Every finding on record at Spring Creek Nursing and Rehabilitation Center LLC

Based on observation, interview, review of the Resident Council Minutes, and review of the facility policy, the facility failed to ensure residents were offered fresh water daily. This affected all residents except four (#27, #37, #43, #56) residents identified as receiving nothing by mouth (NPO). The facility census was 71.Findings include:Observation on 05/04/26 at 9:00 A.M. on the [NAME] hallway revealed residents did not have fresh water in their rooms.Observation on 05/05/26 at 2:00 P.M. revealed staff had not offered residents fresh water throughout the day.Interview on 05/04/26 with Resident #7 revealed the facility did not pass fresh water or offer fresh water daily. Further interview with Resident #7 revealed she has had the same water in her room for three days.Interview on 05/06/26 with Certified Nursing Assistant (CNA) #390 revealed staff does not pass fresh ice water. CNA #390 stated if residents would like water, then they have to ask. CNA #390 was unable to answer about how residents who were cognitively impaired or unable to ask, receive fresh water.Review of the Resident Council Minutes from 04/27/26 revealed residents would like water passed to rooms during the day.Review of the facility policy titled Resident Hydration and Prevention of Dehydration dated 12/2020 revealed nurses' aides will provide and encourage intake of bedside, snack and meal fluids, on a daily and routine basis as part of daily care.

Based on medical record review, staff interview, and facility policy review the facility failed to ensure resident care plans were properly completed to include all identified care areas. This affected six (#03, #11, #13, #21, #25, and # 32) of six residents reviewed for care plan accuracy and had the ability to affect all residents. The facility census was 71.Findings include: 1. Review of Resident #03's medical record revealed an admission date of 06/15/26. Diagnoses included respiratory failure, congestive heart failure, and diabetes mellitus. Review of Resident #03's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's medications included insulin, antianxiety, antidepressant, anticoagulant, diuretic, opioid, hypoglycemic, and an anticonvulsant. Review of Resident #03's medical record revealed physician orders dated 03/16/26 for insulin Lispro for type II diabetes mellitus, and Spironolactone 12.5 milligrams (mg) daily for edema. Orders for Bumex 1 mg daily for edema, and Eliquis 5 mg daily for anticoagulant therapy were dated 01/03/26. Review of Resident #03's most recent care plan revealed the plan was absent regarding the care and monitoring of the resident regarding diuretic, insulin or anticoagulant therapy. Interview with MDS Coordinator #200 on 05/06/26 at 2:33 P.M. verified the care plan was incomplete and had no information regarding Resident #03's intake of diuretic, insulin or anticoagulant medication. 2. Review of Resident #32's medical record revealed an admission date of 10/09/25. Diagnoses included congestive heart failure, lymphedema, chronic kidney disease, chronic obstructive pulmonary disease, and fibromyalgia. Review of Resident #32's quarterly MDS assessment dated [DATE] revealed the resident had an intact cognition and was mobile by wheelchair. Review of Resident #32's most recent care plan revealed it was absent regarding activities or activity preferences. Interview with Resident #32 on 05/04/2026 at 9:28 A.M. revealed the resident wished to participate in outdoor activities and outings, but her last outing was August 2025. Interview with MDS Coordinator #200 on 05/06/26 at 2:33 P.M. verified the care plan was incomplete and had no information regarding activities for Resident #32. 3. Review of Resident #25's medical record revealed an admission date of 06/07/24. Diagnoses included acute transverse myelitis in demyelinating disease of the central nervous system, paraplegia, and stage three and four pressure ulcers. Review of Resident #25's wound care progress notes dated 02/13/26, 03/13/26, and 04/15/26 revealed the resident was to be provided a high protein diet to promote wound healing. Review of Resident #25's most recent care plan revealed the wound care plan was absent of a high protein diet intervention to promote wound healing. Interview with MDS Coordinator #200 on 05/06/26 at 2:33 P.M. verified Resident #25's care plan was incomplete and had no information regarding a high protein diet. 4. Review of Resident #11's medical record revealed an admission date of 09/16/25. Diagnoses included liver failure, autoimmune hepatitis, and biliary cirrhosis. Review of Resident #11's hospice notes revealed the resident began hospice services upon admission to the facility. Review of Resident #11's most recent care plan contained no information regarding hospice care. Interview with MDS Coordinator #200 on 05/06/26 at 2:33 P.M. verified Resident #11's care plan was incomplete and had no information regarding hospice care and communication. 5. Review of the medical record for Resident #21 revealed an admission date of 02/14/25. Diagnoses included unspecified dementia, depression, anxiety, and atherosclerotic heart disease. Review of the quarterly MDS dated [DATE] revealed Resident #21 had cognitive impairment. Review of the physician's orders revealed an order for Buspirone hydrochloride (HCl) 10 mg daily for anxiety dated 12/29/25, Buspirone HCl 7.5 mg daily for anxiety dated 12/30/25, Sertraline HCl 150 mg daily for depression dated 09/25/25, Xarelto 10 mg daily for deep vein thrombosis prophylaxis dated 09/25/25. Review of the care plan dated 02/16/25 revealed no monitoring of antianxiety, antidepressant, or anticoagulant medications. Interview with the MDS coordinator #200 on 05/06/26 at 2:35 P.M. verified the care plan was incomplete and had no information of medication monitoring regarding Resident #21 intake of antidepressants, antianxiety, nor anticoagulant medications. 6. Review of the medical record for Resident #13 revealed an admission on [DATE]. Diagnoses included depression, mental and behavioral disorders, dementia with psychotic disturbance. Review of the annual MDS dated [DATE] revealed Resident #13 had severe cognitive impairment. Further review of the MDS revealed Resident #13 was on antipsychotic, antianxiety, and antidepressant medication. Review of the care plan dated 08/02/23 revealed Resident #13 had impaired cognitive function, dementia, or impaired thought process. Interventions included monitoring and reporting any changes in cognitive function. Review of the physicians orders revealed an order on 01/13/25 for Buspirone oral tablet 10 mg, one tablet in the morning for depression, Buspirone oral tablet 15 mg, one tablet by mouth at bedtime for depression, Cymbalta oral capsule delayed release particles 60 mg, give one tablet by mouth in the morning for depression, Depakote oral tablet delayed release 125 mg, give one tablet by mouth at bedtime for mood and seizures, Seroquel oral tablet 100 mg, give one tablet by mouth at bedtime for paranoia. Further review of the care plan revealed no monitoring of antipsychotic, antianxiety, and antidepressant medication. Interview with MDS Coordinator #200 on 05/06/26 at 2:32 P.M. confirmed there was not a care plan for antipsychotic, antianxiety, and antidepressant medication monitoring for Resident #13. Review of the facility policy titled Resident Care Plan, dated 08/2022; revealed the facility will develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

Based on interview, review of the facility activities calendar, review of Resident Council minutes, and review of the Resident Handbook, the facility failed to ensure activities outside the facility, per resident preferences. This had the potential to affect residents able to travel outside the facility. The facility census was 71.Findings include:Interview with Resident #32 on 05/04/2026 at 9:28 A.M. revealed the resident stated she wished to get out of the facility more often. Due to the facility van being broken residents were not allowed to go on outings. The last outing Resident #32 attended was in August 2025. Interview on 05/04/26 at 12.59 P.M. with Resident #48 revealed the facility did not have activities outside of the facility. Resident #48 stated she preferred to shop for personal items, however the facility stated they cannot provide transportation because they currently do not have a van to accommodate the residents for outings. Interview on 05/06/26 at 10:08 A.M. with Activities Director (AD) #730 revealed the facility did not currently have an activities bus. AD #730 further stated she is not allowed to drive the bus even when they have it due to bad vision. AD #730 stated the only person who can transport residents to outside activities was the transportation aid, and that during the week the transportation aid was busy with appointments and rarely worked weekends. Review of the activities calendar for May 2026 revealed the facility did not offer residents activities outside of the facility. The facility had set days when the Activities Aides would go shopping for residents. Review of the Nursing Facility Resident Handbook, updated March 2026 revealed a variety of activities are provided on a daily basis to residents that are specific to resident's functional levels and varying interests. Common activities included community outings. Review of the Resident Council minutes dated 11/25/25 revealed there were 12 residents in attendance. Residents were reminded that activities would do shopping for all residents at the beginning of every month. Staff would not be going to the store daily, and if needing something later in the month residents had to give a couple of days' notice. Review of the Resident Council minutes dated 04/27/26 revealed residents would like a bus for outings. Staff explained that they are only doing small trips and attempting to work with transport van on days there were no appointments.

Based on observation, medical record review, staff interview, and policy review, the facility failed to store medications in a safe manner. This affected one resident (#27) and had the ability to affect all residents. The facility census was 71. Findings include:1. Review of Resident #27 's medical record revealed an admission date of 03/18/26. Diagnoses included cerebral vascular accident, ventilator dependence, and sialadenitis (an infection of salivary glands).Review of Resident #27's medical records revealed a physician's order dated 03/17/26 for Chlorhexidine Gluconate mouth/throat solution 0.12 percent. The resident was to be given 0.5 ounces by mouth twice daily for oral health. The order was discontinued on 04/20/26. Observation of the100 hall medication cart was completed with LPN #310 on 05/06/26 at 8:17 A.M. revealed an open, undated bottle of Chlorhexidine Gluconate solution for Resident #27 remained in the medication cart. Further observation of the cart revealed open and undated bottles of acetaminophen (analgesic/fever reducer) 325 mg, acetaminophen 500 mg, Ibuprofen 200 mg, Senna Plus, fiber laxative, stool softener, Geri Kot, Vitamin D3 125 micrograms (mcg), Vitamin D3 1250 mcg, Bisacodyl suppositories, and Mucus Relief DM. Interview with LPN #310 on 05/06/26 at 8:20 A.M. verified medication bottles are to be dated when opened and further verified the above mentioned medications failed to be dated when opened and Resident #27's discontinued medication remained in the cart.2. Observation of the [NAME] medication cart on 05/06/2026 at 7:57 A.M. with Licensed Practical Nurse #560 revealed medications were found to be opened and in use and failed to contain open dates on the bottles. The medications were sodium bicarbonate 325 milligram (mg), aspirin 81 mg., Loratadine (antihistamine)10 mg.Interview with LPN #560 on 05/06/26 at 8:00 A.M. verified the multiple use medications are to be dated when opened and further verified the sodium bicarbonate, aspirin, and Loratadine were not dated when opened. Review of the facility policy titled Storage of Medications undated revealed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner.

Based on observation, record review, and staff interview, the facility failed to ensure food was served at a safe, appetizing temperature, and acceptable palatability. This had the potential to affect all residents receiving meal service on hallway one hundred except one resident who the facility identified was to receive nothing by mouth (NPO). The facility census was 71.Findings include:Observation of the breakfast meal on 05/05/26 at 7:30 A.M. of [NAME] #302 as she checked the temperatures of the food prior to food service revealed the Denver scrambled eggs were 180 degrees Fahrenheit (F). The surveyor requested test tray at 7:48 A.M. and hallway trays left the kitchen at 7:50 A.M.Observation of food trays arriving in the one hundred hallway dining room was 7:52 A.M. The first tray passed in the dining room was 8:00 A.M. The remaining room trays were pushed to the hallway at 8:15 A.M. The first hallway tray was delivered at 8:17 A.M. The last tray was passed to residents, and the test tray was removed at 8:33 A.M. The Dietary Manager (DM) #301 checked the temperature of the food and verified the Denver eggs were 120 degrees F. DM #301 verified eggs should be served at a minimum holding temperature of 135 degrees F. Three surveyors and DM #301 did not consume the Denver eggs due to the observed 120 degree temperature.Interview with DM #301 on 05/05/26 at 8:40 A.M. revealed she was unaware of any concerns related to the temperature of food, because she does not have any control of the nursing staff's delayed delivery of the meals once they leave the dietary department.Interview with Resident #32 on 05/05/26 at 9:32 A.M. revealed she received meals in her room and they were served cold.Interview with Resident #34 on 05/05/26 at 1:47 P.M. revealed she received her meals cold when served in her room. She stated she never ate breakfast because eggs and pancakes taste terrible cold.Review of the non-dated facility policy, Food Temperatures stated, all hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees (F). Foods sent to the units for distribution will be transported and delivered to unit storage areas to maintain temperatures at or above 135 degrees (F) for hot foods.

Based on observation, record review, and staff interview, the facility failed to maintain sanitary conditions during meal service for one of two meal observations conducted. This had the potential to affect all residents receiving meal service on hallway one hundred hallway except one resident who the facility identified as receiving nothing by mouth (NPO). The facility census was 71.Findings include:Observation of the lunch meal service on 05/05/26 at 12:00 P.M., staff were observed placing used breakfast trays containing soiled dishes and food debris onto the same food cart holding fresh lunch trays that were actively being distributed to residents. Staff continued passing lunch trays from the cart after the soiled breakfast trays were placed onto the cart.Interview with Certified Nursing Assistant (CNA) #425 on 05/05/26 at 12:06 P.M. verified used breakfast trays were returned to the same cart with clean lunch meal trays because the staff missed picking up the breakfast trays after breakfast.Interview with CNA #405 on 05/05/26 at 12:08 P.M. verified used breakfast trays were placed in the same cart with clean lunch meal trays. CNA #405 indicated this is a common practice if the trays do not get picked up after breakfast.Review of the facility's undated policy titled Employee Hygiene for Food Safety stated, All food and nutrition services employees will practice good personal hygiene and safe food handling procedures.

