Every finding on record at Springfield Nursing & Independent Living

Based on record review and staff interview, the facility failed to have a qualified dietary manager. This had the potential to affect all of the residents residing in the facility with the exception of one facility identified (Resident #17) who did not receive food from the kitchen. The facility census was 61 residents. Findings include: Observation on 06/01/26 at 8:40 A.M. revealed there was no evidence posted indicating the facility Dietary Manager (DM) #343 or other kitchen staff met the minimum qualifications to serve as DM for the facility. Interview on 06/01/26 at 8:41 A.M. with DM #343 confirmed she was working on obtaining ServSafe certification in food safety, but she did not meet the minimum qualifications for the DM role and there was nobody else in the kitchen who met the qualifications. Interview on 06/04/26 at 11:21 A.M. with Registered Dietitian (RD) #405 confirmed she came to the building monthly.

Based on menu review, observation, staff interview, and review of dietary spreadsheets, the facility failed to ensure menus were followed and a substitution log was maintained. This had the potential to affect all of the residents residing in the facility with the exception of one facility-identified (Resident #17) who did not receive food from the kitchen. The facility census was 61 residents. Findings include: 1. Review of the menu dated 06/01/26 revealed residents were to be served chicken, rice, and broccoli at the lunch meal. Observations on 06/01/26 between 11:30 A.M. and 1:00 P.M. made on both units and in the dining room revealed residents were served tuna casserole and peas. Interview on 06/01/26 at 8:40 A.M. with Dietary Manager (DM) #343 stated she did not have a substitution log and was not tracking substitutions made. Interview on 06/01/26 at 1:30 P.M. with DM #343 verified the chicken, rice, and broccoli were not served at lunch and tuna casserole and peas were served instead. DM #343 stated she did not have the food available to serve. DM #343 stated she lets the Administrator know when she serves alternates, but she did not keep a substitution log. DM #343 stated she had made a lot of substitutions during the two months she had been the dietary manager and sometimes talked to the dietitian about the substitutes, but was not aware of the need to keep a log of substitutes and ensure it was approved by the dietitian. 2. Review of the diet spreadsheet dated 06/02/26 revealed all diets were to receive a #8 (4 ounce) scoop of mashed potatoes and pureed diets were to receive a #6 (5.3 ounce) scoop of pureed meatloaf. Observation on 06/02/26 at approximately 11:50 A.M. revealed DM #343 was utilizing a #10 (3 ounce) scoop for the mashed potatoes and a #20 (1.6 ounce) scoop for the pureed meatloaf while plating food on the tray line for the lunch meal. Interview on 06/02/26 at 11:51 A.M. with DM #343 confirmed she was using a #10 scoop for the mashed potatoes and a #20 scoop for the pureed meatloaf. Interview on 06/02/26 at 3:38 P.M. with DM #343 verified the wrong portion of mashed potatoes and pureed meatloaf were served for the entire lunch meal on 06/02/26. DM #343 confirmed both foods were served in a smaller portion than specified on the diet spreadsheet. DM #343 stated she had not reviewed the diet spreadsheet to determine the appropriate serving size for the items. Interview on 06/04/26 at 11:21 A.M. with Registered Dietitian (RD) #405 stated her expectation was to be notified of substitutions to ensure appropriate substitutions were made. RD #405 verified a log should be kept to ensure substitutions were documented appropriately. RD #405 stated she had not been notified of or signed anything regarding meal substitutions in the last few months. RD #405 verified her expectation was for all foods to be served in the portion sizes specified on the diet spreadsheets.

Based on observation, staff interview, record review, and policy review, the facility failed to ensure food was stored in a manner to protect against the potential spread of foodborne illness, failed to maintain the kitchen in a clean and sanitary manner, failed to maintain accurate temperature and chemical logs, and failed to ensure proper chemical utilization for the dishwasher. This had the potential to affect all of the residents residing in the facility with the exception of one facility-identified (Resident #17) who did not receive food from the kitchen. The facility census was 61 residents. Findings include: 1. Observation on 06/01/26 at 8:34 A.M., of the walk-in cooler revealed it contained the following items: three stacks of three stacks of milk crates containing cartons of milk stored directly on the floor, a bag of opened and brown lettuce with a best by date of 05/31/26 with no label or open date, three bags of lettuce which were open and unsealed with no label or open date, a box of eggs stored directly on the floor, a bag of shredded cheese which was open and unsealed with no label or date, a container of opened cottage cheese with no open date, a fruit plate containing strawberries, grapes, and oranges covered in plastic wrap with no date, a jug of hard boiled eggs with the lid not fully covering the top of the container leaving the eggs unsealed. Interview on 06/01/26 at 8:34 A.M. with Dietary Manager (DM) #343 verified the milk and eggs were stored on the floor of the walk-in cooler and should be stored at least six inches off the floor. DM #343 stated the lettuce was brown and not sealed nor dated, the cheese was not sealed nor dated, the cottage cheese and fruit plate were not dated, and the jug of hard-boiled eggs was not sealed. 2. Observation on 06/01/26 at 8:42 A.M. of the dry storage area revealed there was a package of six cans of beans stored directly on the floor with additional boxes stacked on top. Interview on 06/01/26 at 8:42 A.M. with DM #343 verified the beans had been stored on the floor since their delivery on 05/29/26. 3. Observation on 06/01/26 at 8:43 A.M. of the reach-in cooler revealed it contained six pitchers of Kool-aid and water which were not labeled. There was a sign on the outside of the reach-in cooler indicating everything in the refrigerator needed to be labeled and dated. Interview on 06/01/26 at 8:43 A.M. DM #343 verified the pitchers were not labeled. 