Every finding on record at Rae Ann Suburban

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of facility self-reported incident (SRI) including investigation, observations, staff and resident interviews and review of facility Abuse, Neglect, and Misappropriation policy, the facility failed to ensure residents were free from misappropriation of property. This affected eight residents (#21, #77, #86, #88. #89, #90, #91 and #92) of 10 residents reviewed for abuse. The facility census was 81. Findings include:Review of the facility Self-Reported Incident (SRI) tracking number 264428 and 264635 revealed the following information. Review of the Police Investigative Report dated [DATE] revealed the police received a report of suspected fraud on [DATE] involving Certified Nursing Assistant (CNA) #310. The police interviewed previous Resident #88 on [DATE] who reported she had closed her previous debit card due to fraudulent activity that occurred months ago and most of the charges were from Insta Cart. Resident #88 informed the police that she had been a previous resident at the facility in [DATE] and did remember her purse being upside down on the floor one day at the facility. The facility was not aware of allegations at this time. Review of the police Investigative Report titled Supplement dated [DATE] revealed the police received more information about CNA #310 receiving packages from Amazon with Resident #91 and Resident #89 credit card information uploaded into her Amazon account. Police reviewed the transactions tab and found charges to Resident #88 credit card as well. At this time the police called the facility and confirmed Resident #91 was currently a resident at the facility and Resident #89 had passed away. The police came to the facility and interviewed Resident #91 who reported to the police that her card had previous fraudulent activity and the facilities Business Office had assisted her with reporting the fraud to her bank and canceling her card. Between [DATE] to [DATE] an employee questionnaire was distributed to staff members regarding any knowledge of the alleged fraud and all responses were negative. In addition, five residents were interviewed regarding their feelings of safety within the facility and the security of their personal belongings, with no residents reporting any concerns regarding theft of missing property. The facility unsubstantiated the SRI at this time. On [DATE] the DON requested a copy of the police report and received the report from the police department on [DATE]. The police report identified CNA #310 as the alleged perpetrator of the credit card fraud. At this time, CNA #310 was working and was immediately removed from the floor and interviewed by the Administrator, Director of Nursing (DON) and Human Resources. During the interview CNA # 310 admitted to obtaining Resident #91 credit card number and using the card without authorization. CNA #310 was terminated immediately and escorted from the facility. The facility updated the police department, Ohio Department of Health, the nurse aide registry and the facility medical director. On [DATE] the facility was notified by Resident #86 that there was a suspicious charge on her Cash App account on [DATE]. The facility updated the police department and opened SRI 264635 at this time. On [DATE] the facility was notified by Resident #21 that his bank called about fraudulent charges. Resident #21 had his bank card in possession. The account had a balance of $0 and the charge were denied. The facility updated the police regarding the new allegation of fraud. On [DATE] the DON was contacted by the police department to review new potential victims that included former Resident #92 and current Resident #77. The police also confirmed that Resident #86 was listed as victim in the current investigation. Facility interviewed the guardian of Resident #77 and to previous Resident #92 and updated them regarding the misappropriation. Both residents reported no current fraudulent charges.Interview on [DATE] at 7:21 A.M. with the Director of Nursing (DON) and the Administrator revealed the DON received a call on [DATE] that a police officer was at the facility and they needed to speak to Resident #91 about and anonymous tip they received regarding credit card fraud. Facility opened a Self-Reported Incident (SRI) #264428 on [DATE] and interviewed Resident #91 who voiced no concerns or complaints regarding the allegations. Facility believed at this time that Resident #91 credit card information was obtained in the community. Once facility received the police report that had CNA #310 as the alleged perpetrator she was removed from the floor and fired immediately.The deficient practice was corrected on [DATE] when the facility implemented the following corrective actions:-On [DATE] the facility opened an SRI and interviewed Resident #91.-Between [DATE] to [DATE] the facility distributed employee questionnaires regarding alleged fraud of Resident #91 credit card. The facility also interviewed five residents regarding safety and security of their personal belongings.-On [DATE] CNA #310 was removed from the floor and terminated.-Between [DATE] to [DATE] additional employee interviews were conducted regarding misappropriation and all findings were negative. -Between [DATE] to [DATE] additional resident interviews were conducted and Resident #86 reported a suspicious charge on her Cash App account on [DATE]. The facility updated the police department and opened SRI #264635 on [DATE]. -The facility started a Performance Improvement Project (PIP) for Misappropriation on [DATE].-Between [DATE] to [DATE] the facility conducted facility-wide employee education regarding abuse, neglect, exploitation, misappropriation of resident property, mandatory reporting requirements, resident rights and expectations for professional conduct. -On [DATE] the facility implemented a formal Informed Consent to Retain Personal Valuables process. All current residents were provided with the consent form and given the option to either retain valuables in their possession or have valuables secured by the Business Office. The facility completed inventory sheets on all residents -The facility had all residents check their banking accounts for fraudulent activity and called all recently discharged and deceased residents families to update them and have them check banking accounts. -Facility completed audit with all residents regarding cards and bank accounts on [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; and [DATE]. Review of facility policy titled, Abuse, Neglect, Exploitation and Misappropriation with a revised date of [DATE] revealed residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This deficiency represents non-compliance investigated under Complaint Number 2603954, Complaint Number 2569724, and Incident Control Number 2618333.

Based on observation, interviews and facility policy the facility failed to ensure a clean and homelike environment. This had the potential to affect all 81 residents. The facility census was 81. Findings include:Interview and observation on 06/15/26 at 10:23 A.M. with Maintenance Director (MD) #305 revealed the following:-The ceiling outside of room [ROOM NUMBER] had an area estimated to be 1 1/2 feet (ft) in length of dry wall exposed. MD #305 revealed there was a ceiling leak a while ago and it was never painted over.-The wallpaper was peeling off the wall to right of room [ROOM NUMBER].-The ceiling vent by room [ROOM NUMBER] was built up with dust.-The door by the laundry room had dust and debris built-up around the window ledges and the wall vent was dusty.-By room [ROOM NUMBER] there was a water stain on the ceiling in the area that opened up to the attic. MD #305 revealed the pipes produce condensation and will leak. He said he would paint over the area. -By Side 2 the exit door had a crack in the window on the left side of the door.-The wood wall outside of the library had wood trim panel that was unattached and sitting on the trim with exposed nails.-The wood wall panel outside of the library had heavy dust buildup and various splatter stains throughout.-The exit door by room [ROOM NUMBER] had a crack in the window on the right side. Observation and interview on 06/15/26 at 5:12 P.M. with the Administrator in the dining room revealed the ceiling fans were extremely dusty with visible black dust built up around the blades. Two of the fans were currently running above where residents were eating.Review of facility policy titled, Homelike Environment, with a revised date of February 2021 revealed the following: 1. Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment;.This deficiency represents non-compliance investigated under Complaint Number 2578786.

Based on observation, interviews and facility policy the facility failed to ensure a sanitary and clean kitchen. This had the potential to affect all 81 residents. The facility census was 81. Findings include:Observation and interview on 06/15/26 from of the kitchen 9:20 A.M. to 10:00 A.M. with Kitchen Manager #307 revealed the following:-The refrigerator by the tray line had rusted shelves and the bottom of the refrigerator had crumbs and debris.-The oven had crumbs on the handles and the glass had a built-up sticky residue.-Behind the stove there was an oven mitt on the ground and other debris.-Throughout the kitchen the bottom of the tray line had crumbs and various debris.-There were two brown plastic container bins with spices under the tray line that were sticky and had debris and crumbs. None of the spices were dated and some were not standing up right, with unsecured lids causing spices to be spilling out. There was a container of BBQ sauce that said to keep refrigerated that was also in the container. Kitchen Manger #307 confirmed the BBQ should had been kept in the refrigerator.-The tray line warming table had built up brown sticky residue and other debris.-The prep table by the walk-in fridge had crumbs in the utensil drawers and the front of the drawer was dirty and sticky. The prep table had debris and brown and black residue build-up-The ceiling had numerous black spots and dust throughout. The vent by the 2-part sink had visible black dust build-up.-The metal mobile aluminum can racks were dirty and had crumbs throughout.-There were unknown trash items underneath the fridge by the door to the dining room.-There was tile missing in the corner on the floor by the dining room door.-The walls and wall tile throughout the kitchen were dirty with built of residue and various splatter spots.-In the pull out fridge by the dining room door there was 1 container of 2.0 supplement drink with mold on the lid and one container with various splatter and a dead fly on the top.-In the walk-in refrigerator there were multiple packets of individual grapes that were moldy and multiple cantaloupes in a cardboard box were moldy.All above findings were confirmed with Kitchen Manager #307.Review of facility policy titled Sanitization with a revision date of November 2022 revealed 1. All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. 2. All utensils, counters, shelves and equipment are kept clean, maintained in good repair.

