therapy. The resident denied pain. The certified nurse practitioner was notified, and a new order for an x-ray to the right hip and foot was received. Review of the progress note dated 04/06/21 at 7:06 P.M. revealed the x-ray was completed, tolerated well, and awaiting results. Review of the progress note dated 04/09/21 at 6:56 A.M. revealed the resident was not standing and denied pain, and staff will monitor. Review of the progress note dated 04/12/21 at 12:24 P.M. revealed Resident #32 refused an optometry visit. Review of the progress note dated 04/12/21 at 2:34 P.M. revealed Resident #32 was in his room most of the shift even after encouraging him to get up and participate in activities. The resident continued to require one staff assist for all activities of daily living (ADL). The resident did not ambulate at all this shift. The resident denied pain or discomfort, and his skin was intact. Review of the progress note dated 04/14/21 at 12:08 P.M. revealed Resident #32 continued to display signs of right sided weakness. An x-ray was completed with negative results on 04/06/21. Neurology was contacted multiple times, per South Pointe Neurology, but was unsuccessful scheduling due to the hospital had not received a referral from the physician. The resident had stable vital signs. His right-hand grasp was weaker than the left-hand. The resident was also observed with mouth drooping with no drooling. A State tested Nursing Assistant (STNA) reported the resident was eating independently but pocketing food. The physician was notified, and a new order was received to send the resident to the hospital. The resident's family was notified. Review of the progress note dated 04/14/21 at 2:45 P.M. revealed the resident was sent to the hospital at 12:30 P.M. due to right sided weakness. Review of the hospital admission form dated 04/14/21 revealed Resident #32 was admitted with right sided weakness, facial droop, and slurred speech. Further review revealed the resident was found to have had an acute stroke. Review of hospital paperwork dated 04/14/21 revealed stroke specific information that included warning signs of numbness or weakness of the face, arm, or legs especially on one side of the body, sudden confusion, trouble speaking, difficulty walking or sudden severe headache. Further review revealed if one of more of the signs are present to seek medical attention immediately, and medical treatment may be available if action is taken early enough. Review of the progress note dated 04/20/21 at 4:22 P.M. revealed Resident #32 returned to the facility. Review of social services progress note dated 04/21/21 at 8:25 revealed Resident #32 was remitted from hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 10/12/21 at 10:07 A.M. with Physical Therapist Assistant (PTA) # 195 revealed on 04/06/21 nursing asked PTA #195 to assist Resident #32 to the bathroom. Resident #32 was walking with a walker, he was dragging his right leg and had drooping on right side of his face. PTA #195 assisted Resident #32 to the bathroom and called the Former Director of Nursing (DON) #199. Interview on 10/12/21 at 10:20 A.M. with Certified Occupational Therapist Assistant (COTA) #197 revealed on 04/06/21 she was asked to assist an STNA to get Resident #32 up out of bed. Resident #32 needed a lot of cueing and was dragging his right leg. Resident #32's nurse was walking in the hallway when COTA #197 alerted the nurse to Resident #32's change of condition. Review of COTA #197's progress notes dated 04/06/21 at 5:16 P.M. revealed that Resident #32 was dragging his leg when ambulating. COTA #197 consulted with nursing, and nursing viewed an altered gait pattern while the resident was ambulating in hallway. COTA #197 instructed Resident #32 to ambulate back to his bedroom. The resident was leaning on the wall while ambulating, and COTA #197 provided the resident maximum verbal and tactile cues for proper sequencing and proper posture. The resident was not following directions. COTA)#197 instructed the resident to sit on the edge of the bed, and the resident required maximum assist and verbal cues for walker placement and sequencing. The resident was unable to sidestep up to the head of the bed. The resident was unable to follow one-step directions and was very unsteady standing. COTA #197 consulted with nursing about the residents altered status. Review of the occupational therapy notes dated 04/07/21 revealed the resident was discharged due to other reasons. Review of the physical therapy progress notes dated 04/06/21 at 5:31 P.M. revealed gait training was provided to the resident for safe return to prior living and supervision level. The resident ambulated 115 feet and used a two-wheeled walker. The resident was contact guard assist (CGA) during the beginning of ambulation, and Resident #32 began to display right knee flexion, with gait becoming difficult requiring moderate assist for standing, turning and upright posture. The nursing staff and the Former DON #199 were notified and aware. Review of the physical therapy notes dated 04/07/21 revealed the resident was discharged due to other reasons. Interview on 10/12/21 at 2:02 P.M. with Physical Therapist (PT) #198 revealed the resident was discharged from therapy because of a change in condition. Resident #32 was walking everywhere but on 04/06/21 started dragging his right leg. Interview on 10/12/21 at 8:15 A.M. with the DON revealed that she was not present for Resident #23's change in condition. Interview on 10/12/21 at 12:45 P.M. with the DON revealed that no further documentation could be produced that neurology was contacted or any other assessment was completed for Resident #32, then what was in the progress notes. Interview on 10/12/21 at 1:24 P.M. with Licensed Practical Nurse (LPN) #145 revealed that she saw a change in condition for Resident #32 on 04/06/21 and contacted the CNP, who ordered an x-ray. She stated she went on vacation the next day and came back to work on 05/24/21. Interview on 10/12/21 at 1:45 P.M. with Corporate Nurse (CN) #126 revealed that she would talk to the physician for his notes. CN #126 did not produce any notes from Resident #32's physician. Review of the facility policy titled Condition Policy and Procedure, dated 03/23/19, revealed that a change in condition is defined as deterioration in health, mental or psychosocial status of a resident related to a significant change in resident's condition or status. A significant change in resident's clinical condition or status include improvement or decline in (activities of daily living) ADL physical functioning.

