Every finding on record at Sapphire Rehabilitation and Care Center

Based on observations, family interview, and staff interviews, the facility failed to ensure a safe clean comfortable home-like environment. This affected rooms #107, #201, #319, and #410. This had the potential to affect 90 residents. Six residents resided in the newest part of the building on Unit 5 and were not affected. The facility census was 96.Findings include:Observation and interview on 08/11/26 at 11:05 A.M. revealed above room [ROOM NUMBER]'s door, there was a five cm in lengthy by eight cm in width tile on the ceiling with a fuzzy black substance mixed with pea-green, white spots and brown color. Activity Director #114 confirmed the spots were there prior to the rainstorm and commented they looked bigger.Observations and interviews with the Administrator on 08/12/26 at 10:50 A.M. revealed the following environmental concerns above room [ROOM NUMBER]'s door, there was a 10 centimeter (cm) in length by 18 cm in width circle on the ceiling that was a fuzzy black substance, white spots, mixed with pea-green and brown color with a light brown circle around it. In the television room located between the third and fourth unit, on the left side wall , the ceiling had a 10 cm in length by 10 cm in width tile with a circle of black spots which appeared to be wet looking and fuzzy encircled by a tan like color. There were four additional spots on the ceiling titles in the middle of the room which were brown and tan. The Administrator verified the findings during the observation.Observation in the Memory Care Unit (MCU) on 08/12/26 at 11:10 A.M. with the Unit Director #118 confirmed the following: there was a spot above the unit entry door's closest to the entry and the entire ceiling tile had a 10 cm in length by 14 cm in width had brown, black, gray, white fussy like substance. Observations on 08/12/25 at 11:20 A.M. revealed from four feet from the entrance doors to Unit Three, close to the television lounge area, the Director of Nursing (DON) was removing a entire ceiling tile. When the ceiling tile was removed, it was soaking wet and split in half instantly; above the tile, the pipes appeared to be dripping water and the boards inside were wet. Observation of Unit One on 08/12/26 at 12:00 P.M. revealed above room [ROOM NUMBER]'s door, the ceiling had an eight cm in length by eight cm in width spot of brown with tiny black and white fuzzy spots in the center of the tile. This was verified by Licensed Practical Nurse (LPN) #116.Observation and interview for 08/12/26 at 4:30 P.M. revealed in room [ROOM NUMBER]'s room, the ceiling across from the closet had a 48 cm in length by 48 cm in width missing board covering the ceiling. Under the area, there was a trash can with a wet towel around it catching water dripping from the ceiling. The board that covered the ceiling was in the closet; it had black substance around all its edges. This was verified by LPN #116. LPN #116 stated she reported this for the past two weeks and it still hasn't been repaired.Interview with the resident's Family Member #500 in room [ROOM NUMBER] on 08/13/26 at 1:20 PM revealed it has been at least two weeks since the ceiling has been leaking, and they did not move the resident out of room [ROOM NUMBER]. This deficiency represents non-compliance investigated under Complaint Numbers 3123690 and 3153083.

Based on medical record review, hospital medical record review, staff interviews, interview with dialysis center, and policy review, the facility failed to ensure a resident had a safe discharge from the facility. This affected one (Resident #99) of three residents reviewed for discharge. The facility census was 96. Findings include:Review of the medical record for Resident #99 revealed an admission date of 02/19/26. Diagnoses included vascular dementia, cognitive communication deficit, muscle wasting and atrophy, chronic viral hepatitis B, dependence on renal dialysis, and end stage renal disease.Review of the discharge care plan initiated 03/03/26 revealed the resident's plan was to discharge to home with his [daughter]. Resident #99 dialysis's care plan dated 03/03/26 revealed he attended dialysis three times week, Monday, Wednesday and Friday.Review of a hand written care note dated 05/29/26 revealed Resident #99 was discharging home on [DATE]. Resident #99's sister will be in [NAME] at this time (06/03/26) but there were other family members in the apartment to provide assistance. Home Health Service (HHS) #500 to provide home therapies. No durable medical equipment (DME) was needed as Resident #99 had a wheelchair at home. Dialysis already set up. Resident #99's sister joined the care conference by telephone. The care plan note did not address if Resident #99 would have 24-hour care, assistance with medication management, transportation needs to attend dialysis, and if family members would be able to assist Resident #99 with transfers and ambulation.Review of the Occupational Therapy (OT) Discharge summary dated [DATE] revealed Resident #99's prognosis to maintain Current Level of Function (CLOF) was with good with strong family support. On OT discharge date d 06/01/26, Resident #99 required supervision to partial assistance with medication management with independence and good safety awareness to improve independence in daily routines. Prior living arrangement was in a apartment with his daughter. Unsure accuracy of information as the resident appears to be a poor historian. Resident #99 had no awareness of diagnosis and prognosis.Review of the Physical Therapy (PT) Discharge summary dated [DATE] revealed Resident #99 required moderate to minimum assistance from a person with rest stop with maximum cues going up and down eight steps. Discharge recommendations stated 24-hour care for Resident #99. Resident #99's prognosis to maintain CLOF was excellent with consistent staff support. Resident #99 had no awareness of diagnosis and prognosis. Resident #99 was discharged to reside in the long-term care facility.Review of the social services progress note dated 06/02/26 revealed Resident #99 had a planned discharge this date as he was out of skilled days and chooses not to pay privately. HHS #500 was in place. Resident #99 resided with family and attended dialysis. The note did not address if Resident #99 would have 24-hour care, assistance with medication management, transportation needs to attend dialysis, and if family members would be able to assist Resident #99 with transfers, steps, and ambulation.Review of the nursing progress noted dated 06/03/26 (Wednesday) revealed Resident #99 was discharged from the facility. Vital signs were stable at the time of discharge. Resident #99 was transported via the facility transportation.Review of the Discharge summary dated [DATE] revealed Resident #99 was physically dependent on person for walking and required the use of a walker. A current reconciled medication list was provided to Resident #99 upon discharge.Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #99 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 13. Resident #99 was independent with bed mobility, required setup assistance from staff for transfers, and required supervision or touching assistance from staff for ambulation.Review of the hospital medical records dated 06/08/26 revealed Resident #99's dialysis center called the police to do a wellness check and Resident #99 was found wandering around outside his house. Resident #99 was oriented times three in the emergency department (ED). Resident #99 stated that his daughter who usually took care of him recently moved back to [NAME] and will be gone for three months. Resident #99 stated that he feels unsafe living at home, he was unable to cook for himself, and the last time he ate was the previous day. Resident #99 stated he felt lightheaded. Resident #99 stated that he used a cane to walk around, but it was difficult for him to walk. Resident #99 met with a case manager (CM) for a bedside consult for discharge needs. Resident #99 stated there were three flights of stairs to enter his apartment. He does have walker but was unable to use with the stairs so he uses his cane. Resident #99 stated that he cannot cook for himself and forgets to eat. The hospital CM discussed where Resident #99 could go upon discharge until his daughter returns home and Resident #99 was not sure. Resident #99 stated that he tried to get in touch with his son (#1) but could not reach them. The hospital CM discussed with Resident #99 to investigate possible Medicaid services if qualifies. The hospital CM attempted to contact daughter, and the telephone call went straight to voicemail. The hospital CM attempted to contact son (#1), which Resident #99 stated has access to his bank account and it went to voicemail which was not setup. The hospital CM spoke with Resident #99's other son (#2) who was not aware his father was in the hospital and was not clear on whether Resident #99 left the rehabilitation facility on his own or was discharged . Resident #99's son stated he did not know why Resident #99 was at the apartment because there was no one there to take care of him. The hospital CM placed a call to Adult Protective Services (APS) with [NAME] County, Ohio. The progress note dated 06/11/26 revealed the physician assessed Resident #99 as incapacitated to make his own decisions. Resident #99's son agreed to long-term care placement.Interview with Dialysis Social Worker (DSW) #800 on 06/15/26 at 11:04 A.M. revealed Resident #99 did not show up to his dialysis scheduled appointment on Friday (06/05/26) and did a wellness check on Resident #99. DSW #800 spoke to one of Resident #99's son and the son set up a driver pick up for Monday (06/08/26). On 06/08/26, Resident #99's driver pick up did not show up so dialysis got another driver to pick up Resident #99. The second driver took Resident #99 to the dialysis appointment, but Resident #99 arrived late, and the second driver said he had Resident #99 in his car but Resident #99 could not get out of the car. Resident #99 told DSW #800 that he did not feel safe at home, his one son [NAME] him things but didn't stay all the time due work. Resident #99 stated he was not eating because he cannot stand up to make food. DSW #800 stated Resident #99 lost three pounds in the five days (06/03/26 to 06/08/26) and it was unheard for dialysis patients unless they were not eating. DSW #800 stated they called and spoke to a nurse (unknown name) on 06/03/26 when they heard Resident #99 was being discharged to home that day (06/03/26) and the nurse verified Resident #99 was being discharged that day. The nurse took down DSW #800's name and telephone number for social services to call back to understand the discharge plan for Resident #99. The facility's social worker never returned DSW #800's call.Interview on 06/15/26 at 2:09 P.M. and on 06/16/26 at 9:10 A.M. with Social Services Designee (SSD) #220 stated a care conference was completed on 05/29/26 with Resident #99 and their daughter. At the time of the care conference, Resident #99 and daughter were agreeable to a discharge date of 06/03/26 and voiced no concerns. The daughter stated at the care conference that she would be in [NAME] at the time of the discharge, but other family members would be at home to help with care for Resident #99. SSD #220 stated Resident #99 was discharged because they were ready to go home and did not want to pay out of pocket to stay at the facility. SSD #220 stated PT and OT services were set up for Resident #99 through HHS #500. Resident #99 stated he would use his family or the bus as transportation to his dialysis appointments once discharged . SSD #220 stated the final discharge paperwork on 06/03/26 was reviewed with only the resident himself, since he was cognitively intact. SSD #220 stated the family members living in the home was the plan for the 24-hour care of Resident #99. SSD #220 stated no home assessment by therapy was done due to no concerns being brought up by the daughter or resident at the time of the care conference. At no time did SSD #220 state the SR's son was involved in the discharge planning process.Interview on 06/15/26 at 2:43 P.M. with Transportation Driver (TD) #218 stated on the morning of 06/03/26, TD #218 picked up Resident #99 and transported them to their dialysis appointment. TD #218 then picked up Resident #99 after their dialysis appointment and transported them to their home since they were discharged that day. When TD #218 arrived at Resident #99's home, they stated a man and young girl came out of the apartment building to meet Resident #99. Resident #99 and the man exchanged conversation in their native language and then Resident #99 walked into the apartment building unaided with only a cane. The man then collected Resident #99's belongings and went inside the apartment building.Interview on 06/16/26 at 9:21 A.M. and 11:24 A.M. with PT #222 revealed to her knowledge, Resident #99 was being discharged home with family members that lived in the same apartment building. PT #222 stated she believed Resident #99 needed 24-hour care when being discharged home. PT #222 stated she did not believe it was safe for the resident to be home alone and thought Resident #99 should have stayed in the facility longer. PT #222 stated Resident #99 fatigued easily when walking and to prevent a potential fall, Resident #99 would need 24-hour care.Interview on 06/16/26 at 11:18 A.M. with Registered Nurse (RN) #225 revealed Resident #99 voiced concerns about going home to the nurse during discharge on [DATE]. RN #225 stated Resident #99 expressed that he did not feel ready to go home and that he needed more therapy. RN #225 stated this was reported to SSD #220. RN #225 asked if Resident #99 had to leave that day or if he could stay longer in the facility. RN #225 stated the response she received was Resident #99 was being discharged that day due to his insurance.Attempts to interview Resident #99's son and daughter during the survey were unsuccessful.Review of the facility policy titled Facility Discharge and Transfer policy revised 01/2025 revealed the facility will only initiate a discharge or transfer of a resident for appropriate reasons, ensure proper documentation, provide advance notice, and facilitate coordination with receiving providers or services.This deficiency represents non-compliance investigated under Complaint Number 3042593.

Based on observations, resident interviews, staff interviews, and facility policy, the facility failed to maintain resident use shower rooms in a clean, sanitary, and safe condition. This is affected three of three showers rooms located in the facility. This had the potential to affect all 64 residents who utilize the shower rooms. The facility census was 94.Findings include:Interview on 06/09/26 at 10:50 A.M. with Resident #60 revealed concerns regarding the condition of the shower rooms. The resident stated a shower room was not being cleaned and reported concerns regarding the condition of the facility's shower areas on both unit A and B.Interview on 06/09/26 at 10:59 A.M. with Unit Manager #211 revealed the Unit B shower remained in use and was cleaned regularly. Unit Manager #211 stated the shower on Unit B had contained missing tile since she began working on the unit approximately one month earlier.Observation on 06/09/26 at 11:07 A.M. of the Unit B shower room revealed missing wall tiles, warped flooring causing tiles to bulge upward, and separation of wall material beneath the tile surface due to moisture damage. The shower remained in use and a resident shower had recently concluded. Unit Manager #211 confirmed the condition of the shower on unit B at the time of the observation.Interviews on 06/09/26 at 1:40 P.M. revealed Residents #18 and #71 reported concerns regarding shower room cleanliness and maintenance, including missing tiles and inadequate cleaning.Observation on 06/09/26 at 1:51 P.M. with the Administrator revealed the memory care shower room contained mold like substance throughout the shower area, multiple missing/broken floor tiles, and exposed sharp tile edges. Observation of the Unit A shower room revealed a yellow substance present along the corners of the tiled surfaces. The Administrator confirmed the mold like substance conditions observed in the memory care shower room, they yellow substance present along the tile of unit A shower, and confirmed the Unit B shower room contained missing tiles and warped flooring.Interview on 06/09/26 at 2:01 P.M. with Housekeeper #166 revealed the black substance observed in the memory care shower room had been present for months.Interview on 06/09/26 at 2:30 P.M. with Maintenance Director #194 revealed he had been aware of the shower conditions since beginning employment approximately three weeks earlier. Maintenance Director #194 stated he discussed the conditions with his supervisor on the date of this survey (06/09/26). Maintenance Director #194 stated the mold and tile issues were being addressed following surveyor observations but would have remained pending a future remodel project that had not been scheduled yet.Review of the facility policy titled Homelike Environment, revised February 2021, revealed residents were to be provided a safe, clean, comfortable, and homelike environment. The facility was to maximize characteristics of a homelike setting including a clean, sanitary, and orderly environment.This deficiency represents non-compliance investigated under Complaint Number 3022596.

Based on review of the facilities Self-Reported Incidents (SRI) and investigations, policy review, and staff interview, the facility failed to conduct thorough investigations into allegations of physical abuse, neglect, and misappropriation were thoroughly investigated. This affected three of three SRIs reviewed. This affected five resident, Residents #40, #41, #43, #74, and #76. The facility census was 94.Findings include:1. Review of SRI tracking number 274596 dated 05/15/26 revealed an allegation of neglect involving facility staff member, Registered Nurse (RN) #166 and Residents #74 and #41. The narrative summary stated that head-to-toe assessments were completed with no injuries noted, staff and resident interviews were conducted, the alleged perpetrator was interviewed, and the allegation was unsubstantiated. On 06/09/26 at 8:33 A.M., 11:50 A.M., 1:00 P.M., and 4:10 P.M., the State Survey Agency surveyor requested the facilities SRI 274596 and the facilities investigation related to this SRI to the Administrator. The SRI investigation was not provided until 4:56 P.M.Review of the facilities investigation revealed there was no evidence staff and residents interviews were conducted or head-to-toe assessments were completed. Witness statements, including one from RN #166 describing the incident, were only provided to surveyor after survey exit via e-mail. The file contained a statement stating residents were interviewed and listed the residents names regarding concerns with their care and missing items but no evidence of the resident interviews were in the file. Interview on 06/09/26 at 5:07 P.M. with the Administrator revealed he acknowledged the delay in providing the SRI records and investigations. The Administrator confirmed the facility's expectation for thorough investigations including witness statements and resident statements/skin checks but could not explain the gaps in the documentation for the SRI 274596.2. Review of SRI tracking number 274624 dated 05/16/26 revealed an allegation of misappropriation involving Resident #40. The narrative summary stated that the resident was interviewed, other residents and staff were interviewed with no concerns noted, family was contacted, and no inventory record existed for the missing items. The allegation was unsubstantiated. On 06/09/26 at 8:33 A.M., 11:50 A.M., 1:00 P.M., and 4:10 P.M., the State Survey Agency surveyor requested the facilities SRI 274624 and the facilities investigation related to this SRI to the Administrator. The SRI investigation was not provided until 4:56 P.M.Review of the facilities investigation revealed the investigation did not contain staff interview documentation, resident witness statements, or other supporting evidence. The file was primarily composed of care plan information.Interview on 06/09/26 at 5:07 P.M. with the Administrator revealed he acknowledged the delay in providing the SRI records and investigations. The Administrator confirmed the facility's expectation for thorough investigations including witness statements and resident statements/skin checks but could not explain the gaps in the documentation for the SRI 274624.3. Review of SRI tracking number 274784 dated 05/20/26 revealed an allegation of physical abuse (resident-to-resident altercation between Resident #76 and Resident #43). The narrative summary stated head-to-toe assessments were completed, residents were interviewed (limited information due to cognition), staff working on the unit were interviewed, and the allegation was unsubstantiated. Resident #76 was placed on increased supervision. On 06/09/26 at 8:33 A.M., 11:50 A.M., 1:00 P.M., and 4:10 P.M., the State Survey Agency surveyor requested the facilities SRI 274784 and the facilities investigation related to this SRI to the Administrator. The SRI investigation was not provided until 4:56 P.M.Review of the facilities investigation revealed there was no evidence witness statements or resident statements despite the summary claiming they were obtained. The file did contain head to toe assessments of non-interview able residents but the rest of the file was resident profile and care plan information.Interview on 06/09/26 at 5:07 P.M. with the Administrator revealed he acknowledged the delay in providing the SRI records and investigations. The Administrator confirmed the facility's expectation for thorough investigations including witness statements and resident statements/skin checks but could not explain the gaps in the documentation for the SRI 274784. The Administrator stated the witness statements, resident interviews, and any head to toe assessments should have been included in the file and stated he was unsure of their location.Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property dated March 2024, revealed residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. Once the Administrator and ODH are notified the investigation must be completed within five working days. The investigation protocol included to interview the resident, the accused, and all witnesses, and the interviews may need to be expanded to all employees on the shift or unit. Under documentation, evidence of the investigation should be documented in accordance with Quality Assurance (QA) protocols.This was an incidental finding discovered during the course of the complaint investigation.

Based on medical record review and staff interview, the facility failed to properly provide bathing/shower services and oversite for residents that were dependent on staff for care. This affected one (Resident #27) of three residents reviewed for bathing/showering. The census was 96.Findings Include:Resident #27 was admitted to the facility on [DATE]. Her diagnoses were depression, anxiety disorder, hyperlipidemia, atherosclerotic heart disease, dementia, adult failure to thrive, hypertension, hypo-osmolality and hyponatremia, and non-traumatic intracerebral hemorrhage in hemisphere. Review of her minimum data set (MDS) assessment, dated 04/04/26, revealed she had a severe cognitive impairment. Review of Resident #27 MDS Assessment, section GG, dated 04/04/26, revealed she required substantial physical assistance with her baths/showers.Review of Resident #27 care plans, dated 05/07/26, revealed she did not have a care plan related to refusal of baths/showers until it was brought to the attention of facility management on 05/07/26. A revision was made on 05/07/26 to her impaired cognitive function/dementia or impaired thought processes care plan, which added often refuses showers. An intervention for refusals of showers was also added on 05/07/26, which stated, frequent shower refusals: reapproach and offer shower again.Review of Resident #27 Bath and Skin Report, dated 03/02/26 to 04/27/26, revealed the following dates in which Resident #27 refused to take a bath/shower: 03/02/26, 03/07/26, 03/09/26, 03/16/26, 03/21/26, 03/23/26, 03/28/26, 03/30/26, and 04/27/26. There was nothing documented on the bath and skin report about staff reapproaching the resident at a later time to offer a bath/shower again. There was no documentation to support the facility provider was contacted to inform them of the constant refusals as well. Also, on 04/04/26, there was a bath and skin report started with Resident #27 name on it, but there was no other documentation to indicate if a bath/shower was offered and/or completed. Finally, there was no documentation to support a bath/shower was offered to Resident #27 after 04/27/26. Interview with Director of Nursing (DON on 05/11/26 at 11:25 A.M. confirmed Resident #27 care plan was revised to reflect her refusals of baths/showers. Initially, she stated it was already in the care plan, and was just added to the Kardex on 05/07/26, but she confirmed she could not explain why the revisions in the electronic medical record did not reflect that the refusals had already been addressed prior to 05/07/26. She confirmed there was no documentation to support that staff had attempted to reapproach Resident #27 during her documented refusals. She confirmed the care plan and intervention for Resident #27 refusal of baths/showers was not available to be seen by the floor staff because it was not added to the kardex until 05/07/26.This deficiency represents non-compliance investigated under complaint number 2991473 and 2997253.

Based on observation, interview and facility policy review the facility failed to maintain infection prevention and control during medication administration. This affected two (Resident #62 and #64) of three residents observed during medication administration. The census was 98. Findings include:1. Review of Resident #62 medical record revealed an admission date of 02/20/22. Medical diagnoses include anxiety, chronic respiratory failure with hypoxia, paraplegia, neuromuscular dysfunction of the bladder, essential (primary) hypertension and radiculopathy.Review of Resident #62 Minimum Data Set (MDS) 3.0 dated 03/27/26 revealed resident was cognitively intact.Review of Resident #62 Medication Administration Record (MAR) revealed orders for the following medications for the morning observed morning medication administration pass; Furosemide tab 20 mg 1 tab one, Gabapentin cap 300 mg 2 capsules, Spironolactone tab 25 mg 1 tab, 1Baclofen tab 20 mg 1 tab, take with 10mg, Baclofen tab 10 mg 1 tab- take with 20mg, Bethanechol chloride tablet 10 mg 1 tab, Buspirone tab 5 mg 1 tab, Fluoxetine HCl Oral capsule 40 mg, Hydrochlorothiazide oral tablet 12.5 mg 1 tablet, Losartan potassium oral tablet 100 mg 1 tablet, and Jardiance 10 mg tab.Observation on 05/06/26 at 9:19 A.M. with Registered Nurse (RN) #300 revealed RN #300 removed each of Resident #62 medications housed in a blister pack onto her hand and then placing the medication in the medication cup2. Review of Resident #64 medical record revealed an admission date of 04/03/26. Medical diagnoses include essential (primary) hypertension, anxiety, and depression.Review of Resident #64 Minimum Data Set (MDS) 3.0 dated 04/07/26 revealed resident was cognitively intact.Review of Resident #64 Medication Administration Record (MAR) revealed orders for the following medications for the morning observed morning medication administration pass; Carvedilol 12.5 mg give 1 tablet, Eliquis (Apixaban) oral tablet 5 mg 1 tab, Sertraline tab 100 mg, Metoprolol 100 mg 1 tab, and Amlodipine 5 mg 1 tab.Observation on 05/06/26 at 9:27 A.M. with RN #300 revealed RN #300 removed each of Resident #64 medications housed in a blister pack onto her hand and then placing the medication in the medication cup.Interview on 05/06/26 at 10:10 A.M. with RN #300 confirmed she opened each medication housed in a blister pack onto her hand then placed the medication in a medication cup. Review of the facility's policy titled, Administering Medications dated February 2026 confirms staff follow established facility infection control procedures (handwashing, aseptic technique, gloves, isolation precautions, etc.) for administration of medications, as applicable.This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on resident record review, interviews, and policy review, the facility failed to administer a SARS-CoV-2 (COVID-19) vaccination as requested by Resident #59. This affected one out of three residents reviewed for vaccinations. The facility census was 96.Findings include:Review of Resident # 59's medical record revealed an admission date of 04/17/25 with diagnoses including but not limited to asthma, malnutrition and vertigo. Review of Resident # 59's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview in Mental Status (BIMS) of 15 indicating the resident had intact cognition. The resident required assistance from staff with transfers and personal hygiene.Review of Resident immunization history revealed the resident had received a total of four SARS-CoV-2 (COVID-19 vaccinations, with the last being administered on 10/29/24. Review of Resident #59's progress note with effective date 12/30/25 at 2:00P.M. by Licensed Practical Nurse Unit Manager (LPNUM) # 400 revealed the resident requested a SARS-CoV-2 (COVID-19) vaccination and the nurse practitioner was made aware and provided an order for the facility to administer the vaccination. Review of Resident # 59's physicians orders revealed that on 12/31/25 an order was placed for Comirnaty Intramuscular Suspension 30 micrograms (mcg)/ 0.3 milliliters (ML) (COVID-19 (SAR-CoV-2) mRNA Virus Vaccine; instructions to inject 0.3 ML intramuscularly one time a day for Vaccine for one administration with an end order date of 01/08/26. Review of Resident #59's Medication administration Record (MAR) dated January 2026 revealed that on 01/07/26, Licensed Practical Nurse (LPN) # 316 signed the ordered (COVID-19 (SAR-CoV-2) mRNA Virus Vaccine off with code NM for Med Not Available. Further review of January 2026 and February 2026 MARs revealed no administration of the vaccine.Review of progress note dated 02/03/26 at 12:06 P.M. revealed the resident complained of cough, medications were administered as ordered, vital signs were with in normal limits and the resident independently called Emergency Medical Services(EMS 911) and was transferred to the hospital. Interview with Resident #59 on 03/18/26 at 8:00 A.M. revealed the resident contracted COVID-19 and double pneumonia in February. She stated when she got sick the evening before she went out she was not feeling well and the nurse offered to send her to the hospital but she would wait until the next day and then she called 911 herself to go to the hospital. She stated she was in the hospital for eight days on isolation. She stated she had requested the COVID-19 vaccination from the facility and was told she would receive it on 01/07/26 however had not received it being told it was on back order. She said the only option she was offered from the facility was that she could go to the local pharmacy to get the vaccine, but she stated it was too cold to go out. Interview on 03/18/26 at 3:03 P.M. with LPNUM # 400 revealed she did not recall Resident #59 requesting the COVID-19 vaccination and was unsure why she had not received it. Further interview confirmed that LPNUM # 400 placed the order for the vaccination on 12/31/25 and revised the order on 01/07/26. Interview on 03/18/26 at 3:30 P.M. with LPN # 316 revealed on 01/07/26 the COVID-19 vaccine was not available to administer, she stated she called the pharmacy to send the vaccine and was told by the pharmacy that paperwork had to be filled out prior to them sending the vaccination. LPN # 316 stated she notified someone in the facility but could not recall who it was. Interview on 03/19/26 at 10:37 A.M. with Assistant Director of Nurses (ADON) LPN # 472 revealed when nurses order vaccines they should call the pharmacy to confirm the order was received and give any information the pharmacy may need to send the medication. She also confirmed that vaccinations should be offered and given to residents who want them yearly, and any time the resident requests with a doctor's order.Interview with Pharmacy Staff #555 via telephone on 03/19/26 at 11:22 A.M. revealed the COVID-19 vaccination had not been on back order, however the pharmacy needed the facility to complete the vaccine request form for the pharmacy to send the vaccination to the facility and that had not been done so the pharmacy was unable to release the vaccination to the facility. Pharmacy Staff #555 verified the COVID-19 vaccination was available in November and December of 2025 and January, February, and March of 2026. Review of facility policy titled Vaccinations of Residents dated 2001 last revised 2016 revealed all residents will be offered influenza, pneumonia and covid vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated. This deficiency represents non-compliance investigated under Complaint Number 2739120.

