Every finding on record at Rocky River Gardens Rehab and Nursing CTR

Based on medical record review, policy review, and interviews, the facility failed to provide written notice of an immediate facility-initiated discharge to the resident and/or the resident's representative when the facility determined the resident would not be permitted to return following hospitalization. This affected one resident (Resident #1) reviewed for transfer and discharge requirements Findings Include: Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, other chorea, and psychosis. Review of facility census records revealed Resident #1 was transferred and discharged to the hospital on [DATE] due to suicidal behaviors. Further review of the medical record revealed the facility conducted a care conference by telephone with Resident #1's responsible party on 06/29/26. Review of a discharge notice submitted to the Office of the State Long-Term Care Ombudsman, dated 07/07/26, revealed the facility determined Resident #1 would not be permitted to return to the facility because the safety of individuals in the facility was endangered. Interview with Resident #1's responsible party on 07/24/26 at 8:22 A.M. revealed she was not provided with written notice of the facility's determination that Resident #1 would not be permitted to return following the hospitalization. Interview with the Administrator on 07/24/26 at 10:10 A.M. confirmed the facility did not provide Resident #1 or Resident #1's responsible party with a written discharge notice. The Administrator stated the notice was not provided because the responsible party did not return the facility's telephone calls and the facility did not have a current address for the responsible party. Review of the facility policy entitled, Transfer or Discharge Notice, revealed the resident and/or the resident's representative would ordinarily be provided with at least 30 days' advance written notice of an impending transfer or discharge. The policy further indicated that when the safety of individuals in the facility was endangered, notice would be provided as soon as practicable but prior to the transfer or discharge.

Based on medical record review, the facility failed to coordinate the comprehensive assessment and care-planning process with the recommendations identified in a Level II Preadmission Screening and Resident Review (PASRR). This affected one (Resident #1) of three residents reviewed for PASRR requirements. The facility census was 83.Findings include: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included catatonic schizophrenia, unspecified schizophrenia, unspecified psychosis, depression, anxiety disorder, unspecified mood disorder, cognitive communication deficit, and a history of suicide attempt. Review of Resident #1's Level II PASRR determination dated 12/09/25 revealed Resident #1 was approved for nursing-facility services with specialized services. The PASRR identified behavioral-health services to be provided or arranged by the nursing facility, including a crisis-intervention plan; a behavior-management safety plan to decrease inappropriate behaviors and ensure safety; a psychiatric evaluation to clarify Resident #1's psychiatric diagnoses and appropriate treatment; ongoing evaluation of the effectiveness of psychotropic medications on identified target symptoms; ongoing medication review by a psychiatrist or similarly credentialed professional; mental-health counseling; and a behaviorally based treatment plan. Review of the care plan dated 06/26/26 revealed the care did not contain an individualized crisis-intervention plan, behavior-management safety plan, or behaviorally based treatment plan as specifically recommended by the Level II PASRR. The care plan did not identify Resident #1's known behavioral triggers, early warning signs, required level of supervision during a behavioral crisis, specific staff responses, or criteria for increasing observation or initiating emergency psychiatric intervention. Further review of the medical record revealed no documented evidence that the facility completed or arranged the PASRR-recommended psychiatric evaluation, mental-health counseling, ongoing medication review by a psychiatrist or similarly credentialed professional, or ongoing evaluation of the effectiveness of Resident #1's psychotropic medications on identified target symptoms. The record also contained no documentation that the interdisciplinary team reviewed the PASRR recommendations and determined that any recommendation was inappropriate or unnecessary for Resident #1. Interview with the Administrator, Director of Nursing and [NAME] President of Clinical Services on 07/24/26 at 11:45 A.M. verified Resident #1's PASRR recommendations were not implemented into her plan of care as required.

Based on observation, interview, record review and review of the facility policy, the facility failed to maintain infection control practices to include Enhanced Barrier Precautions (EBP) for one resident, (#84) of one resident reviewed for EBP and the facility failed to ensure aerosol masks and tubings were changed timely and stored appropriately for four residents, (#56, #59, #78 and #84), of four residents reviewed for aerosol treatments. The facility also failed to ensure a Continous Positive Airway Pressure (CPAP) mask and tubing was appropriately stored for Resident #84. This had the potential to affect an additional five residents, (#51, #56, #59, #83, and #85) who also received EBP (on the same floor Resident #84 resided) and 15 residents, (#8, #11, #19, #22, #34, #38, #44, #53, #54, #59, #61, #63, #66, #78, and #81) who received aerosol treatments. The facility census was 86.1.Record review for Resident #84 revealed an admission date of 03/18/26. Diagnoses included Type Two Diabetes Mellitus, peripheral vascular disease, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, pressure ulcer of right and left heel, and need for assistants with personal care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #84 was cognitively intact. Resident #84 was always incontinent of bowel and bladder, was dependent for bed mobility, transfers, toileting hygiene and personal hygiene. Resident #84 was at risk for pressure ulcers, had one stage three pressure ulcer, a diabetic foot ulcer and received pressure injury care. Review of the care plan dated 06/12/26 revealed Resident #84 had impaired skin integrity, left heel diabetic ulcer. Interventions included performing wound care treatments as ordered by the physician. Record review of the Wound Report for Resident #84 dated 06/30/26 revealed Resident #84 had a diabetic ulcer to the left heel that was present 03/18/26. Review of the physician orders for Resident #84 revealed orders:1.Left heel clean with vashe, apply silver alginate cover with non-bordered super absorbent dressing wrap with kerlix. Apply betadine to peri wound. The order was dated 06/23/26.2.Enhanced Barrier Precautions related to indwelling medical device and or wounds and or infection colonization with an Multi Drug Resistant Organism (MDRO) (when contact precautions do not apply) during high contact resident care activities every shift for infection control. The order was dated 03/18/26.3.Ipratropium-Albuterol (bronchodialator) inhalation solution 0.5-2.5 milligrams (mg) per three milliliters (ml); one inhalation inhale orally every eight hours for lung support. The order was dated 03/19/26.4.Nebulizer: Tubing and mask change every night shift every Tuesday. The order was dated 04/07/26.5.Auto CPAP 8-20 apply every HS (night), remove in A.M.; The order was dated 03/19/26.Observation on 07/08/26 at 9:30 A.M. revealed Resident #84 had an Enhanced Barrier Precaution (EBP) sign outside the entrance door to his room. Also located near the door was a small storage unit with Personal Protective Equipment (PPE) including gloves and disposable isolation gowns. Resident #84 was lying in bed. Observation revealed Resident #84's aerosol tubing and mask was sitting on top of his dresser, not in a bag, with the mask face up. The top of the dresser was dusty and had a white film of powder. The face mask had a date of 06/11/26 written in large print directly on the mask. The tubing was not dated. Resident #84 confirmed that was the aerosol mask he received for daily aerosol treatment. Observation revealed Resident #84's CPAP mask and tubing was lying on floor uncovered. Resident #84 confirmed he received wound care daily and revealed staff never placed an isolation gown on for any type of care. Resident #84 asked why they would place a gown on. Observation and interview on 07/08/26 at 10:15 A.M. with Certified Nursing Assistant (CNA) #119 provide incontinence care for Resident #84 revealed Resident #84 was saturated with urine. CNA #119 provided incontinence care while repositioning Resident #84 multiples times in bed and changed the complete bed linen due to the saturated linen. Observation revealed CNA #119 never donned an isolation gown during the care. Licensed Practical Nurse (LPN) #163 entered the room during incontinence care. LPN #163 confirmed Resident #84's aerosol mask (lying on top the dusty dresser) and tubing was not stored in a bag and confirmed the aerosol mask was dated 06/11/26. LPN #163 also confirmed Resident #84's CPAP mask and tubing was lying on the floor unbagged. After incontinence care was completed, LPN #163 confirmed CNA #119 should have applied an isolation gown prior to providing care due to the wound on the left foot. CNA #119 revealed she did not need to wear a gown because she did not touch the wound. LPN #163 then removed the dressing to Resident #84's left foot to initiate wound care. Observation confirmed Resident #84 had an opened wound to the left heel. Interview on 07/08/26 at 11:03 A.M. with the Director of Nursing (DON) confirmed Resident #84 required EBP due to the chronic wound to the left heel and revealed aerosol masks and tubing were required to be changed weekly, dated the day they were changed and bagged in a clean bag when not in use. CPAP masks and tubing should also be stored in a clean bag when not in use. 2. Record review for Resident #78 revealed an admission date of 03/11/26. Diagnosis included Chronic Obstructive Pulmonary Disease (COPD), asthma, congestive heart failure, and need for assistants with personal care. Review of the quarterly MDS 3.0 asssessment dated 06/15/26 revealed Resident #78 was cognitively intact, used a wheelchair for mobility and required supervision or touching assistants with ADL's. Review of the physician orders for Resident #78 revealed an order for Ipratropium - Albuterol inhalation solution 0.5-2.5 (3) mg/3ml inhale orally every four hours as needed for wheezing/shortness of breath dated 03/13/26. Observation and interview on 07/08/26 at 10:48 A.M. with LPN #163 revealed Resident #78's aerosol mask and tubing was sitting on the dresser. LPN #163 verified there was no date on the mask or tubing. 3. Record review for Resident #59 revealed an admission date of 01/26/23. Diagnosis included cerebral palsy, asthma, and need for assistants with personal care. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #59 was cognitively intact and required assistants with activities of daily living. Review of the physician orders for Resident #59 revealed an order for Ipratropium - Albuterol inhalation solution 0.5-2.5 (3) mg/3ml inhale orally every six hours as needed for wheezing/shortness of breath dated 01/20/26. An additional order also dated 01/13/26 revealed to change the nebulizer mask and tubing weekly, date and place in plastic bag when not in use. Observation and interview on 07/08/26 at 10:51 A.M. with LPN #163 revealed Resident #59's aerosol mask and tubing was sitting on the dresser. LPN #163 verified there was no date on the mask or tubing and confirmed neither was bagged. 4. Record review for Resident #56 revealed an admission date of 08/23/19. Diagnosis included COPD, cough variant asthma, and need for assistants with personal care. Review of the Annual MDS 3.0 assessment dated [DATE] revealed Resident #56 was severely cognitively impaired and was dependent for activities of daily living. Review of the physician orders for Resident #56 revealed an order for Ipratropium - Albuterol inhalation solution 0.5-2.5 (3) mg/3ml inhale orally every six hours as needed for wheezing/shortness of breath dated 04/12/26. An additional order also dated 04/12/26 revealed to change the nebulizer mask and tubing weekly, date and place in plastic bag when not in use. Observation and interview on 07/08/26 at 10:53 A.M. with LPN #204 revealed Resident #56's aerosol mask and tubing was sitting on the dresser. LPN #204 verified there was no date on the mask or tubing and confirmed neither was bagged. Interview on 07/08/26 at 2:05 P.M. with DON confirmed Resident #78 did not have a physician order of when to change the aerosol mask. DON confirmed nurses were signing the physician orders on the Treatment Administration Records (TAR) that the aerosol tubing's were changed weekly for Resident #56, #59 and #84 and stored in a plastic bag when not in use. DON revealed the tasks were signed as completed but were not completed as ordered. Review of the facility policy titled, Enhanced Barrier Precautions (EBP) Policy and Procedure dated 04/01/24 revealed EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are indicated for residents with any of the following: Wounds or indwelling medical devices. EBP expand the use of PPE and refer to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDRO's (Multi drug-resistant organisms) to staff hands and clothing. MDRO's may be indirectly transferred from resident to resident during these high contact care activities. Nursing Home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDRO's.

Based on observation, interview and record review, the facility failed to ensure resident rooms were homelike and clean. This affected two residents, (#34 and #84's) of four reviewed for homelike environment. The facility census was 86.1. Record review for Resident #34 revealed an admission date of 01/23/26. Diagnosis included schizoaffective disorder and basil cell carcinoma of the skin. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #34 was severely cognitively impaired. Resident #34 was frequently incontinent of bowel and bladder, required partial/moderate assistance for bed mobility, chair/bed to chair transfer, toilet transfer and toileting hygiene. Resident #34 received wound care with dressing changes. Observation on 06/30/26 at 3:40 P.M. revealed Resident #34 was lying in bed with what appeared to be stool smeared on the floor in one large area approximate size of a baseball with tracks of stool leading to the bathroom. There were also multiple dried spills of liquids in a variety of colors with food particles on the floor near the bed. To the left side of the room, on the floor, was two soiled wound dressings with multiple knats' swarming them. Inside the bathroom was a large yellow area partially dried in front of the toilet which had a strong urine odor. Under the sink in the bathroom was a vent near the floor that extended from one wall to the other. On the top surface of the vent, on the under surface of the vent and the floor under the vent thick rust colored particles were observed. On the wall directly above the entire vent, from one end to the other was grey/black circular particles completely covering the area above the vent.Observation and interview on 06/30/26 at 3:45 P.M. of Resident #34's room with Housekeeper #158 confirmed the dried stool tracking on the floor, soiled bandages, liquid spills, food, dried urine on the bathroom floor, and the area on, under and above the vent in the bathroom. Housekeeper #158 revealed the rooms should be cleaned daily but she was unsure when Resident #34's room was last cleaned. Observation and interview on 06/30/26 at 3:48 P.M. with Licensed Practical Nurse (LPN) #202 of Resident #34's room verified there were multiple knats flying around the two soiled wound dressings on the floor. LPN #202 revealed Resident #34 was unable to get out of bed by herself and revealed Resident #34 does throw her soiled briefs and dressings on the floor and stated, This morning someone said she threw her soiled brief on the floor, they must not have cleaned it up and tracked it on the floor. LPN #202 confirmed there was no brief present and confirmed the larger brown area and tracking around it on the floor was stool. LPN #202 revealed they must have picked up the soiled brief but not cleaned the stool or urine off the floor.Observation and interview on 06/30/26 at 3:56 P.M. of Resident #34's room with Maintenance Director #185 revealed the baseboard cover for air conditioner was under the bathroom sink and it measured about 42 inches covering from one side of the wall to the other. Maintenance Director #185 confirmed the rust colored particles and stated I think it's dirt and rust coming from the pipe.2. Record review for Resident #84 revealed an admission date of 03/18/26. Diagnosis included peripheral vascular disease, Type Two Diabetes Mellitus, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, pressure ulcer of right and left heel, and need for assistants with personal care. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #84 was cognitively intact. Resident #84 was dependent for bed mobility and transfers. Interview and observation on 07/08/26 at 9:30 A.M. with Resident #84 revealed the room was cluttered, there was no bag in the trash can and trash was scattered throughout on the floor. There was a soiled towel on floor. There was observed a thick build up of dirt and grime around the edges of the floor in the room and between several floor tiles. The windows were very dirty inside and out, spotty and cloudy from the buildup of dust. A spider web was in the center of the window. The outside window was broken with several large and small pieces of glass lying between the two windows. Resident #84 revealed the window had been broken for months, stating it broke during a storm. The bedside table arm and leg had a large buildup of debris, spills, and dirt grime covering the area. There were multiple nail and screw holes unrepaired on all four walls. Resident #84 revealed if he lived at home, it would not look like the room at the facility, and stated the facility does not do well with cleaning, stating housekeeping would come in and do a quick sweep and that's it. Observation and interview on 07/08/26 at 10:15 A.M. with Certified Nursing Assistant (CNA) #119 confirmed the above observations. At 10:23 A.M. LPN #163 arrived during observation of incontinence care and also confirmed the above observations. This deficiency represents non-compliance investigated under Complaint number 3054744 and number 3044186.

Based on observation, interview, record review and review of the facility policy, the facility failed to assist two residents, (#70 and #84) who had been incontinent in a timely manner. This affected two of two residents reviewed for for incontinence care and had the potential to affect an additional 38 residents (#1, #2, #3, #4, #6, #8, #10, #11, #14, #15, #16, #25, #26, #27, #29, #30, #34, #37, #38, #42, #44, #45, #54, #55, #56, #57, #58, #61, #66, #67, #68, #71, #72, #77, #79, #80, #85, and #88) identified by the facility who were incontinent of bowel and or blabber. The facility census was 86.1.Record review for Resident #70 revealed an admission date of 05/26/25. Diagnoses included Chronic Obstructive Pulmonary Disease (COPD), muscle weakness and need for assistants with personal care. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #70 was cognitively intact, frequently incontinent of urine, had impairment on one side of the upper extremities and was dependent for bed mobility, chair/bed to chair transfer and toileting hygiene. Review of the care plan dated 08/21/25 revealed Resident #70 had bladder incontinence. Interventions included checking and change as required for incontinence. Observation on 07/01/26 at 1:12 P.M. revealed Certified Nursing Assistant (CNA) #203 was sitting at the nurse's station. Surveyor reminded CNA #203 that she returned for a prescheduled (with CNA #203) observation of incontinence care. CNA #203 revealed meal trays arrived late and state no one is allowed to be changed during meals, even if they were not eating they needed to wait until the end of the mealtime due to cross contamination. Licensed Practical Nurse (LPN) #173 approached the nurse's station and stated, No residents are allowed to be changed during meals. Interview on 07/01/26 at 1:16 P.M. with Resident #58 revealed Resident #58 was sitting up in bed eating her lunch. Resident #58 stated when asked about toileting, I am incontinent and have been incontinent during meals. I have to wait to the end of the meal to get changed. I understand they would get contaminated, that's what they told me, I don't like it, but I got used to it and I try to ignore it. Resident #58 revealed she was dry at this time.Interview on 07/01/26 at 1:23 P.M. with Resident #70 revealed, No, they don't change me when I need it, I have been incontinent during meals, they won't change me, one day I laid there a whole day and nobody changed me. I am wet now, I have therapy at 2:00 P.M., they won't change me because it's mealtime. It pisses me off.Interview on 07/01/26 at 1:35 P.M. with the Director of Nursing (DON) revealed if a resident was incontinent during meals, they are allowed to be changed. The CNA should stop what they are doing and take care of residents. DON confirmed the same concern was received a citation in the past. Interview on 07/01/26 at 1:50 P.M. with Resident #70 revealed Resident #70 was still in bed and the meal tray was no longer present. Resident #70 revealed the staff still never came in to assist him with incontinence care. Resident #70 revealed he was upset and stated, They told me they have to collect trays before they can change me. It was my aid. I have to get to therapy. Interview on 07/01/26 at 1:54 P.M. with CNA #127 confirmed she was Resident #70's CNA and revealed staff were not allowed to change residents during meal time due to cross contamination. CNA #127 revealed Resident #70 wanted up by 1:00 P.M. but trays were late and another resident was sick. Entered Resident #70's room at 1:57 P.M. with CNA #127. Resident #70 expressed he was upset; he wanted up and changed for therapy. CNA #127 stated, You just said you wanted up; I told you I was collecting trays. Observation of incontinence care revealed Resident #70's brief was saturated with urine and Resident #70 had a foul odor of urine. Both CNA #127 and Resident #70 confirmed the last time Resident #70 was checked for incontinence or changed was 7:00 A.M., Resident #70 was observed to have a red scrotal area. 2. Record review for Resident #84 revealed an admission date of 03/18/26. Diagnosis included peripheral vascular disease, Type Two Diabetes Mellitus, Chronic Obstructive Pulmonary Disease (COPD), obstructive sleep apnea, pressure ulcer of right and left heel, and need for assistants with personal care. Review of the quarterly MDS dated [DATE] revealed Resident #84 was cognitively intact. Resident #84 was always incontinent of bowel and bladder, was dependent for bed mobility, transfers, toileting hygiene and personal hygiene. Review of the care plan dated 03/19/26 revealed Resident #84 was at risk for skin breakdown due to decreased mobility, diabetes and incontinence. Interventions included to administer treatments as ordered, provided incontinence care as needed, keep skin clean, dry and odor free. Interview with Resident #84 on 07/08/26 at 9:30 A.M. revealed Resident #84 was lying in bed. Resident #84 revealed he had not been changed due to incontinence this shift yet and revealed he needed changed. Observation and interview on 07/08/26 at 10:15 A.M. with CNA #119 revealed she started her shift at 7:00 A.M. and confirmed she had not checked Resident #84 yet to see if he was incontinent or needed changed. Observation of CNA #119 provide incontinence care revealed Resident #84's brief, pad and sheet were all saturated with urine. Interview on 07/08/26 at 11:03 A.M. with DON revealed residents should be checked and changed every two hours and as needed. Review of the facility policy titled, Urinary Continence and Incontinence - Assessment and Management revised September 2010 revealed a check and change strategy involves checking the resident's continence status at regular intervals and using incontinent devices or garments. The primary goals are to maintain dignity and comfort and to protect the skin. This deficiency represents non-compliance investigated under Complaint number 3054744.

Based on record review, interview, and facility policy review, the facility failed to ensure concerns related to Resident #90's care was addressed timely with resolution. This affected one resident (Resident #90) out of three residents reviewed for resident rights. Facility census was 87.Findings include:Review of the medical record for Resident #90 revealed an admission date of 09/22/25 and a discharge date of 04/07/26. Diagnoses included demyelinating disease of central nervous system, cognitive communication deficit, unspecified dementia, alcohol abuse, unspecified psychosis, visual hallucinations, mood affective disorder, and needs help with personal care.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 had intact cognition.Review of the incident reported dated 02/08/26 at 1:24 P.M. revealed Certified Nursing Assistant (CNA) #225 notified Licensed Practical Nurse (LPN) #261 resident had discoloration noted under her right eye and right side of face appeared swollen. Resident #90stated last night, while attempting to retrieve her hairbrush from her bag, the bag shifted and the hairbrush hit her in the face. LPN #261 assessed Resident #90's right side of face. Resident #90 denied pain and vital signs were within normal limits. The physician and Director of Nursing (DON) were made aware. A cold compress was applied to the right side of Resident #90 's face and Resident #90 tolerated intervention. The end of the report noted physician notified on 02/08/26 at 1:28 P.M. and Family Member notified on 02/08/26 at 1:36 P.M.Review of the progress note dated 02/08/26 at 3:58 P.M. revealed Certified Nursing CNA #225 notified LPN #261 Resident #90 had discoloration noted under right eye and right side of face appeared swollen. Resident #90 stated last night, while attempting to retrieve her hairbrush from her bag, the bag shifted and the hairbrush hit her in the face. LPN #261 assessed Resident #90's right side of face. Resident #90 denied pain and vital signs were with normal limits. Physicians and DON were notified. Cold compress applied to right side of the Resident #90's face.Interview on 05/14/26 at 2:03 P.M with LPN #261 confirmed CNA #225 notified her Resident #90 had some bruising and swelling on her face. LPN #261 reported she assessed Resident #90 immediately and Resident #90, who is alert and oriented, told her she was accidentally hit with her hairbrush. LPN #261 denied any abuse. Interview on 05/18/26 at 8:27 A.M. with Resident #90's family revealed she expressed concerns regarding bruising on Resident 90's face with the DON and there was no follow-up. Resident #90's family revealed she never heard back from DON regarding her concerns about Resident #90's bruising.Interview on 05/18/26 at 8:54 A.M. with Regional Director of Clinical Services (RDCS) #303 confirmed for any resident or family concerns, there should be an investigation immediately and follow up call to family of outcome. RDCS #303 confirmed Resident's #90's family's concern was not addressed timely. There was no evidence of follow up regarding Resident #90's family concerns. Interview on 05/18/26 at 9:03 A.M. with DON confirmed she did receive a call from Resident #90's family regarding the incident with concerns of bruising to her face. DON couldn't remember any details as to when the call was made, what time, or anything regarding the call. DON reported she received the call after the incident. DON reported Resident #90's family asked what happened and DON reported she told the family member Resident #90 hit self with her hairbrush in the face. DON doesn't remember Resident #90's family response. DON confirmed she had no evidence of the call or conversation or follow up of the resolution. Review of facility policy, Grievances/complaint staff responsibility, revised May 2017, revealed staff will inform the resident or person acting on the resident behalf as to where to obtain a Resident Grievance/Complaint form and where to locate the procedures for filing a grievance or complaint. The policy further stated all alleged abuse, mistreatment, neglect, injuries of unknown source, and misappropriation of property will be reported to the Administrator immediately not more than twenty-four (24) hours after the alleged incident.Review of facility policy, Grievances/Complaints, filing, revised August 2020, revealed residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The policy further stated all grievances, complaints or recommendations stemming from resident or family concerns will be responded to in writing, including a rationale for the response.Review of facility policy, Grievances/Complaints, Recording and Investigating, revised August 2020, revealed all grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance. The policy further states upon receiving grievance and complaint an investigation into the allegation will begin. The resident or person acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended within 5 working days.This deficiency represents non-compliance investigated under Complaint Number 2744875 and Complaint Number 2727333.

