Every finding on record at Shaker Gardens Nursing and Rehabilitation Center

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on closed medical record review, interviews, local police report review, hospital record review, and facility policy review, the facility failed to provide adequate supervision to prevent a resident, with altered mental status and a history of wandering behaviors, from leaving the facility without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury, and/or death when on 05/26/26 at approximately 9:35 P.M., Resident #48 left the facility without staff knowledge and was later found by the local police approximately five miles away. This affected one resident (#48) of three residents reviewed for elopement. The facility identified four additional residents (#24, #29, #37, and #43) who were additionally at risk for elopement. The facility census was 45.On 07/13/26 at 2:54 P.M., the Administrator, Director of Nursing (DON), Regional Director of Clinical Operations (RDCO) #295, and Administrator-in-Training (AIT) #300 were notified Immediate Jeopardy began on 05/26/26 at approximately 9:35 P.M. when Resident #48, who was cognitively impaired, had a history of wandering behaviors, and resided on the secured unit, exited the third floor to the outside through an alarmed door without staff knowledge. Resident #48's whereabouts were unknown until he was located by the police on 05/27/26 at 12:46 A.M. approximately five miles from the facility lying underneath a parked car. Resident #48 was wearing a hospital gown, blazer, and an incontinence undergarment and was observed to be confused. The police contacted Emergency Medical Services (EMS) due to the resident's confusion and length of time outside. Resident #48 was transported by EMS to a local hospital for evaluation where he was found to have a urinary tract infection (UTI) and was held for observation while the resident was awaiting placement to another skilled nursing facility.The Immediate Jeopardy was removed on 05/27/26 and the deficiency corrected on 06/03/26 when the facility implemented the following corrective actions:On 05/27/26 at 12:30 A.M., the Administrator checked all doors in the facility for magnetic lock and alarm functioning. All four first-floor doors, both second-floor doors, and three third-floor doors were noted to be in good working order and functioning properly.On 05/27/26 at 12:45 A.M., in-person staff education was started by the Administrator and Maintenance Director (MD) #250 to staff on duty including Registered Nurse (RN) #242, RN #236, Certified Nursing Assistant (CNA) #258 and Agency CNA #293. The education included the elopement/wandering policy, indicating that it is the responsibility of all staff to immediately respond to door alarms when triggered. It is the staff's obligation to locate the alarming door then proceed to determine whether a resident has made an unauthorized exit. If an unauthorized exit is determined, staff were educated to follow the steps outlined in the elopement/wandering policy.On 05/27/26 at 1:57 A.M., the local police notified the Administrator that Resident #48 was found near his former home. Resident #48 was taken to a hospital until he was discharged to another local facility.On 05/27/26 at 8:30 A.M., all magnetic locked and alarmed doors were checked again by MD #250. All four first-floor doors, both second-floor doors, and three third-floor doors were noted to be in good working order and functioning properly.On 05/27/26 at approximately 9:24 A.M., Minimum Data Set (MDS) Nurse #291 started elopement/wandering assessments on all 46 in-house residents and reviewed resident care plans. Four residents (#24, #29, #37, and #43) were previously identified to be at risk for elopement and continued to remain at risk for elopement upon reassessment. Their records were reviewed and no care plan changes were required.On 05/27/26 at approximately 10:00 A.M., an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held, coordinated by the Administrator. In attendance was the Administrator, Assisted Living Director #297, MD #240, Activity Director (AD) #246, Social Service Director (SSD) #226, Therapy Director #294, Human Resources (HR) #281, Housekeeping Supervisor #263, Assistant Director of Nursing (ADON) #282, Physician #292, and RDCO #295. The circumstances related to Resident #48's elopement were reviewed with an additional recommendation to obtain an alarming floor mat to be placed inside the third-floor stairwell for an additional layer of an alarm outside the secured unit. There were no additional recommendations from the QAPI committee. The QAPI committee reviewed the elopement/wandering policy and reiterated it was the responsibility of all staff to immediately respond to door alarms when triggered. It is all staff's responsibility to locate the alarming door, then proceed to determine whether a resident has made an unauthorized exit. If an unauthorized exit is determined, staff were to follow the steps outlined in the elopement/wandering policy.On 05/27/26, a root cause analysis was completed coordinated by the Administrator with nursing and maintenance involvement. The root cause analysis indicated the resident was able to exit the secured unit through an egress door by holding down the 15-second release bar and went down the staircase to the outside. Contributing factors included the time of day (evening) with staff providing care in rooms and the nurse completing a medication pass in another part of the hall. The root cause analysis included that staff could not respond to the alarm within an adequate time frame.On 05/27/26 at 6:00 P.M., education was completed for all staff. Education was completed on the elopement/wandering policy and was provided to all staff including 22 CNAs, nine RNs, six LPNs, 21 dietary staff members, 11 housekeeping staff members, and three activity staff members by the Administrator, HR #281, Scheduler #248, Therapy Director #294, MD #250, and ADON #282. The education included the elopement/wandering policy, indicating that it is the responsibility of all staff to immediately respond to door alarms when triggered. It is the staff's obligation to locate the alarming door then proceed to determine whether a resident has made an unauthorized exit. If an unauthorized exit is determined, staff were educated to follow the steps outlined in the elopement/wandering policy. Education was completed to all staff either in person, through the online in-service portal, or by phone. On 05/28/26 at 3:23 P.M., an elopement drill was conducted by MD #250 and RDCO #295. In attendance and participating in the drill was the Administrator, SSD #226, MDS Nurse #291, Therapy Director #294, ADON #282, LPN #253, LPN #205, RN #255, and CNAs #277, #290, #203, and #212. There were no concerns identified with the drill.Beginning on 05/28/26, the Administrator initiated audits of door alarm functions and the staff's response time to the sounding alarms three times weekly for two weeks, twice weekly for two weeks, then three times monthly on a random basis for a duration of two months. The Administrator and MD #250 were responsible for completion of the audits with the results to be reviewed in routine QAPI meetings.On 05/29/26 at 4:51 P.M., education was provided to the facility's only contracted staffing agency by HR #281, informing the agency that any agency staff working within the facility must receive education and acknowledge the facility's elopement/wandering policy prior to working in the facility. This began effective immediately on 05/29/26.On 06/03/26, an alarming door mat was placed on the floor inside the third-floor stairwell door by the Administrator. MD #250 was responsible for checking the alarming door mat weekly with routine fire door audits. On 06/03/26, education was provided by the Director of Nursing (DON) to all staff that an alarm mat was placed on the floor of the third-floor stairwell door. The education informed staff that when the mat is stepped on and released, the chime alarm will sound at the nurse's station and sounds different than the normal door alarms. The education indicated that if the alarm was heard, staff were to respond promptly, as with all alarms. On 06/18/26 at 12:00 P.M., a routine monthly QAPI meeting was held with the interdisciplinary team (IDT) in attendance. Resident #48's elopement and subsequent ongoing audits and elopement drills were reviewed with no further recommendations from the QAPI committee. On 07/13/26 at 4:30 P.M., the Administrator coordinated re-education to all staff on the facility's elopement/wandering policy and timely response to alarms. The education additionally included notation that the alarming door mat was located inside the stairwell door. This education was provided to all staff by the Administrator, HR #281, MD #250, AD #246, Therapy Director #294, SSD #226, Scheduler #248, Dietary Manager #231, the DON, and ADON #282 either in person, through the online portal, or by phone to reinforce previous education.Findings include:Review of Resident #48's closed medical record revealed an admission date of 05/07/26 and a discharge date of 05/27/26. Diagnoses included dementia, altered mental status, restlessness and agitation.Review of Resident #48's admission assessment dated [DATE] revealed in the elopement section, the resident was not recorded as having a history of elopement, wandering, and was not identified to be at risk for elopement.Review of the care plan dated 05/08/26 revealed Resident #48 had impaired cognition as evidenced by deficit in memory, judgement, and decision making related to dementia and altered mental status. The care plan noted the hospital (prior to admission) had started the process for Resident #48 to obtain a guardian. Listed interventions included communicating with the resident, family and caregivers regarding the resident's capabilities and needs as needed and discussing concerns about confusion, the disease process, and nursing home placement with the resident, family, and caregivers. The care plan additionally included keeping the resident's routine consistent as much as possible and monitoring, document, and reporting to the medical provider any changes in cognitive function, including changes in decision making ability, memory, recall and general awareness, or mental status.Review of Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #48 had a Brief Interview for Mental Status (BIMS) score of 10, indicating a moderate cognitive impairment. Resident #48 was noted to be able to walk 10 feet with supervision, was able to walk 50 feet with two turns with partial/moderate assistance, but walking 150 feet and walking 10 feet on uneven surfaces was coded as not attempted due to medical condition or safety concerns. Review of a room change notification assessment dated [DATE] created by Social Services Designee (SSD) #226 revealed a room change for Resident #48 from the second floor to the third floor was requested for safety purposes. Review of elopement assessment dated [DATE] revealed Resident #48 noted to have a history of elopement, was noted to wander aimlessly, and was likely to affect the safety or well-being of self or others. Resident #48 was identified to be an elopement risk.Review of a progress note dated 05/26/26 timed 2:06 P.M. authored by LPN #268 revealed Resident #48 was transferred to unit three (the facility's secured unit) on first shift. The note did not provide a reason for the transfer.Review of a physician order dated 05/26/26 at 3:00 P.M. revealed Resident #48 was ordered a secure care transmitter (a wearable device which triggers an audible alarm or alert when the device gets too close to a sensor on an exit door) which was applied to his left ankle. The order noted the device was to be checked for placement and functioning every shift. Review of an elopement evaluation progress note dated 05/26/26 timed 4:01 P.M. authored by LPN #268 revealed Resident #48 was risk for elopement. Review of a local police report dated 05/26/26 timed 10:56 P.M. revealed on 05/26/26 at 10:55 P.M., the facility had informed the police Resident #48 had left the facility unattended. RN #242 had informed the officers upon their arrival at the facility that she was administering medications and had heard an alarm for the door by the third-floor staircase going off. Shortly after she heard the alarm, she went to check the door and saw it had been opened, leading to an exit door on the bottom floor. The door at the bottom of the staircase alarm was going off as well, leading them to believe Resident #48 had left the building. Resident #48 had last been observed wearing a hospital gown, blazer and an incontinence undergarment. Facility staff provided the police with information on Resident #48 which included that Resident #48 had a diagnosis of dementia. Due to the dementia diagnosis and length of time Resident #48 had been gone, the police initiated a be on the lookout ([NAME]) and Resident #48 was entered as a missing endangered adult. Police units began to search for Resident #48 and a drone was deployed. Additional units responded to Resident #48's previous address and on 05/27/26 at 12:46 A.M., the police located Resident #48 hiding underneath a vehicle in the driveway of his former address. Resident #48 was confused and due to the prolonged time Resident #48 had been outside, EMS was dispatched and had transported Resident #48 to the hospital.Review of hospital paperwork dated 05/27/26 timed 1:26 A.M. revealed Resident #48 presented to the emergency department after wandering from the memory care facility for five hours and had been located by police at his previous residence. Resident #48's workup in the emergency department indicated he had a urinary tract infection (UTI). The note mentioned the resident lacked decision-making capacity. The record indicated the resident had a family member who was the decision maker while guardianship of Resident #48 was still pending. The family member did not want Resident #48 to return to the facility, citing care concerns. Resident #48 remained at the hospital and received treatment for his UTI while placement was arranged for an alternate facility. Review of a progress note dated 05/27/26 timed 7:59 A.M. authored by RN #242 revealed Resident #48 was observed in the hallway walking back and forth and she had taken Resident #48 back to his room. RN #242 noted she was busy passing medications when she heard the [door] alarm sound, she had gone to check the door, the staircase alarm was on, and Resident #48 was not in his room. The note indicated staff checked everywhere and did not locate Resident #48. The note referenced the physician, ADON #282, and family were made aware. A follow-up note dated 05/27/26 timed 8:17 A.M. authored by RN #242 revealed Resident #48 was found and was at the hospital. Interview on 07/08/26 at 2:57 P.M. with CNA #233 revealed the facility's third floor was a locked unit and some residents had wanderguards (brand of secure care transmitters) to prevent them from leaving the unit. CNA #233 stated wanderguards would cause the door to alarm if a resident with a wanderguard attempted to open the elevator or stairwell door. Observation of a wanderguard at the time of interview with CNA #233 revealed the wanderguard alarmed with an attempt to open the elevator, indicating the system was working as designed.Interview on 07/08/26 at 3:02 P.M. with RN #255 revealed Resident #48 had been moved from the second floor to the third floor on 05/26/26, however she was unaware of the reason for the move. RN #255 stated she had placed a wanderguard on Resident #48 upon his arrival to the secured unit and it had been functioning appropriately. RN #255 stated Resident #48 had wandered on the unit.Interview on 07/08/26 at 3:15 P.M. with Administrator and Director of Nursing (DON) revealed the Administrator received a call the evening of 05/26/26 and was informed Resident #48 had left the facility unattended. The Administrator stated staff heard a door alarm near the staircase, responded to the alarm, and then discovered Resident #48 was not present on the unit. The Administrator stated staff searched the premises and could not locate Resident #48. Staff then called the police, who responded to aid in the search, and the police were able to locate Resident #48 at his former residence. The Administrator stated from there Resident #48 was taken to the hospital and had not returned to the facility. The Administrator indicated the facility had completed an investigation into Resident #48's elopement. Interview on 07/09/26 at 8:19 A.M. with CNA #221 revealed Resident #48 had often wandered through the halls of the unit and he was usually able to be redirected. CNA #221 reported Resident #48 had a wanderguard in place.Interview on 07/09/26 at 8:31 A.M. with CNA #235 revealed Resident #48 was confused but was redirectable at times. CNA #235 stated she had observed Resident #48 attempting to exit the unit and observed him attempt to enter a numeric code at the (secured) elevators. CNA #235 reported hearing Resident #48 state multiple times that he needed to go to work and needed to go home. CNA #235 stated she was unsure how Resident #48 was able to exit the facility and stated with his wanderguard the door alarms should have alarmed to alert staff.Telephone interview on 07/09/26 at 9:53 A.M. with RN #236 revealed she had cared for Resident #48 while he resided on the second floor. RN #236 reported Resident #48 was confused; she observed him trying to leave the unit and recalled him making statements that he needed to go to work and needed to go home. RN #236 stated when she had arrived at work on 05/26/26 at approximately 11:00 P.M., she observed ADON #282 entering the building and staff were looking for Resident #48. Interview on 07/09/26 at 10:21 A.M. with SSD #226 revealed she had completed a room change assessment for Resident #48. Review of the assessment with SSD #226 at the time of the interview revealed the assessment was originally created on 05/23/26 as Resident #48 was observed with wandering behaviors. SSD #226 stated at the time the assessment was completed, there was not an available room on the third floor (secured unit) and Resident #48 was not moved until one became available on 05/26/26. Interview on 07/09/26 at 11:18 A.M. with ADON #282 revealed she received a call the evening of 05/26/26 (could not recall the exact time) from RN #242 and was told staff were unable to locate Resident #48. ADON #282 stated she had immediately come to the facility, arriving sometime between 10:00 P.M. and 11:00 P.M. and assisted with searching the premises. ADON #282 stated she had also checked outside and drove around the area. ADON #282 stated RN #242 called the police were later able to locate Resident #48 at his previous residence. ADON #282 denied knowledge of Resident #48 having any exit seeking behaviors prior to his elopement from the facility.Telephone interview on 07/09/26 at 12:43 P.M. with RN #268 revealed on 05/26/26, she observed Resident #48 attempt to get on the elevator of the second-floor multiple times. RN #268 stated Resident #48 had wandered frequently.Telephone interview on 07/09/26 at 2:13 P.M. with Resident #48's family member revealed she had many concerns related to Resident #48's elopement. The family member reported she was at the facility on 05/25/26 and staff informed her they had observed him attempting to leave the unit with other staff or visitors. The family member stated she had been advised at that time they were going to be placing him on the secured unit and she agreed. The family member stated the next evening she had received a call [on 05/27/26] at approximately 12:00 A.M. and was told staff could not find Resident #48. Staff reported they had been searching for two hours, and he was not in the building. The family member asked if anyone had called the police or had looked at video footage and she had been told the cameras were not reviewed. The family member stated she was upset that she had not been called until Resident #48 had been missing for two hours. The family member reported she received another call [on 05/27/26] at approximately 1:00 A.M. from the hospital that Resident #48 had been located and was transported to the hospital. The family member communicated to the hospital to not have Resident #48 return to the facility. The family member reported she received a call from the facility [on 05/27/26] at approximately 2:00 A.M., however she was too upset to take the call. Resident #48's family member stated she was so upset that staff must not have been supervising him, as he was able to leave the locked unit unattended. Interview on 07/09/26 at 2:52 P.M. with Administrator revealed the facility's cameras were not hooked up at that time and confirmed Resident #48 eloped on 05/26/26 at approximately 9:35 P.M. from the secured unit of the facility. The Administrator verified the facility's investigation concluded that Resident #48 was able to elope from the secured unit after staff did not respond timely to the sounding door alarm. The Administrator confirmed facility staff was later informed by the police that Resident #48 was found approximately five miles from the facility at his former residence.Telephone interview on 07/13/26 at 11:26 A.M. with RN #242 revealed on the evening of 05/26/26 at approximately 9:00 P.M., during her evening medication pass, she arrived at Resident #48's room and had observed he was not present in the room. RN #242 stated she continued administering medications for another resident when she heard an alarm. RN #242 responded to the alarm, saw the open door, proceeded to Resident #48's room, and saw he was gone. RN #242 stated she immediately began to search for Resident #48, along with other staff members and could not be located. RN #242 stated she had not observed Resident #48 exit seeking prior to his elopement, however had had been pacing the halls.Review of facility policy titled Wandering and Elopement revised April 2026 revealed the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's interventions will be implemented to maintain the resident's safety. If a resident is missing, initiate the elopement/missing resident emergency procedure that included initiate a search of the building and premises and if not located notify the Administrator, physician, law enforcement, and resident representative.This deficiency represents non-compliance investigated under Master Complaint Number 3073544.