Based on observation, record review and interview the facility failed to ensure a medication rate less than five percent. This affected two (Resident #9 and Resident #56) out of four residents observed during medication administration. The facility census was 81.Findings include: An observation on 06/16/26 between 7:15 A.M. and 8:00 A.M. of four licensed nurses (Licensed Practical Nurse (LPN) #310, LPN #309, LPN #311, Registered Nurse (RN) #312) administer medications to Resident # 9, Resident #56, Resident #74 and Resident #75 with 31 opportunities for error revealed three errors observed. This resulted in a medication error rate of 10 percent.1. A review of Resident #56's clinical record revealed an admission date of 05/28/24 with diagnoses including heart failure, neurocognitive disorder, diabetes mellitus, major depressive disorder with severe psychotic symptoms, high blood pressure and cholesterol, thyrotoxicosis, post-traumatic stress disorder, peripheral vascular disease, suicidal ideation, dental caries, cognitive communication deficit, malingerer (To pretend or exaggerate incapacity or illness), dementia and insomnia.A review of Resident #56's care plan initiated on 02/28/25 revealed Resident #56 had cognitive impairment with aggressive behaviors, a problem with communication, and needed assistance with medication administration, and activities of daily living tasks.A review of Resident #56's physician orders dated 06/01/26 to 06/30/26 indicated the above medications were to be administered in the morning including the following medication before breakfast:Insulin Lispro injection solution, inject 4 units subcutaneously before meals in addition to sliding scale coverage.Insulin Lispro injection solution per sliding scale four times a day:If blood sugar measured 110 to 150 mg/dL give 0 unitsIf blood sugar measured 151 to 200 mg/dL give 2 unitsIf blood sugar measured 201 to 250 mg/dL give 4 unitsIf blood sugar measured 251 to 300 mf/dL give 6 unitsIf blood sugar measured 301 to 350 mg/dL give 8 unitsIf blood sugar measured 351 to 400 mg/dL give 10 unitsIf blood sugar measured greater than or equal to 401 give 10 units and notify the physician.A review of Resident #56's Medication Administration Record (MAR) for June 2026 revealed the Lispro 4 units insulin was scheduled to be administered before meals at 8:00 A.M., 12:00 P.M. and 4:30 P.M. The Lispro sliding scale insulin was scheduled before meals three times a day and at bedtime.During an observation on 06/16/26 at 7:45 A.M. LPN #311 was seen administering medications to Resident #56. LPN #311 dispensed the following medications in a medication cup:Jardiance 25 milligrams (mg) (used to lower blood sugar level) one half an oral tablet (12.5 mg)Bisoprolol fumarate 5 mg one half oral tablet (2.5 mg) (blood pressure medication)Methimazole 5 mg oral tablet (thyroid medication)Spironolactone 25 mg oral tablet (reduce swelling and control high blood pressure) one half tablet (12.5 mg)Sacubitril-valsartan 49-51 mg one oral tablet (blood pressure medication)LPN #311 acknowledged that there were five medication tablets in the medication cup. LPN #311 entered Resident #56's room and obtained his blood sugar level which measured 217 mg/dL. LPN #311 proceeded to administer the oral medication tablets (above listed medications) to Resident #56. Resident #56 consumed the medications and LPN #311 exited Resident #56's room and performed hand hygiene. LPN #311 was asked if she had completed the medication administration for all medications and treatments that were scheduled to be administered at this time. LPN #311 stated all the medications that had been administered were scheduled at this time and no additional medications or treatments were due to be administered. LPN #311 then proceeded to administer medications to Resident #3. At the time of the observation staff were delivering the breakfast meal to the nursing units from the kitchen.An interview with LPN #311 on 06/16/26 at 9:00 A.M. verified she had not administered Resident #56's Lispro insulin medication that was scheduled to be administered at the same time as Resident #56's oral medications earlier in the morning before she started to administer medications to Resident #3. A review of the facility policy titled Administering Medications dated 2001 revealed the policy interpretation and implementation indicated medications are administered in accordance with prescriber orders, including any required time frame. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.2. A review of Resident #9's clinical record revealed an admission date of 02/10/23 with diagnoses including intellectual disabilities, high blood pressure, osteoarthritis with lateral subluxation of the patella, fracture of metatarsal bones of the left foot, neurocognitive disorder, diabetes mellitus, adjustment and mood disorder, anxiety and depression.A review of Resident #9's care plan initiated on 02/13/23 revealed Resident #9 had impaired cognitive function with communication problem and needed assistance with medication administration and activities of daily living tasks.A review of Resident #9's physician orders for June 2026 revealed to administer the following medications in the morning:Cyanocobalamin (vitamin B12) 500 micrograms (mcg) 2 tablets orally one time a day for supplementFerrous sulfate 325 milligrams (mg)orally once a day for supplement for anemiaFolic acid 1 mg orally once a day for supplementLactobacillus oral capsule once a day for supplementLasix 20 mg oral tablet once a day for edema (swelling)multivitamins administer one tablet once a day for supplementThiamine Hydrochloride 100 mg oral tablet once a day for supplementVitamin C 500 mg tablet once a day for supplementClonazepam 1 mg oral tablet twice a day for anxietyVitamin D3 1.25 mg oral tablet for supplementColace 100 mg oral capsule twice a day for constipationDivalproex Sodium 500 mg oral delayed release tablet two times a day for neurocognitive disorder.Metoprolol Tartrate 100 mg oral tablet two times a day for high blood pressure and hold if the systolic blood pressure was less than 100 millimeter of mercury (mmHg) or if heart rate was less than 60 beats per minute.Insulin Lispro (1 unit dial) subcutaneous solution pen-injector 100 units/milliliter (ml) for diabetes mellitus, inject per sliding scale:If blood sugar measured 151 to 200 mg/dL give 2 unitsIf blood sugar measured 201 to 250 mg/dL give 3 unitsIf blood sugar measured 251 to 300 mf/dL give 4 unitsIf blood sugar measured 301 to 350 mg/dL give 5 unitsIf blood sugar measured 351 to 400 mg/dL give 6 unitsIf blood sugar measured greater than or equal to 401 notify the physician.Insulin Lispro (1 unit dial) subcutaneous solution pen-injector 100 units/milliliter (ml), inject 30 units subcutaneously three times a day for diabetes mellitusAn observation of RN #312 on 06/16/26 at 7:55 A.M. administer medications to Resident #9 revealed RN #312 dispensed the above listed oral medications in a medication cup including the Divalproex Sodium delayed release medication and crushed the medications. RN #312 proceeded to place the crushed medications in a medication cup and mixed pudding with the medications and then administered the medications mixed in pudding to Resident #9.An interview with RN #312 on 06/16/26 at 9:00 A.M. revealed she should not have crushed the delayed released Divalproex medications with the other medications. RN #312 checked the medication card and verified the medication card indicated the Divalproex was a delayed release medication. A review of the facility policy titled Administering Medications dated 2001 revealed the policy interpretation and implementation indicated medications are administered in accordance with prescriber orders, including any required time frame. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.This deficiency represents non-compliance investigated under Complaint Number 2649735 and Complaint Number 2578786

Based on observation, interview and facility policy the facility failed to ensure garbage was disposed of properly. This had the potential to affect all 81 residents in the facility. The facility census was 81. Findings include:Observation and interview on 06/15/26 at 9:20 A.M. to 10:00 A.M. with Kitchen Manager #307 during the initial tour of the kitchen revealed the following observations of the outside dumpster area:-Multiple pieces of the old flooring and various trash, including plastic water bottles and other cans, were on the ground to the right of the dumpster.-Trash throughout the dumpster area including gloves and plastic wrap were on the ground.-The vent from the laundry room was blowing lint on the ground outside.-Multiple gloves, screws and various pieces of trash were around the door to the building and the dumpster.Interview and observation on 06/15/26 at 10:23 A.M. with Maintenance Director #305 revealed there was a pillowcase in the grass behind the dumpster and plastic wrap was around a tree. Review of facility policy titled Sanitization with a revision date of November 2022 revealed 14. Garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumpsters/compactors with lids (or otherwise covered). 15. Areas used for garbage disposal are free from odors and waste fats, and maintained to prevent pests.This deficiency represents non-compliance investigated under Complaint Number 2578786.

Based on review of the facility's arbitration agreement and staff interview, the facility failed to ensure its arbitration agreement did not contain any language that prohibits or discourages the resident or anyone else from communicating with federal, state, or local officials and any other relevant advocacy agencies (id est (i.e.) State Survey Agency, Office of the State Long Term Care Ombudsman) regarding the arbitration process and/or outcome of the arbitration settlement. This had the potential to affect all 79 residents residing in the facility. The facility census was 79. Findings Include: Review of the facility's undated arbitration agreement revealed in section 16 titled, Confidentiality, revealed the arbitration shall be confidential and no party (facility or resident) shall disclose any details of the legal controversy, dispute, disagreement or claim between them or the arbitration process in general, without the consent of the other parties. The agreement further noted if necessary to collect an arbitration award through common pleas court, the parties agree to provide minimal details necessary in court pleadings to preserve the confidential nature of the arbitration procedures. The parties understand that confidentiality is one of the primary goals of this agreement and failure to abide by this provision would cause irreparable harm to the parties. Interview with the Administrator on 06/04/25 at 2:30 P.M. verified that facility's arbitration agreement contained language that would discourage residents and/or their representatives from communicating with federal, state, or local officials and any other relevant advocacy agencies (i.e. State Survey Agency, Office of the State Long Term Care Ombudsman) regarding the arbitration process and/or outcome of the arbitration settlement as noted above.

Based on observation and staff interview, the facility failed to ensure its kitchen area was maintained in a clean and sanitary condition. This had the potential to affect all 77 residents receiving food from the kitchen. The facility identified two (#40 and #80) resident who received no food from the kitchen. The facility census was 79. Findings include: Observation during tour of the kitchen, conducted with Dietary Manager (DM) #796 on 06/02/25 from 9:15 A.M. through 9:48 A.M., revealed the the drawer under a food processor had crumbs and dirt in the drawer, one drawer in the food preparation area contained a dirty knife, the drawer with serving utensils had crumbs and debris in the bottom, and there were milk crates with containers of milk stored directly on the refrigerator floor. Further observation revealed there were no testing strips available to check the chemical level of the three-compartment sink or the sanitizer buckets. No staff were able to find any testing strips and there was no record was kept for checking sanitizer levels. Interview with DM #796 verified the above findings during the kitchen tour on 06/02/25 between 9:15 A.M. and 9:48 A.M.

Based on observation, medical record review, staff interview, review of infection control tracking logs and COVID-19 tracking logs, review of the Centers for Disease Control and Prevention documents, and review of facility policies, the facility failed to adequately track infections within the facility and failed to ensure infection control measures were maintained related to obtaining blood glucose levels and proper hand hygiene after resident contact and glove use. This had the potential to affect all 79 residents residing in the facility. The census was 79. Findings included: 1. Review of the COVID-19 tracking log revealed Resident #43, Resident #61, Resident #73, Resident #75, Resident #137, and Resident #236 tested positive for COVID-19 in January 2025, Resident #65 and Resident #68 tested positive for COVID-19 in February 2025, and Resident #237, Resident #238, and Resident #239 tested positive for COVID-19 in March 2025. Review of the infection control logs dated January, February, and March 2025 revealed no documented tracking and/or testing related to COVID-19 and test results for Resident #43, Resident #61, Resident #73, Resident #75, Resident #137, Resident #236, Resident #237, Resident #238, and Resident #239. Interview on 06/05/25 at 3:24 P.M. with the Director of Nursing (DON) revealed she was currently the Infection Control Preventionist (ICP) and there were no current cases of COVID-19 and the last known positive result was in March 2025. The DON revealed the Administrator was responsible for maintaining and tracking the COVID-19 line list. The DON revealed she completed the infection control log at the end of every month for the previous months results and all infections were tracked and listed on the line list and infection control log. The DON revealed without accurate tracking and documentation, facility staff, residents, and visitors were unable to ensure care and services to prevent the spread of COVID-19. The DON confirmed and verified, after review with state surveyor, the COVID-19 line list and infection control logs for January, February, and March 2025 did contain Resident #43, Resident #61, Resident #73, Resident #75, Resident #137, Resident #236, Resident #237, Resident #238, and Resident #239's COVID-19 infections for those months. Review of the Centers for Disease Control and Prevention (CDC) document titled, Infection Control Guidance: SARS-CoV-2, dated 06/24/24, revealed healthcare settings should establish a process to identify and manage individuals with suspected or confirmed COVID-19 infection to prevent transmission to others. Review of the document revealed the facility did not implement infection control practices in the facility to decrease the spread of COVID-19.2. Review of the medical record for Resident #38 revealed an admission date of 04/11/25. Diagnoses included atherosclerotic heart disease and type II diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 had impaired cognition. Observation on 06/03/25 at 8:29 A.M. revealed Registered Nurse (RN) #766 did not perform hand hygiene and gathered supplies to perform a blood sugar test with glucometer. RN #766 applied gloves without performing hand hygiene and entered Resident #38's room and placed the glucometer, lancet, test strips, and alcohol pads on the over bed tray on top of multiple magazines without using a barrier. RN #766 used Resident #38's left hand middle finger to obtain blood for the blood sugar reading. RN #766 then removed her gloves and applied new gloves without performing hand hygiene. Interview on 06/03/25 at 8:40 A.M. with RN #766 verified she did not perform hand hygiene before and after before and after glove usage and she did not use a barrier for the glucometer testing and supplies as she should have. Interview on 06/03/25 at 2:14 P.M. with the Director of Nursing (DON) verified hand hygiene was to be performed before and after glove usage and a barrier was to be placed for glucometer and supplies. Review of facility policy titled, Handwashing/Hand Hygiene, revised August 2019, revealed all personnel shall be trained on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. Use an alcohol-based hand rub or soap and water before and after direct contact with residents, before and after preparing or handling medications, before donning gloves, and after removing gloves. Review of facility policy titled, Infection Control Guidelines for All Nursing Procedures, revised August 2019, revealed employees must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water before and after direct contact with residents, and after removing gloves. In most situations, the preferred method of hand hygiene was with an alcohol-based hand rub for the following situations: before and after direct contact with residents, before preparing or handling medications, after contact with objects such as medical equipment (glucometer), and after removing gloves. Review of facility policy titled, Obtaining a Fingerstick Glucose Level, revised October 2011, revealed the steps in the procedure included to use a disposable cloth (paper towel was adequate) to establish a clean field on the resident's bedside table to overbed table. Place the equipment on the clean field and arrange the supplies so that they can be easily reached. Perform hand asepsis by either washing hands with soap and water or using alcohol-based hand sanitizer, don clean gloves, and remove gloves and perform hand asepsis. This deficiency represents non-compliance investigated under Complaint Number OH00163749.