Based on resident and staff interview and record review, the facility failed to provide a resident's 30-day discharge notice to a representative of the Office of the State Long-Term Care Ombudsman. This affected one (Resident #11) of one resident reviewed for discharge notices. The facility census was 95.Findings include:Review of the medical record revealed Resident #11 was admitted to the facility on [DATE]. Diagnoses included heart failure, renal insufficiency, diabetes mellitus, and depression. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 was cognitively intact, independent with eating, toileting, bathing, and personal hygiene.Review of Resident #11's 30-day discharge notice dated 12/29/25 revealed the effective date of discharge was 01/28/26 and it was signed by the Administrator. There was no evidence the Long-Term Care Ombudsman was notified of Resident #11's discharge notice. Interview on 01/28/26 at 1:27 P.M. with Resident #11 revealed she received a letter stating they were discharging her to a homeless shelter today (01/28/26).Interview on 01/28/26 at 3:00 P.M. with the Administrator confirmed he was unable to provide any evidence the facility provided a copy of Resident #11's 30-day discharge notice dated 12/29/25.to the Long-Term Care Ombudsman's office. This was an incidental finding discovered during the complaint investigation.

Based on observation, resident interview, staff interview, sample of a test tray, and review of Resident Council meeting minutes, the facility failed to ensure food was served at palatable temperatures. This had the potential to affect all 108 residents that received meals from the kitchen. The facility census was 108.Interview on 12/09/25 at 2:00 P.M. with Resident #44 revealed that the food is never served hot.Interview on 12/09/25 at 2:15 P.M. with Resident #18 revealed the food is never hot. Interviews on 12/10/25 at 1:17 P.M. with Residents #33 and #78 revealed the food is always cold.Observation on 12/09/25 from 11:30 A.M. to 12:51 P.M. of the lunch meal service revealed food was above 165 degrees Fahrenheit (F) on the tray line. A food cart left the pantry at 12:51 P.M. and arrived at the unit within a minute. Staff started to serve residents their food trays immediately with the last tray on the food cart was delivered to a resident on 12/09/25 at 12:54 P.M.The Dietary Manager (DM) #24, using a facility thermometer, checked the temperature of the food on the test tray. The turkey was 112 degrees F, the mashed potatoes were 110 degrees F, and the vegetables were 71 degrees F. DM #24 stated that food served to the residents should be hotter, but the facility did not have enough warming food carts. Sample of the food test tray with DM #24 revealed the food was lukewarm.Review of the Resident Council meeting minutes from November 2025 revealed resident food concerns. This deficiency represents non-compliance investigated under Complaint Number 2645018.

Based on observation, staff interview, and review of facility policy, the facility failed to maintain a clean and sanitary kitchen area. This had the potential to affect 108 residents who received meals in the facility. The facility census was 108.Observation on 12/09/25 at 10:31 A.M. of the kitchen with Dietary Manager #24 revealed about 15 ceiling tiles covered with a black dusty substance and a thick layer of dust on the ceiling vents covering food preparation and cook areas. Interview on 12/09/25 at 10:35 A.M. with the Dietary Manager #24 revealed the black stuff would not come off, stating they have tried everything, including a microfiber cloth. Dietary Manager #24 verified the black ceiling tiles and the dust on the ceiling vents and stated they do need cleaned or replaced. Dietary Manager #24 stated there is not a set cleaning schedule for the ceiling or vents. Review of the facility policy titled Homelike Environment stated residents are provided with a safe, clean, comfortable and homelike environment. This deficiency represents non-compliance investigated under Master Complaint Number 2682354, Complaint Number 2651115, Complaint Number 2611472, and Complaint Number 2623673.

Based on medical record review, observation, resident interview, staff interview, and review of Resident Council meeting minutes, the facility failed to ensure resident call systems were functioning in an appropriate manner. This affected one (#16) of three residents reviewed for call lights, with the potential to affect off residents residing in the facility. The facility census was 108.Review of the medical record for Resident # 16, revealed an admission date of 02/20/20. Diagnoses included chronic respiratory failure with hypoxia, type II diabetes mellitus, need for assistance with personal care, major depressive disorder, and chronic obstructive pulmonary disease. Review of Resident #16's care plan revealed the resident required assistance with activities of daily living (ADL) related to dementia, heart failure, chronic respiratory failure, depression, chronic kidney disease, weakness and cancer. Interview on 12/08/25 at 9:30 A.M. with Resident #16 revealed she has attempted to use her call on various occasions, and the staff do not answer. Resident #16 could not recall a date but stated a staff member provided her with a handheld bell because they were unsure of why the call light was not working. Interview, and observation of demonstration on 12/08/25 at 2:00 P.M. with the Administrator and Maintenance Director # 133 of an empty bathroom, a known malfunction with the call system specific to double rooms with shared a bathroom revealed when a metal lever or switch on the bathroom wall when left part way between the on and off position and not pushed all the up in the off position fail to allow the call light above a resident's bed to function properly. Maintenance Director #133 explained, the call lights beside the residents' beds still illuminate, but no signal is received at the nurses' station or outside the room.Interview on 12/08/25 at 3:00 P.M. with Regional Nurse #30 revealed there is no facility policy related to call lights specifically we expect staff to answer call lights timely.Review of the Resident Council meeting minutes from 09/18/25 and 10/16/25 revealed resident concerns with call light response. This deficiency represents non-compliance investigated under Complaint Number 2651115 and Complaint Number 2645018.

Based on observation, resident interview, staff interview, review of maintenance repair logs, and review of facility policy, the facility failed to maintain a clean and homelike environment regarding temperature, sanitation and condition of residents rooms. This affected 10 (#8, #16, #21, #26, #79, #83, #87, #96, #97, and #108) of 10 residents reviewed for environment. The facility census was 108. 1. Observation on 12/08/25 at 9:30 A.M. of Resident #83 and Residents #96's room revealed a hole exposing the drywall. 2. Observation on 12/08/25 at 9:36 A.M. of Resident #26 and# 87's room revealed exposed wires hanging from the wall.3. Observation on 12/08/25 at 9:39 A.M. of Resident #21 and #97's room revealed dried feces on the floor and wall and privacy curtain with brown stains and dried feces.4. Observation on 12/08/25 at 9:59 A.M. of Resident #79 and #108's room revealed privacy curtain with brown stains.5. Observation on 12/08/25 at 10:00 A.M. of Resident #16 and #08's room revealed Resident #16 with gloves and a toboggan hat Interview with Resident #16 at the time of the observation stated it was freezing in her room. Observation of the thermostat with Maintenance Director (MD) #133 revealed the temperature was set at 85 degrees Fahrenheit (F), MD #133 checked room with the facility thermometer revealing the room temperature was 68 degrees F.Interview on 12/08/25 at 10:30 A.M. with MD #133 and Housekeeping Supervisor #150 verified the environmental issues.In a follow up interview on 12/09/25 at 12:30 P.M. with MD #133 revealed the furnace in Resident #16 and #08's room was not in working order and the residents will need to be moved until the furnace is repaired.6. Observation on 12/11/25 at 7:40 A.M. revealed the conference room thermostat had a temperature of 74 degrees F and dropped from 74 degrees F to 69 degrees F from 7:40 A.M. to 10:20 A.M. without any adjustment made to the thermostat. 7. Observations and concurrent interview on 12/11/25 at 10:20 A.M. with MD #133 revealed several facility areas were under the required minimum temperature. The sitting area outside the Director of Nursing's office was 71.1 degrees F, recheck of resident room [ROOM NUMBER], the room which Residents #08 and #16 had been moved out of the day prior was at 69.3 degrees F, the 400-hall hallway ranged from 69 to 70 degrees F upon several readings. The Memory Care unit lobby where several residents were sitting at a table was 69.3 degrees F and a Certified Nursing Aide (CNA) was talking with residents and stated, is cold back here. Two residents were observed walking out to the Memory Care Sunroom which had the thermostat set at 77 degrees F, but the wall thermostat read 65 degrees. MD #133 tested the air temperature with the facility thermometer and obtained readings between 58.8 to 62 degrees F. MD #133 verbalized the room was notably colder. The hall by the dialysis unit had a temperature of 71.4 F and the activity room had a temperature of 63.9 degrees F. The Activity Director stated, that explains why it felt so cold in here. The back conference room had a thermostat that read 69 degrees F, the thermostat was set for heat at 66 degrees F, upon MD #133 checking the temperature with the facility thermometer, conference room had a temperature reading of 63.5 degrees F. MD #133 reported the facility required temperature is 71 to 72 degrees F and that is where all the thermostats in common areas should be sent. MD #133 confirmed several common areas were below the minimum required temperatures.Review of the Maintenance repair logs revealed on 11/28/25 the furnace in room [ROOM NUMBER] was not working and signed off by MD #133 as fixed.Review of facility policy titled Homelike Environment dated 10/2025, revealed 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 cleanliness and order, comfortable yet adequate lighting as needed throughout the facility, inviting colors and decor, personalized furniture and room arrangements, pleasant, neutral scents, plants and flowers; where appropriate, comfortable temperatures and comfortable noise levels.This deficiency represents non-compliance investigated under Master Complaint Number 2682354, Complaint Number 2645733, and Complaint Number 2623673.

Based on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents were assisted and supervised with activities of daily living (ADL), and the facility failed to further ensure the necessary supplies were readily available to staff to ensure residents received timely ADL care. This affected three (#33, #78 and #87) residents received for activities of daily living. The facility census was 108. 1. Review of the medical record for Resident #33 revealed an admission date of 04/17/25, diagnoses including unspecified dementia, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, chronic pain, and difficulty in walking.Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 was cognitively intact, required supervision or touching assistance for toileting hygiene, and bed mobility, partial/moderate assistance for shower/bathing, dressing, personal hygiene and transfers, and was frequently incontinent of bowel and bladder.Review of the care plan revealed Resident #33 has an ADL self-care performance deficit related to lumbar compression fracture, pain, visual impairment, asthma, osteoarthritis, with varying self-performance during the time of day, which may require more assistance, as needed, to maintain safety. Interventions included one person assist with bathing/showering.Interview on 12/10/25 at 1:17 P.M. with Resident #33 revealed she had to have her family purchase bath towels and washcloths due to the facility not having enough to be able to provide her a shower or bath when she asked.2. Review of the medical record for Resident #78 revealed an admission date of 10/19/22 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, chronic atrial fibrillation, hypertension and heart failure. Review of the most recent annual MDS assessment dated [DATE] revealed Resident #78 was cognitively intact, required set up or clean up assistance with shower/bathing, toileting hygiene, and bed mobility, required supervision or touching assistance with ambulation and transfers, and was occasionally incontinent of urine and frequently incontinent of bowel.Review of the care plan for Resident #78 revealed an ADL self-care performance deficit related to fatigue, hemiplegia and hemiparesis affecting right side. Interventions included one person assist with bathing and showering and transfers.Interview on 12/10/25 at 1:17 P.M. with Resident #78 revealed showers or baths were not always provided as the facility did not have enough towels. Resident #78 stated his family purchased bath towels and wash cloths to ensure he could receive a shower/bath upon request without having to wait for linens to become available. Observation on 12/04/25 at 2:00 P.M. of clean linen storage room on unit B revealed five washcloths and eight towels and 500 hall clean linen storage room with two towels.Observation on 12/08/25 at 10:00 A.M. of clean linen storage room on unit B revealed five washcloths and zero towels.Interview on 12/04/25 at 1:47 P.M. with Housekeeping Supervisor #50 revealed the laundry deliveries linen three times a day. Housekeeping Supervisor #50 stated there are not enough washcloths and towels to meet the needs of the residents in the facility timely.Interview on 12/04/25 at 1:53 P.M. with Laundry Staff #50 revealed they need more washcloths and towels, stating there is not enough to go around to meet the residents' needs timely.3. Review of Resident #87's medical records revealed an admission date of 02/26/20. Diagnoses included dementia, Alzheimer's disease, and schizoaffective disorder.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #87 had a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. The resident was assessed to require dependent on staff for activities of daily living including assistance with eating. Observation on 12/08/25 at 1:00 P.M. revealed Resident #87 was in bed with the lunch meal, on the tray was plastic container partially full of juice and a foil lid covering. Further observation revealed Resident #87 chewing on the foil lid.Interview on 12/08/25 at 1:05 P.M. with Certified Nursing Assistant (CNA) #91 verified Resident #87 is confused, should have assistance with feeding and was attempting to eat the foil lid.Interview on 12/09/25 at 2:00 P.M. with the Administrator stated he would provide staff education to remove the foil top for Residents with low cognition or Residents that have difficulty opening the juice themselves.On 12/10/25 review of facility staff education provided by the Administrator revealed, when serving juice, the foil top must be removed for residents with low cognition or residents that have difficulty opening themselves.Further observation of dining on 12/11/25 at 9:10 A.M. revealed Resident #87 in bed with breakfast tray and plastic juice container on tray with foil lid attached to the top.Interview on 12/11/25 at 9:11 A.M. with CNA #138 verified Resident #87 had foil lid on cup and staff received an email sent by the Administrator providing the staff education to remove the foil lid for residents with impaired cognition. CNA #138 verified Resident #87 had impaired cognition. Review of Resident Council Minutes for November 2025 revealed complaints of no washcloths or towels on the weekends.Review of the facility policy titled Resident Rights, dated 10/17/19 stated upon admission and thereafter, residents have the right to adequate medical treatment and nursing care. This deficiency represents non-compliance investigated under Master Complaint Numbers 2682354 and Complaint Number 2623673.

Based on observation, staff interview, and review of facility policies, the facility failed to ensure outdoor lighting was maintained and failed to ensure the proper storage of hazardous maintenance equipment and supplies. This had the potential to effect 14 residents with orders for unsupervised leave of absence (#2, #9, #10, #15, #23, #31, #44, #60, #67, #69, #83, #96, #104, and #107) and seven Residents (#21, #28, #62, #65, #94, #97, and #102) who were identified as cognitively impaired but independently mobile. Facility census was 108. 1. Observation on 12/09/25 at 6:30 P.M. revealed a dark night sky and no functioning lights to the right side or around the back of the building, and no functioning lights in the employee parking lot. Only two of six lights were working in the middle grassy and visitor parking area. The two lights that were working only had one of the three bulbs illuminated. Observation and interview on 12/10/25 at 8:35 A.M. with MD #133 confirmed all but two of the front lights were not functioning properly and further confirmed that not having exterior lights functioning was a safety issue, especially in the dark.2. Observation on 12/09/25 from 1:30 P.M. to 6:30 P.M. and 12/10/25 from 8:30 A.M. to 2:20 P.M. revealed a sitting room next door to the activity area was being used for storage. The room was unlocked and the door was propped open with furniture. Observation also found maintenance equipment including three tubes of caulk and a box with several cans of painting supplies including paint stripper, labeled as hazardous. The caulk and paint stripper had warning labels to avoid contact with eyes and skin and contact occurs, wash thoroughly with water, if symptoms appear, seek immediate Interview on 12/10/25 at 2:25 P.M. with Activity Staff Member #157 revealed some comfortable chairs were placed in the sitting room for residents to come and relax and or have coffee, however staff started to store beds in the area and ever since it has become more of a storage room. Activity Staff Member #157 verified the door to the room was unlocked and propped open with hazardous materials within reach of the residents. Interview on 12/10/25 at 4:45 P.M. with Regional Nurse #30 confirmed the sitting room had maintenance equipment and supplies with hazard warning labels, confirming the room was unlocked and should not have been as residents could enter the unlocked room when passing by the room to go to the activity area.Review of the facility policy titled Storage Areas dated 10/2025, revealed storage areas shall be maintained in a clean and safe manner with hazardous materials stored in a manner that they are not easily accessible to residents. Review of facility policy titled Homelike Environment dated 10/2025, revealed residents shall be provided with a safe environment. The policy also stated the facility staff, and management should maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include cleanliness and order, comfortable yet adequate lighting as needed throughout the facility, inviting colors and decor, personalized furniture and room arrangements, pleasant, neutral scents, plants and flowers; where appropriate, comfortable temperatures and comfortable noise levels. This deficiency represents non-compliance investigated under Master Complaint Number 2682354, Complaint Number 2651115 and Complaint Number 2611472.

Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to accommodate a resident preference to have an electronic monitoring device (camera) placed in the resident's room. This affected one (#16) of three residents reviewed for accommodation of needs/preferences. The facility census was 108. Review of the medical record for Resident # 16, revealed an admission date of 02/20/20. Diagnoses included chronic respiratory failure with hypoxia, type II diabetes mellitus, need for assistance with personal care, major depressive disorder, and chronic obstructive pulmonary disease. Review of Resident #16's care plan revealed the resident required assistance with activities of daily living (ADL) related to dementia, heart failure, chronic respiratory failure, depression, chronic kidney disease, weakness and cancer. Observation on 12/08/25 at 9:30 A.M. of Resident #16's room revealed no electronic monitoring device (camera). Interview on 12/10/25 at 9:19 A.M. with Social Service Designee #135 revealed there was a request from the family to place an electronic monitoring device in Resident #16's room, Social Services Designee #135 states an email correspondence was sent to the guardian of Resident #16's roommate on 09/24/25, requesting consent for a monitoring device to be placed in the room. Social Service Designee #135 there was no evidence of a response and no other evidence of any further correspondence with the guardian. Additionally, Social Services Designee #135 verified no evidence of a response to Resident #16's family's request. Social Service Designee #135 added, the previous Administrator was addressing the situation.Interview on 12/10/25 at 10:00 A.M. with the Administrator revealed he had only been at the facility for a week and did have access to the previous Administrators' emails and could not locate any further correspondence with either Resident #16's family and or Resident #16's roommates guardian regarding a request for an electronic monitoring device to be placed at the bedside of Resident #16.Review of facility policy titled Electronic Monitoring Devices: Ester's Law dated 12/2024, revealed all residents of long-term care facilities have the right to dignity, respect, and privacy when receiving care. Residents have the right to use electronic monitoring devices in their room.This deficiency represents non-compliance investigated under Complaint Number 2623673.

Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure medication error rate was less than five percent. There were three medication errors out of 30 opportunities, resulting in a 10 percent medication error rate. This affected one (#58) out of five residents reviewed for medication administration.Review of the medical record for Resident #58 revealed an admission date 08/22/24 ad diagnoses including rhabdomyolysis, type II diabetes mellitus and hypertension.Observation on 12/09/25 at 9:49 A.M. with Licensed Practical Nurse (LPN) #189 completing medication administration for Resident #58 revealed a physician's order dated 08/23/24 for Mucinex 600 milligrams (mg), one tablet twice daily was not administered per order due to not having any supply on hand. A physician's order dated 04/02/25 for Fluticasone Propionate (treats allergies) nasal spray, two sprays in both nostrils was not administered per order due to not having any supply on hand. A physician's order dated 08/24//24 for glipizide (diabetic medication) 5 mg, give one tablet was not administered per order due to not having any supply in hand. Interview on 12/09/25 at 9:52 A.M. with LPN #189 confirmed Mucinex, Fluticasone Propionate, and glipizide was not administered to Resident #58 as ordered due to the medications being unavailable. LPN #189 stated not having the medications on hand happens often.Review of facility policy titled Administering Medications dated December 2012, revealed The individual administering the medication must check the label against the order to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.This deficiency represents non-compliance investigated under Master Complaint Number 2682354, Complaint Number 2657879, and Complaint Number 2623673.

Based on observation,medical record review, resident interview, staff interview and review of facility policy, the facility failed to ensure medications were properly stored. This affected one (#79) of three residents reviewed for medication storage. The facility census was 108.Review of the medical record for Resident #79, revealed an admission date of 11/11/16. Diagnoses included: vascular dementia, cerebral infarction, and hypertension.Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 had moderate cognitive impairment. Resident #79 required minimal assistance with activities of daily living and ambulates independently.Observation on 12/08/25 at 9:50 A.M. revealed Resident #79's had several medications in a medicine cup sitting on his bedside table. Resident #79 stated he does not know how long they have been there, adding the nurses often leave his medications on the bedside table for him to take.Review of the physician orders revealed Resident #79 did not have an order to self-administer medications or for medications to be left at bedside.Interview on 12/08/25 at 10:00 A.M. with Licensed Practical Nurse (LPN) # 102 revealed she prepared Resident #79's medications. LPN #102 confirmed she left the medications on the bedside table and further confirmed Resident #79 does not have an order for self-administration or for medications to be left at bedside.Review of the updated facility policy titled Medication Administration stated resident may self administer their own medications only if the attending physician in conjunction with the multidisciplinary care planning team has determined the resident has the decision making capability to do so safely.

Based on observation, resident interview, staff interview and policy review, facility failed to ensure residents had privacy when communicating on the phone. This affected one (#35) of three residents reviewed for communication with privacy. Facility census was 108. Review of the medical record for Resident #35 revealed an admission date of 06/06/22. Diagnoses included anxiety, dysphagia, muscle wasting, vascular dementia and Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 00, indicating severe cognitive impairment, and revealed the resident was rarely if ever understood.Review of the medical record for Resident #35 revealed she had a guardian and a family member (son) involved with her care. Observation on 12/10/25 at 2:16 P.M. of the Resident #35's room revealed a corded phone on the nightstand, but not plugged into the wall for service. Resident #35 was unable to be interviewed due to cognitive status. The resident's roommate, Resident #23, had the same type of phone plugged into the wall and the resident stated she had service and confirmed Resident #35's phone jack (outlet) did not have service. Resident #23 reported she knew that the phone jack had not worked for at least several months as she used to stay in that bed on that side of the room and it never worked for her. Interview on 12/10/25 between 5:55 P.M. and 5:57 P.M. revealed mixed answers related to Resident #35's ability to use a phone in private. Licensed Practical Nurse (LPN) #80 stated residents had a private cell phone the facility could provide for a resident to use in their room. LPN #190 and #191 stated every resident had a working phone at their bedside provided by the facility and were unaware of any facility cell phone that could be used for private phone calls by residents. None of staff interviewed could locate the cell phone upon request and reported they had not seen the phone in several months. Interview on 12/10/25 at 6:08 P.M. with the Unit Manager confirmed the room in Resident #35 did not work and stated when the resident would receive calls from her family, about twice a week, Resident #35 would come out to the nurse's station to talk with them. The Unit Manager was unsure whether or not the phone jack worked but confirmed the phone in Resident #35's room did not have a cord to be able to connect to the outlet. Interview on 12/10/25 at 6:20 P.M. with the Regional Nurse and Administrator revealed facility was not required to provide each resident a phone and stated that the resident could request to use the phone in the Social Services Office or the Business Office for privacy. Both the Regional Nurse and the Administrator stated they were not aware staff did not know about the Social Services Office or the Business Office being an option and acknowledged staff will be educated on the option. The Administrator denied knowledge of residents having phones in their rooms without a cord and denied knowing that not all phone [NAME] in the residents' rooms had service. Review of the facility policy titled Phone Usage dated 10/2025, revealed residents shall have reasonable access to phones in a private area. The policy stated designated phones were available to make and receive private phone calls and phones at the nursing station should ordinarily be reserved for staff use. This deficiency represents non-compliance investigated under Complaint Number 2617593.