Based on observation, staff interview, and record review, the facility failed to follow appropriate hand hygiene and infection control practices during meal tray distribution for one of two meal service observations conducted. This had the potential to affect all residents receiving meal service on hallway one hundred except one resident who the facility identified as not receiving anything by mouth (NPO). The facility census was 71.Findings include:1. Observation of the lunch meal service on 05/04/26 at 12:00 P.M., revealed nursing staff did not wash their hands prior to the delivery of meal trays to multiple residents in the dining room. The Nursing staff were observed wearing gloves; however, the staff was noted wearing the same pair of gloves between Residents as they passed the food trays, removed tray lids, cut up foods, and put clothing protectors around Resident's necks. Nursing Staff did not remove their initial pair of gloves while continuing to be observed touching door handles of the food cart, refrigerator doors, cabinetry doors, Resident's wheelchairs, and backs of dining room chairs. Nursing staff were observed leaving the dining room with the same gloves on to push the food cart down the hallway. Nursing staff did not wash hands, disinfect hands, or change gloves from the start of the passing of hallway trays through completion of the tray passage. 2. Observation of the lunch meal service on 05/04/26 at 12:10 P.M Certified Nursing Assistant (CNA) # 405 and CNA #425 were observed knocking on resident's doors, touching the door knobs, moving over bed tray tables, entering Resident's closets, entering Resident's personal refrigerators, removing tray lids, cutting up foods with utensils, touching Resident's tv remotes, turning off call light's while wearing the same pair of gloves without using hand sanitizer, or washing hands upon entering/exiting the Resident's rooms. Interview conducted 05/04/26 at 12:25 P.M. CNA # 405 confirmed staff should remove gloves and perform hand hygiene between resident's rooms when passing food trays. When surveyor asked CNA #401if it was the facilities policy for gloves to be worn to pass hallway trays, CNA #401 informed surveyor she didn't know if it was policy, but she didn't like food to touch her bare hands, so it was her preference. Surveyor noted no hand sanitizer was on top of the cart where a box of gloves was located. 3. Observation on 05/04/26 at 12:27 P.M. of the [NAME] hall revealed two CNA's passing hall trays. CNA #445 walked into a resident room, delivered a tray, did not wash hands, grabbed another tray and entered another resident's room. Further observation revealed CNA #505 walk into a resident's room to deliver a tray, exit the resident room without washing hands, grab another hall tray and deliver it. Interview on 05/04/26 at 12:45 P.M. with CNA #445, and CNA #505 confirmed they did not wash their hands between passing hall trays. 4. Observation on 05/05/26 at 8:15 A.M. revealed CNA#405 and CNA #425 were using hand disinfectant before glove usage, changed their gloves between each resident after using hand sanitizer, but failed to wash their hands at any time during the passage of hall trays. Hand sanitizer and a box of gloves were noted at the top of the tray cart. Review of the facility's Infection Control Policy, revised October 2018, stated, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage the transmission of disease and infection. Review of the facility's Handwashing/Hand Hygiene Policy, revised August 2019, Review of the facility policy titled Handwashing/Hand Hygiene, dated 08/2019, stated, the facility considers hand hygiene the primary means of preventing the spread of infection. The policy further directed staff to use an alcohol-based hand rub containing at least 62% alcohol or soap (antimicrobial or non-antimicrobial) and water in the following situations: before and after direct contact with residents; after contact with a resident's skin; after contact with objects in the immediate vicinity of the resident; after removing gloves; before and after eating or handling food; and before and after assisting a resident with meals. The policy also stated use of gloves does not replace handwashing/hand hygiene with the integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Based on observation, medical record review, resident interview, staff interview, and policy review the facility failed to ensure resident rooms were at comfortable temperatures. This affected one (#25) of two residents interviewed for environmental temperature concerns. The facility census was 71.Findings include:Review of Resident #25's medical record revealed an admission date of 06/07/24. Diagnoses included acute transverse myelitis in demyelinating disease of the central nervous system, paraplegia, and stage three and four pressure ulcers.Review of Resident #25's quarterly Minimum Data Set (MDS) dated [DATE] revealed she had an intact cognition. The resident was documented as having three stage four pressure ulcers and one stage two pressure ulcer.Review of Resident #25's care plan revealed the resident was dependent on staff for all activities of daily living except eating.Interview with Resident #25 on 05/06/26 at 7:32 A.M. revealed her room was cold and she wished the facility would increase the heat. Observation of Resident #25 at the time of the interview revealed the resident was lying in bed in a bathrobe and covered with three blankets and the room wall register was not producing any heat.Observation of Resident #25's room temperature with Maintenance Assistants #503 and #505 on 05/06/26 at 8:10 A.M. revealed the Resident #25's room temperature was 57.7 degrees Fahrenheit. Maintenance Assistant #503 on 05/06/26 at 8:12 A.M. verified that Resident #25's room temperature was 57.7 degrees Fahrenheit and stated he could not explain why and further stated if more information was needed the Maintenance Director would need to assist. Review of the facility policy titled Excessive Temperature Guidelines, dated 05/23 revealed every reasonable attempt will be made to maintain the temperature between 71 and 81 degrees Fahrenheit. If any condition occurs that permits the facility temperature to rise above 81 degrees Fahrenheit or below 65 degrees Fahrenheit in an area of the facility with residents that cannot be moved to another part of the facility notify the Administrator, Director of Maintenance and the Director of Nursing.

Based on medical record review, staff interview, and review of hospice reports, the facility failed to ensure hospice and facility staff had ongoing communication. This affected one (#11) of one resident reviewed for hospice services. The facility identified two Residents (#11, #43) who received hospice service. The facility census was 71.Findings include:Review of Resident #11's medical record revealed an admission date of 09/16/25. Diagnoses included liver failure, autoimmune hepatitis, chronic obstructive pulmonary disease and biliary cirrhosis.Review of Resident #11's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had an intact cognition, received hospice services as of 11/10/25 for cirrhosis of the liver. Review of Resident #11's medical record found the record was free of communication notes to or from hospice.Interview with Registered Nurse (RN) Supervisor #225 on 05/06/2026 at 9:48 A.M. revealed Resident #11 failed to have a communication binder for this particular hospice group. Licensed Practical Nurse (LPN) #253 opened the Resident #11's hard chart and revealed there was a simple flyer regarding the hospice services present but no communication from hospice was available. LPN #253 denied knowledge of any communication binder from hospice for this resident. LPN #253 stated the hospice aide was scheduled to visit to provide care and stated she thought the aide came on Wednesdays and the nurse visited on Thursdays. LPN #253 stated facility nursing staff were required to sign the hospice iPad to verify they were at the facility. Interview with the Director of Nursing (DON) on 05/07/26 at 9:53 A.M. revealed the nurses knew when hospice visited because the nurses had to sign the hospice iPad prior to them leaving the facility. The DON revealed there was no communication book, and everything was completed online. Interview with RN Supervisor #225 on 05/07/2026 at 9:58 A.M. revealed she and LPN #253 spoke to Social Service Director (SSD) #201 regarding the binder for hospice. RN Supervisor #225 was informed that they failed to have a binder, but they could request one from hospice. RN Supervisor #225 verified the nurses have verbalized the importance of needing communication from hospice to coordinate resident care. Review of the Hospice Patient Information Reports for Resident #11 dated 09/15/25 through 05/06/26 revealed the facility had received the visit notes via fax on 05/07/26.

Based on observation, record review, and interview, the facility failed to ensure dental services were provided for one (#37) resident reviewed for dental services. The facility census was 71.Findings include:Review of the medical record for Resident #37 revealed an admission on [DATE]. Diagnoses included traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, subsequent encounter, periodontal diseases, persistent vegetative state, and encephalopathy. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed resident #37 had severe cognitive impairment and was dependent on staff to complete activities of daily living (ADL). Further review of the MDS revealed Resident #37 had inflamed or bleeding gums.Review of the care plan dated 04/09/22 revealed Resident #37 had an ADL self-care performance deficit related to traumatic brain injury. Interventions included glasses to be worn during the day, and staff to perform oral care. Review of the dental health service notes dated 06/05/24, 01/29/25, 04/17/25 revealed Resident #37 was not cooperative during dental exam.Review of the nurse progress notes dated 04/01/26 revealed Resident #37 had inflamed and bleeding gums.Review of the physician's order dated 04/01/26 revealed an order for Peridex Periodontal Solution for bleeding gums. Additional review of the physician orders dated 04/01/26 revealed an order for follow up with dental for teeth extraction.Further review of the physician's orders dated 04/02/26 revealed an order for doxycycline 100 milligrams (mg); give one tablet via gastric tube two times a day for gum infection for ten days.Interview on 05/05/26 at 2:04 P.M. with Dental Health Services Customer Service (DHSCS) #862 revealed Resident #37's last dental cleaning was on 01/26/24 due to Resident #37 not cooperating during other visits. DHSCS #862 further stated the facility had nothing further scheduled for Resident #37, and the last communication between the facility and dental services was on 04/07/26 when the dental clinic was notified that Resident #37's gums were red and inflamed.Interview on 05/05/26 at 4:05 P.M. with Nurse Practitioner (NP) #863 revealed she placed the order for Resident #37 to be seen by an outside dental provider for teeth extraction due to rotting. NP #863 stated Resident #37 would require sedation in order to complete the extractions.Interview on 05/06/26 at 10:49 A.M. with Transportation Aide (TA) #401 revealed she was never notified that Resident #37 needed an appointment for teeth extraction. TA #401 confirmed there was no appointment scheduled for Resident #37 to be seen by a dentist.Review of the facility policy titled Steps to Scheduling Appointments, not dated; revealed staff was to receive request from the unit and check to see if it is transportation and or an appointment that needs scheduled. If there is missing information, call the unit or fax it back with a note stating there was missing information to please fill out completely.

Based on record review and staff interview, the facility failed to ensure provider orders were carried out as prescribed. This affected one (#5) of one resident reviewed for the implementation of provider orders. The facility census was 71.Findings include:Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included dysphasia, unspecified severe protein-calorie malnutrition, hypokalemia, and vitamin D deficiency.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #5 had cognitive impairment.Record review of the clinical record revealed Resident #5 had a monthly weight of 187.9 pounds on 02/08/26, 177.9 pounds on 03/06/26, and a weight on 04/26/26 of 174.0 pounds for 13.9 pounds or -7.40 percent weight loss.Review of the clinical record Individual Nutrition Recommendations/Response form dated 03/12/26, signed by Nutrition and Dietetic Technician, Registered (NDTR) #900 revealed a recommendation for a mighty shake, appetite stimulant, to be added to all due to Resident #5 having significant weight loss in the last 30 days. The recommendation was agreed to and signed on 03/16/26 by Advanced Practice RN Nurse Practitioner (APRN-NP-C) #863. Review of the clinical record revealed the recommendations for the appetite stimulant had not implemented between 03/12/26 and 04/22/26, but instead an order for nutritional supplement of Boost was initiated. Interview on 05/05/26 at 1:50 P.M. with the APRN-NP-C #863 revealed despite her signature on the agreement form to start an appetite stimulant, she did not necessarily want to start the resident on an appetite stimulant because the resident was already on the Magic Cup and Boost. APRN-NP-C #863 also stated the staff were providing Resident #5 more assistance with meals as evidenced by the most recent weight gain of 5.8 pounds with a weight obtained on 05/05/26. Continued interview on 05/05/26 at 1:50 P.M. with APRN-NP-C #863 and the Director of Nursing (DON) verified there was not an order in Resident #5's medical record for the Magic Cup. The DON stated she would have to look into this matter and further verified the resident did not receive an appetite stimulant despite the APRN-NP-C #863's orders.Review of undated policy titled, Immediate Temporary Interventions for Unintended significant Weight Loss, revealed individuals with unintended significant/severe weight loss will receive immediate nutrition interventions to prevent further weight loss, stabilize weight, and/or assist the individual to regain weight as appropriate.Review of the undated policy titled, Significant Weight Loss, revealed the goal of medical nutrition therapy for significant unintended weight loss is to identify underlying causes or factors contributing to the significant unintended weight loss and intervene as appropriate to resolve the problem and stabilize weight. Review of undated policy titled, Medication Therapy, stated all medication orders will be supported by appropriate care processes and practices.

Based on observation, medical record review, interview, and review of the facility policy the facility failed to ensure a resident on dialysis who frequently refused due to nausea and vomiting was monitored, and that the physician was notified. This affected one (#64) resident reviewed for dialysis. The facility census was 71.Findings include:Review of the medical record for Resident #64 revealed an admission on [DATE]. Diagnoses included end stage renal disease, encephalopathy, hypo-osmolality and hyponatremia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #64 had cognitive impairment and was dependent on staff for activities of daily living (ADLs). Further review of the MDS revealed Resident #64 received dialysis. Review of the care plan dated 11/05/25 revealed Resident #64 had pain related to decreased mobility and end stage renal disease (ESRD). Interventions included monitoring and documenting probable cause of each pain episode. Further review of the care plan revealed Resident #64 required hemodialysis related to renal failure. Interventions included monitoring, documenting and reporting signs and symptoms of renal insufficiency such as changes in level of consciousness, changes in skin turgor, oral mucosa, and changes in heart and lung sounds. Review of the physician's orders dated 03/20/26 revealed Resident #64 had an order for Zofran 4 milligrams (mg) give one tablet by mouth every six hours as needed for nausea and vomiting. Review of the Medication Administrator Record (MAR) revealed Resident #64 had not received as needed Zofran 4 mg for the month of May.Interview on 05/04/26 at 10:04 A.M. with Resident #64 revealed she had refused to go to dialysis due to having nausea and vomiting.Review of the nurse progress notes revealed there was no nurse note related to Resident #64 being nauseous or refusing dialysis.Review of Resident #64's missed dialysis days revealed in Apri 2026 Resident #64 missed seven days of dialysis due to nausea and or vomiting, and in May 2026 Resident #64 missed one day. There was no notification to the physician documented or assessments noted.Review of the dialysis communication sheets for April 2026 revealed there were ten days where treatment was stopped early due to Resident #64 feeling nauseous, vomiting, or having leg cramps. There were no notifications or continued assessments documented.Interview on 05/05/26 at 9:59 A.M. with Licensed Practical Nurse (LPN) #310 revealed if Resident #64 refused dialysis, the Nurse Practitioner (NP), should be notified. LPN #310 further confirmed that the NP was not notified and there were no assessments completed pertaining to nausea and vomiting when Resident #64 refused dialysis or came back early from treatment.Interview on 05/05/26 at 11:03 A.M. with Dialysis Registered Nurse (DRN) #715 revealed if a resident refuses dialysis often the nephrologist should be updated. DRN #715 further confirmed there was no notification to the nephrologist stating that Resident #64 was having nausea, vomiting, and cramping during treatment.Review of the Renal Dialysis Coordination Agreement dated 12/01/23 revealed the facility would monitor for altered thought process, nausea, vomiting, agitation, and changes in behavior.