Based on observation, resident interview, and staff interview, the facility failed to ensure an adequate supply of washcloths and towels were available for resident care needs. This had the potential to affect all 46 residents residing in the facility. The facility census was 46.Findings include:Observation and interview with Certified Nurse Aide (CNA) #299 on 05/01/26 at 8:28 A.M. revealed there were no washcloths or towels were available on the first floor for resident care needs.Observation on 05/01/26 at 8:48 A.M. outside the laundry room revealed 26 bags of dirty laundry and three bags of clean laundry pending delivery to residents. Interview with Maintenance Director (MD) #200 at that time revealed only one clothes washer was operational. MD #200 stated a new washer was delivered the previous day; however, installation was delayed due to a non-functioning elevator, which required repair prior to delivery.Observation of the clean laundry room on 05/01/26 at 8:49 A.M. revealed no clean towels or washcloths available for resident care. Interview with MD #200 at the time of the observation stated linens were stored in his office for emergency situations which included nine packages of clothing and four packages of towels; however, he was unaware of the need for linens on resident floors.Observation and interview with CNA #300 on 05/01/26 at 8:55 A.M. revealed, showers barely get done because of linen not being available, and it was hard to do get-ups due to personal clothing not being available. CNA #300 further reported staff have encouraged placing residents in hospital gowns due to lack of clothing; however, CNA #300 declined due to personal belief of dignity concerns for residents.Observation of the linen cart on the third floor on 05/01/26 at 8:57 A.M. revealed one towel and one washcloth available for use. Interview with CNA #300 verified these findings at the time of observation.Interview with Resident #44 on 05/01/26 at 9:50 A.M. revealed he was often cold and had to bring in his own bedsheets and blankets. Resident #44 further stated he did not receive a shower on 04/30/26 due to lack of towels.This deficiency represents non-compliance investigated under Complaint Number 2984248.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of five percent (%) or less. Five medication errors out of 27 observed opportunities for error, created a medication error rate of 18.5%. This affected two of three residents reviewed for medication administration (Resident #5 and #4). The total census was 48. Findings include: 1. Observation of a medication administration procedure for Resident #5 by Licensed Practical Nurse (LPN) #118 on 10/15/24 at 9:03 A.M. revealed the nurse prepared medications including a 2000 unit tabled of vitamin D-3, and polyethylene glycol (a laxative) powder, of which she measured 15 milliliters (ml) into a 30 ml medicine cup. She also prepared two eye drop medications (Brimonidine Tartrate and Ketorolac Tromethamine), which both included pharmacist instructions on their storage bags to wait five minutes between medications administered in the same eye. The nurse administered the above-noted medications and gave the eye drops in the right eye one immediately after the other at 9:19 A.M. Record review of Resident #5 revealed the only active order for vitamin D-3 was for one 5000 unit tablet once per day, and the only active order for polyethylene glycol was for 17 grams once per day. Interviews with LPN #118 on 10/15/24 at 9:42 A.M. and 10/16/24 at 8:35 A.M. confirmed these findings. 2. Observation of a medication administration procedure for Resident #4 by LPN #118 on 10/15/24 at 9:26 A.M. revealed the nurse administered one tablet of vitamin B-12 1000 micrograms (mcg). The nurse also administered one puff of a Fluticasone-Salmeterol 100-50 mcg inhaler, which included pharmacy instructions on the storage bag to rinse the mouth after use. The nurse administered the inhaler, then gave the resident their medications to swallow with a nutrition shake without offering to rinse their mouth first. Record review of Resident #4 revealed the only active order for vitamin B-12 was for one 100 mcg pill to be given daily. Interviews with LPN #118 on 10/15/24 at 9:42 A.M. and 10/16/24 at 8:35 A.M. confirmed these findings. Record review of the facility's medication administration policy dated 09/2018 revealed medication rights including the right dose were to be reviewed by the administering nurse when preparing the medication. The above findings identified five medication errors out of 27 observed opportunities for error, creating a medication error rate of 18.5%.

Based on observation, interview, record review, and facility policy review the facility failed to ensure fall interventions were in place for Resident #47. This affected one resident (#47) of three residents reviewed for falls. The facility census was 50. Findings Include: Review of Resident #47's medical record revealed an admitted [DATE] and diagnoses including acute pulmonary edema, bipolar disorder, generalized anxiety disorder, hypertension, depression, dementia with other behavioral disturbance, and moderate protein calorie malnutrition. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #47 was cognitively impaired and did not reject care. Resident #47 required substantial/partial assistance to sit to stand. Resident #47 could wheel 50 feet in her wheelchair with two turns with supervision or touching assistance. Resident #47 had two falls coded since the prior assessment. Review of a fall risk evaluation dated 02/27/24 revealed Resident #47 had one to two falls in the past three months and had intermittent confusion. The assessment indicated a score of 10 or higher meant the resident was at a high risk for falls; Resident #47 had a score of 11 thus was at risk for falls. Review of the plan of care dated 06/08/23 and revised 02/13/24 revealed Resident #47 was at higher risk for falls due to gait and balance problems due to osteoarthritis of the knee and psychoactive drug use as well as being unaware of safety needs. Interventions listed included Dycem (non-slip material) to wheelchair for safety (dated 06/21/23) and place call before you fall signage in plain view in room (dated 07/12/23). Observation on 03/06/24 starting at 8:03 A.M. of Resident #47 revealed she was dressed and seated in her wheelchair by the nurses' station. Registered Nurse (RN) #116 and RN #103 were asked if Resident #47 had Dycem on her wheelchair as it could not be visualized on the wheelchair while Resident #47 was seated. RN #103 assisted Resident #47 to stand, and no Dycem was noted on her wheelchair. RN #103 then reviewed Resident #47's current care plan for falls with the surveyor and verified the Dycem was not in place per Resident #47's plan of care. During this time RN #103 was questioned regarding the call before you fall signage intervention also listed on Resident #47's plan of care. At 8:08 A.M. RN #103 accompanied the surveyor to Resident #47's room and no sign was visualized. RN #103 verified the lack of signage at the time of observation. Interview on 03/06/24 starting at 9:15 A.M. with the Director of Nursing (DON) revealed Dycem would have been listed in Resident #47's physicians' orders once it was identified as a fall intervention. Resident #47's historical and current physicians' orders were searched with the DON during the interview and no order for Dycem was found. The DON verified the lack of physicians' order for Resident #47's Dycem at the time of discovery. Review of the undated facility policy, Fall Prevention and Management Program, revealed each resident would have a care plan for potential for falls developed and implemented upon admission and updated with each review and when appropriate. This deficiency represents non-compliance investigated under Complaint Number OH00151229 and is an example of continued non-compliance from the complaint survey dated 02/13/24.