Based on medical record review, staff interview, review of the police reports, review of the facility Self-Reported Incidents (SRI), review of the website www.accuweather.com, review of the incident/accident log, review of the hospital discharge record, review of the incident report, review of the staff witness statements, and policy review, the facility failed to provide adequate interventions and/or supervision to prevent a cognitively impaired resident (Resident #10), who was assessed at risk for elopement, from leaving the facility without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury, and/or death on [DATE] when Resident #10 eloped from the facility and the resident was found by the police 0.5 miles from the facility. Additionally, Resident #10 eloped from the facility a second time on [DATE] and was missing for over 17 hours and was eventually found by the police sitting in the middle of an intersection of a residential street with a speed limit of 25 miles per hour and a low overnight temperature of 46 degrees Fahrenheit (F). This affected one (Resident #10) of three (#10, #74, #85) residents reviewed of a total of six (#10, #74, #85, #88, #98, and #99) residents identified by the facility at risk for elopement. The facility census was 106. On [DATE] at 1:04 P.M., the Administrator, Regional Director of Operations (RDO) #7777, Regional Registered Nurse (RRN) #1021, and Director of Nursing (DON) #525 were notified Immediate Jeopardy began on [DATE] at 6:50 A.M. when facility staff were notified Resident #10, who was assessed at risk for wandering and elopement and had documented intermittent confusion and impaired decision-making abilities. On [DATE] at 6:50 A.M. the police were dispatched for a confused elderly man, and Resident #10 was found 0.5 miles aware from the facility. The facility was not aware Resident #10 had eloped from the facility until they were contacted by the police. Additionally, the Immediate Jeopardy continued when Resident #10 eloped from the facility a second time on [DATE] at approximately 5:59 P.M., when staff failed to complete the ordered 15-minute checks and were unaware he was missing until 8:15 P.M. Resident #10 was found on [DATE] at 11:35 A.M., when the police were dispatched for an elderly man with dementia using a walker approximately 2.6 miles from the facility. He was found 17 hours later, sitting in the intersection of two roads that had speed limits of 25 miles per hour. Although the Immediate Jeopardy was removed on [DATE], the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was verified as corrected on [DATE] when the facility implemented the following corrective actions: -On [DATE] at approximately 7:45 P.M., Resident #10 was not in his room, and it was determined that he was last seen between 5:30 P.M. and 6:00 P.M. on [DATE]. The facility immediately initiated a search for Resident #10. -On [DATE] at approximately 8:00 P.M., the facility initiated a head count, and all residents were accounted for except for Resident #10. -On [DATE] at approximately 8:30 P.M., the facility administrator notified the Upper Arlington Police of Resident #10's absence. -On [DATE], the Upper Arlington Police requested assistance from the City of [NAME] Police Department who had access to a [NAME] with Thermal capabilities. -On [DATE], the Ohio Bureau of Criminal Investigations was contacted and at approximately 9:52 P.M., a silver alert was completed and sent out statewide. -On [DATE] around 10:30 P.M., the Hocking County Sheriff's Office was notified and assisted with the search for Resident #10. -On [DATE] at approximately 9:30 A.M., the facility Administrator, RDO #7777, RRN #1021, Regional Clinical Manager (RCM) #4728, Unit Manager #333 and DON #525 conducted an AD HOC Quality Assurance and Performance Improvement (QAPI) meeting. -On [DATE], Resident #10 was found at approximately 11:35 A.M. approximately 2.5 miles from the facility. The Upper Arlington Police along with the emergency medical services (EMS) responded and transported Resident #10 to Riverside Methodist Hospital for an evaluation. -On [DATE], RCM #4728 and RDO #7777 reviewed and updated the facility elopement policy. The facility updated the policy to reflect clearer definitions on elopement, more concise instructions to staff on reporting elopement, investigation procedures, and notification to appropriate agencies and medical staff. -On [DATE] at approximately 2:00 P.M., Resident #10's care plan was updated by the facility DON #525 to reflect resident now resides on the secured unit. -On [DATE] at approximately 2:00 P.M., the facility staff completed a whole house head count as part of the facility's daily audits of residents. All residents were accounted for. -On [DATE] at 2:30 P.M., Resident #10 returned to the facility and was immediately placed on the facility secured unit. -On [DATE] at approximately 3:11 P.M., Resident #10 was assessed by the facility nurse with no significant injuries. The assessment revealed two open areas on the right foot assessed as abrasions. -On [DATE], a whole house audit of all residents was completed to ensure all residents were accurately assessed for elopement risk and no new residents were identified as being high risk for elopement. All residents who were previously identified as being high risks had their care plans reviewed for accuracy and no inaccuracies were found. -On [DATE], facility Unit Manager #333 initiated education on the facility elopement policy which included one facility Registered Nurse (RN), four Licensed Practical Nurses (LPN), and two Certified Nursing Assistants (CNA). -On [DATE], the facility continued education for all staff on the facility elopement policy. Five LPNs, two CNAs were educated in person by facility Unit Manager #333. DON #525 and the Administrator were educated on the facility Elopement Policy by RDO #7777. Medical Director #23 and Certified Nurse Practitioner (CNP) #1002 were educated on the Elopement Policy via the telephone by RDO #7777. -On [DATE], 16 LPN's, 30 CNA's, three Activity Employees, eight Housekeepers, 10 Dietary Staff, four Office Staff, 21 Therapists, five Speech Therapists, and one Maintenance Director were educated on the facility Elopement Policy via the telephone by Human Resources Director #1234. -On [DATE], two RNs, 11 LPNs, 27 CNAs, three Dietary Staff, four Housekeeping Staff, two Office Staff, seven Therapists, and one Maintenance Staff were educated in person by the Administrator and Human Resources Director #1234 on the facility Elopement Policy. -On [DATE] by 12:00 P.M., RRN #1021 and DON #525 reviewed all residents (#10, #74, #85, #88, #98, and #99) who were assessed as a high risk for elopement and had their care plans reviewed for accuracy and updated as necessary. No inaccuracies were found. -On [DATE], RRN #1021 checked the facility elopement binders and verified they reflected the status of the residents in the facility. No changes were identified. -On [DATE], RRN #1021 reviewed the Brief Interview for Mental Status (BIMS) for Residents #10, #74, #85, #88, #98, and #99, who were deemed at high risk for elopement, to ensure the assessments were accurate. There were no changes made to the resident's assessments. -On [DATE], the facility Clinical Managers Unit Manger #272, Minimum Data Set (MDS) #396, DON #525 and RRN #1021 completed a second check of all Elopement Risk Assessments and Elopement Care Plans for Accuracy. -On [DATE], one LPN, one CNA and one Office Staff member were educated on the facility Elopement Policy by the Administrator. -No staff will be permitted to work at the facility who have not received and reviewed the updated facility Elopement Policy. Facility education on the Elopement Policy will be ongoing. -All new hired employees will be educated on the facility Elopement Policy as part of the general orientation. -On [DATE] through [DATE], elopement drills and head counts were completed at various times/shifts. Staff knowledge and review of the drill was completed by RDO #7777 the following day. The Administrator reviewed and verified no actual elopements occurred. -On [DATE], [DATE], [DATE], [DATE], and [DATE], the facility's Interdisciplinary Team (IDT) members which included Unit Manager #272, MDS #396, DON #525, RRN #1021, Social Service (SS) #371, and the Administrator reviewed elopement care plans to ensure interventions were in place. No identified concerns were noted. -The facility will complete weekly elopement drills for eight weeks with the drills rotating between day and night shift to ensure each shift will have at least four elopement drills. Drills will be done monthly and randomly thereafter. -The facility will conduct head counts daily as part of their midnight census procedure which ensures that all residents are accounted for daily. -All new residents will be assessed by the facility nursing staff and follow up completed to ensure proper assessments and interventions are in place for residents deemed to be high risk for elopement. -On [DATE], telephone interviews with LPN #333, LPN #3000, CNA #3020, CNA/Housekeeping/Laundry Aid #3030, RN #3010, Human Resources Director #1234, the DON #525, and the LNHA verified they all had received education on the policies/procedures for elopement. All staff had knowledge of how to respond to an elopement situation. Staff reported there had been no elopements since [DATE]. The LNHA verified he had continued on-going training/education/drills for all staff on elopement policies/procedures. -On [DATE], review of the audits dated [DATE], [DATE], and [DATE] revealed elopement drills were completed successfully and on-going monitoring continued. -The facility denied any further elopements since [DATE] up until exit on [DATE]. Findings Include: Review of the medical record revealed Resident #10 admitted to the facility on [DATE] with an immediate transfer to the emergency room due to low blood sugar. Resident #10 was readmitted to the facility on [DATE] to a non-secured room. Diagnoses included complete traumatic amputation at knee level, lower left leg, chronic systolic heart failure, chronic kidney disease, Type 2 diabetes mellitus, and cerebral infarction. Review of the discharge paperwork from Riverside Ohio Health Hospital dated [DATE] revealed Resident #10 had a nontraumatic intracranial hemorrhage, large left infarct with associated edema and mild mass effect with associated hemorrhagic transformation as well as acute metabolic encephalopathy secondary to recent stroke, hypoglycemia, and hospital-acquired delirium. It also revealed during this resident's hospital stay, he was noted to be oriented to person and year but with tangential and intermittent confusion, similar to recent hospitalization dated [DATE]. Review of Resident #10's admission elopement risk, dated [DATE], revealed a score of a 10.0 indicating a high risk of elopement. The assessment also revealed this resident to be disoriented at times, has had reported episodes of wandering, and the number of reported elopements attempted in the past six months was two. Resident #10's family/responsible party voiced concerns indicating the resident may have wandering tendencies or try to leave. Review of the plan of care initiated on [DATE] for Resident #10 revealed no interventions for elopement risk. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 09 which suggested moderate cognitive impairment. The resident required no assistance with bed mobility and transfers. Review of the physician assessment completed by Medical Doctor #694 dated [DATE] revealed Resident #10 was alert and oriented times two; documented thinks he was supposed to be teaching at a vocational school. Review of the skilled nursing assessment for day shift dated [DATE] at 5:26 P.M. revealed Resident #10 was alert and oriented to person, time and situation but not to place. Review of the skilled nursing assessment for day shift dated [DATE] at 7:06 P.M. revealed Resident #10 was alert and oriented to person, place, and time, but unable to determine situation with impaired decision-making ability, and confusion. Review of the medical record for Resident #10 revealed the cognitive awareness assessment was not completed on [DATE]. Review of the police report dated [DATE] at 6:50 A.M. revealed a caller was walking her dog near her house located approximately 0.5miles away from the facility and advised there was an elderly male who was in the cold and confused, so she brought him into her house. On [DATE] at 7:23 A.M., the police called the facility to see if he was a resident there. On [DATE] at 7:24 A.M. it was verified he was a resident at the facility. On [DATE] at 7:30 A.M. Resident #10 was returned to the facility. Review of the past weather on www.accuweather.com revealed on [DATE] and timed from 2:00 A.M. through 7:00 A.M., revealed the temperature ranged from 63 degrees Fahrenheit (F) to the low of 57 degrees F at 6:40 A.M. Review of the incident report classified as other dated [DATE] at 7:00 A.M. by former DON #400 revealed Resident #10 was assessed as confused, had impaired memory, was an active exit seeker, and wandered. At approximately 7:00 A.M., the nursing staff noted he was absent from his room. Resident #10 was last seen by staff at approximately 2:00 A.M., fully dressed with his shoes on. There was no description in the incident of what clothing the resident had on when he returned to the facility. The resident was found approximately three blocks from the building and was returned to the facility by law enforcement. The resident was assessed and found without injuries. The resident representative and the on-call physician were notified. Resident #10 was placed on one-to-one supervision. Review of a progress note dated [DATE] at 7:32 A.M., entered by former DON #400, revealed Resident #10 exited the facility to take the trash out, and was returned to his room by staff. Assessment completed with no new findings. The responsible party and the on-call provider were notified. Will continue to monitor. Review of the physician orders dated [DATE] for Resident #10 revealed no one-to-one was ordered for resident safety after his elopement on [DATE]. Review of the medical record dated [DATE] for Resident #10 revealed no cognitive awareness evaluation was completed upon his return to the facility, and the resident was returned to the non-secured unit. Review of the elopement risk assessment dated [DATE] revealed Resident #10 scored a 17.0 which indicated he was at high risk for elopement. The assessment revealed the resident was disoriented at times and had attempted to leave or had successfully eloped. Review of the Self-Reported Incidents (SRIs) revealed there was no SRI submitted related to Resident #10's elopement on [DATE]. Review of the plan of care dated from [DATE] through [DATE] revealed Resident #10 had no interventions regarding elopement risk and elopement. Review of the nursing skilled assessment for night shift dated [DATE] at 11:09 P.M. revealed Resident #10 was alert and oriented to person, time and situation, but unable to determine place with delusions. Review of the skilled nursing assessment for night shift dated [DATE] at 11:03 P.M. revealed Resident #10 was alert and oriented to person, place and situation but unable to determine time. Review of the progress note dated [DATE] at 2:03 P.M. written by SS #371 revealed Resident #10 came to her office and expressed being unhappy about not being able to go home and see his dog. SS #371 noted that it was not an appropriate time to go home and get his truck; and his dog was brought in every other day to the facility. Resident #10 was pleasantly confused and rambling from one topic to another. Review of the skilled nursing assessment for day shift dated [DATE] at 6:35 P.M. revealed Resident #10 was alert to person only. Not oriented to place, time and situation and noted to have short-term memory impairment, impaired decision-making ability, and was confused. Review of the physician order dated [DATE] at 6:39 P.M. revealed Resident #10 was started on 15-minute checks every shift. Review of the skilled nursing assessment for day shift dated [DATE] at 2:35 P.M. revealed Resident #10 was alert to person and situation only. Not alert to place and time. Review of the elopement risk assessment dated [DATE] at 9:30 P.M. revealed Resident #10 scored 14.0 which indicated he was at high risk. The resident was also assessed as disoriented at times, had attempted to leave or successfully eloped, had two reported elopement attempts in the past six months and had expressed the desire to go home , pack belongings, or lingered near exits. Review of the nursing progress note dated [DATE] at 11:25 P.M. revealed Resident #10 displayed agitation, aggression, and attempted to leave out the back door of his room numerous times. The resident was redirected back into his room. Resident #10 slammed a chair against the door on numerous occasions displaying anger and aggression. The on-call Certified Nurse Practitioner (CNP) #1111 was notified and an order for one-to-one supervision was obtained. Review of the care plan initiated [DATE] revealed Resident #10 was at high risk for elopement related to cognitive impairment. Interventions included frequent 15-minute checks and observe/record/report to medical doctor risk factors for potential elopement. Review of CNP #1002's physical assessment dated [DATE] revealed Resident #10 was becoming more agitated and aggressive towards staff. He was confused but understood what was going on around him and had poor insight into why he was at the facility. The assessment indicated the resident had moderate impaired cognition and a plan was initiated for 15-minute checks. A trial of Depakote (can be used as a mood stabilizing medication) and Haldol (an antipsychotic medication) as needed was noted and the one-to-one supervision order was discontinued. Review of the progress note dated [DATE] at 11:47 A.M. by RRN #1021 revealed the IDT reviewed the elopement/wandering episode, Resident #10 was immediately placed on one-to-one supervision following the incident. CNP #1002 was aware and reduced monitoring to 15-minute checks. Review of the skilled nursing assessment for night shift dated [DATE] at 11:31 P.M. revealed Resident #10 was alert to person and situation only. The resident was not alert to place and time, had impaired decision-making ability, confusion, and delusions. Review of the medical record from [DATE] through [DATE] revealed no documentation of 15-minute checks for Resident #10. Review of the progress note dated [DATE] at 7:45 P.M. by RRN #1021 revealed Unit Manager #333 was notified by the nursing staff that Resident #10 was not in his room at shift change when rounds were completed. Review of the Upper Arlington police report dated [DATE] at 8:41 P.M. revealed Resident #10 was reported missing from the facility by the Administrator. The police were dispatched to the area to search for the resident. The facility staff notified the responding officers Resident #10 was last seen on [DATE] at 5:20 P.M. for his medication. The resident was scheduled for 15-minute checks, but there was no documented evidence these checks were completed. The facility grounds were searched; the resident was declared missing and placed in the Law Enforcement Automated Data System (LEADS). The video surveillance was obtained and revealed Resident #10 exited the facility out of the front entrance at 5:59 P.M. and headed north bound. Resident #10's Power of Attorney (POA) was called and notified. When asked about dementia or cognitive concerns, the POA stated he is sometimes delusional, but did not have an actual diagnosis. She added Resident #10 has had a decline in his cognitive abilities lately. According to the POA, Resident #10 also expressed wanting to go back home and stated he would walk 15 hours back to Laurelville. The POA allowed the officers to come to her house and do a search for the resident with no success. The Hocking County sheriffs were notified, and the property was checked with no success. It was made known that Resident #10 had walked out of the facility before on [DATE] and was returned by the police, so thermal [NAME] were used to search for the resident. On [DATE] at 11:35 A.M., a Community Member #4444 called in to report she was drinking coffee and observed an elderly man sitting in the street. She spoke with the man and thought he had dementia and called in. When an officer arrived, Resident #10 was sitting at the intersection of Stoneygate Lane and Stonehenge Court (2.6 miles away) with his walker. The resident was transported to Riverside Hospital for evaluation, and all parties were notified. Review of the past weather on www.accuweather.com revealed on [DATE] at 5:59 P.M., through [DATE] at 9:00 A.M., revealed the temperature ranged from 46 degrees F in the evening, night, and early morning hours to 64 degrees F. Review of the statement obtained by CNA #777 who cared for Resident #10 when he eloped revealed she last saw him on [DATE] around 5:45 P.M. when she brought him his dinner tray and he was sitting on his bed. Review of the statement obtained by Licensed Vocational Nurse #424 who cared for Resident #10 when he eloped revealed her last round on the resident was on [DATE] between 5:30 P.M. and 6:00 P.M. Resident #10 was sitting up in his room in his chair finishing dinner. Review of the progress note dated [DATE] at 3:06 P.M. revealed Resident #10 had open areas on the second and third digits of his right foot without noted pain or discomfort. Review of the physician order dated [DATE] by RRN #1021 revealed Resident #10 was ordered on a secured unit related to mood disorder and poor safety awareness. Review of the skin assessment completed by the wound CNP #4217 dated [DATE] revealed Resident #10 had three wound abrasions noted to the right foot: the second digit had an area that measured 0.4 centimeters (cm) by 0.4 cm by an undetermined depth, the third digit had an area that measured 1.5 cm by 1.5 cm by an undetermined depth, and the fourth digit had an area that measured 0.4 cm by 0.4 cm by an undetermined depth. Review of the facility SRIs revealed there was no SRI submitted related to Resident #10's elopement on [DATE]. Review of the facility incident/accident log from [DATE] through [DATE] revealed Resident #10's elopements on [DATE] and [DATE] were not documented. Interview on [DATE] at 12:43 P.M., RRN #1021 verified Resident #10 eloped from the facility on [DATE]. A follow-up interview on [DATE] at 11:25 A.M., RRN #1021 revealed Resident #10 had left the faciity on [DATE] as well but was not considered an elopement since he does have cognitive intact moments. An incident report was created, but no safety measures were put into place even after the event when the resident was still assessed as high risk for elopement. RRN #1021 verified on admission to the facility on [DATE] Resident #10's elopement risk was high, and no care plan and/or care interventions were in place for his safety until [DATE] and the resident had documented cognitive impairments with memory, judgement, and with his assessment which indicated he was at a high risk for elopement. A follow-up interview on [DATE] at 2:15 P.M. RRN #1021 verified Resident #10 was on 15-minute checks since [DATE], but there was no documentation of the checks in the medical record. Interview on [DATE] at 2:32 P.M., the POA revealed Resident #10 was starting to get more confused since he had been admitted to the facility and indicated to the facility, he was at risk for leaving the facility as he had a history of that. Interview on [DATE] at 1:01 P.M., CNA #777 revealed she cared for Resident #10 on the evening of [DATE]. Around 5:30 P.M., he was in bed, and she placed his tray on his bedside table and had not checked on him until rounds and shift change around 7:00 P.M. She thought the nurse on duty was checking on him every 15 minutes for the remainder of the shift and she verified she had not documented her 15-minute checks anywhere in his record. For the checks, it was a verbal exchange between the CNA and the nurse to let each other know when they checked on the resident. Interview on [DATE] at 1:43 P.M. the Administrator verified no notification and/or self-reported incident (SRI) was sent to the Ohio Department of Health for Resident #10's elopement on [DATE]. Multiple attempts to interview former DON #400 and Community Member #4444 were unsuccessful. Review of the facility policy titled Elopement and Missing Resident Policy (undated) revealed it is the policy of this facility to provide a safe and secure environment for all residents. Staff will take proactive measures to prevent elopement. Prevention includes assessment for risk of elopement and develop an individualized care plan. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property dated 03/2024 revealed residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. Neglect is the failure of the facility, its employees, or facility service providers to provide good and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Facility staff should immediately report all such allegations to the Administrator and to the Ohio Department of Health in accordance with the procedures of this policy. Initial reporting involving neglect, exploitation, mistreatment, misappropriation of resident property and injuries of unknown sources will be reported to the Ohio Department of Health immediately, but in no event later than 24 hours from the time the incident/allegation was made known. This deficiency represents non-compliance investigated under Master Complaint Number OH002642701.