Based on record review, staff interview, and review of facility policy, the facility failed to timely identify, assess, and intervene for significant weight loss. This affected one (#5) resident of one resident reviewed for weight loss. The facility census was 71.Findings include:Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included dysphasia, unspecified severe protein-calorie malnutrition, hypokalemia, and vitamin D deficiency.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #5 had cognitive impairment.Record review of the clinical record revealed Resident #5 had a monthly weight of 187.9 pounds on 02/08/26, 177.9 pounds on 03/06/26, and a weight on 04/26/26 of 174.0 pounds for 13.9 pounds or -7.40 percent weight loss.Review of the clinical record Individual Nutrition Recommendations/Response form dated 03/12/26, signed by Nutrition and Dietetic Technician, Registered (NDTR) #900 revealed a recommendation for a mighty shake, appetite stimulant, to be added to all due to Resident #5 having significant weight loss in the last 30 days. The recommendation was agreed to and signed on 03/16/26 by Advanced Practice RN Nurse Practitioner (APRN-NP-C) #863. Review of the clinical record revealed the recommendations for the appetite stimulant had not implemented between 03/12/26 and 04/22/26, but instead an order for nutritional supplement of Boost was initiated. Interview on 05/05/26 at 1:50 P.M. with the APRN-NP-C #863 revealed despite her signature on the agreement form to start an appetite stimulant, she did not necessarily want to start the resident on an appetite stimulant because the resident was already on the Magic Cup and Boost. APRN-NP-C #863 also stated the staff were providing Resident #5 more assistance with meals as evidenced by the most recent weight gain of 5.8 pounds with a weight obtained on 05/05/26. Continued interview on 05/05/26 at 1:50 P.M. with APRN-NP-C #863 and the Director of Nursing (DON) verified there was not an order in Resident #5's medical record for the Magic Cup. The DON stated she would have to look into this matter and further verified the resident did not receive an appetite stimulant despite the APRN-NP-C #863's orders.Interview and review of the medical record on 05/05/26 at 1:58 P.M. with Licensed Practical Nurse (LPN) #864 revealed an order for Magic Cup twice a day was located in the medical record and the order was entered at 1:59 P.M. on 05/05/26.Review of undated policy titled, Immediate Temporary Interventions for Unintended significant Weight Loss, revealed individuals with unintended significant/severe weight loss will receive immediate nutrition interventions to prevent further weight loss, stabilize weight, and/or assist the individual to regain weight as appropriate.Review of the undated policy titled, Significant Weight Loss, revealed the goal of medical nutrition therapy (MNT) for significant unintended weight loss is to identify underlying causes or factors contributing to the significant unintended weight loss and intervene as appropriate to resolve the problem and stabilize weight.

Based on observation, staff interview, resident interview, and policy review, the facility failed to ensure safety by allowing a space heater in a resident's room. This affected one (#70) of one resident reviewed for resident safety. The facility census was 71. Findings include:Review of Resident #70's medical record revealed an admission date of 11/19/25. Diagnoses included multiple myeloma, malignant neoplasm of bone, anemia, thrombocytopenia, and severe protein calorie malnutrition.Review of Resident #70's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had an intact cognition.Observation on 05/05/26 at 10:35 A.M. revealed there was a space heater sitting on the window ledge in Resident #70's room. The heater was operating and blowing hot air.Observation on 05/05/2026 at 1:40 P.M. revealed Resident #70 was sitting in bed with a visitor at bedside. The heater continued to be in use.Interview with Resident #70 on 05/05/26 at 10:37 A.M. verified the space heater was in working order and she required the heater to keep her room warm. Interview with Licensed Practical Nurse (LPN) #355 on 05/05/2026 at 10:35 A.M. verified Resident #70 had a portable heater in her room due to her room being cold and she needed to be comfortable due to receiving chemotherapy. Review of the facility policy titled Portable Space Heating Device dated 04/26 revealed under no circumstances are portable space heaters allowed in resident sleeping rooms, hallways, resident activity areas, or any area accessible to residents.

Based on observation, record review, resident interview, staff interview, and policy review revealed the facility failed to ensure a resident with pressure ulcers was provided a high protein diet as prescribed by a physician. This affected one (#25) of two residents reviewed for wounds. The facility census was 71. Findings include:Review of Resident #25's medical record revealed an admission date of 06/07/24. Diagnoses included acute transverse myelitis in demyelinating disease of the central nervous system, paraplegia, and stage three and four pressure ulcers.Review of Resident #25's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had an intact cognition and was documented as having three stage four pressure ulcers and one stage two pressure ulcers.Review of Resident #25's care plan revealed the resident had pressure ulcers to the right buttock, left posterior thigh, and coccyx. Interventions included to administer treatments as ordered, educate the resident/family/caregivers as to causes of skin breakdown, including transfer and positioning requirements, the importance of taking care during ambulating/mobility, good nutrition and frequent repositioningReview of Resident #25's outside wound care progress notes dated 02/13/26, 03/13/26, and 04/15/26 revealed the resident was to be provided a high protein diet to promote wound healing. Review of the Dietician Quarterly Nutrition Review for Resident #25 dated 03/12/26 revealed the staff were to encourage protein foods at meals.Review of Resident #25's meal ticket dated 05/06/26 revealed the resident was ordered a regular diet with thin liquids.Interview with Resident #25 on 05/06/26 at 7:32 A.M. revealed her meals consisted of a regular diet with no extra high protein foods were served.Observation of meal service on 05/06/26 and 05/27/26 for Resident #25 at lunch revealed the resident was served a regular meal high in carbohydrates and minimum high protein foods. Interview with the Director of Nursing on 05/07/26 at 9:12 A.M. verified Resident #25 had not been provided a high protein meal as ordered by wound care and recommended by the dietician.Review of the undated facility policy titled Therapeutic Diets, revealed a therapeutic diet must be prescribed by the resident's attending physician (or non-physician provider). The attending physician may delegate this task to a registered or licensed dietician as permitted by state law.

Based on medical record review, interview, and review of the facility policy, the facility failed to ensure residents who had vision concerns were seen timely by the ophthalmologist. This affected one (#37) resident reviewed for ancillary services. The facility census was 71.Findings include:Review of the medical record for Resident #37 revealed an admission on [DATE]. Diagnoses included traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, subsequent encounter, periodontal diseases, persistent vegetative state, and encephalopathy. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed resident #37 had severe cognitive impairment and was dependent on staff to complete activities of daily living (ADL). Review of the care plan dated 04/09/22 revealed Resident #37 had ADL self-care performance deficit related to traumatic brain injury. Interventions included glasses to be worn during the day.Review of the ancillary vision service provider notes revealed Resident #37 was seen on 01/28/25. An assessment revealed dry eyes, both eyes, stable with Artificial Tears four times a day for both eyes as needed. Exotropia, constant; left eye; secondary to motor vehicle accident stable today. Myopic astigmatism; both eyes; stable refraction compared to previous exam. Resident #37 used prescription eyeglasses for distance viewing as needed. Recall for comprehensive exam on 01/28/26. Interview on 05/05/26 at 3:09 P.M. with Ancillary Vision Service Provider Customer Care #861 revealed the facility had not scheduled for the vision provider to come to the facility since August 2025, and it was the responsibility of the facility to schedule for the provider to come to the facility.Interview on 05/06/26 at 2:00 P.M. with the Administrator confirmed that the facility had not scheduled for the vision provider to come to the facility, and that the scheduler was unaware that it was the responsibility of the facility. Administrator further confirmed Resident #37 was to be seen on 01/28/26 and has not been seen since 01/28/25.Review of the facility policy titled Steps to Scheduling Appointments undated revealed the schedular would receive the request from unit and check to see if the appointment needs scheduled. If there is any information missing, call the location of the resident's appointment to confirm.

Based on record review, staff interview, and review of the Center for Medicaid and Medicare Services (CMS) manual revealed the facility failed to submit discharge assessments in a time manner. This affected two former residents (#09, #53) reviewed for Minimum Data Set (MDS) report submission. The facility census was 71. Findings include:1. Review of Former Resident (FR) #09's medical record revealed an admission date of 10/21/25 and a discharge date of 12/23/25. Diagnoses included substance abuse disorder, transient ischemic attack, and hip replacement.Review of FR #09's quarterly Minimum Data Set (MDS) revealed it was completed on 12/12/25 and exported. Review of the discharge return not anticipated MDS dated [DATE] revealed it was export ready, but the facility failed to submit the report to CMS.2. Review of FR #53's medical record revealed an admission date of 10/31/25 and a discharge date of 12/15/25. Diagnoses included acute respiratory failure, pneumonia, chronic obstructive pulmonary disease, sepsis, and congestive heart failure. Review of FR #53's entry MDS revealed the assessment was completed and submitted on 10/31/25. The admission Medicare 5-day was completed and submitted on 11/05/25. The resident's discharge return not anticipated assessment was export ready on 12/15/25 but had not been submitted by the facility.Interview with MDS Coordinator #200 on 05/07/2026 at 8:13 A.M. revealed she failed to submit FR #09 and #53's discharge MDS's in a timely matter. Review of the CMS Resident Assessment Instrument Version 2.0 manual revealed discharge records must be completed within 7 days of the event date.

Based on medical record review, resident interview, staff interview, police officer interview, review of Self-Report Incident (SRI) #269318, review of the facility investigation, and review of the facility policy, the facility failed to protect a resident from misappropriation. This affected one resident (#2) of three reviewed for misappropriation. The facility census was 71.Findings include: Review of the medical record for Resident #2 revealed an admission date of 12/04/13. Diagnoses included Multiple Sclerosis (MS), diabetes mellitus type two, chronic obstructive pulmonary disease (COPD), heart failure, chronic kidney disease (CKD) stage three, atrial fibrillation (A-fib), hypertension, and peripheral vascular disease (PDV). Review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #2 revealed the resident had mild cognitive impairment. Review of the statement submitted by Resident #2, dated 01/02/26, revealed the resident reported she reviewed her most recent bank statement and it had charges on the statement that Resident #2 did not make. Resident #2 further stated she was unable to find the debit card. Additionally Resident #2 already called the bank and the debit card was cancelled and the bank was sending paperwork. Review of the police report dated 01/02/26 timed at 3:30 P.M. revealed a police report was filed for stolen credit card from Resident #2. Further review of the police report revealed several transactions were made from various locations and various amounts that totaled to be $514.31 was reported as stolen. The police report further revealed Resident #2 wished to proceed with charging the perpetrator if that person was able to be found. Review of the bank statement addressed to Resident #2 dated 12/23/25 revealed several charges posted against the debit card from 12/19/25 through 12/22/25. The statement revealed there were 12 total charges were in the amount range from $2.69-$104.00. Interview on 03/04/26 at 1:20 P.M. with Resident #2 stated a staff member stole her credit card and used it without permission. Resident #2 further stated the police officer had been to her to report any findings and the last update she was provided was the perpetrator was identified and was going to be prosecuted. Interview on 03/09/26 at 8:28 A.M. with Police Officer #501 stated he was dispatched to the facility for report of stolen credit card with unauthorized use and upon interview with the victim an investigation began and if the perpetrator was found charges would be filed. Police Officer #501 then stated through the investigation the perpetrator (Certified Nursing Assistant - CNA #340) was identified and the case was turned over to the prosecutors office for indictment and then charges filed. Review of the personnel file for former CNA #340 revealed a termination date of 01/06/26. Review of the SRI dated 01/02/26 revealed the facility substantiated misappropriation. CNA #340 was linked to at least one charge on the credit card and police were still investigating and following through with charges against the CNA. Review of the facility policy titled, Abuse, Neglect, Misappropriation of Resident property, and Exploitation, revised 10/23 revealed the purpose is to provide residents an environment that is free from resident abuse, neglect, misappropriation of resident property, or exploitation. Misappropriation defined as the deliberate misplacement or wrongful use of a residents belongings or money without the resident's consent.

Based on medical record review, resident and staff interview, review of resident shower sheets and shower schedules, and facility policy review, the facility failed to ensure residents who were dependent on staff for bathing received showers on their scheduled days per their preference. This affected three (#17, #25, and #67) of four residents reviewed for showers. The facility census was 68. Findings include: 1. Review of the medical record for Resident #17 revealed an original admission date of 12/04/13 with re-admission to the facility on [DATE]. Diagnoses included multiple sclerosis, chronic obstructive pulmonary disease (COPD) and atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. The resident was assessed to require maximal assistance with showers and was dependent on staff to transfer into the shower. Review of the care plan dated 07/26/22 revealed Resident #17 had an activities of daily living (ADLs) self-care performance deficit related to fatigue, musculoskeletal impairment, activity intolerance, limited mobility, pain, and impaired balance. Interventions included Resident #17 was able to bath with ones staff member assist, and transfer with two staff member assist using the mechanical lift. Resident #17 was able to assist with hygiene. Review of the certified nurse aide (CNA) shower documentation in Resident #17's medical record revealed no documentation for the months of August and September 2025 for showers. Review of the skin monitoring shower review sheet completed by the CNAs for the months of August 2025 and September 2025 revealed there was not a sheet completed on Thursday, 09/11/25. Review of the shower schedule document for the One South hall revealed Resident #17 was to receive a shower on Mondays and Thursdays from 7:00 P.M. to 7:00 A.M. Interview on 09/15/25 at 8:56 A.M. with Resident #17 revealed he was scheduled to receive a shower twice a week the night shift and stated he does not always get his showers as scheduled. 2. Review of the medical record for Resident #25 revealed an admission date of 05/22/25. Diagnoses included fracture of the right lower leg, COPD, and bipolar disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #25 had intact cognition as evidence by a BIMS score of 15. Resident #25 was assessed to require moderate assistance with showering, and supervision or touching assistance with transfers. Resident #25 required moderate assistance with transferring in and out of the shower. Review of the care plan dated 05/23/25 revealed Resident #25 had an ADLs deficit related to a right lower extremity fracture. Interventions included providing a sponge bath when a full bath or shower cannot be tolerated. Resident #25 required assistance by staff with personal hygiene and oral care. Resident #25 required one staff member assist for transferring. Further review of the care plan revealed Resident #25 was at risk for falls related to impaired mobility. Interventions included staff meeting the residents' needs for physical assistance. Review of the Three South-Side One CNA report sheet revealed Resident #25 was scheduled for a night shift shower every Sunday and Wednesday. Review of the Three South shower sheet updated 07/22/25 revealed Resident #25 was to receive a shower from 7:00 A.M. to 7:00 P.M. on Sunday and Wednesday. Review of the CNA shower documentation in the medical record revealed Resident #25 did not receive a shower on Sunday, 09/14/25. Review of the skin monitoring CNA shower review for Resident #25 revealed no documentation on 09/14/25. Interview on 09/15/25 at 9:18 A.M. with CNA #342 revealed there were times when residents would have to wait to receive showers. CNA #342 stated staff complete shower documentation in the resident's electronic medical record (EMR) under the Tasks section, and they also fill out the skin monitoring shower review sheet. If residents refuse showers, the staff would document the refusal and notify the nurse. CNA #342 confirmed there was not a shower sheet for Resident #25 on 09/14/25 and there was no documentation in the medical record. Interview on 09/15/25 at 11:18 A.M. with Resident #25 revealed the resident was scheduled to receive showers twice a week and stated showers were not always completed as scheduled. Interview on 09/15/25 at 2:10 P.M. with CNA #301 revealed that on the shower sheet it was documented Resident #25 was a day shift shower; however, on the report sheet it was documented that the resident a third shift shower. CNA #301 stated she gave report to the night shift staff and told them Resident #25 did not receive a shower during the day on 09/14/25, and it needed complete on night shift. CNA #301 stated Resident #25 does not refuse showers unless the resident was in pain and then the CNAs will provide a bed bath. 3. Review of the medical Record for Resident #67 revealed an admission date of 06/05/25. Diagnoses included unspecified fracture of the left femur, polyneuropathy, and COPD. Review of the admission MDS assessment dated [DATE] revealed Resident #67 had intact cognition with a BIMS score of 15. Resident #67 was assessed to require partial to moderate assistance with showering and bathing. Resident #67 was dependent on sitting to stand and required substantial/maximal assistance with transferring to the shower chair. Resident #67 was non-mobile and required a wheelchair to move around the facility. Review of the current plan of care revealed Resident #67 had an ADLs self-care performance deficit related to recent fall with fracture of the right lower extremity. Interventions included encouraging the resident to use the bell to call for assistance. Resident #67 required assistance by staff with bathing/showering as necessary. Resident #67 was at risk for falls related to recent falls and mobility impairment at baseline from meningitis. Review of the One [NAME] shower sheet revealed Resident #67 was to receive showers on Mondays and Fridays from 7:00 A.M. to 7:00 P.M. Review of the CNA documentation in Resident #67's medical record revealed Resident #67 did not receive a shower on Tuesday, 09/09/25. Review of the skin monitoring CNA shower review sheet revealed on 09/09/25 there was a paper filled out with Resident #67's name but was not circled that a shower was complete. Interview on 09/15/25 at 11:49 P.M. with CNA #323 revealed the CNAs document resident care in the EMR and on the shower sheets. CNA #323 stated if a resident refused a shower, it was documented in the EMR and on the shower sheet. Interview on 09/15/25 at 12:03 P.M. with Resident #67 revealed she was scheduled to received showers twice a week in the morning. Resident #67 stated she received a shower on Friday, 09/12/25, and that was the first time she was showered in over a week. Resident #67 stated on 09/09/25 staff told her they would give her a shower after breakfast. Resident #67 stated she waited outside of her room for staff to help her shower before she left for therapy but never received it. Interview on 09/15/25 at 1:17 P.M. with the Director of Nursing (DON) confirmed there were no shower sheets or documentation in the medical records of showers being complete for Resident #17 on 09/11/25, Resident #25 on 09/14/25, and Resident #67 on 09/09/25. Review of the facility policy titled, Bath, Shower/Tub, dated 01/2021, revealed the purpose of the procedure was to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Staff were to document the date of the shower/tub bath was performed, and if the resident refused, the reason. This deficiency represents non-compliance investigated under Master Complaint Number 2611068.