Based on record review, interview, and facility policy review the facility failed to ensure Resident #49 did not leave the facility without staff knowledge and did not ensure a safe discharge. This affected one resident (#49) of three residents reviewed for elopement. The facility census was 48. Findings include: Review of the closed medical record for Resident #49 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included human immunodeficiency virus (HIV), schizophrenia, depression, and dementia. He was his own responsible party. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was moderately cognitively impaired. The assessment identified the resident had no wandering behaviors. The resident required supervision for ambulation. Review of the plan of care dated 01/23/24 revealed no evidence Resident #49 was at risk for elopement. Review of the elopement risk assessment dated [DATE] revealed Resident #49 was not at risk for elopement. Review of the nurses' note dated 02/07/24 at 2:27 P.M. revealed Resident #49 was upset and wanted to go home. Review of the nurse's notes dated 02/10/24 at 5:24 P.M. revealed Resident #49 was not in his room. The facility was searched, and the resident could not be located. The residents' brother was contacted and said Resident #49 was free to leave if he chose to do so. The Director of Nursing (DON) and physician were notified. Review of the nurse's note dated 02/12/24 at 12:27 P.M. revealed Resident #49 left the facility against medical advice (AMA). Interview on 02/12/24 at 9:53 A.M. with Licensed Practical Nurse (LPN) #200 revealed the second floor was not a secured unit. She confirmed Resident #49 was ambulatory and not an elopement risk. Interview on 02/12/24 at 10:31 A.M. with Resident #49's brother confirmed he received a call from the facility on 02/10/24 at approximately 5:00 P.M. informing him the resident was missing. He revealed he was not surprised, and thought the resident likely returned to his apartment. He confirmed this the following day, 02/11/24 at approximately 11:00 A.M. He revealed both he and his mother had been trying to encourage the resident to stay because they were aware the resident wanted to leave. Interview on 02/13/24 at 11:29 A.M. with Registered Nurse (RN) #203 revealed she began work at 3:16 P.M. on 02/10/24. She did not see Resident #49 at that time, so she started looking for him. When she could not locate him, she called the DON around 5:00 P.M. to notify her she could not locate the resident. Interview on 02/13/24 at 11:42 A.M. with the DON revealed the facility called the resident's brother after they could not locate the resident at the facility. The resident's brother said the resident probably went back to his apartment and not to worry about it. The DON confirmed the police were not contacted and no further investigation was conducted as a result. The DON revealed no interventions were in place to prepare for an unexpected discharge for the resident, despite his discussion of wanting to leave on 02/07/24. She confirmed the facility was aware of the residents' intentions to leave, but did not plan for a potential, unplanned discharge. Interview on 02/13/24 at 11:52 A.M. with LPN #204 confirmed she was assigned to Resident #49 on 02/10/24. She last saw him before she left for the day at approximately 3:00 P.M. or 3:30 P.M. She revealed he was in the common area and did not seem distressed, exit seeking, or confused. Interview on 02/13/24 at 12:24 P.M. with the DON confirmed Resident #49 left without staff knowledge and without his medications. She verified the facility did not complete an investigation to determine how the resident was able to leave the facility without staff knowledge. She revealed his brother picked them up either 02/11/24 or 02/12/24. Interview on 02/13/24 at 1:28 P.M. with Resident #49's brother confirmed he picked up the residents' medications on 02/11/24 and delivered them to the resident around 6:00 P.M. that evening. Review of the facility policy titled Discharge Summary dated February 2023 revealed when the facility anticipated a discharge, a discharge summary would be developed that included a post-discharge plan of care including where the resident planned to reside, arrangements for follow up care and any medical and non-medical services needed and a reconciliation of pre-discharge and post-discharge medications. Review of the facility Wandering and Elopement Policy, dated 08/2021, revealed if a resident is missing, initiate the elopement/missing resident emergency procedure including if the resident is not located, notify the administrator and the DON, the resident's legal representative, the attending physician, and law enforcement officials. The policy also states, complete and file an incident report. This deficiency represents noncompliance investigated under Complaint Number OH00151042.

Based on record review and staff interview the facility failed to ensure an accurate medical record regarding resident ordered medications. This affected one (Resident #1) of three residents reviewed for medication administration. The facility census was 41. Findings Include Review of the medical record for Resident #1 revealed an admitted [DATE] with diagnoses that included high blood pressure, type two diabetes and psychoactive substance abuse disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 was cognitively intact and was independent for completing his activities of daily living. Resident #1 discharged home on 12/22/22 with family. Review of the hospital discharge orders sent to the facility dated 12/21/22 revealed the following orders -Insulin Glargine 32 units at bedtime -Insulin Lispro 5 units at bedtime Review of the physician orders for Resident #1 for his stay at the facility (12/21/22 through 12/23/22) revealed no orders for insulin The Director of Nursing verified no orders were obtained or transcribed for insulin for Resident #1 in an interview on 01/07/22 at 12:10 P.M. Review of the policy dated 08/01/20 entitled Ordering and Receiving Non-Controlled Medications the facility must maintain accurate records of medication order and receipt This deficiency represents non-compliance investigated under complaint number OH00138675

Based on record review and interview the facility failed to provide incontinence care in a dignified manner. This affected one (Resident #39) of three reviewed for incontinence care. The census 42 residents. Findings include: Review of the medical record for Resident #39 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/23/22, revealed Resident #39 had impaired cognition. The resident was dependent for bed mobility, transfers, and toilet use. Observation on 11/17/22 at 9:30 A.M., State tested Nurse Assistant (STNA) #4 provided incontinence care for Resident #39. STNA #4 was observed using a washcloth and rotating Resident #39 in a vigorous manner. STNA #4 rotated Resident #39 from back to side and side to back without communicating with the resident. Resident #39 's legs flailed during rotation ending up over the bed. STNA #4 went to the bathroom to change the water; Resident #39 was left lying on his left side facing the wall exposed. Interview immediately after the observation, STNA #4 verified the observations.

Based on observations, staff interview, record review, review of facility infection control policies and the Centers for Disease Control and Prevention (CDC) website the facility failed to implement infection control procedures for Personal Protective Equipment (PPE). This had the potential to affect all 42 residents currently residing in the facility. The facility also failed to ensure [CONDITION(S)] (TB) testing was completed as required. This affected two (Residents #30 and #38) of five residents reviewed for TB testing. Findings include: 1. Observation on 04/25/22 at 7:13 P.M. revealed on the third floor, Licensed Practical Nurse (LPN) #631 with her facemask pulled down exposing her mouth and nose. LPN #631 was standing at the medication cart that was in front of the nurses' station. Interview at this time with LPN #631 verified the observation and stated she sometimes has to pull it down. LPN #631 then pulled up her facemask to cover her mouth and nose. 2. Review of the medical record for Resident #189 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders for April 2022 revealed orders for contact and droplet isolation precautions times 10 days due to not up to date with COVID Booster with a start date of 04/21/22. Observation on 04/27/22 at 9:56 A.M. revealed State Test Nurse Aide (STNA) #597 exiting Resident #189's room without disinfecting her face shield or changing her facemask. Interview on 04/27/22 at 9:58 A.M. with STNA #597 verified the observation and then stated they used a spray disinfectant that was kept at the nurses' station to disinfect the face shield. Observed STNA #597 look for the disinfectant at the nurses' station but she was unable to locate it. Interview on 04/27/22 at 10:42 A.M. with Infection Control Preventionist (ICP) #620 stated staff were to use the disinfectant spray that was kept at nurses' station to disinfectant their face shields when they exited the droplet isolation precaution rooms. ICP #620 stated staff were to let him, the nurse or housekeeping know if they ran out. ICP #620 stated staff should always wear their facemask and face shields when not within six feet away of someone. 3. Observation of the breakfast meal on 04/26/22 beginning at 7:42 A.M. on the second floor revealed STNA #597 was observed wearing a white bonnet, face shield and a mask. STNA #597 obtained a meal tray, brought it to the nurses station and set it down. She donned a gown and gloves then delivered the meal tray to Resident #89 who was in droplet isolation according to the posted sign. Prior to leaving the room, STNA #597 removed her gloves, gown and bonnet and used alcohol based hand rub to cleanse her hands. STNA #597 obtained a meal tray, brought it to the nurses station and set it down. STNA #597 donned a bonnet, gown and gloves and delivered the meal tray to Resident #90 who was in droplet isolation according to the posted sign. Prior to leaving the room, STNA #597 removed her gloves, gown and bonnet and used alcohol based hand rub to cleanse her hands. At no time did STNA #597 sanitize her face shield or change her mask. Review of the facility's policies titled Droplet Precautions and Infection Control-Transmission Precautions both dated March 2020 revealed no instructions related to sanitizing or changing facemask after exiting a droplet isolation precaution room. Review of the Centers for Disease Control and Prevention (CDC) website titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic dated 02/02/22 revealed when used solely for source control, any of the options listed above (a NIOSH- approved N95 or equivalent or higher level respirator, or a respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering face piece respirators (Note: These should not be used instead of a NIOSH-approved respirator when respiratory protection is indicated), or a well-fitting facemask) could be used for an entire shift unless they become soiled, damaged, or hard to breathe through. If they are used during the care of patient for which a NIOSH-approved respirator or facemask is indicated for personal protective equipment (PPE) (e.g., NIOSH-approved N95 or equivalent or higher-level respirator) during the care of a patient with [CONDITION(S)]-CoV-2 infection, facemask during a surgical procedure or during care of a patient on Droplet Precautions, they should be removed and discarded after the patient care encounter and a new one should be donned. Also noted healthcare personnel should wear source control when they are in areas of the healthcare facility where they could encounter patients (e.g., common halls/corridors) 4. Review of the open medical record for Resident #30 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #30's February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #30's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. Review of the closed medical record of Resident #38 revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #38's March 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #38's April 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 04/27/22 at 5:32 P.M. with ICP #620 revealed residents were required to receive the two step Mantoux text on admission. ICP #620 stated he knew that Resident #30 had received the first step of the Mantoux but not step two. ICP #620 stated Resident #38 also received the first step but not the second. ICP #620 stated there were no concerns related to TB with Resident #30 or #38. Review of the facility policy titled [CONDITION(S)] Infection Control Program dated January 2012 revealed the facility's TB infection control program includes the early identification, isolation, and transfer of persons with active [CONDITION(S)]. The program incorporates the following components which included screening and surveillance of residents and employees for latent [CONDITION(S)] infection (LTBI) and active TB as appropriate for the current TB risk class. This deficiency substantiates Complaint Number OH 084.

Based on observation and staff interview, the facility failed to ensure the dumpsters and surrounding areas were maintained and free from trash and debris. This had the potential to affect all 42 residents currently residing in the facility. Finding include: Observation on 04/26/22 at 10:42 A.M. of the outside dumpsters revealed two dumpsters, both with the lids open with a moderate to a large amount of debris and trash on ground around the dumpsters. Interview on 04/26/22 at 10:42 A.M. with Dietary Manager (DM) #536 verified the observation.

Based on observation, record review, staff interview, and policy review the facility failed to ensure serving sizes for vegetables were provided according to the menu. This had the potential to affect all residents except Residents #21, #24, #25, #139, and #190, who received nothing by mouth. The facility also failed to ensure serving sizes for the mechanical soft beef was served according to the menu. This had the potential to affect nine residents (#7, #10, #12, #18, #22, #29, #34, #189, and #239) who received a mechanical soft or ground diet. The facility census was 42. Findings include: Review of the menu for lunch on 04/27/22 revealed a one ½ cup (four ounces) serving of zucchini and for the residents on mechanical soft diet ground Salisbury steak using a number eight (#8) scoop which provided a four ounce serving. Observations on 04/27/22 between 11:23 A.M. and 11:29 A.M. of tray line revealed Dietary Cook (DC) #513 was observed give one serving each of the zucchini using a three-ounce serving spoon. Then observed DC #513 serve one serving each of the mechanical soft beef using a two-ounce spoon. Interview and review of the menu at this time with DC #513 verified the observations. Review of the facility policy titled Portion Control undated revealed individuals will receive the appropriate portions of food as planned on the menu. Control at the point of service is necessary to assure that accurate portion sizes are served.

Based on interview and review of resident accounts the facility failed to notify residents who receive Medicaid benefits when the amount in their account reached $200.00 less than the SSI (supplemental security income) resource limit for one person. This affected five (Residents #9, #17, #33, #36 and #91) of six residents whose accounts were reviewed of nine resident accounts the facility managed. Findings include: Review of Resident #9's account revealed the balance to be #3401.67, Resident #17's balance was $4812.73, Resident #33's balance was $2385.47, Resident #36's balance was $5068.84 and Resident #91's balance was $7063.79. All of these residents received Medicaid benefits and the balance exceeded the Medicaid benefit limit of $2000.00 placing them at risk of losing Medicaid benefits. Interview with the Administrator on 04/27/22 at 4:30 P.M. revealed the residents' accounts were above the limit because of the stimulus monies they received. Stimulus monies were to be used within one year of receipt. Each of the resident's received a $1400.00 stimulus check on 04/07/21. None of the residents had evidence they were notified when the amount in their account reached $200.00 less than the SSI resource limit for one person.

Based on record review and staff interview, the facility failed to ensure influenza and pneumonia vaccinations were completed as required. This affected four (Residents #30, #40, #191, and #192) of five residents (#30, #38, #40, #191, and #192) reviewed for influenza and pneumonia immunizations. The facility census was 42. Findings include: 1. Review of the open medical record for Resident #30 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no noted evidence of influenza or pneumonia immunizations. 2. Review of the closed medical record of Resident #40 revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no noted evidence of influenza or pneumonia immunizations. 3. Review of the open medical record of Resident #191 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no noted evidence of influenza or pneumonia immunizations. 4. Review of the closed medical record of Resident #192 revealed an admitted [DATE] and a discharged date of 03/15/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no noted evidence of influenza or pneumonia immunizations. Interview on 04/27/22 at 5:32 P.M. with Infection Control Preventionist (ICP) #620 stated he could not find evidence of Residents #30, #40, #191, or #192 consenting to and/or receiving or declining of influenza or pneumonia immunizations. ICP #620 stated they had established today moving forward how the influenza and pneumonia immunizations would be tracked.