Based on closed medical record review, hospital record review, review of a facility investigation, review of the facility assessment, policy review, and interview, the facility failed to develop and implement an effective discharge planning process focusing on the safety and total care needs of Resident #23 to ensure the resident was discharged to a safe location with continuity of care post-discharge. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury, and/or death beginning on 08/12/25 when Resident #23, who had been admitted to the facility with a known diagnosis of alcohol abuse, was discharged from the facility without evidence the resident had a safe location in which to go. Following the resident's discharge, on 08/13/25 the facility was notified by an unidentified bystander that Resident #23 wanted the facility contacted and Assistant Director of Nursing (ADON) #341 informed the unknown caller Resident #23 would have to go to the emergency room. The resident was subsequently admitted to the hospital with diagnoses of suicidal ideation and malnutrition. On 09/11/25 at 1:21 P.M., Regional Director of Operations (RDO) #261, Licensed Nursing Home Administrator (LNHA) #271, Regional Nurse #264, and the Director of Nursing (DON) were notified Immediate Jeopardy began on 08/12/25 when Resident #23 was discharged from the facility without proper assessment, without evidence he had a safe location in which to discharge to and without evidence of coordination of care to ensure the resident's medical and psychosocial needs were met resulting in the resident being hospitalized for malnutrition and suicidal ideation. The Immediate Jeopardy was removed on 09/11/25 when the facility implemented the following corrective actions: Resident #23 exited the facility on 08/12/25 at 6:45 A.M. He did not return to the facility. On 09/11/25 at 9:00 A.M., LNHA #271 and the DON were educated on the facility's discharge against medical advice (AMA) and leave of absence (LOA) policies. On 09/11/25 at 12:00 P.M., an audit was completed by LNHA #271 of current residents with plans to discharge to the community. The audit identified five residents (Residents #16, #42, #101, #114, and #122). All five resident's records were audited to ensure discharge planning was in progress and discharge plans were accurately recorded in each resident's record. On 09/11/25 at 3:30 P.M., Social Services Director (SSD) #312 and LNHA #271 were educated by Regional Director of Clinical Services (RDCS) #263 on ensuring support for residents' psychosocial well-being and providing assistance with discharge needs and requests. Additional education included SSD #312 will complete new admission care conferences within 72 hours of admission which will include screening assessments such as the PHQ-9 depression screening tool. On 09/11/25, the DON provided education to the facility's interdisciplinary team (IDT) and licensed nurses on the facility's policies on discharge AMA and LOA policies. The IDT included LNHA #271, ADON #341, Unit Manager (UM) #347, UM #345, SSD #312, Business Office Manager (BOM) #267, Dietary Manager #269, Activity Director #270, Therapy Director #315, Housekeeping Supervisor #280, Maintenance Director #219, Central Supply Coordinator #205, and Medical Records Coordinator #273. Additionally, 20 Licensed Practical Nurses (LPN) and 11 Registered Nurses (RN) were educated. All education was completed on 09/11/25 by 4:30 P.M. The facility held a Quality Assurance Performance Improvement (QAPI) meeting on 09/11/25 which included completion of a root cause analysis of the event and development of a plan of correction. Participants included Medical Director #450, LNHA #271, DON, RDO #261, RDCS #263, and Regional Nurse #264. The QAPI plan was approved by Medical Director #450 and the IDT on 09/11/25 at 4:30 P.M. On 09/11/25 at 4:45 P.M., Minimum Data Set (MDS) Nurse #343 completed an audit of in-house residents with the diagnosis or history of substance abuse or polysubstance abuse. The audit identified six in-house residents (Residents #3, #17, #58, #78, #89, and #120) with a substance abuse or polysubstance abuse history. On 09/11/25 at 5:00 P.M., the DON provided one-on-one education to Residents #3, #17, #58, #78, #89, and #120 on the facility's leave of absences policy. Ad hoc (not scheduled) education will be provided on an ongoing basis by RDCS #263 or Regional Nurse #264 for any staff member who is not correctly implementing the AMA and/or LOA policies on an as-needed basis. Beginning on 09/11/25, newly hired nurses will be trained on the facility's discharge AMA and LOA policies upon hire by the DON or designee. Beginning on 09/12/25, the DON or designee will provide education to agency staff nurses on the facility's discharge AMA and LOA procedures prior to the agency nurse being able to accept the assignment at the facility. Beginning the week of 09/15/25, LNHA #271 or designee will audit weekly discharges for a duration of four weeks to ensure documentation supports a safe discharge, including a discharge plan that meets the residents' behavioral and psychosocial needs. The results of ongoing audits will be reviewed by the facility's QAPI committee to determine if additional audits or education is needed. Beginning on 09/18/25 at regularly scheduled Utilization Review (UR) meetings, LNHA #271 or designee will discuss upcoming resident discharges and safe discharge planning. The weekly UR meetings will be attended by LNHA #271, DON, Therapy Director #315, BOM #770 (start date 09/15/25), and MDS Nurse #343. Although the Immediate Jeopardy was removed on 09/11/25, the deficiency remained at a Severity Level II (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include:Review of the closed medical record for Resident #23 revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), moderate protein-calorie malnutrition, anemia, alcohol abuse, hypertensive heart disease, adult failure to thrive, chronic viral hepatitis C, osteoarthritis, cutaneous abscess of right lower limb, and multiple myeloma. Emergency contacts included a female friend and the resident's sister. The medical record revealed Resident #23 was discharged on 08/13/25.An admission note dated 05/22/25 at 6:19 P.M. authored by Licensed Practical Nurse (LPN) #221 revealed Resident #23 was admitted to the facility from the hospital via medical transport. Review of the physician orders revealed Resident #23's scheduled medications included amlodipine (antihypertensive) 10 milligram (mg) daily, Vitamin D3 (supplement) 125 micrograms daily, Folic Acid (supplement) one mg daily, magnesium oxide (supplement) 400 mg daily, multivitamin with minerals (supplement) one tablet daily, thiamine (supplement) 100 mg daily, Vitamin E (supplement) one tablet daily, zinc (supplement) 220 mg daily, Acyclovir (antiviral) 400 mg twice a day, ascorbic acid (supplement) 500 mg twice a day, Gabapentin (for nerve pain) 500 mg twice a day and 300 mg once a day, senna (laxative) 8.6 mg twice a day, and melatonin (for insomnia) three mg at bedtime.A plan of care dated 05/22/25 revealed Resident #23 was at risk for falls related to weakness, limited mobility, and COPD. Interventions included educating and encouraging Resident #23 to use the ramp when going off a curb, to call for assistance before transferring, and food/fluids and personal care items within reach.An order dated 05/22/25 at 8:47 A.M., given by Certified Nurse Practitioner (CNP) #425, revealed Resident #23 could go on leave of absence (LOA) without supervision. CNP #425 was aware the resident was not signing out when he went on LOA, but the resident was alert and oriented. No care plan was initiated at the time the order was received to ensure the residents' safety when leaving on LOA.The 5-day Medicare Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact, had no documented behavior and required supervision or touching assistance for ambulating. The MDS also revealed Resident #23 had a venous/arterial ulcer.A nursing note dated 06/06/25 at 7:42 A.M. authored by Nursing Supervisor #311 revealed Resident #23 was found outside in his wheelchair wheeling himself down the road in front of the facility. Resident #23 stated he was going to buy beer. Record review revealed no new interventions were initiated at this time to ensure the resident's safety when leaving on LOA.A nursing note dated 06/14/25 at 3:57 A.M. revealed around 3:30 A.M., Resident #23 called the facility and stated he was at a lady friend's house and would return in the morning. Resident #23 refused to give the address of where he was staying. The DON was notified of the phone call. Record review revealed no new interventions were initiated at this time to ensure the resident's safety when leaving on LOA.A nursing note dated 06/14/25 at 10:31 A.M. revealed the outgoing nurse gave report that Resident #23 went on a LOA the previous day and did not return. Resident #23 called on 06/14/25 around 10:15 A.M. and stated he was stalked on [NAME] Road (no clarification was provided regarding what the resident meant by stalked) at the bus stop and needed someone to pick him up. An activity person (unidentified) went to pick Resident #23 up. Record review revealed no new interventions were initiated at this time to ensure the resident's safety when leaving on LOA.A nursing note dated 06/22/25 at 10:30 A.M. revealed Resident #23 was not in his room during morning medication administration. The outgoing nurse did not give report on Resident #23 and stated she took over the shift at 4:00 A.M. The police arrived at the facility around 10:30 A.M. and stated Resident #23 was found sitting in his wheelchair in the street (location not identified). The Administrator sent someone to pick Resident #23 up. Record review revealed no new interventions were initiated at this time to ensure the resident's safety when leaving on LOA. A nursing note dated 07/02/25 at 11:57 P.M. revealed Resident #23 returned to the facility around 11:30 P.M. The note documented the nurse educated Resident #23 about signing out before leaving the facility. Resident #23 stated he would sign out next time. Record review revealed no new interventions were initiated at this time to ensure the resident's safety when leaving on LOA. A Preadmission Screening and Resident Review (PASRR) identification screen dated 07/07/25 revealed Resident #23 had no mental disorders or substance use related disorders. However, review of the resident's admission diagnoses revealed the resident had a diagnosis of alcohol abuse.A plan of care dated 07/19/25 revealed Resident #23 had the potential to be discharged . Resident #23 desired to be discharged to home. Interventions included discussing any special equipment needs and to facilitate obtaining the equipment needed prior to discharge, make referrals to other community agencies as needed, and to talk with Resident #23, allowing the resident to express feelings regarding discharge. A nursing note dated 07/22/25 at 6:42 P.M. authored by Agency LPN #900 revealed the DON notified the nurse Resident #23 had left the building without signing the LOA book. Agency LPN #900 had no knowledge of Resident #23 leaving the building without signing the LOA book. Record review revealed no new interventions were initiated at this time to ensure the resident's safety when leaving on LOA.A plan of care dated 07/23/25 revealed Resident #23 had a history of substance seeking behavior alcohol and had the potential for complications such as substance abuse, withdrawal symptoms, and mood and/or behavioral disturbances (not identified in the medical record). Resident #23 does sign himself out to go drink. Interventions include to discuss behavioral limits and expectations with Resident #23, if Resident #23 returned from leave of absence and appeared to be impaired, the doctor should be notified for directions regarding administration of regularly scheduled medications and observe for indications the resident may be storing drugs or alcohol in room or on person. The doctor should be notified if drugs or alcohol were found. A nursing note dated 08/09/25 at 6:41 A.M. authored by Agency LPN #901 revealed Resident #23 insisted on leaving the facility to go to the mall around 6:00 A.M. The nurse informed Resident #23 that the mall was usually closed at that time, but Resident #23 stated he was leaving anyway. Several staff attempted to redirect Resident #23 without success. The nursing supervisor on call was made aware of Resident #23 leaving the facility. Record review revealed no new interventions were initiated at this time to ensure the resident's safety when leaving on LOA.A social service note dated 08/11/25 at 2:50 P.M. authored by SSD #312 revealed the writer met with Resident #23 to discuss discharge planning. The note included Resident #23 wanted to discharge on ce his therapy goals were met and he was safe to reside on his own. Resident #23 was unclear if he would be able to return to his previous apartment because he had been late on his rent prior to going to the hospital and had made no attempt to pay the rent. Record review revealed no evidence of any social service follow-up or information related to the resident's progress with therapy goals or ability to safely reside on his own.A nursing note dated 08/12/25 at 7:12 A.M. authored by LPN #902 revealed Resident #23 refused a shower after multiple attempts by the Certified Nursing Assistant (CNA). The note included Resident #23 left the building around 6:45 A.M. and failed to comply with signing the LOA book. There was no additional information related to the circumstances surrounding why Resident #23 left and/or what his condition was at the time he left. Record review revealed no evidence the resident's physician, CNP #425 or responsible party were notified the resident had left at this time.Review of the resident's medical record revealed there was no evidence the resident was offered or provided any type of mental health services. There was no evidence of counseling or behavioral health services while the resident resided in the facility.Review of hospital records revealed on 08/12/25 at 6:45 P.M. Resident #23 entered the emergency department at Ohio State University and then left. On 08/13/25 at 11:43 A.M. a follow up note revealed Ohio State University Hospital did not have a bed available for the resident.A nursing note dated 08/13/25 at 8:48 A.M. and authored by LPN #903 revealed Resident #23 was at the hospital (no additional information was provided in the note).A nursing note dated 08/14/25 at 8:18 A.M. authored by RN #235 revealed Resident #23 was at the hospital.The last nursing note in the medical record dated 08/15/25 at 8:00 A.M. authored by RN #235 revealed Resident #23 was hospitalized . Review of hospital records from (Hospital #1) revealed Resident #23 arrived on 08/13/25 at the emergency department on 08/13/25 at 1:32 P.M. Resident #23 had complaints of a headache and lack of housing. Resident #23 stated he had pressure at the top of his head and rated the pain an eight out of ten (on a 0-10 pain scale with zero meaning no pain and 10 being the worst pain the resident has experienced) and described the pain as crushing. The pressure was slow in onset and progressed throughout the day. Resident #23 stated he got headaches infrequently but had headaches like this before. Resident #23 stated he had been outside most of the day and was homeless. Resident #23 denied any trauma and was not sure if he had been under a lot of stress. Resident #23 was discharged (from Hospital #1) on 08/13/25 at 7:35 P.M. (location not identified).Review of hospital records revealed on 08/15/25 at 9:36 P.M. Resident #23 entered Mount Carmel emergency department. An emergency department note dated 08/15/25 from [NAME] Health/Mount Carmel revealed Resident #23 was found in the middle of the road in his wheelchair. Resident #23 admitted to drinking alcohol. Review of hospital records revealed on 08/19/25 at 2:19 P.M. Resident #23 entered Riverside emergency department. An emergency department provider note dated 08/19/25 at 3:44 P.M. revealed Resident #23 had come to the emergency department with concerns for left foot pain and swelling. Resident #23 reported he was ambulatory and walked around a lot. Resident #23 reported he drank some alcohol today and reported suicidal ideation. Resident #23 stated he could not disclose his plan for harming himself. Resident #23 appeared somewhat disheveled and intoxicated and had bilateral lower extremity pitting edema that was 2+ (indentation is three to four millimeters deep and rebounds in less than 15 seconds) with pain overlying erythema (redness) and some venous stasis (where blood flow in the veins slows down or stops) changes. Resident #23's lower extremities would be treated for cellulitis, suspect cellulitis versus venous stasis dermatitis. The first dose of Keflex (antibiotic) would be given. Hospital notes dated 08/19/25 revealed Resident #23 reported he was suicidal and had been since he was at the skilled nursing facility (Sapphire). When asked if Resident #23 had a plan, he stated there was not a building tall enough in Columbus. Resident #23 stated the building would need to be as tall as the Empire State building. Resident #23 reported he had been having suicidal thoughts for months and wanted to stop the misery. Resident #23 was not able to say when he left the skilled facility but stated it was the second time he had left the same facility (he had a prior admission in April 2025). Resident #23 reported he had not really eaten much in the past two weeks. Resident #23 described his sleep as volatile and reported nightmares and used alcohol to mitigate these symptoms. Resident #23 struggled with homelessness and received an eviction notice prior to hospitalization in May 2025. Resident #23 reported sleeping wherever it was safe. Resident #23 had poor hygiene, and his hair was overly long and matted in the back. Further review of the hospital record revealed an emergency department social worker behavioral health initial assessment completed on 08/19/25 at 8:26 P.M. revealed Resident #23 was currently homeless and stayed wherever is safe. Resident #23 stated there was no one to call for a contact person. An emergency social worker behavioral health updated assessment dated [DATE] at 12:05 P.M. revealed Resident #23 had current severe episode of major depressive disorder with psychotic features. Resident #23 continued to endorse thoughts of suicide with a plan to jump from a building. Resident #23 felt he would be better off dead and knows he was not able to manage his medical needs and should have stayed at the skilled nursing facility where he was sent in May. When asked why he left, he admitted to leaving to get a beer. On 08/21/25 at 2:09 P.M., Resident #23 was discharged from Riverside (and transferred to another hospital).Review of hospital records from Hospital #3 revealed Resident #23 was admitted on [DATE] at 2:11 P.M. from another medical center. Resident #23's principal diagnosis included other specified depressive disorder (dysphoria in the context of alcohol use disorder, multiple medical co-morbidities, and psychosocial stressors). Resident #23 had other diagnoses listed that included alcohol use, tobacco use, cannabis use, recent failure to thrive, multiple myeloma, right groin lymphadenopathy, hypertension, coccyx wound, bilateral lower extremity edema (suspected cellulitis versus venous stasis dermatitis, hyponatremia, and limited mobility wheelchair bound). The note included Resident #23 presented to the emergency department at Hospital #3 on 08/19/25 via emergency medical services reporting foot pain/swelling, alcohol use, and suicidal ideation (SI) with thoughts to jump off a building but stated there was not a tall enough structure in Columbus. Resident #23 described SI for months and wanted to stop the misery. Resident #23 was medically stabilized and transferred to Hospital #2 on 08/21/25 for further care. Hospital records revealed Resident #23 was treated for failure to thrive in May of 2025 and then transferred to Sapphire Rehabilitation (Rehab) on 05/22/25. The note included Resident #23 left the facility in search of beer so the staff at Sapphire Rehab told him he could not return. Resident #23 reported he had not eaten in two weeks, had poor sleep and drank alcohol to cope with nightmares. Upon initial evaluation, Resident #23 shared he had been struggling with homelessness and physical health issues. Resident #23 stated he left Sapphire Rehab due to a desire for beer. Resident #23 was amendable to re-referral to skilled nursing facility and indicated he would remain until formally transferred or discharged . Resident #23 was agreeable with transfer to the medical surgical unit for ongoing physical health stabilization and referral to a skilled nursing facility. A nutrition care initial assessment dated [DATE] at 12:19 P.M. revealed Resident #23 had an unintentional weight loss of more than seven pounds in the last month. Resident #23 had a body mass index of less than 23 and was underweight. A behavioral medicine note dated 08/24/25 at 9:02 P.M. revealed Resident #23 stated his mood was not good. Resident #23 had a flat affect. When asked the reason for the resident's mood, Resident #23 stated I am a homeless man I have no idea what I'm going to do when I get out of here.Review of a facility investigation related to Resident #23's discharge, undated, revealed the investigation documented the resident had left the facility Against Medical Advice (AMA). The investigation included Resident #23's face sheet, care plan, progress notes, recent physician orders, and an AMA form signed by the DON and ADON #341 that was not included in the resident's medical record during the investigation. An AMA Informed Signature form that was privileged and confidential (not part of the medical record) dated 08/13/25 at 1:32 P.M. (this was the same time the resident was at Hospital #1) completed by ADON #341 under Nursing Description revealed Resident #23 returned to the facility after a LOA and refused to sign the LOA book. Resident #23 was asked to sign the LOA book. Resident #23 was educated again on signing the LOA book and Resident #23 stated he would not sign the book. Resident #23 was informed that if he refused to abide by facility policies he may not be permitted to return due to insurance authorization (insurance would not pay due to the resident going on LOA). Resident #23 stated he would just leave and refused to sign the LOA book or AMA form. Resident #23 stated Get the (expletive) out of my way. CNP #425 was notified. A note added at the end of the form revealed Resident #23 returned from LOA and stated he was leaving again. The DON and ADON #341 spoke with Resident #23 regarding the LOA and the need to sign out. Resident #23 refused. Resident #23 was educated on the need to sign out LOA for safety. Resident #23 became agitated and stated he would just leave. Resident #23 was alert and oriented. An attempt was made to educate Resident #23 on AMA. Resident #23 stated Get the (expletive) out of my way and refused to sign. Resident #23 left the facility in a wheelchair, and the AMA form was signed by two nurses (DON and ADON #341). ADON #341 was notified on 08/13/25 that Resident #23 had been found outside a hospital and he asked a bystander to call the facility (no clarification as to why the bystander called the facility). The nurse explained to the caller that Resident #23 had left the facility and would need to go to the emergency department for evaluation. Resident #23's girlfriend then came to the facility on [DATE] and stated she could not find Resident #23. The girlfriend was notified where Resident #23 had been taken (hospital information provided since that was near where the unidentified bystander called the facility) and Resident #23 had left. Resident #23's girlfriend/female friend declined to take Resident #23's belongings. The investigation revealed the facility was waiting for further information from the hospital regarding authorization for readmission. There were no staff or resident statements obtained as part of the investigation.During an interview on 08/25/25 at 12:36 P.M., Resident #23's female friend that was listed on the contact list revealed Resident #23 had mental health issues and the facility staff did not care. The friend stated she had located Resident #23, and he was currently at the hospital on a locked behavioral unit. Resident #23 had been living on the streets and was dirty. Resident #23's phone had been shut off and the friend stated she had filed a missing person report because no one knew where Resident #23 was after he left the facility. The friend stated Resident #23 left to get a beer. Resident #23 could not stop drinking and would leave the facility to get beer but always went back to the facility. Resident #23 could not walk very well and had a sore on his bottom when he went to the hospital. During an interview on 08/27/25 at 1:43 P.M., the DON stated Resident #23 liked to leave the facility and not sign the LOA book. The DON reported Resident #23 had left the facility and then come back on 08/13/25 and then wanted to leave again. The DON stated she assumed Resident #23 subsequently went to the hospital because someone called from the area near the hospital at the request of the resident. The DON stated central admissions for the facility was handled offsite, so the DON was not aware if Resident #23 had wanted to return to the facility or where Resident #23 had been discharged to (if discharged ) from the hospital. During an interview on 09/02/25 at 3:24 P.M., the DON verified there was no notification to the police, adult protective services or a home healthcare agency when Resident #23 left the faciity on [DATE]. The DON stated she considered Resident #23 an AMA discharge since he said he was leaving. The DON revealed Resident #23 made bad decisions but always knew to come back to the facility. When asked about the content and thoroughness of the facility investigation related to the incident, the DON revealed the facility did not complete much investigation into the incident because they didn't think it was an issue.During an interview on 09/03/25 at 9:25 A.M., the DON verified Resident #23 did not receive any type of services for substance abuse or mental health while residing at the facility. The DON stated she believed Resident #23 refused services but verified there was no documentation of Resident #23 being offered any services or refusing services. She also verified there was no discharge planning noted in the medical record such as contacting outside resources or looking into alternate places for the resident to live after the resident voiced, he had lost his apartment. The DON verified the resident did have a care plan for anticipated discharge to home but stated it was never followed.During an interview on 09/03/25 at 10:19 A.M., SSD #312 stated she was unsure what her responsibility was when Resident #23 left the faciity on [DATE] because the resident had left on an LOA and never returned. SSD #312 revealed she did contact the police about Resident #23 being missing after his female friend reported she was unable to locate Resident #23. SSD #312 stated she got report that following the resident leaving the facility he was at one hospital, discharged to the community and then was back at a different hospital. During an interview on 09/03/25 at 1:33 P.M., CNP #425 revealed she had not been notified immediately on 08/12/25 when Resident #23 left the facility. CNP #425 was later told Resident #23 had left the facility and would not be returning. During an interview on 09/08/25 at 12:39 P.M., the DON verified Resident #23 left the faciity on [DATE] at 6:45 A.M. and did not return. She verified the resident's medical record contained no documentation supporting the resident verbalized he wanted to leave the facility against medical advice and there was no evidence the resident had any behaviors to support him wanting to leave against medical advice. The DON verified the facility considered the resident leaving the facility an AMA discharge because the resident did not return when he left.During an interview on 09/11/25 at 10:20 A.M., Regional Nurse #264 stated Resident #23 had lost his housing and the facility did not know where the resident went when he left the faciity on [DATE].During an interview on 09/11/25 at 10:20 A.M., LNHA #271, the DON, and Regional Nurse #264 revealed they were unable to provide information as to why the police, APS, Ombudsman and/or the resident's female friend were not notified when Resident #23 left the faciity on [DATE]. Lastly, the DON and Regional Nurse #264 verified Resident #23 was alert and oriented but made unsafe decisions when he wanted alcohol.An attempt to reach the resident's physician (Physician #450) was made on 09/11/25 at 10:48 A.M. The attempt was unsuccessful. A message was left asking the physician to return the call; however, no return call was received.Further review of the medical record revealed no AMA form located within the medical record regarding the resident requesting to leave the facility AMA, no assessment of the resident's ability to safely leave the facility due to potential decision-making impairment related to alcohol use, no communication or attempts to contact the hospital regarding the resident's status and no behaviors documented. Facility staff continued to document through 08/15/25 the resident remained hospitalized (no hospital identified) with no mention the resident had refused to sign an AMA form and left the facility or make mention the resident had discharged from the facility. The facility policy titled Resident Leave of Absence, dated 12/2024, revealed that all residents leaving the facility must have orders for supervised or unsupervised leave of absence. Residents leaving the facility on leave of absence must sign out when leaving. Prior to opening the door to allow a resident to leave, the nurse would verify the leave of absence order and would communicate the leave of absence with the receptionist. Staff observing a resident leaving the premises and having doubts about the resident being properly signed out, should notify their supervisor at once. The nurse would document in a progress note the time the resident leaves the facility and if known, the purpose. Review of the Facility Assessment Tool dated 07/31/25 revealed the number/average or range of residents with behavioral health needs was four to five residents, and those with active or current substance use disorders were four to five residents. The assessment revealed the facility managed the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/post-traumatic stress disorder, and other psychiatric diagnoses, intellectual or developmental disability. Emotional support and mental well-being and support with helpful coping mechanisms would be provided. The facility would identify hazards and risks for residents. Behavioral and mental health providers were available to provide services to residents.This deficiency represents noncompliance investigated under Complaint Number 2596080.

Based on interview, medical record review, policy review, review of an Ohio Department of Health (ODH) educational pamphlet, and facility policy review, the facility failed to ensure Resident #107 was adequately supervised while outside and had a way to summon staff assistance. Actual Harm occurred on 08/16/25 when Resident #107, who had been outside in 88 degree Fahrenheit (F) weather, had a change in condition and had a body temperature of 106 degrees F (normal body temperature 98.6 degrees F) and was subsequently hospitalized for heat exhaustion. An additional finding that did not rise to Actual Harm but had the potential for more than minimal harm occurred when the facility failed to ensure Resident #15's fall was thoroughly investigated and accurately documented. This affected two (Residents #107 and #15) of five residents reviewed for accidents. The facility census was 96. Findings include: 1.Review of Resident #107's medical record revealed an admission date of 07/20/17 with diagnoses including dysphagia, cognitive communication deficit, type two diabetes mellitus, cerebral infarction, vascular dementia, peripheral vascular disease, epilepsy, sickle-cell disease, contracture of left foot and hand, and flaccid hemiplegia affecting left nondominant side. Review of Resident #107's plan of care, revised 05/10/24, revealed the resident had an activity of daily living (ADL) self-care performance deficit related to decreased mobility, use of assistive devices, assist of staff, left side flaccid hemiplegia and contractures, diagnoses, impaired decision making and safety awareness. Interventions included varying ADL levels, hoyer for transfers, distant supervision for meals, assisting with ADL's as needed, assist with propelling around facility as needed, and therapy evaluation as needed. Review of Resident #107's Minimum Data Set (MDS) quarterly assessment, dated 06/14/25, revealed the resident had intact cognition. He was dependent on staff for wheelchair mobility. Review of Resident #107's progress note dated 08/16/25 at 12:53 P.M. revealed Resident #107 was outside by the door drinking water. Staff observed the resident display symptoms that included dizziness, fatigue, and flushed skin. The resident was immediately assisted indoors and positioned in a cool shaded area. Additional cool fluids were offered and damp cloths were applied to cool the resident. His vital signs showed an elevated temperature of 106 degrees F, a blood pressure of 109 over 56 millimeters of mercury (mmHg), oxygen saturation at 80 percent and heart rate of 123 beats per minute. Oxygen was administered at two liters. The resident was alert and oriented to person only. The physician and family were notified and the resident was sent to a local hospital for further evaluation. When emergency medical services arrived, Resident #107's temperature was 99.1 degrees F. Review of Resident #107's hospital paperwork from 08/16/25 to 08/18/25 revealed the resident presented to the hospital with dyspnea and hypotension. The resident was diagnosed with acute respiratory failure and newly required supplemental oxygen. The hospital records referenced the resident's body temperature had registered 106 degrees F at the facility and the resident's symptoms were likely an element of heat exhaustion and dehydration from being outside. Resident #107 received intravenous fluids and oral intake was encouraged. Resident #107 was discharged from the hospital and returned to the facility on [DATE]. Review of the website www.timeanddate.com/weather/usa/columbus/historic revealed on 08/16/25 at 11:51 AM and 12:51 P.M., the temperature was 88 degrees F in Columbus, Ohio. Review of Resident #107's medical record and facility documents revealed no further documentation related to this incident. During an interview on 08/26/25 at 2:31 P.M., the Director of Nursing (DON) stated the facility had not conducted any further investigation into this incident as she felt the progress note covered it. During an interview on 08/26/25 at 2:51 P.M., Residents #3 and #96 stated Resident #107 was brought into the courtyard by staff and left unattended by staff on multiple occasions. They stated Resident #107 was unable to move his wheelchair on his own. Resident #3 and Resident #96 reported on 08/16/25, Resident #107 had been placed in the sun. Resident #96 stated he told staff that he thought Resident #107 was too hot and it took them 15 to 20 minutes to check on him. During an interview on 08/26/25 at 4:43 P.M. and on 08/27/25 at 12:06 P.M., Registered Nurse (RN) #253 initially stated Resident #107 was brought outside after breakfast and then clarified this to state the resident was taken outside around 11:00 A.M. Resident #107 was taken back inside around 12:00 P.M. RN #253 reported she had been checking on Resident #107 every twenty minutes while he was outside. He was in the shade and had fluids within reach. She reported it was very hot outside that day, and he was wearing a polo shirt, long pants, and had a top sheet on him. During one of her checks, she discovered his change in condition and brought him inside. RN #253 verified when he was outside, the resident had no way to get the staff's attention, and it was the staff's responsibility to check on him. Review of the Ohio Department of Health (ODH) pamphlet titled Heat-related illness in individuals using psychiatric medication, dated 2022, revealed risk for heat-related illness increase with age over 65 and diseases including heart disease, hypertension, and diabetes. Heat exhaustion was a moderate form of heat related illness. It occurs in high heat conditions when excessive sweating leads to fluid and salt loss and the body is unable to cool itself. Symptoms include heavy sweating, rapid and weak pulse, pale and clammy skin, muscle cramps, tiredness or weakness, dizziness or fainting, and nausea or vomiting. Heat stroke was a severe form of heat-related illness and a medical emergency. In this condition the body temperature can rise to temperature of 106 degrees F or higher, which can lead to permanent injury or death. Signs included very high body temperature, skin that is hot, red, dry or damp, rapid strong pulse, confusion or unconsciousness, dizziness or fainting, and nausea or vomiting. 2. Review of the medical record revealed Resident #15 was admitted on [DATE] with diagnoses of unspecified psychosis, left side rib and right lower leg fracture, blindness, and delirium. The care plan for falls dated 02/20/25 revealed Resident #15 was at risk for falls due to history of falls, impaired balance/poor coordination, poor safety awareness, potential medication side effects, unsteady gait, and vision/hearing problems. Interventions dated 02/20/25 included to administer medications as ordered, do not leave on the toilet unattended, encourage non-skid footwear to be worn for transfers and ambulation, encourage resident to participate in activities, encourage to transfer and change positions slowly, evaluate medications if resident demonstrates changes in mental status, activities of daily living (ADL) function, appetite, and neurological status. Commonly used articles to kept within easy reach. Reinforce Resident #15 to call for assistance. The development of pain, bruises, change in mental status, ADL function, appetite, and neurological status aft a fall. The care plan was updated on 04/24/25 for Resident #15's urinal to be in a designated place. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #15 had impaired cognition. Resident #15 used a wheelchair and required partial to moderate assistance for transfers. The care plan was updated on 06/05/25 for Resident #15 to be in the common area when out of bed. A nursing note dated 06/08/25 at 7:44 P.M. revealed Resident #15 was found on the floor with a head laceration. There was a moderate amount of blood noted on Resident #15's gown. Resident #15 was transported to the emergency department for evaluation. A fall risk evaluation dated 06/08/25 at 7:44 P.M. revealed Resident #15 had intermittent confusion, one to two falls in the past three months, was chair bound, was legally blind, and required assistive devices. The previous care plan was followed when the fall occurred (nothing identified what interventions were in place). A new intervention was put in place to offer Resident #15 toileting after dinner. The fall investigation dated 06/08/25 revealed Resident #15 was found in the bathroom. Resident #15 had been walking and had an unwitnessed fall. Resident #15's call light was within reach but was not on. Resident #15's room was well lit, and Resident #15 was wearing gripper socks. Resident #15 was alert and oriented to the situation. Resident #15 had a right-side head laceration and was sent to the hospital with seven out of ten pain on a scale of zero to ten with ten being the worst pain. There had been no recent medication changes or infections. Resident #15's care plan was not updated. Review of the fall investigation that was marked as privileged and confidential and not part of the medical record dated 06/08/25 revealed Resident #15 had gait imbalance, was ambulating without assistance, The care plan was updated on 06/08/25 with a new intervention to offer Resident #15 toileting after dinner. A nursing note dated 08/12/25 at 7:07 A.M. revealed Resident #15 was found on the edge of the floor mat scooting towards the door. Resident #15 stated he scooted off the bed but was unable to stand. An observation on 08/26/25 at 2:48 P.M. revealed Resident #15 was lying in a low bed with a regular sized mattress on the floor next to the bed. An observation on 09/02/25 at 10:26 A.M. revealed Resident #15 was lying in low bed, and a regular sized mattress was propped up against the wall. An interview on 09/02/25 at 10:27 A.M. with Registered Nurse #254 revealed the mattress was only to be used at night. An observation on 09/02/25 at 10:52 A.M. revealed Resident #15 was lying in a low bed, and the regular mattress was now on the floor next to Resident #15's bed. An interview on 09/03/25 at 3:54 P.M. DON stated Resident #15 was probably in bed and got out of bed when he fell on [DATE]. The DON stated she interviewed a staff member after the surveyor asked where Resident #15 had been prior to the fall, and they said Resident #15 had been in bed prior to ambulating to the bathroom by himself. The DON verified the documentation did not reveal if Resident #15 had been in bed prior to the fall and if Resident #15's urinal was in the designated spot. The DON also verified there was not an order or a fall intervention in place for the use of a mattress on the floor in Resident #15's room. DON verified a problem with the documentation and implementation of fall interventions for Resident #15. Review of the Fall Prevention Policy dated November 2024 revealed all residents will be assessed for fall risk on admission, readmission, and with any significant change in condition. Staff will take proactive measures to ensure resident safety and minimize fall risks.