Based on observation, resident and staff interviews, and review of the facility policy, the facility failed to ensure the resident's call devices were functioning in their bathroom and/or bedrooms and failed to ensure the residents had accessibility and/or functionality of call devices in the shower rooms. This affected three (#22, #23, and #24) of five residents reviewed for call lights and had the potential to affect the residents who utilize the showers on first and third floor. The facility census was 74.1. Observation and interview on 08/14/25 at 8:45 A.M. revealed Resident #22's bathroom call light did not work. Resident #22 stated he would just wait for staff to come back after he was toileted. He could not recall if he used his call light or not. Interview on 08/14/25 at 11:10 A.M. with Plant Operation Director (POD) #102 confirmed Resident #22's bathroom call light did not work. 2. Observation and interview on 08/14/25 at 8:30 A.M. revealed Resident #23's bathroom call light was in the pulled position and the light was not functioning. Interview on 08/14/25 at 8:30 A.M. with Resident #23 revealed sometime in July she was in the bathroom and pulled the call light and it did not work. Resident #23 stated she sat on the toilet for over an hour. During that time, she said she yelled out for help and someone came and helped her. Interview on 08/14/25 at 11:10 A.M. with Plant Operation Director (POD) #102 confirmed the call light in Resident #23's bathroom did not work. POD #102 stated the bathroom call systems function on batteries, and if the batteries die there was no way to know. POD #102 stated sometimes the wiring in the call systems fry the wiring and do not allow the batteries to function for more than a day. 3. Observation on 08/14/25 at 8:40 A.M. in Resident #24's room revealed his bedside call light and bathroom call light were not working. Observation on 08/14/25 at 8:48 A.M. of the one west hall shower room revealed two call lights in the shower room did not function when pulled. Observation on 08/14/25 at 12:30 P.M. of the third-floor bathroom revealed there was no call light in the area of the shower. There was a call light on the opposite side of the wall next to the wash basin and one approximately ten feet from the shower that did not have a pull cord. Interview on 08/14/25 with Plant Operation Director (POD) #102 confirmed Resident #24's bedroom call light and bathroom call light did not work, the one west bathroom call lights. POD #102 confirmed the third floor bathroom did not have a call light readily available in the shower and furthermore the call lights that were in the bathroom did not work. Review of the policy titled Answering the Call Light dated March 2021 revealed periodically as needed staff should explain and demonstrate the use of the call light to residents. Staff should be sure the call light is plugged in and functioning at all times. Some residents may not be able to use their call light. Be sure to check on these residents frequently. Report all defective call lights to the nurse supervisor promptly. This deficiency represents non-compliance investigated under Complaint Number 2565440.