4. Observation on 06/01/26 at 8:46 A.M. revealed there were 20 boxes of food stored directly on the floor of the walk-in freezer with additional boxes stacked on top. Interview on 06/01/26 at 8:46 A.M. with DM #343 verified there were 20 boxes of food stored directly on the floor of the walk-in freezer which had been stored there since delivery on 05/29/26. Interview on 06/04/26 at 11:21 A.M. with Registered Dietitian (RD) #405 verified food should always be stored at least six inches off the floor. 5. Observation on 06/02/26 at 10:58 A.M. revealed DM #343 tested the sanitizer level in the dish machine with a testing strip. Upon dipping the strip in the dishwasher, the strip did not change color. Further observation revealed the dishwasher had three tubes leading down to buckets below the counter. One tube lead to an empty bucket of dish detergent, another tube lead to a full bucket of dish detergent, and the third tube lead to a bucket of rinse aid. Next to the three buckets was a bucket of sanitizer which was not opened and not connected to anything. Interview on 06/02/26 at 10:58 A.M. with DM #343 verified the testing strip indicated there was no sanitizer in the dishwasher. DM #343 verified one tube was connected to an empty bucket of dish detergent and there were no tubes connected to sanitizer. DM #343 stated she was not sure how long the sanitizer had not been connected to the dish machine and was not sure who ordered the chemicals for the dish machine. 6. Review of the Three-Compartment Sink Sanitizer Log dated April 2026 revealed all of the readings in each column were the same. The log had typed areas crossed out and labeled in hand-writing as day shift and night shift. The first column had the date of the month, the second column started below day shift had 120 listed for all rows, the third column had 75 listed for all rows, the fourth column had 50 listed for all rows, the fifth column had staff initials, the sixth column started below night shift and had 120 on all rows, the seventh column had 75 listed for all rows, the eighth column had 50 listed for all rows, and the ninth column had staff initials. Further review of the log revealed Dietary Aid (DA) #376's initials were listed on 04/02/26, 04/04/26, 04/05/26, 04/08/26, 04/10/26, 04/11/26, 04/12/26, 04/13/26, 04/14/26, 04/15/26, 04/16/26, 04/17/26, 04/18/26, 04/19/26, 04/20/26, 04/21/26, 04/22/26, 04/24/26, 04/25/26, 04/26/26, 04/27/26, 04/28/26, 04/29/26, 04/30/26 (and 04/31/26). Interview on 06/02/26 at 10:43 A.M. with DA #376 verified she placed her initials were on the log. DA #376 stated the log was used for the dish machine, however she did not know what any of the numbers meant. DA #376 stated she filled the log in because there were blanks and someone needed to fill it out. DA #376 stated she did not test anything before filling out the log. 7. Review of the Dish Machine Temperature Log dated May 2026 revealed, with the exception of 05/30/26 and 05/31/26 at breakfast all wash and final rinse temperatures were documented as 117 or 118 and sanitizer concentration was documented at 50 for breakfast, lunch, and dinner. Further review of the log revealed DA #376's initials were listed every day from 05/01/26 through 05/30/26 for one to three meals each day. At the bottom of the log was a statement indicating the required temperature was 120 (degrees Fahrenheit) and sanitation level was 50 (parts per million [ppm]) with instructions to report temperatures and PPM that were below the required levels to the DM and/or maintenance immediately. Interview on 06/02/26 at approximately 11:45 A.M. with DA #376 confirmed she placed her initials on the log. DA #376 stated she filled in the log because there were blanks and someone needed to fill it out. DA #376 stated she did not test anything on the dishwasher before filling it out and further stated she did not know what any of the numbers meant. Interview on 06/02/26 at approximately 11:45 A.M., with DM #343 verified the documented temperatures did not meet the minimum required temperatures for the dish machine. 8. Observation on 06/02/26 at 10:50 A.M. of the dry storage area revealed numerous brown and pink spatters of varying size, dark-colored wheel trails throughout the area, and a clear/shiny dried liquid stain measuring approximately 12 inches in length. Interview on 06/02/26 at 10:50 A.M. with DM #343 verified the floor of the dry storage had numerous splatters wheel trails, and stains throughout. DM #343 stated the area was supposed to be mopped daily and verified it had been awhile since the floor had been mopped. 9. Observation on 06/02/26 at 10:53 A.M. of the dry storage area revealed there were four jugs of corn syrup dated 09/15/23 and three additional jugs of corn syrup dated 05/16/25. There were no manufacturer's expiration dates noted on any of the jugs. Interview on 06/02/26 at 10:53 A.M. with DM #343 verified the seven jugs of corn syrup were outdated and should only be stored for one year after the received date. 10. Observation on 06/02/26 at 11:30 A.M. revealed the flat iron grill was coated in charred and dried food which was also dripping down the sides of the grill. The grease drawer of the grill was overflowing with food scraps and debris and there was a large (approximately 20 inches by 12 inches) shallow pan below the grill which was half full of grease. Further observation revealed a sign above the grill indicating the grill needed to be cleaned after every shift. Interview on 06/02/26 at 11:30 A.M. with DM #343 verified the grill was not clean, the grease drawer was overflowing with food scraps, and an additional pan below the grill contained additional grease. DM #343 stated the grill and surrounding area had not been cleaned at least since before the weekend and should be cleaned after every meal. 11. Observation on 06/02/26 at 11:31 A.M. revealed the pipes and support bars for the ceiling lights above all food service areas and the hood vent box above the kitchen hood were heavily coated in a dark grey fuzzy material. Interview on 06/02/26 at 11:41 A.M. with DM #343 verified the areas were coated in a dark grey fuzzy material. DM #343 stated it was dust and needed to be cleaned at night, when the kitchen was not in use. Review