Based on observation, interview, record review, and review of the facility policy the facility failed to ensure infection control practices were maintained during care for Resident #34 and #52. This had the potential to affect all residents in the facility. The facility census was 91. Findings included: 1.Record review for Resident #52 revealed an admission date of 11/22/25. Diagnosis included post-polio syndrome, hemiplegia, lymphedema, muscle weakness and need for assistants with personal care. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #52 was cognitively intact. Resident #52 was dependent for toileting hygiene, bed mobility, and chair/bed to chair transfers. Resident #52 had two stage three pressure ulcer injuries that were present upon admission. Review of the physician orders for Resident #52 dated January 2026 revealed cleanse right hip with normal saline, dry, apply triad paste and dry dressing one time a day for wound care. Review of the care plan with date initiated of 11/29/25 revealed no mention of enhanced barrier precautions (EBP), however, a care plan for pressure ulcer care was noted with a goal to show signs of improvement and prevent infection. Observation on 01/08/26 at 9:24 A.M. of wound care for Resident #52 completed by Wound Care Nurse Licensed Practical Nurse (LPN) #303 revealed after entering Resident #52 ' s room, Wound Care Nurse LPN #303 repositioned Resident #52 in bed then removed the soiled dressing to the right hip. Wound Care Nurse LPN #303 assessed, cleaned and redressed the wound to the right hip without ever donning an isolation gown. Observation with Wound Care Nurse LPN #303 confirmed Resident #52 had a sign on the entrance door to her room revealing Enhanced Barrier Precaution (EBP) and revealed staff were to wear gloves and gown for the following high contact resident care activities which included wound care. Located in the hall next to Resident #52 ' s door was a three drawer container. Wound Care Nurse LPN #303 confirmed the container was used for isolation supplies and confirmed on top of the container used for isolation supplies was a thick layer of dust and grime with lines going down the sides which appeared to be dried liquid spills. Wound Care Nurse LPN #303 verified she never donned an isolation gown during wound care for Resident #52 and confirmed she should have. Interview on 01/13/26 at 10:15 A.M. with Resident #52 revealed, They (staff) never wear an isolation gown when providing care. 2. Record review for Resident #34 revealed an admission date of 01/30/25. Diagnoses included neuromuscular dysfunction of bladder, muscle weakness, and need for assistance with personal care. Review of the significant change MDS dated [DATE] revealed Resident #34 was cognitively intact. Resident #34 had an indwelling catheter, frequently was incontinent of bowel, and was dependent for personal hygiene. Review of the care plan dated 05/12/25 for Resident #34 revealed EBP related to indwelling foley. Interventions included gloves and gown for high contact resident care. Review of the physician orders dated 05/03/25 for Resident #34 revealed foley (cathetar) output every shift for foley care. Observation on 01/08/26 at 3:10 P.M. of Certified Nursing Assistant (CNA) #230 emptying the urine from Resident #34 ' s indwelling catheter bag revealed CNA #230 never donned an isolation gown. CNA #230 drained 300 milliliters from the urine bag. CNA #230 confirmed he never wore an isolation gown and revealed he did not need to. Interview on 01/08/26 at 5:00 P.M. with Director of Nursing (DON) revealed if staff were providing catheter care including emptying the drainage bag, or wound care, they should donn Personal Protective Equipment (PPE) which included gloves and an isolation gown. DON confirmed CNA #230 and LPN #303 work throughout the facility and could expose all residents requiring care. Interview on 01/13/26 at 10:38 A.M. with Resident #34 revealed staff never wore an isolation gown when providing personal care including catheter care. Review of the facility policy titled, Enhanced Barrier Precautions (EBP) Policy and Procedure dated 04/01/24 revealed EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are indicated for residents with any of the following: Wounds or indwelling medical devices. EBP expand the use of PPE and refer to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDRO ' s (Multi drug-resistant organisms) to staff hands and clothing. MDRO ' s may be indirectly transferred from resident to resident during these high contact care activities. Nursing Home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDRO ' s. This deficiency represents non-compliance as an incidental finding investigated under Complaint Number 1360479.

Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure water temperatures were maintained as required for 45 residents (Resident #1, #2, #6, #7, #9, #11, #13, #14, #15, #17, #18, #16, #24, #25, #29, #30, #31, #32, #33, #37, #41, #42, #44, #46, #47, #48, #49, #50, #51, #52, #53, #59, #61, #65, #71, #73, #74, #77, #81, #82, #83, #85, #88, #91, and #93) on the third floor and rooms were clean and maintained for Resident #7, #39 and #73. This affected 46 residents of 91 residents residing in the facility. The facility census was 91.Findings included: 1. Observation was conducted on 01/06/26 at 1:56 P.M. during an environmental tour with Maintenance Director (MD) #306 of MD #306 taking facility water temperatures using the facility thermometer on the resident occupied third floor. The water temperature in Resident #18 ' s bathroom sink reached 100 degrees Fahrenheit (F) after running for five minutes but then quickly dropped to 62 degrees. MD #306 revealed the water temperatures should be 105 degrees F to 120 degrees F and revealed the facility had been having concerns with the mixing valve. MD #306 revealed he put an order in for a rebuilt kit on 12/23/25 when he was made aware of the hot water concerns and he then went on vacation. MD #306 stated he called the company on 12/26/25 to verify the part was ordered but when he was returning from vacation, the employees at the company he ordered parts from left for vacation as he returned so he had to wait until they returned. MD #306 revealed they could use a different company but chose not to and confirmed they never called a different company to see if they could receive the service sooner. An interview with Resident #18 at the time of the observation revealed she was concerned with the hot water, the staff had to run the water for a long time to get slightly warm. Resident #18 revealed when the staff cleaned her the water felt sometimes slightly warm and sometimes cold. Resident #18 stated, It ' s been going on a long time and confirmed she told the Administrator. Observation on 01/06/26 at 2:05 P.M. with MD #306 revealed Resident #15 ' s bathroom water temperature did not reach above 54 degrees F after running for over three minutes. Observation on 01/06/26 at 2:24 P.M. with MD #306 revealed Resident #24 ' s bathroom water temperature reached 99 degrees F after six minutes. Resident #24 was present in the room and stated he gets bed baths with cold water. MD #306 stated if the water temperatures were low in three resident rooms then the temperatures would be the same for the entire third floor because it was the same water line and the pressure was not enough to sufficiently get the hot water to the third floor. Interview on 01/06/26 at 4:26 P.M. with Certified Nursing Assistant (CNA) #210 revealed residents have expressed concerns of the water temperatures not getting hot enough. Interview on 01/06/26 at 4:30 P.M. with MD #306 confirmed the first and second floors had sufficient hot water if the water ran long enough, but the third floor was not always reaching the appropriate temperature of 105 to 120 degrees F. Interview on 01/07/26 at 10:33 A.M. with CNA #221 and #237 revealed the staff have to let the water run for a while before it would get warm but sometimes it could run for hours and not get warm on the third floor. Interview on 01/08/26 at 1:25 P.M. with Administrator revealed the reason the hot water was not working correctly was because the mixing valve was broke. The facility was first made aware on 12/23/25 and ordered the part. Administrator confirmed there were no interventions put into place so residents on the third floor could wash or be washed with warm water. Administrator stated, I felt they should have used a different shower room on a different floor, I don ' t think that was connected to the staff. 2. Record review for Resident #39 revealed an admission date of 01/25/25. Diagnoses included end stage renal disease, muscle weakness and abnormalities of gait and mobility. Review of the annual Minimum Data Set (MDS) 3.0 dated 12/31/25 revealed Resident #39 was cognitively intact. Resident #39 had impairment on both sides of the lower extremities, was always incontinent of bowel and bladder, was dependent for personal hygiene, bed mobility, and chair/bed to chair transfer. Interview on 01/06/26 at 4:12 P.M. with Resident #39 revealed he was upset because his toilet would not flush and stated, It has been that way for a week, the light above his bed was not working correctly for several weeks and the socket by his bed did not have a cover since he been there. Observation with Resident #39 confirmed the toilet would not flush, there were two lights above his bed, one pointing down to the head of the bed and one pointing upward. The light pointing upward had no bulb. Resident #39 revealed he cannot use the one pointing down because when he is in bed it shined directly in his eyes and was uncomfortable to his eyes where the one that no longer worked provided the lighting he needed without hurting his eyes. Interview and observation on 01/06/26 at 4:30 P.M. with MD #306 confirmed Resident #39 ' s toilet was not working and revealed he had been on vacation. Maintenance Director #306 stated, I took the bulb out (of the light socket above the bed) two or three weeks ago, didn ' t replace it because I am ordering a bunch of new lights, and the socket for the phone jack is broke, no one told me. 3. Record review for Resident #7 revealed an admission date of 07/11/24. Diagnosis included malignant neoplasm of prostate, cognitive communication deficit, and muscle weakness. Review of the quarterly MDS dated [DATE] revealed Resident #7 was moderately cognitively impaired. Resident #7 was dependent for personal hygiene, required partial/moderate assistants for bed mobility and chair/bed to chair transfers. Observation on 01/08/26 at 8:42 A.M. of Resident #7 room revealed five visible tiles under the bed was broken and had missing pieces of the tiles, the floor and floor mat next to the bed was very dirty with ground in dirt, dried spills and what appeared to be food particles, there were large areas of a thick black/brown substance that appeared to be removed floor strips and portions of the bottom of a mat still stuck to the floor, the dresser drawer had a broken handle, and dust and dried spills were on the dresser. Observation on 01/08/26 at 8:56 A.M. of Resident #7 ' s room with Administrator confirmed there were five visible tiles under the bed was broken and had missing pieces of the tiles, the floor and floor mat next to the bed was very dirty with ground in dirt, dried spills and what appeared to be food particles, there were large areas of a thick black/brown substance that appeared to be removed floor strips and portions of the bottom of a mat still stuck to the floor, the dresser drawer had a broken handle, and dust and dried spills were on the dresser. Interview on 01/12/26 at 3:30 P.M. with Resident #7 revealed, They need to clean better, I would like that if they did. 4. Record review for Resident #73 revealed an admission date of 04/22/25. Diagnoses included chronic kidney disease, muscle weakness and need for assistance with personal care. Review of the quarterly MDS assessment dated [DATE] revealed Resident #73 was cognitively intact. Resident #73 required supervision/touch assistants with personal hygiene, bed mobility and chair/bed to chair transfers. Observation on 01/08/26 at 8:44 A.M. revealed Resident #73 ' s room was very dirty, there was ground in dirt and mud throughout the floor, there were multiple trash items under the bed and protruding out from under the bed into the walkway including used tissues, dirty clothing items, crinkled papers, and wrappers. The floor had embedded dirt and grime under and beside the trash laying on the floor. There were no sheets on the mattress Resident #73 was resting on. Resident #73 revealed he preferred to lay on sheets but the sheets they do put on the bed did not fit and would not stay in place. Resident #73 confirmed his room was very dirty and stated, They wipe the middle of the floor, they don ' t really clean, there ' s no deep cleaning, it ' s been that way forever. Interview on 01/08/26 at 8:50 A.M. with CNA #223 who observed Resident #7 and #73 ' s room stated, Well it ' s disgusting, they don ' t do a good job here. CNA #223 confirmed the halls on the third floor including going around the entire nurses station was scuffed with multiple large scrapes that were discolored grey. The edges revealed the color of the tiles were originally a light tan color. Observation on 01/08/26 at 8:57 A.M. of Resident #73 ' s room with Administrator confirmed Resident #73 ' s room was very dirty, there was ground in dirt and mud throughout the floor, there were multiple trash items under the bed and protruding out from under the bed into the walkway including used tissues, dirty clothing items, crinkled papers, and wrappers. The floor had embedded dirt and grime under and beside the trash laying on the floor. There were no sheets on the mattress. Administrator also confirmed the halls on the third floor including going around the entire nurses station was scuffed with multiple large scrapes that were discolored grey. The edges revealed the color of the tiles were originally a light tan color. Observation and interview on 01/08/26 at 9:01 A.M. with Administrator and Housekeeping Manager #260 of Resident #7 and 73 ' s room revealed Housekeeper Manager (HM) #260 stated, This is not right. HM #260 also confirmed the condition of the floors in the hallways and around the nurses station and revealed none of the floors in the facility had a deep cleaning in over a year and stated, I have been asking for several months, it ' s been a year, we do not have the equipment or the person to do it and I keep asking and nothing happens. Interview on 01/08/26 at 9:16 A.M. with Licensed Practical Nurse (LPN) #279 stated, This building is filthy, everybody knows that. Review of the facility policy titled, Quality of Life - Homelike Environment revised May 2017 revealed residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Staff shall provide person centered care that emphasizes the residents ' personal needs and preferences. The facility staff and management shall maximize , to the extent possible the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: Clean, sanitary and orderly environment; Comfortable (minimum glare) yet adequate lighting; Clean bed and bath linens that are in good condition. This deficiency represents non-compliance investigated under Complaint Number 2690478, 1360476, and 1360479.

Based on observation, interview, and review of the facility policy the facility failed to ensure medications were stored in a safe, secure manner. This had the potential to affect all 32 residents residing on the second floor excluding five residents (#3, #23, #40, #60 and #70) the facility identified as needing assistance with mobility, and 45 residents residing on the third floor excluding six residents ( #2, #41, #51, #52, #74, and #77) the facility identified as requiring assistance with mobility. The facility census was 91.Findings included:Observation on 01/08/26 at 8:15 A.M. revealed the Medication Cart located on the third floor, North hall was unlocked. Observation revealed no staff were visible, Resident #50 was sitting in a chair nearby and additional residents were observed in the halls. Observation on 01/08/26 at 8:20 A.M. revealed Licensed Practical Nurse (LPN) # 297 returned to the Medication cart. LPN #297 stated, Oh, I was just down the hall doing my blood sugars. LPN #297 verified the Medication cart was left unlocked when she stepped away to do blood sugars. Observation on 01/12/26 at 9:33 A.M. revealed the Medication Cart located on the second floor near the nurse station was left unlocked. No staff were visible. Residents were observed in the halls and near the nurses station. Observation on 01/12/26 at 9:37 A.M. with LPN #297 verified the medication cart was left unattended while LPN #297 stepped away from the cart. Review of the facility policy titled, Storage of Medications revised April 2007 revealed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Compartments including but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. The deficiency represents noncompliance investigated under complaint number 2614805