Based on medical record review, review of facility incident investigations with witness statements, review of staff education, staff interviews, review of a resident handbook, review of a facility Self-Reported Incident (SRI), and review of facility smoking policies, the facility failed to ensure Resident #75 who had a known history of smoking with oxygen on, was assessed as an independent smoker, exhibited safe smoking practices and did not smoke while wearing oxygen. This resulted in Immediate Jeopardy and serious life-threatening harm, injuries and/or death when Resident #75 lit a cigarette while wearing oxygen therapy via nasal cannula, in the designated smoking area. Resident #75's oxygen ignited and set Resident #75 on fire with the oxygen. Resident #75 sustained singed facial hair, and the skin around his mouth, nose, and bilateral cheeks was charred black. Resident #75, while being treated by the local emergency medical squad, began to experience a deteriorating airway and adventitious lung sounds (respiratory noises beyond that of normal breath sounds) that were identified as stridor (high-pitched wheezing sound caused by disrupted airflow due to obstruction of the upper respiratory tract). Resident #75 was life flighted to a burn hospital and subsequently passed away approximately eight hours later from smoke inhalation and thermal burns. This affected one (Resident #75) of three residents reviewed for smoking and who utilize oxygen therapy. The facility identified 11 residents (#01, #04, #07, #13, #20, #26, #31, #32, #41, #49, and #71) who smoke independently and six residents (#12, #17, #27, #57, #63, and #73) who require supervision with smoking. The facility identified Resident #17 and #26 who smoke and who utilize supplemental oxygen. The facility census was 73. On [DATE] at 3:32 P.M., the Administrator and the Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at approximately 2:15 A.M., when State tested Nurse Aide (STNA) #14 observed a weird flash of light from the smoking area and ran out to the area. Resident #75 was on fire in the smoking area and the oxygen tubing was on fire. STNA #14 yelled the resident was on fire, grabbed the tubing and disconnected it from the oxygen cylinder. Resident #75 was alert and oriented and was observed to have singed facial hair, and the skin around his mouth, nose, and bilateral cheeks was charred black. Licensed Practical Nurse (LPN) #401 arrived and instructed STNA #14 to call emergency services. Upon emergency squad arrival, Resident #75 was assessed to have deteriorating lungs sounds with stridor (a harsh noise when breathing, caused by obstruction of the windpipe). Air transport was completed from the facility to the burn hospital where Resident #75 died from smoke inhalation and thermal burns at 10:44 A.M. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at approximately 2:15 A.M., facility staff witnessed Resident #75's oxygen ignite while smoking in the facility smoking area, extinguished the fire and called for emergency services. On [DATE] at 9:00 A.M., the Interdisciplinary Team (IDT) met and reviewed the facility smoking policy and discussed a possible smoking area closure, but no changes were made at this time. On [DATE], an SRI was submitted to the Ohio Department of Health. On [DATE], the Administrator individually met with 15 alert and oriented residents (Resident #01, Resident #04, Resident #07, Resident #12, Resident #13, Resident #17, Resident #20, Resident #26, Resident #27, Resident #31, Resident #32, Resident #41, Resident #49, Resident #57, and Resident #63) who smoke, and provided education on the smoking policy and safety, including with oxygen. On [DATE], the Administrator met with families of residents in the smoking area to educate them on the smoking policy and safety. On [DATE] and [DATE], the DON and Nursing Facility Registered Nurse (NFRN) #7000 completed smoking assessments on all residents who smoke. There were no additional residents who were identified to smoke and utilize oxygen. At this time, care plans were reviewed on all residents who smoke. The care plans for Residents #17, #26 and #75 were updated to be supervised smokers, and all Kardex's were updated. On [DATE], the facility smoking assessment form was revised to reflect residents who smoke and utilize oxygen will require supervision for smoking and retired the previous smoking assessment utilized by the facility. Review of the new smoking assessment form revealed all residents who smoke and use oxygen now require supervision to smoke. On [DATE], nursing supervisors were notified and educated of the change to the smoking assessment form by the DON and nursing education on the new assessment for was initiated. On [DATE] through [DATE], the occupational therapy (OT) department evaluated all smokers for dexterity and speech therapy (ST), in conjunction with nursing, evaluated all smokers for cognition. The results of these evaluations were reviewed by the DON and NFRN #7000 and no changes in care plans were needed. Review of the assessments revealed all smokers were re-assessed. On [DATE], all residents were notified of the smoking area time changes via a letter from the Administrator. Facility staff were notified via the mass messaging application GreyMAR (a messaging system utilized by the facility to disseminate communication to staff which also shows acknowledgement of receipt of message) by the Administrator. This message stated, Effective immediately, the smoking area outside 1 South will be closed from 11p-6a to everyone. Please make sure the doors are closed. We will monitor the cameras to make sure we are in compliance. This is for resident safety. Please see Administrator if you have any questions. Thank you. On [DATE], the smoking policy, safety of not smoking with oxygen, and updated smoke area times are discussed in the Resident Council Meeting by Director of Activities #31. On [DATE], the Administrator educated independent smokers on the closure of the smoking area from 11:00 P.M. to 6:00 A.M. for supervised smokers. The Administrator provided staff education on this closure via the GreyMAR messaging system. This message stated, As of today, the smoking area will be closed to supervised smokers from 11 P.M. - 6 A.M. Independent smokers can utilize the smoking area. The independent smokers have been educated to use the doorbell when needed as well. If questions, please see Administrator. Thank you. At this time, education was also initiated individually with staff. On [DATE], the DON placed the facility's updated smoking safety education on Clipboard (a website education platform utilized by agency staff). On [DATE], the facility began audits to monitor smoking safety that will be conducted two times per shift, four times per week, for four weeks. After that time, the audits will continue one time per shift, four times per week, for four weeks. After that time, audits will continue one time per shift, three times per week, for four weeks. After that time, audits will continue monthly for three months. The audits will be completed by the DON or designee and reviewed at the facilities monthly Quality Assurance and Performance Improvement (QAPI) meetings, which are held on the third Wednesday of each month. Review of the audit form revealed the facility began conducting the audits to monitor smoking safety on [DATE] and continued them on [DATE]. On [DATE], the facility finalized updating the facility smoking policy as well as updated the facility handbook to reflect smoking changes along with the updated policy. On [DATE], the activities department ensured all residents were provided with copies of the new handbook and received their signatures. On [DATE], the Administrator provided staff education on the updated smoking policy to staff via the GreyMAR messaging system. This message stated, The updated resident smoking policy is posted at the time clocks. Please review and let me know if you have any questions. Thank you. Review of the GreyMAR system revealed staff acknowledge completion of education with a check mark by their name. On [DATE], the DON placed the facilities updated smoking safety education on Clipboard (a website education platform utilized by agency staff). Agency staff acknowledge reading prior to taking an assignment at the facility. Interviews on [DATE] between 10:00 A.M. and 3:30 P.M., with Certified Occupational Therapy Assistant #44, Certified Medication Aide #302, Hospitality Aide #300, and Registered Nurse #36, revealed they were educated regarding the facility smoking policy after the incident took place with Resident #75, the changes to the facility smoking policy, and verified they were knowledgeable regarding the education provided to them. Review of Resident #17 and #26's medical records revealed they both were smokers who utilized oxygen therapy. Both residents had been evaluated by OT and the new smoking evaluation/assessment had been completed. Both residents were now supervised for smoking. Care plans and Kardex's were updated to reflect the supervision required due to oxygen usage. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of Resident #75's closed medical record revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure, personal history of COVID-19, anxiety, atherosclerotic heart disease, type two diabetes mellitus, anemia, dementia, elevated white blood cells, hypo-osmolality, dermatitis, hyperlipidemia, vitamin D deficiency, nicotine dependence, and alpha 1 antitrypsin deficiency. Review of the most recent quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact and required assistance with oral hygiene, toileting, shower/bathing self, lower body dressing, putting on/taking off footwear, personal hygiene, standing from a sitting position, chair transferring, toileting transferring, transferring from the tub/shower, and walking 10 feet. Review of the social services progress note dated [DATE] at 12:20 P.M., revealed the Administrator/Licensed Social Worker (LSW), who acts as both, met with the resident and educated him on the facility smoking policy. Resident #75 stated he understood safety protocol for taking off oxygen, if he goes to the smoking area. He stated he had a problem in the past at home while trying to smoke with his oxygen on, so he knows the importance of turning it off and removing the tubing. Review of a nursing note dated [DATE] at 2:28 P.M. revealed writer, [Registered Nurse (RN) #36], noted the resident to be outside smoking. Writer advised resident of smoking with oxygen risks and informed him of the danger to himself and others. Resident #75 extinguished his cigarette and was upset stating that he knew what he was doing and didn ' t need to be told of the dangers as he has already blown himself up once. Writer notified the DON. The DON went to speak with the resident. Review of a nursing note with an effective date of [DATE] at 3:02 P.M., (with a late entry date created of [DATE] at 2:47 P.M.) by the DON, revealed spoke with Resident #75 at this time regarding smoking policy and safety. Resident #75 states he is aware of the safety measures due to a previous incident while at home. Educated on safety again for self and other residents. Resident #75 states he is aware and understands. Agreeable to policy and plan. Very respectful towards writer during conversation. Will continue plan of care (POC). Review of the Smoking Safety Screen dated [DATE] revealed Resident #75 did not have cognitive loss, had no visual deficits, had no dexterity problems, smokes ,d+[DATE] cigarettes per day, likes to smoke in the afternoon and evening, is able to light his own cigarette, needs the facility to store his lighter and cigarettes, the plan of care is used to assure the resident is safe while smoking, the resident is able to turn off O2 support, verbalized safe smoke rules, and utilized smoking receptacles. Review of the Smoking Safety Screen dated [DATE] revealed Resident #75 did not have cognitive loss, had no visual deficits, smokes ,d+[DATE] cigarettes per day, likes to smoke in the afternoon and evening, is able to light his own cigarette, supervision, needs the facility to store his lighter and cigarettes, the plan of care is used to assure the resident is safe while smoking, notes on safety from interdisciplinary team conference (IDTC) revealed Resident #75 needs supervision for smoking due to cognition and use of oxygen and the team decision is the resident is safe to smoke with supervision. Review of the Smoking Safety Screen dated [DATE] revealed Resident #75 did not have cognitive loss, had no visual deficits, had no dexterity problems, smokes ,d+[DATE] cigarettes per day, likes to smoke in the afternoon and evening, is able to light his own cigarette, needs the facility to store his lighter and cigarettes, the plan of care is used to assure the resident is safe while smoking, the resident is able to turn off O2 support, verbalized safe smoke rules, and utilized smoking receptacles. Review of the care plan for smoking dated [DATE] revealed Resident #75 was safe to smoke unsupervised. The goal is listed as resident will have no injury or decline related to smoking through review. The interventions are listed as educate as needed related to risks associated to smoking, educate/remind not to smoke with O2 (oxygen), and safe to smoke unsupervised. Review of a nurse progress note dated [DATE] at 10:27 A.M., revealed another resident alerted writer that he (Resident #75) was smoking with O2 (oxygen) on, writer notes he is outside at smoking area with a cigarette but not lit. Educated him that he can (later confirmed as a clerical error during an interview with LPN #304 which should have been documented as can ' t) smoke while O2 is on, and he states he knows that and is not smoking. Advised him he should not be in the smoking area while O2 is on, while other people are smoking either; he states he is aware of this and returned to his unit at this time. Review of the social service note dated [DATE] at 2:36 P.M., revealed the Administrator/LSW (who acts as both) met with the resident and re-educated him on the smoking policy and process. He acknowledged understanding. Review of the Smoking Safety Screen dated [DATE] revealed Resident #75 did not have cognitive loss, had no visual deficits, had no dexterity problems, smokes more than 10 cigarettes per day, likes to smoke at all times during the day, can relight their own cigarette, needs the facility to store their lighter and cigarettes, the plan of care is used to assure the resident is safe while smoking, is able to turn off O2 support, and verbalized safe smoke rules and utilized smoking receptacles. Resident #75 was assessed as a safe smoker and able to smoke independently. Review of the nursing note dated [DATE] at 3:11 A.M., revealed Resident #75 came to the nursing station at 2:00 A.M. and asked for a new oxygen tank. He stated his old tank was running low, so this nurse changed client's oxygen tank, client was stable, and he wheeled away in his power chair. Review of the written witness statement from State tested Nursing Assistant (STNA) #14, dated [DATE], revealed at 2:10 A.M., she was standing at the 1 south nurses station copy machine making copies when she happened to see a light and looked outside to see Resident #75 outside swiping at his face to get his oxygen cord away from his face that was on fire. STNA #14 and her hall partner (STNA #91), and Licensed Practical Nurse (LPN) #401, all ran out the doors to help. When STNA #14 got outside she grabbed the cord and ripped it from his oxygen tank and put the fire out, then took the tank and shut it off and took it away from the scene. At that time STNA #91 called 911 at 2:15 A.M. Review of the written witness statement from LPN #58, dated [DATE] at 2:33 P.M., revealed she was notified of this incident at approximately 2:20 A.M., when STNA #329 came to the third floor and notified LPN #58 of a smoking related incident on the first floor, outside, in the resident smoking area, and that 911 had been called. LPN #58 observed Resident #75 sitting upright in his power wheelchair, sitting next to the picnic table with STNA #91 standing next to him. LPN #58 observed Resident #75's facial hair was singed, and his skin was black around his upper lip, nose, and bilateral cheeks. Resident #75 had oxygen tubing in his hand. LPN #58 asked Resident #75 what happened, and he stated, I don ' t know what happened. Resident #75 was A&O (alert and oriented) to name and place. Resident #75 knew who LPN #58 was and stated her name. LPN #58 applied cold, wet cloths to Resident #75's face and took Resident #75's SpO2 (blood oxygen concentration reading) and it measured 77 percent (%), and respirations were 22 (breaths per minute). Oxygen was applied to resident, via NC (nasal canula: a device that delivers extra oxygen through a tube and into the nose), as ordered. At this time EMS (emergency medical services) arrived. The 1 south nurse took the rest of the VS (vital signs) in residents left arm. EMS workers were assessing resident subjectivity at this time, and resident stood up out of his wheelchair, sat down on the gurney, and was put into the ambulance by EMS workers. Review of the written witness statement from STNA #91, dated [DATE], revealed STNA #14 noticed Resident #75 was on fire in the smoking area. She first noticed what looked like a weird flash of light. After taking a second look, STNA #14 noticed his oxygen tubing was on fire. STNA #14 yelled he (Resident #75) is on fire. STNA #91, STNA #14, and LPN #401 went running outside. STNA #14 grabbed the tubing and disconnected it from the oxygen cylinder. Also, putting out the fire. STNA #91 stayed with Resident #75 until his nurse came. Resident #75's nurse had her call 911. This was at 2:15 A.M. The squad came. Review of the written witness statement from LPN #401, dated [DATE], revealed they were alerted on [DATE] at approximately 2:10 A.M., that Resident #75 was outside in the smoking area and there was a bright light outside near Resident #75. When LPN #401, STNA #14, STNA #91, and STNA #329 arrived in the smoking area, they noticed the oxygen tubing was on fire. The aide removed the oxygen tubing, turned O2 off, and put out the fire. Emergency 911 was called at 2:15 A.M. LPN #401, STNA #14, STNA #91, STNA #329, and LPN #58 stayed with Resident #75 until the resident was put onto the stretcher by EMTs (emergency medical technicians), who stated they were taking the resident to the local hospital. Review of the County Emergency Medical Service (EMS) documentation revealed they received notification of this incident at 2:16 A.M., and an advanced life support (ALS) squad was dispatched. The ALS squad arrived at the facility at 2:24 A.M., with one driver, one advanced emergency medical technician (AEMT), and two paramedics. Upon their arrival, Resident #75 was noted to have signs of charring on the face with a nasal cannula in the mouth. The initial EMS assessment of Resident #75 noted the majority of his face was charred, and his nasal cavity (the inside of the nose) was black with no nasal hair present. Once transported from the smoking area, where the incident occurred, to the ambulance, intravenous (IV) access was obtained, and Resident #75 was placed on a non-rebreather mask (a face mask to supply a more concentrated level of supplemental Oxygen) at 15 liters per minute. Review of the facility electronic medical record revealed Resident #75 utilized three liters of supplemental Oxygen via a nasal cannula at baseline. After obtaining IV access, County EMS contacted Life Flight for air transport to St. Vincent's Hospital in [NAME], Ohio as Resident #75 was noted to have a deteriorating airway and adventitious lung sounds (respiratory noises beyond that of normal breath sounds) that were identified as stridor (high-pitched wheezing sound caused by disrupted airflow due to obstruction of the upper respiratory tract). Upon their arrival, intraosseous (IO) access (a procedure that involves inserting hollow needle into a bone's marrow cavity to deliver fluids and medications) was obtained in Resident #75 and the Life Flight crew was able to intubate (insert a tube through the mouth and into the airway to aid with breathing) utilizing rapid sequence intubation (an airway management technique that produces immediate unresponsiveness and muscular relaxation). At this time, Resident #75 was ventilated utilizing a bag valve mask (BVM), transferred from the ambulance to the helicopter, and transported via helicopter to St. Vincent's Hospital. Review of the death certificate revealed Resident #75 expired on [DATE] at 10:44 A.M. and listed the immediate cause of death as smoke inhalation and thermal burns, with a description of how the injury occurred as ignited self-smoking while using oxygen supplementation. Interview on [DATE] at 10:15 A.M. with the DON revealed that on [DATE] Resident #75 requested a new Oxygen tank from staff and then went outside to smoke. On [DATE] at approximately 2:10 A.M., Resident #75 lit a cigarette and ignited his oxygen, and he was burned as a result. Interview on [DATE] at approximately 8:00 A.M. with the Administrator revealed the facility was aware of the history of an incident involving Resident #75 smoking while wearing Oxygen prior to his admission to the facility. Interview on [DATE] at 8:55 A.M. with the Administrator revealed Resident #75 had expressed that he had a history of smoking with oxygen on. Resident #75 knew the policy and he was encouraged to follow the smoking policy. The Administrator stated she did not feel Resident #75 was having an issue with smoking with his oxygen on. Facility staff would check on Resident #75 periodically and his oxygen was never turned on during these checks. Sometimes other residents would report concerns that Resident #75 was smoking with his oxygen on, but when the facility investigated these reports, they were never validated. Interview on [DATE] at 9:15 A.M. with LPN #304 revealed the word can in the progress note dated [DATE] was a clerical error that was not realized until the Ohio Department of Health (ODH) entered the facility for the survey. LPN #304 stated it should have been can ' t. At this time, LPN #304 was advised by administration to not change her documentation during the complaint investigation. Interview on [DATE] at 9:53 A.M. with the DON revealed the facility did not know Resident #75 had a history of smoking with oxygen turned on at home. The care plan for Resident #75 was written for Resident #75 based upon his assessment while he was in the facility. The [NAME] verified the care plan did not address the storage of the smoking materials. The DON stated the IDT team met on [DATE] due to the resident having a urinary tract infection and made him a supervised smoker. They met again on [DATE], when the urinary tract infection was gone, he was re-assessed and made an independent smoker. The DON stated sometimes Resident #75 kept his own smoking materials and sometimes the facility kept them. According to the policy, he can store them, but if the family brings in a large quantity of cigarettes, the facility will store the excess. When the facility was bought by a new owner, the policy was re-evaluated, and things were updated. The assessments couldn't be re-assessed and changed because the facility didn ' t have access to change it in the electronic medical record system for a while. Interview on [DATE] at 9:52 A.M., with the DON revealed the Smoking Safety Screens performed on [DATE] and [DATE], were performed four days apart as the resident had a urinary tract infection (UTI) on [DATE] and had decreased cognition and those cognition issues had resolved on [DATE]. Interviews with witnesses to the [DATE] incident with Resident #75 were attempted multiple times from [DATE] to [DATE] but were unsuccessful. Review of the policy titled, Smoking Policy-Residents, revised [DATE], revealed the facility shall establish and maintain safe resident smoking practices. Oxygen use is prohibited in smoking areas. Residents are not permitted to give smoking articles to other residents. Residents without independent smoking privileges may not have or keep any smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision. Review of the policy titled, Smoking policy revised [DATE], revealed oxygen use is prohibited in smoking areas. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include current level of tobacco consumption, method of tobacco consumption, desire to quit smoking if a current smoker, and ability to smoke safely with or without supervision, and oxygen prescription. The staff shall consult with the attending physician and the DON. Services to determine if safety restrictions need to be placed on a resident's smoking privleges are based on the Safe Smoking Evaluation. Review of the undated resident handbook stated that adherance to the smoking policy is necessary to provide a safe and healthy enviroment. The designated smoke area will be closed from 11 PM-6AM daily for supervised smokers. This deficiency represents non-compliance investigated under Complaint Number OH00157190.