of the facility policy titled Dietary-Receiving and Storing Food and Supplies dated 06/30/23 revealed all products should be dated upon receipt or when they are prepared and a use date should be marked on all foods according to the Dry, Refrigerated, and Freezer Storage Chart. All food should be stored at least six inches off the floor. Any opened products shall be placed in containers with tight-fitting lids or plastic bags. All food should be labeled and dated with the date received date, date opened, and the date the item expired. Storage areas should be clean and sanitized. Walls, ceiling, and floor shall be regularly cleaned. Review of the facility policy titled Dry, Refrigerated, and Freezer Storage Chart undated revealed syrups could be stored for up to 12 months. Review of the facility policy titled Dietary-Equipment Operations, Infection Control, and Sanitation dated 02/02/24 revealed all food surfaces and equipment shall be washed with a sanitizing solution. When operating the dish machine, check to see if the machine is ready for use and chemical containers are full. Record the dish machine temperature before each use. The wash and rinse temperatures of the dish machine should reach a minimum temperature of 120 degrees Fahrenheit. Any inaccurate temperatures must be brought to the attention of the Dietary Manager immediately. Record PPM on the dish machine three times daily. The grill should be cleaned after each use, by scraping the grill to loosen burned-on particles, clean the grill surface with a grill stone and diluted degreaser or grill cleaner and mild soap and water, including removing, emptying, and washing the grease tray. Hoods should be kept free of dust at all times.

Based on observation, staff interview, and policy review, the facility failed to ensure garbage cans in the kitchen were covered when not in use. This had the potential to affect all of the residents residing in the facility with the exception of one facility-identified (Resident #17) who did not receive food from the kitchen. The facility census was 61 residents. Findings include: Observation on 06/01/26 at 8:43 A.M. revealed two garbage cans in the kitchen, one next to the oven and another near the pots and pans storage area, were not covered and were not in use. Lids were observed on the floor directly next to each garbage can. Observation on 06/02/26 at 11:12 A.M. revealed the same two garbage cans remained uncovered with the covers lying on the floor next to them. The garbage cans were not in use. Interview on 06/01/26 at 11:28 A.M. with Dietary Manager (DM) #343 verified the two garbage cans were not covered and should be covered when not in use. Review of the facility policy titled Dietary-Equipment Operations, Infection Control, and Sanitation dated 02/02/24 revealed all food waste must be placed in covered garbage and trash cans.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to provide hand hygiene during medication pass for one (Resident #2) , failed to use appropriate personal protective equipment (PPE) for wound care for one (Resident #33), and failed to provide documentation for flushing and monitoring facility water for legionella. This had the potential to affect all residents at the facility. The facility census was 61 residents. Findings include: 1.Review of the medical record for Resident #33 revealed an admission date of 02/04/16 with diagnoses including schizoaffective disorder, spinal stenosis, anxiety disorder, and major depressive disorder. Review of the Minimum Data Set (MDS) dated [DATE] revealed was cognitively intact and required staff assistance with activities of daily living (ADLs.) Review of the care plan for Resident #33 dated 04/27/26 revealed the resident required enhanced barrier precautions (EBP) related to wounds. Interventions included the following: clean hands before entering and when leaving residents room, ensure signage remained on door at all times, personal protective equipment for staff while providing care per policy, gloves and gown to be worn when providing high-contact resident care activities including wound care, and providing hygiene. Observation on 06/03/26 at 3:40 P.M. of wound care for Resident #33 per Licensed Practical Nurse (LPN) #345 revealed the nurse did not wear a gown while performing wound care for the resident. Interview on 06/03/26 at 3:55 P.M. with LPN #345 verified Resident #33 was on EBP and she should have worn a gown while providing wound care. Review of the facility policy titled Enhanced Barrier Precautions dated 01/01/25 revealed the facility would implement EBP for residents with wounds and staff should wear a gown and gloves while providing direct care. 2.Observation on 06/02/26 at 8:00 A.M. revealed LPN #322 pulled medications from the medication cart, crushed the medications, placed them in applesauce, entered Resident #2's room, obtained vital signs for Resident #2, raised the head of the bed, and administered medications. LPN #322 did not complete hand hygiene and was completed before or after preparing the medications or before administering the medications to the resident. Interview on 06/02/26 at 8:45 A.M. with LPN #322 confirmed she had not completed hand hygiene before preparing and administering Resident #2's medications. Review of facility policy titled Medication Administration dated 06/26/24 revealed nurses should complete hand washing prior to administering medications. Review of facility policy titled Hand Hygiene dated 04/06/17 revealed hand washing was to be completed between resident contacts and before preparing or handling medication. 3. Review of the facility policy titled Legionella Surveillance dated 01/01/24 revealed the facility would establish primary and secondary strategies for the prevention and control of Legionella infections. Legionella grew best in waters temperatures between 77 degrees Fahrenheit (F) and 108 degrees F. Review of the Legionella monitoring dated 06/01/25 through 06/01/26 revealed the facility had been monitoring hot water temperatures only. Interview on 06/03/26 at 4:55 P.M. with Maintenance Director (MD) #358 verified that the facility had only monitored hot water temperatures for the past year. MD #358 stated he had no documentation in monitoring water flushing and monitoring for legionella.