Based on observation, interview, record review and review of the facility policy, the facility failed to provide timely incontinence care for Resident #48 and #96, and failed to ensure Resident #18, #50, 64 and #87 received showers/bathing as scheduled. This affected six residents (Resident #18, #48, #50, #64, #87 and #96) of seven residents reviewed for assistance with activities of daily living (ADL). The facility census was 91.Findings included:1. Review of the closed medical record for Resident #96 revealed an admission date of 05/13/25 and a discharge date of 08/11/25. Diagnosis included spinal stenosis, muscle weakness, need for assistants with personal care, repeated falls, and schizoaffective disorder bipolar type. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #96 had no behaviors exhibited, was not on a toileting program, was always incontinent of urine and frequently incontinent of bowel. Resident #96 had no impairment of the upper or lower extremities, used a wheelchair for mobility, required supervision or touching assistance for sit to stand, partial moderate assistants for chair/bed to chair transfer, required substantial/maximal assistants with toileting hygiene, supervision or touch assist with upper body dressing and was dependent for lower body dressing and personal hygiene. Review of the care plan dated 05/18/25 revealed Resident #96 had a self-care deficit related to need for staff assistants with various activities of daily living and transfers. Interventions included one to two assists required with assistive device for ambulation and one to two assist required for toileting. The care plan dated 05/28/25 revealed Resident #96 was on diuretic therapy related to edema. Resident #96 was also at risk for falls related to unsteady gait and repeated falls. Interventions included anticipating and meeting the resident ' s needs, be sure the resident ' s call light is within reach and encourage the resident to use it for assistants as needed. Resident #96 needed prompt response to all requests for assistants. Interview on 01/07/26 at 2:35 P.M. with Licensed Practical Nurse (LPN) #303 revealed she recalled Resident #96 and revealed, One day (Resident #96) wanted changed when we were doing the dining room at mealtime. It was the middle of lunch, we told him let us finish passing trays and we turned his call light off and he turned it right back on, he removed his soiled brief and threw it in the hallway. LPN #303 revealed the Certified Nursing Assistant (CNA) was CNA #237 and after the occurrence CNA #237 went and reported to her. LPN #303 stated, If a resident needs go to the bathroom during meals, the resident has to wait, that ' s the policy. I said to him ( Resident #96) that ' s not appropriate, he said they always make me wait, he was upset and did not like being here. Interview on 01/07/26 at 2:51 P.M. with CNA #237 revealed she recalled the incident with Resident #96. CNA #237 stated, We were in the middle passing lunch, me and (Central Supply/CNA #245) were on the floor, and he ( Resident #96) was coming back from smoking. We were in the middle of tray passes and he wanted us to change him, I said ( Resident #96) you know we don ' t do patient care during tray pass. I said give us a second till I finish. He rolled to his room, the trays just came when he asked, we have around 48 trays to pass, so he needed to wait; he went to his room, I am passing trays, he turned on the bathroom call light, I took his meal tray in and said you can turn your call light off, I will come back when I am finished passing trays. I was in the dining room when he hit his call light again, on my way walking down he threw the soiled brief with urine in the hall. I seen the brief in the hall he was yelling so I went to go get (LPN #303). The policy is no patient care during meal passes. Interview on 01/07/26 at 3:00 P.M. with Central Supply/CNA #245 who confirmed she recalled the situation with Resident #96. Central Supply/CNA #245 stated, He ( Resident #96) asked me to change him, I am unsure time of day, if I was passing trays I would say give me a second, I was told no personal care including incontinent care while meals were going on. I really can ' t remember the rest but he did want changed. Interview on 01/08/26 at 8:24 A.M. with Resident #33 revealed Resident #33 was in bed eating her breakfast. Resident #33 revealed she was not changed yet today and was incontinent but needed to wait until after breakfast. Resident #33 stated, You have to wait during meals to get changed because they have to feed people. Interview on 01/08/26 at 8:30 A.M. with Resident #41 who stated, I was told if I go during meals I have to wait to get changed until after the meal is over, it makes me feel not good, but there aren ' t very many people so they can ' t. 2. Record review for Resident #48 revealed an admission date of 02/14/24. Diagnoses included chronic obstructive pulmonary disease (COPD), muscle weakness, need for assistance with personal care, and fibromyalgia. Review of the quarterly MDS dated [DATE] revealed Resident #48 was moderately cognitively impaired. Resident #48 was frequently incontinent of bowel and bladder, used a motorized wheelchair for mobility, was dependant for toileting hygiene, toilet transfer, and substantial/maximal assistants for chair/bed to chair transfer. Review of the care plan for Resident #48 dated 02/19/24 revealed Resident #48 displayed frequent incontinence of bowel. Interventions included to check for incontinence, clean and dry skin if wet or soiled. Resident #48 also had frequent bladder incontinence. Interventions included to check and change Resident #48 every two hours and as needed. Cleanse peri area with each incontinent episode. Interview and observation on 01/08/26 at 8:32 A.M. with Resident #48 revealed Resident #48 was up in an electric wheelchair exiting her room. Resident #48 revealed she sleeps in the wheelchair every night per her choice. Observation revealed Resident #48 ' s pants were saturated/wet in the front. Resident #48 confirmed she was wet with urine and revealed staff had not changed her yet today. Resident #48 stated, The staff are doing breakfast so they are not allowed to change me. I am resident council president, they told us they can ' t change us during meals, they are not allowed during feeding hours. I can ' t see it or feel it because I am paralyzed from my waist down. Interview on 01/08/26 at 8:35 A.M. with CNA #225 revealed she started her shift at 7:00 A.M. and worked 12 to 16-hour shifts, and after breakfast she started changing her residents. CNA #225 stated We can ' t change residents during meals, it ' s the policy. Interview on 01/08/26 at 9:15 A.M. with CNA #225 revealed Resident #48 was just changed. CNA #225 confirmed Resident #48 was wet with urine including her pants and this was her first incontinence care for Resident #48 since start of her shift. Interview on 01/08/26 at 2:32 P.M. with Resident #48 revealed the last time staff checked or changed her was 'around 9:00 A.M. Resident #48 revealed she did not sleep well the previous night, so she slept most of the day.Observation of incontinence care for Resident #48 on 01/08/26 at 2:48 P.M. provided by CNA #223 revealed the outside of the front and back of Resident #48 ' s pants were saturated. The pad on the seat of Resident #48 ' s chair was heavily soiled with urine and stool. The brief Resident #48 was wearing was heavily soiled with urine and stool and Resident #48 had stool down her side and in her peri area. CNA #223 verified she was Resident #48 ' s primary CNA and verified the last time Resident #48 was checked or changed was around 9:00 A.M.; CNA #233 revealed she usually waited for Resident #48 to tell her when she needed changed. Resident #48 revealed to the CNA she was sleeping all day and did not realize she needed changed. Resident #48 revealed some CNA ' s check her to see if she needed changed and some do not. Resident #48 revealed she would not mind if they woke her up to change her. Observation revealed Resident #48 ' s buttocks and upper thighs had creased in several areas from sitting in the chair without moving for several hours, the inner buttocks was deep red. Resident #48 stated, I don ' t know when I go, that ' s the problem. Interview on 01/08/26 at 5:00 P.M. with Administrator and DON revealed the DON had been employed for approximately one month. DON revealed a resident could receive incontinent care during meals if needed. Administrator revealed the best practice would be for the staff to check and change the residents before the meal then confirmed it also should be done as needed. 3. Record review for Resident #18 revealed an admission date of 09/11/21. Diagnoses included chronic diastolic congestive heart failure (CHF), muscle weakness, and need for assistance with personal care. Review of the quarterly MDS dated [DATE] revealed Resident #18 was cognitively intact. Resident #18 was frequently incontinent of urine and was dependent for showers/bathing, personal hygiene and toileting hygiene. Review of the care plan dated 09/29/21 revealed Resident #18 had an activity of daily living (ADL) self-care performance and mobility deficit related to weakness. Resident #18 required assistance by two staff with daily bathing and biweekly shower and as necessary. Review of the shower schedule revealed Resident #18 had showers scheduled on Tuesday and Friday. Interview on 01/06/26 at 1:56 P.M. with Resident #18 revealed she had not been receiving her showers/bed baths routinely as scheduled. Interview on 01/06/26 at 3:57 P.M. with CNA #227 revealed Residents ' have been complaining about their showers/baths not getting done. Record review on 01/12/26 at 10:22 A.M. of the Shower/Tub bath/ Bed Bath sheets provided by the DON and reviewed with DON for Resident #18 from 10/14/25 through 01/06/26 revealed there was no shower record for Resident #18 for 10/17/25, 10/31/25, 11/07/25, 11/14/25, 11/21/25, 11/28/25, 12/16/25, 12/19/25, 12/23/25, 12/26/25, 12/30/25, and 01/02/26. DON revealed when a resident received a shower or bath or refused a shower or bath, a shower sheet would be completed and signed by the CNA and then the nurse would also sign to verify the result. DON also confirmed the electronic medical record where CNA ' s also documented had the same results with the exception of some CNA ' s document every shift that a resident received a bath/shower and confirmed those were inaccurate. DON confirmed Resident #18 would not have received or been offered her shower/bath as scheduled for the time period reviewed. 4. Record review for Resident #87 revealed an admission date of 01/30/25. Diagnoses included spinal stenosis, muscle weakness, and need for assistants with personal care. Review of the quarterly MDS dated [DATE] revealed Resident #87 was cognitively intact. Resident #87 required substantial/maximal assistants with showers/bathing. Review of the care plan dated 07/28/25 revealed Resident #87 had an ADL self-care performance deficit related to impaired balance and limited mobility. Interventions included the resident required assistance by staff with bathing. Interview on 01/07/26 at 9:52 A.M. with Resident #87 revealed the staff did not give her her scheduled showers consistently on shower days stating, They say there ' s not enough staff. Resident revealed she never refused showers/baths and revealed it was upsetting when she could not have them.Review of the shower schedule revealed Resident #87 was scheduled showers on Mondays and Thursdays. Review of the Shower/Tub bath/ Bed Bath sheets for Resident #87 from 10/09/25 through 01/06/26 revealed Resident #87 did not receive or offered a bath or shower on 10/13/25, 11/10/25, (refused 11/17/25), 11/24/25, 11/27/25, 12/15/25, 12/18/25, (Refused 12/25/25), and 01/05/26. Interview and record review on 01/12/26 at 2:30 P.M. with the DON verified the shower sheets for Resident #87 were all there, there were no more and the days were accurate for when the Resident #87 received or was offered a shower/bath. 5. Record review for Resident #64 revealed an admission date of 03/15/24. Diagnoses included chronic respiratory failure with hypoxia, muscle weakness, and need for assistance with personal care. Review of the census form included Res #64 was hospitalized on [DATE] and returned 10/17/25. Review of the quarterly MDS dated [DATE] revealed Resident #64 was cognitively intact. Resident #64 used a wheelchair for mobility and was dependent for bathing/showers. Review of the care plan dated 07/18/24 revealed Resident #64 required staff assistants for bathing and showering. Review of the shower schedule revealed Resident #64 was scheduled for showers on Tuesdays and Fridays on the 7:00 A.M. to 7:00 P.M. shift. Interview on 01/07/26 at 10:37 A.M. with Resident #64 revealed, I been begging for a bath for three days, there ' s no hot water they say, I don ' t get washed up period, they only give me one shower a month. I am not getting bed baths, sometimes they ask me in the middle of the night if I want to take my shower, I don ' t want take it in the middle night. I want it in the daytime; I tell them don ' t wake me up in the middle of the night to take a bath. Record review of the Shower/Tub bath/ Bed Bath sheets for 10/14/25 through 01/06/26 revealed Resident #64 ' s scheduled shower sheets were completed and signed as completed. Review of the shower record revealed on 10/14/25 Resident #64 received her shower, however, this would not have been possible because Resident #64 was hospitalized . Review of the shower sheet completed and signed by CNA #235 on 12/09/25 compared to a shower sheet dated 01/06/26 on which there was a signature for CNA #235 that was written twice on top of each other and did not match CNA #235's signature from 12/09/25, the 01/06/26 shower sheet indicated Resident #64 received a bed bath. Interview on 01/12/26 at 1:10 P.M. with DON confirmed Resident #64 was not in facility at the time the shower sheet was documented as completed on 10/14/25. DON revealed night shift showers should not be offered after 11:00 P.M. unless it was a resident preference and confirmed CNA #235 ' s signature dated 01/06/26 did not match the signature dated 12/09/25. Phone interview on 01/12/26 at 1:45 P.M. with CNA #235 revealed she did not have Resident #64 on 01/06/26 so she did not know if she received the shower/bath and confirmed she did not sign the shower sheet on 01/06/26. Interview on 01/12/26 at 2:10 P.M. with Scheduler #245 confirmed CNA #235 did not have Resident #64 on 01/06/26 and revealed CNA #237 had her on that day. Interview on 01/12/26 at 2:20 P.M. with CNA #237 confirmed she had Resident #64 on 01/06/26 and confirmed she did not give her her scheduled bath or shower and she did not sign the shower sheet stating, she would have signed her own name. CNA #237 revealed she did not remember why she did not offer or give the shower/bath on 01/06/26. 6. Record review for Resident #50 revealed an admission date of 09/24/20. Diagnoses included systemic lupus erythematosus, need for assistants with personal care, cerebral palsy and muscle weakness. Review of the quarterly MDS dated [DATE] revealed Resident #50 was cognitively intact. Resident #50 used a wheelchair for mobility and required substantial/maximal assistants for bathing/showering. Review of the care plan dated 11/11/20 revealed Resident #50 had an ADL self-care performance deficit related to impaired balance. Interventions included to provide sponge bath when a full bath or shower cannot be tolerated.Review of the shower schedule revealed Resident #50 was scheduled showers on Wednesday and Saturday. Interview on 01/08/26 at 8:40 A.M. with Resident #50 revealed she did not have a shower in three weeks. Observation revealed Resident #50 ' s hair was very oily. Resident #50 stated, It makes me feel disgusting, I told the Administrator this is bull (expletive). Resident #50 stated she was not showered due to hot water issues on her unit. Record review of the Shower/Tub bath/ Bed Bath sheets for Resident #50 revealed a shower was refused on 01/03/26 and 01/07/26. Both sheets were signed by CNA #225. Review of the shower sheets revealed the nurse signature was difficult to read for both days. Interview on 01/08/26 at 12:00 P.M. with the DON revealed she was unable to read the Nurse signature that signed the shower sheets on 01/03/26 and 01/07/26. Interview and review of the Shower/Tub bath/ Bed Bath sheets on 01/08/26 at 12:10 P.M. dated 01/03/26 and 01/07/26 for Resident #50 with LPN #286 and CNA #225 revealed CNA #225 stated Resident #50 never refused her showers on either of those dates. CNA #225 became upset and loudly questioned, Who signed my name? That is not my signature (while pointing at the shower sheets dated 01/03/26 and 01/07/26) she did not refuse, that is a lie, there was no hot water, look here is my signature (pointing out the signature on the shower sheet for Resident #50 dated 11/03/25) it looks nothing like that. LPN #286 confirmed the signatures signed on 01/03/26 and 01/07/26 did not resemble the signature dated 11/03/25. Interview on 01/08/26 at 12:36 P.M. with the DON revealed each resident should receive a minimum of two showers/baths per week and confirmed the third floor had a hot water issue since 12/23/25 and revealed if the water was not warm enough to bath in, it would not be considered the resident was refusing the shower. The resident would not be expected to take a cold shower or bed bath. The CNA should document the resident did not receive the bath or shower instead of the resident refused. DON confirmed no other staff member should sign a signature for a CNA except the CNA providing the care. Review of the facility policy titled, Shower/Tub Bath revised October 2010 revealed the purpose of the procedures are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident ' s skin. Be sure the bath area is at a comfortable temperature for the resident. The deficiency represents noncompliance investigated under Complaint number 2690478 and 1360479.

Based on observation, interview, record review, and review of the facility policy revealed the facility failed to ensure interventions for fall prevention were in place for Resident #84 and #50. This affected two residents (#84 and #50) of three residents reviewed for falls. The facility census was 91.Findings included:1. Record review for Resident #84 revealed an admission date of 02/01/22. Diagnoses included unspecified dementia, cognitive communication deficit, need for assistance with personal care, abnormalities of gait and mobility, and muscle weakness. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #84 was moderately cognitively impaired. Resident #84 used a walker and wheelchair for mobility, was occasionally incontinent of urine and frequently incontinent of bowel, required supervision or touch assistance for toileting hygiene, bed mobility, chair/bed to chair transfer, walking 50 feet and making two turns, and propelling the wheelchair. Resident #84 has had falls since admission/entry or reentry or prior assessment and had one injury. Review of the Morse Fall scale dated 12/02/25 revealed Resident #84 was at high risk for falling. Review of the care plan for Resident #84 dated 05/20/22 revealed Resident #84 was at risk for falls. Interventions included call don't fall signage to resident room, bed in lowest position, and nonskid strips in front of the bed. Observation and interview on 01/08/26 at 11:07 A.M. with Certified Nursing Assistant (CNA) #210 revealed Resident #84 was at risk for falls. Observation with CNA #210 revealed Resident #84 was lying in her bed. Observation revealed, and CNA #210 verified the bed was not in a low position, there was no call don ' t fall signage and CNA #210 revealed she did not remember ever seeing one. CNA #210 also verified the bed was over top of the non-skid strips. 2. Record review for Resident #50 revealed an admission date of 09/24/20. Diagnoses included systemic lupus, erythematosus, need for assistance with personal care, cerebral palsy and muscle weakness. Review of the quarterly MDS assessment dated [DATE] revealed Resident #50 was cognitively intact. Resident #50 used a wheelchair for mobility, required supervision or touch assistants for bed mobility and required partial/moderate assistants for chair/bed to chair transfer. Resident #50 had two or more falls since admission /entry/reentry or prior to assessment. Review of the care plan date initiated 11/11/20 revealed Resident #50 was at risk for falls related to impaired balance, use of psychotropic medications, history of TIA, and impulsive behaviors. Interventions dated 01/26/21 included applying dycem to the wheelchair. Review of the fall risk assessment dated [DATE] revealed Resident #50 was at moderate risk falling. Observation on 01/08/26 at 2:20 P.M. with Licensed Practical Nurse (LPN) #279 revealed Resident #50 was sitting up in her chair. Resident #50 transferred to her bed. LPN #279 confirmed there was no dycem in Resident #50 ' s chair. Resident #50 revealed she did not ever remember having dycem in her wheelchair. LPN #279 searched Resident #50 ' s room and revealed there was no dycem in her room. Record review with LPN #279 confirmed Resident #50 ' s care plan included staff were to apply dycem to the chair. Review of the progress note for Resident #50 dated 01/09/26 at 5:48 P.M. completed by LPN #279 revealed another nurse found resident (#50) on the floor in another resident room. The note included dycem in place in chair. Review of the care plan dated 11/11/20 (at risk for falls) revealed on 01/09/26 applying dycem to the wheelchair was added again (located on the care plan interventions twice 01/26/21 and 01/09/26). Interview on 01/12/26 at 12:14 P.M. with LPN #279 revealed when Resident #50 was found on the floor on 01/09/26, she did not have dycem in the chair. Dycem was applied to the chair after Resident #50 was found on the floor as an intervention. LPN #279 confirmed the note documented on 01/09/26 at 5:48 P.M. revealed dycem in place in chair and confirmed this was not until after Resident #50 was found on the floor. Review of the facility policy titled, Assessing Falls and Their Causes revised October 2010 revealed the purpose of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Preparation included to review the resident care plan to assess for any special needs of the resident. Falls are the leading cause of morbidity and mortality among the elderly in nursing homes. Residents must be assessed timely for potential causes of falls. When a resident falls, the following information should be recorded in the resident ' s medical record to include appropriate interventions taken to prevent future falls. The deficiency represents noncompliance investigated under complaint number 1360476

Based on interviews, record reviews, and review of the facility policy, the facility failed to ensure accurate and complete documentation for Resident #50 and Resident #64. This affected two residents (#50 and #64) of eleven residents reviewed for records. The facility census was 91.Findings included: 1. Record review for Resident #64 revealed an admission date of 03/15/24. Diagnoses included chronic respiratory failure with hypoxia, muscle weakness, and need for assistance with personal care. Review of the census form included Res #64 was hospitalized on [DATE] and returned 10/17/25. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 was cognitively intact. Resident #64 used a wheelchair for mobility and was dependent for bathing/showers. Review of the care plan dated 07/18/24 revealed Resident #64 required staff assistants for bathing and showering. Interview on 01/07/26 at 10:37 A.M. with Resident #64 revealed, I been begging for a bath for three days, there ' s no hot water they say, I don ' t get washed up period, they only give me one shower a month. Record review of the Shower/Tub bath/ Bed Bath sheets for 10/14/25 through 01/06/26 revealed Resident #64 ' s scheduled shower sheets were completed and signed as completed. Review of the shower record revealed on 10/14/25 Resident #64 received her shower, however, this would not have been possible because Resident #64 was hospitalized . Review of the shower sheet completed and signed by Certified Nursing Assistant (CNA) #235 on 12/09/25 compared to a shower sheet dated 01/06/26 on which there was a signature for CNA #235 that was written twice on top of each other and did not match CNA #235's signature from 12/09/25, the 01/06/26 shower sheet indicated Resident #64 received a bed bath. Interview on 01/12/26 at 1:10 P.M. with Director of Nursing (DON) confirmed Resident #64 was not in facility at the time the shower sheet was documented as completed on 10/14/25. DON confirmed CNA #235 ' s signature dated 01/06/26 did not match the signature dated 12/09/25. Phone interview on 01/12/26 at 1:45 P.M. with CNA #235 revealed she did not have Resident #64 on 01/06/26 so she did not know if she received the shower/bath and confirmed she did not sign the shower sheet on 01/06/26. Interview on 01/12/26 at 2:10 P.M. with Scheduler #245 confirmed CNA #235 did not have Resident #64 on 01/06/26 and revealed CNA #237 had her on that day. Interview on 01/12/26 at 2:20 P.M. with CNA #237 confirmed she had Resident #64 on 01/06/26 and confirmed she did not give her her scheduled bath or shower and she did not sign the shower sheet stating, she would have signed her own name. CNA #237 revealed she did not remember why she did not offer or give the shower/bath on 01/06/26. 2. Record review for Resident #50 revealed an admission date of 09/24/20. Diagnoses included systemic lupus erythematosus, need for assistance with personal care, cerebral palsy and muscle weakness. Review of the quarterly MDS assessment dated [DATE] revealed Resident #50 was cognitively intact. Resident #50 used a wheelchair for mobility and required substantial/maximal assistants for bathing/showering. Review of the care plan dated 11/11/20 revealed Resident #50 had an activity of daily living (ADL) self-care performance deficit related to impaired balance. Interventions included to provide sponge bath when a full bath or shower cannot be tolerated. Interview on 01/08/26 at 8:40 A.M. with Resident #50 revealed she did not have a shower in three weeks. Observation revealed Resident #50 ' s hair was very oily. Resident #50 stated, It makes me feel disgusting, I told the Administrator this is bull (expletive). Resident #50 stated she was not showered due to hot water issues on her unit. Record review of the Shower/Tub bath/ Bed Bath sheets for Resident #50 revealed a shower was refused on 01/03/26 and 01/07/26. Both sheets were signed by CNA #225. Review of the shower sheets revealed the nurse signature was difficult to read for both days. Interview on 01/08/26 at 12:00 P.M. with the DON revealed she was unable to read the Nurse signature that signed the shower sheets on 01/03/26 and 01/07/26. Interview and review of the Shower/Tub bath/ Bed Bath sheets on 01/08/26 at 12:10 P.M. dated 01/03/26 and 01/07/26 for Resident #50 with LPN #286 and CNA #225 revealed CNA #225 stated Resident #50 never refused her showers on either of those dates. CNA #225 became upset and loudly questioned, Who signed my name? That is not my signature (while pointing at the shower sheets dated 01/03/26 and 01/07/26) she did not refuse, that is a lie, there was no hot water, look here is my signature (pointing out the signature on the shower sheet for Resident #50 dated 11/03/25) it looks nothing like that. LPN #286 confirmed the signatures signed on 01/03/26 and 01/07/26 did not resemble the signature dated 11/03/25. Interview on 01/08/26 at 12:36 P.M. with the DON confirmed no other staff member should sign a signature for a CNA except the CNA providing the care. Review of the facility policy titled, Charting and Documentation revised July 2017 revealed documentation in the medical record will be objective (not opinionated or speculative), complete and accurate. The deficiency represents noncompliance investigated under complaint number 2614805