Based on review of medical records, interviews with staff, residents, and the local police department, review of discharge discussion meeting notes, review of facility Self-Reported Incidents (SRI) and associated investigations, review of a discharge notice, and review of the facility's Abuse policy, the facility failed to prevent the sexual assault of a cognitively impaired resident (#02) by providing adequate supervision and ongoing monitoring of the sexual behaviors of Resident #01, identified by the facility to exhibit physically inappropriate, aggressive sexual behaviors. This resulted in Immediate Jeopardy and actual harm for Resident #02 when Resident #01 was discovered by staff with his hand inside Resident #02's incontinence brief at the genital area. As a result, Resident #02 acquired a labial laceration. This affected one (#02) of three residents reviewed with limited cognitive and communicative abilities who were vulnerable to be targeted as victims of abuse by others. The facility identified five residents (#02, #03, #04, #10, and #11) with impaired cognition and/or impaired communication abilities. The facility census was 61. On 11/19/18 at 4:25 P.M., the Administrator and the Director of Nursing (DON) were notified Immediate Jeopardy began on 11/10/18 at 12:15 P.M when Resident #01, with a history of sexual behaviors and after having recently been identified to have exhibited an increase in sexual behaviors, was not being provided any ongoing supervision or behavior monitoring from the facility and was found with his hand inside Resident #02's incontinence brief at the location of her genital area by Licensed Practical Nurse (LPN) #45. LPN #45 immediately separated the two residents and remained with Resident #02 while Resident #01 was taken to his room and placed on one-to-one direct supervision by State tested Nurse Aide (STNA) #50. An assessment of Resident #02 revealed an abrasion on the top of the right labia measuring approximately 1.0 centimeter (cm) long by 0.3 cm wide. Resident #01 was transferred to the hospital for a psychological evaluation at 3:10 P.M. The Immediate Jeopardy was removed on 11/13/18 when the facility implemented the following corrective actions: · On 11/10/18 at 12:16 P.M., Residents #01 and #02 were separated by LPN #45. Resident #01 was placed on one-to-one direct supervision from STNA #50. · On 11/10/18 at 12:30 P.M., LPN #45 notified Registered Nurse (RN) #400 of the incident. · On 11/10/18 at 1:15 P.M., Assistant Director of Nursing (ADON) #01 performed a head-to-toe assessment of Resident #02. The results of the assessment revealed an abrasion on the top of the right labia measuring approximately 1.0 cm long by 0.3 cm wide. · On 11/10/18 at 1:30 P.M., Nurse Practitioner #01 and Resident #02's spouse were notified of the incident. · On 11/10/18 at 2:15 P.M., ADON #01 began investigating the incident by interviewing Resident #01. · On 11/10/18 at 2:45 P.M., ADON #01 notified Resident #01's guardian of the incident. · On 11/10/18 at 2:50 P.M., Resident #01's physician was appraised of the incident and ordered Resident #01 to be transferred to a hospital for a psychological evaluation. At 3:10 P.M., Resident #01 was transported to the hospital. · On 11/10/18 at 4:00 P.M., the local police were informed of the incident. After speaking with the county prosecutor, Resident #01 was arrested and taken to the county jail. · On 11/10/18 at 5:30 P.M., Resident #01 was booked at the county jail. At 6:00 P.M., LPN #71 transported 14 days of medications and a Medication Administration Record [REDACTED]. · On 11/10/18, ADON #01 began providing in-service training for all nursing staff regarding the facility abuse policy. On 11/12/18, the DON or designee began providing in-service training to all facility staff regarding the facility abuse policy. · On 11/14/18, the DON provided additional training to all staff regarding resident sexual abuse. The content of the education was regarding sexual abuse of elderly residents, signs of sexual abuse in the elderly, and what to do when abuse was suspected. One hundred and forty staff were educated as of 11/20/18. A plan for the remaining 17 contingent staff was developed for education prior to the start of their next shift. · On 11/11/18 at 11:30 A.M., Resident #01's legal guardian arrived at the facility to remove Resident #01's belongings. The legal guardian indicated Resident #01 will not be returning to the facility. · On 11/11/18 at 11:44 A.M., the facility submitted an initial SRI of the allegation of sexual abuse to the State Survey Agency. · On 11/12/18, all four female residents residing on the Two South Unit, where Resident #01 resided were interviewed by the Administrator and Social Worker Designee #01. Three of the four female residents had intact cognition and one female resident had moderately impaired cognition. All four females were able to verify they had encountered no interaction with any person of a sexual nature. All four females could verbalize who they would tell if any unwanted sexual encounters should happen. · On 11/13/18 at 12:30 P.M., Social Worker Designee #01 hand-delivered an immediate discharge notice to Resident #01's legal guardian. The legal guardian signed acknowledgement of the discharge notice. · On 11/13/18, the DON conducted a complete chart audit and assessment for all male residents. The facility identified five male residents (#05, #06, #07, #08, and #09) with a history of sexual behaviors. There were no current issues discovered with these residents. Behavior monitoring, and supervision revisions were made to the care plans as necessary. · On 11/15/18, the facility concluded the SRI investigation regarding the sexual assault and substantiated the allegation. · Beginning on 11/16/18, the DON or a designee will conduct random audits of the nursing notes of the five identified male residents with a history of sexual inappropriate behaviors. These audits will be completed weekly for four weeks. A review of the audits conducted on 11/16/18 and 11/19/18 identified no concerns or revisions needed to the care plans. · Interviews conducted on 11/19/18 at 4:35 P.M. with STNA #10, at 4:41 P.M. with STNA #55, at 4:44 P.M. with STNA #110, at 4:46 P.M. with LPN #45, at 4:49 P.M. with Nurse Practitioner #01, at 4:50 P.M. with Respiratory Therapist (RT) #30, at 4:53 P.M. with STNA #120, at 4:59 P.M. with STNA #130, and at 5:08 P.M. with LPN #83 all verified they had received recent education on sexual abuse. All staff were aware of who to report abuse to, when to report it, and immediate actions to take in an abuse situation. · Review of the medical record for Resident #05 and Resident #06, identified by the facility to have a history of exhibiting sexual behaviors, revealed no concerns with abuse towards others. Supervision levels and monitoring were identified. · Review of the medical record for two additional residents, Resident #03 and Resident #04, identified by the facility to have impaired cognition and/or decreased communication skills leaving them vulnerable to abuse by others, revealed no concerns. Although the Immediate Jeopardy was removed on 11/13/18, the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Review of a facility SRI dated 04/19/18 revealed an STNA (#203) reported intervening when Resident #01 was found at the bedside of a female resident (Resident #03) with his hands under the sheet of her bed. STNA #203 told Resident #01 to leave the room and when Resident #03 was observed the closures of her incontinence brief were noted to be unattached, however, the brief was still in place and unmoved. STNA #203 indicated Resident #01 could not have been in Resident #03's room very long because he had just been observed leaving the dining room. The facility ' s SRI investigation revealed an interview with Resident #01 where he admitted he was in Resident #03's room, however he denied he had touched her. Interventions as a result of the incident, included Resident #01 was moved to another floor of the facility at 2:00 P.M. away from any other residents who were in any type of vegetative or comatose state. A psychiatric nurse practitioner spoke with Resident #01's guardian and prescribed the hormone Depo-[MEDICATION NAME] to control his inappropriate sexual behaviors. The results of the investigation revealed the facility did not believe Resident #01 harmed Resident #03 because he was found soon enough to prevent harm, however, the facility believed Resident #01 intended to harm Resident #03. Review of Resident #01's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Resident #01 had a legal guardian. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/24/18, revealed Resident #01 had moderately impaired cognition, required supervision with one-person physical assistance for locomotion on and off the unit, and was assessed with [REDACTED]. Review of a psychiatric wellness group progress note, dated 04/19/18, revealed Resident #01 was assessed for psychiatric services at the facility for reason of depression and sexual inappropriate tendencies. The note indicated per staff report Resident #01 had a history of [REDACTED]. Per the chart review on 04/19/18 he was discovered in a female resident's room and had removed the tabs on her incontinent briefs. During the assessment Resident #01 denied the episode and voiced no concerns with depression, anxiety, appetite, or sleep. Review of a physician order [REDACTED].#01 was ordered Depo-[MEDICATION NAME] five milligrams (mg) by mouth daily for sexually inappropriate tendencies. Review of a care plan, dated 04/30/18, revealed Resident #01 demonstrated non-consensual sexual attention towards another resident. The care plan interventions included Resident #01 was followed by psychiatric services, administer medications as ordered, staff should report any suspected or known inappropriate behaviors to the supervisor immediately, and Resident #01 was not to be on the One South Unit. Resident #01 was to wear a Wanderguard so staff could monitor when he left the unit he resided on. Review of a medical visit note, dated 05/10/18, revealed Resident #01 was assessed for his monthly visit with no new concerns. His plan of care indicated Resident #01's inappropriate sexual tendencies were treated to Depo-[MEDICATION NAME]. Review of a psychiatric services progress note, dated 05/17/18, revealed Resident #01 had no physical sexual actions towards other residents, but still had some verbal remarks towards staff. Resident #01's Depo-[MEDICATION NAME] medication was continued without changes. Review of a nursing progress note, dated 06/02/18, revealed Resident #01 placed his call light on and upon entering the room an STNA found Resident #01 involved in the act of self stimulating sexual behavior. The STNA turned the call light off and indicated to the resident she would return later. Review of a progress note, dated 07/22/18, revealed Resident #01 was found on the One South Unit back hall. Resident #01's guardian requested the psychologist call her to review Resident #01's medication and possibly increase his Depo-[MEDICATION NAME] medication. Review of a psychiatric services progress note, dated 08/16/18, revealed Resident #01's mood had been stable with no further inappropriate sexual mannerisms noted. Resident #01 was assessed and denied any inappropriate sexual desires. The plan was to continue the Depo-[MEDICATION NAME] medication without changes. Review of a progress note, dated 09/02/18, revealed the facility received report from a visiting family member that Resident #01 was watching pornography on the computer in the common dining room. The family member called an STNA to the area and the STNA confirmed Resident #01 was watching pornography. Review of a care conference note, dated 09/06/18, addressed the incident with the resident watching pornography on the facility computer in the common area on 09/02/18. Resident #01's legal guardian desired for the facility nurse practitioner to address the issue. There was also discussion about Resident #01 leaving the unit he resided on without telling staff. Resident #01 was educated during the conference and was able to repeat and understand that he would let staff know when he was going outside. Review of a medical visit note, dated 09/18/18, revealed Resident #01 was assessed for a monthly visit. The note documented Resident #01 was observed watching pornography in the dining room and needed to continue to work with psychiatric services. Review of a physician order [REDACTED].#01's Depo-[MEDICATION NAME] was increased from 5 mg daily to 10 mg daily. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of documentation of notes dated 09/25/18, revealed a meeting occurred between the facility, the Ombudsman, and Resident #01's legal guardian. The purpose of the meeting was to discuss Resident #01's discharge plans per facility recommendations as they believed Resident #01 was inappropriately placed and posed a threat to residents living in the facility. The facility identified the incident in (MONTH) (YEAR) between Resident #01 and Resident #03 which had resulted in Resident #01 being moved off the third floor away from Resident #03. However, since the incident in April, the third floor of the facility was closed, and Resident #03 had been moved to the first floor. In (MONTH) (YEAR), Resident #01 was found wandering on the first-floor hallway in the area near Resident #03's room. The resident was removed from the area by a nurse. The facility also identified in (MONTH) (YEAR), Resident #01 was found in the common area watching pornography on the facility computer. The note documented the facility identified Resident #01 continued to exhibit sexually-seeking behavior even though Resident #01 had been ordered a hormone medication to reduce his sexual drive in (MONTH) (YEAR). The notes indicated the facility had identified Resident #01's behaviors as predator, sexually seeking, sexually deviant behavior, and safety risk to others when discussing them with the Ombudsman and legal guardian. The meeting note indicated the facility wanted to transfer Resident #01 to a treatment facility which specialized in behaviors that occurred as a result of his diagnoses. The meeting notes documented the facility had an obligation to be aware of Resident #01's behavior because of the past incidents and so the facility can continue to keep other female residents safe. The legal guardian refused to entertain the idea of transferring the resident to a treatment facility for treatment of [REDACTED]. A review of the care plan revealed no new interventions, changes in the monitoring of Resident #01's behavior, or changes in the frequency of supervision were made as a result of the family meeting and facility ' s increased concerns regarding the resident's sexual behaviors. Review of a medical visit note, dated 09/28/18, revealed Resident #01 was assessed for depression, obsessive compulsive behaviors, and inappropriate sexual tendencies. After a lengthy discussion with Resident #01 and his legal guardian, both voiced understanding for the need to stop the Depo-[MEDICATION NAME] due to the increased risk for the development of blood clots. The use of the anticonvulsant [MEDICATION NAME] and the antidepressant [MEDICATION NAME] for inappropriate sexual behaviors, depression, and obsessive compulsive behaviors were discussed. Both Resident #01 and his legal guardian agreed with the medication change. Review of a physician order [REDACTED].#01's Depo-[MEDICATION NAME] was decreased from 10 mg daily to 5 mg daily for one week then to discontinue the medication. Resident #01 was ordered [MEDICATION NAME] 20 mg daily for one week for treatment of [REDACTED].#01 was ordered [MEDICATION NAME] 50 mg twice a day for two weeks to manage inappropriate sexual behaviors. On 10/05/18 the [MEDICATION NAME] was increased to 40 mg daily for one week. Review of the (MONTH) and (MONTH) (YEAR) MARs revealed Resident #01 received all medications as ordered. Review of a behavior sheet revealed beginning 10/10/18 social services reviewed Resident #01's medical record for documentation of any inappropriate sexual comments and inappropriate sexual contact. The behavior sheet revealed there were no sexual behaviors documented. Review of the physician orders [REDACTED].#01's [MEDICATION NAME] was increased to 100 mg twice a day and the [MEDICATION NAME] was increased to 60 mg daily. Review of the (MONTH) (YEAR) MARs revealed Resident #01 received all medications as ordered. Review of a psychiatric services progress note, dated 10/24/18, revealed Resident #01 reported moderate persistent anxiety and panic attack symptoms. The staff member reviewed Resident #01's current concerns and reviewed effective coping skills for management of mood and symptoms. The staff member maintained a plan for continued psychotherapy and monitoring of behaviors with a recommendation for facility staff to implement a behavior record to improve documentation of frequency or absence of behaviors. Review of the medical record revealed this behavior record was not initiated as recommended. Review of a medical visit note, dated 11/09/18, revealed Resident #01 was assessed for his monthly visit. Resident #01 continued to receive [MEDICATION NAME] and [MEDICATION NAME] for inappropriate sexual tendencies and behavior with nursing reporting Resident #01 was doing well. The note indicates an increase in the medications will be considered if needed. Review of a nursing progress note dated 11/10/18 at 12:41 P.M., revealed Resident #01 was witnessed by staff touching a female resident (Resident #02) inappropriately. Resident #01 was taken to his room but left his room and attempted to come to the nurses' station to approach the female resident. The nurse was between Resident #01 and the female resident and removed Resident #01, taking him to his room. Resident #01 was placed on a one-to-one observation with an STNA. The DON and physician were contacted. The physician provided an order to transfer Resident #01 to the hospital for an evaluation. Resident #01 did not return to the facility from the hospital. A progress note dated 11/10/18 at 1:25 P.M., revealed a nurse spoke to Resident #01 in his room about the incident. Resident #01 was alert and oriented to name and place but confused about the date and time. The nurse asked Resident #01 if he had touched any residents inappropriately today and Resident #01 stated, while smiling at the nurse, he did not know what the nurse was talking about. Review of a progress note dated 11/10/18 at 2:50 P.M., revealed an order was received from the physician to send Resident #01 to the emergency room (ER) for a psychiatric evaluation. The ER nurse was informed of the physician's recommendation for hospitalization for psychiatric treatment. At 3:10 P.M. the transportation company arrived and transported Resident #01 to the ER. Review of a progress note dated 11/11/18 at 10:30 A.M., revealed Resident #01's legal guardian arrived at the facility, removed all of Resident #01's belongings, and indicated Resident #01 was not returning to the facility. Review of Resident #02's medical record revealed an original admission date of [DATE], and a re-admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the MDS assessment, dated 10/22/18, revealed Resident #02 had severely impaired cognition and required extensive assistance with all activities of daily living. Review of a progress note dated 11/10/18 at 2:56 P.M., revealed the Assistant Director of Nursing arrived at the Two South nurses' station and observed Resident #02 sitting in her wheelchair covered by a lap pad attached to the wheelchair and a blanket wrapped around her lower body as Resident #02 did not have any clean pants. The resident was returned to her room and a head to toe assessment was completed. Resident #02 had an abrasion to her right labia measuring 1.0 cm long by 0.3 cm wide with no depth. There was no bleeding noted. Resident #02's husband was notified who stated he took all of Resident #02's clothes home to wash because they were soiled. Review of the facility SRI revealed on 11/10/18 at 12:15 P.M. an incident occurred at the Two South nurses' station involving Resident #01 and Resident #02. The report indicated Respiratory Therapist (RT) #30 stated she observed Resident #01 to be very close to Resident #02, leaning in and talking to her. RT #30 did not recall seeing the placement of Resident #01's hands and arms. The incident documented LPN #45 was several feet behind the respiratory therapist and as she approached the two residents LPN #45 observed Resident #01's hands between Resident #02's legs and his hand was inside her brief. LPN #45 demonstrated Resident #01's hand entering the top right portion of Resident #02's brief up to about his knuckles. Resident #01 was taken to his room and placed on one-to-one observation. ADON #01 performed a head to toe assessment of Resident #02 and found an abrasion on the top of the right labia measuring approximately 1 cm long by 0.3 cm wide with no depth. The investigation revealed STNA #50 stated she performed peri-care to Resident #02 at 10:30 A.M. and the abrasion was not present. An order was received to transport Resident #01 to the hospital for a psychological evaluation. The local chief of police responded to the hospital and after speaking to the county prosecutor, the chief of police arrested Resident #01 and took him to the county jail. The investigation revealed on 11/13/18, Resident #01's guardian was given a hand-delivered immediate discharge notice. The SRI was created in the state agency reporting system on 11/11/18 at 11:44 A.M. by the Administrator and closed on 11/15/18 with the allegation of sexual abuse being substantiated. Review of the written statement by RT #30 in the investigation provided revealed on 11/10/18 at approximately 12:35 P.M. she was going to the Two South Unit to perform [MEDICAL CONDITION] care. She passed Resident #01 sitting near Resident #02. They were both in the hall by Resident #02's room and near the elevator. Resident #02 had a blanket over her lap. Resident #01 was talking to Resident #02 but was kind of close. RT #30 walked toward Residents #01 and #02 and observed LPN #45 was moving Resident #02 away from the situation. As the LPN had the situation under control, RT #30 went to find a nurse to report the issue. On 11/11/18 at 1:00 P.M., RT #30 wrote she did not recall where Resident #01's hands and arms were as she walked past Residents #01 and #02. Review of LPN #45's written statement, dated 11/10/18 at 12:35 P.M., revealed she was walking down the hall and noticed RT #30 walking really fast. LPN #45 noticed Resident #01 was facing Resident #02. Resident #01 had his right hand between Resident #02's legs, putting his hand into her brief. A blanket was on the floor beside Resident #02. LPN #45 covered Resident #02 with the blanket and moved her to the other side of the hall where she waited with her. Review of STNA #50's written statement, dated 11/10/18, revealed she provided incontinence care for Resident #02 at 10:30 A.M. on 11/10/18 and there were no issues. Resident #02 was changed again at 1:00 P.M., after the incident, and had a red scratch on her right labia. Review of a discharge notice, signed by Resident #01's legal guardian on 11/13/18, revealed Resident #01 was given an immediate discharge notice from the facility because of his sexual actions toward another female resident in the facility. During an interview on 11/19/18 at 8:42 A.M., RT #30 stated at approximately 12:35 P.M. on 11/10/18 she was walking down to the Two South Unit to perform [MEDICAL CONDITION] care. RT #30 stated she saw Resident #01 in his wheelchair facing the wall and all she could see was Resident #01's back. RT #30 stated it appeared Resident #01 was having a conversation with Resident #02, who was sitting in a wheelchair facing toward RT #30. RT #30 stated the two resident's wheelchairs were positioned in a manner that the residents were sitting partially side-by-side. RT #30 stated Resident #02 had a blanket on. RT #30 stated it seemed odd to her that Residents #01 and #02 would be talking to each other because Resident #02 cannot have a normal conversation, so she approached Residents #01 and #02. RT #30 stated she never saw Resident #01's hands but stated LPN #45 arrived at the area immediately prior to her reaching the two residents. LPN #45 separated the two residents. LPN #45 reported to RT #30 she had observed Resident #02 touching Resident #01 inappropriately. RT #30 stated she then left both residents with LPN #45 and went to the first floor of the facility to find the RN #400. During an interview on 11/19/18 at 8:54 A.M., LPN #45 stated she was walking towards the Two South Unit. LPN #45 stated as she was going around the corner near the elevator she observed Resident #01's back. Resident #02 was facing toward her. LPN #45 stated she saw Resident #01's right hand inside Resident #02's incontinence brief and his hand was moving up Resident #02's left side in her upper leg area. LPN #45 stated Resident #01's hand was inside Resident #02's brief about to his knuckles. LPN #45 stated Resident #02 was sitting in her wheelchair with only the brief on. There was a blanket on the floor beside her chair. LPN #45 stated she put the blanket on Resident #02 and took her to the other side of the hallway. RT #30 arrived and then went to go find a nurse downstairs. LPN #45 stated Resident #01 had a history of [REDACTED]. LPN #45 stated at that time, he went into a female resident's room, put his hands under her blanket, and was found with her incontinence brief undone. LPN #45 stated Resident #01 was not allowed to go to the third floor after the incident. LPN #45 verified Resident #01 was able to move about the floor and facility on his own. During an interview on 11/19/18 at 9:03 A.M., STNA #62 stated she refused to walk into Resident #01's room alone and would walk out of his room backwards because he would grab her buttocks. STNA #62 stated Resident #01 was very sexually oriented. When staff would go into Resident #01's room to check him for incontinence, he would already have his incontinence brief undone and would be masturbating. STNA #62 stated Resident #01 would masturbate multiple times a day and often when staff would be providing incontinence care he would get an erection. STNA #62 stated Resident #01 always had lotion and tissues by his bed so he could masturbate and would always watch pornography in his room. STNA #62 stated Resident #01 had no monitoring of his behaviors or supervision other than standard checks every two hours. During an interview on 11/19/18 at 9:15 A.M., STNA #50 stated she performed incontinence care to Resident #02 after the incident and saw a scratch on her labia. ADON #01 came in later to do a head to toe assessment on Resident #02 and observed the scratch. STNA #50 stated Resident #02 did not act any differently and when questioned by the nurses the resident denied being touched. STNA #50 stated after the incident she observed Resident #01 keep trying to come out of his room and sit by Resident #02. Resident #01 was acting like he did not do anything wrong. STNA #50 verified Resident #01 did not have any special monitoring to be completed by staff other than to ensure his Wandergard was in place every shift. During an interview on 11/19/18 at 9:23 A.M., STNA #55 stated she was working on the Two South Unit on the day of the incident. She last observed Resident #01 sitting by the nurses ' station wearing a brief, a T-shirt, and a blanket, but could not recall the time. STNA #55 stated she was aware of Resident #01's previous incident and verified he was only receiving standard two-hour checks. During an interview on 11/19/18 at 9:30 A.M., LPN #75 stated Resident #01 would always be in his room watching pornography and would be masturbating. LPN #75 stated on two occasions she knocked on his door to enter the room and Resident #01 said to come in. Upon entering the room, he was masturbating. LPN #75 stated she was not aware of any special monitoring for Resident #01. During an interview on 11/19/18 at 11:27 A.M., the DON stated she was notified on 11/10/18 at 12:49 P.M. by ADON #01 of the incident between Resident #01 and Resident #02. The DON stated she instructed ADON #01 to put Resident #01 on one-to-one observation, perform a physical assessment on Resident #02, and obtain witness statements. The DON stated the physician and the legal guardians for Residents #01 and #02 were contacted on 11/10/18. The physician provided orders to send Resident #01 to the hospital. The DON stated Resident #01 was sent out on 11/10/18 at 3:15 P.M. and has not returned to the facility. The DON verified Resident #01 had not been receiving any increase in monitoring other than the standard every two-hour check. During an interview on 11/19/18 at 11:34 A.M., the Administrator stated she received a telephone call from the DON on 11/10/18 at 12:52 P.M. about the incident between Resident #01 and Resident #02. The Administrator verified Resident #01 did have another inappropriate sexual encounter with Resident #03 in (MONTH) (YEAR). The Administrator stated Resident #03 had a disease where she cannot communicate or move. As a result, the Administrator stated Resident #01 was moved to the second floor and had a Wanderguard applied. When Resident #01 entered the elevators, the Wanderguard would not allow the cart to move unless one of the staff would activate the cart. This way staff would be able to monitor his whereabouts. The Administrator stated Resident #01 was not to have access to the third floor at that time. In (MONTH) (YEAR), the facility's third floor was closed, and Resident #03 was moved to the first floor. The Administrator stated Resident #01 did have access to the first floor to use the vending machines, go outside, or go to the business office. Staff would know when he was on the first floor but verified Resident #01 was not receiving constant visual supervision. There was a time when Resident #01 was found on the first floor and he was redirected outside by a staff member. The Administrator stated Resident #01 was started on Depo-[MEDICATION NAME] in (MONTH) (YEAR) and Social Worker Designee #1 began monitoring his behaviors on 10/10/18 through chart review. The Administrator verified Resident #01 was found in the dining room on the second floor watching pornography. Following this discovery, the facility decided to have a meeting with Resident #01's legal guardian and the Ombudsmen about moving Resident #01 to a different facility that could manage his behaviors better. Nurse Practitioner (NP) #306 was at the meeting and stated she could at