Based on record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed toconsider the views of residents in the decisions impacting the residents' home and lives, failed to discuss significant decisions impacting the residents with the residents, and failed to respond to the resident's concerns and grievances. This affected six (Residents #12, #20, #45, #47, #55, #59) of six residents reviewed for resident rights. The facility census was 61 residents. Findings include: Review of a memo posted on the door of the social services office dated 05/28/26 revealed as part of regional operational standards the facility had made the decision to have the two facility cats removed no later than 06/05/26. Review of a handwritten petition undated titled Save Our Cats revealed it had 35 signatures. Observation on 06/03/26 at 4:00 P.M. revealed Resident #55 expressed sadness and concern to the Administrator, over the plan to get rid of two facility cats. Resident #55 stated she enjoyed the cats and did not want them to be taken away. Interview on 06/03/26 at 12:15 P.M. with Resident #55 confirmed she was concerned because the facility was getting rid of the two nursing home cats on 06/05/26. Resident #55 stated the facility would not share where the cats were being taken. Resident #55 stated that for residents who were at the facility, the cats were great because they were therapy for the residents who were sick, on hospice, and were used for mental health. Resident #55 stated she will be very sad when the two brother cats are taken away. She reported last week management staff told the line staff and they told the residents. She stated some residents were crying. Resident #55 asked about contacting the Ombudsman and stated it was a violation of their rights. Interview on 06/04/26 at 1:03 P.M. with Resident #55 confirmed she started a petition to keep the facility cats because she and everyone else was upset about the facility administration's decision to get rid of the cats. Resident #55 stated she wanted the cats to stay in the facility because they kept the mouse population controlled, but mostly because they were therapeutic for her and many other residents. Resident #55 stated she gave the Administrator the petition to save the cats on 06/03/26 but when she talked with the Administrator on 06/04/26 the Administrator told her the cats had to go. Resident #55 stated the facility had not offered any type of grief counseling or alternatives to getting rid of the cats. The resident was observed with tears streaming down her cheeks during the interview and stated taking the cats away was a violation of the residents' rights. Observation on 06/04/26 at 12:45 P.M. revealed one of the facility cats was lying at the foot of Resident #59's bed. Interview on 06/04/26 at 12:45 P.M. with Resident #59 confirmed she concerned the facility cat to be her kitty and did not want the cats to be removed. Interview on 06/04/26 at 12:46 P.M. with Resident #45 confirmed she was very upset about the cats leaving and stated she had signed a petition for them to stay. Interview on 06/04/26 at 12:48 P.M. with Resident #20 confirmed he was very upset about the cats leaving the facility. He stated he used the cats for companionship and to help keep him calm and he would move out if the cats were gone. Interview on 06/04/26 at 12:56 P.M. with the Administrator confirmed she had seen the petition from the residents but stated the decision to remove the cats came from corporate and there was nothing she could do. She stated a memo had been distributed to the residents to notify them of the cats leaving. She reported any resident who was grieving could handle that through regular counseling means. Interview on 06/04/26 at 1:55 P.M. with the Social Services Designee (SSD #392) revealed notification about the cats leaving was discussed during activities. She stated she had not gone around to residents to notify them if they had not come to the group activity. Observation on 06/04/26 at 2:00 P.M. revealed the two facility cats were removed from the facility by outside parties while the residents watched. Interview on 06/04/26 at 2:00 P.M., the Administrator confirmed she received the petition on 06/03/26 and got rid of the cats the next day, which was a day earlier than stated on the memo provided to staff and residents. Interview on 06/04/26 at 2:27 P.M. with Resident #12 revealed he would will miss the cats and they should not have gotten rid of them as all the residents loved and enjoyed the cats. Interview on 06/04/26 at 2:30 P.M. revealed Resident #47 reported he wanted them to keep the cats and he had a favorite one who laid at the end of the bed with him and made him happy. Review of the facility policy titled Safe and Homelike Environment dated 06/01/24 revealed in accordance with residents' rights, the facility would provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. Review of the facility policy titled Resident Rights dated 06/01/24 revealed the residents had a right to make choices about their lives in the facility that were significant to them. Residents had a right to voice grievances and the facility must make prompt efforts to resolve any grievances the residents may have. This deficiency represents noncompliance investigated under Complaint Number 2711853.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure the flooring in the common area was clean. This affected the 32 residents who reside on the secured unit. The facility census was 61 residents. Findings include: Observation on 06/01/26 at 11:00 A.M. of the west secured unit near the entrance and outside the dining room revealed the floor had loose dirt, scratch marks, and stains throughout on the entire floor. Interview on 06/01/26 at 11:55 A.M. with the Director of Nursing (DON) verified the floor outside the dining room at entrance to the west unit had dirt and spots on the entire floor. Observation on 06/01/26 at 12:00 P.M. of the west dining room prior to meal service revealed the floor was dirty and had food debris and spills of red liquid throughout the floor. Interview on 06/01/26 at 12:10 P.M. with Certified Nurse Aid (CNA) #305 confirmed the dining room floor to the west unit was dirty and the lunch meal had not been served yet. Review of the facility policy titled Safe and Homelike Environment dated 06/01/26 revealed the facility would provide residents with a safe, clean, comfortable and homelike environment. This deficiency represents noncompliance investigated under Complaint Number 2808183.