Based on record review and interview the facility failed to ensure residents' signed advance directive forms were contained in their medical record. This affected two (Residents #189 and #191) of two residents reviewed for advance directives. The facility census was 42. Findings include: 1. Review of the medical record for Resident #191 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #191's medical record revealed no signed and dated DNR Comfort Care form. 2. Review of the medical record for Resident #189 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #189's medical record revealed no signed and dated DNR Comfort Care form. Interview on 04/26/22 at 9:55 A.M. with Licensed Practical Nurse (LPN) #616 verified Residents #191 and #189 both had orders for DNRCC- Arrest and neither had the signed and dated DNR forms in their medical records.

Based on record review, staff interview, and policy review the facility failed to identify a reason for an immediate discharge. This affected one (Resident #38) of three residents (#38, #40, and #192) reviewed for discharges. The facility census was 42. Findings include: Review of the closed medical record for Resident #38 revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the discharge care plan dated 03/29/22 revealed the resident would state he was leaving Against Medical Advice (AMA) to the community but then chooses not to leave. Interventions included social services to assist with discharge planning. Review of the admission Minimum Data Set (MDS) assessment, dated 04/03/22, revealed the resident had impaired cognition. The resident required supervision and assistance of one staff for bed mobility and transfers, and required supervision and set up help only for ambulation. Review of a late entry progress note dated 04/04/22 at 12:12 P.M. revealed Social Worker (SW) #572 spoke with Resident #38 regarding concerns that he wanted to leave the facility. He stated he was not looking to leave but wanted to know where he was. He stated he was still interested in moving to an assisted living. He was calm and pleasant while interacting with this worker and presented no psychosocial issues at this time. SW #572 will update as needed. Review of the social service note revealed a late entry note dated 04/07/22 at 12:17 P.M. for a care conference held with the resident's daughter, SW #572, the DON, and the therapy director. The daughter stated she felt the resident needed long-term care due to his declining cognition and increase in behaviors. The daughter was informed of the facility concerns regarding exit seeking behavior from the resident and asked the daughter if she agreed with him having a leave of absence (LOA) order. The daughter did not want resident to leave the facility. She stated the resident had been aggressive toward her at home, had issues with substance abuse, was non-compliant with medication, and felt that some family members had misappropriated the his funds in the past. The daughter was educated that this facility was not a locked dementia unit. It was suggested that due to resident's physical abilities, an alternative placement more appropriate to meet his needs should be explored. The daughter expressed interest in moving him to an assisted living facility. The daughter was informed the resident would be allowed to come and go from the facility's assisted living as it was considered the community. The daughter stated she did not want to hinder his freedom but felt he would be at risk if he was permitted to leave the facility at will. The daughter stated she would explore alternative settings and asked staff to send the residents information to a specific assisted living and other facilities the facility identified that were more appropriate to meet his needs and safety. The resident was also seen by psychiatry outside the facility. The daughter also stated she planned to pursue guardianship of the resident. SW #572 will update as needed. Review of the late entry social services note dated 04/08/22 at 12:49 P.M. revealed Resident #38's daughter was notified the assisted living facility she requested would not accept him due to his needs. Will update as needed. Review of the late entry social services note dated 04/8/22 at 12:52 P.M. revealed the DON faxed Resident #38's information to skilled nursing facilities (SNF) #1, SNF #2, and SNF #3. SNF #2 and #3 declined due to the resident's needs. SNF #1's Administrator contacted the DON and stated they would accept resident to their locked dementia unit. Transportation to be arranged by receiving facility. Will update as needed. Review of the progress note dated 04/18/22 at 2:26 P.M. revealed Resident #38 was discharged to SNF #1 with his belongings and medications. Interview on 04/27/22 at 10:04 A.M. with Licensed Practical Nurse (LPN) #616 revealed Resident #38 was a nice guy. LPN #616 stated the resident was put on a watch. LPN #616 stated one time he was down by the window looking out and they thought he was trying leave, but he was not. LPN #616 stated there was some type of family dynamics between resident and his daughter. LPN #616 stated she was not working the day Resident #38 discharged but knew he went to another facility. LPN #616 stated the plan was for the resident to go to an assisted living. LPN #616 stated she did not know how the resident's discharge came about but knew someone from the other facility had come to visit the resident. Interview on 04/27/22 at 6:11 P.M. with Resident #38's daughter revealed she was the Power of Attorney (POA) for Resident #38, and they had discharged him without her knowledge or consent. Resident #38's daughter stated the resident had called her from his cell phone the day the facility had discharged him, and he was in distress. She said she heard someone telling him he had to leave, and the phone hung up so she got into her car and headed to the facility. When she arrived at the facility the resident was in the transportation car with his belongings and the transportation lady told her she did not know what was going on and that the nurse had gone back into the facility to get oxygen for the resident. The daughter stated the resident was having trouble breathing and they did not have him on oxygen. The daughter stated the resident was already in the car and had rolled down the window and said to her they told him he had to leave. The daughter stated when they had the care conference, eight to 10 days before they discharged him, she had informed them she wanted Resident #38 to discharge to an assisted living facility and that she wanted to tour the facilities first. The daughter stated when she went into the facility on the day he was discharged , she had also asked for the discharge paperwork and had not received it. She went into the facility and spoke with two female staff members who told her they ' d called her, she did not remember their names, but no one had called her. The daughter stated the facility did not follow necessary procedures and felt they just kicked him out. She stated the resident was not able to make his own decisions and she was recently awarded guardianship at the hearing on 04/26/22. Interview on 04/28/22 at 10:40 A.M. with State tested Nurse Aide (STNA) #603 revealed she packed Resident #38's belongings. STNA #603 stated he had told her he was not going anywhere and had planned to be discharged home the following Tuesday. STNA #603 stated Resident #38 had called his sister on his cell phone, and she did not know what was going on. STNA #603 stated the resident would not get dressed or allow her to pack his things and she had to inform the nurse. STNA #603 stated the nurse had to call the DON multiple times because the resident was not allowing her to pack his items. STNA # 603 stated she learned that day Resident #38 was being discharged and was told by the nurse. STNA #603 stated Resident #38 was alert and oriented, slept most of time, and was independent. STNA #603 stated he toileted himself and all they provided were towels for bathing. STNA #603 stated the resident finally allowed her to pack his items. STNA #603 stated she and a housekeeper took the resident and his items downstairs where transportation was waiting outside, and the DON was down there as well. STNA #603 stated the resident was a little upset but not yelling. STNA #603 stated she was not sure if Resident #38 was told ahead of time that he was discharging. Interview on 04/28/22 at 11:10 A.M. with SW #572 stated she had been out and returned to work on 04/25/22 and Resident #38 was already gone. SW #572 stated when she returned, she had a stack of papers on her desk and verified she had entered those late entry progress notes on 04/26/22. SW #572 stated she'd met with Resident #38 when she was notified that the nurse indicated he was exit seeking. SW #572 stated when she met with Resident #38, he was own responsible party, he was alert and oriented, and pleasant. SW #572 stated when she did his brief interview mental status (BIMS) his score was 10 (indicating moderate cognitive impairment). SW #572 stated she did the BIMS for admission but liked to wait about two weeks later for a more accurate BIMS when the resident was more settled in, but he was gone before she could do that. SW #572 stated when she spoke with Resident #38, he said to her why would he try to leave when she was helping him find a place. SW #572 stated Resident #38 came from the hospital but was living home with his daughter prior to that. SW #572 stated there were issues between the resident and his daughter. SW #572 stated they had a care conference that included herself, the DON, the resident's daughter, and therapy, although the resident was not receiving skilled services. SW #572 stated the resident was not included due to his daughter's request as she did not want to upset him. SW #572 stated they discussed in the care conference pursuing future placement because the resident was not able to return home with the daughter. SW #572 stated Resident #38's daughter wanted her to send a referral to a specific assisted living, but it allowed the resident to come and go. SW #572 stated the daughter wanted the resident to be private and secured and did not want the resident to just come and go. SW #572 stated it she thought it was related to the resident's drug history and to keep his siblings from taking his money. SW #572 stated it was to protect the resident from them not so much himself. SW #572 stated she only sent the one referral the resident's daughter had requested and informed her of the denial and that was extent of her involvement with Resident #38's discharge. SW #572 stated when she returned to work, she went through the referrals and things that had been done and by who that she documented into the electronic health record on 04/26/22. Interview on 04/28/22 at 11:41 A.M. with the DON revealed while SW #572 was out she managed the discharge by sending referrals to SNF #1, #2, and #3. the DON stated she did not send any referrals to assisted living facilities because she was not aware of any that took waivers and had secured units. the DON stated it was not her area. The DON stated Resident #38 was noted to be exit seeking and had to be put on one on one supervision. The DON stated she was hearing from the nurses and had a brief conversation with the resident where he inquired about Leave of Absences (LOAs). The DON stated she did not have a conversation with the resident regarding exit seeking. The DON stated his cognition was okay. The DON stated based on his history of drug use and family dynamics it was only a matter of time before he tried to leave the facility and she was uncomfortable with the potential risk. The DON stated the resident's daughter wanted him on a secured unit, wanted to restrict his visitors and for him to be in a secure place with freedom and the facility was not a lock down unit. The DON stated Resident #38 had dementia, [CONDITION(S)], and the daughter was in the process of getting guardianship. The DON stated it was a gray area when it came to the resident's daughter as his POA. The DON stated when SNF #1's administrator came out to visit the resident she did not recall the administrator saying one way or the other whether the resident agreed to transfer to that facility. The DON stated she was not sure who informed the resident of the discharge, she had not but believed SW #572 left a voicemail message for the daughter. The DON stated the day Resident #38's discharge was hectic and eventually she had made it upstairs and staff were packing his items. The DON stated the resident was ready to go and walked downstairs with his walker. The DON stated Resident #38 had not mentioned to her that he did not want to leave and did not seem to be upset. The DON stated she believed he wanted to delay his discharge. The DON stated after the resident left, the daughter had come into the facility and stated she did not know about the discharge. The DON stated Resident #38's sister had called the facility and stated she was going to call the police but could not give her any information and told her to call the resident's daughter. Review of facility policy titled Resident Transfer and Discharge Policy and Procedure, undated, revealed the facility shall not transfer or discharge a resident while an appeal is pending if the resident exercises his or her right to appeal a transfer or discharge notice from the facility, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility shall document the danger that failure to transfer, or discharge would pose. All transfers or discharges must be documented in the medical record and appropriate information is communicated to the receiving health care institution or provider. Documentation in the resident's medical record must include: the basis for the transfer, the specific resident need(s) that cannot be met, and the facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s). The resident's physician must make the documentation when transfer or discharge is necessary; and when transfer or discharge is necessary. This deficiency substantiates Complaint Number OH 084.