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, closed record review, review of hospital records, review of a protective order, review of a police report, facility policy review and interview, the facility failed to provide adequate supervision and comprehensive individualized interventions to prevent an unauthorized leave of absence (LOA) for Resident #200, who was under adult protection services (APS) with a guardian and guardian directive which prohibited Resident #200's husband from taking the resident off facility premises or into his vehicle. This resulted in Immediate Jeopardy and actual harm/death beginning on [DATE] at approximately 6:00 P.M. when Resident #200's husband took the resident outside the facility and then left the facility grounds with the resident in his vehicle without staff knowledge. Resident #200 was found deceased by local police on [DATE] approximately 1.5 miles from the facility with a gunshot wound to the head. Resident #200's husband was also deceased with an apparent self-inflicted gunshot wound to the head. This affected one resident (#200) of one sampled resident with a protective order reviewed for safety/supervision. The facility identified that 24 residents (#1, #2, #4, #5, #11, #25, #26, #27, #29, #30, #31, #41, #45, #50, #63, #70, #72, #74, #77, #79, #82, #94, #98, and #100) who had guardians and no additional residents with protection orders in place. On [DATE] at 2:58 P.M. the Administrator, by [NAME] President of Operations (VPO) #303, [NAME] President of Clinicals (VPC) #304, and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 6:00 P.M. when staff failed to prevent Resident #200's husband from taking the resident off facility premises (as per a guardian directive). On [DATE] Resident #200 was found deceased by local police approximately 1.5 miles from the facility with a gunshot wound to the head. The Immediate Jeopardy was removed and the deficiency corrected on [DATE] when the facility implemented the following correction actions: On [DATE] at 10:29 P.M. Licensed Practical Nurse (LPN) #300 notified the DON Resident #200 was not in the facility. The DON instructed LPN #300 to notify Physician #302 and Adult Protective Services (APS) Guardian #320. On [DATE] at 10:53 P.M. LPN #300 notified Physician #302 and left a voicemail to return call to facility. On [DATE] at 10:54 P.M. the DON attempted to contact Resident #200's husband and left a voicemail asking him to return the call as soon as possible. On [DATE] at 10:55 P.M. the DON attempted to contact Resident #200's husband again but did not leave a voice mail. On [DATE] at 10:55 P.M. LPN #300 notified APS Guardian #320 that Resident #200 was not in facility. On [DATE] at 11:20 P.M. the DON notified the local police department of an unauthorized LOA for Resident #200. On [DATE] at 11:45 P.M. the DON arrived at facility and spoke with Police Officer (PO) #322 regarding the situation and supplied him with Resident #200's face sheet and diagnosis list. Officer #322 assigned report #[DATE]. On [DATE] between 9:45 A.M. and 10:00 A.M. a root cause analysis was conducted by VPO #303, VPC #304, Regional Director of Operations (RDO) #305, Regional Director of Clinical Services (RDCS) #306, Administrator, and DON related to the incident. System failure was identified as failure to ensure LOA sign-out was monitored and failure to adequately supervise Resident #200's LOA. On [DATE] at 10:05 A.M. VPCS #304 and VPO #303 educated the DON and Administrator on the facility adequate supervision of residents, LOA procedure, and facility abuse/neglect policy. On [DATE] at 10:10 A.M. the DON spoke with PO #322 from the local police department and received an update that Resident #200 had expired. On [DATE] at 10:25 A.M. the DON and Administrator educated all department heads on adequate supervision of residents, abuse/neglect policy and LOA procedure. The LOA procedure included that LOA books must be in secured location behind each nurse's station and the front desk, employee must verify LOA status via bed board (list of all residents by room number, payer and LOA status) resident or responsible party must sign out on the book with estimated return time. If the resident is not back by the estimated time, the facility will make contact and ask for an updated return time. On [DATE] at 10:49 A.M. RDCS #306 reviewed all residents' medical records for guardian status, to ensure appropriate LOA orders and any protective orders were in place and care planned. The facility identified 24 Residents (#1, #2, #4, #5, #11, #25, #26, #27, #29, #30, #31, #41, #45, #50, #63, #70, #72, #74, #77, #79, #82, #94, #98, and #100) with guardians. There were no additional residents currently residing in the facility who had protection orders. On [DATE] from 11:00 A.M. through 4:00 P.M. the DON, Assistant Director of Nursing (ADON) #308, LPN #309, Human Resource Director (HR) #310, Dietary Manager (DM) #311, Director of Rehabilitation (DOR) #312, Housekeeping Supervisor #313, Activities Director (AD) #314 educated their departments so that all staff were in-serviced on the facility adequate supervision of residents, LOA procedure, and facility abuse/neglect policy. Staff who were not in the building received a phone call with the information. On [DATE] at 11:15 A.M. Admissions Director #315, reviewed and updated the facility bed board per LOA orders. On [DATE] at 11:30 A.M. the DON updated the LOA sign-out books with a new form to include anticipated return time at all nurse's stations and the front desk. On [DATE] at 11:45 A.M. LPN #309 updated and implemented the nurse report sheets at all nurse's stations. The nurse report was updated to include the report of residents on LOA. On [DATE] at 2:33 P.M. Physician #303 was informed of the situation surrounding Resident #200's death by the DON. On [DATE] at 2:41 P.M. Medical Director #316 was notified of Resident #200's death and a Quality Assurance and Performance Improvement (QAPI) meeting was held with the interdisciplinary team (IDT) including Medical Director #316, Physician #302, Administrator, DON , AD #314, HR #310, LPN #309, Maintenance Director #317, Admissions #315, and Maintenance Assistant #318 to review root cause analysis, facility interventions, facility policies, and facility response. The Administrator educated attendees on the policy if an order was obtained that allowed outside visits on facility property or with contingencies such as: not allowed to sit in car, the outside visit must occur during supervised smoke times so staff were still able to supervise that the order restrictions were being followed, the adequate supervision of residents with orders, LOA procedure, and facility abuse/neglect policy. Orders must be complete and thorough with details that the facility would be able to follow. If any orders were received that were unable to followed or that could not be met and managed, the facility must call the prescriber/person back and explain why the order could not be followed and get a new or updated order. All communication for clarifying orders must be documented in Point Click Care (PCC) (electronic medical record). If any order comes that the facility is questioning the manageability, a call must be placed to regional staff for review. This included all orders for medications, LOA, protective orders, treatments, etc. On [DATE] at 3:55 P.M. APS Guardian #320 was notified by the DON of the situation surrounding the death of Resident #200. On [DATE] at 4:00 P.M. LPN #319 reviewed LOA orders, protective orders and LOA care plans for accuracy and updated as necessary. No other residents currently had protective orders. Audits were initiated the week of [DATE] for bed board completion and accuracy. Audits would be conducted five times a week for four weeks then weekly for four weeks and randomly thereafter by the Administrator or designee. Audits were initiated the week of [DATE] for completion and accuracy of LOA books. Audits would be conducted five times a week for four weeks then weekly for four weeks and randomly thereafter by the Administrator or designee. Audits were initiated the week of [DATE] for accuracy and completion of nursing report sheets. Audits would be conducted five times a week for four weeks then weekly for four weeks and randomly thereafter by the DON or designee. Audits were initiated the week of [DATE] for new admission or existing residents for new or revised protective orders, guardian status, and updated LOA orders to reflect in the residents' care plans. Audits would be conducted five times a week for four weeks then weekly for four weeks and randomly thereafter by the Social Worker or designee. Audits were initiated the week of [DATE] for new admission or existing residents with a mental health diagnosis to ensure they were offered psychological services. Audits would be conducted five times a week for four weeks then weekly for four weeks and randomly thereafter by the DON or designee. Observational audits were initiated on [DATE] of ten residents who required supervision of care to ensure monitoring was effective. Audits would be conducted five times a week for four weeks then weekly for four weeks and randomly thereafter by the DON or designee. Interviews on [DATE] and [DATE] at various times from 6:45 A.M. through 4:00 P.M. with Registered Nurse (RN) #569, Housekeeper #524, LPN #595, RN #557, Certified Nursing Assistant (C.N.A.) #571, C.N.A. #611, C.N.A. #588 and Receptionist #618 revealed that they were in-serviced on elopement, abuse, and visitation. Review of signed in-service sheets dated [DATE] verified employees were in-serviced on resident supervision with all tasks according to their plan of care, missing residents' best practice, LOA books, and LOAs with restrictions. Findings include: Review of the closed medical record for Resident #200 revealed an admitted [DATE] and a re-admitted [DATE] with diagnoses including unspecified psychosis not due a substance, Crohn's disease, generalized anxiety disorder, depression, and delusional disorder. Based on review of a police report, Resident #200 was pronounced deceased on [DATE] as a result of a gunshot wound to the head. The circumstances surrounding Resident #200's death was not included as part of the resident's medical record. Review of Resident #200's hospital admitting paperwork dated [DATE] revealed the resident had been hospitalized for treatment of acute psychosis. Resident #200 was brought to the hospital emergency department on [DATE] from home as she reportedly been increasingly confused and paranoid. She presented it to the hospital after a stress-induced seizure after a fight with her husband. Resident #200 presented to her primary care provider (PCP) on [DATE] with a right arm injury stating her husband slammed a metal door on her arm and held it closed causing multiple abrasions. She declined hospital and police at that time and was returned home. She and her husband continued to argue, the police were notified by neighbors, and Resident #200 was brought to hospital. Resident #200 was a poor historian. She had multiple visits to the hospital with psychosis and paranoia (mostly regarding her husband). Adult Protective Services (APS) had been involved with Resident #200 since 2013 related to the resident's accusations of abuse from her husband. The resident lived with her husband for over [AGE] years, and police visited the home multiple times due to domestic complaints. Upon examination, Resident #200 appeared drowsy but does engage. She voiced fear and paranoia of her husband. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #200 was cognitively intact and required set up for activities of daily living. Resident #200 did use a wheelchair but could transfer herself. Review of a protective order dated [DATE] revealed Resident #200 needed protective services, was incapacitated and that there was no person authorized by law or court to give consent (for the resident). It was ordered that APS would be authorized by law or court to be able to give consent. It was further ordered that APS should have the authority to consent to medical treatment and nursing home admission. Review of a Social Service note dated [DATE] revealed Social Service Designee (SSD) #800 attempted to call APS Guardian #320 multiple times for discharge instructions for the resident. The note indicated this was an APS case, and the resident was not allowed to leave with her husband, but they were insisting on her leaving the facility and going home. A message was left with APS Guardian #320, and APS stated that he would reach out Friday or Monday. Review of the progress note dated [DATE] at 2:47 P.M. revealed the Administrator spoke to APS Guardian #320, (a temporary guardian), about Resident #200's husband being able to walk Resident #200 around the building. APS Guardian #320 stated that it was okay. They note indicated, per the APS Guardian, they were not allowed to leave the premises, but they could walk outside around the building. Review of a social services note dated [DATE] at 2:48 P.M. revealed Social Service Designee (SSD) #800 spoke with APS Guardian #320 regarding visitation by Resident #200's husband. The note revealed as of this date, Resident #200's husband was informed he was not allowed to sit in his car with his wife, and that they could just walk around the building. The note reflected third floor nursing (where the resident resided) and the front desk were notified. Review of Resident #200's medical record revealed no care plan was implemented for visitation, the resident's protection order and/or any restriction(s) on visitation with the resident's husband. In addition, there were no interventions initiated to ensure the resident was adequately supervised or her whereabouts monitored as it pertained to visitation with the resident's husband and per APS Guardian #320's directive. Review of the facility LOA logbook revealed on [DATE] Resident #200's husband signed in at 6:00 P.M. Record review revealed no nursing progress notes were written from [DATE] at 6:00 P.M. through [DATE] at 2:42 A.M. Review of a nursing progress note, created on [DATE] at 2:42 A.M. with an effective date of [DATE] at 9:28 P.M. (the police report below notes a time of 11:28 P.M.) authored by LPN #300 revealed she arrived to Resident #200's room and noticed Resident #200 wasn't in the room. The note indicated she looked in the bathroom and the resident was not there. Staff did a building search inside and outside. Resident #200's frequent visitor (identified to be her husband) was contacted with no answer. A voicemail was left. The nurse reached out to the DON, contacted the local police who arrived at the facility at 11:39 P.M., and a report was made. APS Guardian #320 was made aware of the situation. The note included will have dayshift follow up. Review of a police report (report #,d+[DATE]) dated [DATE] revealed the local police were called to the facility at 11:28 P.M. for a missing person [Resident #200]. Officer #322 spoke with LPN #300, who reported Resident #200 left the faciity on [DATE], between the approximate hours of 6:28 P.M. and 11:26 P.M. LPN #300 continued to state Resident #200 had a court ordered guardian [APS Guardian #320] and was not permitted to leave the property, without her guardian's permission. LPN #300 stated at approximately 11:26 P.M. she went to Resident 200's room to administer her night medications. It was at this time she realized Resident #200 was missing from her room. LPN #300 then stated that when she checked the visitor logbook, she observed that Resident #200's husband had signed the logbook as arrived for a visit. LPN #300 stated she then attempted to call the resident's husband by phone but received no response. She then proceeded outside and located Resident #200's wheelchair hidden behind bushes, in the rear parking lot of the facility. Officer #322 interviewed other staff members, and they believed the husband took Resident #200 in his car. Officer #322 drove by the husband's house and there was no activity. Officer #322 called the local medical examiner's office and was informed Resident #200 and her husband were found dead at a nearby golf course. The officer closed the report on [DATE] at 4:02 A.M. The report did not state the actual time Resident #200 and her husband her found deceased . Information provided by the facility during the investigation revealed on [DATE] between 9:45 A.M. and 10:00 A.M. a root cause analysis was conducted by VPO #303, VPC #304, Regional Director of Operations (RDO) #305, Regional Director of Clinical Services (RDCS) #306, the Administrator, and DON related to the incident. System failure was identified as failure to ensure LOA sign-out was monitored and failure to adequately supervise Resident #200's LOA. Interview on [DATE] at 8:15 A.M. with Receptionist #618 revealed the facility had a list of residents who could not go on LOAs. The list changed frequently. Receptionist #618 revealed Resident #200 was not allowed to go out on LOAs at first but then the resident's guardian allowed her to go outside the facility building with her husband if she did not get into the car or leave the premises. Receptionist #618 revealed the resident's husband would always park down on the right side (outside the facility), and she could not see the car. She stated she was not on duty on [DATE] at the time of the incident. During the interview, Receptionist #618 revealed she was responsible to ensure Resident #200 did not get in her husband's car when they were outside; however, she again reiterated she was not present in the facility at the time of the incident on [DATE]. Observation on [DATE] at 8:20 A.M. from front desk revealed no parked cars were visible from the front desk. Interview on [DATE] at 10:48 A.M., with the DON verified the content of the social service notes which directed (per the APS Guardian) that Resident #200 could not be in car with her husband. The DON stated the facility did not have a person assigned to supervise Resident #200 when she went outside. He stated the receptionist knew the husband should not have taken Resident #200 off the premises. Information from APS revealed Resident #200 had been an active client with APS as of [DATE]. An APS investigation validated physical abuse (with a history of domestic violence) and self-neglect involving Resident #200. This resulted in APS pursuing a Protective Service Order (PSO) which made APS the temporary decision maker for the client. The resident was subsequently placed at the facility while APS pursued getting the client a guardian. The resident's husband was not pleased with either the PSO or the decision to place the resident in the facility. Following admission and during the resident's stay in the facility, APS was in regular contact with the resident's husband and the facility concerning visitation issues. Resident #200's husband wanted to take the resident out and away from the facility, but he could not be trusted to return her, so eventually the facility was directed by APS that the husband could visit, but he was not allowed to take her away from the facility. Interview with APS Guardian #320 on [DATE] at 2:44 P.M. revealed APS the facility told him that they would watch Resident #200 on the grounds. He stated the facility told him that they try not to limit visitors. Interview on [DATE] at 3:42 P.M. with LPN #580 revealed Resident #200 did not say much but did go outside with her husband. LPN #580 stated Resident #200 was not supposed to leave the premises. The LPN provided no additional information as to how staff were to ensure the resident did not leave the premises with her husband or how staff monitored the resident's whereabouts when the husband was visiting with her, or they were outside. Interview on [DATE] at 3:18 P.M. with Certified Nursing Assistant (CAN) #571 revealed during the resident's admission, she had become more social and was starting to talk. CNA #571 was aware Resident #200's husband visited a lot, and that the resident did go outside with him. CNA #571 denied the resident having any other visitors besides her husband. The CNA stated she was aware Resident #200 was not supposed to leave the premises. The CNA provided no additional information as to how staff were to ensure the resident did not leave the premises with her husband or how staff monitored the resident's whereabouts when the husband was visiting with her, or they were outside Interview on [DATE] at 3:28 P.M. with CNA #611 revealed Resident #200 was very quiet and stayed in her room. CNA #611revealed the resident's husband did visit a lot and he took her off the floor. The CNA stated she was aware the resident was not supposed to leave the grounds with her husband. The CNA provided no additional information as to how staff were to ensure the resident did not leave the premises with her husband or how staff monitored the resident's whereabouts when the husband was visiting with her, or they were outside Interview on [DATE] at 3:33 P.M. with CNA #588 revealed Resident #200 was becoming more social and starting to talk. Resident #200's husband visited a lot, and she went outside with him. CNA #588 stated Resident #200 had no other visitors, and Resident #200 was not supposed to leave the premises. The CNA provided no additional information as to how staff were to ensure the resident did not leave the premises with her husband or how staff monitored the resident's whereabouts when the husband was visiting with her, or they were outside Review of the facility policy dated [DATE] titled, Abuse, Neglect, Exploitation and Misappropriation of Resident Property, revealed the facility would not tolerate neglect of any resident. The definition of neglect was the failure of the facility, its employees, or facility service providers to provide goods and services to a resident necessary to avoid harm, pain, mental anguish, or emotional distress. This deficiency represents non-compliance investigated under Master Complaint Number OH00160035 and Complaint Number OH00160019.

Based on interview, record review and review of the facility policy, the facility did not ensure appropriate monitoring of Resident #201's ability to urinate and/or signs of urinary discomfort after the removal of an indwelling urinary catheter (a hollow flexible tube that collects urine from the bladder and leads to a drainage bag). This finding affected one (Resident #201) of three residents reviewed for urinary catheters. The facility census was 97. Findings include: Review of Resident #201's medical record revealed the resident was admitted on [DATE] and discharged on [DATE] with diagnoses including acute kidney failure, benign prostatic hyperplasia without lower urinary tract symptoms, and lymphedema. Review of Resident #201's October 2024 physician orders revealed an order dated 10/13/24 to provide urinary catheter care every shift; an order dated 10/13/24 for a 16 French Foley catheter with a 10 milliliters (ml) balloon; an order dated 10/13/24 for the catheter to be changed as needed if leaking or occluded; an order dated 10/13/24 to discontinue the Foley catheter and start the bowel and bladder program for three days. Review of Resident #201's October 2024 Documentation Survey Report of the Bowel and Bladder Tracking revealed the form had time slots to document Resident #201's bowel and bladder episodes including 12:00 A.M., 2:00 A.M., 4:00 A.M., 6:00 A.M., 8:00 A.M., 10:00 A.M., 12:00 P.M., 2:00 P.M., 4:00 P.M., 6:00 P.M., 8:00 P.M. and 10:00 P.M. Further review of Resident #201's Documentation Survey Report revealed on 10/12/24, the tracking for the 8:00 A.M., 10:00 A.M., 12:00 P.M. and 2:00 P.M. time slots (all documented at 12:54 P.M.) revealed the resident was continent of urine, continent of bowel, independent with toilet use (self-performance) and no setup or physical help was required from staff for toilet use (support provided). The documentation did not include the amount of urine that Resident #201 voided during these time slots. The 4:00 P.M., 6:00 P.M., 8:00 P.M. and 10:00 P.M. time slots were blank. The documentation on 10/13/24 for 12:00 A.M., 2:00 A.M., 4:00 A.M. and 6:00 A.M. (all entries documented at 6:08 A.M.) stated not applicable (n/a). The 8:00 A.M. time slot (documented at 7:15 A.M.) revealed the resident did not urinate, had no bowel movements, required total dependence with one person assist. The Documentation Survey Report revealed Resident #201 from 10/12/24 at 4:00 P.M. to 10/13/24 at 7:34 A.M. when the resident was discharged to the hospital (approximately 14.5 hours) there was no documented evidence that the resident urinated. Review of Resident #201's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition and had an indwelling urinary catheter. He required partial to moderate assistance with toileting hygiene. Review of the nursing note dated 10/12/24 at 6:15 A.M. and authored by Registered Nurse (RN) #589 revealed Resident #201's urinary catheter was removed at this time, and education was provided to the resident on voiding and when to alert staff if he did not urinate. Resident #201 voiced understanding and the oncoming nurse was made aware. Review of nursing notes dated from 10/12/24 at 6:15 A.M. to 10/13/24 at 7:34 A.M. there was no further documentation regarding if Resident #201 was assessed after his indwelling urinary catheter was removed including if he urinated, if he had any discomfort, amount that he urinated, and/or any bladder/abdominal assessment. Review of Resident #201's Situation-Background-Assessment-Recommendation (SBAR) form at 10/13/24 at 7:34 A.M. authored by RN #585 indicated the resident complained of pain with the recommendation to send to the emergency room (ER). Review of the After Visit Summary dated 10/13/24 revealed Resident #201 was seen in the hospital emergency room by Physician Assistant (PA) #950 and diagnosed Resident #201 with urinary retention and urinary tract infection (UTI) with hematuria (blood in urine). PA #950 ordered an indwelling urinary catheter until follow up with the urologist and prescribed Macrobid (antibiotic) for urinary tract infection. Review of Resident #201's readmission progress note dated 10/13/24 at 12:22 P.M. authored by RN #585 indicated the resident was sent to the hospital at 7:00 A.M. and returned to the facility at 12:00 P.M. The resident had a diagnosis of urinary retention, and a 16 French Foley catheter was placed. A new order for Macrobid 100 milligrams (mg) twice daily for seven days due to a UTI was ordered. The physician and family were made aware. The Foley catheter was patent and draining yellow urine. Interview on 12/02/24 at 2:33 P.M. with [NAME] President of Operations #303 verified from the time the catheter was removed on 10/12/24 at 6:15 A.M. until 10/12/24 at 4:00 P.M. the staff documented that he was continent of urine but that there was no documented evidence of the amount that he had urinated and/or if he was having any difficulty with urination. She also verified Resident 201's October 2024 Documentation Survey Report of the Bowel and Bladder Tracking revealed he did not urinate per the documentation from 10/12/24 at 4:00 P.M. to 10/13/24 at 7:34 A.M. (approximately 14.5 hours) and that the documentation on 10/12/24 for 4:00 P.M., 6:00 P.M., 8:00 P.M. and 10:00 P.M. time slots were blank. She verified that there was no documentation after his urinary catheter was removed on 10/12/24 at 6:15 A.M. including if he was voiding without difficulty, amount he was voiding, any pain, and/or any bladder/abdominal assessment until on 10/13/24 at 7:34 A.M. when it was documented he was sent to the hospital for pain. Interview on 12/02/24 at 3:03 P.M. with Resident #201 revealed the facility removed his urinary catheter on 10/12/24 early in the morning, and he had not urinated. He revealed no staff including a nurse had ever checked on him including checking if he voided, if he had any discomfort, and/or completed any bladder/abdominal assessment. He revealed that after he had not voided for a prolonged period, he contacted the emergency rescue squad (EMS) to transport him to the hospital. He revealed he had not communicated with the nurse that he had contacted EMS until they arrived as he felt that if they did not care enough to check on him, then why should he let them know he had contacted EMS to take him to the hospital. Review of the facility policy labeled, Behavioral Programs and Toileting Plans for Urinary Incontinence last revised October 2010 indicated the purpose of the procedure was to provide guidelines for the initiation and monitoring of behavioral interventions and/or toileting plan for the resident with urinary incontinence. The policy revealed the staff would monitor, record, and evaluate information about the residents' bladder habits including voiding pattern (frequency, volume, time, quality of urine stream, and pain or discomfort. The policy revealed to notify the supervisor if the resident refused the procedure and to report other information in accordance with facility policy and professional standards of practice. There was nothing in the policy in regard to monitoring after a urinary catheter was discontinued. This deficiency represents non-compliance investigated under Complaint Number OH00159584.