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to provide a dignified dining experience for two (Residents #25 and #54) of 17 residents sampled. The facility census was 61 residents. Findings include: 1.Review of medical record for Resident #54 revealed an admission date of 08/23/13 with diagnoses including cerebrovascular disease, dementia, schizoaffective disorder, and major depressive disorder. Review of the Minimum Data Set (MDS) for Resident #54 dated 03/20/26 revealed the resident was severely cognitively impaired and required staff assistance with activities of daily living (ADLs.) Observation 06/01/26 at 9:47 A.M. revealed Resident #54 was sitting in the dining room wearing a hospital gown and an incontinence brief with the resident's back and incontinence brief exposed. Interview on 06/01/26 at 9:48 A.M. with Certified Nurse Aid (CNA) #305 confirmed Resident #54 was sitting in the dining room wearing only a hospital gown and a brief and the resident's back and the brief were exposed. Observation on 06/01/26 at 12:10 P.M. revealed Resident #54 was sitting in the dining room wearing a hospital gown and an incontinence brief with the resident's back and incontinence brief exposed. Interview on 06/01/26 at 12:10 P.M. with CNA #305 confirmed Resident #54 was still sitting in the dining room wearing a hospital gown and an incontinence brief with the resident's back and incontinence brief exposed. CNA #305 stated she should have placed a robe or a second hospital gown over the resident's back to provide privacy. Observation and interview on 06/01/26 at 12:50 P.M. with another CNA #333 who verified that Resident #54 was sitting in the dining room, with open hospital gown, incontinent brief exposed, and had strong urine odor. CNA #333 also verified that other residents were complaining about the urine odor while eating their meal. Interview on 06/01/26 at 12:58 P.M. with CNA #305 who verified that Resident #54 was still in the dining room from this morning and had never left the table. CNA #305 verified that she still had same gown on, and incontinent brief. CNA #305 verified there was a urine odor. Interview on 06/01/26 at 5:00 P.M. with CNA #305 stated she finally took Resident #54 back to her room to lay down. CNA #305 verified that she had not received activity of daily living today. 2. Observation on 06/01/26 at 12:06 P.M. revealed Residents #18, #25, and #34 were seated together in the dining room at lunch. CNA #305 delivered meals to Resident #18 and Resident #34 but did not deliver a meal tray to Resident #25. Observation on 06/01/26 at 12:26 P.M. revealed CNA #305 placed Resident #25's meal tray on the table in front of the resident and left. Interview on 06/01/26 at 12:26 P.M. with CNA #305 confirmed Residents #18 and #34 had been served lunch while Resident #25 sat at the table waiting for assistance with his meal. CNA #305 stated Resident #25 needed staff assistance with feeding and would need to wait for CNA #333 to finish some duties in the main dining room before coming back to feed Resident #25. Observation on 06/01/26 at 12:36 P.M. revealed CNA #333 was feeding Resident #25 lunch. Interview on 06/01/26 with CNA #305 verified Resident #25 had been sitting in the dining room since 12:06 P.M. and had watched Residents #18 and #34 consume their meals and had not been fed his lunch until 12:36 P.M. Review of the facility policy titled Resident Rights dated 06/01/24 revealed residents had the right to be treated with dignity and respect. This deficiency represents noncompliance investigated under Complaint Number 2711853 and Complaint Number 2671044 and Complaint Number 1382280.

Based on medical record review, staff interview, review of facility Self-Reported Incidents (SRIs), and review of the facility policy, the facility to report allegations of misappropriation to the state agency. This affected one (Resident #33) of 17 sampled residents. The facility census was 61 residents. Findings include: Review of medical record for Resident #33 revealed an admission date of 02/04/16 with diagnoses including schizoaffective disorder, spinal stenosis, anxiety disorder, and major depressive disorder. Review of the Minimum Data Set (MDS) for Resident #33 dated 03/20/26 revealed the resident was cognitively intact. Review of the facility SRIs dated 02/01/26 through 06/01/26 revealed there were no SRIs filed for Resident #33. Interview on 06/01/26 at 11:00 A.M. with Resident #33 confirmed he had money in a lock box that was kept in the office of Former Administrator (FA) #500, but when FA #500 left the facility could not find the lock box of money. Interview on 06/04/26 at 8:16 A.M. with the Administrator confirmed in February 2026 Resident #33 stated he had been storing his money in a lock box kept in the office of FA #500, but the facility could not find the lock box of the resident's money. The Administer verified the facility had not reported Resident #33's allegation of the missing lock box of money to the state agency. Interview on 06/04/26 at 8:53 A.M. with Social Service Designee (SSD) #392 stated Resident #33 made an allegation in February 2026 that he a lock box containing $280 which had been stored in FA #500's office. SSD #392 called FA #500 who stated she knew about a lock box of money for Resident #33. SSD #392 stated Resident #33 agreed after this incident he would open a resident fund account. Review of the facility policy titled Abuse and Neglect dated 06/12/24 revealed should report allegations of misappropriation to the state agency. This deficiency represents noncompliance investigated under Complaint Number 2671044.