Based on record review, staff interview, and policy review the facility failed to notify the resident and the resident's representative of a discharge. This affected one (Resident #38) of three residents (#38, #40, and #192) reviewed for discharges. The facility census was 42. Findings include: 1. Review of the closed medical record for Resident #38 revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment, dated 04/03/22, revealed the resident had impaired cognition. The resident required supervision and assistance of one staff for bed mobility, transfers, and required supervision and set up help only for ambulation. Review of the social service note revealed a late entry note dated 04/07/22 at 12:17 P.M. for a care conference held with the resident's daughter, SW #572, the Director of Nursing (DON), and therapy director. The daughter stated she felt the resident needed long-term care due to his declining cognition and increase in behaviors. The daughter was informed of the facility concerns regarding exit seeking behavior from the resident and asked if she agreed with him having a leave of absence (LOA) order. She did not. The daughter was educated that this facility was not a locked dementia unit. It was suggested that alternative placement more appropriate to meet the resident's needs should be explored. The daughter expressed interest in moving him to an assisted living. She was informed he would be allowed to come and go from the facility's assisted living. She stated she did not want to hinder his freedom but felt he would be at risk if he was permitted to leave the facility at will. She stated she would explore alternative settings and asked staff to send his information to a specific assisted living and other facilities that were more appropriate to meet his needs and safety. SW #572 will update as needed. Review of the late entry social services note dated 04/08/22 at 12:49 P.M. revealed Resident #38's daughter was notified that specified assisted living will not accept him due to his needs. Will update as needed. Review of the late entry social services note dated 04/08/22 at 12:52 P.M. revealed the DON faxed Resident #38's information to skilled nursing facilities (SNF) #1, SNF #2, and SNF #3. SNF #2 and #3 declined due to the resident's needs. SNF #1's Administrator contacted the DON and stated they would accept resident to their locked dementia unit. Transportation to be arranged by receiving facility. Will update as needed. Review of the progress note dated 04/18/22 at 2:26 P.M. revealed Resident #38 and his belongings and medications were discharged to SNF #1. Interview on 04/27/22 at 6:11 P.M. with Resident #38's daughter revealed she was the Power of Attorney (POA) for Resident #38, and they had discharged him without her knowledge or consent. Resident #38's daughter stated the resident had called her from his cell phone the day the facility had discharged him, and he was in distress. She stated she heard someone telling him he had to leave, and the phone hung up so she got into her car and headed to the facility. When she arrived he was in the transportation car with his belongings. The daughter stated the transportation lady told her she did not know what was going on. The resident rolled down the window and said to her they told him he had to leave. The daughter stated when they had the care conference, eight to 10 days before they discharged him, she had informed them she wanted him discharged to an assisted living and that she wanted to tour the facilities first. When she went into the facility on the day he was discharged , she had also asked for the discharge paperwork and had not received it. She went into the facility and spoke with two female staff members who told her they had called her, she did not remember their names, but no one had called her. She said the facility did not follow necessary procedures and felt they just kicked him out. She stated the resident was not able to make his own decisions and she was recently awarded guardianship at the hearing on 04/26/22. Interview on 04/28/22 at 10:40 A.M. with State tested Nurse Aide (STNA) #603 stated she packed Resident #38's belongings. STNA #603 stated he had told her he was not going anywhere and had planned to be discharged home the following Tuesday. The resident would not get dressed or allow her to pack his things and she had to inform the nurse. The nurse called the DON multiple times because the resident was not allowing her to pack his items. STNA #603 stated she learned that day Resident #38 was being discharged and was told by the nurse. The resident finally allowed her to pack his items and she and a housekeeper took him and his items downstairs where transportation was waiting outside, the DON was down there as well. He was a little upset but not yelling. STNA #603 stated she was not sure if Resident #38 was told ahead of time that he was discharging. Interview on 04/28/22 at 11:10 A.M. with SW #572 stated she had been out and returned on 04/25/22 and Resident #38 was already gone. SW #572 stated they had a care conference that included herself, DON, the resident's daughter, and therapy. SW #572 stated the resident was not included due to his daughter's request did not want to upset him. SW #572 stated they discussed in the care conference pursuing future placement because the resident was not able to return home with the daughter. SW #572 stated Resident #38's daughter wanted her to send a referral to a specific assisted living, but it allowed the resident to come and go. SW #572 stated the daughter wanted the resident to be private and secured and did not want the resident to just come and go. SW #572 stated she only sent the one referral the resident's daughter had requested and informed her of the denial and that was extent of her involvement with Resident #38's discharge. SW #572 stated when she returned to work, she went through the were referrals and things that had been done and by who that she documented into the electronic health record on 04/26/22. Interview on 04/28/22 at 11:41 A.M. with the DON reveled while SW #572 was out she managed the discharge by sending referrals to SNF #1, #2, and #3. The DON stated she did not send any referrals to assisted livings because she was not aware of any that took waivers and had secured units. The DON stated Resident #38 was noted to be exit seeking and had to be put on one on one supervision. She did not have a conversation with the resident regarding exit seeking and his cognition was okay. She stated based on his history of drug use and family dynamics it was only a matter of time before he tried to leave the facility and the potential risk made her pretty uncomfortable. The resident's daughter wanted him on a secured unit, wanted to restrict his visitors and wanted him to be in a secure place with freedom, not a lock down unit. The DON stated Resident #38 had dementia, [CONDITION(S)], and the daughter was in the process of getting guardianship. She DON stated it was a gray area when it came to if the resident's daughter was his POA. the DON stated when SNF #1's administrator came out to visit the resident she did not recall the administrator saying one way or the other whether the resident agreed to transfer to that facility. The DON stated she was not sure who informed the resident of the discharge and believed SW #572 left a voicemail message for the resident's daughter. The DON stated it was not her. The DON stated after the resident left, the daughter had come into the facility and stated she did not know about the discharge. Review of facility policy titled Resident Transfer and Discharge Policy and Procedure, undated, revealed before the facility transfers or discharges a resident, the facility shall, in a written notice notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. This deficiency substantiates Complaint Number OH 084.

Based on record review, staff interview, and policy review the facility failed to ensure a resident was oriented and prepared for discharge from the facility. This affected one (Resident #38) of three residents (#38, #40, and #192) reviewed for discharges. The facility census was 42. Findings include: Review of the closed medical record for Resident #38 revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment, dated 04/03/22, revealed the resident had impaired cognition. The resident required supervision and assistance of one staff for bed mobility and transfers, and required supervision and set up help only for ambulation. Review of a late entry progress note dated 04/04/22 at 12:12 P.M. revealed Social Worker (SW) #572 spoke with the resident regarding concerns that he wanted to leave the facility. Resident stated he was not looking to leave but wanted to know where he was. He stated he was still interested in moving to an assisted living. He was calm and pleasant while interacting with this worker and presented no psychosocial issues at this time. SW #572 will update as needed. Review of a late entry social service note dated 04/07/22 at 12:17 P.M. revealed a care conference was held with resident's daughter, SW #572, the Director of Nursing (DON), and therapy director. The daughter stated she felt the resident needed long-term care due to his declining cognition and increase in behaviors. The daughter was informed of facility concerns regarding exit seeking behavior from the resident and asked if she agreed with him having a leave of absence (LOA) order. She did not. She was educated that this facility was not a locked dementia unit and it was suggested that alternative placement more appropriate to meet the resident's needs should be explored. She expressed interest in moving the resident to an assisted living. The daughter was informed that the resident would be allowed to come and go from the facility's assisted living. The daughter did not want to hinder the resident's freedom but felt he would be at risk if he was permitted to leave the facility at will. She stated she would explore alternative settings and asked staff to send his information to a specific assisted living and other facilities more appropriate to meet his needs and safety. SW #572 will update as needed. Review of the late entry social services note dated 04/08/22 at 12:49 P.M. revealed Resident #38's daughter was notified that specified assisted living will not accept due to resident's needs. Will update as needed. Review of the late entry social services note dated 04/08/22 at 12:52 P.M. revealed the DON faxed Resident #38's information to skilled nursing facilities (SNF) #1, SNF #2, and SNF #3. SNF #2 and #3 declined due to the resident's needs. SNF #1's Administrator contacted the DON and stated they would accept resident to their locked dementia unit. Transportation to be arranged by receiving facility. Will update as needed. Review of the progress note dated 04/18/22 at 2:26 P.M. revealed Resident #38 and belongings and medications were discharged to SNF #1. Interview on 04/27/22 at 10:04 A.M. with Licensed Practical Nurse (LPN) #616 revealed Resident #38 was a nice guy. LPN #616 stated the resident was put on watch. LPN #616 stated one time he was down by the window looking out and they thought he was trying leave, but he was not. LPN #616 stated there was some type of family dynamics between resident and his daughter. LPN #616 stated she was not working the day Resident #38 discharged but knew he went to another facility. LPN #616 stated the plan was for the resident to go to an assisted living. LPN #616 stated she did not know how the resident's discharge came about but knew someone from the other facility had come to visit the resident. Interview on 04/27/22 at 6:11 P.M. with Resident #38's daughter revealed she was Power of Attorney (POA) him, and they had discharged him without her knowledge or consent. The daughter stated the resident called her from his cell phone the day the facility discharged him, and he was in distress. She heard someone telling him he had to leave, and the phone hung up so she got into her car and headed to the facility. When she arrived he was in the transportation car with his belongings. The transportation lady told her she did not know what was going on and that the nurse had gone back into the facility to get oxygen for the resident. The daughter stated the resident was having trouble breathing and they did not have him on oxygen. The resident was already in the car, he rolled down the window and said to her they told him he had to leave. The daughter stated when they had the care conference, eight to 10 days before they discharge him, she had informed them she wanted Resident #38 to discharge to an assisted living and that she wanted to tour the facilities first. The daughter stated she did not want him confined, she wanted him in an assisted living with his own apartment but with memory care. The daughter stated when she went into the facility on the day he was discharged , she had also asked for the discharge paperwork and had not received it. She went into the facility and spoke with two female staff members who said they had called her, she did not remember their names, but no one had called her. The daughter stated the facility did not follow necessary procedures and felt they just kicked him out. She said the resident was not able to make his own decisions and she was recently awarded guardianship at the hearing on 04/26/22. Interview on 04/28/22 at 10:40 A.M. with State tested Nurse Aide (STNA) #603 stated she packed Resident #38's belongings. STNA #603 stated he had told her he was not going anywhere and had planned to be discharged home the following Tuesday. STNA #603 stated Resident #38 had called his sister on his cell phone, and she did not know what was going on. STNA #603 stated the resident would not get dressed or allow her to pack his things and she had to inform the nurse. The nurse called the DON multiple times because the resident was not allowing her to pack his items. STNA # 603 stated she learned that day Resident #38 was being discharged and was told by the nurse. STNA #603 stated Resident #38 was alert and oriented, slept most of time, and was independent. He finally allowed her to pack his items then she and a housekeeper took him downstairs where transportation was waiting outside. The DON was down there as well. STNA #603 stated the resident was a little upset but not yelling. STNA #603 stated she was not sure if Resident #38 was told ahead of time that he was discharging. Interview on 04/28/22 at 11:10 A.M. with SW #572 revealed been out and returned on 04/25/22 and Resident #38 was already gone. SW #572 stated she had met with Resident #38 when she was notified that the nurse indicated, he was exit seeking. SW #572 stated when she met with Resident #38, he was own responsible party, he was alert and oriented, and pleasant. SW #572 stated when she did his brief interview mental status (BIMS) it was a 10 (indicating moderate cognitive impairment). SW #572 stated she did the BIMS for admission but liked to wait about two weeks later for a more accurate BIMS when the resident was more settled in, but he was gone before she could do that. SW #572 stated when she spoke with Resident #38, he said to her why would he try to leave when she was helping him find a place. SW #572 stated Resident #38 came from the hospital but was living home with his daughter prior to that. SW #572 stated there were issues between the resident and his daughter. SW #572 stated they had a care conference that included herself, DON, the resident's daughter, and therapy. SW #572 stated the resident was not included due to his daughter's as she did not want to upset him. SW #572 stated they discussed in the care conference pursuing future placement because the resident was not able to return home with the daughter. SW #572 stated Resident #38's daughter wanted her to send a referral to a specific assisted living, but it allowed the resident to come and go. SW #572 stated the daughter wanted the resident to be private and secured and did not want the resident to just come and go. SW #572 stated it she thought it was related to the resident's drug history and to keep his siblings from taking his money. SW #572 stated it was to protect the resident from them not so much himself. SW #572 stated she only sent the one referral the resident's daughter had requested and informed her of the denial and that was extent of her involvement with Resident #38's discharge. SW #572 stated when she returned to work, she went through the referrals and things that had been done and by who that she documented into the electronic health record on 04/26/22. Interview on 04/28/22 at 11:41 A.M. with the DON revealed while SW #572 was out she managed the discharge by sending referrals to SNF #1, #2, and #3. The DON stated she did not send any referrals to assisted livings because she was not aware of any that took waivers and had secured units. The DON stated Resident #38 was noted to be exit seeking and had to be put on one on one supervision. The DON stated she was hearing from the nurses and had a brief conversation with the resident where he inquired about LOAs. The DON stated she did not have a conversation with the resident regarding exit seeking. She stated his cognition was okay and based on his history of drug use and family dynamics it was only a matter of time before he tried to leave the facility and the potential risk made her pretty uncomfortable. The DON stated the resident's daughter wanted him on a secured unit, wanted to restrict his visitors and wanted him in a secure place with freedom and the facility was not a lock down unit. The DON stated Resident #38 had dementia, [CONDITION(S)], and the daughter was in the process of getting guardianship. The DON stated it was a gray area when it came to if the resident's daughter was his POA. The DON stated when SNF #1's administrator came out to visit the resident she did not recall the administrator saying one way or the other whether the resident agreed to transfer to that facility. The DON stated she was not sure who informed the resident of the discharge and believed SW #572 left a voicemail message for the resident's daughter of the discharge. the DON stated it was not her. The DON stated the day Resident #38's discharge was hectic and eventually she had made it upstairs and staff were packing the his items. The DON stated he was ready to go and walked downstairs with his walker. Resident #38 had not mentioned to her that he did not want to leave and did not seem to be upset. The DON stated she believed he wanted to delay his discharge. the DON stated after the resident left, the daughter had come into the facility and stated she did not know about the discharge. The DON stated Resident #38's sister had called the facility and stated she was going to call the police but could not give her any information and told her to call the resident's daughter. Review of facility policy titled Resident Transfer and Discharge Policy and Procedure, undated, revealed orientation for transfer or discharge, the facility shall provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the Facility. This orientation must be provided in a form and manner that the resident can understand. This deficiency substantiates Complaint Number OH 084.