Based on record review, interviews, police report review, self-reported incident review, policy review, and facility assessment review, the facility failed to identify, address, and obtain appropriate services to meet the behavior health care needs of Resident #5 and failed to develop and implement an individualized comprehensive care plan to address and support the behavioral health care needs of Resident #5. Actual harm occurred on 08/03/25 when Resident #5, who had diagnoses of anxiety, intellectual disability, traumatic brain injury (TBI) and a history of self-injurious behavior of cutting, became agitated with staff during care and brandished a knife and threatened Certified Nursing Assistant (CNA) #350 that he was going to gut her. The police were contacted and Resident #5 was subsequently removed from the facility and placed in jail after a warrant was issued for his arrest. Prior to the incident, the facility failed to ensure comprehensive and individualized behavioral health interventions were in place to prevent the incident from occurring. This affected one (Resident #5) of three residents reviewed for mental health disorders. The facility census was 96. Findings include: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including chronic pain, anxiety disorder, history of traumatic brain injury (TBI) in 2019, and paraplegia. A diagnosis of mood disorder was added on 08/12/25. The hospital exemption pre-admission screening notification dated 07/14/25 revealed Resident #5 had a mood disorder including depression and anxiety. Resident #5 also had a TBI and resided at an intermediate care facility (ICF) or intermediate care facility for individuals with intellectual disabilities (IID) before hospitalization. Review of employee list provided by Regional Director of Operations (RDO) #261 revealed Social Service #700 was employed from 06/06/24 to 07/18/25. Social Service #312 was hired on 07/31/25 and started working on 08/11/25. The facility did not have social services from 07/19/25 through 08/10/25.Review of physician orders revealed Resident #5 was ordered Cymbalta (antidepressant) 30 milligram (mg) in morning, Cymbalta 60 mg in the evening, Trazodone (antidepressant) 25 mg at bedtime, Depakote (used as a mood stabilizer) 500 mg every 12 hours, and hydroxyzine (used to treat anxiety) 25 mg three times a day.Review of hospital records (part of Resident #5's facility medical record) revealed Resident #5 was transferred to the hospital on [DATE] with intractable pain. Hospital records revealed Resident #5 had an inpatient consultation for behavioral health on 07/20/25. The record revealed Resident #5 was a [AGE] year-old male with a known intellectual disability and TBI, paraplegia, and chronic pain syndrome. Behavioral health services were consulted to evaluate Resident #5's episodes of agitation and labile (rapid and uncontrollable shifts in emotional states, often resulting in exaggerated emotional responses that may seem inappropriate to the situation) encounters with staff. Resident #5 has a history of depression and anxiety which were thought to be related to his TBI. This was complicated by poor frustration tolerance and maladaptive (inappropriate) coping strategies that often times involved him having episodes of agitation. Due to TBI, Resident #5 would always struggle with poor frustration and irritability. This was further limited by baseline intellectual disability and maladaptive coping skills. Resident #5 had past self-injurious behavior of cutting as recently as February 2025. A psychotropic medication consent dated 07/24/25 revealed Resident #5 took antianxiety, antidepressant, and sedative/hypnotic medication. Diagnoses or indications for use included anxiety, depression, and insomnia/sleep disorder with targeted behaviors of agitation, decreased socialization/withdrawal, and insomnia/sleep disturbance.An admission Medicare Minimum Data Set (MDS) dated [DATE] revealed Resident #5 was cognitively intact and had no behaviors. An incident report from the police department dated 08/03/25 revealed at 6:15 P.M. the police were dispatched on a report of a resident with a knife. Upon arrival at 6:17 P.M., the resident was located and complied with officers' commands to drop the knife. The suspect (Resident #5) and victim (CNA #350) stated the incident arose from an argument regarding Resident #5's care. During the argument, Resident #5 began throwing food, feces, and miscellaneous items at CNA #350 causing minor injury to CNA #350's arm and hand. Resident #5 brandished a knife and drove CNA #350 out of his room. The knife used in the incident and another small knife were seized from Resident #5's room. Due to the patient's condition, officers were unable to remove Resident #5 from the facility. CNA #350 was provided with the report number and victim's rights information. The narrative notes from the police department revealed Resident #5 was located in the hallway outside of his room in possession of a multicolored butterfly knife (a folding pocketknife with two handles that rotate around a pivot to enclose the blade. When the handles are swung apart, the blade becomes exposed, and the handles can then be gripped to click it in an open position). A police officer commanded Resident #5 to drop the knife and Resident #5 complied. Once the scene was secured, Resident #5 and CNA #350 were interviewed. Resident #5 had a bowel movement on an incontinence pad and CNA #350 had entered the room to provide care. Resident #5 overheard CNA #350 discussing what had happened with another staff member and Resident #5 became frustrated. Resident #5 and CNA #350 engaged in a verbal argument about Resident #5's care, which quickly escalated verbally. Resident #5 then began to throw food, a water pitcher, and a soiled incontinence pad causing minor injury to CNA #350's forearm and hand. CNA #350 left Resident #5's room and entered the hallway. Resident #5 followed CNA #350 in his wheelchair, brandishing a multicolored butterfly knife. Resident #5 stated the knife was open while he was in his room, but he closed it when he went into the hallway. Resident #5 denied making any threatening statements related to the knife towards CNA #350. CNA #350 stated Resident #5 threatened to stab and gut her. While there were numerous caretakers and residents in the hallway that observed Resident #5 wielding the knife, there were none close enough to provide a statement on what words Resident #5 used nor the events leading up to Resident #5 leaving his room and entering the hallway. The butterfly knife and a [NAME] multitool (a versatile, portable device that packs multiple tools, such as pliers, knives, screwdrivers, and saws, into a single, compact design) were seized from Resident #5's room. Due to Resident #5's condition, he was unable to be transported to police headquarters or jail. The report revealed Resident #5 would remain at the facility to receive treatment until other arrangements could be made. As part of the facility investigation beginning 08/03/25, the following statements were obtained:A typed statement by the Director of Nursing (DON) about an incident on 08/03/25. The nurse was notified there had been an incident between a resident and a staff member. Resident #5 was being assisted by CNA #350 with incontinence care. CNA #350 cleaned up Resident #5 and placed the soiled linens in a trash bag. CNA #350 exited the room to speak with Resident #5's nurse regarding care when Resident #5 became agitated and started yelling. Resident #5 began throwing items at CNA #350. Resident #5 picked up a urinal to throw at CNA #350 and CNA #350 pushed the trash bag aside with her foot and closed the door. Resident #5 then came out of his room and yelled profanities and racial slurs at CNA #350. Resident #5 was brandishing a switchblade style knife and threatening CNA #350. The police were called, and the knife was removed from Resident #5 by the police. The police searched Resident #5's room for additional contraband. The police took statements from the staff and Resident #5 was placed on frequent observations until cleared by Certified Nurse Practitioner (CNP) #425 after a face-to-face visit. A handwritten, undated, statement by Unit Manager/Licensed Practical Nurse #347 revealed they received call from the weekend supervisor (unidentified) on 08/03/25 at 6:20 P.M. The supervisor stated that police were in the facility because Resident #5 pulled a knife on a staff member. This nurse asked to speak with the staff member (CNA #350). CNA #350 stated Resident #5 became upset with CNA #350 after care was completed. Resident #5 then grabbed a knife and followed CNA #350 out of the room into hallway. Resident #5 was yelling I will gut you (expletive). Resident #5 began throwing items, screaming and yelling. This nurse advised the supervisor to make sure all staff and residents were out of harm's way. This nurse then notified the DON and administrator. A statement by CNA #257 revealed the CNA was picking up trays and saw Resident #5 with a knife. CNA #257 stated Resident #5 wheeled out fast toward CNA #350 yelling and saying Resident #5 would wound CNA #350. CNA #257 quickly walked past Resident #5's door and alerted all staff and residents who were around to run. As everyone was running Resident #5 took the soiled linen out of the bag and put feces on top of the medication cart and on the floor. CNA #257 only knew what happened when Resident #5 came out with a knife.A handwritten statement by Unit Manager (UM) #345 revealed CNA #350 called about the incident which involved Resident #5 and a knife. CNA #350 stated after completing incontinence care for Resident #5, she suggested Resident #5 use disposable incontinence pads. CNA #350 left the room to notify the nurse that the dressing to Resident #5's bottom was soiled. Resident #5 began yelling and CNA #350 went to see what was wrong. Resident #5 began throwing items at CNA #350. Resident #5 was cursing and using racial slurs. Resident #5 reached for his urinal with urine in it. CNA #350 shut Resident #5's door to prevent Resident #5 from hitting CNA #350 and others with objects that were being thrown. Moments later, Resident #5 came out of his room in his wheelchair holding a knife and wheeled toward CNA #350 stating he was going to gut CNA #350. The police were called. The medical record revealed a form completed with 15-minute checks for Resident #5 from 08/03/25 at 5:45 P.M. until 08/04/25 at 11:15 A.M.A care plan dated 08/04/25 (following the incident) revealed Resident #5 had alteration in behavior with abusive attacks on staff and/or other residents. Resident #5 was physically abusive and pulled a knife on a staff member. Interventions included to approach Resident #5 in a low, calm voice, document the behavior as to type, duration, and precipitating causes, encourage Resident #5 to discuss and vent angry feelings, inform the doctor/nurse practitioner of worsening behavior, intervene as needed to protect the rights and safety of others, approach/speak to Resident #5 in a calm manner, divert attention, remove from situation and take to another location as needed, and set limits on aggressive behavior and communicate expectations to resident to prevent injury to Resident #5 and others.A note dated 08/04/25 by Certified Nurse Practitioner (CNP) #425 revealed Resident #5 was seen for an alleged altercation. Resident #5 allegedly pulled a knife on a CNA. Resident #5 reported different circumstances and stated CNA #350 threw trash at Resident #5. The weapons had been removed from Resident #5, and it was okay to remove Resident #5 from one-on-one monitoring. No concerns were found during the exam and there were no concerns about safety. Resident #5 had a mood disorder versus personality disorder versus manipulative behaviors with increasing agitation. A note dated 08/05/25 by Physician #450 revealed Resident #5 became aggressive and threatening towards staff over the weekend. The police were called and de-escalated the situation and confiscated his knife. Resident #5's overall demeanor since that episode had been improved and Resident #5 was no longer irritable and no longer threatening staff. Physician #450 was unclear about the details about what started the incident as Resident #5 stated he did not like something the staff member did.The incident report from the police department revealed on 08/05/25 at 2:00 P.M. a detective returned to the facility to request information regarding Resident #5's ability to leave the facility to attend court. It was confirmed there were no witnesses to this incident and facility cameras in the hallway were not working. The facility staff stated they were starting the process to have Resident #5 relocated to another facility and CNA #350 would be kept from working the unit Resident #5 resided on. The incident report from the police department revealed on 08/07/25 at 11:41 A.M. a detective returned to Mirandize Resident #5. Resident #5 refused to answer questions or provide a statement. Resident #5 was served with two charges and given summons to appear in court on 08/22/25 at 9:00 A.M. The detective spoke with someone in the manager's office and notified them that Resident #5 had been served. The male in the manager's office (not identified) stated the process had been started to transfer Resident #5 to another facility. A preadmission screening and resident review (PASRR) dated 08/12/25 was completed because Resident #5's hospital exemption notification ([NAME]) was expiring. A mental disorder of panic or other severe anxiety disorder was checked. A mood disorder was not checked. Indications of intellectual and developmental disability revealed Resident #5 had a TBI. A referral had been made for Level II evaluation. The typed statement/timeline completed by the DON revealed on 08/22/25 Resident #5 was scheduled to attend his arraignment at [NAME] County Municipal Court. Transportation was arranged by the facility, but Resident #5 refused to attend.A progress note dated 08/27/25 at 4:05 P.M. revealed two officers arrived to arrest Resident #5. Resident #5 had an active warrant for Aggravated Menacing and Assault. Resident #5 was transported to jail via an ambulance due to his health conditions. An interview on 08/27/25 at 1:56 P.M. with the DON revealed she was told the police arrived within a few minutes of being called and Resident #5 was in the hallway in front of his room when the police arrived (the date of the incident). Resident #5 was put on 15-minute checks after the police left. The DON thought Resident #5 would be put on a 72-hour psychological hold but he was not. The CNP talked with Resident #5 the next day, and felt Resident #5 was no longer a threat and Resident #5 was taken off the 15-minute checks. An interview on 08/28/25 at 10:19 A.M. CNA #350 revealed on 08/03/25 Resident #5 had removed his incontinence brief to defecate on a cloth pad in the bed. CNA #350 cleaned up the feces and placed the soiled linens in a trash bag. While cleaning Resident #5, CNA #350 noticed the bandage to Resident #5's bottom was soiled. CNA #350 stated the nurse was outside Resident #5's room. CNA #350 sat the trash bag down inside the doorway of Resident #5's room and started telling the nurse about the bandage being soiled. Resident #5 became upset and started yelling not to talk about him. CNA #350 went back into Resident #5's room to explain why she was talking to the nurse. Resident #5 threw a Styrofoam food container and then his tray. CNA #350 put her arms up to block the tray, and her arms had become bruised. Resident #5 then picked up his urinal with urine in it. CNA #350 used her foot to kick the trash bag with soiled linen out of the way and went out into the hallway and shut Resident #5's door so she and anyone else would not be hit with the urinal. Resident #5 must have transferred himself to his wheelchair and opened the door leading into the hallway. Resident #5 opened the trash bag and threw the soiled linens. Feces from the soiled lines went onto the floor and medication cart. Resident #5 had a knife and started towards CNA #350 stating he was going to gut her. CNA #350 verified there were residents in the hallway and CNA #350 was afraid that Resident #5 would focus his anger on other residents if she ran away. CNA #350 called the police on her cellphone but stood still in the hallway. CNA #350 stated she talked with a Unit Manager and gave a report to the police. CNA #350 stated the facility did not ask her to write a statement about what happened. CNA #350 verified there was no information provided to staff, verbally or in the medical record, about Resident #5 becoming easily agitated or upset or there being any concerns with inappropriate behavior or coping skills.An interview on 08/28/25 at 10:41 A.M. CNA #257 verified there were residents in the hallway when Resident #5 had a knife. CNA #257 stated everyone ran away and the staff waited for the police to arrive. CNA #257 stated she had not provided any care for Resident #5 that day or any time prior. CNA #257 ended the interview stating she should not say any more. An interview on 08/28/25 at 10:44 A.M. DON verified there was not an individualized or comprehensive plan of care in place to address Resident #5's behavioral/mental health needs including his poor frustration tolerance, intellectual disabilities, and maladaptive coping strategies that could involve him in having episodes of agitation, irritability.The facility filed self-reported incident tracking number 264663 on 08/29/25 related to an allegation of emotional/verbal abuse by staff towards Resident #5. Resident #5's relevant conditions included mood disorder, anxiety disorder, TBI, and paraplegia. An interview on 09/02/25 at 9:09 A.M. with the DON revealed the facility received a police report regarding the incident (on 08/03/25) with Resident #5 and CNA #350. Verbiage in the police report included verbal altercation so Licensed Nursing Home Administrator #271 felt out of abundance of caution a self-reported incident should be filed with the State agency. The DON stated CNA #350 refused to write a statement stating she had given a statement to the police. The DON verified Resident #5 was taken to jail for failure to appear in court and was still in jail as of this date. An interview on 09/03/25 at 9:25 A.M. with the DON revealed she believed Resident #5 had declined any psychological services. However, the DON was unable to provide any documentation of services being offered and Resident #5 refusing any such mental health services. In addition, the DON revealed the facility had had six different social service workers since 02/22/24 (social service staff were responsible for overseeing mental health services for residents in the facility). An interview on 09/03/25 at 1:33 P.M. with CNP #425 revealed she thought Resident #5 did receive services from psychiatric services but was unsure where the documentation was to determine why. CNP #425 also revealed she was not aware Resident #5 had a history of cutting himself. An interview on 09/03/25 at 3:56 P.M. with the DON verified she was not aware Resident #5 had a history of cutting himself and problems with agitation. The DON stated admissions were done off-site and the facility had to admit the residents that the central admissions department sent them. An interview on 09/04/25 at 10:06 A.M. with Social Services (SS) #312 revealed the PASSAR for Resident #5 was completed by the listed diagnoses. SS #312 verified diagnoses of an intellectual disability, and a mood disorder were not added for Resident #5 until 08/12/25 even though the [NAME] assessment dated [DATE] indicated Resident #5 had a mood disorder including depression, anxiety, and TBI. The [NAME] also revealed Resident #5 had resided in an ICF/IID prior to hospital admission. SS #312 verified Resident #5 had been discharged from the facility with an anticipated return to the facility because Resident #5 was in jail. SS #312 verified a Level II referral had been made on 08/12/25 when the new PASSAR was completed.An interview on 09/04/25 at 10:13 A.M. with MDS Nurse # 343 revealed previous diagnoses such as self-harm or intellectual disabilities could not be used unless the doctor ordered the diagnoses. An interview on 09/04/25 at 2:14 P.M. with the DON verified Resident #5 was still in jail as of this date. The DON verified the facility did not send a medication list, list of diagnoses, or medical history to the jail. The DON stated the police officers thought Resident #5 would be returning to the facility the same day. The DON stated the jail could contact the facility if they needed any information about Resident #5. Review of the Facility Assessment Tool dated 07/31/25 revealed the number/average or range of residents with behavioral health needs was four to five residents, and those with active or current substance use disorders were four to five residents. The assessment revealed the facility managed the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/post-traumatic stress disorder, and other psychiatric diagnoses, intellectual or developmental disability. Emotional support and mental well-being and support with helpful coping mechanisms would be provided. The facility would identify hazards and risks for residents. Behavioral and mental health providers were available to provide services to residents.

Based on medical record review, review of hospital records, review of Self-Reported Incidents (SRIs), staff interview, and review of the facility policy, the facility failed to ensure residents were free from physical abuse. This resulted in Actual Harm on 05/27/25 for Resident #12 who was admitted to the hospital and treated for facial bruising and a laceration above the left eye with sutures after being punched in the face by another resident. This affected one (Resident #12) of three residents reviewed for abuse. The facility census was 109 residents. Findings include: Review of the medical record for Resident #12 revealed an admission date of 08/03/24 with diagnoses including dementia, type two diabetes mellitus, anxiety disorder, and depression. Review of the care plan for Resident #12, initiated 08/04/24, revealed the resident had a behavior problem related to dementia, which included wandering into other residents' rooms. Interventions included the following: attempt to redirect the resident when showing wandering behaviors, anticipate and meet the resident's needs, staff to intervene as necessary to protect the rights and safety of others, remove from situation and take to an alternate location if needed. Review of the Minimum Data Set (MDS) assessment for Resident #12, dated 03/04/25, revealed the resident was severely cognitively impaired and required staff assistance with activities of daily living (ADLs.) Review of the nurse progress note for Resident #12, dated 05/24/25, revealed the resident continued to go into other residents' rooms taking belongings. Staff redirected Resident #12 several times during the shift, but the resident continued to wander and open doors to other residents' rooms. Review of the nurse progress note for Resident #12, dated 05/27/25, revealed LPN #112 was charting when Resident #20 approached the nurse and reported she witnessed one resident beating up another resident. The nurse responded to Resident # 28's room and found Resident #12 standing in the middle of the room bleeding profusely from his face. The resident, who attacked Resident #12, admitted he had beat the resident with his hands. The nurse applied direct pressure to the bleeding area on Resident #12's face and called 911 to transport the resident to the hospital. Review of the SRI regarding Resident #12, dated 05/27/25, revealed LPN #112 was charting when Resident #20 informed her Resident #28 was physically assaulting Resident #12. LPN #112 responded to Resident #28's room and found Resident #12 standing in the middle of the room with facial bleeding. The two residents were separated, and Resident #12 was sent to the hospital via ambulance for treatment of his injuries. Social Services Designee (#105) interviewed Resident #28, who told the SSD Resident #12 kept coming into his room and Resident #28 became frustrated after several failed attempts to stop the resident from coming into his room. Resident #28 said he reacted by punching Resident #12, because he just couldn't take it anymore. Review of a witness statement per SSD #105, dated 05/29/25, revealed the SSD interviewed Resident #28 who confirmed he had punched Resident #12 on 05/27/25, because Resident #12 kept coming into his room and he had asked him multiple times to stop coming into his room. Further review revealed Resident #28 confirmed he punched Resident #12 because he just couldn't take it anymore. Review of the hospital records for Resident #12, dated 05/27/25 to 05/31/25, revealed the resident was admitted to the hospital as an assault victim. Resident #12 had been hit in the face and had a hematoma and laceration on the left side of his face with admitting diagnoses of periorbital ecchymosis and swelling and facial laceration with stitches. Review of the nurse progress note for Resident #12, dated 05/31/25, revealed the resident was readmitted to the facility. Resident #12 had swelling to the left side of his face, a bruise to his left eye, and a laceration above the left eye with stitches. Review of the medical record for Resident#28 revealed a readmission date of 01/27/25, with diagnoses including stroke, hypertension, peripheral vascular disease (PVD), and dementia. Review of the care plan for Resident #28, initiated 03/03/23, revealed the resident had a behavior problem, which included hitting other residents. Interventions included the following: assist the resident to develop more appropriate measures for coping and interacting, encourage the resident to express feelings appropriately, and a stop sign across the door of the room (added 05/27/25). Review of the MDS assessment for Resident #28, dated 04/09/25, revealed the resident had mild cognitive impairment. Interview on 06/12/25 at 8:00 A.M. with the Director of Nursing (DON) and the Administrator confirmed the facility initiated an SRI when Resident #28 assaulted Resident #12 resulting in facial bruising and a laceration requiring sutures above Resident #12's left eye. The facility did not substantiate abuse because they believed Resident #28 had not intended to hurt Resident #12. Interview confirmed the facility implemented a new intervention after the incident had occurred. After Resident #12 returned from the hospital, the facility decided to place a stop sign across Resident #28's door to prevent unwanted visitors. Interview on 06/12/25 at 12:16 P.M. with LPN #112 confirmed when she walked into Resident #28's room on 05/27/25 she found Resident #12 standing in the middle of the room with his face in his hands because he was bleeding badly. LPN #112 confirmed she asked Resident #28 what happened, and Resident #28 told the nurse he had hit Resident #12 in the face which had caused the injuries. LPN #112 confirmed she separated the residents and sent Resident #12 to the hospital via ambulance for treatment of his injuries. LPN #112 confirmed Resident #12 was free of any bruises or cuts to his face prior to the incident. Observations on 06/11/24 and 06/12/25, between 8:00 A.M. to 4:30 P.M., revealed there was no stop sign to Resident #28's door blocking entry to the room. Interview on 06/12/25 at 12:30 P.M. with Certified Nursing Assistant (CNA) #106 confirmed there was no stop sign to Resident #28's door because Resident #28's roommate had ripped the sign off the wall. Review of facility policy, titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property undated, revealed residents had the right to be free from abuse including resident to resident abuse. Abuse was defined as the willful infliction of injury. Willful meant the individual must have acted deliberately, not that the individual intended to cause harm.