Based on medical record review, observation, interviews with facility staff, interview with the local Police Chief and review of the police report, review of the facility's Self-Reported Incident (SRI) and investigation documents, review of the Emergency Medical Services (EMS) squad run report, review of the hospital emergency room (ER) report and review of the National Weather Service computerized environmental temperatures, the facility staff failed to provide adequate monitoring to ensure for the safety of the residents assigned to their care. This resulted in Immediate Jeopardy and serious life-threatening injuries when Resident #1 left the facility without staff knowledge, was ultimately determined to be missing from the facility, and was eventually found lying on frozen ground by local law enforcement with an unobtainable body temperature. This affected one (#1) of three residents (#1, #2, and #3) reviewed who were at risk for potential accidents during independent outings of a total of five residents identified who leave the facility independently. On 02/08/18 at 3:45 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 02/02/18 at approximately 8:20 P.M., when Resident #1 left the facility alone in an electric wheelchair and was subsequently discovered approximately seven hours and twenty minutes later in a secluded park on the ground and partially undressed with an unobtainable body temperature. The facility was unaware Resident #1 was missing until approximately 1:00 A.M. Resident #1 independently exited the building into 14 degree Fahrenheit air temperatures and winter weather conditions. When the resident was finally discovered by local law enforcement, he was laying on the frozen ground, with purple skin color and bleeding abrasions. The resident was transported to the local hospital ER for evaluation and treated for [REDACTED]. The Immediate Jeopardy was removed on 02/03/18 when re-education was provided to all nursing staff regarding every two-hour rounds and walking rounds at shift change, and the facility implemented the following corrective actions: · On 02/03/18, all nursing staff were re-educated on the topic of Walking Rounds at Shift Change and Rounds Every Two Hours as a standard of providing good care. This education included a written protocol to remind staff of the specific requirements of their responsibilities, directing they must visualize the presence of the resident to make sure that he/she is where they are supposed to be and/or they know where the resident is to ensure they are safe. · On 02/05/18, the staff/receptionists at the front desk positions were re-educated to ensure that if a resident is leaving the building, staff are to ensure that the resident signs out in the Resident Log and to indicate how long the resident intends to be gone. Additionally, they are to ensure that the resident leaving the building is dressed appropriately for the weather outside and if not, they are to educate the resident on appropriate dress for the outdoor conditions or encourage the resident to remain inside the building. If the resident insists on leaving without proper attire or appears to be intoxicated or in any other unsafe manner, staff are to immediately call and notify the floor staff on the unit which the resident resides to make them aware the resident has left the facility. · On 02/05/18, the facility's administrative staff met with the alert and oriented independent residents that travel out of the facility daily to discuss a practice that would address the need to meet the facility's responsibilities of ensuring for their safety while honoring the residents desire to maintain independence. As a result, an Out on Pass Therapeutic Leave policy was established. · On 02/06/18, facility staff was in-serviced and began implementing the new policy titled Out on Pass for a Therapeutic Absence. · On 02/07/18, interview with two residents (#2 and #3), Registered Nurse (RN) #125, Licensed Practical Nurse (LPN) #205 and State tested Nurse Aide (STNA) #307 verified attendance at the in-service and were knowledgeable of the therapeutic absence policy. Although the Immediate Jeopardy was removed on 02/03/18, 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 is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings Include: Review of the medical record of Resident #1 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most current Minimum Data Set (MDS) assessment dated [DATE] the resident is identified with a Brief Interview for Mental Status(BIMS) score of 15, which indicates alert and oriented mental status. The resident is noted with effective speech, vision and the ability to make needs known. The resident was identified to be independent with locomotion while off the facility unit by utilizing a walker or wheelchair and requires extensive physical assistance of two staff for ambulation. According to nurse's notes on 01/29/18 at 7:00 P.M., the resident signed out of the facility to go to the store. Resident #1 was asked not to venture out due to the late hour and weather conditions. The resident proceeded to leave for the store and returned to the facility at 7:30 P.M. The nurse making the entry in the nurse's notes documented being informed by the one South unit at 8:30 P.M. that the local police had to help the resident when he had gotten his electric wheelchair stuck in the snow while on an outing in the community. The resident returned in his wheelchair at 8:35 P.M. Resident #1 was asked to sign out each time he decides to leave the facility so staff can be aware he is not in the facility. The resident agreed and the local police department was called and informed of the resident's return to the facility. Review of a facility SRI dated 02/03/18 revealed at 1:00 A.M. on 02/03/18, staff were unable to locate Resident #1 in the building. A Code Brown (Missing Resident Policy) was implemented and the administrator responded along with the DON and the police. Additional staff, the county sheriff, the local fire department/EMS, and local police responded, searching the outside radius of the building and village. Resident #1 was found at 2:40 A.M. in the park just north of the facility. His powered wheelchair was on its side, and Resident #1 was found approximately 50 yards from the chair. The resident had crawled along a ditch embankment toward the road. He was alert and responsive. He was taken to the local hospital where he was diagnosed with [REDACTED]. The facility cameras show the resident leaving the facility on his power wheelchair at 8:20 P.M. wearing his coat and shoes but no hat or gloves. According to the SRI, the administrator interviewed the resident in the emergency room at the hospital at approximately 4:00 A.M. and when the resident was asked if he remembered what happened, he replied I was driving in the grass, it got slippery, and I fell . That was all the resident could state at that time due to chattering teeth and shivering. The resident suffered frostbite to his hands and feet, and his core body temperature dropped to 90 degrees Fahrenheit according to hospital personnel. Review of EMS squad run report revealed on 02/03/18 at 2:26 A.M. EMS was dispatched to assist in the search of a missing person (Resident #1) who was last seen on 02/02/18 at 8:00 P.M. At 2:53 A.M. the resident was found in the fetal position next to a tree. Appears to have fallen from motorized wheelchair and rolled down to a creek. The resident was alert and oriented however, did not recall the incident. Skin appears to be mottled on all extremities and trunk. Resident has multiple abrasions to hands and knees, where it appears that he was crawling. Two attempts to obtain an oral temperature were unsuccessful with both readings showing low on the thermometer. At 3:13 A.M. the resident was transported to the hospital and at 3:15 A.M. care was initiated by hospital ER staff. According to the local hospital ER report dated 02/03/18 at 3:10 A.M., Resident #1 was assessed and treated for [REDACTED]. The resident's temperature was 90.7 degrees Fahrenheit. His hands and feet were very cold to touch with numerous abrasions and ecchymosis to the hands, dorsal feet, and knees. The resident was placed under a warming blanket and two liters of warm normal saline was administered intravenously. Interview with the administrator on 02/06/18 at 3:30 P.M. revealed on 02/03/18 at 1:33 A.M. she received a telephone call from the RN Supervisor #1 reporting Resident #1 was discovered missing around 1:00 A.M. She was informed facility staff had conducted a search and the missing person procedure had been implemented. The facility had notified the county Sheriff, called 911 and the local police. At 2:00 A.M., the county Sheriff, local fire and police departments arrived at the facility. The local police chief assumed command of the incident and the one south unit was designated as the command center location. During this time, the administrator and social worker reviewed the security camera footage and determined the resident left the facility at 8:18 P.M. No footage indicated the resident had returned to the facility. At 2:35 A.M., while at the command center, the administrator overheard on the police chief's radio the search team had found an overturned wheelchair (w/c) in the park which was located north of the facility. The police chief proceeded to leave the facility. The administrator and LPN #201 also proceeded to the location of the w/c. Upon arrival, the search team had found Resident #1. EMS placed the resident into the ambulance and transported him to the local hospital. The administrator went to the hospital and spoke with Resident #1. He was alert and able to communicate. Resident #1 stated to the administrator he had got into the grass and the grass was slippery causing him to fall from the w/c. The administrator returned to the facility and started re-educating staff on walking rounds and rounds on each resident every two hours. On 02/06/18 at 3:45 P.M., interview with Resident #1 revealed on 02/03/18 he left the facility building in his electric w/c and was going to get cigarettes at a store located north of the facility. On the way off the unit, Resident #1 indicated he told LPN #202 he was leaving the facility. He attempted to go on the path to the parking lot and it was too muddy so he decided to return to the facility. Resident #1 stated his w/c wheels went off the side of the path and he fell to the ground. He could not get the wheelchair upright and decided to crawl along the creek side which was the shortest way to the main road. While resting next to a tree, someone located him. He stated he does not remember who found him or what happened after he was discovered. Interview on 02/07/18 at 11:23 A.M. with STNA #303 revealed he was scheduled to work the second shift (3:00 P.M. to 11:00 P.M.) on 02/02/18. STNA #303 worked from 3:00 P.M. to 7:00 P.M. on the one south unit and at 7:00 P.M. he was directed to work on the two-north unit. While conducting walking rounds with STNA #400, he was instructed to report to the two-south unit to assume the care of the residents. STNA #303 was not provided with a report of the residents on the two-south unit and did not conduct walking rounds. STNA #303 stated he had not worked the two-south unit before and the STNA which worked the previous shift indicated she had not worked on the two-south unit before and was not familiar with the residents. STNA #303 indicated he was unsure if all the residents were in their rooms or on the two-south unit. STNA #304 was also assigned to work the two-south unit between 7:00 P.M. and 11:00 P.M. on 02/02/18. STNA #303 stated this was the first time for STNA #304 to work on the unit and she was redirected from the three-south unit. The nurse assigned to the two-south unit was LPN #203 who did not inform the STNAs of the residents or their care needs. STNA #303 stated he did not complete visual confirmation of Resident #1's presence or care for Resident #1 during the shift which ended at 11:10 P.M. STNA #303 also stated he did not conduct walking rounds or resident report with the oncoming STNAs at 11:00 P.M. Interview with STNA #304 on 02/07/18 at 11:45 A.M. revealed on 02/02/18 she was assigned to her usual unit three south. During the shift, STNA #304 was reassigned to the residents on unit two south and reported to the unit at 7:50 P.M. STNA #304 stated she had never worked on the nursing unit two south and was not familiar with the residents or their care needs. STNA #304 was given a, three minute, verbal report and shown a list of residents with check marks next to names, indicating they were in their rooms. STNA #304 was assigned to work with STNA #303 who indicated he had not worked on the two-south unit before. Additionally, LPN #203 was the nurse assigned to the two-south unit and was unfamiliar with the residents on the unit. STNA #303 indicated when assuming the shift and associated resident care responsibilities a room to room resident round and two hour rounds are to be made. STNA #303 and #304 provided care to the residents on the unit until approximately 11:10 P.M. when she finished the shift and went home. STNA #304 stated she did not know what Resident #1 looked like and could not identify him as she did not encounter the resident during the shift on 02/02/18. STNA #304 was told by the oncoming STNA #305 she could go home and no report or rounds were conducted. On 02/07/18 at 1:35 P.M., interview with the DON revealed STNA staff are to conduct shift to shift report by going resident room to room when assuming the shift responsibilities. This is the standard of practice. The DON stated she has conducted training regarding maintaining safety of residents. Review of in-service training during the months of (MONTH) and (MONTH) (YEAR) noted the expectation and standard of care is walking rounds and visualizing residents every two hours. Interview with the local Police Chief and review of the police report on 02/07/18 at 2:00 P.M. revealed on 02/03/18 at 1:44 A.M. he was dispatched to the facility due to a missing person report regarding Resident #1. The Police Chief stated while in route to the facility he began to check potential locations in the community which the resident was known to frequent and then reported to the facility. Once assuming command of the search, two Sheriff's deputies and the local fire department were directed to search for the resident. Approximately one hour later Sheriff Deputy #44 reported he had discovered a w/c located in a ravine in the park north of the facility. The Police Chief said he drove through the area twice prior to arriving at the facility to assume command. The area was extremely dark without illumination with hills and a creek and uneven terrain (hills, trees, stream). The Police Chief then responded to the location. The fire department arrived at the scene and assisted with lighting the area. A short time later, the Police Chief found Resident #1. The resident's shoes were lying next to the creek and the resident was on the hill by the street with his pants and underwear down below his knees. The resident was approximately 200 feet east of the w/c. An assessment of the resident's skin was noted with legs and hips purple in color and cold to touch. The resident's hands were with abrasions which were bleeding. The Police Chief placed his coat around the resident and summoned EMS at which time the EMS staff reported being unable to obtain a temperature reading. EMS staff indicated the thermometer would only read temperatures above 91 degrees Fahrenheit. The Police Chief stated the resident was alert and able to verbalize. Further interview revealed the resident was known to drive his w/c down the middle of the road and in some occurrences the Police Chief had to stop traffic for the resident to safely access the facility from the road. This had occurred as recent as the day before the incident on 02/01/18. On 02/07/18 at 2:30 P.M. observation of the incident scene with the Police Chief revealed the location to be .30 miles north of the facility. The area was wooded with unlevel surfaces and a creek (stream) leading east through a drainage culvert under a state route. A 45-degree sloped hill was next to the state route next to the culvert. On 02/07/18 at 2:33 P.M., interview with LPN #202 revealed he did not work the date of the incident and was not present at the facility to be informed by Resident #1 he was leaving the facility. Interview with STNA #305 on 02/08/18 at 6:39 A.M. revealed on 02/02/18 she was assigned to work on the two-south unit and reported to the unit at approximately 11:00 P.M. When STNA #305 arrived at the unit, STNA #304 was at the nursing station with multiple call lights illuminated. STNA #305 indicated STNA #304 was not sure about the residents on the unit and told STNA #304 to go home. No walking rounds were completed and STNA #305 did not visualize Resident #1. At approximately 1:00 A.M. or 1:30 A.M. she was informed by LPN #203 Resident #1 was not in his room and directed STNA #305 to initiate a search of the unit and associated facility. On 02/08/18 at 6:53 A.M., interview with STNA #306 revealed on 02/02/18 she reported to work at 10:45 P.M. on the two-north unit which was her normal floor. At approximately 11:00 P.M. she was sent to the two-south unit. She proceeded to assist STNA #303 with a resident with behaviors. After five to ten minutes STNA #303 left the facility. No walking rounds were completed that night. STNA #306 was unaware if Resident #1 was in his room. No report on the residents was obtained. STNA #303 was not familiar with the floor or the residents on the two-south unit. At approximately 1:30 A.M., LPN #203 reported she noticed Resident #1 was not in his room or in the smoke room. LPN #203 and STNA #306 checked the resident sign-out logs and asked other residents that smoke if they had seen Resident #1. They proceeded to conduct a search and initiate the missing person protocol. STNA #306 verified she did not see Resident #1 since reporting to the two-south unit at approximately 11:00 P.M. on 02/02/18. Interview with LPN #203 on 02/08/18 at 7:32 A.M. revealed on 02/02/18 she reported to the facility at 6:30 P.M. on the one south unit and was then directed to the two-south unit. She received report from the off going nurse that Resident #1 was OK. LPN #203 last observed Resident #1 at 7:45 P.M. on 02/02/18 during medication administration. At 11:00 A.M. LPN #203 stated she delegated the 11:00 P.M. two hour rounds to the two STNAs working on the unit and at 1:00 A.M., LPN #203 started her every two hour rounds. At approximately 1:00 A.M. LPN #203 noted all residents on the two-south unit were accounted for except Resident #1. She looked at the sign-out log and did not find the resident had signed out of the facility. The nursing supervisor was then notified of the missing resident and initiated the missing person policy. According to the resident sign-out log located on the two-south unit there were only two entries indicting the resident had exited the facility. The documentation listed 01/20 at 1530 returned at 1600. Another entry was undated at 10:40 A.M. There were no other entries documented on Resident #1's sign-out log. Review of the National Weather Service computerized environmental temperatures on 02/03/18 at 12:15 A.M. revealed the outside air temperature was recorded at 14 degrees Fahrenheit. Between 12:15 A.M. and 2:45 A.M., the outside air temperatures ranged between 14 degrees Fahrenheit and 15 degrees Fahrenheit. This deficiency substantiates Complaint Number OH 072.