Based on observation and staff interview, the facility failed to ensure its dryers were free from excessive lint build up. This had the potential to affect all 79 residents. The facility census was 79. Findings include: Observation of the laundry room on 06/09/25 at 4:22 P.M. revealed two of two dryers had a thick layer of lint built up in the lint traps that appeared to be significantly more than one dryer loads worth of lint. Interview on 06/09/25, at the time of the observation, with Housekeeping Director (HD) #799 revealed both dryers had not been cleaned and confirmed and verified the lint build up.

Based on record review and staff interview, the facility failed to ensure the preadmission screen and resident review (PASRR) status was coded correctly on the Minimum Data Set (MDS) assessment. This affected four (#9, #18, #34, and #58) of 23 residents identified by the facility with a level two mental illness currently residing at the facility. The facility census was 79. Findings Include: 1. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, opioid dependence, and delusional disorder. Review of the PASRR level two assessment dated [DATE] revealed Resident #9 had a level two mental illness. Review of section A of the most recent comprehensive Minimum Data Set (MDS) 3.0 assessment of Resident #9 dated 04/03/25 revealed the facility answered No to the question asking, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability (mental retardation in federal regulation) or a related condition? 2. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, suicidal ideations, and adjustment disorder. Review of the PASRR level two assessment dated [DATE] revealed Resident #18 had a level two mental illness. Review of section A of the most recent comprehensive MDS 3.0 assessment of Resident #18 dated 09/19/24 revealed the facility answered No to the question asking, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability (mental retardation in federal regulation) or a related condition? 3. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia, muscle weakness, and chronic obstructive pulmonary disease. Review of the PASRR level two assessment dated [DATE] revealed Resident #34 had a level two mental illness. Review of section A of the most recent comprehensive MDS 3.0 assessment of Resident #34 dated 02/22/25 revealed the facility answered No to the question asking, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability (mental retardation in federal regulation) or a related condition? 4. Review of the medical record revealed Resident #58 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, hypertension, and muscle weakness. Review of the PASRR level two assessment dated [DATE] revealed Resident #58 had a level to mental illness. Review of section A of the most recent comprehensive MDS 3.0 assessment of Resident #58 dated 08/06/24 revealed the facility answered No to the question asking, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability (mental retardation in federal regulation) or a related condition? Interview with MDS Nurse #762 on 06/04/25 at 3:00 P.M. verified Resident #9, Resident #18, Resident #34, and Resident #58 all were determined to have a level two mental illness by the state and confirmed the residents' PASRR statues were inaccurately assessed on their MDS assessments.

Based on observation, resident interview, staff interview, and medical record review, the facility failed to ensure preferences were followed regarding application of compression bandages. This affected one (#41) of one resident reviewed for preferences. The facility census was 79. Findings include: Review of the medical record for Resident #41 revealed he was admitted to the facility on [DATE] with diagnoses that included cellulitis, heart failure, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 had a Brief Mental Status (BIMS) score of 12 that indicated he had moderate cognitive impairment. Review of the MDS assessment revealed Resident #41 required some assistance from staff for activities of daily living (ADLs). Review of the physician orders dated 12/05/24 revealed Resident #41 had an order in place to apply ACE wraps (compression bandages) to bilateral lower extremities before rising and remove at night two times a day for compression therapy and document refusals. Review of the care plan dated 04/30/25 revealed Resident #41 had skin impairment with interventions that included to monitor and treat as ordered. Review of the electronic medication administration record (EMAR) note dated 05/07/25 at 5:50 A.M. revealed Resident #41 refused to have ACE wraps applied due to wanting them applied after his shower. Review of the EMAR note dated 05/14/25 at 6:25 A.M. revealed Resident #41 refused to have ACE wraps applied after his shower. Review of the EMAR note dated 05/17/25 at 6:36 A.M. revealed Resident #41 refused to have ACE wraps applied and wanted them after his morning shower. Review of the EMAR note dated 05/27/25 at 6:27 A.M. revealed Resident #41 refused his ACE wraps due to wanting to take his shower first before having them applied. Review of the EMAR note dated 05/28/25 at 6:53 A.M. revealed Resident #41 wanted his ACE wraps applied after his shower. Interview and observation on 06/02/25 at 2:11 P.M. with Resident #41 revealed staff were to wrap his legs twice a day, but they were not doing it. Resident #41 revealed he preferred his legs to be wrapped after he took his shower due to not having the wraps get wet or having to apply and reapply. Resident #41 lower bilateral legs appeared red in color and swollen. Interview on 06/02/25 at 2:21 P.M. with Certified Nurse Aide (CNA) #710 revealed Resident #41 preferred to have his legs wrapped after his showers, but nurses did not always follow his preference. Interview and observation on 06/02/25 at 3:06 P.M. with Resident #41 and the Director of Nursing (DON) revealed Resident #41 was seated at the reception desk in his wheelchair. Resident #41's legs were observed to be unwrapped with a knee patch dated 06/02/25, for the current date. Resident #41 revealed he had a shower, but his legs were not wrapped, as preferred, but staff applied his other dressing. Resident #41 revealed due to wanting his legs wrapped after his shower, staff did not apply them because they wanted to do it in the early morning. The DON stated Resident #41 refused to have his legs wrapped; however, Resident #41 intervened and stated he refused to have his legs wrapped before his showers due to wraps getting wet or ruined and it made sense to apply after being showered and dressed. The DON confirmed and verified Resident #41 legs were not wrapped and staff were not honoring his preferences.

Based on medical record review, resident and resident representative interview, staff interviews, and facility policy review, the facility failed to ensure requests for medical records were honored in a timely manner. This affected one (#78) of one residents reviewed for medical record requests. The facility census was 79. Findings include: Review of the medical record for Resident #78 revealed she was admitted to the facility on [DATE] with diagnoses that included encephalopathy, mesothelioma, and type II diabetes. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #78 had a Brief Interview for Mental Status (BIMS) score of six that indicated the resident was cognitively impaired. Review of the MDS assessment revealed Resident #78 required some assistance from staff for activities of daily living (ADLs). Review of the progress note dated 05/28/25 at 12:31 P.M. revealed Registered Nurse (RN) #746 discussed with Resident #78 and Resident #78's sister a request for medical records. Review of the progress note dated 05/29/25 at 12:26 P.M. revealed RN #746 spoke with Resident #78's elderly advocate, who was in the process of obtaining guardianship, in regard to requested medical records. Review of the progress note dated 05/29/25 at 3:04 P.M. revealed Resident #78's elderly advocate called demanding copies of Resident #78 requested medical records. Review of the progress note dated 05/30/25 at 10:46 A.M. revealed RN #746 talked to Resident #78 about signing a release for medical records in accordance to facility policy. Resident #78 refused to sign form. Review of the progress note dated 05/30/25 at 1:24 P.M. revealed the Administrator spoke with Resident #78's elderly advocate in regard to release of medical records. Resident #78's elderly advocate informed the Administrator that Resident #78 would sign the form in her presence. The Administrator stated the facility would be following facility protocols in regard to medical records release. Review of the progress note dated 06/05/25 at 1:11 P.M. revealed RN #746 informed Resident #78 she could review her medical records with her but Resident #78 refused. RN #746 revealed Resident #78's release for copies of her medical record would be available on 06/06/25. Review of the progress note dated 06/06/25 at 12:49 P.M. revealed Resident #78 was given her medical records which were approved by the corporate compliance office. Interview on 06/05/25 at 1:23 P.M. with Resident #78's elderly advocate revealed she and Resident #78 had been attempting to obtain Resident #78 medical records to continue the process of discharge and getting services in place required in the community. Resident #78's elderly advocate revealed Resident #78 signed medical record release form and also requested copies to be given to her; however, the facility refused to provide requested information. Interview on 06/05/25 at 3:47 P.M. with RN #746 revealed if a resident requested medical records, there was a form to sign, which was then sent to the corporate compliance office and returned within 48 to 72 hours. RN #746 revealed Resident #78 requested her medication and treatment administration record but was denied by the corporate compliance office. RN #746 stated she was informed by the corporate compliance office that resident medication and treatment administration records are not provided regardless if requested or placed on the medical release form. RN #746 revealed she did what the corporate compliance office told her to do. RN #746 confirmed and verified Resident #78 requested her full and complete medical record and was not being provided with the medication and treatment administration records. Interview on 06/09/25 at 12:15 P.M. with Resident #78 and Resident #78's elderly advocate revealed Resident #78 was given some of her medical records but not what was requested. Interview revealed Resident #78 requested her medication administration records and treatment administration records and was denied access to both. Follow-up interview on 06/09/25 at 2:03 P.M. with RN #746 revealed she provided Resident #78 with her medical records on 06/06/25. RN #746 revealed she only provided Resident #78 with what she was told to give by the corporate compliance office. RN #746 confirmed and verified Resident #78 did not receive all of her requested medical record including the medication and treatment administration records. Interview on 06/09/25 at 3:03 P.M. with the Administrator revealed residents were allow to request their medical records by completing the medical release form. The Administrator revealed once the form was sent to the corporate compliance office and/or legal counsel, they decided what the resident could have. The Administrator confirmed and verified the medication and treatment administration records were not able to be released to residents per corporate and legal counsel. Review of the facility document titled, Release of Information, revised November 2009, revealed the facility had a policy in place that all information contained in the medical record were confidential and only released by the written consent of the resident and/or legal representative, can be released to anyone the resident wishes, and may have access within 24 hours after request and hard copies after 48 hours.