Based on observation, medical record review, review of the facility investigation, hospital record review, review of the facility root cause analysis, review of facility policy and interviews, the facility failed to provide adequate supervision and monitor WanderGuard (wearable device to help keep residents at risk of wandering safe) functioning for Resident #69, a resident with a history of exit seeking behavior to prevent elopement. This resulted in Immediate Jeopardy and the potential for serious harm, injury and/or death on [DATE] at approximately 7:44 P.M. when Resident #69 eloped from the facility without staff knowledge, through a smoking patio exit door and traveled from Ohio (OH) to Wisconsin (WI), under unknown circumstances. Resident #69 was not seen by facility staff for nearly three hours before he was discovered missing at approximately 10:30 P.M. Resident #69 was missing from the facility for over two days when he was found on [DATE] by a university police department on a college campus in WI, approximately 425 miles away from the facility. Resident #69 was subsequently transported to a local hospital in WI for evaluation and treatment and then transferred back to the facility on [DATE]. During the time Resident #69 was missing, the resident missed hemodialysis (treatment that filters waste and excess fluid from the blood when the kidneys are unable to) treatment and several prescription medications including those to treat high blood pressure, angina (chest pain) and mental illness. This affected one resident (#69) of six residents reviewed for elopement. The facility census was 101. On [DATE] at 2:52 P.M. the Administrator, Regional Director of Operations (RDO) #800 and Regional Director of Clinical Services (RDCS) #801 were notified that Immediate Jeopardy began on [DATE] at approximately 7:44 P.M. when the facility failed to provide adequate supervision and ensure a functional WanderGuard for Resident #69. Resident #69 was able to exit the facility, without staff knowledge, through the smoking patio door and traveled out of state, approximately 425 miles away, under unknown circumstances. Resident #69 was placed at increased risk due to the unknown circumstances of his travel to WI and medical treatments, (including dialysis and medications) not being provided. Resident #69 was not located until [DATE], at which time he was transported to a local hospital in WI for evaluation, treatment and supervision until he was transported back to the facility on [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 10:30 P.M., Registered Nurse (RN) #811 was unable to locate Resident #69 for medication administration and instructed State tested Nursing Assistant (STNA) #823 and STNA #824 to search the unit. On [DATE] at 10:45 P.M. RN #811 called a code and Licensed Practical Nurse (LPN) #825 and LPN #826 searched all facility floors and outside areas. On [DATE] at 11:01 P.M., RN #827 notified the Director of Nursing (DON) that Resident #69 was missing. The DON instructed RN #811 to complete a resident head count of the entire facility and obtain witness statements from all staff present at that time. On [DATE] at 12:00 A.M., Police Officer (PO) #834 arrived from the local police department and took a report from RN #811. RN #811 provided the officer with Resident #69's demographic information, the last time he was seen and a brief description of what he was wearing (blue jeans, a white and blue striped shirt and a navy-blue lightweight jacket) prior to the elopement. On [DATE] at 6:00 A.M., a root cause analysis was conducted by RDO #800, RDCS #801, the Administrator and the DON. The root cause of Resident #69's elopement was determined to be a system failure to ensure the resident ' s WanderGuard was in place and/or functional and adequate supervision. On [DATE] at 6:15 A.M., RDO #800 re-educated the DON and the Administrator on the facility's elopement policy and best practice, WanderGuard protocol, elopement risk assessments and interventions, door alarm response and adequate supervision of residents. On [DATE] at 8:00 A. M., the DON initiated in-person education with all facility staff on the elopement policy and best practice, WanderGuard protocol, elopement risk assessments and interventions, door alarm response and adequate supervision of residents. Dietary Manager (DM) #828, Housekeeping Director (HD)#806, Activities Director (AD) #808 and Assistant Director of Nursing (ADON) #838 assisted with the education, after receiving the education from the DON and/or Administrator. By 4:30 P.M., 113 of 113 staff received the education. Education will be provided for all new employees during orientation. On [DATE] from 10:30 A.M. to 1:30 P.M., ADON #838, Unit Manager (UM) #829 and Wound Nurse (WN) #830 re-assessed all residents for elopement and verified care plans were up to date. On [DATE] at 10:15 A.M., Director of Maintenance (DOM) #804 checked all doors equipped with WanderGuard sensors to ensure functionality. On [DATE] at 11:00 A.M., an Ad-Hoc Quality Assurance Performance Improvement (QAPI) meeting was held to review the root cause analysis, facility interventions, facility policies on wandering and elopement and facility response. In attendance were Medical Director (MD) #831, Primary Physician (PP) #802, the Administrator, the DON, AD #808, HD #806, Social Services Designee (SSD) #810, DM #828, Human Resources Director (HRD) #832, UM #829 and DOM #804. The Administrator re-educated attendees on the elopement policy, WanderGuard protocol, door alarm response and supervision of residents. On [DATE] from 11:30 A.M. to 1:30 P.M., RDCS #801 reviewed residents with WanderGuard orders (Residents #20, #30, #31, #35, #39, #40, #44, #49 and #51) to ensure placement and functionality of the WanderGuards and the residents' care plans were accurate. All reviewed residents had functioning WanderGuards in place and care plans were updated. On [DATE] from 1:00 P.M. to 4:00 P.M., Minimum Data Set Nurse (MDSN) #833 conducted a second review of all resident care plans and updated, as needed, to ensure all care plans accurately reflected elopement risk and WanderGuard use/interventions. Beginning on [DATE], DOM #804, or designee, would conduct checks of doors equipped with WanderGuard sensors five times per week for two weeks then weekly until [DATE]. Beginning on [DATE], the DON, or designee, would audit nine WanderGuard placement and function three times weekly for four weeks then one time weekly for four weeks. On [DATE] at 8:00 A.M., LPN #812 was notified by university police in Milwaukee, WI that Resident #69 was found on their campus. LPN #812 immediately notified ADON #838, who then immediately notified the DON and Administrator. On [DATE] at 9:00 A.M., university police transported Resident #69 to an area hospital for further evaluation due to missed medications and hemodialysis treatments. On [DATE] at 9:20 A.M., AD #839 and STNA #840 picked-up Resident #69 from the hospital in Milwaukee, WI and transported the resident back to the facility. On [DATE] at 7:09 P.M., Resident #69 returned to the facility. LPN #814 assessed Resident #69 and the resident was placed on one-on-one supervision for safety. The resident's WanderGuard was replaced and tested to ensure it properly functioned. On [DATE] at 8:00 P.M., RDCS #801 reviewed Resident #69's care plan for accuracy. On [DATE] at 2:28 A.M., LPN #837 reassessed Resident #69 for elopement risk. Resident #69 was assessed to be at high risk for elopement. On [DATE] at 6:00 P.M., DOM #804 conducted an elopement drill with no concerns identified with staff response. On [DATE], MDSN #833 updated Resident #69's care plan to include updated elopement risk and interventions. Resident #69's physician orders were updated to check WanderGuard placement and function each shift. On [DATE] at 4:00 P.M., DOM #804 placed an order for an additional WanderGuard testing device and WanderGuard bracelets to provide additional supplies. Beginning on [DATE], DOM #804, or designee, would conduct elopement drills/resident supervision on each shift weekly for four weeks and then monthly indefinitely. Beginning on [DATE], the DON or designee, would audit elopement assessments and interventions for accuracy and completeness weekly for four weeks. Interviews on [DATE] from 8:51 A.M. to 3:56 P.M. and on [DATE] from 11:35 A.M. to 2:43 P.M. with LPN #813, LPN #814, STNA #815, STNA #816, STNA #817, STNA #818, STNA #819 and STNA #820 verified the facility provided education on the elopement policy and procedure, WanderGuard protocol, elopement risk assessments and interventions, door alarm response and adequate supervision of residents. Review of the open medical records for five additional residents (#20. #35, #39, #40 and #49) revealed elopement assessments were completed, and care plans were reviewed and updated as needed. Although the Immediate Jeopardy was removed on [DATE], the deficiency remains at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #69 revealed an admitted [DATE] with diagnoses including schizophrenia, bipolar disorder, anxiety disorder, end stage renal disease with dependence on renal dialysis, left below knee amputation, cirrhosis of the liver, type two diabetes mellitus and essential hypertension. Resident #69 had a legal guardian and resided on the facility third-floor, long-term care unit. Review of the Admit/Readmit Progress Note, dated [DATE], revealed Resident #69 admitted to the facility with episodes of delusions and hallucinations. Resident #69 had a WanderGuard applied to his wheelchair as the resident was known to exit seek and become combative. Resident #69 admitted to the facility under supervision of a legal guardian. Review of a physician's order, dated [DATE], revealed an order for WanderGuard check every shift for location of the device. There was no evidence of an order to check the WanderGuard functionality. Review of the Statement of Expert Evaluation for the local county probate court, dated [DATE], revealed Resident #69 had mental impairment related to mental illness of schizophrenia, major depressive disorder, anxiety disorder and bipolar disorder. Resident #69 lacked insight and judgement into mental health diagnoses and lacked proper decision-making skills. The physician noted Resident #69 was not mentally or physically capable of caring for himself and guardianship should be continued. Review of the Elopement Review assessment, dated [DATE], revealed Resident #69 was assessed to be low risk for elopement. The assessment indicated Resident #69 had no elopement attempts in the last three months, was cognitively intact and ambulatory with the use of a wheelchair. Review of Medicare Minimum Data Set (MDS) Annual assessment dated [DATE] revealed Resident #69 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. There were no noted wandering behaviors on the MDS assessment. Resident #69 was independent for dressing, bed mobility, wheelchair use, and transfers. Resident #69 used a wander or elopement alarm daily. The assessment revealed Resident #69 required dialysis. In addition, review of the active physician orders revealed Resident #69 received (hemo)dialysis three days a week. Resident #69 was ordered the following medications to treat high blood pressure and/or angina (chest pain): two 25 milligram (mg) tablets of Carvedilol two times per day, 100 mg tablet of Hydralazine three times per day, 30 mg tablet of Isosorbide Mononitrate in the evening, 60 mg tablet of Nifedipine two times per day, and 4 mg tablet of Doxazosin Mesylate one time per day. Additionally, Resident #69 was on 2.5 milliliters (ml) of 2 mg/ml Haldol by mouth three time per day and 25 mg intramuscular injection of Risperdal one time per day for control of symptoms associated with schizophrenia. Review of the treatment administration record (TAR) for [DATE] and [DATE] revealed Resident #69's WanderGuard was checked for placement, per the physician order at the time. Further review of the medical record revealed no evidence Resident #69 ' s WanderGuard was checked for functionality. Review of the psychiatric note, dated [DATE], revealed Resident #69 was guarded and evasive during the visit. Resident #69 denied having mental illness. Nursing reported Resident #69 had behaviors and refused medications at times. Resident #69's insight and judgement were poor as evidenced by self-defeating or endangering behaviors without regard to consequences. Review of nursing progress note dated [DATE] at 3:47 P.M. revealed Resident #69 had returned from dialysis treatment. It was noted Resident #69 was administered an injection of Risperdal. Review of the nursing progress note, dated [DATE], at 10:36 P.M., revealed the nurse (RN #811) witnessed Resident #69 get on the elevator and leave the third floor between 7:30 P.M. and 8:30 P.M. Resident #69 was not found in his room during medication pass. All staff began searching the facility and outside premises. Review of Elopement Incident Report, dated [DATE] at 11:01 P.M., revealed Resident #69 was missing from the facility. Search of the building and surrounding area did not locate Resident #69. The Administrator, DON and police were notified. Risk factors included end stage renal disease, impaired vision, taking psychoactive drugs, diabetes, non-compliance, amputation and active exit seeking. Resident #69's physician was notified on [DATE] at 11:10 P.M. and Resident #69's guardian notified on [DATE] at 11:20 P.M. Review of nursing progress note, dated [DATE] at 2:09 A.M., revealed Resident #69 was not located in the facility or outside premises. The DON was notified on [DATE] at 11:01 P.M. The nurse contacted the local hospital, local police and guardian. The local police arrived and took a report from the nurse. Review of the late entry admit/readmit progress note, dated [DATE] at 8:00 A.M., revealed the DON was notified Resident #69 was not located in the facility. A complete search of the facility and surrounding area was completed. The DON instructed nursing staff to notify the local police and fill out a missing person report. The local police arrived at the facility at approximately 12:00 A.M. on [DATE]. The DON and Administrator came to the facility and another search of the facility and surrounding area was conducted. Review of the nursing progress note dated [DATE] at 10:39 A.M. revealed a follow up call was placed to Resident #69's guardian. The unit manager left a voicemail to contact facility for emergent notification. Review of the late entry social services progress note dated [DATE] at 11:32 A.M. revealed MD #831 was notified Resident #69 was not located in the facility. Review of the social services progress note dated [DATE] at 1:15 P.M. revealed Resident #69's guardian returned the phone call and was provided with an update on Resident #69. Review of the revised care plan, dated [DATE], revealed Resident #69 had history of cutting off the WanderGuard on [DATE]. Further review of the medical record revealed no information related to events or occurrences of Resident #69 attempting to remove the WanderGuard. Review of the general progress note dated [DATE] at 8:02 A.M. revealed the nurse received a call from a police department in Milwaukee, Wisconsin. Resident #69 was at the police station. The nurse gave police officer information on Resident #69's medical history. Resident #69 was sent to a local hospital in Milwaukee. The nurse notified Resident #69's guardian, physician, and ADON. Review of hospital records revealed Resident #69 arrived at the emergency room (ER) on [DATE] at 8:01 A.M. via ambulance. The resident reported no symptoms and last had dialysis three days prior. Resident #69 had labs drawn, a chest x-ray and an electrocardiogram (EKG - measures electrical activity of the heart). The hospital nephrologist (kidney specialist) recommended 30 milligrams (mg) of Kayexalate (treats high levels of potassium in the blood) and no dialysis treatment. Social work was consulted related to legal guardianship in Ohio. The guardian reported to hospital staff Resident #69 was in a locked facility, managed to elope and used public transportation to get to WI. The social worker reached RDO #800 at the facility to arrange Resident #69 ' s return. Resident #69 was scheduled to be picked up in a facility van by two facility staff on [DATE] at 9:00 A.M. Review of Interdisciplinary Team (IDT) note dated [DATE] at 8:26 A.M. revealed the IDT reviewed the root cause of Resident #69 leaving the facility. Interventions upon Resident #69's return included one- on-one supervision and exit doors would be monitored for proper function of WanderGuard equipment. Review of the admit/readmit progress note dated [DATE] at 7:09 P.M. revealed Resident #69 readmitted to the facility in a wheelchair. Resident #69 was alert and oriented to person, place, and time. Resident #69 had no complaints of pain or discomfort. Resident #69 was placed on one-on-one supervision until further notice. Resident #69's guardian, ADON, unit manager, and nurse practitioner were notified of his return. Review of the late entry nursing progress note dated [DATE] at 7:47 P.M. revealed staff obtained Resident #69's weight, provided a shower, obtained vital signs and completed a skin assessment. Review of the revised care plan dated [DATE] revealed Resident #69 was at high risk for elopement related to diagnosis of schizophrenia, history of attempts to leave the facility unattended and impaired safety. Interventions included to distract resident from wandering with pleasant diversions, structured activities, food, conversation, television, or books; identify a pattern of wandering; divert wandering as needed; intervene as appropriate; monitor for fatigue or weight loss, and wander alert to resident's wheelchair. A telephone interview on [DATE] at 11:20 A.M. with Program Manager (PM) #822 with the volunteer guardian program revealed on [DATE], at approximately 2:00 A.M., they received a call indicating Resident #69 was missing from the facility. PM #822 stated the facility noticed Resident #69 was missing during the nighttime medication pass on [DATE]. PM #822 reported they were informed Resident #69 left out of the smoking patio door and kept going. PM #822 indicated Resident #69 was in a wheelchair so she was unsure how Resident #69 could have gotten so far without anyone noticing. PM #822 stated on [DATE] they were notified Resident #69 was found in Milwaukee, WI, sitting on a bench on the university campus, by the university police. Resident #69 told the police he was waiting to meet with admissions about going to graduate school. PM #822 stated this was a common fixation for Resident #69. PM #822 explained Resident #69 was originally from New Jersey and traveled to Ohio under similar circumstances as his elopement to WI. While it was unknown how Resident #69 traveled to WI, it was believed he had been withdrawing money from his resident fund account and storing the funds prior to his elopement. PM #822 verified the facility Administrator reached out to her on [DATE] to discuss alternative placement for Resident #69. A telephone interview on [DATE] at 12:48 P.M. with Primary Physician (PP) #802 revealed he was notified immediately after Resident #69 was determined to be missing. PP #802 noted Resident #69 had schizophrenia and was always talking about going to a university. PP #802 was unaware if Resident #69 wore a WanderGuard but indicated he would suggest one. PP #802 noted Resident #69 would have missed dialysis and medications while in the community. Interview on [DATE] at 2:34 P.M. with LPN #812 revealed she worked from 7:00 A.M. until 7:00 P.M. on [DATE] and was assigned to Resident #69's unit. LPN #812 stated Resident #69 went to dialysis at approximately 8:00 A.M. that morning and returned at approximately 2:00 P.M. LPN #812 stated Resident #69 was agitated upon return from dialysis and had called 911, for unknown reasons, while he was at the dialysis clinic. LPN #812 stated Resident #69 was resting in bed when she completed rounds at the end of her shift. LPN #812 revealed she observed Resident #69's WanderGuard was in place. LPN #812 stated Resident #69's physician orders included checking placement of the WanderGuard; however, there was no order to ensure it was properly functioning. On [DATE], LPN #812 stated she received the phone call that Resident #69 was found in Milwaukee, WI. LPN #812 stated the police had picked the resident up when he was lingering around the police station and seemed off. LPN #812 stated she provided the police with the resident's medical and mental illness history and then she notified the unit manager of the phone call. A telephone interview on [DATE] at 2:53 P.M. with RN #811 revealed she was Resident #69's assigned nurse on [DATE] from 7:00 P.M. to 7:00 A.M. RN #811 stated she was told in report that Resident #69 had an incident at dialysis, received a Risperdal injection upon return to the facility and had been lying down for a few hours. At approximately 7:30 P.M., RN #811 stated she was standing at the medication cart when she saw Resident #69 in his wheelchair. RN #811 stated she asked the resident how he was doing and he indicated he was fine and proceeded down the hall to the elevator. RN #811 stated Resident #69 frequently utilized the elevator to go downstairs to the vending machines, so she was not concerned with his actions. At approximately 10:30 P.M., RN #811 stated she went to Resident #69's room to pass medications and he was not there. RN #811 indicated she asked other staff if they had seen him, without success. RN #811 was unable to locate Resident #69 and staff began searching the building, then searched outside the facility. At 11;01 P.M., when staff were unable to locate Resident #69, RN #811 called the DON. The DON instructed RN #811 to ensure a thorough search was completed and to call the police. The DON was going to call the guardian. RN #811 stated she gave report to the police, collected witness statements from staff and asked other residents if they had seen Resident #69. RN #811 confirmed Resident #69 wore a WanderGuard; however, she had not yet done her assessment to confirm placement. RN #811 stated she was unsure how the WanderGuard system worked as it did not alarm at the third-floor elevator. RN #811 indicated she did not check the functioning of Resident #69's WanderGuard, just the placement, and she did not know who was responsible for checking the functioning of his WanderGuard. RN #811 stated Resident #69's WanderGuard order was different than the other residents' because his asked about behaviors and not about functionality. Interview on [DATE] at 7:37 A.M. with the Administrator revealed he was notified Resident #69 was missing from the facility by the DON on [DATE]. He was unable to recall the exact time of notification. The Administrator indicated he met the DON at the facility and drove around the community looking for Resident #69 until about 7:00 A.M. on [DATE]. The Administrator indicated that he, and other facility management, continued to search the community for Resident #69 on [DATE] and [DATE]. The Administrator stated there was camera footage on [DATE] at 7:44 P.M. of Resident #69 getting off the elevator and going in the direction of the smoking patio. The Administrator indicated the camera footage overwrites after a few days and the footage from the evening Resident #69 eloped had not been retained; however, it was unclear how Resident #69 exited the smoking patio door as there was no camera footage in that area. The Administrator confirmed the smoking patio door was equipped with a WanderGuard sensor and should have alarmed. Observation on [DATE] at 7:46 A.M. of the door leading to the outside smoking patio, with the Administrator, revealed a locked door with a keypad next to the door. The door was equipped with the WanderGuard system. The patio was not fully enclosed and led out to the back parking lot driveway. The smoking patio door was located in a room with several tables. The room was located on an administrative hallway, which included offices, laundry and the kitchen. Observation on [DATE] at 7:53 A.M. with DOM #804 and Maintenance Assistant (MA) #805 revealed the smoking patio door was locked. DOM #804 held a WanderGuard, and the keypad indicated the system was in working order. DOM #804 stated the smoking patio door was locked from 8:00 P.M. to 8:00 A.M. and demonstrated that pushing on the smoking patio door for 15 seconds, while locked, would set off an audible alarm prior to the door releasing and opening. From 8:00 A.M. to 8:00 P.M., DOM #804 stated the door was unlocked but a functional WanderGuard would set off an audible alarm. DOM #804 further explained a functional WanderGuard would trigger the door to lock and then alarm if the door was pushed on. Continued observation confirmed the audible alarm was loud enough for staff working in resident care areas on the first floor to hear the alarm in order to respond. Interview on [DATE] at 8:18 A.M. with RDO #800 revealed she was notified Resident #69 was missing by the Administrator on [DATE]. RDO #800 indicated she arrived at the facility on the morning of [DATE] to assist with search efforts. RDO #800 reported interviews with staff revealed no evidence of Resident #69's WanderGuard system alarming. RDO #800 stated she assisted with trying to obtain information on where Resident #69 might have gone. RDO #800 reported she called Resident #69's guardian to find out if he had any local friends or family that could be contacted. RDO #800 found that Resident #69 had taken out 130 dollars from his funds account over the previous two weeks. RDO #800 stated Resident #69's room was searched, with no indication of where he may have gone, and it did not appear the resident had taken any of his personal belongings. RDO #800 stated medical documents were found from a previous facility indicating Resident #69 had taken a bus from New Jersey to Ohio and was found disoriented at a bus stop needing dialysis. RDO #800 noted Resident #69 had a history of paranoia and was fixated on not being in a facility and going back to college. When Resident #69 was found the morning of [DATE], she coordinated transportation for the resident to be returned to OH from WI. RDO #800 reported the resident's WanderGuard was still attached to his wheelchair upon his return. RDO #800 stated the facility determined Resident #69 was able to leave the facility undetected as his WanderGuard was not in working order and it was replaced upon his return. Additionally, RDO #800 stated Resident #69 was placed on one-on-one supervision. RDO #800 indicated there was no written policy for WanderGuard use but the protocol was to check placement and functioning every shift. Interview on [DATE] at 9:05 A.M. with Resident #69 revealed Resident #69 refused to answer questions about why he left the facility and how he traveled to Milwaukee, WI. Resident #69 indicated he felt safe while out of the facility and had his coat on. Resident #69 stated he did not like it at the facility and asked if surveyor was going to take him back to WI. Resident #69 ended the interview. Interview on [DATE] at 10:46 A.M. with the Administrator, RDO #800, and RDCS #801 revealed they believed the cause of Resident #69's elopement was failure of his WanderGuard functionality. Interview on [DATE] at 11:35 A.M. with STNA #816 revealed on [DATE] he supervised the nighttime smoke break, which occurred at approximately 8:00 P.M. that evening. STNA #816 reported there was no evidence of the smoking patio door alarming or having been tampered with. STNA #816 denied seeing Resident #69 during the smoke break. Interview on [DATE] at 2:43 P.M. with STNA #815 revealed on [DATE] she was assigned to Resident #69's unit from 3:00 P.M. to 11:00 P.M. STNA #815 stated, at the start of her shift, Resident #69 was agitated and combative with staff. STNA #815 stated Resident #69 received a shot and slept in his room until 5:30 P.M., when the resident exit his room and stated he was going to the dining room. STNA #815 indicated she remained busy with patient care and was notified by RN #811 that Resident #69 was missing. STNA #815 indicated she assumed Resident #69 was in the dining room and had not checked on him as he did not need care from her, adding the resident was independent with activities of daily living (ADLs). Review of the Resident Trust Funds Withdrawal Authorizations revealed Resident #69 withdrew 50 dollars on [DATE], 50 dollars on [DATE], and 30 dollars on [DATE]. Review of the Root Cause Analysis dated [DATE] revealed staff failed to verify WanderGuard placement and function by root cause of inattention and knowledge deficit. Review of the facility policy titled Wandering, Unsafe Resident, revised [DATE], revealed residents would be evaluated for risk of unsafe wandering or elopement, at risk residents may wear a Secure Care or other such bracelet for additional security and prevention, and the care plan would identify a detailed monitoring plan to ensure safety. Review of facility policy, Elopements, dated [DATE], revealed if an employee observes a resident leaving the premises they should attempt to prevent departure in courteous manner, get help from other staff, and instruct other staff to inform Charge Nurse or DON. This deficiency represents non-compliance investigated under Complaint Number OH00158807.