Based on observations, staff interviews, review of the medical record, accuweather.com, timeanddate.com, and the facility's Elopement: Missing Resident Policy & Procedure, the facility failed to provide adequate supervision to prevent the elopement of one resident (Resident #47) who was assessed with [REDACTED]. This resulted in Immediate Jeopardy on 04/09/20 at approximately 7:30 P.M. when Resident #47 hopped onto a bench, jumped over a five-foot wall and walked off the property without staff knowledge during an evening supervised smoking break. The likelihood of actual harm, serious injury or death occurred when Resident #47 walked approx. 0.2 miles down the side walk of a residential street to a five lane busy street in the dark where he was found by former Assistant Director of Nursing (ADON) #209 who was called at her home and subsequently went looking for the resident in her personal car. This affected one of 14 residents (Resident #47) who smoked and were at risk for elopement (Residents #5, #9, #10, #19, #25, #37, #36, #46, #47, #50, #53, #54, #58 and #67). The facility census was 77. On 10/01/20 at 1:55 P.M., the Administrator, Director of Nursing (DON) and Corporate Vice President of Operations were notified Immediate Jeopardy began on 04/09/20 at 7:30 P.M. when Resident #47, who was at risk for elopement and exhibited wandering behaviors, jumped a wall during a supervised smoke break and walked off the property without staff knowledge. Resident #47 was subsequently found approximately 0.2 miles from the facility, in front of a bank, walking on the sidewalk along a five-lane busy road by former ADON #209 who was searching for the resident in her personal car. The Immediate Jeopardy was removed on 10/04/20 at 7:30 P.M. when the facility implemented the following corrective actions: · On 09/24/20 at 2:00 P.M., smoking education was provided to all nurse managers, housekeeping staff, activities staff, and all direct care staff either directly one on one or by phone. The education included smoking policy changes including supervision of residents and social distancing. This education was provided by the DON and Assistant Director of Nursing (ADON). Review of the education sign in sheet dated 09/24/20 confirmed 39 staff were educated verbally by phone and 49 staff received in person one to one education. · On 09/25/20 at 9:00 A.M., smoking groups were revised by the DON and Activity Director to reduce the number of residents and to maximize supervision. · On 10/01/20 at 2:30 P.M., a head count was conducted on all residents in the facility for safety and accuracy by the ADON and Nursing Supervisor #163. · On 10/01/20 at 2:30 P.M., Social Service Designee (SSD) #206 completed an audit on all current residents to assure Brief Interview Mental Status (BIMS) scores were accurate and up to date. · On 10/01/20 at 2:30 P.M., the ADON and Unit Manager #211 completed a safety assessment of all residents. · On 10/01/20 at 2:30 P.M., the DON provided in person elopement and smoking education to Dietary staff (DS) #106, DS #11, DS #131, DS #179, Licensed Practical Nurse (LPN) #120, LPN #156, LPN #173 and State tested Nurse Aide (STNA) #101. The training included reduced size of smoking groups; smoking contracts; smoking supervisor must be within full view of all residents and the perimeter during smoke breaks; ensuring the smoking area was clean of all cigarettes and debris; proper use of the fire extinguisher, and review of the facility's elopement policy. Review of an education sign in sheet dated 10/01/20 confirmed this staff training. · On 10/01/20 at 2:45 P.M., the ADON and Unit Manger #211 completed an audit to ensure the accuracy of all elopement assessments. · On 10/01/20 at 3:00 P.M., SSD #206 completed an audit of the Elopement Binders kept at the nurse's stations to ensure accuracy of information. The binders included the facility elopement policy, a list of residents at risk for elopement, the face sheet (a document that gives a resident's information at a quick glance) of each resident at risk for elopement, and current elopement risk assessment. · On 10/01/20 at 3:15 P.M., the Maintenance Director inspected and conducted maintenance on all doors to ensure proper functioning of alarms and Wanderguard systems (an automatic locking system that is engaged when a resident wearing a monitoring device nears the door). All doors were functioning properly. · On 10/01/20 at 3:30 P.M., Minimum Data Set Nurse (MDS) #205 completed an audit of all residents to assure elopement care plans were accurate and up to date. · On 10/01/20 at 5:00 P.M., the wooden bench in the smoking area which Resident #47 used to climb over the wall was relocated away from the wall and placed within eyesight of the smoking supervisor. This was confirmed by observation on 10/01/20 at 5:00 P.M. · On 10/01/20 at 4:40 P.M., the Administrator and Admission Director sent out education on smoking and elopement to 89 current employees via a prerecorded computer-generated messaging call system. The education included reduced size of smoking groups; smoking contracts; smoking supervisor must be within full view of all residents and the perimeter during smoke breaks; ensuring the smoking area was clean of all cigarettes and debris; proper use of the fire extinguisher, and review of the facility's elopement policy. Review of a computer-generated sheet dated 10/01/20 verified calls went out and were received at 4:45 P.M. and 5:51 P.M. · Review of revised supervised smoking schedules dated 10/01/20 revealed additional supervised smoking breaks were added, and the group sizes had been reduced. · On 10/01/20 at 5:15 P.M., a quality assurance and performance improvement (QAPI) meeting was conducted by the DON for department managers. Information reviewed included the new smoking policy, smoking contract, smoking group size and positioning of staff during supervised smoking breaks. The department managers in attendance included the Human Resource Manager, ADON, Business Office Manager, Activity Director, Housekeeping Director, Dietary Manager, Maintenance Director, Unit Manager #211, the Rehabilitation Director, Admission Director, Social Service Director, MDS Coordinator and Medical Director. · Beginning on 10/01/20 all residents at risk for elopement will be reviewed weekly DON. · On 10/04/20 at 7:30 P.M., a missing person drill was conducted by Staff Development Nurse #100. Licensed Practical Nurse #117, LPN #184, LPN #188, LPN #200, STNA #121, STNA #144, STNA #150, STNA #153 and STNA #172 participated in this drill. The staff responded appropriately and followed facility procedure. · On 10/06/20 at 10:30 A.M., contractors installed fencing to increase the height