Based on record review and staff interview, the facility failed to ensure Notice of Medicare Non-Coverage (NOMNC) documents contained all required information. This affected three (#12, #75, and #139) of three residents reviewed for beneficiary notices. The facility census was 79. Findings Include: 1. Review of Resident #12's NOMNC form for services ending 02/26/25, and signed 02/21/25, revealed the notice contained no specific information about what services would be discontinued. 2. Review of Resident #75's NOMNC form for services ending 02/17/25, and acknowledge by the resident's family via telephone on 02/13/25, revealed the notice contained no specific information about what services would be discontinued. The area on the form that discussed which services would be discontinued was blank. 3. Review of Resident #139's NOMNC form for services ending 04/08/25, and signed 04/06/25, revealed the notice contained no specific information about what services would be discontinued. The area on the form that discussed which services would be discontinued was blank. Social Service Designee #782 verified the NOMNC forms for Resident #12, Resident #75, and Resident #139 lacked specific information about what services were being discontinued in an interview on 06/05/25 at 3:30 P.M.

Based on medical record review, resident and staff interview, and Ombudsman interview, the facility failed to facilitate an orderly discharge when necessary medical supplies were not provided timely to a resident upon discharge. This affected one (#136) of four residents reviewed for discharges. The facility census was 79. Findings include: Review of the medical record for Resident #136 revealed an admission date of 01/31/25. The resident was discharged home on [DATE]. Diagnoses included acute respiratory failure with hypoxia, pneumonia, morbid obesity, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment, dated 03/24/25, revealed Resident #136 had intact cognition. Review of the physician order dated 03/17/25 revealed an order for oxygen at one to six liters via nasal cannula for the resident to maintain an oxygen saturation rate greater than or equal to 92 percent (%) every six hours as needed for cough, shortness of breath, wheezing, or resident request. Review of the clinical nurse practitioner (CNP) progress note dated 03/28/25 at 5:34 P.M. revealed Resident #136 was seen regarding her request for discharge from the facility. The resident would benefit from remaining in long-term care (LTC) but was insisting on leaving. The resident was educated on the benefits of remaining in the facility but was adamant about leaving. The resident was on supplemental oxygen and lung sounds were diminished throughout all fields. Review of the physician order dated 03/28/25 revealed an order that Resident #136 may discharge home on [DATE] with home health care, physical therapy, occupational therapy, speech therapy, nursing, and oxygen in place. Review of the discharge planning note dated 03/29/25 at 1:36 P.M. revealed Resident #136 was discharged home at 1:20 P.M. with her sister. Discharge instructions and prescriptions were explained and given to the resident along with a portable oxygen tank. Resident #136 did not express any concerns at that time. Review of the social services note dated 04/02/25 at 12:00 P.M., which was a late entry documented on 04/10/25 at 7:10 A.M., revealed the medical services/equipment company called back and informed Registered Nurse (RN) Manager/Social Service Designee (SSD) #746 that since the company did not follow-up with the facility and Resident #136 discharged on Saturday, RN/SSD #746 had to go to another oxygen company. Review of the social services note dated 04/01/25 at 2:00 P.M., which was a late entry documented on 04/10/25 at 7:08 A.M., revealed RN/SSD #746 was informed the insurance company for Resident #136 called due to oxygen not being delivered. RN/SSD #746 called the initial medical company and was told to leave a message, and they would get back in 24 hours. RN/SSD #746 called a different company, sent a facsimile (fax) of the discharge order information to them and Resident #136 was set up with oxygen within two hours of the company getting the paperwork. Review of the interdisciplinary Discharge summary dated [DATE] revealed the scripts for medications were sent with Resident #136. Pharmacy, home care services, and medical equipment, including supplemental oxygen were arranged. A telephone number to call was given and discharge instructions were explained. Under the Comments section it was stated the company was unable to deliver supplemental oxygen, a call was placed to a new company, and the oxygen was delivered. Interview on 06/04/25 at 3:45 P.M. with the Ombudsman revealed their office had been actively involved with Resident #136's discharge situation. The Ombudsman stated the resident's oxygen was ordered late Friday, 03/28/25 and information was sent to a durable medical equipment (DME) supplier. Resident #136 was anxious to get home on that Saturday. The resident was given a portable oxygen tank by the facility to take home since no oxygen was at home at the time of discharge. The oxygen never came on Monday and Resident #136 ended up calling another company to get oxygen on Tuesday. Interview on 06/05/25 at 12:14 P.M. with RN/SSD #746 revealed she sent the script for the oxygen to the DME supplier on 03/28/25 in the morning. The supplier called her back because they were having trouble reading/understanding the script. The RN/SSD had to read them the script and after it was read to them, they said every thing was okay. RN/SSD #746 stated the company did not say they could not supply the oxygen and did not say they needed a new script. The company did not call back so RN/SSD #746 thought everything was set. The DME supplier never contacted the facility and said the oxygen could not be sent. Resident #136 had not called and said the oxygen had not been delivered. Interview on 06/05/25 at 12:35 P.M. with the prior Administrator revealed the facility had a conversation with Resident #136 on Thursday 03/28/25. The resident was packed and ready to go. The prior Administrator also spoke with Resident #136's sister. The sister agreed the resident should stay longer for everything to be arranged. The resident said she was leaving Saturday no matter what because they could get the oxygen right away, they had the physician approve the concentrator to be sent home with the resident. On 06/05/25 at 12:40 P.M. RN/SSD #746 verified she did not confirm when the oxygen was to be delivered or called to confirm it had been delivered. RN/SSD #746 confirmed the second DME supplier was contacted on Tuesday, 04/01/25 and Resident #136 did not have oxygen on Saturday, Sunday, Monday, or Tuesday until the oxygen delivery. Interview on 06/05/25 at 2:17 P.M. with Resident #136 stated she called the facility over the weekend and got no answers, so the resident called the company for supplemental oxygen. This deficiency represents non-compliance investigated under Master Complaint Number OH00164296 and Complaint Number OH00162914.

Based on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure residents were provided with appropriate incontinence and perineal care. This affected one (#4) of two residents reviewed for bowel and bladder. The facility census was 79. Findings included: Review of the medical record for Resident #4 revealed an admission date of 03/19/25. Diagnoses included chronic obstructive pulmonary disease, pain in the right hip, and repeated falls. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had intact cognition. Review of the bladder and bowel section revealed Resident #4 was always incontinent of bladder and bowel. Review of the care plan dated 04/03/25 revealed Resident #4 had self-care performance deficits with an intervention to assistance with toileting. Observation on 06/05/25 at 9:29 A.M. of perineal care for Resident #4 revealed Certified Nurse Aide (CNA) #703 gathered supplies, knocked on the door, provided privacy, and explained the procedure to the resident. CNA #703 used hand sanitizer from her pocket and donned gloves. CNA #703 placed four (4) washcloths in the bottom of the resident's sink with running water. CNA #703 then applied shampoo and body wash directly to the washcloths in the bottom of the sink with running water. CNA #703 then picked up the washcloths from the bottom of the sink and placed them in a basin with water. CNA #703 placed the basin on the resident's chair in her room. CNA #703 began to provide perineal care to Resident #4 and used one washcloth from the soapy water basin to cleanse the peri area. CNA #703 then used one washcloth from the soapy water basin for her rinse washcloth, then assisted Resident #4 to turn without patting the peri area dry. CNA #703 then removed one washcloth from the soapy water basin and cleansed the resident's buttocks. CNA #703 then removed one washcloth from the soapy basin to provide the rinse to buttocks. CNA #703 did not pat the resident's buttocks area dry. CNA #703 placed a new incontinence brief on Resident #4, positioned her, and placed call light in reach. CNA #703 doffed her gloves and performed hand hygiene. Interview on 06/5/24 at 9:35 A.M. with CNA #703 verified she did not perform the perineal care correctly. CNA #703 verified she should not have placed the clean washcloths in the bottom of the sink and she should have used the soap washcloths separate from the rinse washcloths. Interview on 06/05/25 at 10:20 A.M. with Registered Nurse (RN) Unit Manager #775 verified CNA #703 should not have placed the washcloths at the bottom of the sink due to infection control issues. RN Unit Manager #775 reported CNA #703 should have used one basin for soapy water and one basin for clean water and place the basins on the over bed tray per the policy. Review of facility policy titled, Perineal Care, revised February 2018, revealed the procedure was to place the equipment on the bedside stand and fill the wash basin one-half full of warm water and wet the washcloth and gently rinse and dry the area. This deficiency represents non-compliance investigated under Complaint Number OH00162914.

Based on review of personnel records and staff interview, the facility failed to ensure its certified nurse aides (CNAs) received 12 hours of in-service training per year as required. This had the potential to affect all 79 residents. The facility census was 79. Findings Include: 1. Review of the personnel record for CNA #713 revealed a hire date of 05/01/24. Review of in-service records from 05/01/24 through 05/01/25 revealed CNA #713 received 4.5 hours of in-service training all of which took place in the year 2025. 2. Review of the personnel record for CNA #740 revealed a hire date of 04/08/24. Review of in-service records from 04/08/24 through 04/08/25 revealed CNA #740 received 4.5 hours of in-service training all of which took place in the year 2025. Interview with the Administrator on 06/09/25 at 2:00 P.M. verified the lack of required in-services hours for CNA #713 and CNA #470. The Administrator further noted the facility had no evidence of education of in-services for CNAs prior to the year 2025.

Based on medical record review, observation, interview, and facility policy review, the facility failed to ensure the complete physician-ordered treatment was applied to Resident #20's sacral pressure ulcer. This affected one (Resident # 20) of three residents reviewed for wound care. The facility census was 87. Findings include: Review of the medical record for Resident #20 revealed an admitted [DATE] with diagnoses including iron deficiency anemia, obesity, surgical wound, atrial fibrillation, rheumatoid arthritis, pressure ulcer of sacral region, surgical aftercare following surgery on the digestive system. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 had intact cognition and had moderate depression. The resident was dependent on staff for activities of daily living. Review of the January 2025 physician's orders revealed Resident #20's had an order dated 12/02/24 for a wound dressing for a sacral pressure ulcer. The order called for the wound to be cleansed with normal saline, packed with silver alginate, covered with an absorbent pad, secured with paper tape, and changed daily. Additional instructions in the order included to apply zinc ointment around the sacral pressure ulcer daily. Review of the Treatment Administration Record (TAR) for January 2025 revealed Resident #20's sacral wound care was listed as completed daily as ordered. Review of the weekly wound assessment dated [DATE] revealed Resident #20 had a stage four pressure ulcer(indicating a full thickness wound which can extend into muscle, tendon, ligament, cartilage, or bone) to her sacrum. The assessment indicated the wound was healing. The listed treatment included cleanse the wound, apply silver alginate, cover with an absorbent pad, secure the wound with paper tape, and change daily. The assessment indicated triad cream (a zinc-oxide-based paste which can be applied to wounds to encourage healing or to intact skin to protect skin from irritation) was to be applied to the skin surrounding the wound. Observation on 01/22/25 at 2:41 PM with Licensed Practical Nurse (LPN) #288 who completed Resident #20's wound care revealed LPN #288 first prepared to change the resident's sacral wound. LPN #288 removed the old dressing, cleansed the wound with normal saline and packed the wound with silver alginate. LPN #288 then covered the wound with an absorbent pad and secured the dressing with paper tape. LPN #288 did not apply zinc or any cream or ointment to the skin surrounding the resident's wound. Interview on 1/22/25 at 3:00 P.M. with LPN #288 verified she did not apply zinc around the sacrum wound. LPN #288 confirmed the physician's order called for zinc to be applied, but stated if zinc was applied, the tape wound not adhere to the resident's skin. Review of the policy titled Wound Care, revised October 2010, revealed to verify that there is a physician's order for the procedure, and to ensure that the physician order matches the wound Nurse Practitioner (NP) order. This deficiency represents non-compliance investigated under Master Complaint Number OH00161530.