Based on observation, interview and record review, the facility failed to develop an individualized care plan for Resident #7's risk for skin breakdown or develop an individualized care plan for Resident #9's refusal of assessed contracture prevention devices and nail care. This affected two (Residents #7 and #9) of 20 residents whose care plans were reviewed (#2, #11, #15, #16, #22, #24, #25, #26, #29, #30, #31, #32, #38, #40, #139, #189, #191 and #192). The facility census was 42. Findings include: 1. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the orders dated 08/26/20 revealed bilateral ankle foot orthotics and a hip abductor orthosis were to be worn for up to eight hours daily. Review of the annual comprehensive assessment Minimum Data Set (MDS 3.0) dated 04/11/22 indicated he was moderately cognitively impaired, and no refusal of care or treatment was indicated. He was totally dependent on two plus staff for activities of daily living. He had functional limitations in range of motion on both upper and lower extremities. He did not receive splint or brace assistance or range of motion. Review of the plan of care lacked development of planned interventions related to his ordered orthotics. There was also no plan of care related to nail care. Interview with and observation of Resident #9 on 04/25/22 at 8:59 P.M. revealed him to be seated in an electric wheelchair. His left hand appeared tight, his nails were excessively long, and some were jagged. Both feet were positioned with the toes pointed. Resident #9 indicated he did not prefer his nails to be long and desired for them to be trimmed. His hand, nails and feet appeared to be in the same condition upon each observation between 04/25/22 and 04/26/22. On 04/27/22 at 8:08 A.M. observation with Licensed Practical Nurse (LPN) #620 present revealed his ankle foot orthotics and the hip abductor were present in the room but not on the resident. LPN #620 asked Resident #9 why he was not wearing the ankle foot orthotics and he responded he refused because they hurt. He did say they apply the hip abductors in the daytime. LPN #620 verified the excessive length of his fingernails. He reported the resident was previously treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . He indicated to LPN #620 he preferred them to be trimmed. LPN #620 asked LPN #616 about the refusal of orthotics. LPN #616 reported Resident #9 consistently refused to use the orthotics, but the physician refused to remove the order. LPN #616 indicated she was one of the few nurses that was able to cut his nails because they were long with skin growing underneath the nails. She feared cutting then for him. LPN #620 suggested getting them professionally trimmed and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with the assessment nurse LPN #635 on 04/27/22 at 12:11 P.M. indicated she was not aware of his refusal of care or staff difficulty in trimming his nails for fear of injuring him and verified those areas were not captured in the care plan. 2. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the history and physical dated 01/25/22 lacked indication of skin impairment. Review of the skin risk assessment (Braden scale) dated 02/01/22 indicated she was at moderate risk for the development of pressure sores. Review of the admission comprehensive assessment MDS 3.0 dated 02/03/22 indicated she was severely cognitively impaired. She required the extensive assistance of one person for activities of daily living and the limited assistance of one staff for eating. She weighed 126 pounds and was 60 inches tall. Resident #7 was identified at risk for the development of a pressure ulcer but had none currently. She was not receiving Hospice services. A significant change MDS 3.0 was in progress with the date of 04/28/22. Review of the aide documentation of skin observation since 03/30/22 indicated on 04/05/22 an open area was present. On 04/18/22 a skin tear was noted. Open areas were noted on 04/17/22, 04/21/22, 04/22/22 and 04/26/22. On 04/21/22 an area was noted as new. Review of the progress notes since admission revealed on 04/14/22 at 3:07 P.M. staff made the nurse aware Resident #7 had an area on the sacrum and left heel. The area was cleaned and measured 0.4 centimeters (cm) x 0.4 cm. Barrier cream was applied. The resident yelled out in pain and pain medication was provided. The nurse practitioner and granddaughter were notified. On 04/14/22 at 3:09 P.M. the heel measured 0.7 cm x 0.7 cm. No depth or description was noted. Review of the pressure ulcer skin grid dated 04/20/22 at 1:17 P.M. indicated Resident #7 sustained a pressure ulcer on 04/15/22 to the left heel. The area measured 2.2 cm x 1.8 cm x UTD Unstageable. This was an unstageable wound of left heel. The wound base was composed of 50% granulation tissue and 50% slough. The wound bed was pink and partially slough. The surrounding skin was dry with moderate serous drainage. Review of the plan of care revealed a skin risk plan was not initiated until 04/25/22 after the development of the pressure ulcers. The plan indicated she had an alteration in skin integrity to the left and right heels and sacrum. Interventions included an air mattress, initiate wound treatment, monitor weekly, refer to dietitian for intervention, turn and reposition with routine rounds and as needed. Interview with the assessment nurse LPN #635 on 04/27/22 at 12:35 P.M. verified the plan of care was not developed for Resident #7 when she was identified at risk for pressure ulcers.

Based on record review, staff interview, and policy review the facility failed to obtain weights as ordered by the physician to ensure accurate assessment and treatment by the dietitian for a resident identified at nutritional risk. This affected one (Resident #24) out of three residents reviewed for nutritional related concerns. The facility census was 42. Findings include: Review of the medical record for Resident #24 revealed an admitted [DATE]. The resident was discharged to the hospital on 01/29/22 and returned to the facility with a percutaneous endoscopic gastrostomy (PEG) tube on 02/12/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the electronic weight records for Resident #24 revealed on 02/12/22 the resident weighed 140.14 pounds. No weights were documented for 02/14/22, 02/21/22, 02/28/22, or 03/07/22 as ordered. The resident was documented to weigh 111.4 pounds on 03/09/22. Review of additional weight records documented on paper, revealed the resident weighed 139 pounds on 03/01/22, and 109.8 pounds on 03/08/22. Review of the most recent quarterly Minimum Data Set (MDS) assessment, dated 03/16/22, revealed the resident had impaired cognition. The assessment also noted Resident #24 sustained weight loss greater than 5% in the past month or 10% in the past six months. Interview on 04/27/22 at 3:02 P.M. with Dietitian #635 verified Resident #24's weight was not obtained or documented per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Dietitian #635 reported having access to weights for 02/12/22 and 03/09/22 as documented in the electronic medical record. Dietitian #635 was unaware of any other weights being obtained for Resident #24 within the required time period. Dietitian #635 verified having access to additional weights would have impacted Resident #24's care and treatment. Interview on 04/28/22 at 9:40 A.M. with the Director of Nursing (DON) revealed the DON would begin asking nursing staff to submit resident weights so the DON could ensure weights were being documented in resident medical records. Review of facility policy titled Weight Policy, not dated, revealed weights would be obtained in a timely and accurate manner, documented and responded to in an appropriate manner.

Based on interview, observation and review of temperature logs the facility failed to ensure foods were served at a palatable and appetizing temperature. This affected 39 of 41 residents who take food by mouth. Findings include: Interviews with Residents #3, #18 and #35 on 01/10/22 between 8:35 A.M. and 8:50 A.M. revealed taste and temperature of the food was not palatable. The residents reported sometimes the staff just microwave it before serving the food. On 01/10/22 at 8:19 A.M. tray line was observed for the breakfast meal. All meals were served in three compartment, clear plastic containers with attached lids. Interview with Cook #230 on 01/10/22 at 8:25 A.M. indicated the facility was using disposable items due to having COVID 19 positive residents in the building. He reported he knew the food would be cold by the time the resident's received the meal but he made sure the food was hot when it left the kitchen. Review of the food temperature logs for the last 30 days revealed a beginning temperature and an end temperature of the foods on the steam table. The temperatures of the foods exceeded 160 degrees F with the majority at 180 to 210 degrees F when on the steam table. Indicating the food was leaving the kitchen at a hot temperature. On 01/10/22 at 11:00 A.M. tray line was observed for the lunch meal. Cook #230 was observed to take the temperatures of the foods on the steam table. The breaded pork chops measured 179 degrees Fahrenheit (F), rice measured 195 F, zucchini measured 200 F, hamburger measured 182 F, chicken breast measured 194 F, gravy 200 F and pureed foods 184 F. All foods were served in Styrofoam containers. On 01/10/22 at 11:37 A.M. the test tray was placed on the open air cart, covered with a thin plastic cover. The cart arrived on the unit at 11:46 A.M. The first tray was passed at 11:49 A.M. State tested Nurse Aide (STNA) #210 was observed to heat up the meal in the microwave prior to delivering it to the room. STNA #256 placed six meals on a smaller cart and delivered them without heating them up. Registered Nurse (RN) #252 also delivered meals without heating them up. The last tray was passed at 12:30 P.M. A test tray was conducted independently of facility staff despite a request for staff to be present. The test tray was conducted on 01/10/22 at 12:32 P.M. The pork measured 90 F, rice with gravy measured 100 F and the zucchini measured 105 F. All of the food was tasted. The foods tasted luke warm to cold causing the flavor of the food to not be appetizing. The Administrator was informed of the test tray findings. A request for a food temperature policy was requested but not received. This deficiency substantiates Complaint Number OH 857.