of the wall around the smoking area an additional two feet. · Beginning on 10/12/20 the DON and ADON will audit elopement assessments, elopement care plans, elopement binders, BIMS scores, elopement drills, functioning of alarms and Wander guard system on exit doors two times a week for two weeks. Then beginning on 10/26/20 audits will be conducted weekly for two weeks and then randomly. · Beginning on 11/04/20 all audits will be reviewed through the facility QAPI process monthly. · On 10/08/20 at 9:30 A.M. and 12:30 P.M., during mandatory staff meetings, staff education was again provided by the DON and Administrator regarding supervised smoke breaks and elopement policies and procedures. All staff that were not present at the meeting received the same education via phone by their department managers. · On 10/08/20 from 10:35 A.M. to 1:21 P.M. interviews with eight staff across all shifts (Registered Nurse (RN) #202, LPN #101, LPN #203, STNA #101, STNA #114, STNA #118, STNA #123 and STNA #167) revealed they were knowledgeable regarding the facility's elopement and smoking policies and procedures. Although the Immediate Jeopardy was removed on 10/04/20 at 7:30 P.M. the deficiency remained at a Severity Level 2 (no actual harm with the potential for minimal harm that is not Immediate Jeopardy) as the facility was continuing with audits to ensure compliance and determine if further action required. Findings Include: Review of Resident #47's medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #47 was seen routinely by psychiatric services. Review of Resident #47's care plan dated 01/11/20 revealed the resident resided on a secured unit due to impaired decision-making, paranoid [MEDICAL CONDITION] and history of wandering. The care plan indicated Resident #47 was at risk for elopement. Resident #47 was to be escorted and supervised by facility staff when not on the unit. The care plan also indicated Resident #47 was a supervised smoker that resided on a secured unit where he would be accompanied to the smoking area. He required one on one assistance with smoking. Resident #47 exhibited pacing and restless behaviors at times and was at risk for elopement. Resident #47 was to be escorted and supervised by facility staff when not on the unit and redirected from exit doors. Review of a physician order [REDACTED].#47 was to reside on a secure unit. Review of the secure unit assessment dated [DATE] revealed Resident #47 was alert to self and place, had cognitive impairment and wandering behaviors. Review of the smoking risk assessment dated [DATE] revealed Resident #47 required supervision for smoking. Review of the elopement risk assessment dated [DATE] revealed Resident #47 was at risk for elopement. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #47 had moderate cognitive impairment, wandering behaviors and required supervision for activities of daily living and with movement off the unit. Review of a recapitulation of physician's orders [REDACTED].#47 was prescribed two antipsychotic medications, [MEDICATION NAME] and [MEDICATION NAME]. He was also ordered Trazadone, an antidepressant used for sleep. Review of the Nurse Progress note dated 04/10/20 at 2:59 A.M. authored by LPN #151 revealed Resident #47 was out on a smoke break and jumped the wall. The resident and was found and brought back unharmed. Review of the facility investigation revealed the investigation included three statements. A statement dated 09/29/20 at 8:30 A.M. by the Administrator indicating Resident #47 jumped over the wall during smoke break. A State tested Nursing Assistant (STNA) stated that they had eyes on the resident during the entire time and followed the resident until they were able to bring him back to the nursing home. Another witness statement dated 04/09/20 by STNA #147 revealed she overheard Resident #47 jumped over the wall. A third witness statement dated 04/09/20 by STNA #128 indicated STNA #128 saw Resident #47 jump over the wall. STNA #128 and another staff member followed and brought Resident #47 back to the facility. Observation of Resident #47 on 09/22/20 at 10:00 A.M. revealed he was six feet tall, lean and walked with a steady gait. Resident #47 was aware of self and place, followed commands and answered questions in short simple phrases. Observation of the supervised smoke break on 09/24/20 at 10:00 A.M. with residents from the secure unit and STNA #101 providing supervision revealed the smoking area was located off the main dining room on the first floor. The area was 'L' shaped, surrounded by a five-foot brick fence with a semi enclosed square patio area that contained three wooden park benches, three chairs, and two cigarette extinguishers. The patio area opened out to a courtyard with a five-foot high brick wall that extended out and down the side of the building. There was a wood park bench against one side of the brick wall. STNA #101 supervised the residents from a chair located next to the dining room and from this position the full courtyard perimeter was not in view. During an interview with Resident #47 on 09/24/20 at 10:42 A.M. he said he jumped the wall and the police brought him back. He said this happened a year ago. Resident #47 then laughed got up and walked away. On 09/27/20 at 2:07 P.M., a call was placed to Licensed Practical Nurse (LPN) #151, the nurse on duty in the secure unit at the time Resident #47 eloped from the facility. The voice message stated the mailbox was full and unable to take messages. Additional calls were made 09/28/20 at 9:36 A.M. and 5:00 P.M. with the same message. Interview with STNA #147 on 09/28/30 at 10:47 A.M. revealed she worked day shift on 04/09/20 and had overheard Resident #47 jumped over the wall and was brought back. STNA #147 was unable to recall any further details of the incident. Interview with LPN #204 on 09/28/20 at 1:30 P.M. revealed LPN #204 worked 7:00 A.M. to 7:00 P.M. on 04/09/20 and 04/10/20 in the secure unit. LPN #204 said during the nurse's shift report on 04/10/20 it was shared Resident #47 jumped the wall during a smoke break, was found down the street and was brought back to the facility. LPN #204 was unable to provide any additional information. Interview with STNA #101 on 09/29/20 at 9:38 A.M. revealed she was unaware of any elopements from the facility. A follow up interview with STNA #101 on 09/29/20 at 12:15 P.M. revealed STNA #101 had heard Resident #47 went over the wall but STNA #101 was unable to recall any details and stated, that was a long time ago. Interview with Former Director of Nursing #207 on 09/29/20 at 4:13 P.M. revealed she received a call from the facility indicating during a smoke break Resident #47 jumped the wall and was brought