Based on observation, staff interview and policy review, the facility failed to ensure its kitchen area was maintained in a clean and sanitary condition. This had the potential to affect all residents. The facility census was 90. Findings include: Observation of the kitchen area on 12/15/24 between 7:30 A.M. and 8:00 A.M. with Dietary Aides (DA) #600 and #601 revealed the following that was verified at the time of discovery; - A large puddle of water was noted in the facility's dishwasher area. DA #600 explained that a drain to the dishwasher had not been working for some time. DA #600 estimated months and thus created a pool of water in the area. - The sanitizer bucket underneath the dishwasher was open and had a swarm of fruit flies around the lid of the bucket. - A package of bacon was observed to be defrosting in the warming area underneath the steam table. The bacon was noted to be lying in a pool of water on the steam table that was yellow in color and had many noticeable food particles floating in the water. - The left side door of the facility's convection oven was completely stained with grease to the extent you could not see in or out of the door. - The hood suppression system had noticeable buildup of grease and rust. - The area beneath the coffee pots in the kitchen was leaking water from an unknown source. - In the walk-in cooler, a rotten green bell pepper, a package of brown (discolored) celery, three undated peanut butter and jelly sandwiches, and two undated ham and cheese sandwiches were noted. - In the dry storage area, an undated container of cherries and two undated and opened bottles of vanilla extract were noted. Review of the policy entitled Preventing Foodborne Illness-Food Handling dated 07/01/14 revealed food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. This deficiency represents non-compliance investigated under Complaint Number OH00160140.

Based on observation and staff interview the facility failed to ensure its dumpster area was maintained in a clean and sanitary condition. This had the potential to affect all residents. The facility census was 90. Findings include: Observation of the dumpster area with Dietary Aide # 601 on 12/15/24 at 9:05 A.M. revealed multiple areas of food debris, plastic gloves, and other numerous instances of other trash/refuse. DA #601 verified the condition of the dumpster area on 12/15/24 at 9:07 A.M. DA #601 stated (while smiling) cant say I am surprised. This deficiency represents an incidental finding of non-compliance discovered during the complaint investigation.

Based on record review and interview the facility failed to ensure Resident #65's concern was addressed promptly. This affected one resident (#65) of three residents reviewed for grievances. The facility census was 87. Findings Include: Review of the medical record for Resident #65 revealed an admittance date of 06/29/20. Diagnoses included dementia, depressive disorder, bipolar, psychosis, schizoaffective disorder, alcohol abuse. Review of the concern log form dated 03/11/24 through 10/30/24 revealed no identified concerns for Resident #65. Review of the email correspondences dated 10/10/24 at 10:49 A.M. through 10/29/24 at 10:59 A.M. between Resident #65's sister, Resident #65's Power of Attorney (POA), the Director of Nursing (DON), Administrator, and the ombudsmen revealed Resident #65's sister emailed the above recipients regarding concerns that occurred on 10/05/24 when Resident #14 threw a dish towards Resident #65 and on 10/08/24 when Resident #14 pulled Resident #65's private caregiver's hair. The email stated Resident #65's sister and Resident #65's POA would be available for a group call. On 10/25/24 at 10:26 P.M. Resident #65's sister sent a second email stating she was following up with concerns expressed on 10/10/24 and had not received a response by email or nor phone call. On 10/26/24 at 7:31 P.M. the Administrator responded stating she was sorry it took some time to respond but she been in and out of the building due to the Jewish holiday this month. Resident #65's sister and POA are welcome to call the facility next time and request to speak with someone if needed a timelier response. The incident was reported to the Resident #14's representatives and the facility was dealing with them regarding the next step. Interview on 10/31/24 at 11:00 A.M. with the Administrator stated due to the Jewish holiday she was in and out of the facility. Resident's 56's sister could have called the facility to talk to someone or she could have texted if she needed a timely response. The Administrator did verify the email was received on 10/10/24 and she did not respond until 10/26/24. Interview on 11/03/24 at 11:05 A.M. with the Director of Nursing (DON) stated she did not want to respond to the email in fear it would exoculate Resident #65's sisters concerns. Review of the facility policy titled Resident Rights dated January 2022, stated voiced grievances to the facility or those agency/entity that hears grievances without discrimination or reprisal, including those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other resident, and other concerns regarding their long-term care facility stay. The facility must make prompt efforts to resolve grievance. This deficiency represents non-compliance investigated under Complaint Number OH00158843.