Based on closed medical record review, video footage with audio review, emergency medical services (EMS) run sheet review, hospital record review, interviews, and review of the facility's Change in a Residents' Condition or Status policy and procedure and Abuse, Neglect, Exploitation and Misappropriation policy and procedure, the facility failed to provide adequate and necessary care and services to prevent neglect involving Resident #101. This resulted in Immediate Jeopardy, including actual harm and subsequent death beginning on [DATE] at 7:03 P.M. when an incident of neglect occurred when the facility failed to prevent a fall with injury (rib fracture), to ensure timely and appropriate treatment was provided immediately post fall, to timely identify an acute change in condition and obtain immediate medical care. Review of video footage with audio dated [DATE] timed 7:03 P.M. revealed Resident #101, who was dependent on staff for personal care including bed mobility, was lying naked on her right side at the edge of her bed which was in high position as one State tested Nursing Assistant (STNA), STNA #400, who was standing behind Resident #101, was placing a fitted sheet on the bed. Resident #101 asked STNA #400 are you going to pull me back, and STNA #400 responded Honey, I'm trying to fix your bed today as she continued to place the fitted sheet on the bed. Resident #101 then stated, Well I'm about to fall on the floor and then yelled out I'm falling as she fell from the bed face down. As Resident #101 was lying face down on the floor with her left leg resting on the side of the bed, STNA #400 walked around the bed, pushed the bed away from the resident causing Resident #101's left leg to drop to the floor with a thud. STNA #400 exclaimed damn (name of resident) and exited the room without speaking to Resident #101. Resident #101 was heard crying and yelling out help me, help me . is anybody going to get me up? Resident #101 was subsequently transferred to the hospital. Resident #101 returned to the facility on [DATE] sometime between 11:00 P.M. and 12:00 A.M. with a diagnosis of a closed rib fracture. After her return to the facility on [DATE] the facility failed to complete neurological (neuro) checks and timely identify an acute change in condition and obtain immediate medical care resulting in an emergent transfer to the hospital on [DATE]. Emergency Medical Services (EMS) were called on [DATE] at 6:31 A.M. The resident was transported to the hospital where she subsequently expired at 7:49 A.M. This affected one resident (#101) of four sampled residents and one of seven residents (Residents #3, #33, #39, #50, #60, #71, and #78) identified as requiring two-person (staff) assistance with care. Facility census was 99. On [DATE] at 4:55 P.M. the Administrator and Regional Nursing Home Administrator were notified Immediate Jeopardy began on [DATE] at 7:03 P.M. when Resident #101 who had diagnoses of right leg amputation, diabetes, chronic kidney disease and congestive heart failure, and required two staff members for all care, was receiving care by one staff member (STNA #400) and fell out of bed landing on the floor face down requiring emergent transport to the hospital where she was diagnosed with a rib fracture. On [DATE] at 2:39 P.M. the Administrator and Regional Director of Clinical Services (RDCS) #401 were notified upon further review of hospital records, additional video footage and follow-up interviews the Immediate Jeopardy encompassed neglect related to failing to prevent the fall with injury, failing to provide timely and appropriate treatment immediately post fall, ensuring timely identification of an acute change in condition, and obtaining immediate medical care which resulted in the death of Resident #101 on [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective action: On [DATE] at 11:30 A.M., RDCS #401 met with the Interdisciplinary Team (IDT) team including the Director of Nursing (DON), Assistant Director of Nursing (ADON), Administrator, and Unit Manager (UM) #171 to complete a root cause analysis. The IDT identified a system failure because STNA #400 provided care alone for Resident #101 who required a two person assist and did not follow facility policy for rolling and supervision of resident. The facility also identified Resident #101 was not monitored per protocol, specifically the completion of neuro checks for 72 hours post-fall, upon readmission to facility. On [DATE] from 11:40 A.M. to 12:00 P.M., RDCS #401 educated the Administrator, DON, ADON and UM #171 on post fall monitoring including skilled charting, vital signs every shift for 72 hours, neuro checks for all unwitnessed falls or witnessed falls with head injury per neuro check form for 72 hours, and two-person assist for care. On [DATE] from 12:45 P.M. to 1:15 P.M. a Quality Assurance Performance Improvement (QAPI) meeting was held with the medical director, Administrator, RDCS #401, DON, ADON, UM #171, Human Resources (HR) #252, Business Office Manager (BOM) #110, Dietary Manager (DM) #180, Admissions Director (AD) #152, Housekeeping Supervisor (HS) #199, Medical Records (MR) #232, and Licensed Social Worker (LSW) #134 to review the root cause analysis. All agreed that the root cause was a system failure as STNA #400 provided care alone for Resident #101 who required a two person assist and did not follow facility policy for rolling and supervision of resident. The QAPI team also identified Resident #101 was not monitored per protocol, specifically the completion of neuro checks for 72 hours post-fall, upon readmission to facility. RDCS #401 provided education to team including post fall monitoring including skilled charting and vital signs every shift for 72 hours and neuro checks for all unwitnessed falls or witnessed falls with head injury per neuro check form for 72 hours, two person assist for care, and checking binder at nurse's station for number of persons required to assist with resident care at the start of nursing shift. On [DATE] between 2:30 P.M. and 5:30 P.M. the Administrator, DON, ADON, UM #171, DM #180, HS #199, and BOM #110 educated all facility staff on post fall monitoring including skilled charting, vital signs every shift for 72 hour, neuro checks for all unwitnessed falls or witnessed falls with head injury per neuro check form for 72 hours, two person assist for care, and checking the binder at nurse's station for two person assist for resident care at the start of nursing shift. Staff hired after [DATE] would be educated on the above information during new hire orientation. On [DATE] at 6:00 P.M., UM #171 reviewed fall investigations for past 30 days to ensure interventions, including but not limited to fall mats, enabler bars, proper positioning, visual reminders, therapy evaluations, and assistive devices were in place and appropriate care plans were in place for all residents. No additional issues were identified. On [DATE] at 7:00 P.M. the DON and Minimum Data Set (MDS) Nurse #251 audited care plans, Kardex (brand name for system that staff use to quickly reference resident information and care plans) and physician orders for all residents to ensure all assistance orders were in place and care planned appropriately. On [DATE] at 7:00 P.M. the ADON and UM #171 created a binder for each nurse's station that contained the number of persons required to provide resident care. On [DATE] at 3:15 P.M. the Regional Director of Operations (RDO) met with the IDT including the DON, ADON, Administrator, and UM #171 to complete an additional root cause analysis. The IDT identified a system failure as Licensed Practical Nurse (LPN) #150 failed to identify Resident #101's change in condition and provide timely intervention. LPN #150 failed to assess Resident #101 and identify a change in condition of mental status and did not obtain any vital signs or blood sugar checks. On [DATE] between 3:40 P.M. and 4:00 P.M. a QAPI meeting was held with the Medical Director, Administrator, DON, ADON, UM #171, BOM #110, DM #180, AD #152, HS #199, MR #232, Social Service Designee (SSD) #202, and Central Supply #107 to review the root cause analysis. All agreed that the root cause was a system failure as LPN #150 failed to identify resident change in condition and provide timely intervention. The RDO provided education to the team on abuse and neglect policy and acute change in condition policy to include changes in mental status, vital signs or blood sugar. On [DATE] Between 4:00 P.M. and 4:45 P.M. Maintenance Director (MD)#104, HS #199, BOM #110, DM #180, MR #232 and SSD #202 interviewed residents with a Brief Interview of Mental Status (BIMS) score of 13 or greater (BIMS score of 13 and above indicates cognition is intact) to ensure no further instances of neglect or change in condition without identification/intervention with no negative findings. On [DATE] between 4:00 P.M. and 7:00 P.M. the RDO provided education to the IDT team on abuse and neglect policy and acute change in condition policy to include changes in mental status, vital signs or blood sugar. The Administrator, DON, ADON, UM #171, DM #180, HS #199, and BOM #110 then educated all facility staff on the facility abuse and neglect policy and acute change in condition policy. Staff hired after [DATE] would be educated on the above information during new hire orientation. On [DATE] at 4:30 P.M., UM #171 assessed residents with a BIMS score of 12 or lower (moderate to severe cognitive impairment) to ensure further instances of neglect or change in condition without identification/intervention. No negative findings. On [DATE] at 4:30 P.M. the DON reviewed the 72- hour report to ensure there were no residents with identified change in condition without appropriate follow-up. No negative findings were noted. On [DATE] at 4:45 P.M. the DON reviewed change of condition assessments from [DATE] to present to ensure appropriate interventions. No negative findings were noted. On [DATE], LPN #150 was suspending pending an investigation for resident neglect. On [DATE] at 8:44 P.M. the RDO submitted a Self-Reported Incident (SRI) for neglect related to Resident #101. The facility implemented a plan for audits to be completed by the DON/designee for every fall occurrence to ensure appropriate post fall monitoring including skilled charting, vital signs, and neuro checks as indicated for eight weeks beginning [DATE] and ending [DATE]. The facility implemented a plan for audits to be completed to ensure the appropriate number of staff were providing care per identified needs would be completed by DON/designee on five random residents throughout all units five times weekly for eight weeks beginning [DATE] and ending [DATE]. The facility implemented a plan for audits to be completed to ensure the person assist binders were accurate and up to date would be completed by DON/designee five times weekly for eight weeks beginning [DATE] and ending [DATE]. The DON/designee would complete random staff interviews on all shifts to ensure binders were reviewed at start of shift. Two staff members to be interviewed five times weekly for eight weeks beginning [DATE] and ending [DATE]. All new physician orders related to transfer status would be audited by DON/designee five times a weekly for eight weeks beginning [DATE] and ending [DATE]. The DON/designee would observe 10 random residents a day five times a week for four weeks, then 10 random residents a week for four weeks, and randomly thereafter to ensure no change in condition without assessment and intervention and no signs of abuse or neglect beginning [DATE] and ending [DATE]. The DON/designee would interview five random residents a day five times a week four weeks, then five random residents a week for four weeks to ensure no allegations of abuse or neglect beginning [DATE] and ending [DATE]. The DON/designee would randomly review charting five times a week for four weeks to ensure no change in condition without assessment and intervention beginning [DATE] and ending [DATE]. All audits would be reviewed during monthly QAPI meetings, and any identified concerns addressed immediately by QAPI committee. Review of in-service sign-in sheets confirmed most facility staff received the training/education. Staff who did not attend would receive the training/education at the start of their next shift. Although the Immediate Jeopardy was removed on [DATE] the deficiency remained at Severity Level II (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as staff in-servicing and auditing to ensure continued compliance was still in process. Findings include: Review of the closed medical records for Resident #101 revealed an admitted [DATE] and a discharge and deceased date of [DATE]. Resident #101 had diagnoses including right leg amputation, diabetes, chronic kidney disease and congestive heart failure. Review of the care plan dated [DATE] revealed Resident #101 required one person assist with bed mobility, toileting, transfers and personal hygiene. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #101 had intact cognition, required substantial/maximal assistance from staff for toileting and was dependent with rolling, bathing and personal hygiene. Review of current physician orders for [DATE] revealed Resident #101 was ordered two persons with all care. Resident #101 was ordered Plavix (antiplatelet) 75 milligram once daily with a start date of [DATE]. Review of the progress note dated [DATE] timed 9:57 P.M. authored by LPN #205 revealed a STNA reported Resident #101 was on the floor. Upon entering Resident #101's room the resident was observed lying face down on the floor. Resident #101 was assisted back into bed via a Hoyer (mechanical) lift and assessed. Resident #101 stated she hit her head, and a small amount of emesis was observed on Resident #101's face and on the floor. Resident #101's vital signs were stable. EMS was called and transferred Resident #101 to the hospital. Resident #101's daughter was notified via a Bluetooth device in the resident's room. The DON was also notified. Review of the progress note dated [DATE] timed 11:45 P.M. authored by LPN #214 revealed Resident #101 was returned from the hospital. The note indicated the resident was negative for any abnormalities. The note also indicated Resident #101 was non-compliant with obtaining a head-to-toe assessment and vital signs. Review of the progress note dated [DATE] timed 12:09 P.M. authored by LPN #208 revealed Resident #101 was alert and oriented and able to make her needs known, vital signs and neuro checks were within normal limits. The progress note did not include the vital signs. Review of the progress note dated [DATE] timed 2:01 P.M. authored by Social Services (SS) #134 revealed Resident #101 had a camera in her room and the fall had been recorded on video. SS #134 placed a call to Resident #101's daughter requesting a copy of the video for review and was awaiting receipt of video. The progress note indicated Resident #101's daughter requested half rails be placed on Resident #101's bed. The progress note also indicated the DON would interview the staff member that had been present at the time of the fall and all STNAs would be educated on proper positioning and a new bed with rails had been provided. Review of the progress note dated [DATE] timed 4:49 P.M. authored by LPN #404 revealed Resident #101's vital signs were blood pressure ,d+[DATE], heart rate 82, and oxygen saturation was 94% (normal ,d+[DATE]%). Review of a progress note dated [DATE] timed 9:43 P.M. and authored by LPN #150 documented Resident #101 was arousable to verbal stimuli, resident sleeping, and medications were held. There was no additional information as to why the resident's medications were held at this time. Review of a progress note dated [DATE] timed 12:10 A.M. and authored by LPN #150 documented Resident #101 remained asleep, no distress. Review of a progress note dated [DATE] timed 3:55 A.M. and authored by LPN #150 documented Resident #101 continued to rest with no distress noted. Review of the progress note dated [DATE] timed 5:30 A.M. authored by LPN #150 revealed Resident #101 was arousable to verbal stimuli and pain, dressing was changed without incidence with no distress noted. Review of the progress note dated [DATE] timed 7:35 A.M. authored by LPN #150 revealed Resident #101 had a change in condition with altered mental status. Blood pressure was ,d+[DATE], heart rate 76, and oxygen saturation was 97% on room air. Review of the progress note dated [DATE] time 8:03 A.M. authored by LPN #150 revealed Resident #101 was noted to have increased drowsiness throughout the evening with a change in mental status as Resident #101 was not at her baseline. Resident #101 responded to pain but was not answering questions appropriately. Resident #101's vital signs were fluctuating. Emergency Services were called, and Resident #101 was transported out of the facility. The ADON was notified. Review of the EMS run report dated [DATE] revealed a call was received at 6:31 A.M. and EMS were in route at 6:35 A.M., on scene at 6:38 A.M. and at Resident #101 at 6:39 A.M. The report indicated Resident #101 was unresponsive with altered mental status for two days. Blood pressure taken at 6:53 A.M. was ,d+[DATE], heart rate was 86 and weak, oxygen was 96% on room air and blood sugar was 40 (normal ,d+[DATE]), skin was cool and pale. Upon arrival Resident #101 was in a reclining chair and was slow to respond only responding to painful stimuli. The EMS report indicated Resident #101 was last seen normal yesterday ([DATE]) and normal mental status was alert and oriented. Review of hospital documentation dated [DATE] revealed Resident #101 presented with altered mental status along with low blood pressure and low blood sugar. Resident #101 was last known well sometime yesterday ([DATE]). Resident #101 was declared deceased on [DATE] at 7:49 A.M. Review of Resident #101's recorded vital signs revealed on [DATE] at 9:18 P.M. staff documented her blood pressure was ,d+[DATE], on [DATE] at 10:45 A.M. her blood pressure was ,d+[DATE] and on [DATE] at 7:36 A.M. her blood pressure was ,d+[DATE]. Review of Resident #101's closed medical record including the hard/paper chart revealed no documented evidence of any type of neurological checks were completed following the resident's fall. Review of the facility progress note dated [DATE] timed 10:20 A.M. and authored by SS #134 revealed Resident #101 expired on [DATE] at 8:24 A.M. Review of video footage with audio provided by Resident #101's daughter, dated [DATE] timed 7:03 P.M., revealed Resident #101 lying naked on her right side at the edge of her bed which was in high position without siderails as STNA #400, who was standing behind Resident #101, was placing a fitted sheet on the bed. Resident #101 asked STNA #400 are you going to pull me back, and STNA #400 responded Honey, I'm trying to fix your bed today as she continued to place the fitted sheet on the bed. Resident #101 then stated, Well I'm about to fall on the floor and then yelled out I'm falling as she fell from the bed face down. As Resident #101 was lying face down on the floor with her left leg resting on the side of the bed, STNA #400 walked around the bed, pushed the bed away from the resident causing Resident #101's left leg to drop to the floor with a thud. STNA #400 exclaimed damn (name of resident) and exited the room without speaking to Resident #101. Resident #101 was heard crying and yelling out help me, help me . is anybody going to get me up? Video footage timed 7:06 P.M. revealed STNA #400 re-entering Resident #101's room with three additional staff members. Resident #101 remained on the floor yelling out help me and she let me fall on the floor. The staff members were observed placing a Hoyer pad underneath Resident #101 and applying a gown. Resident #101's daughter could be heard asking staff what happened. STNA #400 responded I was putting the sheet on the bed and instead of her holding on to the bed, she was digging in her nose. Resident #101 stated I was holding on to the bed. STNA #400 began to argue stating No you weren't you were digging in your nose. Resident #101 said STNA #400 was lying and STNA #400 stated Girl bye. Video footage timed 7:10 P.M. revealed staff assisting Resident #101 back into bed via a Hoyer lift. An unidentified staff member asked Resident #101 if she was having pain and Resident #101 replied all over. Video footage timed 7:12 P.M. revealed staff placed an incontinence brief on Resident #101. No physical assessment was completed, and vital signs were not obtained. Video footage timed 7:14 P.M. revealed Resident #101 stating I can't believe she let me hit the floor. The staff members present in the room did not respond. Video footage timed 7:30 P.M. revealed EMS arrived. Resident #101 stated I don't believe that girl let me fall out of this bed. Review of the facility's fall investigation with an initiation date of [DATE] revealed a statement authored by STNA #400. The statement indicated STNA #400 placed Resident #101 in bed at approximately 7:00 P.M., while placing a fitted sheet on Resident #101's bed the resident was digging in her nose and tried to throw away a tissue in the trash and while reaching for the trash Resident #101's body went over the edge of the bed. Review of the facility investigation revealed no evidence a second staff person was in the room to assist with the resident's transfer to bed or to assist with personal care/bed mobility. Further review of the investigation revealed no documentation neuro checks were completed. The investigation indicated Resident #101 was transferred out of the facility. The investigation included hospital paperwork dated [DATE] that indicated Resident #101 had a CT scan and a chest x-ray. The hospital paperwork indicated Resident #101 had a closed left sided rib fracture. The results of the CT were not included with the paperwork. Telephone interview on [DATE] at 7:30 A.M. with Resident #101's daughter revealed on [DATE] she received a call from Resident #101 via an electronic device. Resident #101 told her she had fallen out of bed, and she was lying on the floor. Resident #101's daughter stated Resident #101 told her she was hurting all over. Resident #101 was transported to the hospital after the fall and was returned to the facility shortly after. Resident #101's daughter had concerns about Resident #101 being returned to the facility so quickly especially since she was on blood thinners. Resident #101's daughter stated she had spoken with the nurse (couldn't recall name) and asked that thestaff check on her mother more frequently. The daughter stated the nurse informed her Resident #101's CT scan was negative, and that Resident #101 had a rib fracture. Resident #101's daughter went to the facility on [DATE] and spoke with SS #134 and showed him the video footage of the fall; she also sent the link to view the video via text message to SS #134. Resident #101's daughter stated SS #134 did not say much about the video, but she was told the facility would begin an investigation. Resident #101's daughter further stated she reviewed additional camera footage and on the evening of [DATE] the camera, which was motion activated had not detected anyone entering Resident #101's room; the camera did not detect anyone from the evening of [DATE] until the morning of [DATE] at 5:30 A.M. At 5:30 A.M. a nurse entered to change Resident 101's wound dressing. The camera footage also showed staff placing Resident #101 into a dialysis chair and Resident #101 appeared to be unresponsive at that time. Resident #101's daughter was told Resident #101 was taken to the hospital and on the way to the hospital she crashed. The daughter was told by hospital staff Resident #101's blood pressure and blood sugar were low and she became unresponsive on the way to the hospital and passed away sometime after arriving to the hospital. Telephone interview on [DATE] at 11:48 A.M. with LPN #205 revealed on [DATE] shortly after 7:00 P.M. STNA #400 informed her Resident #101 was on the floor. STNA #400 did not provide any specific details of the fall. LPN #205 and three other staff members entered Resident #101's room and she observed Resident #101 was face down on the floor by her bed and was complaining of pain all over. LPN #205 stated she did not observe any obvious injuries. Resident #101 told her she had told STNA #400 she was falling out of bed. LPN #205 assisted with getting Resident #101 back into bed and then called EMS (911). LPN #205 stated Resident #101's daughter was notified of the fall via an electronic device located in the room at the time of the fall. LPN #205 stated Resident #101 required two person staff assistance for all care. LPN #205 had collected STNA #400's statement and STNA #400 told her as she was assisting Resident #101 with a bed change, Resident #101 was digging in her nose and had not been holding onto the bed. Resident #101 returned to the facility sometime between 11:00 P.M. and 12:00 A.M. and another nurse had taken over care of Resident #101 after her return. LPN #205 did not care for Resident #101 after her return from the hospital. Telephone interview on [DATE] at 12:12 P.M. with LPN #150 revealed she had cared for Resident #101 on the evening of [DATE] from 7:00 P.M. to [DATE] at 7:00 A.M. LPN #150 stated she entered Resident #101's room around 9:30 P.M. to administer Resident #101's evening medications and Resident #101 was sleepy but had spoken. Resident #101 appeared to be too sleepy to give her the medications and so she had not administered the medications. LPN #150 stated she entered Resident #101's to check on her a few times throughout the evening and she continued to sleep. When LPN #150 entered Resident #101's room on the morning of [DATE] at approximately 5:30 A.M. to complete her wound care, Resident #101 was sleepier than she had been earlier. Resident #101 was not easily arousable and was not responding appropriately. LPN #150 said she took Resident #101's blood pressure and it was low. LPN #150 called the physician and received orders to call 911. LPN #150 called 911 between 7:00 A.M. and 7:30 A.M. and Resident #101 was transported to the hospital. LPN #150 continued to get Resident #101 ready for dialysis and out of bed and took her from her room to the hall before calling 911 because she stated she felt the condition the resident was displaying was somewhat normal for her. The hospital called about an hour later and reported Resident #101 had passed away. Interview on [DATE] at 12:57 P.M. with Registered Nurse (RN) #185 revealed she had responded and assisted with Resident #101's fall on [DATE]. When RN #185 entered Resident #101's room she observed Resident #101 face down on the floor and Resident #101 was yelling out in pain. RN #185 was not aware how the fall occurred and stated Resident #101's assigned nurse (LPN #205) had called 911 and Resident #101 was transported to the hospital. RN #185 did not care for Resident #101 after her return from the hospital. Interview on [DATE] at 1:07 P.M. with STNA #103 revealed she was not present when Resident #101 fell out of bed, however she cared for her the next morning after her return from the hospital. STNA #103 stated Resident #101 usually used her call light early in the morning for assistance out of bed, but that morning Resident #101 did not use her call light or ask to get out of bed. When STNA #103 entered Resident #101's room that morning (could not recall time) Resident #101 appeared to be more tired than normal and did not want to get up. Interview on [DATE] 1:54 P.M. with RDCS #401 and the ADON revealed they completed an investigation into Resident #101's fall. RDSC #401 stated STNA #400 was terminated because she did not follow Resident #101's plan of care regarding the number of staff required when providing care. RDCS #401 stated Resident #101 was transported to the hospital after the fall and returned shortly after. RDSC #401 stated the hospital paperwork did not include results of the CT scan, but the hospital called and informed the nurse of the results being negative. RDCS #401 stated neurological (neuro) checks were not completed because the resident's CT scan was negative. Interview on [DATE] at 8:54 A.M. with the DON revealed she received a call on the evening of [DATE] from LPN #205 informing her Resident #101 had a fall and was being transported to the hospital. LPN #205 had not provided specific information regarding how the fall occurred. The DON stated Resident #101 was transported to the hospital and returned shortly after. The DON was surprised Resident #101 had returned so quickly. The hospital gave the discharge paperwork to Resident #101. The DON asked Resident #101 for the hospital paperwork the following morning. The hospital paperwork indicated Resident #101 had a rib fracture. The paperwork did not include the results of the CT scan. The DON confirmed neuro checks were not completed upon Resident #101's return and said they were not completed because the CT results were reported as being negative. Resident #101's daughter was present at the facility on [DATE] and she had video footage of Resident #101's fall. Resident #101's daughter played the video; however, the DON did not see the video she only heard the audio. The DON asked Resident #101's daughter to send the actual video because she was unable to open the link to view. The DON stated when she listened to the audio of the video, she heard Resident #101 ask to be pulled back and she heard the crash. The facility initiated an investigation on [DATE] which included Resident #101 was a two person assist with care and during the investigation she educated STNA #400 regarding following proper resident care and fall protocol that included not leaving a resident who was on the floor. The DON reviewed STNA #400's statement regarding the fall and stated STNA #400's statement was not truthful based on what she had heard on the video. The DON viewed the video footage the morning of [DATE] which was the morning she was notified Resident #101 had been lethargic and had low blood pressure and was being sent to the hospital. Upon review of the video footage STNA #400 was terminated. Interview on [DATE] at 12:54 P.M. with RDCS #401 revealed she was aware video footage existed regarding Resident #101's fall but she had not viewed the video until [DATE]. Telephone interview on [DATE] at 3:36 P.M. with STNA #400 revealed she cared for Resident #101 on multiple occasions, and she was aware Resident #101 required two-person assistance with care. STNA #400 stated she had often cared for Resident #101 by herself and on the evening of [DATE] Resident #101 requested to be put into bed and she had used the Hoyer lift by herself to place Resident #101 into bed. STNA #400 stated she gave Resident #101 a bed bath and began placing the fitted sheet on the resident's bed. Resident #101 was up on her side in bed and STNA #400 had a hand on Resident #101 the whole time and she told Resident #101 to hold on to the bed. STNA #400 stated Resident #101 had not held on to the bed, rolled out of the bed and fell to the floor. STNA #400 left the room to go get help and returned with the nurse and some additional staff. They got Resident #101 up and placed her back into her bed and the nurse called 911. Resident 101 was taken to the hospital and returned later that evening. STNA #400 had not cared for Resident #101 upon her return from the hospital. STNA #400 stated the following day ([DATE]) she arrived to work between 3:00 P.M. and 4:00 P.M. and the DON told her she was not allowed to care for[TRUNCATED]

Based on interview, review of video footage with audio and review of the facility's Resident Rights policy, the facility failed to ensure residents were treated with respect and dignity. This affected one of three residents observed for dignity during care, Resident #101. The facility census was 99. Findings include: Review of the closed medical records for Resident #101 revealed an admitted [DATE] and a discharge and deceased date of [DATE]. Diagnoses included, right leg amputation, diabetes, chronic kidney disease and congestive heart failure. Review of the care plan dated [DATE] revealed Resident #101 required one person assist with bed mobility, toileting, transfers and personal hygiene. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #101 had intact cognition and required substantial/maximal assistance with toileting and was dependent with rolling, bathing and personal hygiene. Review of current physician orders for [DATE] revealed Resident #101 was ordered two persons with all care. Review of video footage with audio provided by Resident #101's daughter, dated [DATE] timed 7:03 P.M., revealed Resident #101 lying naked on her right side at the edge of her bed as STNA #400, who was standing behind Resident #101, was placing a fitted sheet on the bed. Resident #101 asked STNA #400 are you going to pull me back, and STNA #400 responded Honey, I'm trying to fix your bed today as she continued to place the fitted sheet on the bed. Resident #101 then stated, Well I'm about to fall on the floor and then yelled out I'm falling as she fell from the bed face down. As Resident #101 was lying face down on the floor with her left leg resting on the side of the bed, STNA #400 walked around the bed, pushed the bed away from the resident causing Resident #101's left leg to drop to the floor with a thud. STNA #400 exclaimed damn (name of resident) and exited the room without speaking to Resident #101. Resident #101 was heard crying and yelling out help me, help me . is anybody going to get me up? Video footage timed 7:06 P.M. revealed STNA #400 re-entered Resident #101's room with three additional staff members and . Resident #101 yelled out help me and she let me fall on the floor. Resident #101's daughter was heard asking the staff how this occurred and STNA #400 stated I was putting the sheet on the bed and instead of her holding on to the bed, she was digging in her nose. Resident #101 stated I was holding on to the bed, and STNA #400 began to argue stating No you weren't . you were digging in your nose. Resident #101 stated STNA #400 was lying and STNA #400 stated Girl bye. Video footage timed 7:14 P.M. revealed Resident #101 stated I can't believe she let me hit the floor. Staff members present in the room did not respond to Resident #101's comment. Review of the facility policy Resident Rights revised [DATE], revealed resident had the right to be treated with respect, kindness and dignity. This deficiency represents non-compliance investigated under Complaint Number OH00155612, OH0055552 and OH00155548.