Based on closed medical record review, staff interviews, Emergency Medical Technician (EMT) interview, review of Emergency Medical Services (EMS) run report, review of the tracheostomy handbook, and review of the facilities policies and procedures, the facility failed to ensure the proper respiratory support was provided to a resident who was experiencing respiratory distress. This resulted in Immediate Jeopardy and serious life-threatening harm and/or negative health outcomes when Resident #199, who had a tracheostomy (a small surgical opening through the skin and into the windpipe), was not administered respiratory support including suctioning the tracheostomy, administering an as needed breathing treatment which was ordered for shortness of breath, changing the inner cannula of the tracheostomy to ensure its patency or attaching an Ambu (also known as a bag 0 valve-mask resuscitator) to the residents tracheostomy to provide breaths. The lack of providing respiratory support during this emergency resulted in Resident #199 experiencing shortness of breath, loss of consciousness, loss of respirations, loss of pulse and was subsequently pronounced deceased in the emergency room. This affected one (Resident #199) of two residents reviewed for tracheostomy care. The facility does not currently have any residents with tracheostomies. The facility census was 93. On [DATE] at 2:50 P.M., the Administrator, Director of Nursing (DON), and Regional Director of Clinical Operations (RDCO) #306 were notified of Immediate Jeopardy that began on [DATE] between 2:30 P.M. and 3:00 P.M., when Resident #199 had complaints of shortness of breath which led to unconsciousness, loss of respiration and pulse. On [DATE], Resident #199 complained of shortness of breath when Assistant Director of Nursing (ADON) #157 proceeded to check all oxygen tubing connections to ensure there was no leakage and increased Resident #199 ' s oxygen being delivered from 4 to 5 liters per minute. Resident #199 was noted to show no improvement, so ADON #157 left the residents ' room to call 911 (EMS) and prepare this resident ' s medical paperwork for transfer to the hospital. Licensed Practical Nurse (LPN) #303 was to remain in the room with Resident #199. EMS was noted to arrive at the facility at 3:08 P.M. where upon entering Resident #199 ' s room, the resident was found to be alone with no staff at bedside, face appeared pale, and hands and feet appeared cyanotic (bluish) in color. Resident #199 was noted to be laying in a semi-Fowler ' s position (when a person lies on their back with their head and upper body raised 30 - 45 degrees) with no supplemental oxygen in place. EMT ' s were noted to check Resident #199 ' s carotid arteries on both sides of her neck where no pulse was detected. Cardiopulmonary resuscitation (CPR) was immediately initiated with no detectable pulse ever noted. Resident #199 was transported to the local emergency room where she was pronounced deceased . The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: • On [DATE], Resident #199 was transferred to the hospital via EMS. • On [DATE], the DON audited charting over the last seven days to see if any other residents reported respiratory distress with no findings. The DON or designee will complete a weekly audit for the next 30 days regarding residents reporting respiratory concerns and ensure appropriate interventions are put in place. • On [DATE] at 4:30 P.M., the Administrator validated no residents currently reside in the facility with tracheostomies. • On [DATE] at 5:38 P.M., the facility completed a Quality Assurance and Performance Improvement (QAPI) meeting which included a root cause analysis of the event and developed a plan of correction. Participants included Medical Director #300, the Administrator, the DON, Unit Manager #117, Unit Manager #41 and RDCO #306. The QAPI plan was approved by Medical Director #300 and the Interdisciplinary Team (IDT) on [DATE]. • On [DATE], a new Emergency Tracheostomy Care Policy was put into effect. • On [DATE], a Code Blue Competency Drill was conducted by RDCO #306 and the DON. The drill also included education on responding to respiratory distress, suctioning, and monitoring of residents in respiratory distress and education on the Emergency Tracheostomy Care Policy. The Code Blue Competency and education was held on day and night shift on [DATE]. The DON completed the day shift Code Blue Competency Drill at 5:12 P.M. on [DATE] and ADON #157 completed the night shift Competency Drill at 7:18 P.M. on [DATE]. • At this time, the facility does not have a resident with a tracheostomy; however, if the facility admits a resident with a tracheostomy, the resident will be interviewed three times weekly regarding quality of respiratory care. Staff will also be interviewed three times a week for responding to respiratory distress, suctioning, and monitoring of residents in respiratory distress and education on the Emergency Tracheostomy Care Policy. These audits will continue for the next 30 days after admission. • On [DATE] at 6:00 P.M., the Administrator electronically delivered RN/LPN education to all licensed nurses regarding emergency tracheostomy care via the One Call delivery system. • On [DATE], all facility staff in Environmental Services, Dietary, Administration, Maintenance, Therapy, and Activities departments were educated on responding to respiratory distress by the Administrator. • The DON/designee will educate all agency staff prior to taking an assignment on the Emergency Tracheostomy Care Policy and will ensure they receive competency validation on tracheostomy care at the start of their shift. The DON or designee will ensure on going education with All Agency Nurses. Any nurse who did not complete the training above will not be permitted to take an assignment until completed. • The DON and/or designee will perform three staff interviews five times a week, across all shifts times 4 weeks to ensure all LPNs and RNs are knowledgeable in responding to situations of respiratory distress and steps to take to maintain oxygenation. • The QAPI committee will review the results of these audits and processes to determine if additional audits or education is 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 closed medical record for Resident #199 revealed an admission date of [DATE] and a discharge date of [DATE]. Diagnoses included acute respiratory failure with hypoxia (absence of enough oxygen in the tissue to sustain bodily function) and hypercapnia (occurs when there is too much carbon dioxide [CO2] in the bloodstream), bacterial pneumonia, morbid obesity, and tracheostomy status. Review of the admission Assessment for Resident #199 dated [DATE] at 2:41 P.M. revealed this resident admitted to this facility from a local hospital with an admission diagnosis including acute hypoxic/hypercapnic respiratory failure. Resident #199 was noted to have a full code status indicating if this patient ' s heart stops or they stop breathing, all possible medical interventions, including CPR, intubation, and defibrillation will be used to try and revive them. Resident #199 ' s respiratory assessment revealed clear bilateral lung sounds with no abnormal sounds noted and shortness of breath was experienced when Resident #199 was laying flay. Resident #199 was noted with a non-productive cough. Resident #199 was noted to be alert and orientated to person, place, time, and situation and able to make needs known and understood others. Resident #199 was noted to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating an intact cognition for daily decision-making abilities. Review of the care plan for Resident #199 failed to identify a plan to provide respiratory or tracheostomy (trach) care. Review of physician orders for Resident #199 revealed the following: -Elevate the head of bed to prevent shortness of breath related to Asthma. -Trach care every shift and as needed. -Change oxygen tubing filters and humidification bottle every week and as needed on Sunday night. -Supplemental oxygen continuously via trach at 4 liters per minute every shift for Chronic Obstructive Pulmonary Disease (COPD) -Albuterol Sulfate Nebulization Solution (2.5 milligrams [mg]/3 milliliter [ml]) 0.083% Inhale 3 ml orally via nebulizer every 6 hours as needed for shortness of breath. -Clonazepam oral tablet, 0.5 mg. Give 1 tablet by mouth every 12 hours as needed for anxiety for 14 days. Review of the medication administration record revealed no administration of the ordered nebulizer treatment on [DATE] for shortness of breath. Review of the nursing progress note dated [DATE] at 3:30 P.M., created by LPN #303, revealed Resident #199 requested to be suctioned due to reported difficulty clearing secretions. This nurse obtained assistance from another nurse (ADON #157) to perform suctioning. Procedure was completed with a moderate amount of mucus suctioned. After suctioning resident requested to be changed, while this nurse and aids were assisting resident with repositioning, resident began complaining of shortness of breath, appearing in acute respiratory distress with labored breathing and cyanosis noted. Pulse oximeter (non-invasive equipment used to measure the percent of oxygen in a person ' s blood) applied and oxygen saturations were found critically low fluctuating between 50-20%, heart rate dropped rapidly. Resident #199 maintained a weak pulse initially. 911 was immediately called by an assisting nurse (ADON #157). The face sheet, medication list and necessary documentation were printed and prepared for EMS. Upon EMS arrival the resident lost pulse, and CPR was initiated by the EMT. The resident was transported to a local hospital for further evaluation and treatment. On call clinical staff were notified and provided full report. Power of Attorney (POA) contacted and informed of the incident and resident transfer to hospital. Review of the EMS run report dated [DATE] revealed the 911 call from the facility was received at 3:02 P.M. for Resident #199 who was unconscious, Medic Unit #72 was notified of the dispatch at 3:03 P.M., Medic Unit #72 was enroute to the facility at 3:04 P.M. and arrived at the facility at 3:08 P.M. Resident #199 was found lying in her bed unconscious and not breathing. Primary assessment of Resident #199 when medics arrived was cardiac arrest which was noted prior to any EMS arriving. No vitals were able to be obtained due to this patient ' s condition. Continued reviews indicated that no CPR was being performed by facility staff prior to EMS arriving at the facility. Medic Unit was noted to leave the facility at 3:26 P.M. and arrived at the local hospital at 3:32 P.M. Interview on [DATE] at 2:56 P.M. with ADON #157 revealed she has worked at this facility for about six years and over the years they have had multiple trach patients. ADON #157 stated that on [DATE] she came in just to grab some paperwork and that was when LPN #303 asked her if she could just help with suctioning Resident #199. LPN #303 stated she knew how to do it but was busy. ADON #157 stated that while she set up the sterile suctioning kit, she had placed the pulse oximeter on Resident #199 ' s finger to see what her oxygen saturations were, and they were in the high 90s and her pulse per what she remembered was fine. ADON #157 reported that she placed the suction catheter in once and there were not a lot of secretions noted. The resident requested to be suctioned again so she waited about 5 minutes and then did it again all while the pulse oximeter was in place and her sats were still at baseline and good. After the second time suctioning, Resident #199 requested to be pulled up in bed, which she assisted with. Then she said she needed to be changed. As the Certified Nursing Assistants (CNAs) were coming in to do this care, Resident #199 started to complain she could not breathe, ADON 157 noticed her pulse and oxygen level started to decline. Resident #199 was already receiving 4 liters of oxygen, so she bumped it up to 5 liters with no positive outcome. ADON #157 stated she called 911 and the EMS arrived quickly. All during this time, the primary nurse (LPN #303) remained at bedside and this resident was still alert and had a pulse during this time. EMS took this resident to the hospital. Interview on [DATE] at 6:38 P.M. with Agency LPN #303 reported Resident #199 requested to have her tracheostomy suctioned and ADON #157 was at the facility so she figured the resident would be more comfortable with a full-time staff member doing this care instead of her, so she asked ADON #157 to complete this care. After this care was completed twice, this resident requested to be changed. When Resident #199 ' s head of bed was lowered to provide care, she started to complain of shortness of breath. Her head was raised up and ADON #157 increased her oxygen level from 3 to 4.5 or 5, she could not remember the exact number. Resident #199 did not appear to be any better, so ADON #157 went to call 911 and get the residents ' paperwork ready. During this time, she remained with the resident until EMS arrived. The pulse oximeter remained in place and while she could not recall the patient ' s pulse, she remembered her oxygen saturations reading in the low 80%. Until EMS arrived at the facility, her oxygen saturation was in the low 80s and then it suddenly dropped to about 25% but again she could not recall the pulse because she was more focused on her respiration and oxygen saturations. LPN #303 claimed Resident #199 ' s head of bed was raised high, and she was receiving oxygen support via trach mask when EMS arrived. LPN #303 confirmed that no one attempted to suction the patient, did not administer as needed breathing treatment for shortness of breath, did not change the inner trach cannula nor did they attempt to attach an Ambu bag for breathing assistance. An interview was conducted on [DATE] at 2:45 P.M. with EMT #308 and Battalion Chief #310. EMT #308 revealed he has been a medic for two years now. He stated he was the lead of Medic Unit #72 who responded to this facility for Resident #199 who was reported in respiratory distress. The station received the call at 3:02 P.M., and they arrived at the facility at 3:08 P.M. When they walked through the facility ' s ambulance entrance her room was right there. EMT #308 reported they walked into her room and no staff members were in the room, and the patient was laying in a semi-Flowers position and had no supplemental oxygen on. Her face was pale, and her hands and feet were blue. He immediately checked both carotid arteries and felt no pulse. Chest compressions were immediately started, and he then instructed another Medic to obtain an airway. This was when they realized this patient had a trach but due to how she was laying and her size, they could not see it. They were able to obtain an airway with her trach and CPR continued. Epinephrine was administered, which is a medication used during CPR which acts as adrenaline to stimulate the body ' s sympathomimetic system or the Fight-or-Flight response. Medic #308 stated CPR was started within 60 seconds of arriving at the facility. He could not recall if there was a pulse oximeter on her finger or not, but she did not have a pulse per his assessment. Per Medic #308 and Battalion Chief #310, per the appearance of this patient, her pulse had not just stopped when they entered the facility. Each patient is different in the way they decline but the pale face and blue feet and hands do not happen immediately. Further interview revealed they cannot say for sure what the facility did or did not do but they strongly feel not all respiratory measures were taken to help this patient with respiratory distress. Interview on [DATE] at 4:25 P.M. with CNA #191 revealed she did work the day shift on [DATE] but was not Resident #199's primary caregiver. CNA #191 stated she assisted the other CNAs with changing her that morning. After this, Resident #199 requested to be suctioned so they told the nurse. CNA #191 reported Resident #199 pulled her call light multiple times during the day requesting to be suctioned and the nurse would say okay but would not do it. Around 2:00 P.M. on [DATE] when she came into Resident #199 ' s room she was upset and looking on the Internet for different facilities for her to transfer to, claiming she did not feel safe. CNA #191 stated she gave the patient the Administrators number for her to contact him and let him know what was going on. The patient was claiming that she had not been suctioned since she arrived at the facility. Review of the undated Smiths Adult trach handbook the facility provided revealed that during an emergency, a bag ventilation device is used when resident is not able to breathe with ease or has stopped breathing. Using the bag allows you to assist his/her breathing or to completely take over breathing for him/her. This is to be used with CPR if the resident is not breathing and you cannot find a pulse. It may also be used to help resident breathe whenever there is difficulty or shortness of breath. Review of the facility policy titled, Lower Airway (tracheostomy tube) Suctioning dated [DATE] revealed, the purpose was to remove secretions, maintain a patent airway, and prevent infection to the lower respiratory tract. Review of facility policy titled, Advanced Directives dated [DATE] revealed under the section titled Full Code, when a resident is identified as a full code the facility staff will provide emergent measures in an attempt to resuscitate the patient. This may involve chest compressions, electric shocks, and emergency medications that act to temporarily keep blood moving to essential organs such as the brain. The facility staff must continue any resuscitative efforts until EMS arrives and takes over. This deficiency represents noncompliance under Complaint Number OH00164689.

Based on medical record review, review of hospital discharge summaries, resident and staff interviews, and facility policy review, the facility failed to ensure Resident #58 was administered diabetic medication as ordered. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death on [DATE] when Resident #58 was readmitted to the facility from the hospital with orders for Lantus (a long-acting insulin) and Humalog (a fast-acting insulin) and Resident #58 was not administered any diabetic medications or insulin on [DATE] or [DATE]. On [DATE] at approximately 11:30 A.M., Resident #58 was sent back to the hospital when Resident #58's blood sugar was checked and showed high. Resident #58's blood sugar was 624 milligrams per deciliter (mg/dL) at the hospital and Resident #58 was treated for hyperglycemia and diabetic ketoacidosis (DKA). Resident #58 remained in the hospital until [DATE]. This affected one (Resident #58) of six residents reviewed for unnecessary medication and/or diabetic medications. The census was 87. On [DATE] at 4:50 P.M., the Administrator #149 and Director of Nursing (DON) #163 were notified that Immediate Jeopardy began on [DATE] when Resident #58 returned to the facility at approximately 1:00 P.M. with orders for the following medications: Lantus (a long-acting insulin) 14 units every morning and Humalog (a fast-acting insulin) per corrective scale three times a day before meals. Resident #58 was not administered any insulin or diabetic medications from [DATE] at approximately 1:00 P.M. through [DATE] at approximately 11:30 A.M., and there was no evidence Resident #58's blood sugar levels were checked from [DATE] at approximately 1:00 P.M. until [DATE] at approximately 11:30 A.M. when Resident #58's blood sugar level measured high, and Resident #58 was sent back to the hospital. Resident #58's blood sugar level at the hospital was 624 mg/dL (A normal blood glucose before a meal for someone with Diabetes is 80 to 130 mg/dL and a normal blood glucose one to two hours after beginning a meal is less than 180 mg/dL per the American Diabetes Association) and Resident #58 was treated for hyperglycemia and DKA (a serious diabetes complication where the body produces excess blood acids or ketones that occurs when there is not enough insulin in the body). Resident #58 remained in the hospital until [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility completed the following corrective actions: On [DATE], Resident #58 returned to the facility from the local hospital. On [DATE], the facility began reviewing all new admissions for the last seven days to ensure orders were entered correctly and timely. Resident #58 was included in the audit. Any concerns identified in the admission audit were corrected at that time. This was completed by the Traveling Director of Nursing #242 on [DATE] at 11:00 A.M. On [DATE], Administrator #149 sent a one call education to all nurses regarding the input of resident admission orders. This education was initiated and completed on [DATE]. On [DATE], Medical Director (MD) #218 received the facility Quality Assurance and Performance Improvement (QAPI) plan which reviewed the facility plan to correct and determine the root cause of the incidents. The QAPI plan findings revealed the root cause was agency staff, nurse education, poor understanding of the admission process, timely completion of new admissions, and difficulty navigating hospital paperwork. The plan included education to nurses on the Facility Admission checklist which includes reviewing the after-visit summary and discharge summary by the admitting nurse and follow up audits by the Unit Managers. These audits will be reviewed by the Director of Nursing or designee. MD #218 responded via email on [DATE] and indicated she approved of the plan with no additions. On [DATE], the DON or designee-initiated education for all nurses present in the building. On [DATE], the DON or designee completed medication administration audits for all nurses working and the audits will continue before any nurse starts a shift. The education was initiated on [DATE]. Medications must be entered into the system during the shift of admission and medications must be administered per doctor's orders. The education was completed by the Administrator via automated phone calls on [DATE]. On [DATE], all residents were audited to ensure their medication orders were accurate and complete. This audit was completed on [DATE] by the DON or designee. On [DATE], the medication order policy was reviewed by the Interdisciplinary Team (IDT) and no changes were recommended. On [DATE], a one call education for the nurses was completed. The education included medication orders and follow up appointments for all new and current residents must be entered into the system timely after admission or the order is received. Medications must be administered per physician orders. Medications must be entered by the admitting nurse and then audited during the next nurse shift. All new licensed nurses and licensed agency nurses have been included in all education and will continue to be educated on medication orders before working with residents. Education was also sent out to the four agencies in order to educate their staff prior to working at the facility by Staffing Coordinator #107 on [DATE]. The education was added to the facility's agency education binder. The DON or designee will complete random audits daily for the next 30 days to ensure new admission orders are entered timely and accurately. These audits will continue for the next 30 days and will be reviewed by the QAPI committee to see if additional education or interventions are necessary. Interviews on [DATE] from 3:48 P.M. through 3:55 P.M. revealed Assistant Director of Nursing #179, Licensed Practical Nurse (LPN) #113, and LPN #121, were knowledgeable regarding ensuring residents receive medications as ordered, ensuring medications are entered appropriately upon admission/readmission, and reviewing appropriate forms from the hospital when a resident is admitted or readmitted . Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #58 revealed an initial admitted on [DATE] and a readmitted on [DATE]. Resident #58's medical diagnoses included metabolic encephalopathy, Type one Diabetes Mellitus with ketoacidosis without coma, and long-term use of insulin. Review of the census report for Resident #58 revealed Resident #58 was hospitalized from [DATE] to [DATE] and from [DATE] to [DATE]. Review of the care plan, dated [DATE], revealed Resident #58 was at risk for adverse outcomes from potential hypoglycemic or hyperglycemic episodes due to a diagnosis of Type one Diabetes Mellitus. Interventions for Resident #58 included Accu-check blood sugar testing as ordered and administer insulin as ordered. Review of the Medicare Five Day Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed Resident #58 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #58 required extensive assistance to total dependence from one to two staff to complete Activities of Daily Living (ADLs). Resident #58 received daily insulin injections and had insulin orders changed one time during the review period. Review of physician orders, dated [DATE], revealed Resident #58 did not have any insulin orders or diabetic medication orders entered on [DATE] and [DATE]. Resident #58 had an order to send to the emergency room (ER) for observation dated [DATE]. Review of the Medication Administration Record (MAR), dated [DATE], revealed Resident #58 was not administered any insulin on [DATE] or [DATE]. Review of the blood sugar results for Resident #58, dated from [DATE] through [DATE], revealed Resident #58 did not have any blood sugar levels entered on [DATE] and the only blood sugar level entered on [DATE] showed a reading of 1.0 (1.0 was entered due to being unable to enter high) at 4:55 P.M. Review of progress notes, dated from [DATE] to [DATE], revealed on [DATE] at 4:53 A.M., Resident #58 reported having chest pain and shortness of breath. Resident #58 was sent out to the hospital for an evaluation and was admitted to the hospital. On [DATE] at 1:11 P.M., an agency nurse (Agency Nurse #260) noted Resident #58 arrived at the facility from the hospital. On [DATE] at 2:00 P.M., LPN #137 noted Resident #58 arrived at the facility via transport. Resident #58 was provided lunch. Resident #58's medications were verified with the physician and entered into the electronic medical record for delivery via the pharmacy. Resident #58's representative was notified of Resident #58's arrival. On [DATE] at 11:25 A.M., LPN #135 noted she was notified by the aide and therapy that Resident #58 was not at baseline. Resident #58's vital signs were stable. Resident #58's blood sugar was high, with trembles and Resident #58 was disoriented. Certified Nurse Practitioner (CNP) #215 was notified and a verbal order was received to send Resident #58 to the emergency room for an evaluation. Resident #58's responsible party was notified. On [DATE] at 12:35 P.M., Resident #58 was readmitted to the facility from the hospital. Review of the Discharge Summary, dated [DATE] and included in Resident #58's electronic medical record, revealed Resident #58 was admitted to the emergency roiagnom on [DATE] at 3:47 P.M. Resident #58 presented with shortness of breath. Resident #58's metformin (diabetic medication) was stopped. Resident #58's Lantus insulin (long-acting insulin) was reduced from 18 units to 14 units on [DATE] due to hypoglycemia. Resident #58's new medications at discharge included Lantus insulin with instructions to inject 14 units under the skin every morning and Resident #58's continued medications included Humalog insulin (short acting insulin) with instructions to inject three units under the skin three times a day before meals plus corrective scale insulin. Review of the Discharge Summary, dated [DATE], revealed Resident #58 was admitted on [DATE] with hyperglycemia and found to have DKA. The discharge summary revealed Resident #58 reported the facility ran out of insulin and he was not administered any insulin for one day. Resident #58's blood glucose was 642 milligrams per deciliter (mg/dl), Anion Gap (AG) was 23 (a normal anion gap is typically 4 to 12 millimoles per liter (mmol/L)), and Beta-Hydroxybutyrate (BHB) was seven (normal BHB levels are less than or equal to 0.3 mmol/L and are typically greater than 2.0 mmol/L in patients with ketoacidosis). A continuous insulin infusion protocol was started for Resident #58. Resident #58 was transitioned to subcutaneous (under the skin) insulin on [DATE]. Resident #58 was discharged back to the facility on [DATE]. Interview on [DATE] at 6:07 P.M. with Resident #58 revealed there was a mix-up with obtaining his insulin at the facility and his blood sugar level increased to over 600. Resident #58 stated he was sent to the emergency room (ER) on [DATE] after he did not receive any insulin injections for one to one and a half days. Resident #58 stated he typically received insulin injections early in the morning and with meals as needed. Resident #58 stated he did not receive any insulin injections and had to stay in the hospital for a couple of days. Interview on [DATE] at 4:39 P.M. with Agency Licensed Practical Nurse (ALPN) #240 confirmed Resident #58 did not have any insulin orders entered in the medical record on [DATE] and [DATE]. Interview on [DATE] at 10:55 A.M. with Regional Nurse (RN) #235 confirmed there was a medication error that occurred when Resident #58 returned to the facility on [DATE]. RN #235 stated the floor nurse who was present when Resident #58 returned to the facility was an agency nurse (Agency Nurse #260) and failed to enter all of Resident #58's medication orders into the medical record. RN #235 confirmed Resident #58 did not receive any insulin from [DATE] at approximately 1:00 P.M. when Resident #58 returned to the facility through [DATE] at approximately 11:30 A.M. when Resident #58 was sent out to the hospital. RN #235 also confirmed Resident #58's blood sugar levels were not checked during the same timeframe. Interview on [DATE] at 11:06 A.M. with LPN #137 revealed when a resident was readmitted to the facility following a hospital stay, the floor nurse was responsible for gathering information and entering the resident's medication orders into the electronic medical record. LPN #137 stated the progress note she entered on [DATE] at 2:00 P.M., was incorrectly dated. LPN #137 stated she completed an admission audit of Resident #58's medical record on [DATE], not [DATE], and no medication orders were entered until [DATE]. LPN #137 stated an agency nurse (Agency Nurse #260) was the floor nurse who was present when Resident #58 arrived back at the facility from the hospital on [DATE]. Interview on [DATE] at 12:20 P.M. with CNP #215 revealed she was on-site at the facility on [DATE] when Resident #58 returned to the facility from the hospital. CNP #215 stated she verified Resident #58's medication orders. CNP #215 stated Resident #58 returned with orders to discontinue the sliding scale insulin, Humalog, and to reduce Resident #58's Lantus insulin to 14 units in the morning. CNP #215 stated she used a discharge summary from Resident #58's hospital chart that was dated [DATE] to verify Resident #58's medication orders. CNP #215 stated the staff called her on [DATE] at 4:55 P.M. (over 24 hours after Resident #58 was readmitted to the facility and after Resident #58 had already been sent back out to the hospital) to verify Resident #58's sliding scale insulin. CNP #215 confirmed she would expect Resident #58's blood sugar levels to be checked at least in the morning at a minimum and with a sliding scale insulin order, should be checked prior to administering any sliding scale insulin to confirm the correct amount of insulin was administered. Review of the Discharge Summary, dated [DATE] and received from CNP #215 via email on [DATE] at 3:29 P.M., revealed Resident #58 had orders for Lantus insulin with instructions to inject 14 units under the skin every morning and Humalog insulin with instructions for corrective (sliding) scale three times a day before meals. The prandial (insulin taken at mealtime) insulin was discontinued. Review of the facility policy, Medication Orders Non-Controlled Medication Orders, dated ,d+[DATE], revealed the policy stated Written transfer orders (sent with a resident from a hospital or other health care facility), implement a transfer order without further validation if it is signed and dated by the resident's current attending physician, unless the order is unclear or incomplete or the date signed is different from the date of admission. If the order is unsigned or signed by another prescriber or the date is other than the date of admission, the receiving nurse verifies the order with the current attending prescriber before medications are administered. The nurse documents verification on the admission order record by entering the time, date, and signature. The nurse who transcribes the orders to the physician order sheet and/or Medication Administration Record (MAR) documents on the admission form the date, the time, and by whom the orders were noted. Orders are transmitted to the pharmacy with any additional information required for new admission.