Based on observation, closed medical record review, hospital record review, review of a police report, review of staff witness statements, review of the facility elopement policy and procedure and interviews, the facility failed to provide adequate supervision to prevent Resident #84, who had a diagnosis of dementia with behavioral disturbances and lacked sufficient decision-making ability to make an informed decision to leave the facility, from eloping from the facility. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm on 11/12/23 at approximately 4:30 P.M. when Resident #84 who had been agitated, verbally abusive and combative since the lunch meal packed her bags, placed them on a wheelchair and walked through an unidentified secured door pushing the wheelchair to the outside without staff knowledge. The facility staff were not aware Resident #84 was missing until Resident #84's daughter called the facility on 11/12/23 around 5:00 P.M. and reported Resident #84 was with her at her workplace. Resident #84 walked about a half mile along a busy road, crossed a major intersection, and walked across a busy shopping area to reach her daughter's workplace. The facility staff were unable to transport Resident #84 back to the facility. Resident #84 was agitated and potentially combative and a family member contacted the police for assistance. Resident #84 was transported at 5:59 P.M. by police officers to the local hospital for evaluation. This affected one resident (#84) of three reviewed for elopement. On 11/27/23 at 1:25 P.M. the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 11/12/23 at approximately 4:30 P.M. when Resident #84 packed her bags, placed them on a wheelchair and walked through an unidentified secured door pushing the wheelchair along a busy road, crossed a major intersection and walked across a busy shopping area to her daughter's workplace. Staff were unaware Resident #84 eloped from the facility at the time of the incident. The Immediate Jeopardy was removed on 11/13/23 when the facility implemented the following corrective actions: On 11/12/23, at 5:00 P.M., after Resident #84 was reported missing by her daughter, Registered Nurse (RN) #292 and Licensed Practical Nurse (LPN) #299 did a head count of all other residents, all other 81 residents were present. The Unit Manager, DON, and the Administrator were all notified. On 11/12/23, by 7:00 P.M. the DON collected statements from the four nurses and the six STNA's (State tested Nursing Assistant's) who were present in the facility at the time Resident #84 left. On 11/12/23, the DON (Director of Nursing) and LNHA (Administrator) investigated the incident as a possible elopement. By 11:00 P.M., after interviewing staff and collecting staff statements, the facility concluded Resident #84 had a Brief Interview for Mental Status (BIMS) of 14 out of 15, was alert and oriented times four, had a low risk elopement assessment, had displayed the desire to go home, initiated a call to family requesting to be picked up, when no one was willing to pick her up, resident decided to leave the facility and walk to her daughter's place of work. On 11/12/23, by 11:00 P.M., the DON and Unit Managers ensured all residents had current elopement assessments completed. Residents who were assessed to be high risk and had displayed exit seeking behavior, had wander guards in place and care plans had been updated. On 11/12/23, by 11:00 P.M., the DON ensured all wander guards were in place and functioning for the residents that were assessed, care planned, and had orders. There were six residents that were assessed and had orders for wander guards. No issues were identified. On 11/12/23, by 11:00 P.M. an elopement binder at the front desk was updated by the DON with residents assessed to be an elopement risk. There were six residents assessed to be high risk. On 11/12/23, by 11:00 P.M. DON checked all doors to ensure they were functioning properly. All doors were functioning, and alarming if pressed to exit with a 15 second egress. The front door was open during the hours a receptionist was present and then locked like the other doors when receptionist leaves. If a door was seen to have an issue, the alarm company was called immediately to be addressed. Wind caused issues on 11/27/23 for two doors and Maintenance Director #264 called the alarm company. The alarm company came to the facility on [DATE] and replaced the transformers for mag locks due to high winds. On 11/12/23, by 11:00 P.M. all facility staff were educated by DON on the elopement policy and AMA policy. Policies included education for investigating, exit seeking behavior, safety, and reporting to LNHA and DON so corrective measures and interventions could be put into place. Staff from every department were educated including four RN's, seven LPNs, and twenty STNAs. Staff that were not present were called, texted, and educated by the evening of 11/12/23. On 11/12/23, by 11:00 P.M. nursing schedules were checked and verified by DON to ensure sufficient staffing was present for shift 7:00 A.M. to 7:30 P.M. There were four LPN's and six STNA's. On 11/12/23, by 11:00 P.M. the three facility receptionists were educated by LNHA (the Administrator) on notifying staff if they were on break so another staff member could cover the front desk. On 11/12/23, LNHA began auditing doors, elopement assessments to ensure completion and interventions were in place, nursing documentation for exit seeking behavior, three times a week for three weeks to ensure continued compliance. All results would be reviewed with the QAPI committee to ensure continued compliance. Although the Immediate Jeopardy was removed on 11/13/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was not in substantial compliance at the time of the current survey for the specific regulatory requirement(s), as referenced by the specific tag. Findings include: Review of Resident #84's ED (Emergency Department) Provider Note and History and Physical Exam dated 09/21/23 included Resident #84 was transported to the hospital Emergency Department via ambulance and was accompanied by her niece and daughter. Resident #84's niece stated Resident #84 was unable to care for herself, her house was unsanitary, unkept and she was being evicted. Resident #84's niece and daughter stated Resident #84 was not eating or drinking and was incontinent. Resident #84's niece and daughter requested a competency evaluation completed so Resident #84 could be placed in an assisted living or skilled nursing facility. Resident #84's niece and daughter did not feel Resident #84 could live safely on her own and were concerned Resident #84 was going to get hurt. Resident #84 was alert, agitated and her judgement was inappropriate (her main concern was care for her dogs when she was not taking care of herself). As Resident #84 was at risk for being discharged home and displayed failure to thrive and inability to care for self, the plan would be to admit Resident #84 to the hospital for further evaluations. Resident #84 had a history of delirium and neuro cognitive disorder (dementia). Review of Resident #84's After Visit Summary dated 09/21/23 through 09/26/23 included Resident #84 was seen in the Emergency Department for concerns of not managing home life. Resident #84 was admitted to the hospital due to failure to thrive. After admission to the hospital Resident #84 was evaluated by a geriatric team who felt Resident #84 was not able to make home-going decisions. Due to this, Adult Protective Services (APS) was involved and felt Resident #84 should be discharged to an extended care facility. Problems and diagnoses included failure to thrive in adult, major neurocognitive disorder (HCC), generalized weakness and encounter for assessment of decision-making capacity. Resident #84 had no resolved hospital problems. A new medication, Seroquel (Quetiapine) 12.5 milligrams daily at bedtime for three doses, and then 0.5 tablet by mouth every eight hours as needed for agitation up to three days was ordered. Review of Resident #84's Mental Capacity Note dated 09/25/23 stated Resident #84 had a primary diagnosis of delirium and psychoses and lacked sufficient decision-making ability to make informed decisions to leave the hospital. The note indicated Resident #84 should not be allowed to leave the hospital against medical advice. Resident #84 should be stabilized medically until a clinical point was reached where she could be reevaluated. An attempt would be made to identify an appropriate surrogate decision maker to be an active participant in the Resident #84's care. Review of Resident #84's closed medical record revealed the resident was admitted to the skilled nursing facility on 09/26/23 with diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbances, major depressive disorder, unsteadiness on feet, and adult failure to thrive. Resident #84 was discharged from the facility on 11/12/23. Review of Resident #84's Admission progress note dated 09/26/23 at 3:56 P.M. included Resident #84 was alert and oriented times two (person and place), was confused at times and made poor decisions. Resident #84 was anxious and had behaviors. Resident #84 was in the hospital for failure to thrive, lived by self and had dementia. APS was involved. Resident #84 was incontinent at times. Review of Resident #84's Fall Risk Evaluation dated 09/26/23 revealed Resident #84 was at high risk for falls. Resident #84 received antidepressants, antihypertensives, hypoglycemics, laxatives and narcotic analgesics. Resident #84 ambulated with staff assistance with no stability, gait impairment. Resident #84's elimination status was elimination with assistance. Review of Resident #84's progress notes dated 09/27/23 at 11:27 P.M. included Resident #84 was having erratic behavior, was unable to be redirected, was touching another resident's catheter, going in other resident rooms and was combative with staff. Review of Resident #84's Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #84 was cognitively intact and used a walker. Resident #84 required partial to moderate assistance with personal hygiene and required supervision or touching assistance to walk ten feet in a room, corridor, or similar space. Resident #84 had non-Alzheimer's dementia. Review of Resident #84's Family, Resident Communication Note dated 10/05/23 at 2:46 P.M. included a family conference was held with the DON, Director of Rehab (DOR), the Administrator, Resident #84 and Resident #84's niece, Daughter #291 and son in-law. Discussed Mental Capacity Note completed while she was in the hospital by Certified Nurse Practitioner (CNP) #290. APS was involved when Resident #84 resided in the community. Daughter #291 was the resident's power of attorney (POA) for health and was working to get a guardianship in place. Resident #84 was notified by her family she would be staying at the facility, her house was foreclosed, and her animals were placed in foster homes. Resident #84 stated her pets were the most important thing to her. Review of Resident #84's progress note dated 10/05/23 at 4:44 P.M. included Resident #84 continued to be very agitated and difficult to redirect. Resident #84 stated she was leaving the facility. Discussed wander guard with Daughter #291 and other family members and all were in agreement with a wander guard being placed. Review of Resident #84's Elopement Evaluation dated 10/05/23 included Resident #84 had a Neurocognitive Disorder with Lewy Bodies (the Administrator stated Resident #84 had a Neurocognitive Disorder, but her diagnoses did not specify Lewy Bodies, and this diagnosis was an error), was alert, had poor safety, environment awareness and had one elopement in the past three months. A wander guard was placed to Resident #84's right ankle. Daughter #291 was one hundred percent agreeable to having Resident #84's wander guard placed. Resident #84 was non-compliant consistently and would be at a higher risk of removing the wander guard. Review of Resident #84's physician orders dated 10/05/23 revealed secure band to right ankle, check placement, skin, every shift for elopement risk related to Neurocognitive Disorder with Lewy Bodies (Resident #84 had a Neurocognitive Disorder but it did not specify Lewy Bodies). Further review revealed to discontinue physical therapy (PT) services. Resident #84 required supervision for transfers and ambulation with wheeled walker. Review of Resident #84's Physical Therapy Discharge Summary signed 10/05/23 at 12:00 P.M. included discharge recommendations were for 24-hour care, assistive device for safe functional mobility and functional mobility program (FMP), restorative nurse program (RNP). RNP, FMP to facilitate patient maintaining current level of performance and to prevent decline, development and instruction in the following RNPs was completed with the interdisciplinary team (IDT), ambulation and active range of motion (ROM). Review of Resident #84's progress notes dated 10/09/23 included Resident #84 had constant exit seeking behaviors but was easily redirected. Review of Resident #84's progress notes dated 10/13/23 at 1:03 P.M. included a call was placed to Daughter #291's with an update on Resident #84's wander guard and Resident #84's noncompliance. Daughter #291 agreed to leave Resident #84's wander guard off. Review of Resident #84's care plan dated 10/13/23 included Resident #84 exhibited behaviors related to dementia. Resident #84 would go into other residents' rooms and touch their belongings, she would touch other resident's catheter, and was combative with care at times. Resident #84 would exhibit behaviors one time a week. Interventions included staff to monitor Resident #84 closely, for example, sitting outside her room for a while. There were no further interventions documented after Resident #84's wander guard was discontinued on 10/13/23. There was no care plan for a wander guard or risk of elopement. Review of Resident #84's Social Services progress note dated 10/23/23 at 4:02 P.M. included Resident #84 was anxious, confused and upset. Resident #84 was throwing her belongings away in the garbage and stated she was going home. Social Services Designee (SSD) reminded Resident #84 her home was foreclosed, and the APS worker was in the process of establishing a guardian for her. Resident #84 was told a doctor completed an expert evaluation during her hospitalization prior to her admittance to the facility. Review of Resident #84's progress notes dated 10/23/23 at 10:18 P.M. included Resident #84 had balance problems and an unsteady gait. Resident #84 appeared upset after finding out her house was in foreclosure per Daughter #291. Review of Resident #84's Long Term Care Encounter note dated 11/01/23 written by Psychiatric Certified Nurse Practitioner (CNP) #296 included Resident #84 was seen in her room, resting in bed and watching television. Resident #84 was alert and oriented to self, location, time and date of birth. Resident #84 stated she was waiting to die, was stuck in the facility and did not have her house or stuff. Resident #84 voiced anger towards Daughter #291 because she gave away her cat and two dogs and sent her to the facility to die. Resident #84 endorsed depression and anxiety and stated she did not choose or prepare to be here. No delusions were noted. Staff reported Resident #84 was stable. Resident #84 refused to take showers, have laundry done, declined medication adjustments and would be referred for counseling. Resident #84's problems included adjustment disorder with mixed anxiety, depressed mood and unspecified dementia, unspecified severity with other behavioral disturbances. Review of Resident #84's Skilled Nursing Evaluation dated 11/07/23 included Resident #84 Resident #84 was alert and oriented to person, place, time, and situation and did not have neuromuscular disorder. Review of Resident #84's