Based on medical record review and staff interview, the facility failed to ensure a significant change assessment was completed in a timely manner. This affected one (Resident #3) of one residents reviewed for hospice. The facility census was 61 residents. Findings include: Review of the medical record for Resident #3 revealed an admission date of 11/10/14 with diagnoses includingschizoaffective disorder, major depressive disorder, type two diabetes mellitus, chronic obstructive pulmonary disease, and stage four chronic kidney disease. Resident #3 began receiving hospice services on 04/15/26. Review of the physician's orders for Resident #3 revealed an order dated 04/15/26 for the resident to begin receiving hospice services. Review of the comprehensive Minimum Data Set (MDS) assessment for Resident #3 dated 05/13/26 revealed the resident had moderately impaired cognition and required staff assistance with activities of daily living (ADLs.) Interview on 06/03/26 at 12:39 P.M. with the Director of Nursing (DON) verified the comprehensive MDS for Resident #3 was not completed in a timely manner. The DON verified the assessment should have been completed within 14 days of the resident being picked up by hospice.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to provide proper incontinence care to dependent residents. This affected one (Resident #54) of 17 residents sampled. The facility census was 61 residents. Findings include:Review of medical record for Resident #54 revealed an admission date of 08/23/13 with diagnoses cerebrovascular disease, dementia, schizoaffective disorder, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) for Resident #54 dated 03/20/26 revealed the resident was severely cognitively impaired and required maximal assistance for toileting and personal hygiene. Review of the care plan for Resident #54 dated 03/23/26 revealed the resident was at risk for altered mood and behaviors related to having diagnoses of schizophrenia, had delusional thoughts, refused medication at times, and kicked and bit staff at times. Interventions included the following: always approach in calm manner, attempt to redirect when resistive to care, if unable to redirect ensure resident was safe and leave for short time and then reapproach to assist in to complete care, do not argue with resident, encourage the resident to comply with care daily. Review of the care plan for Resident #54 dated 03/23/26 revealed the resident had bladder and bowel incontinence. Interventions included staff should provide incontinence care using disposable briefs and staff should change the resident every two hours as needed. Observation 06/01/26 at 9:47 A.M. revealed Resident #54 was sitting in the dining room wearing a hospital gown and an incontinence brief. Interview on 06/01/26 at 9:48 A.M. with Certified Nursing Assistant (CNA) #305 confirmed Resident #54 was sitting in the dining room wearing a hospital gown and an incontinence brief. Observation on 06/01/26 at 12:10 P.M. revealed Resident #54 was sitting in the dining room wearing a hospital gown and an incontinence brief. Interview on 06/01/26 at 12:10 P.M. with CNA #305 confirmed Resident #54 was still sitting in the dining room wearing a hospital gown and an incontinence brief. Observation on 06/01/26 at 12:50 P.M. revealed Resident #54 was sitting in the dining room wearing a hospital gown and a disposable incontinence brief. There was a strong odor of urine in air near the resident. Interview on 06/01/26 at 12:50 P.M. with CNA #333 confirmed there was a strong urine odor emanating from Resident #54 and other residents in the dining room were complaining about the urine odor. Interview on 06/01/26 at 12:58 P.M. with CNA #305 confirmed Resident #54 was still in the dining room from the morning and had never left the table. CNA #305 verified Resident #54 was still wearing the same gown and incontinence brief from the morning. CNA #305 stated there was a urine odor emanating from Resident #54 and the aide verified Resident #54 had not received incontinence care. Observation on 06/01/26 at 5:00 P.M. of Resident #54 with CNA #305 revealed the resident was in bed lying on her side and was wearing a hospital gown and two incontinence briefs. Interview on 06/01/26 at 5:00 P.M. with CNA #305 confirmed at 3:30 P.M. she had taken Resident #54 back to her room and assisted her to bed. CNA #305 verified she had placed an extra brief on Resident #54 because she had refused to have her brief changed.Interview on 06/04/26 at 3:00 P.M. with Registered Nurse (RN) #334 confirmed staff should provide timely incontinence care and should never apply two briefs to a resident. RN #334 stated when Resident #54 refused care staff should reapproach the resident and should notify the nurse. Review of the facility policy titled Incontinence dated February 2023 revealed incontinent residents would receive appropriate treatment and services per the resident's care plan. Review of the facility policy titled Resident Rights dated 06/01/24 revealed residents had the right to be treated with dignity and respect and to receive timely care. The facility would ensure all direct care staff were educated on resident rights and how to properly care for residents. This deficiency represents noncompliance investigated under Complaint Number 3015945 and Complaint Number 2978326 and Complaint Number 2978226 and Complaint Number 2711853 and Complaint Number 1382280 and Complaint Number 1382279.