Based on interview and record review the facility failed to promptly notify Residents #3, #27 and #35 of a change in room or roommate assignment. This affected three of three residents reviewed for room/roommate changes. Findings include: 1. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress note dated 12/04/21 at 3:50 P.M. revealed the emergency contact and the physician were made aware she tested positive for COVID 19. She was moved to a private room. The note indicated the resident, emergency contact and physician were made aware of the room change and were in agreement. There were no other room or roommate change notes in the progress notes. The census tab indicated on 08/01/21 she was moved to semiprivate room, 12/04/21 she was moved to private room and on 12/22/21 she was moved to a semiprivate room. Interview with Social Worker (SW) #214 on 01/11/22 at 10:00 A.M. and the Director of Nursing (DON) on 01/11/22 at 1:35 P.M. verified the facility lacked evidence the resident or representative were notified promptly of all changes in room or roommate assignments. 2. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of census revealed she resided in the same room since her admission on 08/26/20. Further record review revealed on 12/22/21, Resident #35 was admitted as her roommate. There was no evidence found in the medical record she was notified she would receive a roommate. Interview with SW #214 on 01/11/22 at 10:00 A.M. and the DON on 01/11/22 at 1:35 P.M. verified the lack of evidence the resident or representative were notified promptly of changes in room or roommate assignments. 3. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was moved from to a new room on 01/07/22. There was no notation in the medical record of the reason for transfer or of notification of the transfer. Interview with SW #214 on 01/11/22 at 10:00 A.M. and the DON on 01/11/22 at 1:35 P.M. verified the facility lacked evidence the resident or representative were notified promptly of changes in room or roommate assignments. This deficiency substantiates Complaint Number OH 739.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on medical record review, observation, interviews with staff, and review of the facility ' s investigation, the facility failed to ensure adequate supervision to prevent a resident, who was displaying exit seeking behavior from climbing out of a third floor window and falling onto a ledge located just below the second floor. This resulted in Immediate Jeopardy when Resident #41 climbed out of the third-floor window of another resident ' s room without staff knowledge. Actual harm occurred when Resident #41 was hospitalized with unspecified compression fractures of the vertebrae, tongue hematoma, and decreased kidney function. This affected one of four residents (#5, #15, #32, and #37) identified as being at risk for elopement and who resided on the third floor. Facility census was 40. On 11/16/20 at 5:36 P.M. the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 11/08/20 at approximately 2:30 A.M. when State tested Nurse Aide (STNA) #109 noticed Resident #41 was not in his room. At 3:00 A.M. STNA #109 notified Licensed Practical Nurse (LPN) #103 that she was unable to locate Resident #41. LPN #103 searched the floor and at 3:11 A.M. notified the DON she was unable to locate Resident #41. LPN #103 called a Doctor Walker (overhead page alerting all staff of missing resident) and initiated a search of the surrounding area. At approximately 3:20 A.M., the second-floor nurse, LPN #107 located Resident #41 on a ledge outside of room [ROOM NUMBER]. Emergency Medical Services (EMS) were immediately called. EMS arrived shortly after 3:22 A.M. and had to break the window in room [ROOM NUMBER] to rescue Resident #41 from the ledge. The resident was transported to the hospital. The Immediate Jeopardy was removed and corrected on 11/13/20 when the facility implemented the following corrective action: · On 11/08/20 at 3:30 A.M., a full house head count was completed by LPN #103 on the third floor and by LPN #107 on the second floor. All residents were accounted for. · On 11/08/20 at 3:35 A.M., Wanderguard placement and function was verified for all residents with orders for a Wanderguard (a device that activates an audible alarm when a resident wearing the device attempts to leave monitored doors) by LPN #103. · On 11/08/20 at 3:45 A.M., an audit of the elopement binder was completed by the DON. The elopement binder was complete and up to date. · On 11/08/20 at 4:30 A.M., a full house window and door alarm audit was completed by Maintenance Director (MDR) #110. All door and door alarms were working properly. All windows were working appropriately except for the locking mechanisms on the windows in rooms [ROOM NUMBERS] which were damaged by Resident #41 and EMS. The window locking mechanisms were repaired by MDR #110. · On 11/08/20 at 4:37 A.M., Resident #41 ' s physician was notified of the incident by the DON. · On 11/08/20 at 4:45 A.M., the Administrator initiated full house window audits which will be completed by MDR #110 or designee three times a week for three weeks and then once a month for three months. Results will be reported to the Quality Assurance Committee. · On 11/08/20 at 5:15 A.M. Resident #41 ' s guardian was notified on the incident by the DON. · On 11/08/20 at 7:00 A.M., education on elopement, ensuring residents are free from accidents and hazards, and appropriate window opening was started by the Administrator. All department managers were educated by the Administrator and they began educating the staff in their respective departments. Review of sign-in sheets confirmed All department managers received the education. · On 11/08/20 between 7:02 A.M. and 3:10 P.M., the DON audited all residents with wandering behaviors and completed elopement risk screens for all residents. Care plans were updated to reflect the current elopement risks. · On 11/08/20 at 1:30 P.M., the Medical Director was notified of the incident by the DON. · On 11/08/20 at 7:00 P.M., the education on elopement, ensuring residents are free from accidents and hazards, and appropriate window openings was completed for all staff by the department managers. Review of sign-in sheets confirmed all facility staff received the education. · On 11/09/20 at 9:30 A.M., additional hardware was installed to further secure all windows by Maintenance Workers (MW) #115 and #116. · On 11/11/20 at 3:30 P.M., education on communication of changes of conditions including increased wandering and exit seeking behaviors was initiated by the DON. This education was completed on 11/13/20. Review of sign-in sheets confirmed all direct care staff received the education. · The incident investigation, plan of correction, education, and ongoing audits will be presented to the Quality Assurance Committee for review and recommendations. · On 11/17/20 from 4:24 P.M. to 4:49 P.M. and on 11/18/20 at 11:26 A.M. interviews with LPN #102, LPN #107, STNA #100, STNA #105, and STNA #109 regarding elopement, ensuring residents were free from accidents and hazards, appropriate window openings, adequate supervision, and nursing call off procedures revealed all staff were knowledgeable regarding the policies and procedures. Findings include: Record review revealed Resident #41 was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and required supervision with no set up help for bed mobility, transfers, and was independent with ambulation. Review of Resident #41 ' s elopement risk screen dated 07/24/20 revealed the resident was at risk for elopement. Review of the November 2020 recap of physician orders [REDACTED].#41 ' s left ankle. Review of nursing notes dated 07/31/20 at 6:33 A.M. revealed Resident #41 was observed several times attempting to get on the elevator, upon redirection the resident stated he was leaving. A Wanderguard was placed on his left ankle. The note indicated staff was monitoring closely throughout shift. Review of the elopement risk assessment dated [DATE] revealed Resident #41 was not at risk for elopement. Review of the nursing notes dated 10/11/20 at 3:24 P.M. revealed Resident #41 was very confused, pacing the unit, asking where is my room? The resident was also observed wandering into other rooms, resident denied pain, denied not feeling well, blood sugar was 410. The Nurse Practitioner (NP) was notified and new order given to obtain urinalysis. Review of the nursing note dated 10/31/20 at 5:20 A.M. revealed Resident #41 began displaying exit seeking behaviors. Resident #41 was redirected multiple times by LPN #107 and the STNAs. Review of the nursing note dated 11/08/20 at 3:20 A.M. revealed Resident #41 was observed lying on a ledge outside. EMS was immediately called, arrived at the facility, and transported Resident #41 to the hospital. The legal guardian and NP were notified. Review of the facility ' s investigation dated 11/08/20 revealed Resident #41 dismantled a window security mechanism in room [ROOM NUMBER] and attempted to climb out the window to the second-floor balcony outside of the window in room [ROOM NUMBER] at about 3:11 A.M. Further review of the facility investigation revealed the root cause was identified as increase in exit seeking behaviors. Further review of the investigation revealed an undated handwritten statement by STNA #109 indicating she last saw Resident #41 at 2:00 A.M. when she was doing her rounds. When STNA #109 came back to complete Resident #41 ' s roommate ' s bed check after 2:30 A.M. she noticed Resident #41 was not sitting in his chair anymore. STNA #109 stated they searched all the rooms on the third floor. Another staff member noticed him outside on the roof and called the police. Review of a handwritten statement dated 11/08/20 by LPN #103 revealed at about 2:25 A.M. Resident #41 was observed in his room writing on the wall while sitting on the side of the bed. At 3:00 A.M. the STNA noticed Resident #41 was not in the room, a room search began on the floor and throughout the facility. The DON was called while LPN #103 was doing an outside perimeter search at 3:11 A.M. The nurse on the second floor, LPN #107, called and notified LPN #103 that Resident #41 was on the second-floor ledge. EMS was called around 3:20 A.M. The DON was called again at about 3:22 A.M. and the rescue squad, fire department, and police arrived while speaking with the DON. Resident #41 was taken from the ledge to the ambulance for transport to the hospital. Review of a handwritten statement dated 11/08/20 by LPN #107 revealed at around 4:00 A.M., LPN #103 told her she could not find Resident #41 and had asked LPN #107 to check the Assisted Living (AL) unit. When LPN #107 returned to her unit, she called and informed LPN #103 she did not see Resident #41. LPN #103 stated she was going to search around the building. Once LPN #107 was off the phone with LPN #103 she looked out the window in the dining area and saw Resident #41 laying on a ledge. LPN #107 called LPN #103 to come down because she saw Resident #41 outside on a ledge. LPN #103 came down, immediately called 911, and they both watched Resident #41 from the window until help arrived and he was safe. LPN #107 indicated LPN #103 made all the appropriate phone calls. Review of a typed statement by the DON revealed she was called by LPN #103 at 3:11 A.M. and notified Resident #41 was missing and search of the facility and immediate surrounding areas was in process. The DON contacted the Administrator at 3:15 A.M. to notify him of the missing resident. The DON indicated at 3:20 A.M. she received a call Resident #41 had been found and was lying on a ledge by room [ROOM NUMBER]. When the DON arrived at 3:30 A.M. Resident #41 was in the squad on a cart, lying on his left side with his knees flexed. The squad personnel were cutting the arm of the coat off Resident #41. The DON was informed the resident was conversing and told the police officer that he did not know what happened. The DON interviewed the resident in room [ROOM NUMBER] (Resident #4) who told the DON that he was sleeping and had no knowledge of what happened. The resident did say he thought someone was trying to climb out of his window, but his back was toward the window and he had his eyes closed. The resident in room [ROOM NUMBER] had his bed placed against the wall and in front of the window. Upon entry to room [ROOM NUMBER], it was noted that the foot of the bed had been pulled out from the wall about a foot. Review of the care plan initiated on 11/09/20 revealed Resident #41 exhibited behavior symptoms such as verbal aggression, wandering and exit seeking behavior at times. Interventions included document all behaviors, attempt to identify pattern to target interventions, provide Wanderguard, redirect negative behavior. Tour of the facility on 11/16/20 at 9:30 A.M. revealed no observed concerns related to the windows in the common areas. There was no observation of a balcony. Interview on 11/16/20 at 9:58 A.M. with the Administrator and DON revealed they were notified about 3:00 A.M. on 11/08/20 of Resident #41 being missing. The Administrator stated somehow the resident broke the lock on the window and climbed out the window and was found on the balcony and ledge. When Resident #41 was found he was wearing his coat. The Administrator said Resident #41 was in the hospital, but they did not have any real details except that he was stable but in serious condition. Resident #41 had movement of his arms and legs. The Administrator stated they had no indication Resident #41 was capable of doing this, he wore a Wanderguard, and resided on the dementia unit. The Administrator stated Resident #41 was last seen in his room [ROOM NUMBER] minutes prior. Interview on 11/16/20 at 11:17 A.M. with LPN #102 revealed Resident #41 had exit seeking behaviors periodically. Observation of the window in room [ROOM NUMBER] with LPN #102 revealed a white block of wood with three screws. LPN #102 stated she never paid attention to the windows before. Further observation in the dining area revealed the ledge where Resident #41 was found. The ledge was small and located on the second level, just below the window. The ledge did not have a railing or any form of enclosure. One shoe was observed on the ledge. LPN #102 said the shoe belonged to Resident #41. LPN #102 explained the windows were recently reinforced and only partially open. LPN #102 did not think the windows were prevented from fully opening before, the white block of wood preventing the window from fully opening was new. Observations of all windows on the second and third floors on 11/16/20 from 1:14 P.M. to 1:33 P.M., revealed no concerns, the windows did not fully open. The windows slid open toward the left and were prevented from opening all the way by a white block of wood that was screwed into the window track. During interview with Resident #4 on 11/16/20 at 1:34 P.M. he initially stated he did not know what happened, he was asleep. However, he then stated someone was messing with his window. Resident #4 stated he did not know what the man was doing because he was asleep. Interview on 11/16 /20 at 1:38 P.M. with the Administrator and DON revealed the DON received a referral from the hospital for Resident #41 to return to the facility. The DON stated she had not read through the referral but stated Resident #41 may need [MEDICAL TREATMENT] due to the sedation medications affecting his kidney and that he had some broken bones. Interview on 11/16/20 at 1:54 P.M. with MDR #110 revealed he usually completed window checks twice a year. MDR #110 started working at the facility in May 2020 and did the first window checks on 06/10/20 and had planned to do another window check in December 2020. MDR #110 stated when he checked the windows in June, he looked for broken glass and ensured the windows opened six inches. There were no concerns at that time. There was either a [MEDICATION NAME] or a single screw to the aluminum track of the window to prevent it from opening more than six inches. MDR #110 came in the facility on the day of incident and the window in room [ROOM NUMBER] was okay it was just missing the screw. MDR #110 looked for the screw under the bed but did not find the screw, he was not sure what happened to the screw. Interviews on 11/16/20 at 2:35 P.M. and 4:59 P.M. with STNA #109 revealed there were two nurses and one STNA working in the facility on the third shift at the time Resident #41 went out the window. STNA #109 stated on the day of the incident Resident #41 had some confusion and stated he wanted to get the hell out of here. Resident #41 had to be redirected multiple times by her and LPN #103. STNA #109 had last seen Resident #41 around 2:00 A.M. sitting in the chair in his room with his coat and shoes on while she was doing her rounds. STNA #109 went to another resident room and then went to gather supplies for Resident #41 ' s roommate. STNA #109 stated as she was going to Resident #41 ' s room, LPN #103 was coming down the hall, and that ' s when she asked LPN #103 where Resident #41 was. STNA #109 had assumed LPN #103 was in another resident ' s room when she saw her coming down the hall. After they did a search LPN #107 called and said Resident #41 was outside on the ledge. When they went to room [ROOM NUMBER], the blinds were down and closed but looked slanted and the window was wide open. The resident in room [ROOM NUMBER] was in bed and had stated he did not know anything; he was asleep but then stated a man went out his window. STNA #109 stated the resident in room [ROOM NUMBER] had been confused. Interview on 11/16/20 at 2:49 P.M. with LPN #102 revealed she worked a double shift on 11/07/20 from 7:00 A.M. to 11:00 P.M. on the third floor and Resident #41 was okay, no agitation, nothing unusual. Follow up interview on 11/16/20 at 3:22 P.M. with the DON revealed she had not read through the entire referral but Resident #41 ' s injuries included an undetermined compression [MEDICAL CONDITION]. The DON stated it was undetermined due to chronic arthritis of the spine. The DON stated Resident #41 also had a tongue hematoma from biting his tongue. Interview on 11/16/20 at 5:29 P.M. with the Administrator and DON revealed there were three no call no shows on the third shift, 11:00 P.M. to 7:00 A.M., on 11/07/20 going into 11/08/20. The DON stated the no shows were from contracted agencies. The charge nurse was to call the agencies to find out about the staff that did not show up. The DON did not know about the three no calls no shows until she was notified about the incident involving Resident #41. The Administrator stated they looked at staffing in relation to the incident and felt there were no concerns related to staffing levels. Interview on 11/17/20 at 8:40 A.M. and 9:34 A.M. with LPN #103 revealed on the day of the incident Resident #41 was exit seeking, stating he was going home, and had to be redirected twice by her. LPN #103 stated she believed she last saw Resident #41 at approximately 2:15 A.M., right before she left the unit and went downstairs to relieve LPN #107 who was working on the second floor. LPN #103 stated Resident #41 was in his room, sitting on his bed, writing on the wall with a [MEDICATION NAME]. LPN #103 had asked him what he was doing, and he responded for her to just chill. LPN #103 said it was unusual behavior for Resident #41 to write on the wall. STNA #109 was sitting in the day area when she left the unit to relieve LPN #107. LPN #103 stated they were working short because three-agency staff did not show up. LPN #103 called the three agencies and only received one return call, and that agency was unable to locate the staff. LPN #103 said working with three staff was hard. When LPN #103 returned to the unit a little before 3:00 A.M., STNA #109 was in the day area sitting. LPN #103 went to the nurse ' s station and STNA #109 stated they could provide care to Resident #41 ' s roommate and started walking toward the room. STNA #109 then asked where Resident #41 was. That was when they began the search, checking every room, AL, and searched outside in her personal car. LPN #107 and STNA #109 stayed in the building and continued to search while LPN #103 was searching outside in her car. LPN #103 received a call from LPN #107 indicating she looked out the window and saw Resident #41 on a ledge. The DON arrived after Resident #41 was found. LPN #103 stated the window which Resident #41 had exited was wide open and appeared to be opened to the right and the screw was to the left (the windows normally opened by sliding it to the left toward the screw). Interview on 11/17/20 at 11:27 A.M. with LPN #107 revealed she worked the day of the incident and they were short staffed with only one STNA in the building. LPN #107 stated the staffing agencies were contacted but only one responded but could not locate the staff. LPN #107 did not contact the DON regarding the staffing because she felt it was quiet on the second floor. They assigned the STNA to work on the third floor because the third-floor unit needed more hands because of the wandering behaviors of the residents. LPN #107 stated LPN #103 came down to relieve her around 3:00 A.M. for about 30 minutes, LPN #107 did not remember the exact time because a lot happened. LPN #107 stated when she returned to the unit LPN #103 went back up to the third floor and as soon as she did, she called stating Resident #41 was missing. LPN #107 stated after she searched the AL, she had called LPN #103 who then stated she was going to search around the building. LPN #107 was in the dining area on the second floor and just happened to look out of the window and saw Resident #41. LPN #107 called LPN #103 who called 911 and the DON. LPN #107 stated working with three staff, two nurses and one STNA, was not okay. A second observation of the ledge from the third-floor dining area window on 11/18/20 at 11:37 A.M. revealed a flat surface, partially covered with snow which was approximately two feet wide by six feet long, with no railings or any form of enclosure, located just below the window located on the second floor. The ledge appeared to be above an entry way adjacent to a black canopy that stretched over the walkway. A shoe was observed near the edge of the ledge facing the dining area window. Review of timeanddate.com revealed on 11/08/20 from 12:00 A.M. to 6:00 A.M. the temperature was 41/45 degrees Fahrenheit. Review of the facility's policy titled Elopement Prevention revised 01/17/20 revealed it was the facility ' s policy to ensure that a resident's environment remained as free from accident hazards as was possible while living in the facility. Further, it was the goal of the facility to provide a safe environment for all residents while using the least restrictive measures possible. This deficiency substantiates Complaint Number OH 185.