progress notes dated 11/12/23 from 12:00 P.M. through 5:00 P.M. revealed there was no documentation Resident #84 was agitated, upset, attempted to hit a nurse with her cane, and stated she wanted to go home. There was no evidence interventions were implemented. Review of Resident #84's progress notes dated 11/12/23 at 6:56 P.M. revealed prior to Registered Nurse (RN) #292's lunch break Resident #84 was sitting on the side of the bed in her room. RN #292 informed Nurse #293 she was going to take a meal break. When she returned from lunch RN #292 was told Resident #84 tried to hit Nurse #293 with a cane. RN #292 went to Resident #84's room and was unable to locate her. When RN #292 returned to the nurse's station she was told by the Receptionist (Receptionist #272) that Resident #84's family member (Daughter #291) was on the phone and wanted to speak with her. Daughter #291 told RN #292 that Resident #84 was with her and had a wheelchair and her suitcase and she would call RN #292 back. RN #292 informed management and also notified CNP #294. A follow up call placed to Daughter #291 revealed Resident #84 was transported to the local hospital. Management was notified. Review of a witness statement dated 11/12/23 and written by Licensed Practical Nurse (LPN) #293 revealed Resident #84 was angry after lunch and stated she hated her food, and the barbecue sauce was nasty. Resident #84 became verbally abusive and combative with the staff and attempted to hit a staff member with a cane. Resident #84 stated she hated the facility, and her daughter (Daughter #291) would come and get her. Resident #84 was redirected and went calmly into her room. The statement indicated this was the last time LPN #293 saw Resident #84; however, the time LPN #293 last saw Resident #84 was not documented. Review of a witness statement dated 11/12/23 around 5:00 P.M. and written by State tested Nursing Assistant (STNA) #229 revealed she saw Resident #84 walk into the sitting area and Resident #84 was highly upset. Resident #84 called her daughter and asked her daughter to pick her up, and State tested Nursing Assistant (STNA) #229 assumed Resident #84's daughter said no because Resident #84 cursed the daughter out and afterwards she hung up the phone and walked out of the sitting area. STNA #229 stated she did not see Resident #84 go out the door. There was no documentation STNA #229 told the nurse assigned to Resident #84 what she overheard and observed. Review of Resident #84's undated Telephone Witness Statement with a time documented as 4:00 P.M. to 4:30 P.M. revealed STNA #220 last saw Resident #84 in the common area on the nursing unit she resided on. STNA #220 stated she saw a nurse (unidentified) talk to Resident #84 and then Resident #84 walked back to her room. Review of Resident #84's Telephone Witness Statement undated revealed STNA #297 last saw Resident #84 around 3:30 P.M. to 3:40 P.M. and she was in her room changing clothes. Review of a witness statement dated 11/12/23 revealed Receptionist #272 stated Resident #84 asked to use the phone, Receptionist #272 took her to the library and Resident #84 called Daughter #291. After Resident #84 called her daughter, Daughter #291 called the facility and told Receptionist #272 that Resident #84 was very irritated and threatening to leave the facility. Receptionist #272 stated Resident #84's nurse was on break and she immediately found LPN #293 who was covering for RN #292 while she was on break and told her Daughter #291 called the facility and was on hold and wanted to speak to Resident #84's nurse. Receptionist #272 stated LPN #293 told her she would handle it. Receptionist #272 stated at around 5:00 P.M. Daughter #291 called to say Resident #84 was at her (the daughter's) workplace. Receptionist #272 stated she put Daughter #291 on hold and ran to find Resident #84's nurse (RN #292) so she could take the call. Receptionist #272 stated she did not see Resident #84 leave the facility. Review of a Call for Service Report dated 11/12/23 at 5:19 P.M. from the local police department included police officers were dispatched at 5:22 P.M. and arrived at 5:31 P.M. at a local business located in a shopping plaza. The Complainant (Niece #295) reported Resident #84 left the (nursing) facility on foot, unaccompanied and Niece #295 had no idea how Resident #84 was able to leave there safely. Niece #295 stated Resident #84 had Alzheimer's Disease and was unable to make decisions for herself. Niece #295's cousin (Resident #84's Daughter #291) worked at a local business at the shopping plaza and called Niece #295 to report Resident #84 showed up at her workplace and she was in the back room of the store. Niece #295 was en route to the store (Daughter #291's workplace) to escort Resident #84 back to the facility but was afraid Resident #84 would become defiant, combative. Resident #84 agreed to be transported to the local hospital by the police. Review of Resident #84's ED Provider Note dated 11/12/23 at 6:44 P.M. included Resident #84 walked out of the facility and walked to a local shopping plaza. Resident #84 presented to the ED for evaluation of behavior concern. Resident #84 stated she was not happy at the facility and convinced someone to open the door and let her out of the locked unit (locked door) after she told them she was trying to take her bags to the car. Resident #84 packed her bags and brought them with her. Resident #84 stated she walked approximately one mile to find her daughter and her daughter called the police to bring her to the Emergency Department. Resident #84 was escorted by police to the emergency room . Resident #84 complained of mild nausea and stated she was not happy with the food at the facility, asked for an antacid, was not given the antacid, became upset and decided to leave the facility. Daughter #291 arrived to the bedside and stated during Resident #84's previous admission there were concerns that Resident #84 was not able to make her own medical decisions. Daughter #291 was Resident 84's Medical Power of Attorney and was working on a guardianship. A psychiatric evaluation was requested. Resident #84 complained of nausea, back pain after walking out of the facility. Resident #84 was cooperative but intermittently agitated, and a sitter was in place throughout Resident #84's ED stay. Resident #84 had a urinary tract infection, delirium and agitation. Resident #84 was admitted to the hospital. Review of Resident #84's hospital History and Physical dated 11/12/23 at 11:08 P.M. included Resident #84 had agitation and walked out of the facility and was transported to the hospital by the police. Resident #84 had a past medical history including Alzheimer's Disease and behavior agitation and paranoia, MDD (Major Depressive Disorder), anxiety and mood disorder. Resident #84 was brought to the hospital by police after she walked out of the facility to a shopping plaza. Resident #84 was agitated and had paranoia when Daughter #291 found her at the shopping plaza. Resident #84 refused to return to the facility and was brought to the hospital by police for evaluation. Per daughter Resident #84 had cognitive decline which became worse over time to the point where she ignored to care for herself at home with mood changing easily and Resident #84 would become agitated and had paranoia. Resident #84 was deemed not competent to make her own decisions and was sent to the facility. Since her admission to the facility Resident #84 had more mood changes, depression and was easily agitated and had paranoia. Today Resident #84 attempted to walk out of the facility, finally succeeded and walked to a shopping plaza. Police were called due to Resident #84 was agitated and uncooperative. In the ED Resident #84 was agitated, uncooperative and when an exam was attempted Resident #84 threatened to hit the ED provider and staff because they did not give her what she requested, and she waited a long time. Resident #84 had mild confusion, agitation and paranoia. Resident #84's principal problems included moderate late onset Alzheimer's dementia with agitation, untreated depression, anxiety and mood disorder and acute infection. Interview on 11/21/23 at 5:58 P.M. with Daughter #291 revealed Resident #84 wore a wander guard while she resided in the facility because she was trying to elope, but she kept removing the wander guard, so the facility discontinued it. Daughter #291 stated she was concerned Resident #84 might leave the facility. Daughter #291 stated on 11/12/23 Resident #84 called her and said she was not feeling well, and she was threatening to leave the facility. Daughter #291 stated she called the facility and told the staff to send Resident #84 to the hospital if she was not feeling well and she also told the staff Resident #84 was threatening to leave the facility. Daughter #291 stated she talked to the Receptionist after Resident #84 left the facility and was told Resident #84 was agitated and waving her cane around before she left. Daughter #291 indicated Resident #84 tried to get out the door used by ambulance staff, was unsuccessful then put her bags on a wheelchair and walked out the front door. Daughter #291 stated Resident #84 walked about a half mile and crossed a busy intersection to get to Daughter #291's workplace. Daughter #291 stated the facility staff did not know Resident #84 was gone from the facility and were not able to pick her up and take her back to the facility. Daughter #291 indicated Resident #84 was agitated and was taken by the police to the local hospital. Daughter #291 stated while Resident #84 was in the hospital from 09/21/23 through 09/26/23 she had a Statement of Expert Evaluation, and it was determined she could not make her own decisions regarding living arrangements. Daughter #291 indicated APS was involved in Resident #84's care and her caseworker was working on a state guardianship. Daughter #291 stated the facility indicated they did not have the Mental Capacity Note initially during the conference and Resident #84's APS caseworker was contacted. Daughter #291 stated Resident #84's caseworker was going to email the Mental Capacity Note, however, before it was mailed, someone in the facility found it, brought it to the area where Resident #84's care conference was conducted, and the APS caseworker did not have to email the Mental Capacity Note to the Administrator. Daughter #291 stated she did not know the name of the staff member who found the Mental Capacity Note but felt the facility was aware or should have been aware of the content of the note during the resident's stay. Observation on 11/22/23 at 12:30 P.M. of the road and intersection Resident #84 crossed to walk to Daughter #291's workplace revealed the road leading to the intersection was a very busy road with many cars traveling in both directions on the road. Observation of the intersection Resident #84 traveled on foot revealed Resident #84 walked across six lanes of traffic in a high traffic area. Observation of the shopping plaza Resident #84 walked across to reach her daughter's workplace revealed the shopping plaza was large, with a large parking lot and many cars entering and exiting the shopping area. Interview on 11/22/23 at 12:48 P.M. with CNP #294 revealed CNP #294 took care of Resident #84 when she resided in the facility and was told by the facility Resident #84 left against medical advice (AMA), but he did not remember the date it happened. CNP #294 stated Resident #84 was confused, yelled out a lot and whenever he visited her and was often in her bed in her room yelling out. CNP #294 stated Resident #84 had behaviors. CNP #294 stated Resident #84 had cognitive deficits, it was not a good idea for Resident #84 to be outside by herself and it was unsafe for her to be walking by a main road. CNP #294 stated he was not aware Resident #84 had a wander guard ordered, thought she was going to stay in the facility long term, and did not know anything about a guardian for Resident #84. CNP #294 stated he did not know anything about Resident #84's Mental Capacity Note and psychiatry services would do the Mental Capacity Note. Interview on 11/22/23 at 1:01 P.M. with Registered Nurse (RN) #292 revealed she took care of Resident #84 on 11/12/23 but she was on lunch break when the incident occurred. RN #292 stated Resident #84 was upset about the barbecue sauce served with her lunch meal and hours later she was still upset about it and was still nasty. RN #292 stated Resident #84 kept saying the facility should get better barbecue sauce and RN #292 tried to redirect her. Resident #84 told her she was going back to her room. RN #292 indicated she took her lunch break around 4:30 P.M., checked on Resident #84 before she took her break and Resident #84 was sitting on the side of her bed. Resident #84 was still upset and asked RN #292 what do you want. RN #292 stated she sat in the parking lot and ate her sandwich, came back around 4:50 P.M., and did not see Resident #84 outside the facility. RN #292 revealed while she was on break Resident #84 tried to hit another nurse with her cane. RN #292 stated she went to check on Resident #84 and Resident #84 was not in her room and her suitcases were gone. RN #292 stated when she walked out of Resident #84's room Receptionist #272 told her Daughter #291 was on the phone and wanted to speak with Resident #84's nurse. RN #292 indicated Daughter #291 told her Resident #84 was at her workplace and wanted Resident #84 picked up. RN #292 told Daughter #291 it was a liability issue, and she could not pick Resident #84 up in her car. RN #292 asked Daughter #291 to bring Resident #84 back to the facility, because her workplace was in a shopping plaza not far from the facility. Daughter #291 told RN #292 she would call her back. RN #292 stated she notified CNP #294 and told him Resident #84 left the facility. RN #292 stated she called Daughter #291 because she had not heard back from her and was told Resident #84 was transported to the local hospital. RN #292 stated STNA #229 heard Resident #84 call her daughter to come to the facility and pick her up and Resident #84 was upset and slammed the phone down after the call. RN #292 indicated STNA #229 did not tell her this happened until after Resident #84 left the facility, and she did not know if STNA #229 told LPN #293 about it. RN #292 revealed LPN #293 told her Resident #84 tried to hit her with a cane while she was on break. RN #292 stated Resident #84 should have been wearing a wander guard even though she was alert, and she had a wander guard on while she resided in the facility. RN #292 did not know why Resident #84's wander guard was discontinued. Interview on 11/22/23 at 1:23 P.M. with State tested Nursing Assistant (STNA) #298 revealed she was working on 11/12/23 when Resident #84 left the facility, but she was not assigned to the nursing unit Resident #84 resided on and did not see her leave the facility. STNA #298 stated sometimes Resident #84 talked about leaving the facility. STNA #298 stated Resident #84 was supposed to use a walker and she did not think it was safe for Resident #84 to be outside by herself walking around. STNA #298 stated Resident #84 was confused at times, and she thought she had dementia. Interview on 11/22/23 at 1:46 P.M. with the DON revealed Resident #84 was admitted to the facility and did not want to be in the facility. The DON stated Resident #84 was feisty, had a mind of her own and a guardianship was being looked into for her. The DON stated on Sunday 11/12/23 she was called at home because Daughter #291 called the facility and said Resident #84 was with her at her workplace. The DON stated Resident #84 said she was leaving and packed her suitcase and walked to Daughter #291's workplace. The DON stated Resident #84 had a wander guard, Resident #84 cut if off and it was discontinued because the DON felt l [TRUNCATED]