Based on medical record review, staff interview, physician interview, and review of the facility policy, the facility failed to ensure medications were administered per the physician's order. This affected one (Resident #53) of three residents reviewed for nutrition. The facility census was 61 residents. Findings include: Review of the medical record for Resident #53 revealed an admission date of 07/15/11 with diagnoses including schizoaffective disorder and moderate protein-calorie malnutrition. Review of the physician's orders for Resident #53 revealed an order dated 12/26/25 for Megace oral suspension five milliliters (ml) by mouth once daily to promote weight gain. Review of the Minimum Data Set (MDS) assessment for Resident #53 dated 05/15/26 revealed the resident had severely impaired cognition. Review of the Medication Administration Records (MARs) for Resident #53 dated December 2025, January 2026, February 2026, March 2026, April 2026, May 2026, and June 2026 revealed the medication was not administered because it was not available for administration. Interview on 06/01/26 at 1:01 P.M. with Registered Nurse (RN) #334 verified Resident #53 had a current order for Megace which had been in place since 12/26/25 but the medication had never been available for administration. RN #334 stated she thought it was because insurance would not cover the medication. RN #334 was unsure whether the physician had been notified the resident had not received the medication from December 2025 through June 2026. Interview on 06/04/26 at 2:50 P.M. with Physician #415 stated she did not recall being notified of the Megace not being available for Resident #3. Physician #415 stated her expectation was for staff to notify her if the medication was not available so she could determine the ongoing treatment plan. Review of the facility policy titled Medication Administration dated 06/02/26 revealed medications should be administered in accordance with physician orders. This deficiency represents noncompliance investigated under Complaint Number 2576619

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure medications were stored in a proper manner that prevented misidentification. This affected thirty residents with medications stored on the secured unit. The facility census was 61 residents. Findings include: Observation on [DATE] at 2:52 P.M. of the back medication cart in the behavior unit revealed there were 19 loose, unidentified pills lying on the bottom surface of the top drawer. Interview on [DATE] at 2:52 P.M. with Registered Nurse (RN) #338 confirmed the back medication cart contained 19 loose unidentified pills. Observation on [DATE] at 2:57 P.M. of the front medication cart in the behavior unit revealed there were 26 loose, unidentified pills lying on the bottom surface of the top drawer. The drawer also contained an opened bottle of glucose tablets with 10 tablets remaining with an expiration date of [DATE]. Interview on [DATE] at 2:57 P.M. with RN #338 confirmed front medication cart contained 26 loose unidentified pills and an expired bottle of glucose tablets. Review of facility policy titled Medication Storage dated [DATE] revealed all medication rooms should be routinely inspected by the consult pharmacist for discontinued or outdated medications.This deficiency represents noncompliance investigated under Complaint Number 3015945.

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to provide timely dental services. This affected one (Resident #52) of 17 residents sampled reviewed. The facility census was 52 residents.Findings include:Review of medical record for Resident #52 revealed admission date 06/27/23 with diagnoses including dementia, heart failure, adult failure to thrive, and anxiety disorder. Review of the speech therapy note for Resident #52 dated 08/28/25 by per Speech Therapist (ST) #369 revealed the resident had a general lack of dentition and some remaining decaying teeth. Review of the progress note for Resident #52 dated 09/18/25 per Social Service Designee (SSD) #392 revealed the resident was examined by the facility dentist. Review of the speech therapy note for Resident #52 dated 10/02/25 by per ST#369 revealed the resident had multiple decaying and missing teeth. Review of the Minimum Data Set (MDS) assessment for Resident #52 dated 03/27/26 revealed the resident was cognitively impaired and required staff assistance with oral hygiene. Review of care plan for Resident #52 dated 04/07/26 revealed the resident had oral and dental health problems related to poor oral hygiene. Interventions included the following: coordinate arrangements for dental care, transportation as ordered for appointment, monitor and document signs and symptoms of oral and dental problems, provide mouth care. Observation on 06/02/26 at 11:30 A.M. of Resident #52 revealed the resident had seven lower teeth three of which were broken off and blackened at the tips and two of which were broken off at the gum line. Interview on 06/02/26 at 11:30 A.M. with Resident #52 confirmed the facility dentist had determined her remaining teeth needed to be pulled and it was supposed to have been done in summer 2025. Interview on 06/03/26 at 9:30 A.M. with Social Service Director (SSD) #392 verified Resident #52 had been seen by the facility dentist who had determined the resident needed to have her remaining teeth pulled, but the facility dentist could not perform the tooth extractions because they were broken off at the gumline. SSD #392 confirmed the facility was trying to arrange for another dental provider who could pull Resident #52's remaining decaying teeth but had not yet done so. Review of the facility policy titled Dental Services dated November 2017 revealed routine and emergency dental services were available to meet the resident's oral health services in accordance with the resident's assessment and plan of care.