right back by staff. Resident #47 was in the parking lot and the staff always had their eyes on him, this was not considered an elopement. Former Director of Nursing #207 was unable to recall the staff members involved or the exact time of the incident. Former Director of Nursing #207 revealed the administrator completed a risk assessment and there was a file with all the information from the incident. Interview with STNA #123 on 09/30/20 at 11:20 A.M. revealed STNA #123 worked 7:00 A.M. to 7:00 P.M. on 04/09/20. STNA #123 said she and another staff member were in the dining room at the time Resident #47 went over the wall. STNA #123 said the STNA supervising the smoke break told STNA #123 Resident #47 jumped over the wall. STNA #123 and the other STNA went out to the parking lot and brought the resident back into the building. The STNA supervising the smoke break always had Resident #47 in eye view. STNA #123 was unable to recall the time of incident, the STNA supervising the smoke break or the STNA who brought Resident #47 back with her. Interview with LPN #120 on 09/30/20 at 12:40 P.M. revealed LPN #120 worked day shift and was unaware of any elopements at the facility on 04/09/20. Interview with LPN #117 on 09/29/20 at 12:49 P.M. revealed she worked 7:00 P.M. to 7:00 A.M. on 04/09/20 and heard Resident #47 jumped over the fence. LPN #117 said Former Director of Nursing #207, Former Assistant Director of Nursing #209 and other staff went looking for Resident #47 and found him down the street. The incident happened at approximately 9:00 P.M. and the resident was gone for approximately 30 minutes. Interview with STNA #172 on 09/29/20 at 6:22 P.M. revealed STNA #172 worked 7:00 P.M. to 7:00 A.M. on 04/09/20 and at approximately 7:30 P.M. the STNA who supervised the smoke break for residents in the secure unit came back to the unit and noticed Resident #47 missing and notified the nurse. Former Director of Nursing #207, Former Assistant Director of Nursing #209 and other staff immediately started searching for Resident #47. STNA#172 stayed in the building and searched her assigned hall for Resident #47. STNA #172 said Former Assistant Director of Nursing #209 lived down the street from the facility and started searching and found Resident #47 at a gas station and brought him back to the facility. Resident #47 was missing approximately 30 minutes. STNA #172 observed Resident #47 later that night and he smiled and waved to her. Interview with Former Assistant Director of Nursing #209 on 09/30/20 at 1:56 P.M. revealed she had just arrived home and put her pajamas on when she received a call from the facility to come back because Resident #47 jumped the wall while on smoking break. Former Assistant Director of Nursing #209 said she lived close to the facility and got into her car to go back to facility. Former Director of Nursing #207 was also called and was already in route to the facility. Former Assistant Director of Nursing #209 said it was dark as she was driving down a busy five lane road to the facility and saw Resident #47 walking on the sidewalk in front of a bank. Former Assistant Director of Nursing #209 called out to Resident #47 and he got into her car. Former Assistant Director of Nursing #209 took Resident #47 for a ride to the next intersection before returning to the facility where she dropped him off at the door and waited until he entered the building. Former Assistant Director of Nursing #209 said Resident #47 told her he just wanted some fresh air. She said Resident #47 had jumped onto a planter to a bench and over the wall and was missing for approximately 15 minutes. She also said an investigation was completed regarding Resident #47's elopement on 04/09/20 with witness statements from the STNAs. Resident #47 was placed on safety monitoring checks every 15 minutes. A follow up interview with Former Assistant Director of Nursing #209 on 09/30/20 at 2:56 P.M. revealed she filled out and submitted a witness statement regarding Resident #47's elopement. Resident #47 was wearing a jacket, pants, shoes and no socks when found. Review of daily historical temperatures on accuweather.com revealed a high of 60 degrees Fahrenheit (F) and low of 36 degrees F on 04/09/20. Review of sunset times on timeanddate.com revealed sunset on 04/09/20 was 8:04 P.M. Interview with the Administrator on 09/30/20 at 4:04 P.M. revealed Former Director of Nursing #207 told her that eyes were always on Resident #47 when he jumped the wall. Resident #47 was found in the parking lot and brought right back. A risk assessment and investigation were not completed because it was not considered an elopement. The Administrator denied there was any additional documentation regarding the incident. Interview with former STNA #210 on 10/05/20 at 1:08 P.M. revealed she was the STNA who was supervising the smoke break on the evening of 04/09/20. Former STNA #210 revealed she worked as needed (PRN). Former STNA #210 indicated she was supervising six to nine residents that evening from the inside dining room door. There were several residents that went around the back corner of the courtyard and she had to peek around the corner to see them. That evening it was dark and cold and Resident #47 was wearing a jean's jacket, jeans and shoes. After the smoke break Former STNA #210 was on the elevator with the residents returning to the secure unit when she realized Resident #47 was missing. Former STNA #210 notified LPN #151, who was the secure unit nurse, that Resident #47 was missing. LPN # 151 notified Former Director of Nursing #207 and a search was started. A couple staff went searching in cars and a couple searched on foot. Former STNA #210 stayed on the secure unit during the search. Former STNA #210 was not informed Resident #47 was an elopement risk and was trained to supervise smoking residents from inside the dining room door. A follow up interview with the Administrator on 10/01/20 at 10:54 A.M. revealed she was informed by Former Assistant Director of Nursing #209 that Resident #47 was followed in car and was brought back to the facility and he was within eye view at all time. The Administrator could not recall if Resident #47 was picked up in parking lot or down the street. Interview with STNA #123 on 10/05/20 at 1:26 P.M. revealed supervision during smoke breaks prior to Resident #47's elopement could be completed from either inside the dining room door or outside. Review of the facility's undated policy titled Elopement: Missing Resident Policy & Procedure revealed if a resident was found to be missing, prompt action must be taken to locate the resident and bring them back to safety. This deficiency substantiates Complaint number OH 888.