Based on medical record review, review of hospital records, review of dental records, staff interview, and facility policy review, the facility failed to ensure one resident (Resident #72) was provided dental care in a timely manner. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm and/or medical emergency on 03/30/23 when Resident #72 was readmitted to the facility from the hospital where Resident #72 had been treated with three antibiotics for sepsis (the body's extreme response to an infection) caused by several abscessed teeth. Resident #72 was discharged from the hospital with an order to follow-up with a dentist as soon as possible (ASAP) for tooth extractions. Resident #72 did not receive any follow-up with a dentist and was readmitted to the hospital on 05/12/23 due to septic shock (the most severe stage of sepsis) which was most likely due to Resident #72's abscessed teeth. Resident #72 received oral surgery in the hospital to extract the several abscessed teeth. This affected one (Resident #72) out of three residents reviewed for dental services. The facility census was 87. On 06/14/23 at 4:50 P.M., the Administrator #149 and Director of Nursing (DON) #163 were notified that Immediate Jeopardy began on 03/30/23 when Resident #72 was discharged from the hospital where he received treatment for sepsis due to several abscessed teeth. Resident #72 was discharged with an order to follow-up with a dentist ASAP for tooth extractions. Resident #72 did not receive any dental follow-up services for tooth extraction between 03/30/23 and 05/12/23. Resident #72 was readmitted to the hospital on 05/12/23 and was treated for septic shock with symptoms of significant hypothermia (a significant and potentially dangerous drop in body temperature), leukopenia (low white blood cell count), hypotension (low blood pressure), and a short-term course of vasopressor support (a serious intervention that can only be done in the intensive care unit (ICU) and usually means someone has a critical medical condition). A Computerized Tomography (CT) scan of the maxillofacial area (face, head, neck, and jaw) on 05/13/23 showed several large dental caries (cavities), several periapical teeth lucencies (holes in bone formed as a result of inflammation under the root of the tooth), suspicious for odontogenic abscesses (infections that originate in the teeth and/or their supporting tissues), and soft tissue swelling at the base of the tongue. Resident #72 was moved to the Medical Intensive Care Unit (MICU) due to worsening confusional episodes, hypothermia, and hypotension. Resident #72 was treated with intravenous (IV) antibiotics for the infection and received oral surgery to extract the several abscessed teeth. The Immediate Jeopardy was removed on 06/15/23 when the facility completed the following corrective actions: On 05/18/23, Resident #72 was readmitted to the facility from the hospital after having his teeth extracted in the hospital. On 06/14/23, all residents had their oral health assessed by DON #163, Assistant Director of Nursing (ADON) #179, Clinical Manager #137, Clinical Manager #164, Wound Nurse #153, Infection Preventionist #135, and Traveling Director of Nursing (TDON) #242. Residents were interviewed regarding their oral health. Residents who expressed concern or were unable to answer due to impaired cognition had an oral assessment by a licensed nurse. All residents who were identified were communicated to the facility contracted dental provider on 06/15/23 by the Regional Director of Nursing (RDON) #235 via email. All new admissions and residents returning to the facility will be interviewed regarding their oral health and have an oral assessment completed by licensed nursing staff. The DON or designee will weekly randomly review these assessments for accuracy and completion. These audits will continue for the next 30 days and will be reviewed by the Quality Assurance and Performance Improvement (QAPI) committee where the facility will determine if additional audits or education are needed. On 06/14/23, Social Services #146 completed an audit of all residents in order to see when they were last seen by dental services. Residents who were not signed up for dental services had that option reviewed with them or their representative. This was completed on 06/14/23 by Social Services #146. On 06/14/23, education was initiated for all scheduled nurses to ensure dental services were provided. Nurses were educated that all new admissions and current residents that receive consultations for dental services must be scheduled by the facility for follow up. Residents with concerns regarding their oral health must be assessed for their oral health and have follow up documented. The education was initiated by the DON via in-person education on 06/14/23. The education was completed by Administrator #149 via automated phone calls on 06/15/23. On 06/14/23, MD #218 received the facility QAPI plan which reviewed the facility plan to correct and determined the root cause of the incidents. The QAPI plan findings revealed the root cause was agency staff, nurse education, poor understanding of the admission process, timely completion of audits for new admissions, and difficulty navigating the hospital paperwork. MD #218 responded via email on 06/14/23 and indicated she approved of the plan with no additions. On 06/15/23, the dental services policy was reviewed by the Interdisciplinary Team (IDT) with no revisions recommended. On 06/15/23, education was initiated for State tested Nurse Aides (STNAs) by TDON #242 and was sent out by the Administrator via automated phone call on 06/15/23 and all STNAs were verified to have completed the education on 06/15/23. All new direct care staff and direct care agency staff will be educated on dental services prior to starting their shift. On 06/15/23, Facility Staffing Coordinator #107 sent out education to the four agencies utilized by the facility in order for them to educate their staff prior to coming to the facility. The education was added to the facility agency education binder. All new admissions and residents returning to the facility will be interviewed regarding their oral health and will have an oral assessment completed by licensed nursing staff. The DON or designee will randomly review these assessments weekly for accuracy and completion. These audits will continue for the next 30 days and will be reviewed by the QAPI committee. The QAPI committee will determine if additional audits or education are needed. Although the Immediate Jeopardy was removed on 06/15/23, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #72 revealed an initial admitted on 02/15/21 with readmitted s on 03/30/23 and 05/18/23. Resident #72's medical diagnoses included encephalopathy, severe sepsis with septic shock, respiratory arrest, periapical abscess without sinus, cellulitis and abscess of mouth, encounter for surgical aftercare following surgery on the teeth or oral cavity, and periodontal disease. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 01/03/23, revealed Resident #72 had severely impaired cognition and scored a three out of 15 on the Brief Interview for Mental Status (BIMS) assessment. There were no dental issues noted on the assessment. Review of the Summary Report for dental care, dated from 02/01/22 through 06/14/23, revealed Resident #72 was seen by a dentist on 02/01/22 and 02/09/23. Resident #72 had not been seen by a dentist since 02/09/23. On 02/09/23, Resident #72 was seen for a periodic examination, no x-rays were taken, and there were no complaints. Review of Resident #72's progress notes dated 03/21/23, revealed Resident #72 was seen by Certified Nurse Practitioner (CNP) #215 for altered mental status. Resident #72 had a change in mental status, would not leave his room, was not eating, and displayed garbled speech. CNP #215 ordered for Resident #72 to be sent to the hospital for an evaluation to rule out stroke. Review of the hospital records, dated 03/30/23, revealed Resident #72 was admitted to the hospital on 03/21/23. On 03/24/23, Resident #72 was seen by Infectious Disease (ID) #223 who noted Resident #72 had one positive blood culture identified as Actinomyces (a type of bacteria commonly found in the mouth). Resident #72 was hypothermic with a white blood cell count of 4,000. Vancomycin, Cefepime, and Ampicillin (three different antibiotics) were initiated. ID #223 noted there was a relatively high suspicion for dental source as the cause of the infection based on the Computed Tomography (CT) scan showing periodontal disease and tooth infection. ID #223 ordered for Resident #72 to start penicillin (an antibiotic) for possible Actinomyces bacteremia. On 03/26/23, Resident #72 was seen by Physician #220 who was called by the nurse for worsening encephalopathy and recurrent hypothermia (sudden drop in body temperature). The nurse reported Resident #72's mentation had been worsening all day with increased lethargy (lack of energy) and Resident #72 was now unresponsive and required the [NAME] again (warming blankets that bring heat close to the patient's body to help increase blood flow). An oral and maxillofacial surgery consult note, dated 03/27/23, revealed Resident #72 had overall poor dentition due to neglect. A blood culture was done and showed actinomyces (a type of bacteria usually found in the mouth and/or around teeth) in the face of multiple carious (cavities) teeth. The current hospital medications included Penicillin G Potassium (an antibiotic) 12 million units in sodium chloride 0.9% (normal saline) 500 milliliters (mL) intravenous (IV) every 12 hours. A CT scan of the maxillofacial area with contrast showed dental caries (cavities) and scattered apical lucency/abscess and paranasal sinus disease. A CT scan of the head and neck showed scattered dental caries and periodontal disease/tooth infection. Review of the After Visit Summary (AVS), dated 03/30/23, stated Handoff to Primary Care Physician (PCP), PCP to address the following: dental visit as soon as possible (ASAP) to remove remaining teeth. Resident #72 was to receive oral Augmentin (an antibiotic) through 04/05/23. The AVS noted Resident #72 had a positive blood culture, was hypothermic with a temperature of 93 degrees Fahrenheit (F), leukopenia with white blood cells of 3,000 on admission, and acute encephalopathy. A urinalysis (UA) was done and was without signs of infection. Resident #72 was to see an outpatient dentist ASAP for removal of remaining teeth. Infectious Disease was following, and Resident #72 received intravenous (IV) Penicillin G while hospitalized then transitioned to Augmentin on discharge with a stop date of 04/05/23. Review of the physician orders dated March 2023 revealed Resident #72 had an order for Augmentin oral tablet 875-125 milligrams (mg), give one tablet by mouth two times a day for six days for urinary tract infection. The order had a start date of 03/30/23 and an end date of 04/05/23. Review of Resident #72's physician orders from 03/30/23 through 05/12/23 revealed there were no orders for Resident #72 to have a tooth extraction completed. Review of Resident #72's progress notes dated 03/30/23 at 3:53 P.M., revealed Resident #72 returned from the hospital by ambulance. Resident #72's vital signs were within normal limits. Resident #72 had no signs or symptoms of pain or distress. The physician and family were made aware of the resident's return. Review of Resident #72's progress notes dated 04/01/23 at 6:57 A.M, revealed Resident #72 was noted to be on antibiotics for a urinary tract infection (UTI). Review of Resident #72's progress notes dated 04/04/23, revealed Resident #72 was seen by CNP #215 as a follow up for Resident #72's muscle weakness and recent altered mental status. There was no indication that Resident #72 was on antibiotics or that Resident #72 was treated for sepsis due to abscessed teeth and had an order to follow-up with a dentist as soon as possible to have teeth extracted. Review of Resident #72's progress notes dated 04/05/23, revealed Resident #72 was seen by Physician #218 for a regular visit and follow-up on blood pressure. There was no indication that Resident #72 was on antibiotics or that Resident #72 was treated for sepsis due to abscessed teeth and had an order to follow-up with a dentist as soon as possible to have teeth extracted. Review of Resident #72's progress notes dated 04/05/23 at 1:22 P.M., revealed Resident #72 was reviewed for readmission by Registered Nurse (RN) #250 to the facility on [DATE]. Resident #72 was noted to have readmitted to the facility on [DATE] status post (s/p) sepsis and continued on antibiotics through 04/05/23 for a UTI. Review of the care plan for Resident #72, revised 05/03/23, revealed Resident #72 needed ancillary services such as dental. Interventions included to coordinate with Social Services for scheduling of Resident #72's need to see in-house specialty physicians, educate Resident #72 to communicate the need for an appointment with nursing and social services in order to be set-up as needed, notify the specialty physician and responsible party of any changes or concerns regarding appointments, obtain consent from Resident #72 and/or responsible party prior to consulting the in-house specialty physician, and review progress notes from specialist and communicate with Primary Care Physician (PCP) any recommendations/changes to medication or treatment plan. Review of the dental note, dated 05/08/23, revealed Resident #72 was seen by a dental hygienist only and was not seen by a dentist. The dental hygienist looked in Resident #72's mouth but Resident #72 was not cooperative outside of that. No prophylaxis was completed however oral hygiene instructions were provided. Review of Resident #72's progress notes dated 05/10/23 at 2:07 P.M., revealed Resident #72 was noted to have been seen by the dentist on 05/08/23. Review of Resident #72's progress notes dated 05/12/23, revealed Resident #72 was seen by CNP #215 due to Resident #72 having no urine output for 24 hours. Staff were unable to straight catheterize Resident #72 for urine. Resident #72's abdomen was firm and distended. Resident #72 was sent to the hospital for further evaluation and was admitted to the hospital. Review of the hospital records, dated 05/12/23, revealed Resident #72 was admitted to the Medical Intensive Care Unit (MICU) on 05/12/23 at 3:15 P.M. Physician #227 saw Resident #72 on 05/12/23 at 8:14 P.M. in the MICU due to confusional episodes, significant hypothermia, leukopenia, and subsequent hypotension. Resident #72 was treated with a low dose of norepinephrine (a medication to increase alertness, arousal, and attention). Physician #227 agreed to continue intravenous Vancomycin and Zosyn (antibiotics) to treat septic shock. Review of the hospital records dated 05/14/23 at 3:23 P.M., revealed Resident #72 was seen by Dentist (DDS) #225 in the hospital. Resident #72 had generalized poor dentition with multiple decayed and abscessed teeth. A CT scan revealed multiple decayed teeth with periapical abscesses present. The plan was to send Resident #72 to the operating room on 05/15/23 for extraction of the multiple decayed and abscessed teeth that were a potential source of the sepsis. Review of the hospital records dated 05/15/23 at 5:24 A.M., revealed Resident #72 was seen by Physician #231 in the MICU for septic shock, acute on chronic encephalopathy, and actinomyces bacteremia. Resident #72 was treated for septic shock presumptively from a dental source as Resident #72 previously grew actinomyces and had a very similar presentation. Resident #72 needed extensive dental extractions to minimize the source of infection. Physician #231 noted Resident #72 needed a minimum of six months of antibiotic therapy in Physician #231's opinion. Review of the hospital records dated 05/15/23 at 7:07 A.M., revealed Resident #72 was seen by CNP #234 in the hospital who noted Resident #72 was treated for septic shock which was suspected to be secondary to oral abscesses. A urine culture on 05/12/23 was negative. A CT scan completed on 05/13/23 showed several large dental caries (cavities), several periapical teeth lucencies which were suspicious for odontogenic abscesses, and soft tissue swelling at the base of the tongue. At prior hospitalization , Oral and Maxillofacial Surgery (OMFS) recommended follow up with an outpatient dentist ASAP for removal of remaining teeth. Resident #72 did not follow up for dental extractions. Review of the hospital records dated 05/15/23 at 7:36 P.M., revealed during Resident #72's hospitalization , Resident #72 underwent a surgical procedure to extract multiple abscessed teeth by DDS #225. Review of the hospital records dated 05/18/23, revealed Resident #72 was discharged from the hospital back to the facility. Review of Resident #72's progress notes dated 05/19/23 at 1:13 P.M., revealed Resident #72 was reviewed by LPN #137 for readmission to the facility on [DATE] following extraction of an infected tooth and encephalopathy. Resident #72 was prescribed Amoxicillin (an antibiotic) 500 mg every eight hours for ten days for s/p tooth extraction. Review of the quarterly MDS 3.0 assessment, dated 05/21/23, revealed Resident #72 had severely impaired cognition and scored a 99 on the BIMS assessment signifying the resident was unable to complete the assessment. Resident #72 required extensive assistance from one to two staff to complete ADLs. Resident #72 was noted to have mouth or facial pain, discomfort, or difficulty with chewing. Interview on 06/14/23 at 11:19 A.M. with RDON #235 confirmed Resident #72 had not been seen by a dentist since 02/09/23. RDON #235 stated the facility received two AVS's from Resident #72's hospitalization in March 2023 and only one of them indicated the need for Resident #72 to follow up with a dentist. RDON #235 confirmed Resident #72's discharge summary showed the need for Resident #72 to follow-up with a dentist ASAP for tooth extractions and had been received by the facility. RDON #235 stated they used the AVS and did not usually review the entire discharge summary. Interview on 06/20/23 at 3:55 P.M. with LPN #121 revealed as part of the admission process, nurses review the hospital after visit summary and discharge summary for follow up needs. The nurses are supposed to look at what appointments have been made or need to be made and enter that information into the electronic medical record as well as fill out a transportation request form for the transport to the appointments. Interview on 06/21/23 at 1:41 P.M. with Social Worker (SW) #146 and Corporate Director of Social Services (CDSS) #280 revealed the social worker is responsible for scheduling routine follow up visits with the contracted dental provider. SW #146 stated she was not aware Resident #72 needed any dental follow up after his hospitalization in March 2023. SW #146 stated the contracted dental provider rotates every three to six months between a hygienist visit and a dentist visit. Resident #72 was seen by a dentist in February 2023 and then by a hygienist in May 2023. SW #146 stated the nursing staff was responsible for scheduling outside dental appointments and if a tooth extraction was needed, Resident #72 would need to be sent out to an outside dentist for treatment. The contracted dentist had not been back to the facility since May 2023. If a resident needed treatment in between the regular routine visits, then the resident would need to be scheduled for an outside dentist appointment and nursing would be responsible for making those arrangements. Review of the facility policy titled Dental Services, dated 11/15/17, revealed the policy stated, the purpose of this policy is to ensure the Center assists patients/residents in obtaining routine and 24-hour emergency dental care. It is the responsibility of the clinical team to monitor, assess and recommend interventions to maintain the highest practicable dental care for all patients/residents. Upon admission or during a patient/resident's stay if it is determined a patient/resident is in need of routine and/or emergency dental care the Center will have available a means to provide routine and/or emergency dental care.

Based on review of the medical record, interviews with facility staff, interview with a family member, interview with the physician, review of local law enforcement documents, review of the facility's definition of assistance with dining and review of the facility policy on mechanically altered diets, the facility failed to provide adequate supervision for one resident (#01) with [DIAGNOSES REDACTED]. This resulted in Immediate Jeopardy and serious life-threatening consequences when Resident #01 was left unsupervised in his room while eating dinner and died . The facility identified 16 of 89 residents with a dysphagia [DIAGNOSES REDACTED]. On [DATE] at 5:20 P.M., the facility Administrator, Director of Nursing (DON), Corporate Administrator #111, Corporate Nurse #110, Corporate Rehabilitation Director #112 and Facility Owner #113 were notified Immediate Jeopardy began on [DATE] at 5:39 P.M. when Resident #01, who had [DIAGNOSES REDACTED]. On [DATE] at 6:30 P.M., the resident was found unresponsive in bed. Cardiopulmonary resuscitation (CPR) was initiated and Emergency Medical Service (EMS) was called. Resident #01 was pronounced dead by EMS personnel at 6:53 P.M. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE], Resident #01 expired. · On [DATE], the DON/designee identified other residents at potential risk for choking and reviewed the medical records of all 16 current residents (#05, #12, #17, #19, #25, #41, #42, #48, #56, #58, #74, #77, #78, #80, #81 and #90) with a [DIAGNOSES REDACTED]. · On [DATE], the DON/designee reviewed and updated the care plans of the 16 residents identified with dysphagia and receiving mechanically altered diets to reflect the level of assistance required with meals and swallowing precautions. · On [DATE], the DON and Registered Dietitian (RD) #120 reviewed all residents' physician prescribed diet orders to ensure diet delivery was consistent with ordered texture. · All staff will be educated in person or via phone by [DATE] by the DON or Therapy Director #121 on supervision of residents with meals. As needed staff (PRN), and staff on leave for Family Medical Leave Act (FMLA) or on vacation will be educated upon first day of return to work. · All new diet upgrades by Speech Therapy (ST) will immediately receive a physician order for [REDACTED]. · Any diet changes by ST will be communicated on a physician order and communicated to the nursing staff per the facility communication form. · Beginning on [DATE], the RD/Dietary Manager will audit trays of mechanically altered diets for accuracy every meal time for seven days and then daily random audits times for four weeks. All diet orders will be audited daily times three weeks for upgrades per the DON/designee to assure appropriate orders are in place, then weekly, times four weeks. All residents with a diet upgrade will be observed for meal supervision daily, times three weeks, then weekly, times four weeks. All 16 residents identified as at risk for potential choking will be audited every meal for appropriate level of assistance by the facility team managers for seven days and then daily random audits, times four weeks. Any discrepancies will be reported to the Quality Assurance (QA) committee. · On [DATE] and [DATE], observations of meals, which included mechanically altered diets, verified the resident's supervision during meals was provided according to the residents' assessments and care plans. · On [DATE], medical record reviews for two additional residents (#80 and #81), identified with a [DIAGNOSES REDACTED]. · On [DATE] from 4:10 P.M. to 4:20 P.M., interviews with Licensed Practical Nurse (LPN) #122, State tested Nursing Aide (STNA) #108 and STNA #123 revealed knowledge of proper procedures for resident supervision during meals and were aware of the residents at risk for choking and required supervision. Although the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at Severity Level 2 (the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective actions and monitoring for effectiveness and on-going compliance. Findings include: Review of the medical record for Resident #01 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The resident was a full code status. Review of the hospital [MEDICATION NAME] swallow evaluation (a special x-ray that allows the radiologist and Speech Language Pathologist to identify swallowing problems), dated [DATE] and prior to admission to the facility, revealed a recommendation of mechanical soft diet with ground meat, honey thickened liquids. It also recommended 100 percent supervision. Review of the physician's orders, dated [DATE], revealed Resident #01 was placed on a regular diet, mechanical soft texture, with honey thickened liquid consistency. On [DATE], Resident #01 was down-graded to a pureed texture, honey thickened liquid consistency due to poor intake. Review of the care plan, dated [DATE], revealed Resident #01 was at nutritional risk related to end stage MS, mechanically altered diet texture and honey thickened liquids as well as a history of significant weight loss. Interventions included to assist the resident with tray set up and/or meals as needed, observe for/document/report to physician for signs and symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, or appears concerned during meals. Provide the diet per physician order and monitor effectiveness, provide recommendations to physician as needed such as honey thickened liquids between meals. Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #01 had moderate cognitive impairment. His functional status for eating was listed as supervision with one-person physical assistance. Review of the dietary note, dated [DATE], revealed Resident #01 was to continue a pureed diet with honey thickened liquids. He had been eating meals with supervision to limited assistance from staff and consuming ,[DATE] percent of most meals. Review of the physician's orders, dated [DATE], revealed effective [DATE], Rehabilitation Speech Language Pathologist (SLP) Recertification would continue with the SLP plan of care, which may include: dysphagia treatment, oral/laryngeal exercises, compensatory safe swallow techniques, diet analysis/modification, and caregiver education three to five times a week times two weeks. Review of the physician's note, dated [DATE], revealed Resident #01 was severely debilitated from the disease (MS). It also revealed Resident #01 complained about the consistency of his meals. The resident wanted to eat regular food. The physician's note revealed the resident failed his modified [MEDICATION NAME] swallow test in (MONTH) of last year and was working with speech therapy in the facility. Review of Speech Therapist (ST) #200's notes, dated [DATE] to [DATE], revealed Resident #01 had short-term and long-term goals. The short-term goals included the resident will complete lingual strength therapy exercises at the level of mild impairment to improve safety with intake and decrease a risk of aspiration. The resident will complete pharyngeal strength therapy exercises with mild verbal cues to increase his safety with intake and decrease the risk of aspiration. The staff will demonstrate 100% competency with diet recommendations and swallow strategies including positioning to increase safety and decrease risk of aspiration/choking. The resident will demonstrate carryover of strategies including upright position, slow rate, double swallow, chin tuck with 80% accuracy to increase his safety with intake and decrease the risk of aspiration and/or choking. The long-term goal was the resident will improve his swallow abilities to moderate as evidenced by the ability to safely and efficiently swallow the least restrictive diet with minimal to absent signs and symptoms of oral dysphagia, coughing and/or wet vocal quality post swallows to decrease the risk of laryngeal penetration/aspiration, decrease the signs of oral/pharyngeal dysphagia, safely consume the least restrictive diet and meet his primary nutrition/hydration needs. Review of the speech therapy notes, dated [DATE], revealed the resident was seen in a wheelchair in the dining area. The resident presented with a therapeutic trial of a banana. He required moderate cues for bolus and rate modification secondary to his impulsivity. He had adequate management of bolus via swallowing compensatory strategies. No overt signs or symptoms of penetration/aspiration noted. The therapist instructed the resident in use of increased time between swallows to facilitate pharyngeal clearance, training in hard throat clear re-swallow to facilitate clearance and decrease signs of penetration, training in utilization of double swallow to facilitate pharyngeal clearance, and analysis of type/amount of cueing to complete a task. Review of the speech therapy notes, dated [DATE], revealed the resident was seen with a therapeutic trial of mechanical soft trial tray. The resident was positioned upright and required minimal to no cues to reduce bolus size and required no cues for reduced rate. The resident demonstrated adequate mastication, though mildly prolonged, and functional bolus formation and transport. No overt signs of aspiration or penetration. SLP #200 recommended to upgrade the resident's diet to a mechanical soft texture with ground meats, pureed fruits, and no bread. Review of the physician orders, dated [DATE], revealed the resident's diet was upgraded to a mechanical soft with ground meat texture, honey thickened liquid consistency, no bread and pureed fruit. There were no swallowing precautions or type of supervision required noted on the physician orders or on the resident's care plan on this date. Review of the speech therapy notes, dated [DATE], revealed the resident was supervised with a mechanical soft lunch meal. The resident was positioned generally upright and required minimal cues to position self completely upright to a 90-degree hip flexion for increased safety. The resident had a carryover of strategies with 80 percent accuracy, requiring minimal to occasional cues to reduce the bolus size. No overt signs and symptoms of aspiration or penetration. Review of the diet menu Resident #01 filled out, dated [DATE], revealed he requested lasagna with a bread stick and pudding for his dinner meal. Review of the dietary therapeutic spreadsheet, dated [DATE], revealed the regular lasagna was appropriate for a mechanical soft diet. Review of the nursing progress note, dated [DATE] at 9:38 P.M., revealed Resident #01's dinner tray was delivered at approximately 6:00 P.M. The resident was sitting upright. STNA #50 assisted the resident with cutting up his food. Resident #01 denied any need for further assistance. When STNA #50 returned to pick up the dinner tray, Resident #01 was found unresponsive. LPN #77 was immediately made aware and responded at the resident's bedside. Resident #01 was found absence of pulse and respirations. The resident was immediately lowered to the floor and CPR was initiated. The facility Administrator was present and called the EMS. Code blue was called overhead, and the EMS arrived at the resident's room at 6:40 P.M. and took over CPR. The rescue efforts continued until 6:53 P.M. at which time, death was declared. Review of Dietary Staff #150's written statement, dated [DATE], revealed she was making the tray for Resident #01 for the dinner meal at approximately 5:15 P.M. Resident #01 had been upgraded from a pureed to a mechanical soft texture on [DATE]. Resident #01 had picked lasagna and bread stick for his dinner, but his ticket said no bread, so he received the lasagna and not the breadstick. Review of the police detective report notes, dated [DATE], revealed the detective went to the coroner's office and spoke to the Pathologist who performed the autopsy on Resident #01. He revealed he found a full blockage in Resident #01's trachea. He also revealed the contents in the resident's stomach was photographed and showed pasta noodles. Review of the police report, for the EMS note, dated [DATE], revealed the lead medic was unable to determine if Resident #01's airway was obstructed. Review of the facility's video camera footage on [DATE] at 5:45 P.M. with Information Technologist #121 and Facility Owner #113 revealed on [DATE] at 5:33 P.M., the 400 Hall meal cart arrived on the hall and was parked on the same side of the hall of Resident #01's room. Resident #01's room was located one to two rooms from the food cart. Due to the meal cart, the video coverage from both angles does not allow you to see Resident #01's room directly. The trays get passed immediately. A blonde STNA, identified by the facility as STNA #50, went into the resident's room at 5:37 P.M. and left the room at 5:39 P.M. At 5:42 P.M., all trays were passed on the 400 Hall. At 5:50 P.M., the trays begin being put back into the cart. At 5:57 P.M., 5:59 P.M., 6:00 P.M. and 6:08 P.M. staff put trays into the 400 Hall cart. At 6:21 P.M., the Administrator was walking in the hallway. Throughout the entire video, you see staff walk through the hallway. No staff appear to stop by Resident #01's door or go into his room. At 6:30 P.M., STNA #50 walks into Resident 01's room and immediately runs back out of room. At 6:31 P.M. and 6:32 P.M., multiple staff are observed running in and out of the resident's room. The crash cart arrived at 6:32 P.M. and at 6:41 P.M., EMS arrived on the hallway and went to the resident's room. Interview with the STNA #50 on [DATE] at 12:15 P.M. revealed when she brought the dinner tray into Resident #01's room at approximately 6:10 P.M. (note: this time is different than the video camera footage) he was on his lap top. She revealed she laid the tray on the bedside table and sat the resident in an upright position (90-degree angle), pulled his bedside table over his lap and removed the lid of the dinner plate. She also stated she explained to Resident #01 what was on his dinner tray. She stated he had pureed fruit, a regular texture piece of lasagna, and two glasses of thickened liquids. She stated she cut up the resident's lasagna into small pieces as the therapist had told her to do. She stated she placed the bed controller and call light in the resident's lap and reminded him to take his time eating. She revealed the therapist did not tell her to stay and watch the resident, she told her to just to tell him to go slow and cut up his meal. She stated she picked up Resident #01's tray at approximately 6:30 P.M. and noticed he was still in an upright position but leaning toward the window. He was unresponsive and pale. She stated she immediately went and got LPN #77 and the crash cart and called the receptionist to page Code Blue. STNA #50 stated when she took away Resident #01's tray, there was a little spot of what looked like vomit on the tray. It was reddish in color. She stated the call light was laying on his lap, but not activated, when she removed the tray. From there, everything happened in a matter of seconds with the nurse doing CPR. Subsequent interview with STNA #50 on [DATE] at 10:43 A.M. revealed the resident ate about 40% of his lasagna, 90% of his fluids and 0% fruit for his dinner meal on [DATE]. Interview with ST #200 on [DATE] at 12:22 P.M. revealed she was the therapist working with Resident #01 on his swallowing. She revealed her evaluation was to upgrade the resident's diet to a mechanical soft with ground meat texture, no bread and pureed fruit. She revealed she had been working with Resident #01 for approximately six weeks total to help with his swallowing and strategies to use, which was to go slow, small bites and swallow twice. She also revealed, over the course of the six weeks, she had been trialing a mechanical soft diet. She revealed she would bring him trays with different items to see how he was doing. ST #200 also revealed Resident #01 always ate his meals in his room and could feed himself. She stated when she upgraded his diet, she spoke with STNA #50 about setting him up and making sure he was taking small bites and going slow. She revealed part of what she was working on was making the resident more independent by using the strategies. ST #200 revealed Resident #01's carryover of slow rate and small bites was 80 percent. She considered that as doing well. During a subsequent interview with ST #200 on [DATE] at 8:26 A.M. she stated she only educated STNA #50 and a clinical nurse regarding the resident's swallowing precautions. She verified she did not write a physician order for [REDACTED]. The ST stated the resident was not due for another [MEDICATION NAME] swallow test because it would not show much change since it was just completed in ,[DATE]. Interview with the resident's Physician #300 on [DATE] at 9:55 A.M. revealed Resident #01 was cognitively aware of his surroundings and the resident wished for his diet to be changed to a regular texture. The physician explained to the resident that this was unsafe for him to be on a regular texture due to the resident failing his [MEDICATION NAME] swallow in ,[DATE] and he educated him on the risks of choking. The physician revealed Resident #01 was fixated on his diet. The physician verified the resident had [DIAGNOSES REDACTED]. He said he thought Resident #01 was being supervised during his meals, but he said he would rely on the ST to provide the swallowing precautions and supervision level. Interview with Resident #01's daughter on [DATE] at 4:15 P.M. revealed the coroner's report showed large pieces of cheese and noodles blocking his trachea. The daughter revealed the facility had a history of [REDACTED]. She stated she was told by the facility staff, the night of her father's death, he was left alone for approximately one hour before being discovered unresponsive. Interview with LPN #77 on [DATE] at 5:15 P.M. revealed Resident #01 was sitting upright when she entered his room. The tray was in front of him and looked like lasagna on his tray, but nothing was found in his mouth. LPN #77 revealed another nurse (Registered Nurse (RN) #80) started compressions and she took over. She also revealed during CPR compressions nothing was coming out of the resident's mouth or airway. LPN #77 revealed she was not aware of the resident's diet change or of swallowing precautions. She revealed Resident #01's treatment record did not show signs of needing supervision and any swallowing precautions. Interview with Dietitian #120 on [DATE] at 10:36 A.M. revealed she would expect a resident with dysphagia and end stage MS, on a mechanical soft diet, to have supervision when eating. An attempt to interview RN #80 and the pathologist at the coroner's office during the survey was unsuccessful. The coroner's office explained they will only speak to the next of kin. Review of the facility's form for definitions of assistance with dining, undated, revealed the definition for supervision or set up was the resident was able to self-feed with supervision (requires stand-by assistance, verbal cueing or encouragement with no assist) or set-up (e.g. another person must apply the orthosis, open containers, cut up the meat, butter the bread, etc.) The definition of minimal assistance is when the resident's tray is set up, the utensils placed in the hand and the resident is assisted to eat using light physical assistance. This process will be repeated throughout the meal. The resident expends 75% or more of the effort to self-feed. Review of the facility's undated policy on mechanically altered diets revealed mechanically altered diets shall be prepared and served as prescribed by the physician. Mechanically altered diets include that all residents with physician orders for a mechanical soft diet shall receive foods or nearly regular textures with the exception of very hard, sticky or crunchy foods. Food still needs to be moist and should be in bite-size pieces. The tray ticket system and care plan shall be maintained to be a current reflection of the status of each resident. This deficiency substantiates Complaint Number OH 656 and OH 660.