Based on record review, interview, and facility policy review, the facility failed to implement adequate and necessary interventions to prevent, timely identify and properly treat pressure ulcers for Resident #7. Actual Harm occurred on 02/17/23 when Resident #7, who was admitted on [DATE] with no skin breakdown, and required extensive assistance from one staff for bed mobility and transfers, developed two in-house acquired unstageable pressure ulcers (characterized by full-thickness skin and tissue loss in which the extent of tissue damage cannot be determined because it is obscured by debris, slough, or eschar) to the left and right coccyx area which were not identified prior to being unstageable. Following the development of the pressure ulcers, the ulcers deteriorated and became infected requiring hospitalization . This affected one resident (#7) of three residents identified with pressure ulcers. The facility census was 57. Findings include: Record review for Resident #7 revealed an admitted [DATE]. Diagnoses included fracture of unspecified metatarsal bone left foot, muscle weakness, lateral subluxation of left patella, type one diabetes mellitus, and unspecified intellectual disabilities. Review of the Admission assessment dated [DATE] timed 5:13 P.M. completed by Licensed Practical Nurse (LPN) #202 revealed Resident #7 had no skin impairment. Review of the Braden scale for predicting pressure ulcers dated 02/10/23 completed by Unit Manager Registered Nurse (RN) #201 revealed Resident #7 was at low risk for pressure ulcers. Review of the care plan dated 02/13/23 revealed Resident #7 had a potential for impaired skin integrity due to limited mobility, medically compromised status, and recent hospitalization . Interventions included inspecting skin especially at bony prominences, keeping skin clean and dry after each incontinence, and pressure relieving device as needed. Review of Resident #7's physician's orders and care plans from 02/10/23 to 02/17/23 revealed no specific pressure relieving devices were ordered and no specific pressure relieving devices were included as an intervention in Resident #7's care plan. Review of a Daily Skin Wound Note dated 02/17/23 timed 12:00 P.M., completed by the previous Director of Nursing (DON), revealed a small, reddened area was noted on Resident #7's right inner buttocks measuring 3 centimeters (cm) length by 2 cm width, and at 12 o'clock there was an area of slough (dead tissue) measuring 0.5 cm by 0.5. The note indicated the area was found while completing rounds. The wound was assessed to be unstageable due to the presence of slough. Duoderm Thin (a hydrocolloid dressing indicated for the management of lightly exuding wounds) was applied to the wound. Review of the physician's orders dated 02/17/23 revealed an order entered by Registered Nurse (RN) #203 for a wound care consult for pressure areas, a pressure relieving mattress to bed and a dietary consult for pressure area. Review of the Nutritional Risk Assessment, dated 02/20/23 timed 3:47 P.M., completed by Registered Dietitian (RD) #209 revealed Resident #7's intake met 76 to 100 percent of estimated needs. Resident #7 was ambulatory, alert, able to feed self, and had no chewing or swallowing problems. Resident #7 was at nutritional risk related to increased nutritional needs related to sacral wound. The documentation included Resident #7 had a very good appetite and had no change in weight. Due to sacral wound, the nutritional needs were elevated. Recommendations included a supplement, Boost Glucose Control two times a day, multivitamin daily, Vitamin C 500 milligram (mg), and nursing to record percent of meal and fluids consumed. Review of physician orders revealed the nutritional recommendation made by RD #209 for Boost Glucose Control was not implemented until 03/15/23, Vitamin C was not implemented until 03/09/23, and the multivitamin was not implemented until 04/06/23. Review of the Wound Care Assessment, dated 02/22/23, completed by Certified Nurse Practitioner (CNP) #206, revealed an initial wound consult for Resident #7's pressure ulcer wounds. Measurements included an area to the right coccyx that measured 2.2 cm length by 0.8 cm width by 0.1 cm depth; the area was unstageable. The pressure area had 10 percent slough. Directions for treatment included cleansing areas with normal saline and apply 50 percent Triad paste and 50 percent Medihoney, cover with foam dressing. The dressing was to be changed twice a day and as needed. An Equagel cushion (helps to prevent pressure injuries) was to be placed in chair while up. Review of the physician's order, dated 02/22/23, revealed to apply a Medihoney dressing to right and left inner buttock topically two times a day for open areas. (This order did not match the recommendation of CNP #206, which was to cleanse areas with normal saline and apply 50% Triad paste and 50% Medihoney.) Review of the Wound Care assessment dated [DATE], completed by CNP #206, revealed the pressure area to the coccyx measured 2.0 cm by 3.0 cm by 0.4 cm depth. The assessment indicated the resident now had one large coccyx ulcer; the wound bed was mostly granulation tissue with some slough (30 percent). CNP #206 recommended cleansing the wound with normal saline, applying Medihoney and covering with foam dressing twice a day and as needed. Review of the physician's order, dated 03/08/23, revealed an order for a Medihoney external gel to inner right/left buttock topically two times a day and Medihoney/large foam for open area. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/09/23 revealed Resident #7 was moderately cognitively impaired. Resident #7 required extensive assistance of one person for bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #7 was always continent of bowel and bladder. Resident #7 was at risk for pressure ulcers and had one unstageable pressure ulcer that was not present upon admission. Review of the Wound Care Assessment for Resident #7 dated 03/15/23, completed by CNP #206, revealed the resident's pressure area to the coccyx measured 3.8 cm by 3.8 cm by 0.6 cm depth. The pressure area had 80 percent black eschar (hard scabbed dead tissue) and 20 percent yellow slough. The documentation indicated the ulcer had worsened, with recommendations to cleanse the area with normal saline, apply Medihoney and calcium alginate, and change dressing two times a day and as needed. Review of the Nutritional Risk assessment dated [DATE] timed 11:11 A.M., completed by RD #209, revealed Resident #7 was currently in isolation until 03/17/23 due to being positive for COVID-19. Per the wound registered nurse, the coccyx, right/left buttocks wounds had worsened to 3.0 cm by 3.8 cm by 0.6 cm depth In addition to the Vitamin C and zinc, the dietitian recommend 30 milliliters (ml) Active Liquid Protein two times a day which would provide 60 kilocalories/15 grams (gm) protein/2.4 gm arginine; fluids should be encouraged related to renal solute load; 10,000 international units (IU) Vitamin A for 10 days; weight verification; increase Boost Glucose Control to three times a day; and continue to monitor percent of meals consumed, weight and skin integrity. Review of physician's orders from 03/16/23 to current dated revealed the recommendation for fluids to be encouraged and monitored was never initiated. Review of the progress note dated 03/21/23 at 6:13 P.M., completed by Licensed Practical Nurse (LPN) #204, revealed Resident #7 was admitted to the hospital with a diagnosis of wound infection. Review of the wound note dated 04/03/23 timed 1:05 P.M., completed by RN #205, revealed Resident #7 returned from the hospital at 12:46 P.M. Resident #7 was observed with a wet to dry dressing on the coccyx area. The documentation indicated Resident #7 was scheduled to have wound vacuum installed and would be followed by the wound physician. Review of the physician's order dated 04/03/23 revealed an order for Vancomycin HCL oral suspension (antibiotic) 125 ml by mouth every six hours until 04/14/23 at 11:59 P.M. Review of the Wound Care assessment dated [DATE], completed by CNP #206, revealed Resident #7's pressure area to the coccyx measured 4.0 cm by 5.6 cm by 2.5 cm depth. The wound bed was 100 percent granulating tissue. The treatment indicated to cleanse with normal saline and change the wound vacuum three times weekly and as needed. Additional interventions from the care plan (with an initiation date of 02/13/23) included Boost Glucose Control three times a day dated 04/18/23, one Magic cup (nutritional supplement) daily dated 04/25/23, one scoop of protein powder to be sprinkled over one food with each meal dated 05/15/23, and 30 ml of Prostat or appropriate alternate two times a day dated 04/18/23. Review of the Wound Care assessment dated [DATE] completed by CNP #206, revealed Resident #7's pressure area to the coccyx measured 4.2 cm by 4.8 cm by 2.0 cm the wound had improved slightly. The wound bed had 60 percent slough and 40 percent granulation tissue. The order indicated to cleanse area with normal saline and apply foam to wound bed. The treatment indicated to change the wound vacuum three times weekly and as needed and keep Resident #7 turned every two hours while in bed and place on equagel cushion in chair. Review of the progress note dated 05/12/23 at 12:15 P.M., completed by LPN #204, revealed the nurse entered Resident #7's room and Resident #7 was lethargic. LPN #204 noted the coccyx/buttock wound had a noticeable odor and a brownish drainage. LPN #204 spoke to CNP #206 who obtained an order to send Resident #7 to the emergency room . Review of the progress note dated 05/12/23 6:19 P.M. LPN #204 revealed Resident #7 was admitted to the hospital for sepsis. Interview on 05/15/23 at 3:48 P.M. with LPN #204 revealed some nurses who were scheduled to change Resident #7's wound vacuum dressing did not know how, and no training was provided by the facility. LPN #204 stated she had observed several occasions where the wound vacuum was not working appropriately. LPN #204 stated the nurses did not address the vacuum not working and left the wound vacuum off for extended amounts of time. There were times when LPN #204 worked 12-hour shifts, and the wound vacuum was off due to malfunction while the dressing was still in place. LPN #204 stated she would leave at the end of her shift, return two days later and the vacuum was still not running while the dressing was still in place. LPN #204 revealed she did not report this because she did not feel comfortable telling another nurse how to do their job. LPN #204 revealed Resident #7 was currently in the hospital and being treated for sepsis related to the condition of her wound. Interview on 05/15/23 at 3:50 P.M. with Unit Manager RN #203 revealed Resident #7 developed a Stage IV (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) pressure wound after being admitted to the facility. Unit Manager RN #203 stated the wound was unstageable when first noted and continued worsening. Resident #7 ended up with a wound vacuum after going to the hospital for debridement (the removal of damaged tissue) and sepsis. Unit Manager RN #203 revealed she observed Resident #7's wound dressing saturated, and undated on different occasions. Unit Manager RN #203 said the nurses did not know how to use the wound vacuum, there was no formal training for the nurses, and many felt uncomfortable with the wound vacuum. Unit Manager RN #203 said there should have been more education for the nurses on the wound vacuum. Interview on 05/16/23 at 12:50 P.M. with LPN #204 revealed she did not know how to correctly apply the Medihoney/Triad/foam treatment. LPN #204 applied Medihoney to the wound, then applied the triad and foam dressing. Interview on 05/16/23 at 12:53 P.M. with LPN #215 revealed she was not clear on how to apply the Medihoney/Triad/foam treatment. LPN #215 applied the Triad then Medihoney then the foam dressing. Interview on 05/16/23 at 1:00 P.M. with Resident #7's parents revealed Resident #7 fractured her leg and needed a cast which was why she was placed at the facility. Resident #7's parents stated when they visited, they observed the wound vacuum not running and Resident #7 was up in the chair all day. Resident #7's parents stated the physician was very upset the staff at the facility put the wound vacuum dressing on wrong. The physician told them the wound vacuum was a special piece of equipment and not everyone knew how to use it. Attempts to reach the physician for interview were unsuccessful. Interview on 05/16/23 at 1:20 P.M. with the Director of Nursing (DON) confirmed the written order for Resident #7 included a Medihoney/Triad/foam dressing was not transcribed into the electronic medical record system exactly as CNP #206 ordered. The Medihoney should have been mixed in a cup 50/50 with the Triad cream then applied to Resident 7's pressure ulcer. The DON confirmed nurses were responsible for entering physician's orders in the electronic medical system and the order should have been entered exactly as CNP #206 ordered. The DON also confirmed the registered dietitian's recommendations were not implemented timely, documentation of Resident #7's meal intakes were inconsistent and there was no documentation on Resident #7's fluid intake. Interview on 05/16/23 at 4:58 P.M. with CNP #206 revealed she came in to consult with Resident #7 and to assist with the wound vacuum. CNP #206 was unable to provide a date because she did not have her notes available at the time of the interview. CNP #206 revealed at times she was concerned Resident #7's dressings were not dated, and the dressings were saturated (needing changed). CNP #206 stated she completed her assessments of Resident #7's wounds with facility staff present. The staff who were present during these assessments no longer worked at the facility. Interview on 05/17/23 at 3:30 P.M. with Registered Dietitian #209 revealed she consulted with Resident #7 on 02/20/23 per the physician order written 02/17/23. RD #209 said when she made recommendations, the recommendation should be initiated within 24 to 48 hours after receipt. RD #209 revealed the Boost, Vitamin C, and multivitamin were for wound healing. RD #209 wanted Resident #7' s meal and intakes to be monitored to guide future recommendations and wanted the fluid intake monitored due to the added proteins. RD #209 confirmed the recommendations for Resident #7 were not put in place timely, monitoring of meal intakes was inconsistent, and there was no documentation related to fluid intake. Interview on 05/17/23 at 3:45 P.M. with the DON confirmed RD #209's recommendations were not timely implemented for Resident #7. The DON was unable to provide documentation confirming nurses were trained on how to apply and trouble shoot/repair the wound vacuum/dressing when the machine alerted a malfunction. The DON revealed she had only been the DON at the facility for a few weeks. Review of facility policy titled Wound Care, dated October 2010, revealed the purpose of the procedure was to provide guidelines for the care of wounds to promote healing. Preparation included verification of physician's order for the procedure. Dress the wound and mark the tape with initials and date and apply to dressing. This deficiency represents non-compliance investigated under Complaint Number OH00142350.