Based on observation, record review and interview, the facility failed to ensure Resident #24, who had identified risk factors for the development and delayed healing of pressure ulcers, had the necessary precautions in place to prevent the continuous bumping of the wheelchair against her left ankle. This resulted in harm to Resident #24 when the resident was assessed to have an unstageable pressure ulcer to the left ankle as a result of the contact with the wheelchair. The facility also failed to ensure Resident #58 had a dressing in place to a pressure ulcer as ordered. This affected two residents (Resident #24 and #58) of four residents reviewed for pressure ulcers. Findings include: 1. Review of Resident #24's medical record revealed the resident had [DIAGNOSES REDACTED]. The pressure ulcer risk assessment dated [DATE] revealed the resident was at mild risk for the development of a pressure ulcer. The care plan dated 01/11/13 revealed the resident was at risk for skin breakdown due to diabetes and occasional incontinence and required supervision to assist with bed mobility, transfers, hygiene and bathing. The care plan dated 10/04/13 revealed the resident had an open area to the left ankle. The care plan dated 10/04/13 indicated the resident was at risk for complications due to the wound to the left ankle. The nurse's notes dated 10/04/13 at 10:00 A.M. revealed the resident informed the charge nurse of an open wound on the left ankle. The wound measured one centimeter (cm) long by 0.5 cm wide and 0.2 cm deep with 50% slough tissue present. A repair requisition form dated 10/04/13 regarding Resident #24 revealed the wheelchair wheel bolt hit the resident's ankle. The wheel bracket hit the resident's leg whenever she turned in the wheelchair. The requisition indicated the bracket would be covered with lamb's wool from the therapy department. The wound evaluation flow sheet dated 10/09/13 revealed an in house wound was discovered on 10/09/13 that measured 1.0 cm long by 0.6 cm wide and 0.1 cm deep. The wound had a moderate amount of serosanguineous drainage with necrotic tissue present. The wound care consultants note dated 10/09/13 revealed the resident had an open wound to the left ankle. The medical condition included infection. The wound type was listed as diabetic/neuropathic. The wound had necrotic tissue. The notes dated 10/14/13, 10/23/13, 11/06/13, 11/13/13 and 11/20/13 indicated the ulceration type was a pressure ulcer. The occupational therapy discharge summary notes, dated 11/24/13 revealed the resident's ankle wound was caused by the resident bumping her left ankle with the front wheel of the wheelchair while propelling in the wheelchair. The progress notes dated 12/14/13 indicated the resident had a left ankle wound that was sustained after hitting the left ankle on the wheelchair. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact and at risk for developing pressure ulcers. The care plan dated 02/14/14 revealed the resident had self care deficits. On 08/27/14 at 3:25 P.M. the resident was observed in bed. The resident was alert and oriented. She stated the ankle wound developed from the "steel piece" on the wheelchair in October 2013. She stated she had requested the maintenance man fix the wheelchair, but he never did until the wound developed. At 3:35 P.M. LPN #100 was observed changing the outer ankle dressing. The LPN changed the dressing using appropriate infection control precautions and following the physician's orders [REDACTED]. The wound bed was red. The LPN cleansed the wound with normal saline, patted dry, applied foam dressing and gauze wrap. An interview with the director of nursing (DON) on 08/28/14 at 2:40 P.M. verified the documentation revealed the left ankle wound grids and progress notes indicated the left ankle wound was not discovered until it was unstageable on 10/09/13. The DON verified the resident required assistance for personal hygiene and activities of daily living. She stated the staff perform skin checks when assisting with personal hygiene. An interview with corporate registered nurse (RN) #103 on 08/28/14 at 3:45 P.M. revealed the physician and nurse practitioner notes indicated the resident developed the wound from hitting her ankle on the wheelchair. She verified the documentation indicated the ankle wound was not discovered until it was unstageable. She verified the documentation indicated the wound had slough and was necrotic at the time it was discovered. An interview on 08/29/14 at 10:50 A.M. with RN #103 verified the documentation in the nurse's notes and the occupational therapy summary notes indicated the resident's ankle wound was caused by the resident bumping her left ankle with the front wheel of the wheelchair while propelling in the wheelchair. She verified there were [DIAGNOSES REDACTED]. 2. Review of Resident #58's medical record revealed the resident was admitted to the facility on [DATE] and had current [DIAGNOSES REDACTED]. The resident was diagnosed with [REDACTED]. Review of the MDS 3.0 assessment, dated 06/19/14 revealed the resident had moderate cognitive impairment and required extensive assistance from staff to meet her daily needs. The resident had an indwelling urinary catheter and was always incontinent of bowel. The resident was at risk for pressure ulcer development. Review of physician's orders [REDACTED]. [MEDICATION NAME] AG is a wound treatment that contains Ionic Silver and is indicated for wound with moderate to high amounts of drainage which are infected or at risk of infection. Review of the skin grids and physician wound progress notes of 08/26/14 revealed the resident had a Stage IV sacral ulcer that measured three cm long by three cm wide with one cm depth and 25 % slough tissue present. A Stage IV pressure ulcer involves full thickness tissue loss with exposed bone, tendon or muscle. On 08/27/14 at 2:32 P.M., the treatment nurse, licensed practical nurse (LPN) #100 and registered nurse (RN) #6 entered the resident's room. The director of nursing (DON) was also was present in the room. LPN #100 prepared for the treatment by cleansing the table, placing a barrier, gathering the dressing supplies and then washed her hands and applied gloves. RN #6 then turned the resident over to her right side and she untaped the brief to expose the pressure ulcer. There was no dressing covering the wound at that time and there was an approximate 3 cm by 3 cm area of wound drainage noted on the brief. LPN #100 verified she had not been notified the dressing had been removed. She verified there was a small amount of purulent drainage on the brief. The DON left the room and LPN #100 proceeded with the treatment as ordered. Before the treatment was completed, the DON returned and stated she had asked LPN #55 about the wound dressing. She stated LPN #55 had been notified by the state tested nursing assistants at approximately 1:45 P.M. that they had checked and changed the resident and the dressing was off. LPN #55 stated she knew the dressing was going to be changed, so she did not notify the wound nurse or place a clean barrier over the open draining wound. Interview with LPN #55 immediately after the wound treatment had been observed revealed she wasn't exactly sure of the time she was notified, but verified she should have covered the wound. This deficiency substantiates Complaint Number OH 997.