Based on observation, interview and policy review, the facility failed to ensure foods were labeled, dated and not retained when expired. This had the potential to affect 106 residents receiving food from the facility's kitchen as four residents (Residents #19, #41, #74 and #103) were ordered nothing-by-mouth (NPO). The facility census was 110. Findings include: Observation of the facility's nourishment refrigerators on [DATE] starting at 9:51 A.M. with Food Service Director (FSD) #440 revealed the following: In the first floor resident refrigerator, there were two expired yogurts dated [DATE], two expired yogurts dated [DATE] and a half-gallon of milk dated [DATE]. In the second floor resident refrigerator, there was an unidentified pink substance on the inside base of the refrigerator and there was frozen popsicle material on the inside base of the freezer. In the third floor resident refrigerator, there were two containers labeled with Resident #85's room number on it but no date. Interviews with FSD #440 verified the above findings at the time of observation. FSD #440 indicated she or another dietary staff would check the refrigerators every Friday for expired food. FSD #440 stated housekeeping staff helped with this process but ultimately nursing staff were supposed to take expired food out of the refrigerators. FSD #440 stated these refrigerators were also cleaned weekly. FSD #440 confirmed there was no documentation regarding staff going through these refrigerators for expired food. Review of the facility policy, Food Brought by Family/Visitors, revised February 2014 revealed perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers will be labeled with the residents' name, the item and the use by date. The nursing staff is responsible for discarding perishable foods on or before the use by date. The nursing and/or food service staff must discard any foods prepared for the resident that show obvious signs of potential foodborne danger.

Based observation, interview, and facility policy review the facility failed to keep medication in a secured environment, and failed to discard expired tuberculin solution. This had the potential to affect all 110 residents in the facility. The facility census was 110. Findings Include: 1. Observation on [DATE] at 11:15 A.M. revealed the second-floor medication room door was ajar and not latched completely allowing the door to be pushed open without the use of the door handle. The door handle was part of a code locking system with the number 7 button stuck enabling the door to be unlocked. Observation on [DATE] at 11:20 A.M. revealed the third-floor medication room door was closed but not locked. By turning the door handle it opened the door without having to enter the code to unlock the door. Observation on [DATE] at 3:26 P.M. revealed State tested Nursing Assistant (STNA) #418 opening the door of the third-floor medication room and entering without having a nurse as an escort into the medication room. STNA #418 then exited the medication with several boxes of gloves to be used in the resident's rooms. Interview on [DATE] at 3:24 P.M. with Licensed Practical Nurse (LPN) #534 revealed the second-floor medication room door has not been able to be locked in several days due to the number 7 on the code box being stuck. Interview on [DATE] at 3:30 P.M. with STNA #418 revealed the third-floor medication room was also where the resident supplies were stored, and the door had not been locked for several days. The STNAs could go into the medication room to get the supplies needed to take care of the residents. Interview on [DATE] at 4:00 P.M. with the Director of Nursing (DON) confirmed the medication rooms on the second and third floors were unlocked, and the staff were able to enter and exit without using a code to unlock the doors. Review of the facility policy titled, Storage of Medications dated ,d+[DATE] revealed, Only persons authorized to prepare and administer medications shall have access to the medication room, including any keys. 2. Observation on [DATE] at 10:48 A.M. in the first floor medication refrigerator revealed two partially used vials of Apisol Tuberculin (TB) solution with out opened dates on either the vials or the manufacturer boxes. Interview on [DATE] at 10:55 A.M. with Licensed Practical Nurse (LPN) #475 confirmed the two partially used TB solution vials without an opened date on the vials or the boxes. LPN #475 stated, Those vials and boxes should have an opened date on them. Observation on [DATE] at 11:05 AM in the third floor medication room refrigerator revealed one partially used vial of Aplisol TB solution without an opened date on the vial or the manufacturer's box. Interview on [DATE] at 11:10 A.M. with the Assistant Director of Nursing (ADON) confirmed the one partially used vial of Aplisol TB solution without an opened dated on the vial or the box. The ADON stated, The vials and the boxes should have an opened date and not be used passed 30 days from the opened date. Review of the Aplisol TB solution manufacturer guidelines revealed, Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency.

Based on interview and record review the facility failed to ensure resident funds were disbursed as required and in a timely manner after death. This affected one resident (Resident #120) of five residents reviewed for resident funds. The facility census was 110. Findings include: Review of Resident #120's medical record revealed an admitted [DATE] and diagnoses including paranoid schizophrenia, unspecified psychosis, major depressive disorder, schizophrenia unspecified, unspecified severe protein-calorie malnutrition, psychotic disorder with hallucinations due to known physiological condition and history of COVID-19. Review of a Minimum Data Set (MDS) 3.0 dated [DATE] revealed Resident #120 expired in the facility. Review of a nurses' note dated [DATE] revealed Resident #120 expired in the facility. Review of Resident #120's resident fund statement revealed as of [DATE], Resident #120 had an ending balance of $1069.28. There was no evidence of final disbursal for review. Interview on [DATE] at 4:25 P.M. with Business Office Manager (BOM) #405 revealed she contacted Resident #120's guardian a week after she died regarding the funds and he had said he would contact the family. BOM #405 stated she never heard anything back after that. BOM #405 verified Resident #120's resident funds were not disbursed within 30 days as required after her death.

Based on record review, facility policy and procedure review and interview, the facility failed to provide Resident #30 adequate supervision and ensure proper footwear while ambulating to prevent a fall with injury. The facility also failed to complete a thorough fall investigation following the fall with injury. Actual harm occurred on 02/23/23 when Resident #30, who was severely cognitively impaired, at risk for falls and required (staff) supervision with ambulation fell while ambulating independently and sustained a fractured right clavicle and right hip requiring surgical intervention. This affected one (#30) of three residents reviewed for falls. The facility census was 103. Findings include: Review of Resident #30's medical record revealed an admitted [DATE] and re-admission 02/26/23, with diagnoses including asthma, dementia, and congenital kyphosis unspecified region. Review of Resident #30's care plan dated 12/20/22 included Resident #30 had a self-care deficit related to dementia. Resident #30 would be clean, well groomed, and would have no decline from admission. Interventions included Resident #30 required supervision for ambulation and assistance of one staff member for grooming and hygiene. Further review revealed Resident #30 was at risk for falls. The goal developed was for Resident #30 to be free of falls (through review date). Interventions included to ensure Resident #30 was wearing appropriate footwear and to specify and describe correct client footwear, for example brown leather shoes, tartan bedroom slippers, black non-skid socks when ambulating. Review of Resident #30's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 had severe cognitive impairment. The assessment revealed Resident #30 required supervision of one staff member for bed mobility, transfers, toilet use and locomotion on the unit. Review of Resident #30's progress note, dated 02/23/23 at 3:37 P.M., documented the nurse heard a loud noise, a State tested Nursing Assistant (STNA) yelled for help and Resident #30 was found on the floor in the doorway to her room. Resident #30 was bleeding from her head, 911 was called, pressure was applied to head wound. Vital signs were taken. Resident #30 stated she lost her balance and tripped over her shoe. Resident #30 complained of pain to her right leg, right shoulder, pelvis, and head. Resident #30 had a laceration to the right eyebrow and a hematoma to the right side of her forehead. Resident #30 was transported to the local hospital Emergency Department. The Director of Nursing (DON), the Nurse Practitioner, and Resident #30's guardian were notified. Review of Resident #30's progress notes dated 02/24/23 at 9:31 A.M., revealed Resident #30 was admitted to the hospital with a fractured right clavicle and had surgery, open reduction, and internal fixation right hip. Interview on 06/08/23 at 8:46 A.M., with Regional Nurse #617 revealed she read the investigation report of Resident #30's fall. The investigation report revealed the nurse heard a loud noise, the STNA called for help, Resident #30 was on floor and said she tripped over her shoe. Two nurses and an aide assisted Resident #30. Resident #30 was bleeding, pressure applied to her head wound, 911 was called, vital signs were stable and blood pressure was 166/97. Resident #30 was confused with impaired memory. The Nurse Practitioner, Director of Nursing (DON) and responsible party were notified. A head-to-toe assessment was completed and Resident #30 was unable to state if she had pain in the past five days. Interview on 06/08/23 at 8:46 A.M., with Assistant Director of Nursing/Licensed Practical Nurse (ADON/LPN) #529 revealed she watched the camera footage of Resident #30's fall. ADON/LPN #529 stated Resident #30's shoes were not all the way on her feet, and she was walking on the back of the shoes and tripped. ADON/LPN #529 stated she believed Resident #30 was high functioning for activities of daily living (ADL)'s and was able to put her own shoes on. ADON/LPN #529 stated Resident #30 was walking out of her room and tripped. ADON/LPN #529 indicated Resident #30 took naps throughout the day. ADON/LPN #529 stated the aide was charting three doors down from Resident #30 when she fell . Interview on 06/08/23 at 10:08 A.M., with State tested Nursing Assistant (STNA) #597 revealed he knew Resident #30 well and took care of her most days when he worked. STNA #597 stated he was not working on the nursing unit Resident #30 resided on the day she fell . STNA #597 stated before her fall Resident #30 needed assistance getting dressed, putting her pants and undergarments on. STNA #597 stated he had to put Resident #30's shoes on, and she could not do it herself. Interview on 06/08/23 at 11:19 A.M., with Regional Nurse #617 revealed she read the witness statements from Licensed Practical Nurse (LPN) #565 and STNA #625 and the notes confirmed the progress note documentation. Regional Nurse #617 confirmed the investigation notes did not reveal the events leading up to the fall or if staff assisted Resident #30 with her shoes (prior to the incident/fall). Regional Nurse #617 confirmed the investigation did not state if Resident #30 was trying to use the bathroom, if she was alone or with other residents, or which shoes were on her feet. Interview on 06/08/23 at 11:29 A.M., with LPN #565 revealed on 02/23/23 she was sitting at the nurse's station and saw Resident #30 walking back to her room. LPN #565 stated she heard a loud bang, ran to Resident #30 to assist her, and stayed with Resident #30 because she thought she fractured her hip by the way it looked. LPN #565 stated the DON was notified of Resident #30's fall. LPN #565 indicated Resident #30 tripped over her shoe when she was turning to enter her room. LPN #565 stated she could not remember if it was the right or left shoe, but stated one of her shoes was off and laying in the doorway. LPN #565 stated Resident #30 could walk independently, and she could not remember if Resident #30's shoes had shoelaces. LPN #565 indicated the fall occurred between lunch and dinner, and Resident #30 told her she was going to use the bathroom. LPN #565 stated the aide who assisted Resident #30 after the fall no longer worked at the facility. Interview on 06/08/23 at 11:44 A.M., with ADON/LPN #529 revealed she only looked at the camera footage at the point of Resident #30's fall and could not tell if Resident #30 was walking in or out of her room. ADON/LPN #529 stated she just wanted to make sure no one pushed Resident #30 or if there was any obstruction in her path. ADON/LPN #529 did not know if Resident #30 was lying down before the fall, did not know what Resident #30 was doing before the fall, and if staff assisted her with her shoes or Resident #30 had tried to put her shoes on herself. Interview on 06/08/23 at 12:52 P.M., with Regional Nurse #617 revealed no staff were interviewed to determine who (if anyone) put Resident #30's shoes on and helped her dress that day. Regional Nurse #617 indicated the investigation did not reveal if staff were interviewed about Resident #30 ambulating by herself. Review of the policy titled Assessing Falls and Their Causes revised October 2010 included the purpose of the procedure was to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. After an observed or probable fall, the staff would clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred. Within 24 hours of the fall the nursing staff would begin to try to identify possible or likely causes of the incident. Staff would evaluate chains of events or circumstances preceding a recent fall including what the resident was doing, whether the resident was among other persons or alone and whether the resident was trying to get to the toilet.