Based on medical record review, review of a personal file, staff interview, family interview and policy review, the facility failed to ensure Resident #23 who was identified as a high fall risk was appropriately supervised while using the toilet resulting in an avoidable fall. This resulted in actual harm when Resident #23 sustained a head laceration as a result of the fall from the toilet and required an emergency room visit with stapling of the laceration. This affected one (#23) of three residents reviewed for falls. The facility identified seven residents at high fall risks. The facility census was 78. Findings include: Review of closed medical record for Resident #23 revealed an admitted on 07/19/14. Resident #23 was discharged to the hospital on [DATE] related to a fall. Resident #23 had the [DIAGNOSES REDACTED]. Review of quarterly minimal data set assessment ((MDS) dated [DATE] revealed Resident #23 had moderate cognitive impairment with a score of 12 out of 15 on her Brief Interview for Mental Status (BIMS). Hearing was marked as adequate without the use of hearing aids and there were no behaviors noted. Resident #23 required extensive assist for transfers and toileting with two person assist. She did need one person assist for locomotion. Resident #23 was independent with eating and only needed assistance with setting up. Resident #23 used a wheelchair and a walker. She was frequently incontinent of bladder but always continent of bowel. Toileting was noted as extensive assist requiring two staff members. Review of Resident #23's physician orders [REDACTED]. Review of the current plan of care reveals Resident #23 was at risk for injury as she was noncompliant with her alarms and has a history of falls. She has poor mobility and requires staff assistance with transfers. The care plan instructions documented not to leave the resident in the bathroom alone. Review of the interdisciplinary fall team meeting dated 12/08/16 identified staff to be educated to no leave the Resident #23 on the toilet alone because she has alarms. Review of nursing documentation on 12/08/16 at 5:30 P.M. noted staff contacted 911 and resident was sent to the emergency room . Review of the Physician communication tool dated 12/08/16 at 5:49 P.M. revealed Resident #23 had a fall and complained of left shoulder pain and an open area to the left side of her head measuring 1.0 centimeters (cm) with bleeding. Staff applied pressure to open area and pressure dressing was applied to Resident #23 head. Resident #23 was noted to have confusion and alert and oriented to name. Review of neurological assessment dated [DATE] at 5:44 P.M. revealed Resident #23 blood pressure of 159/ 99, temperature of 98.0 degrees Fahrenheit (F) a pulse of 82 beats per minute and respiration of 20 per minute. Resident #23 was oriented to person and place only. She was alert and able to respond to simple commands. She did verbalize pain and had full range of motion. Review of the fall risk assessment for Resident #23 completed on 12/08/16 revealed resident had intermitted confusion, had a history of [REDACTED]. Resident #23 fall risk score was twenty three; thus placing her as a high risk for fall as a score of ten or above is noted as high risk. Further review of hospital progress note dated 12/08/16 documented Resident #23 was rolled to examine back of her head and a small laceration was noted on the left side of head, the bleeding had stopped. The note further documented a staple was placed to close the laceration per the nurse practitioner. According to the hospital progress note Resident #23 was admitted to the hospital for a urinary tract infection, [DIAGNOSES REDACTED] and a fall. Review of the personnel record for state tested nursing assistant (STNA) #95 revealed a hire date of 09/16. Disciplinary discussion summary dated 12/09/16 for STNA #95 documented she left Resident #23 on the commode and also left he room. The resident had a resistance free alarm in place at the time which in turn means she is to never be left unattended on the toilet due to the risk of her getting up alone. Interview on 12/29/16 at 8:51 A.M. with the Administrator verified Resident #23 was placed on the toilet by STNA #95 on 12/08/16 and the aide left her unattended. The Administrator stated Resident #23 was not to be left alone as she was a fall risk and it was part of her care plan. The Administrator stated STNA #95 did not have a previous written warning; however the facility raised the level of offense due to the severity of the offense. STNA #95 was terminated on 12/09/16 for not reporting to work on 12/09/16. Interview on 12/27/16 at 10:27 A.M. with Licensed Practical Nurse (LPN) #80 stated she was not in the facility the day Resident #23 fell in the bathroom but she stated she did hear the aide left her on the toilet and left the room. LPN #23 stated Resident #23 then tried to get up on her own and fell and she was sent to the hospital afterward. LPN #80 stated Resident #23 should not be left alone on the toilet due to a fall risk. Interview on 12/29/16 at 10:50 A.M. with the Director of Nursing (DON) verified STNA #95 left Resident #23 on the commode unattended which is against facility policy and also against Resident #23's assessment/ care plan. Interview on 12/29/16 at 9:53 A.M. with Resident #23's family member revealed the resident did go to the hospital and received a staple in her head. The family member stated Resident #23 was a known fall risk and the staff left her alone while she was on the commode. The family member stated Resident #23 was admitted to the hospital for a urinary tract infection, low blood sugars and the fall. Review of policy dated 10/16 titled Fall Risk Safety stated it is the policy to ensure the safety of residents at risk of falls while toileting or bathing. If indicated on the plan of care, direct staff will assist any patient to the restroom. No resident determined to be high risk for falls or unsafe, shall be left unattended while toileting. The resident is to be assisted back to bed or chair by the direct care staff. Direct care staff is to ensure that all safety devices are in place prior to leaving the resident. This deficiency substantiates Complaint Number OH 630.