Based on observation, record review and interview, the facility failed to ensure all residents received adequate and appropriate assistance and necessary services to prevent falls and/or meet their safety needs. Resident #38 sustained a fall during care on 02/03/12. The resident was transferred to the emergency roiagnom on [DATE] with a left hip fracture. Resident #54 sustained a fall with complaints of bilateral knee pain during care on 01/18/12. Resident #33, who had a physician order [REDACTED]. This affected three residents (Residents #33, #38 and #54) of five residents reviewed for falls and/or accidents. The facility census was 78. Findings include: 1. Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed the resident had a history of [REDACTED]. A plan of care, dated 01/13/12 revealed the resident was at risk for falls related to [DIAGNOSES REDACTED]. The goal developed was for the resident to be free of falls and fall related injuries. Interventions included to assist with mobility as needed, keep bed in lowest position, ensure resident was wearing non-skid footwear when out of bed, the use of a Velcro alarming self-release seat belt and for one to two staff to assist with all transfers. A physician order [REDACTED]. Review of nurse's notes, dated 02/03/12 at 9:00 P.M., revealed the resident was in her wheelchair in her room. The note indicated two state tested nursing assistants (STNAs) were in her room preparing her for bed and had removed her seat belt. While preparing her for bed, the resident fell out of the wheelchair and complained of left hip pain. The STNAs reported she had been sitting on her buttocks on the floor and denied the resident had hit her head. The note indicated the nurse assessed the resident and she complained of left hip pain when range of motion was attempted. The nurse indicated she medicated the resident with Tylenol for complaints of pain at that time and would continue to monitor her. The next entry in the nurse's notes, dated 02/03/12 at 11:00 P.M. (two hours later), revealed the physician was notified of the resident's fall. An order was obtained for an x-ray at that time. The note indicated the resident was resting. On 02/04/12 at 1:00 A.M., nurse's notes revealed the resident was resting. On 02/04/12 at 4:00 A.M., nurse's notes revealed the resident had been assisted up to her wheelchair to go to dialysis. The note indicated the resident stated her left hip was still a little sore. The resident left the facility at 5:00 A.M. for dialysis. No x-ray had been obtained as of that time. Review of nurse's notes revealed the resident returned from dialysis on 02/04/12 at 10:15 A.M. The note indicated the resident was "still complaining" of pain to her left hip from the fall, was medicated with Tylenol and staff would continue to monitor. On 02/04/12 at 6:15 P.M. nurse's notes revealed portable x-ray results of the left hip were normal. On 02/05/12 at 6:00 A.M. the resident was medicated with Tylenol for complaints of left hip discomfort that was unrelieved with repositioning. The note indicated the resident voiced "some relief" following the medication administration. On 02/05/12 at 1:00 P.M., nurse's notes revealed the resident was on bed rest and complained of moderate pain, rating it a seven on a scale of one to ten. The note indicated the resident was given Tylenol for pain and staff would monitor. On 02/05/12 at 9:10 P.M., nurse's notes revealed the resident was again medicated with Tylenol for complaints of hip pain and staff would continue to monitor. On 02/06/12 at 6:30 A.M. the resident was medicated with Tylenol for complaints of left hip pain. The note indicated the physician would be called to see if the resident could have a prescription that would give her more pain relief. On 02/06/12 at 7:00 P.M. a new order for the pain medication, Ultram 50 milligrams twice a day as needed was received. The next entry in the nurse's note, dated 02/07/12 at 10:20 A.M. revealed the resident had returned from dialysis at 10:00 A.M. not feeling well. The note indicated the resident stated she was sweating and needed to be sent out. The physician was notified and an order was received to transfer the resident to the emergency room . On 02/07/12 at 10:30 A.M., nurse's notes revealed the resident was being picked up by the ambulance company and was in extreme pain. The resident was admitted to the hospital with [REDACTED]. Review of hospital documentation revealed a CAT scan of the resident's pelvis showed a non-displaced fractured inverted left femoral head. An orthopedic consult was requested and the plan was for the resident to have surgery. The note also indicated the resident would be given pain medication to control her pain. On 02/15/12 at 10:27 A.M., interview with Resident #38's niece revealed she had concerns related to her aunt's care and the circumstances surrounding a fall on 02/03/12. The niece indicated she was not notified of the fall until 02/04/12 around 9:00 A.M., the day after it happened. The niece stated she was told an x-ray was going to be performed but later found out the resident had been sent to dialysis before the x-ray was done. During the interview the niece voiced concerns that no one from the facility had called her and the x-ray that was ordered was not done in a timely manner. The niece indicated she was aware the x-ray done by the facility was negative, but when the resident continued to complain she was in so much pain all weekend long she was concerned that nothing more was being done for her. The resident's niece indicated the resident continued to complain of pain in her hip all weekend and then on Tuesday after returning from dialysis she was sent to the hospital because she was in so much pain. The niece indicated the resident was admitted to the hospital with [REDACTED]. The niece indicated the surgery was completed, but the resident passed away in the hospital on [DATE]. On 02/16/12 at 2:00 P.M., interview with Registered Nurse (RN) #15 revealed she was the nurse assigned to care for Resident #38 on 02/03/12 during the 7:00 P.M. to 7:00 A.M. shift. The RN verified Resident #38 sustained a fall while staff were providing care to her in her room. RN #15 verified the documentation of the fall occurring at 9:00 P.M. and the physician being notified at 11:00 P.M. (two hours later). The RN also verified she did not call the resident's niece at the time of the fall indicating it had been a busy night. The RN indicated it was around 9:00 A.M. the next day, after the resident had already left for dialysis that the resident's niece was notified of the fall. During the interview, RN #15 indicated she had processed the paperwork to have the x-ray completed, but verified the x-ray was not done before the resident went to dialysis. The RN indicated her shift had ended and she had gone home prior to Resident #38 returning from dialysis and did not provide care again for the resident between 02/04/12 and 02/07/12 when she was transferred to the hospital and admitted with the left hip fracture. 