Based on medical record review, observation, staff interview, hospice staff interview, policy review, and information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to timely assess and treat a pressure ulcer for Resident #31. This resulted in actual harm when Resident #31 developed an unstageable pressure ulcer to the coccyx (slough and/or eschar known but not stageable due to coverage of wound bed by slough and/or eschar) that was not previously identified by facility staff. This affected one (#31) of three residents reviewed with pressure ulcers. The facility identified 12 residents with pressure ulcers. The facility census was 101. Findings include: Review of the medical record revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Review of the care plan, initiated 04/15/16, revealed Resident #31 was at risk for pressure related skin alterations due to impaired mobility, fragile skin, disease process, and incontinence. Interventions included to check and change every two hours as needed, weekly visual skin checks, and assist to turn and reposition in bed. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/10/18, revealed the resident had cognitive impairment, the resident had no rejection of care, and had no unhealed pressure ulcers. Further review revealed the resident was dependent on staff for toileting, always incontinent of bowel and bladder and required extensive assistance of two staff with bed mobility. Review of the Braden assessment, dated 06/18/18, revealed a score of 12 indicating the resident was at a high risk for developing a pressure ulcer. The assessment revealed the resident's ability to respond meaningful to pressure-related discomfort was slightly limited, was occasionally moist, was bedfast, was completely immobile, probably had inadequate nutrition, and friction/shear was a potential problem. Review of hospice aide note, dated 06/29/18, revealed Hospice Aide (HA) #220 identified an area on Resident #31's coccyx that was not open. She documented she reported the skin concerns to the (unidentified) facility nurse. The note, dated 07/02/18, revealed HA #220 noted a small open area on the coccyx that was slightly open. She reported skin concerns to the (unidentified) facility nurse. The note, dated 07/06/18, revealed HA #220 noted an area on the coccyx that was slightly open. The note, dated 07/10/18, revealed HA #220 noted an area on the coccyx that was slightly open. She notified the (unidentified) facility nurse. Review of note, dated 07/11/18, revealed HA #220 noted an area on the coccyx that was slightly open. Review of hospice aide note, dated 07/16/18, revealed a different hospice aide, HA #230, noted a sore on Resident #31's coccyx that was open. Review of hospice nursing progress notes, dated 07/19/18, revealed Hospice Registered Nurse (RN) #120 collaborated with the facility unit manager in regards to the coccyx. The unit manager stated it was better and cream was still being applied with each incontinent episode. Review of bowel continence report revealed Resident #31 had an incontinent bowel movement on 07/19/18 at 9:54 P.M. and required hands on assistance by State tested Nurse Aide (STNA) #200. Review of a written statement by STNA #200, dated 07/20/18, revealed on 07/19/18 was the first time she cared for Resident #31 in a week or two besides when she had orientation. Further review of the statement revealed the night before when she helped the nurse with the skin assessment on her first round, was the first time she saw any skin issues on her coccyx. Review of the physician orders [REDACTED]. review of the resident's medical record revealed [REDACTED]. Review of progress note, dated 07/20/18, revealed the nurse was completing a skin assessment that morning around 4:00 A.M. when she noted an area to the coccyx. A treatment was implemented, hospice and the responsible party were made aware immediately. The area measured two centimeters (cm.) length by two cm. in width and had 25 percent eschar (black/brown). Review of skin assessment, dated, 07/20/18, revealed an unstageable pressure ulcer to the coccyx measuring two cm. in length by two cm. in width. The pressure ulcer was identified on 07/20/18. The wound was described to have a scant amount of thin red serosanguineous drainage with no odor. The wound bed had devitalized (yellow, slough, stringy) tissue and eschar. Surrounding tissue edges were [MEDICAL CONDITION] and discolored. Observation on 07/26/18 at 3:50 P.M. of Resident #31's wound revealed an unstageable pressure ulcer on her coccyx. LPN #300 measured the wound as four cm. in length by six cm. in width. The wound bed had black eschar in the center with pale pink tissue around the edges. The peri-wound was pink and blanchable. Resident #31 was cooperative with care and allowed the staff to turn and reposition her. Interview on 07/26/18 at 4:00 P.M. with the Director of Nursing revealed she was informed of Resident #31's open wound on 07/20/18. Upon assessment of the wound, she noted an unstageable pressure ulcer on the coccyx with black eschar. Further interview revealed she was unaware of the hospice aides documenting the resident had noted skin concerns since 06/29/18 and was unaware the facility had a hospice-facility communication book and was unaware where the hospice nurse/aides were documenting. Interview on 07/27/18 at 2:00 P.M. via telephone with HA #220 confirmed she found an open area on Resident #31's coccyx during several visits and reported to the nurse at the facility. The HA was unable to recall what nurse she notified. HA #220 stated it was red, open, and bleeding enough to leave blood on her attends. HA #220 said the resident never refused care for her. The HA said there was a communication book, where hospice would document communications to the facility, located behind the nurse station, where she also wrote this information. Interview on 07/27/18 at 2:00 P.M. via telephone with Hospice Registered Nurse (RN) #120 confirmed HA #220 emailed her to report the open areas on Resident #31's coccyx. RN #120 spoke with Clinical Manager #400 in regards to the open area. Clinical Manager #400 asked RN #120 to bring in two tubes of barrier cream for the area of excoriation because it was better than what the facility had. RN #120 brought in two tubes of Calazinc barrier cream on 07/06/18 and gave it to Clinical Manager #400. Review of a facility policy titled Prevention of Pressure Ulcers, revised (MONTH) 2013, revealed the facility should have a system/procedure to assure assessments were timely and appropriate and changes in condition area recognized, evaluated, reported to the practitioner, physician, and family, and addressed. Review of information from the NPUAP, 2014, defined an unstageable pressure ulcer as full thickness tissue loss in which the base of the ulcer was covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar was removed to expose the base of the wound, the true depth, and therefore category/stage, cannot be determined. This deficiency substantiates Complaint Number OH 111. This deficiency is an example of continued non-compliance to the complaint survey completed on 05/15/18.

Based on record review, observation, resident interview and staff interview, and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to ensure a resident received care to prevent the development of a pressure ulcer. This resulted in actual harm when Resident #9 was not turned and repositioned every two hours per his physician's orders [REDACTED]. This affected one (#9) of three residents reviewed for pressure ulcers. The facility identified eight residents who had pressure ulcers and were residing in the facility at the time of the survey. The facility census was 97. Findings include: Record review revealed Resident #9 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's admission Minimum Data Set (MDS) assessment, dated 01/26/18, revealed the resident was cognitively intact and was totally dependent on staff for transfer, toilet use, and locomotion on and off unit. Resident #9 required extensive assistance for bed mobility, and he was always incontinent of both bowel and bladder. The resident had lower impairment on both lower extremities and was admitted with a stage two pressure ulcer with interventions including: pressure reduction device to chair and bed, pressure ulcer care, and nutrition or hydration program. Review of a physician order, dated 01/19/18, revealed Resident #9 was to be turned and repositioned every two hours and as needed. Review of the Pressure Ulcer Assessment, dated 01/19/18 and 03/28/18, revealed Resident #9 was at high risk for developing pressure ulcers. Review of a weekly skin sheet, dated 03/24/18, revealed no documented skin issues for Resident #9. Review of Former Staff Member (FSM) #23 separation form, dated 03/27/18, revealed that on an unspecified date check and changes were not completed, residents were left soiled, and every two hour rounds were not completed on unit B and she was terminated on 03/27/18. Review of a progress note, dated 03/28/18, revealed Resident #9 was observed with a 5.8 centimeter (cm.) long by 8.5 cm. wide eschar area on his right hip. Review of a Certified Nurse Practitioner Wound Progress Note, dated 05/08/18, revealed Resident #9 had a right ischial/thigh wound (hip) that was categorized as a stage four pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) measuring 7.2 cm. in length by 6.2 cm. in width and approximately 3 cm. in depth. The wound was 25 percent slough and 75 percent beefy red. Observation on 05/14/18 at 12:45 P.M. revealed Registered Nurse #24 completing Resident #9 dressing change on his right ischial/ thigh. The wound was cleansed with normal saline and a four by four gauze was soaked with a quarter strength Dakins solution, and packed the wound. Santyl was applied to the wound and it was covered with an [MEDICATION NAME] dressing. The wound was round in shape and the size appeared seven cm. in length by 6 cm. in width and approximately 3 to 4 cm. in depth. Interview with Resident #9 on 05/14/18 at 3:45 P.M. revealed that at the end of March, (YEAR) an aide left him up in his wheelchair from around 11:00 A.M. until about 7:00 P.M. and the aide no longer worked at the facility. He stated he put his call light on once about 5:00 P.M. and the aide said she was busy and she would come back and said they were short of staff. She came back about 7:00 P.M. and put me in bed. He said he does not have any feeling or sensation lower than his diaphragm (lower chest) and can only be up about two hours at a time. He stated he doesn't refuse to lay down or get out of his chair. The resident stated that he has been left up in his chair probably three times for an extended period of time. Interview with Licensed Practical Nurse #21 on 05/15/18 at 11:15 A.M. revealed that Resident #9 was always compliant with care. Interview on 05/15/18 at 12:30 P.M. with Former Staff Member (FSM) #23, revealed she worked at the facility from (MONTH) (YEAR) until 03/27/18. FSM #23 stated the facility fired her on 03/27/18 and said Resident #9 was sitting in his chair all day and that she did not change him. Former Staff Member #23 verified that she worked on 03/23/18 and that she did not reposition Resident #9 from 1:00 P.M. until at 7:00 P.M. when she left work that day. FSM #23 stated that Resident #9 had never refused to be turned for her but that he did not like to get out of bed early. Interview with Licensed Practical Nurse #20 on 05/15/18 at 1:20 P.M. revealed that she has never had any issues with Resident #9 being non-compliant with his care. Review of information from the NPUAP revealed an unstageable pressure ulcer is full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. The NPUAP further instructed to offload the pressure injury and to turn and reposition the individual. This deficiency substantiates Complaint Number OH 954 and OH 726.

Based on record review, physician and staff interviews, the facility failed to ensure effective pain management was provided to a resident. This resulted in actual harm when Resident #4 exhibited severe pain for four days, without documented evidence of effective pain relief. After four days the resident was found with a right femur fracture which required surgical intervention. This affected one (#4) of three residents reviewed for pain management. Facility census was 97. Findings include: Review of the medical record for Resident #4 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of interdisciplinary team note dated 12/06/17 revealed on 12/01/17 Resident #4 had sustained a fall that resulted in a closed fracture of pubic rami and of the left humerus. Review of nurses notes dated 12/07/17 revealed Resident #4 was found on floor in her room with no noted injuries. Review of nurses notes dated 12/10/17 revealed Resident #4 had lowered herself to the floor with no noted injuries. There was no further documentation of any other falls or injuries sustained in the medical record. Review of nurses notes dated 12/19/17 revealed Resident #4 had complained of pain to right knee and physician was made aware and order was obtained for X-ray. Review of nurses notes dated 12/20/17 revealed Resident #4 continued to complain of pain and Doppler order was obtained. Review of nurses notes dated 12/21/17 revealed arterial and venous Doppler studies was negative. There was no documentation in the medical record of any signs or assessment completed revealing resident had any indication of a [MEDICAL CONDITION]. Review of nurses notes dated 12/23/17 revealed X-ray results were received and physician made aware and resident was sent to the hospital. Review of occupational therapy (OT) notes dated 12/19/17 revealed Resident #4 was in her bed screaming out in pain to her right lower extremity. This was discussed with nursing and nursing to address pain but stated there were no reports of fall or any other incidents. Resident #4 was unable to roll side to side in bed. Review of OT note dated 12/20/17 revealed Resident #4 screaming out stating her right lower extremity was in pain and nursing was made aware and was going to medicate her accordingly. Review of physical therapy (PT) notes dated 12/19/17 revealed a state tested nursing assistant reported that Resident #4 was in bed all day due to pain in her right lower extremity and refused lunch. Therapist attempted to change resident and she screamed and did not allow therapist to touch her right lower extremity and reported pain to right knee. Resident #4 screamed most of the therapy session secondary to pain to right lower extremity and therapist did notify the nurse and resident was given pain medication. The nurse also stated they were calling the physician to request an X-ray to right knee. Review of PT note dated 12/20/17 revealed Resident #4 was in bed and was very confused and reported severe pain in her right lower extremity. PT assisted to apply residents pants due to pain and tenderness in right lower extremity. Per the Director of Nursing (DON) the resident is going to receive a Doppler for possible [MEDICAL CONDITION] in right lower extremity. Review of PT note dated 12/21/17 revealed Resident #4 was howling out in pain whenever therapist touched her right lower extremity and nursing reported that her Doppler was negative and advised against resident receiving therapy this date. Review of PT note dated 12/22/17 revealed Resident #4 complained of severe pain to right knee and refused to be touched and screamed out in pain with any attempts to assess pain area or movement of any body parts. Resident #4 refused to put her feet on the floor for transfer and was assisted into bed with dependent lift of three staff as she was screaming out in pain. Resident #4 refused any movement to right lower extremity. Upon PT's second encounter on 12/22/17 Resident #4 was found slumped on bed with left lateral trunk flexion and was assisted to position for normal spinal alignment while complaining of pain. This was discussed with a registered nurse who reported an X-ray of right lower extremity had been ordered. Review of physicians orders dated 12/20/17 revealed to obtain Doppler of right leg for pain. Further review of the physician orders [REDACTED]. Resident had orders for [MEDICATION NAME] every four hours as needed for pain. Review of X-rays revealed a Doppler was performed on 12/20/17 to residents right leg due to pain and was negative. Review of right femur X-ray dated 12/23/17 revealed an acute proximal right femur fracture. Review of December 2017 Medication Administration Record [REDACTED]. There was no documentation on the MAR indicated [REDACTED]. Review of hospital discharge summary note dated 12/27/17 revealed resident had a right [MEDICAL CONDITION] status [REDACTED]. Summary read this fracture is likely new and not related to her fall from earlier this month as X-ray of hip was focused on the left at time of fall but did show right hip as well. Previous X-ray dated 12/01/17 revealed mild [MEDICAL CONDITION] changes of the right hip joint. It is unclear when she fell or caused this injury however a fall had not been noted. Pathological fracture of femur due to combination of diffuse osteopenia and trauma that alone would not have caused this fracture. Interview was conducted on 01/25/18 at 9:30 A.M. with OT #88 and she stated she took care of Resident #4 on 12/19/17 and she had complained of pain in her right leg and did not specify her right knee just pain to right leg. She reported Resident #4 was in so much pain to the point that they could not work with her. She stated they could not even touch Resident #4's right leg. She reported the facility did finally do X-rays. She verified that she did report Resident #4's severe pain to the nurse but could not recall which nurse. Interview was conducted on 01/25/18 at 10:11 A.M. with PT #89 and she stated she seen Resident #4 on 12/19/17 and she had to treat her in bed due to she was in a lot of pain and could not get out of bed. She stated Resident #4's pain was in her right knee and she reported it to the DON who looked at her knee and checked her for [MEDICAL CONDITION]. PT #89 stated Resident #4 was in a lot of pain for two to three days and was very confused. She stated Resident #4's Doppler did come back negative and that she would scream out if you touched her and nursing reported that they were getting an x-ray once her Doppler came back negative which was on 12/21/17. Interview was conducted on 01/25/18 at 11:46 A.M. with Registered Nurse (RN) #60 and he stated it was just brought to his attention this date that he did not document when he gave Resident #4 Tylenol and when he did talk with the physician one day about her pain medication. He stated he was talking to the physician on 12/22/17 about another resident and that he just mentioned to him that Resident #4 was having pain and Tylenol was not effective. RN #60 stated the physician did not want to order her anything stronger due to her confusion. He stated the facility did a Doppler because of her pain to right knee. RN #60 denied Resident #4 had any redness, swelling, or warm to touch and no pain to right calf. He stated he did not recall being told that Resident #4 had severe pain and was crying out during therapy on 12/19/17. Interview was conducted on 01/25/18 at 11:58 A.M. with Licensed Practical Nurse (LPN) #62 and he stated he was Resident #4's nurse on 12/19/17. He stated he did give her Tylenol and was not sure of exact times he gave it because it was not documented on medication administration record. He first stated he did get X-ray order on 12/19/17 and verified he wrote the nurses note on 12/19/17 indicating he made physician aware of pain and x-ray was ordered. Interview was conducted on 01/25/18 at 12:12 P.M. with LPN #62 and he stated the documentation and nurses note that he entered on 12/19/17 must have been a mistake and that he did not get an X-ray order that day because a Doppler was ordered first and then once that was negative they received an order for [REDACTED].#4 was screaming out in pain on 12/19/17. He could not recall exact date when he spoke with physician. Phone interview was conducted on 01/25/18 at 1:46 P.M. with Physician #90 revealed he could not remember the exact day he ordered the X-ray but he knew it was the same day he was notified with the results that the resident had a fracture. Physician #90 stated he would have ordered the X-ray to be done immediately if he would have known she was having pain in the right leg. He stated he did not recall being notified of Resident #4 screaming out in pain and that she needed anything stronger than her Tylenol that was ordered. Physician #90 stated he did not state he would not order her anything for pain because of her confusion. Interview was conducted on 01/25/18 at 2:07 P.M. with the DON and she verified there was a problem with missing documentation in Resident #4's medical record. She stated Resident #4 was being treated for [REDACTED]. She stated Resident #4 received a Doppler because her pain was in her right knee and she did her assessment for a [MEDICAL CONDITION] and verified that was not documented. The DON stated X-ray order was obtained once venous and arterial Doppler was negative; however, the DON verified the nurses notes on 12/19/17 documented the physician was notified of pain and x-ray order obtained. The DON verified Resident #4 first exhibited pain during therapy visit on 12/19/17. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on record review, physician and staff interviews, the facility failed to seek timely treatment from the physician of a resident with continuous severe leg pain for four days. This resulted in actual harm when Resident #4 was found with a right femur fracture which required surgical intervention. This affected one (#4) out of eight residents reviewed for delivery of care and services. Facility census was 97. Findings include: Review of the medical record for Resident #4 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of interdisciplinary team note dated 12/06/17 revealed on 12/01/17 Resident #4 had sustained a fall that resulted in a closed fracture of pubic rami and of the left humerus. Review of nurses notes dated 12/07/17 revealed Resident #4 was found on floor in her room with no noted injuries. Review of nurses notes dated 12/10/17 revealed Resident #4 had lowered herself to the floor with no noted injuries. There was no further documentation of any other falls or injuries sustained in the medical record. Review of nurses notes dated 12/19/17 revealed Resident #4 had complained of pain to right knee and physician was made aware and order was obtained for X-ray. Review of nurses notes dated 12/20/17 revealed Resident #4 continued to complain of pain and Doppler order was obtained. Review of nurses notes dated 12/21/17 revealed arterial and venous Doppler studies was negative. There was no documentation in the medical record of any signs or assessment completed revealing the resident had any indication of a [MEDICAL CONDITION]. Review of nurses notes dated 12/23/17 revealed X-ray results were received and physician made aware and resident was sent to the hospital. Review of occupational therapy (OT) notes dated 12/19/17 revealed Resident #4 was in her bed screaming out in pain to her right lower extremity. This was discussed with nursing and nursing to address pain but stated there were no reports of fall or any other incidents. Resident #4 was unable to roll side to side in bed. Review of an OT note dated 12/20/17 revealed Resident #4 screaming out stating her right lower extremity was in pain and nursing was made aware and was going to medicate her accordingly. Review of physical therapy (PT) notes dated 12/19/17 revealed a state tested nursing assistant reported that Resident #4 was in bed all day due to pain in her right lower extremity and refused lunch. Therapist attempted to change resident and she screamed and did not allow therapist to touch her right lower extremity and reported pain to right knee. Resident #4 screamed most of the therapy session secondary to pain to right lower extremity and therapist did notify the nurse and resident was given pain medication. The nurse also stated they were calling the physician to request an X-ray to right knee. Review of PT note dated 12/20/17 revealed Resident #4 was in bed and was very confused and reported severe pain in her right lower extremity. PT assisted to apply residents pants due to pain and tenderness in right lower extremity. Per the Director of Nursing (DON) resident is going to receive a Doppler for possible [MEDICAL CONDITION] in right lower extremity. Review of the PT note dated 12/21/17 revealed Resident #4 was howling out in pain whenever therapist touched her right lower extremity and nursing reported that her Doppler was negative and advised against resident receiving therapy this date. Review of PT note dated 12/22/17 revealed Resident #4 complained of severe pain to right knee and refused to be touched and screamed out in pain with any attempts to assess pain area or movement of any body parts. Resident #4 refused to put her feet on the floor for transfer and was assisted into bed with dependent lift of three staff as she was screaming out in pain. Resident #4 refused any movement to right lower extremity. Upon PT's second encounter on 12/22/17 Resident #4 was found slumped on bed with left lateral trunk flexion and was assisted to position for normal spinal alignment while complaining of pain. This was discussed with a registered nurse who reported an X-ray of right lower extremity had been ordered. Review of physicians orders dated 12/20/17 revealed to obtain Doppler of right leg for pain; however, there was no order for an X-ray. Further review of the physician orders [REDACTED]. Review of X-rays revealed a Doppler was performed on 12/20/17 to residents right leg due to pain and was negative. Review of right femur X-ray revealed date of service of X-ray was dated 12/23/17 and revealed an acute proximal right femur fracture. Review of hospital discharge summary note dated 12/27/17 revealed resident had a right [MEDICAL CONDITION] status [REDACTED]. Summary read this fracture is likely new and not related to her fall from earlier this month as X-ray of hip was focused on the left at time of fall but did show right hip as well. Previous X-ray dated 12/01/17 revealed mild [MEDICAL CONDITION] changes of the right hip joint. It is unclear when she fell or caused this injury however a fall had not been noted. Pathological fracture of femur due to combination of diffuse osteopenia and trauma that alone would not have caused this fracture. Interview was conducted on 01/25/18 at 9:30 A.M. with OT #88 and she stated she took care of Resident #4 on 12/19/17 and she had complained of pain in her right leg and did not specify her right knee just pain to right leg. She reported Resident #4 was in so much pain to the point that they could not work with her. She stated they could not even touch Resident #4's right leg. She reported the facility did finally do X-rays. She verified that she did report Resident #4's severe pain to the nurse but could not recall which nurse. Interview was conducted on 01/25/18 at 10:11 A.M. with PT #89 and she stated she seen Resident #4 on 12/19/17 and she had to treat her in bed due to she was in a lot of pain and could not get out of bed. She stated Resident #4's pain was in her right knee and she reported it to the Director of Nursing (DON) who looked at her knee and checked her for [MEDICAL CONDITION]. PT #89 stated Resident #4 was in a lot of pain for two to three days and was very confused. She stated Resident #4's Doppler did come back negative and that she would scream out if you touched her and nursing reported that they were getting an x-ray once her Doppler came back negative which was on 12/21/17. Interview was conducted on 01/25/18 at 11:46 A.M. with Registered Nurse (RN) #60 and he stated it was just brought to his attention this date that he did not document when he gave Resident #4 Tylenol and when he did talk with the physician one day about her pain medication. He stated he was talking to the physician on 12/22/17 about another resident and that he just mentioned to him that Resident #4 was having pain and Tylenol was not effective and he did not want to order her anything stronger due to her confusion. He stated the facility did a Doppler because of her pain to right knee. He denied Resident #4 had any redness, swelling, or warm to touch and no pain to right calf. He stated he did not recall being told that Resident #4 had severe pain and was crying out during therapy on 12/19/17. Interview was conducted on 01/25/18 at 11:58 A.M. with Licensed Practical Nurse (LPN) #62 and he stated he was Resident #4's nurse on 12/19/17. He stated he did give her Tylenol and was not sure of exact times he gave it because it was not documented on medication administration record. He first stated he did get X-ray order on 12/19/17 and verified he wrote the nurses note on 12/19/17 indicating he made physician aware of pain and x-ray was ordered. Interview was conducted on 01/25/18 at 12:12 P.M. with LPN #62 and he stated the documentation and nurses note that he entered on 12/19/17 must have been a mistake and that he did not get an X-ray order that day because a Doppler was ordered first and then once the Doppler was negative they received an order for [REDACTED].#62 stated he did not know why X-ray was not done till 12/23/17. LPN #62 denied being told that Resident #4 was screaming out in pain on 12/19/17. He could not recall exact date when he spoke with physician. Phone interview was conducted on 01/25/18 at 1:46 P.M. with Physician #90 revealed he could not remember the exact day he ordered the X-ray but he knew it was the same day he was notified with the results that the resident had a fracture. Physician #90 stated he would have ordered the X-ray to be done immediately if he would have known she was having pain in the right leg. He stated he did not recall being notified of Resident #4 screaming out in pain and that she needed anything stronger than her Tylenol that was ordered. Physician #90 stated he did not state he would not order her anything for pain because of her confusion. Interview was conducted on 01/25/18 at 2:07 P.M. with the DON and she verified there was a problem with missing documentation in Resident #4's medical record. She stated Resident #4 was being treated for [REDACTED]. The DON stated Resident #4 received a Doppler because her pain was in her right knee and she did her assessment for a [MEDICAL CONDITION]; however, verified that was not documented. She stated the X-ray order was obtained once venous and arterial Doppler was negative and that the nurses documentation on 12/19/17 that the physician was notified of pain and x-ray order obtained was written in error. The DON verified Resident #4 first exhibited pain during therapy visit on 12/19/17. This deficiency substantiates Complaint Number OH 785.