Based on observations, resident interviews, staff interviews, medical record review, admission agreement review, smoking policy review, review of the Secured Unit Agreement, and resident rights policy review, the facility failed to ensure residents were free from involuntary seclusion when cognitively intact residents were not afforded the opportunity to go outside without an escort of staff or interference. This resulted in actual psychosocial harm for two Residents (#57 and #252) were not allowed to freely go outside at will. This resulted in cognitively intact Resident #57 expressing wanting to leave the facility and was told by staff he could not leave. The resident was so distraught and resorted to physically removing the screen from his window, taking his wheeled walker and oxygen tank through the window, and leaving the facility to go to the store. Resident #252, who is cognitively intact and was assessed in activities as being very important to him to go outside to get fresh air when the weather was good, was told he could no longer go outside alone. Resident #252 stated he felt like he was in prison and there was nothing he could do about it. In addition, the facility failed to ensure two cognitively intact Residents (#17 and #19) were not being confined to a secured second floor nursing unit. This also affected two Residents (#69 and #24) that were not at harm level of 37 residents reviewed for involuntary seclusion. The facility census was 103. Findings include: Observations from 06/05/23 at 8:00 A.M. through 06/13/23 at 3:00 P.M. revealed the entrance doors were always secured and could only be opened with the receptionist pushing the hand- held remote to open the door. Review of the facility admission agreement revealed no criteria of the facility being locked and residents requiring an escort to go outside of the facility. Interview on 06/06/23 at 1:30 P.M., with the Administrator, revealed people drive fast in the front parking lot. To keep the residents safe, all residents need to have supervision when they go outside, and they cannot go outside unassisted. Interview and observation on 06/07/23 at 10:54 A.M., with Administrator and [NAME] President of Operations #622 revealed two sitting areas outside the facility, one smoking area and one next to the smoking area, that was not in the pathway of the driveway and had an exit door of the facility leading directly to the area. [NAME] President of Operations #622 revealed she was unaware of residents not being allowed to sit outside unsupervised, staff would be updated on resident rights, and alert and oriented residents should be allowed to go outside unassisted. Interview on 06/07/23 between 4:32 P.M. and 4:36 P.M., with State tested Nursing Assistant (STNA) #436, #570, and Licensed Practical Nurse (LPN) #575 revealed all residents must have an escort to go outside the facility. Interview on 06/12/23 at 3:36 P.M., with Social Worker (SW) #598 revealed he was gone from 05/18/23 to 05/24/23. When he returned, he was told no residents were able to leave the interior of the facility, even to just sit outside, without an escort or facility staff, and the escort had to show identification before going outside with the resident. SW #598 revealed he never received a written policy, but some residents were upset they could not go outside any longer unless someone was with them. Interview on 06/12/23 at 4:05 P.M., with Receptionist #593 and #607 revealed the doors to the facility were locked 24 hours a day, seven days a week. Residents were not allowed to go outside to even sit outside or leave the premises unless they had a staff member with them, or they had an escort that showed an identification (ID). The facility was in lockdown. Receptionist #593 and #607 revealed at no time did they, or were they asked to monitor residents sitting outside. Interview on 06/12/23 at 4:25 P.M., with the Director of Nursing (DON) revealed the building was secure and no residents were allowed outside unless they had an escort. DON revealed she and other staff members told residents verbally that residents were no longer allowed to go outside the facility without an escort. DON confirmed staff did not document in residents charts that residents were notified they were no longer allowed to go outside the facility without an escort. DON revealed she also educated all the staff residents were not allowed to go outside, even to sit unless they had an escort on 05/23/23. Interview on 06/13/23 at 9:16 A.M., with the Administrator confirmed all exit doors to the facility were secured, residents or visitors cannot exit the facility without a staff member assisting them with the code to open the door. Review of the policy titled, Residents Rights, dated December 2016, revealed residents have the right to be free from corporal punishment or involuntary seclusion, physical or chemical restraints not required to resident's symptoms. 1. Review of Resident #57's medical record revealed an admitted [DATE], with diagnoses including: chronic obstructive pulmonary disease, muscle weakness, gait abnormalities, lack of coordination and need for personal care. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/01/23, revealed the resident had intact cognition and was independent with mobility. No behaviors were noted. The resident does not have a legal guardian. Review of Resident #57's nurse progress notes, dated 05/18/23, revealed at approximately 7:00 P.M., the receptionist called Resident #57's nurse telling her he was leaving the facility without a leave of absence (LOA). The nurse and two aides came to the lobby to assess the situation. Resident #57 was observed walking back from the store. He stopped to sit in a field next to the facility. The nurse went out to check on Resident #57 and he reassured her he did not fall, he just wanted to sit in the sunshine for a bit. The sister of Resident #57 was called to redirect him to come inside, which she did. The resident returned with no injuries. Review of Resident #57's nurse progress notes, dated 05/20/23, revealed around 2:00 P.M., the resident wanted to walk to the store. The nurse checked for an LOA order from his physician and did not find one. The nurse informed Resident #57 that he could not leave the facility and he got very upset, yelled, and went back to his room. The nurse called Resident #57's sister about his request and she was planning to come to the facility with some items for Resident #57. Approximately at 2:30 P.M., the nurse received a phone call from Resident #57's sister stating the resident had climbed out his window. The nurse immediately checked Resident #57's room and discovered the screen had been removed and the resident was gone. Resident #57 did take his wheeled walker and his oxygen with him. The resident returned on his own and was not injured. Review of the form titled Elopement Review dated 05/25/23 completed by Registered Nurse (RN) #596 revealed Resident #57 was low risk for elopement. Review of the plan of care revealed no behavior or elopement care plans. Interview on 06/12/23 at 2:59 P.M., with Resident #57 stated he was pissed off, that he was not allowed to go outside without an escort. Resident #57 stated that was why he climbed out his window the other day. 2. Review of Resident #252's medical record revealed an admitted [DATE]. Diagnoses included end stage renal disease and abnormalities of gait and mobility. This resident does not have a legal guardian. Review of the Annual MDS assessment dated [DATE] revealed Resident #252 required extensive assistants of two for bed mobility, transfers, extensive assistants of one for locomotion, and set up help only with eating. Resident #52 had no impairment of the upper or lower extremities and used a wheelchair for mobility. Resident #252's hearing was adequate, speech was clear, vision was adequate, made self-understood, and was able to understand. No behaviors were exhibited. Resident #252's favorite activities were very important to him. Review of Resident #252's nurse progress notes for the past six months, revealed no concern related to the resident going on LOA's or outside on smoke breaks. Record review the form titled Elopement Review dated 05/25/23 completed by RN #596 revealed Resident #252 was low risk for elopement. Review of the plans of care for Resident #69 revealed no evidence of elopement risk or behaviors. Review of the Brief Interview of Mental Status (BIMS) score dated 05/26/23 completed by Social Service Director (SS) #598 revealed Resident #252 was cognitively intact. Review of the Activity assessment dated [DATE] completed by Activities Director #503 revealed it was very important to Resident #252 to go outside to get fresh air when the weather was good. Interview on 06/05/23 at 10:42 A.M., with Resident #252, stated he liked to go sit outside, that was what he enjoyed, and he use to sit outside nearly all day because he loved it. Resident #252 stated, staff told him he couldn't go outside anymore without an escort, and they don't have one to go with him. Resident #252 stated he felt like he was in prison and there was nothing he could do about it. Interview 06/07/23 10:46 A.M., with Activities Director #503 revealed Resident #252 loved to go outside. Resident #252 would set out all day and he has never tried to leave the facility grounds. Activities Director #503 revealed all residents needed an escort to go outside, even to sit. Activities Director #503 revealed she did not know why; she was just told the policy changed and that was how it was. Activities Director #503 revealed there was a patio that was not near the driveway where residents could sit. Activities Director #503 confirmed there were times Resident #252 requested to go sit outside and there were no staff available to take him. 3. Review for Resident #69's medical record revealed an admitted [DATE], with diagnoses including: paraplegia, muscle weakness, major depressive disorder, and generalized anxiety. This resident does not have a legal guardian. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #69 was cognitively intact. Resident #69 was total dependent for transfers and extensive assistants of two with locomotion. Resident #69 used a wheelchair for mobility, had no impairment of upper extremities, and was impaired on both sides of lower extremities. Review of the care plan dated 04/12/23 revealed Resident #69 was a smoker. Interventions included Resident #69 would be educated on smoking policy and was aware of smoke times. Review of the plans of care for Resident #69 revealed no evidence of elopement risk or behaviors. Review of Resident #69's nurse progress notes, for the past six months, revealed no concern related to the resident going on LOA's or outside on smoke breaks. Review of the form titled Elopement Review dated 05/25/23 completed by Registered Nurse (RN) #596 revealed Resident #69 was low risk for elopement. Interview on 06/05/23 at 11:39 A.M., with Resident #69 revealed the facility cut the smoke breaks down to two smoke breaks a day on weekends because someone eloped. Resident #69 stated he felt that was not right and that was upsetting to him. Resident #69 continued to state, he thinks it was not right that we are not allowed to go outside to get fresh air when we want, and we must be supervised just to sit outside. I feel confined. It made me mad and upset they can do that to us. Interview on 06/07/23 at 9:17 A.M., with the DON and Administrator revealed there were designated smoking times and all residents who smoked must be supervised. The Administrator revealed the housekeepers monitor the smoke breaks; smoking times on the weekend were decreased from three a day to two a day last month due to consistency of staffing with agency on the weekend and safety. Administrator revealed the residents were notified of the change and signed the new policy. Administrator confirmed there were 18 residents residing in the facility who smoked cigarettes and some residents were upset resulting in one resident leaving the facility. The Administrator also confirmed the decrease in resident smoking breaks was due to available staffing for the weekends. Review of the form titled, I have been advised of the change in smoke break and understand the new time parameters. 05/13/23 revealed 18 residents signed the form dated 05/13/23. Interview on 06/13/23 at 1:38 P.M., with Environmental Service Director #502 revealed the same day residents signed the change in smoking times, Saturday, 05/13/23, was the same day the residents not being allowed outside independently was initiated. Review of the undated admission packet area titled, Rocky River Gardens Smoking Policy, revealed residents were permitted to smoke as per the below facility smoking policy. All smokers will be supervised by an employee of the facility. Smoke breaks will take place on the back patio only during the designated smoke break times. The policy revealed there were three smoking breaks per day that were scheduled between 9:00 A.M. and 7:50 P.M. for 20 minutes per smoking break. Review of an undated policy titled, Rocky River Gardens Smoking Policy revealed smoking times Monday through Friday occurred three times a day starting at 9:30 A.M. and ending at 7:50 P.M. Saturday and Sunday two smoke breaks per resident were scheduled per day starting at 9:30 A.M. and ending at 2:50 P.M. for 20 minutes per smoking break. 4. Review for Resident #19's medical record revealed an admitted [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes mellitus, and muscle weakness. This resident does not have a legal guardian. Record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #19 was cognitively intact. Resident #19 required extensive assistants of one person for transfers, supervision with locomotion and eating. Resident #19 had no impairment of the upper or lower extremities and utilized a wheelchair for mobility. Review of the form titled Elopement Review dated 04/25/23 completed by RN #596 revealed Resident #19 was at low risk for elopement. Interview on 06/08/23 at 2:25 P.M., with Resident #19 revealed he wanted to go outside just to sit and to enjoy the fresh air whenever he wanted. Resident #19 revealed the residents including himself, used to be able to go and sit outside whenever they wanted, then a couple people ruined that by leaving and now everyone was being punished and had to suffer. Resident #19 revealed it made him feel sad and angry. 42013 5. Review of Resident #17's medical record revealed an admitted [DATE], with diagnoses including major depressive disorder, generalized anxiety disorder, and unspecified dementia. Resident #17 was her own responsible party. Resident #17 was admitted to the secured nursing unit on 02/01/22. Review of Resident #17's Admission Wandering Risk assessment dated [DATE] revealed Resident #17 was at low risk for wandering. Review of Resident #17's Admission Secured Unit Screener dated 02/01/22 revealed Resident #17 was not appropriate for the secured unit. Review of Resident #17's progress notes dated 02/26/22 revealed Resident #17's daughter was contacted because Resident #17 attempted to leave the facility. Resident #17's daughter was alright with a one-to-one care intervention, and Resident #17's Nurse Practitioner and the facility management staff were notified. One to one supervision by facility staff was terminated after a wanderguard was placed on Resident #17's right ankle. Review of Resident #17's Elopement Review dated 02/26/22 revealed Resident #17 was a high risk for elopement. Review of Resident #17's Secured Unit Screener dated 02/26/22 revealed Resident #17 was appropriate for admission to the secured unit. Review of Resident #17's Secured Unit Screener revealed from 02/27/22 through 06/07/23 Resident #17 did not have a Secured Unit Screener completed. On 06/08/23 Resident #17's Secured Unit Screener revealed a continued stay on the secured unit. Review of Resident #17's physician orders dated 02/28/22 revealed wanderguard in place to right ankle. Check for placement every shift, and check skin integrity around wanderguard every shift. Every shift for safety, secured unit. Review of Resident #17's Elopement Review dated 08/26/22, 11/22/22, 02/26/23 and 05/26/23 revealed Resident #17 was a low risk for elopement. Review of Resident #17's Quarterly MDS assessment dated [DATE] revealed Resident #17 was cognitively intact. Resident #17 required supervision of one staff member for bed mobility, transfers, locomotion on and off the unit, and for activities of daily living (ADL's). Resident #17 was not feeling down, depressed, or hopeless and had no thoughts of harming herself. Review of Resident #17's care plan revised 05/03/23 included Resident #17 was an elopement risk, wanderer related to disoriented to place. Resident #17 had impaired safety. Resident #17's safety would be maintained through the review date. Interventions included Resident #17 had a wander alert (wanderguard) to ankle, check placement and function every shift, Resident #17 resided on a secured unit. identify pattern of wandering, divert as needed and intervene as appropriate. Interview on 06/07/23 at 7:28 A.M., with LPN #550 revealed all residents who resided on the second floor wore a wanderguard. LPN #550 stated some of the residents were alert and oriented but if they were outside the facility, they were unable to find their way back in and back to the second floor. LPN #550 stated Resident #17's son did not want her to leave the facility unless he or another family member escorted her. LPN #550 stated the other alert and oriented residents who resided on the secured second floor nursing unit needed an escort to leave. Interview on 06/06/23 at 1:30 P.M., with the Administrator revealed residents residing on the secured second floor nursing unit could not leave the unit unescorted. The Administrator stated there was no policy for admission to the secured nursing unit, but the residents or the legal representative signed an agreement for placement on the secured nursing unit. Observation on 06/05/23 at 3:38 P.M., of Resident #17 revealed she was sitting in a chair in her room and had a wanderguard on her right ankle. Interview on 06/05/23 at 3:38 P.M., with Resident #17 revealed she usually stayed in her room, and a couple of the residents who resided on the second-floor nursing unit upset her. Resident #17 stated the lady who lived in the room next to her cursed loudly all the time, and she could hear the cursing through the walls. Resident #17 did not know the resident's name. Resident #17 stated Resident #96 was always walking around the nursing unit and would come in her room four to five times daily and it really upset her. Resident #17 stated last night he came in her room around 3:00 A.M. and she yelled at him to leave her room. Interview on 06/08/23 at 9:26 A.M., with Nurse Practitioner (NP) #612 revealed Resident #17 was on the secured unit when started working at the facility. NP #612 stated she was not sure why Resident #17 was on the secured unit. NP #612 stated if Resident #17 was not an elopement risk she did not need to be on the secured unit. NP #612 stated she had no reports from the nursing staff that would make her think she was at risk and did not see any reason for her to be on a secured unit. NP #612 stated Resident #17 should have a much more detailed exam per psychiatric services, but it had not been done. Interview on 06/08/23 at 10:18 A.M., with State tested Nursing Assistant (STNA) #589 revealed the second-floor nursing unit was a secured unit. STNA #589 stated no residents were allowed to leave the unit unescorted. STNA #589 stated when a resident wearing a wanderguard was near the elevator the elevator sounded an alarm but would still work. STNA #589 stated sometimes the residents used the elevator to leave the unit. STNA #589 stated the staff often needed to go to other areas of the facility to find residents who had left the floor. STNA #589 indicated some of the residents knew how to lift the plastic cover for the elevator and push the call button. Observation on 06/08/23 at 10:20 A.M., of the of the secured second floor nursing unit revealed an elevator, and the elevator call button had a plastic cover that needed to be lifted to push the button to have the elevator come to the floor. An electronic control panel was noted near the elevator and STNA #589 stated it was for the wanderguard system. Observation of doors leading to stairways revealed electronic panels that needed a code before the door would open. Interview on 06/08/23 10:31 A.M., with Resident #17 revealed Resident #17 stated someone cut the wanderguard off her right ankle this morning. Observation revealed there was no wanderguard on the resident. Interview on 06/08/23 at 1:50 P.M., with Resident #17 revealed the situation with Resident #96 coming into her room uninvited was better because she would slide her dresser in front of her door to keep him from coming in. Resident #17 stated she liked to keep her door closed. Resident #17 stated when she first arrived at the facility she wanted to go to the store and did not know she was not allowed to leave. Resident #17 indicated the staff stopped her from leaving before she crossed the street on her way to the store. Resident #17 stated she wished she could leave this floor and it bothered her that she could not leave unless she was accompanied by her family. Resident #17 stated she really wanted to be able to go outside and had not been outside recently. Review of Resident #17's undated form titled Secured Unit Assessment revealed the form was not signed by Resident #17. Resident #17's daughter signed the form which included this resident had been assessed by his or her interdisciplinary care team, and such assessment revealed that he or she had specific medical symptoms and or needs that warrant placement on the facility's secured unit, which was a specialized secured unit that restricted resident freedom of movement throughout the facility. The secured unit included the possibility of reduced social contact and benefits. 6. Review of Resident #24's medical record revealed an admitted [DATE], with diagnoses including unspecified dementia with other behavioral disturbance, post-traumatic stress disorder, and hemiplegia (weakness) affecting the left non-dominant side. Resident #24 was his own representative. Resident #24 was admitted to the secured nursing unit. Review of Resident #24's physician orders dated 02/17/23 revealed wanderguard to right ankle. Check placement and function every shift. Check skin integrity around wander guard every shift. Review of Resident #24's Elopement Review dated 02/17/23 revealed Resident #24 was at high risk for elopement. Review of Resident #24's progress notes dated 02/20/23 revealed Resident #24 did not need a wanderguard and could leave the unit without supervision. Wanderguard was removed from the right ankle. Review of Resident #24's progress notes dated 02/21/23 revealed he was alert and oriented to time, place, person and requested to utilize the campus for fresh air. Resident #24 was oriented to the residential sitting areas and mentioned how close the store was. Resident #24 was informed that he did not currently have a leave of absence order and was not permitted to leave the healthcare campus. Resident #24 was seen off campus in a motorized wheelchair. Facility staff proceeded to resident's current location and Resident #24 was transported back to the facility. Resident #24 was notified as self-representative and educated again regarding the leave of absence protocol. Certified Nurse Practitioner was notified of unauthorized leave of absence and a wanderguard was placed on Resident #24's left ankle. Review of Resident #24's Secured Unit assessment dated [DATE] revealed it was not signed by Resident #24. Resident #24's brother signed the form which included this resident had been assessed by his or her interdisciplinary care team, and such assessment revealed that he or she had specific medical symptoms and or needs that warrant placement on the facility's secured unit, which was a specialized secured unit that restricted resident freedom of movement throughout the facility. The secured unit included the possibility of reduced social contact and benefits. Review of Resident #24's Quarterly MDS assessment dated [DATE] revealed Resident #24 was cognitively intact. Resident #24 required extensive assistance of two staff members for bed mobility, transfers, and personal hygiene. Resident #24 required supervision of one staff member for locomotion on and off the unit, Resident #24 used a wheelchair. Resident #24 felt down, depressed, or hopeless, and did not have thoughts that he would be better off dead or hurting himself in some way. Interview on 06/12/23 at 9:23 A.M., with Resident #24 revealed he was placed on the secured nursing unit because he escaped, was by himself, got turned around and a civilian helped him find his way back to the facility. Resident #24 stated he was not alright with being on the secured nursing unit and not being allowed to leave the unit when he wanted to. Resident #24 stated he hated that he could not even go to the vending machine by himself. Resident #24 indicated that was why he got so upset a couple days ago and fought the staff when he was at the vending machine, and they tried to make him go back to the secured unit. Resident #24 stated he just wanted a drink out of the vending machine. Resident #24 stated he did not sign a paper saying he agreed to be on the secured unit. Interview on 06/12/23 at 9:43 A.M., with STNA #585 revealed the second floor was a secured unit and residents were not allowed to leave without escort. Interview on 06/13/23 at 11:18 A.M., with Regional Director of Operations #616 revealed Resident #24 represented himself, did not have a guardian and was getting moved off the secured nursing unit and would be residing on the third-floor nursing unit. This deficiency represents non-compliance investigated under Complaint number OHO0143495.

Based on observation, record review and interview the facility failed to provide comprehensive and individualized pressure ulcer care for Resident #91. The facility failed to implement preventative measures and timely identify an area of skin breakdown to one resident's coccyx (Resident #91) until it was assessed to be 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 ulcer. Actual Harm occurred on 10/02/20 when Resident #91, who was paraplegic with a [MEDICATION(S)] spinal cord injury and required staff assistance for activities of daily living including bed mobility, was identified to have an open area to the coccyx with no evidence the area was comprehensively assessed, the physician was notified or a treatment was initiated. On 10/09/20, the first assessment of the pressure ulcer revealed it was a Stage IV ulcer with a large amount of serosanguinous drainage with a slight odor noted. The resident required treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . As of 05/26/21 the resident continued to require treatment to the area. This affected one Resident (#91) of one resident reviewed for pressure ulcers. The facility identified no other resident's with in-house acquired pressure ulcers. The facility census was 88. Findings include: Review of Resident #91's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #91's plan of care dated 03/31/20 revealed no evidence the resident was at risk for pressure ulcers. There were no goals identified and no pressure ulcer interventions implemented at the time of admission. After a Stage IV pressure ulcer to Resident #91's coccyx/inner buttocks was assessed on 10/09/20 a care plan was initiated on 10/12/20 for a Stage IV pressure ulcer for the coccyx/inner buttocks related to immobility, with a goal the pressure ulcer would show signs of healing and remain free from infection through the review date. Interventions on 10/12/20 included to administer treatments as ordered, monitor for effectiveness, and follow policies, protocols for prevention and treatments of skin breakdown. Review of Resident #91's Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] revealed the resident was at high risk for developing a pressure sore. Braden Scale for Predicting Pressure Sore Risk assessments dated 03/31/20, 04/14/20, 04/21/20, 05/20/20, 05/27/20 and 06/10/20 and 06/03/20 continued to reveal the resident was at risk for developing a pressure sore. Resident #91 had very limited mobility, made occasional slight changes in body or extremity position but was unable to make frequent or significant changes independently, required moderate to maximum assistance in moving and complete lifting without sliding against sheets was impossible. There were no further Braden Scale assessments completed until 02/09/21. Review of the Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #91 required extensive assistance from staff for bed mobility. The assessment revealed the resident did not have any pressure ulcers but was at risk for pressure ulcer development. Further review of the MDS assessment dated [DATE] revealed Resident #91 was not on a turn and reposition program, and had pressure reducing devices to his bed and chair. Review of Resident #91's physician orders revealed orders dated 03/31/20 for a pressure reducing mattress and cushion. The pressure relieving mattress and cushion were discontinued on 05/20/20. New orders were not written until 10/08/20 for an air mattress and pressure relieving cushion for Resident #91's wheelchair. Interview on 05/27/21 at 3:45 P.M. with MDS Nurse #412 revealed she could not answer why Resident #91's MDS assessment from 07/08/21 included pressure relieving devices to the bed and chair when those orders were discontinued 05/20/20 and not re-ordered until 10/08/20. MDS Nurse #412 stated she was not the MDS Nurse in July, 2020. Review of the Weekly Skin Observation Form dated 10/02/20 revealed Resident #91 had a skin wound/open ulcer to the coccyx. There were no measurements, staging or description of the area at that time. Record review revealed no evidence the physician was notified of the area and no evidence a treatment was initiated. Review of the progress note dated 10/07/20 revealed an open wound to the resident's coccyx with drainage of bright red blood. The unit manager was notified at that time. Record review revealed no additional assessment, measurements, description or staging of the ulcer was completed. A treatment order dated 10/07/20 revealed an order to cleanse the coccyx with normal saline, pat dry and cover with border foam. At the time this treatment order was obtained, there was no evidence the resident had any pressure reducing/skin prevention interventions in place (i.e. no pressure reducing cushion, no order/interventions for turning and repositioning, no use of an air mattress). On 10/08/20, an order was obtained for an air mattress to the resident's bed and a Roho cushion (which decreases amount of pressure to sitting area) to the wheelchair at all times. On 10/09/20, an order was obtained for staff to turn the resident every two hours while in bed and document if the resident refused to be turned. Review of the weekly wound observation tool dated 10/09/20 revealed Resident #91 had a wound between the upper buttocks and coccyx which was acquired during the resident's stay in the facility. This was the first documented assessment of the pressure ulcer. The pressure ulcer was assessed to be a Stage IV pressure ulcer with granulation tissue present and 40 percent slough present and a large amount of serosanguinous drainage. The pressure ulcer measured 4.0 centimeters (cm) length by 3.0 cm width with 0.5 cm depth. The peri-wound (tissue surrounding the wound) was dark pink to pink, epibole (rolled or curled under closed wound edges that may be dry, calloused, or thickened) was irregular and an infection was suspected. A wound culture was obtained at that time. Review of Resident #91's wound culture lab report revealed the specimen was collected on 10/09/20 and the results were reported on 10/12/20. The culture revealed moderate growth of Escherichia coli (E Coli), moderate growth proteus mirabilis and gram-positive rod. On 10/14/20, two days after the wound culture results were obtained, a physician order to insert a midline catheter for intravenous antibiotic therapy was noted. The resident was ordered the antibiotic, [MEDICATION(S)] 500 milligram (mg) in 100 milliliters (ml) of normal saline to infuse intravenously at 200 milliliters (ml) per hour every six hours for ten days. Record review revealed the IV antibiotic was first administered on 10/15/20, and the resident received the antibiotic until 10/28/20. Review of Resident #91's medical record revealed on 02/03/21 bright red bleeding was noted from the coccyx, buttocks wound, and resident was sent to the local hospital emergency room for evaluation. Review of Resident #91's General Surgery Brief Op Note on 02/03/21 revealed an infected sacral decubitus ulcer, abscess with computerized tomography (CT) scan findings consistent with chronic [CONDITION(S)] (bone infection) for the coccyx tip. Resident #91 had a wound debridement and placement of a wound VAC on 02/03/21. Review of Resident #91's operative report dated 02/05/21 revealed the resident had a debridement of sacral wound with final measurements 7.0 cm depth, 10.0 cm to the left buttock, 15.0 cm to the right buttock and 8.0 cm long in the midline. A wound vac was placed. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #91 was cognitively intact and required extensive assistance from two staff for bed mobility. Review of Resident #91's assessment from the Wound Clinic on 05/26/21 revealed the wound was an open surgical wound on the gluteus; the wound was from a pressure injury. The wound was 2.4 cm length by 5.0 cm width with a depth of 5.0 cm. The wound had 67-100 percent red granulation tissue with small (one to thirty three percent) adherent slough. On 05/25/21 at 9:29 A.M. interview with Resident #91's father revealed the resident had developed a bed-sore while residing in the facility and it had become infected. The resident's father believed the ulcer had become infected because the resident had not been properly cared for. Resident #91's father did not give specific information about what care his son did not receive that contributed to the infection. On 05/25/21 at 3:17 P.M. interview with Registered Nurse (RN) #400 revealed she was the facility Director of Nursing from November, 2020 through April, 2021 but had not been employed by the facility in September and October 2020. RN #400 revealed Resident #91's coccyx pressure ulcer was first assessed on 10/09/20 but it appeared as though the area had first been identified on 10/02/20. RN #400 revealed it was possible the nurse who first found the area on 10/02/20 was not comfortable and wanted to wait for the facility wound nurse to assess the area and complete documentation of the area. RN #400 revealed a small reddened area was identified on 09/19/20 to Resident #91's right buttock and an order was obtained for [MEDICATION(S)] Ointment to be applied twice daily to the area. RN #400 confirmed the pressure ulcer to Resident #91's coccyx/inner buttocks should have been visible when the [MEDICATION(S)] ointment was applied to the right buttocks twice daily. She stated the facility identified the wound on 10/02/20 but could not explain why it was not assessed until 10/09/20 when it was documented as a Stage IV pressure ulcer. On 05/26/21 at 1:10 P.M. Resident #91 was observed in bed. The resident had just returned from an appointment and his wound vac had not yet been reconnected. At the time of the observation, interview with Resident #91 revealed concerns related to facility staffing. The resident indicated the facility was short staffed and about 50 percent of the time he had to remind the state tested nursing assistant (STNA) staff to turn and reposition him. Interview on 05/25/21 at 2:11 P.M. with STNAs #403 and #404 revealed they worked on the first-floor nursing unit where Resident #91 resided until 09/11/21 when he was transferred to the third-floor nursing unit. STNAs #403 and #404 stated everything was going great for Resident #91, and he did not have a pressure ulcer. STNA #404 stated they were upset when they found out Resident #91 developed a pressure ulcer while residing on the third floor. On 05/26/21 at 2:27 P.M. interview with STNA #410 revealed she usually worked on the third-floor nursing unit, and she had cared for Resident #91 in September, 2020 and October, 2020. STNA #410 did not remember when Resident #91 first developed the pressure ulcer to his coccyx or how it happened, but after it was discovered he needed turned and repositioned every two hours. During the interview, STNA #410 revealed there was not enough staff working to get all the work done (including turning and repositioning residents). Review of Resident #91's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #91's medical record did not reveal documentation Resident #91 was turned and repositioned every two hours until 10/09/21. Observation of the wound was not completed due to the wound vac was changed off-site at the wound clinic. The wound vac was intact and functioning upon observations throughout the survey. Review of the facility policy titled Prevention of Pressure Ulcers, Injuries, revised 07/2017, revealed the purpose of this procedure was to provide information regarding identification of pressure ulcer, injury risk factors and interventions for specific risk factors. Review of the resident's care plan and identification of the risk factors as well as interventions designed to reduce or eliminate those considered modifiable. Assess resident on admission for existing pressure ulcer, injury risk factors. Repeat the risk assessment weekly and upon any change in condition. At least every two-hours, reposition residents who are reclining and dependent on staff for repositioning. This deficiency is an incidental finding to Complaint Number OH 306.

Based on observation, medical record review and staff interview, the facility failed to provide interventions to assure the safe transfer of one cognitively impaired resident (#53) resulting in a fall with bruising and a nasal fracture. This affected one of three residents reviewed for accidents and had the potential to affect 83 residents requiring assistance with transferring. Findings include: A review of the medical record for Resident #53 revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) 3.0 dated 07/20/12 revealed Resident #53 had cognitive and physical deficits. The MDS Activities of Daily Living (ADL) assessment revealed that Resident #53 required extensive assistance of one person with toileting, transferring. The Fall Risk Care Plan initiated on 02/02/11 had an intervention to provide assistance with all transfers. A review of the medical record for falls revealed Resident #53 sustained three fall incidents over the previous three months. On 05/11/11, Resident #53 was found on the floor next to the bed after attempting to self-transfer. On 07/03/12, the resident was found "wedged between another resident's bed and nightstand". On 08/09/12, Resident #53 was found face first on the floor in the bathroom after being left on the toilet by facility staff and an attempt to self-transfer. The post fall assessment revealed injuries to the nose and forehead. Resident #53 was transferred to the hospital for further evaluation on 08/09/12 and returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 08/15/12 at 2:00 P.M., the surveyor observed Resident #53 in bed with the wheelchair next to the bed. At 2:15 P.M., the surveyor observed Resident #53 propel her wheelchair into the dining room unassisted. State tested Nurse Aide (STNA) #12 asked the resident how she got in her chair and Resident #53 stated that she did it on her own. STNA #12 immediately propelled Resident #53 back to the hallway towards her room. STNA #12 accompanied the surveyor on a search of the hallway for staff that might have assisted the resident; no staff were available in the immediate area of Resident #53. At 2:20 P.M., Licensed Practical Nurse (LPN) #11 was in the central nurse station and stated she did not see anyone transfer Resident #53. LPN #11 located STNA #10 who was assigned to the care of Resident #53. During an interview with STNA #10 on 08/15/12 at 2:20 P.M., she stated that Resident #53 transfers without assistance frequently. On 08/15/12 at 1:20 P.M., an interview with the Director of Nursing (DON) revealed interventions to provide additional monitoring and surveillance for the unassisted transfers of cognitively impaired Resident #53 had not been considered for the plan of care.