2. Resident #54 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Record review revealed a plan of care, initiated 09/30/10 related to altered thought process. The care plan revealed the resident exhibited short and long term memory loss, poor decision making and required supervision and cueing. A second plan of care, initiated 10/07/11 revealed the resident exhibited deficits with self care and activities of daily living. Interventions included the resident was a total assist for transfers via a mechanical/Hoyer lift. Review of a fall plan of care, initiated 04/19/10 revealed the resident was at risk for falls and had a past medical history of [REDACTED]. The goal developed was for the resident to remain free from falls/injury. Interventions included to explain call bell/light, keep bed at lowest level, postural support/restraint with physician's orders [REDACTED]. The plan of care also reflected the use of a tilt in space wheelchair with rear anti-tippers, bilateral leg rests and cushion as per order. Review of current physician orders, dated February 2012 revealed the resident required the use of a specialized tilt in space wheelchair when up. Nursing assessment documentation for the tilt in space, dated 04/22/11, 07/11/11, 09/27/11, 11/05/11, 01/31/12 revealed the resident was alert to self and unable to follow directions. The assessments revealed the resident exhibited poor safety awareness and transferred with a Hoyer lift. The assessment failed to contain any documentation related to any type of leaning or issues with sitting posture control. Additionally, as the tilt in space chair had the capability of being in various positions, the assessments did not contain any information related to how the chair should be positioned when the resident was in it. Review of an acute medical note, dated 01/18/12 revealed the resident was seen at the facility related to a fall. The note indicated the resident had fallen from the wheelchair that morning. The note indicated, "apparently the wheelchair was not reclined at the time of the fall". The resident complained of knee pain and was medicated with Tylenol and bilateral knee x-rays were ordered. The note indicated the resident was bed bound, up to a tilt in space wheelchair daily as tolerated and wheeled in the chair by others. Review of a nurse's note, dated 01/18/12 at 6:00 A.M., revealed an STNA reported after putting the resident in her wheelchair this morning, the resident attempted to get out of the wheelchair and fell forward out of the chair and onto the floor. The resident complained of knee pain and x-rays were ordered. X-ray results were negative. The note indicated staff would continue to monitor. Review of the facility investigation revealed after assisting the resident to the chair, STNA #12 turned from the resident to talk to another staff member without first placing the leg rests on the tilt in space wheelchair and without reclining the tilt in space chair. When the STNA turned back around to tend to the resident, she was falling out of the chair. The STNA was unable to prevent the fall and the resident landed on the floor. The facility concluded the leg rests were not immediately applied to the wheelchair following the transfer, and the resident was not tilted which resulted in the resident's fall while not being adequately supervised by STNA #12. On 02/16/12 at 9:53 A.M., interview with licensed practical nurse (LPN) #4 verified Resident #54, who was dependent on staff for transferring and mobility, sustained a fall from the tilt in space wheelchair on 01/18/12. The LPN verified the resident's plan of care did not include any information related to the position the tilt in space wheelchair should be kept in. On 02/16/12 at 1:25 P.M., additional interview with LPN #4 revealed she was in the doorway to the resident's room when the resident fell , although she didn't observe the fall. LPN #4 indicated the fall occurred when STNA #12 turned from the resident without first placing the foot rests on the wheelchair or reclining the tilt in space wheelchair. 3. Resident #33 was re-admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the resident's current physician orders [REDACTED]. Record review revealed a plan of care, dated 01/30/12 related to deficits in self-care performance related to the CVA and dementia. Interventions included to be up to a wheelchair as tolerated with a right arm support, chair alarm and self-releasing seat belt. The plan of care also indicated the resident required a mechanical aid/Hoyer lift for transfers. A second plan of care, also dated 01/30/12, revealed the resident was at risk for falls related to syncope, CVA and dementia. The goal developed was for the resident to be free from falls and fall related injury through the next review. Interventions included the use of a wheelchair with rear antitippers and a right arm support as tolerated and a mechanical lift/Hoyer lift for transfers to and from bed and wheelchair. On 02/14/12 at 10:14 A.M., the door to Resident #33's room was closed. After knocking on the door and obtaining permission to enter, Resident #33 was observed sitting in his room in a wheelchair. A stated tested nursing assistant (STNA) #9 was observed in the room with him at that time. Interview with the STNA and resident revealed the resident was going to get back to bed. STNA #9 proceeded to transfer the resident back to bed by himself at that time and without the use of a Hoyer lift. On 02/14/12 at 10:39 A.M., interview with STNA #9 revealed he always transferred the resident by himself and the resident did good for him. STNA #9 stated he was able to transfer him by himself because he was a guy and indicated the resident did have an order for [REDACTED]. Review of an STNA bedside plan of care sheet for Resident #33 revealed effective 04/12/10, the resident required a Hoyer lift and two-person assistance to transfer. On 02/16/12 at 10:36 A.M., interview with STNA #11 revealed there were two STNA's working on the unit on this date. The STNA stated she just helped STNA #9 assist Resident #33 back to bed using the Hoyer lift. STNA #11 stated she did not assist STNA #9 to get the resident up out of bed earlier in the shift, but did help get him back to bed. On 2/16/12 at 10:38 A.M., interview with Resident #33 revealed STNA #9 had assisted him out of bed earlier that morning by himself. The resident stated, "he's strong" and indicated he did not need anyone to help him. The resident verified some staff used the Hoyer lift and some didn't when transferring him and indicated he had no preference one way or the other. On 02/16/12 at 10:45 A.M., interview with STNA #9 verified he assisted Resident #33 out of bed earlier by himself and without using the Hoyer lift. The STNA indicated after the resident was up in the chair he placed a Hoyer lift pad underneath him and then he and STNA #11 assisted the resident back to bed. This deficiency substantiates allegations contained in Complaint Number OH 477.