Based on observation, record review, interview, and review of facility policy, the facility failed to provide adequate supervision and a safe environment when Resident #20, who was at risk for elopement, left the nursing unit unaccompanied by staff and was found wandering in the Assisted Living building, where there were two unlocked stairwells leading to two unlocked exit doors and a balcony area. This resulted in Immediate Jeopardy for one resident (Resident #20) who displayed exit seeking behaviors, and although had been provided a Wanderguard bracelet, the exterior doors did not have the Wanderguard system installed or the doors were unlocked. Additionally, staff failed to implement measures to prevent possible elopement. This affected one of four residents identified at risk for elopement. The facility census was 45. On 01/15/15 at 2:53 P.M., the Administrator, Vice President of Clinical Operations #108, Corporate Administrator #109, and Regional Quality Assurance Nurse #107 were notified that Immediate Jeopardy began on 01/14/15 at 12:01 P.M. when unlocked double doors were observed on the second floor assisted living area that led to an unlocked balcony area. On 01/14/15 at 12:05 P.M., a second unlocked door on the second floor assisted living area led to a stairwell which lead to another unlocked door without a Wanderguard system installed that led to the outside of the building. On 01/14/15 at 1:09 P.M. another unlocked door was observed past the unlocked double doors on the second floor assisted living area which led to a stairwell which led to an unlocked exterior exit door not equipped with the Wanderguard system. The Immediate Jeopardy was removed on 01/14/15 at 4:00 P.M. when Resident #20 was placed on a 1:1 staff monitoring. This was verified by observation on 01/14/15 at 4:00 P.M. and reduced the potential for imminent danger to Resident #20. Although the Immediate Jeopardy was removed, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility had not yet implemented their plan to move Resident #20 to the third floor skilled nursing unit and place a Wanderguard alarm on the third floor skilled nursing unit exit door. The three other residents assessed as at risk for elopement, Residents #22, #36 and #51, reside on the third floor skilled nursing unit, the doors have keypad releases, and the residents wear Wanderguard bracelets. Findings include: Review of the medical record for Resident #20 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident#20 resided on the second floor skilled nursing unit. Review of a physician order [REDACTED].#20 was to have a Wanderguard bracelet (an electronic device that locks any doors connected to the Wanderguard system, preventing exit from the facility), applied to the right lower leg and to check placement of the device every shift. Review of the plan of care dated 07/21/14 revealed Resident #20 exhibited the problematic behavior of wandering related to his cognitive impairment, inability to locate own room, attempted to leave unit/building if not prevented and removed Wanderguard bracelet. The goal of the plan of care was for Resident #20 to wander only within specified boundaries however the plan did not provide any parameters of those specified boundaries. Interventions included to allow the resident to wander on the unit, escort resident to and from dining room and activities, provide supervision during recreation programs and to take resident for walks when he exhibited wandering behavior. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 was severely cognitively impaired and had a behavior of wandering four to six days per week. Resident #20 was also assessed to require limited assistance of one person physical assist for movement off of the unit. Review of an elopement risk decision tree form dated 11/01/14 identified Resident #20 to be at risk for elopement. Review of a nurses ' note dated 01/03/15 at 10:00 A.M., written by Registered Nurse (RN) #102, indicated Resident #20 left the nursing unit to go to the second floor assisted living area and became agitated when staff attempted to stop the resident from leaving. The nurse called the assisted living nurse to inform the nurse that the resident was coming in that direction and to watch the resident and the assisted living nurse agreed. The note reflected the assisted living nurse returned Resident #20 to the nursing unit at 10:15 A.M. Review of a nurses ' note dated 01/03/15 at 10:45 A.M., written by RN #102, identified Resident #20 left the unit again walking to the second floor assisted living area and became very agitated when staff attempted to stop the resident from leaving the unit. The assisted living nurse was called to inform her that Resident #20 was coming in that direction and to watch the resident. The assisted living nurse returned Resident #20 to the nursing unit at 11:00 A.M. Review of a nurses ' note dated 01/03/15 at 11:55 A.M., written by RN #102, stated Resident #20 left the unit again, went to the second floor assisted living area and continued to become agitated when staff tried to stop the resident from leaving the unit. The nurse documented that the assisted living nurse was called to inform her that Resident #20 was coming in that direction and to watch the resident and the assisted living nurse agreed. The note further reflected at 11:57 A.M., Resident #20 returned to the unit on his own. Staff asked the resident to sit for lunch and the resident agreed. Observation of the exit door from the second floor skilled nursing unit to the assisted living unit on 01/12/15 at 4:40 P.M. revealed the door had a motion sensor alarm but was not locked or connected to the Wanderguard system. Observation on 01/12/15 at 4:55 P.M. on the second floor skilled nursing unit revealed an unidentified staff member was heard yelling into the second floor nursing unit that Resident #20 was outside of the unit. Licensed Practical Nurse (LPN) #100 notified State-tested Nurse Aide (STNA) #101 who returned Resident #20 to the nursing unit. Interview with LPN #100 on 01/12/15 at 4:58 P.M. revealed it was preferred that Resident #20 have a staff member with him when he was off of the unit but it was not required. Resident #20 was observed lying in his bed on 01/13/15 at 8:26 A.M. His eyes were closed and his legs were covered by blankets, consequently the Wanderguard bracelet was unable to be visualized. Interview with RN #102 on 01/13/15 at 4:24 P.M. revealed Resident #20 could wander to the assisted living area but staff should stay within eye sight of the resident when doing so. Interview on 01/13/15 at 4:57 P.M. with LPN #100 verified Resident #20 wandered outside of the second floor skilled nursing unit and into the assisted living area. LPN #100 stated she did not know the name of the staff member who notified her that the resident was off of the unit but verified that the staff member was not working on the unit. LPN #100 stated she did not know when the resident left the unit and was unsure if the two STNAs assigned to the unit were aware when the resident left the unit. LPN #100 stated Resident #20 should be escorted by a staff member when off of the unit. Interview with Maintenance Director #106 on 01/14/15 at 7:31 A.M. stated the Wanderguard system was checked weekly. Review of a work history report dated 01/16/15 revealed that the Wanderguard system had been checked on 01/12/15. Interview with Maintenance Director #106 on 01/16/15 at 12:57 P.M. verified that all of the doors with the Wanderguard system were functioning on 01/12/15. Interview with Receptionist #103 on 01/14/15 at 11:52 A.M. stated she would call the nurse on the second floor skilled nursing unit to let her know the resident was on the first floor. She said she had seen Resident #20 wandering on the first floor in the past. She couldn ' t recall the exact date but it was during the warm months. Observation on 01/14/15 at 12:01 P.M. of the second floor assisted living building revealed an unlocked set of double doors at the end of the hallway to the left of the exit from the second floor skilled nursing unit. These doors led to a room with storage lockers on the right and straight ahead to an unlocked door to a patio area with a balcony. Observation on 01/14/15 at 1:09 P.M. of this room revealed another storage area on the left and a stairwell which led to an unlocked exit door from the building. These observations were verified on 01/14/15 at 1:22 P.M. with the Administrator, Vice President of Clinical Operations #108 and Regional Quality Assurance Nurse #107. Observation of the second floor assisted living area on 01/14/15 at 12:05 P.M. revealed at the end of the long hallway to the right of the exit from the second floor skilled nursing unit, there was an unlocked door leading to a stairwell that led to an unlocked exit from the building. This observation was verified with the Administrator on 01/14/15 at 1:17 P.M. Interview with STNA #105 on 01/14/15 at 12:09 P.M. stated Resident #20 attempted to wander off the unit three to four times per week during the day. STNA #105 stated the resident had attempted to get down the stairs at the end of the hallway on the second floor in the assisted living area. STNA #105 stated the resident would not know which door to use to come back to the unit. Interview with the Administrator on 01/14/15 at 12:51 P.M. stated Resident #20 should be escorted when going to and from activities in the assisted living area. Interview with STNA #104 on 01/14/15 at 3:31 P.M. stated Resident #20 made attempts to leave the skilled nursing unit at least daily. Interview with STNA #101 on 01/14/15 at 3:38 P.M. stated Resident #20 made attempts to leave the skilled nursing unit daily. Interview with LPN #106 on 01/14/15 at 3:47 P.M. stated Resident #20 did make attempts to leave the unit and the frequency in which he did so depended on the day. LPN #106 stated the resident attempted to leave the unit several times on 01/14/15. Interview with STNA #101 on 01/14/15 at 3:53 P.M. stated Resident #20 would attempt to go to the elevator but did not know how to work the elevator. Observations on 01/15/14 at 8:30 A.M. of the second floor revealed an elevator at the end of the hall that was secured with a number code and an exit door adjacent to the elevator that was locked. Interview with Maintenance Director #106 on 01/15/15 at 8:45 A.M. stated the lock to the double doors on the second floor hallway in the assisted living area that led to the storage and balcony area had stopped functioning on 01/11/15 and needed to be repaired. There was no evidence the facility had initiated a plan to fix the door locks. Interview with the Director of Nursing (DON) on 01/15/15 at 9:51 A.M. verified that the progress notes dated 01/03/15 indicated Resident #20 was not under direct supervision when he left the second floor skilled unit on 01/03/15. A telephone interview with STNA #101 on 01/15/15 at 10:49 A.M. revealed on 01/12/15, she was notified by LPN #100 to go get Resident #20 and walk with him. STNA #101 stated when she came upon Resident #20 he was at the end of the hallway on the second floor assisted living area to the left of the exit of the skilled nursing unit by the windows next to the elevator. STNA #101 stated she observed no other staff members in the immediate area of where she found Resident #20. STNA #101 stated she had difficulty redirecting Resident #20 to the unit and then was assisted by another staff member from the assisted living area to bring the resident back to the unit. A telephone interview with LPN #100 on 01/15/15 at 11:06 A.M. revealed she was unsure if Resident #20 was at the skilled nursing unit door or was through the door and on the assisted living unit on 01/12/15. Interview on 01/15/15 at 11:27 A.M. with RN #102, who wrote the nurses ' notes on 01/03/15, revealed an unknown STNA was sent with Resident #20 and had stayed within eyesight of the resident when he left the unit on 01/03/15. Interview with the DON on 01/15/15 at 4:03 P.M. verified the progress note dated 01/03/15 at 11:57 A.M. documented Resident #20 returned to the unit on his own. The DON indicated that she believed the nurse was indicating the resident returned to the unit without being told to do so. Observation of the main entrance doors on 01/15/15 at 10:32 A.M. with Maintenance Director #106 and the Life Safety Code surveyor revealed the two doors were equipped with a Wanderguard system and were tested . The testing device was placed next to the right side door. The door should have locked when the testing device was placed next to the sensor on the side of the door however, the door remained open and did alarm. This was verified with Maintenance Director #106 at the time of observation. Observation of a side door entrance on 01/15/15 at 10:37 A.M. with Maintenance Director #106 and the Life Safety Code surveyor revealed the door was equipped with a Wanderguard device on the side of the door and was tested . The testing device was placed next to the sensor of the door. The door should have locked however, the door remained open. This was verified with Maintenance Director #106 at the time of observation. Maintenance Director #106 stated that the door did have an alarm that was sent to a notification center on the nursing units and a staff member should respond to the alarm. A staff member did respond to the alarm at 10:39 A.M. Review of the facility ' s Immediate Plan of Correction dated 01/15/15 revealed all staff would be educated on the changes in the Elopement Policy and Procedure, which included the addition of a Wanderguard alarm at the third floor skilled nursing unit ' s door to the assisted living area and moving Resident #20 to the third floor skilled nursing unit. Review of the Inservice Sign-In Sheets dated 01/15/15 through 01/19/15 revealed 39 nurses and STNAs, three activities staff, five therapy staff, 10 housekeeping staff, 13 dietary staff and 18 assisted living staff were educated on the changes to the policy. Review of a facility policy entitled ' Resident Safety: Elopement ' last updated 10/06/06, included interventions for residents at risk for elopement to have redirection by staff and volunteers, stop signs on exit door, and alarms on all exit doors.