Based on record review and interview, the facility failed to ensure preventative measures were in place and skin assessments were completed to prevent the development of an unstageable pressure ulcer to the left ear of Resident #84. This affected one of three residents reviewed that developed pressure ulcers. The facility census was 82 residents. Findings include: Resident #84 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 dated 09/06/11 revealed the resident had moderately impaired cognition. The resident was independently ambulatory with supervision, and independent in meeting all his other daily personal needs. The resident fell on [DATE] and sustained a right [MEDICAL CONDITION]. The resident was re-admitted on [DATE] with an unstageable pressure ulcer to his coccyx that measured 4.0 centimeters (cm) long by by 5.0 cm wide. The wound nurse, Licensed Practical Nurse (LPN) #1, noted the area was pink with dark soft necrotic tissue at the posterior wound. The re-admission nursing assessment revealed the resident was now non-ambulatory and required extensive assistance of two persons to transfer and was totally dependent for toileting and hygiene needs. The resident was admitted to the hospital with [REDACTED]. The resident also returned with a right heel unstageable pressure ulcer that measured 8.5 cm long by 5.0 cm wide. The resident's mattress was changed from a pressure reduction perimeter mattress to a low air loss perimeter mattress. A wound treatment was ordered for the coccyx wound and the right heel was padded with a thick gauze pad and wrapped with Kerlix (a gauze wrap). There was no evidence of a preventative measure in place for the left heel. Review of Nurse's Notes dated 10/15/11 at 4:30 P.M. revealed the resident had an elevated temperature, pulse and respirations. The resident was readmitted to the hospital and returned to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Wound Progress Notes dated 10/25/11 revealed the resident returned with two additional pressure ulcers, one to his right ear lobe and one to his left heel. LPN #1 noted the resident had a Stage III pressure ulcer to his right ear lobe. A Stage III ulcer is defined as a full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to underlying fascia. The ulcer presents as a deep crater with or without undermining of adjacent tissue. The nurse noted the area was 2.0 cm wide by 1.0 cm deep and was oozing thin, bloody drainage with cartilage showing. The resident also returned with a left heel unstageable pressure ulcer that measured 4.0 cm long by 6.0 cm wide. LPN #1 also documented the other two areas he returned with, which included the sacrum (previously noted as the coccyx pressure ulcer). The sacral pressure ulcer was an unstageable area that measured 10.5 cm long by 11.0 cm wide with thick slough and necrotic tissue around the wound. The right heel had a Stage III pressure ulcer that measured 9.0 cm long by 6.0 cm wide and although the nurse noted no depth, she noted the ulcer was a Stage III. Review of the 10/25/11 re-admission physician orders [REDACTED]. The resident was not to be positioned on his right side. The resident was ordered to receive oxygen continuously at two liters per nasal cannula. Review of Nurse's Notes dated 11/04/11 at 10:00 P.M., revealed the resident had a "new order" to cleanse the left ear with wound cleanser, apply [MEDICATION NAME] and bandage. The wound nurse, LPN #1, also noted on her Wound Progress Note dated 11/04/11 a note about all the resident's pressure ulcers and also noted the resident had an unstageable open area (1.0 cm. long by 1.0 cm wide) to his left ear with eschar present and thin blood tinged drainage. During an interview with the director of nursing (DON) and LPN #1 on 11/28/11 at 5:30 P.M., the DON said the resident's left ear had been padded. The DON and surveyor reviewed the documentation which included: physician's orders [REDACTED]. There was no evidence the ear had been padded. Also, there was no evidence on the three skin breakdown care plans initiated by the MDS nurse and the skin integrity care plan initiated by LPN #1, of any preventative measure regarding the resident's left ear. The DON said there might be an additional skin care plan that was not included in the closed record and the MDS nurse would look for it. The DON did verify if the area had been padded there was no documentation of the nurse's removing the padding to check the status of the skin. The DON and LPN #1 said skin checks were completed two times a week on bath/shower days. LPN #1 said she had initiated an investigation regarding the development of the unstageable left ear pressure ulcer and determined the pressure ulcer was unavoidable. She said the resident had declined and he was already on a low air loss mattress. She also said the area "had to be coded" as a pressure ulcer, and there was just a small necrotic area on the upper earlobe. Nurse's Notes dated 11/06/11 at 12:15 A.M., revealed the resident had a temperature (100.5 F) and elevated blood sugar (336 mg/dl). The physician was notified and the resident was sent to the hospital and admitted . The resident did not return to the facility on discharge from the hospital. This deficiency substantiates Complaint Number OH 183.