Based on medical record review, observation, resident interview, staff interview, review of dietary spreadsheets, and review of the facility policy, the failed to ensure residents received food according to their diet orders. This affected two (Residents #49 and #52) of three residents reviewed for nutrition. The facility identified 13 residents who received mechanically altered diets. The facility census was 61 residents. Findings include: 1.Review of the medical record for Resident #52 revealed an admission date of 06/27/23 with diagnoses including dementia, heart failure, adult failure to thrive, dysphagia, mild protein calorie malnutrition, and anxiety disorder. Review of the physician's orders for Resident #52 revealed an order dated 10/10/25 for a regular diet with mechanical soft texture. Review of the Minimum Data Set (MDS) assessment for Resident #52 dated 03/27/26 revealed the resident was cognitively impaired and required staff assistance with meals. Observation 06/03/26 at 12:10 P.M. revealed Resident #52 was served a whole chicken breast at lunch. Interview on 06/03/26 at 12:10 P.M. with Resident #52 confirmed the resident could not eat the chicken breast because she had multiple teeth missing. Interview on 06/03/26 at 12:11 P.M. with Certified Nursing Asssistant (CNA) #329 verified Resident #52 was served a whole chicken breast at lunch. Interview on 06/03/26 at 1:02 P.M. with ST #369 verified Resident #52 had an order for mechanical soft textured meals and a whole chicken breast would not be appropriate for the resident because it was not ground. Interview on 06/04/26 at 11:21 A.M. with Registered Dietician (RD) #405 verified serving Resident #52 a regular chicken breast would not be appropriate and the food would need to be ground. 2. Review of the medical record for Resident #49 revealed an admission date of 01/19/17 with diagnoses including cerebral infarction and dysphagia. Review of the MDS assessment for Resident #49 dated 03/31/26 revealed the resident had intact cognition, required setup/cleanup assistance with eating, and received a mechanically altered diet. Review of the physician's orders for Resident #49 revealed an order dated 11/17/25 for the resident to receive a mechanical soft diet. Review of the care plan for Resident #49 dated 03/30/26 revealed the resident was at nutritional risk related to dysphagia and the need for mechanically altered textures. Interventions included to provide the diet per the physician's order. Review of the diet spreadsheet for 06/01/26 revealed regular diets were to receive a whole cheeseburger on a bun and mechanical soft diets were to receive a ground cheeseburger on a bun. Observation on 06/01/26 at 12:15 P.M. revealed Resident #49 was seated in the dining room and had a whole cheeseburger on a bun on the plate in front of him. Resident #49's meal ticket indicated he was on a mechanical soft diet. Interview on 06/01/26 at 12:21 P.M. with Registered Nurse (RN) #334 verified Resident #49 had a whole cheeseburger and was on a mechanical soft diet. Observation on 06/01/26 at 12:56 P.M revealed Resident #49 took a bite of his cheeseburger and was observed coughing and could not stop coughing. Continued observation revealed CNA #333 approached Resident #49 upon hearing him cough, asked if he was okay, and tapped his back. Resident #49 stopped coughing after a few minutes. Interview on 06/01/26 at 1:30 P.M. with Dietary Manager (DM) #343 verified Resident #49 received a whole cheeseburger at lunch on 06/01/26. Interview on 06/03/26 at 1:02 P.M. with ST #369 verified a whole cheeseburger would not be appropriate to serve Resident #49 for his mechanical soft diet order. Review of the facility policy titled Therapeutic Diets dated June 2018 revealed the facility provided therapeutic diets per resident need and preference.

Based on medical record review, staff interview, and policy review, the facility failed to ensure speech therapy services were provided in a timely manner. This affected one (Resident #49) of three residents reviewed for nutrition. The facility census was 61 residents. Findings include: Review of the medical record for Resident #49 revealed an admission date of 01/19/17 with diagnoses including cerebral infarction and dysphagia. Review of the the Minimum Data Set (MDS) assessment for Resident #49 dated 03/31/26 revealed the resident had intact cognition, required setup/cleanup assistance with eating, and received a mechanically altered diet. Review of a progress note for Resident #49 dated 03/25/26 revealed during med pass the resident has difficulty swallowing medications whole. Staff contacted the Nurse Practitioner (NP) who gave orders for the medications to be crushed and for the resident to have a speech therapy evaluation. Review of the physician's orders for Resident #49 revealed an order dated 03/25/26 for speech therapy evaluation and treatment as indicated per the NP for dysphagia. Review of the medical record revealed no evidence of a speech evaluation being completed for Resident #49 following the order dated 03/25/26. Interview on 06/03/26 at 1:09 P.M. with Speech Therapist (ST) #369 confirmed the facility had not completed a speech therapy evaluation for Resident #49. Interview on 06/03/26 at 11:51 A.M. with Regional Director of Therapy (RDOT) #410 verified there was no record of a speech evaluation being completed on Resident #49 following the 03/25/26 order for speech therapy evaluation and treatment. Interview on 06/04/26 at 1:11 P.M. with Regional Director of Clinical Operations (RDCO) #400 confirmed the speech evaluation for Resident #49 should have been completed within a few days of the order.

Based on observations, staff and resident interviews, record review and policy review, the facility failed to ensure temperatures were maintained in a safe and comfortable range. This had the potential to affect all 58 residents residing in the facility. The facility census was 58. Findings include: Observation on 01/27/26 from 11:20 A.M. through 11:55 A.M. revealed residents in the East Hall were observed lying in bed with multiple (two or more) blankets on. Staff in the East Hall Nurses Station were observed wearing jackets and hats. Residents in the East TV Room were observed sitting in their wheelchairs and wearing coats. Residents in the [NAME] Hall were observed lying in bed also with multiple blankets. The air temperature felt warmer in the [NAME] Hall than in the East Hall. The dining room was observed with multiple residents eating, wearing sweatpants and hooded sweatshirts. Two random residents were observed wearing coats and hats. Staff were also observed wearing hooded sweatshirts. No observation of space heating units was noted anywhere in the facility. Interview on 01/27/26 at 11:23 A.M. with Resident #10 revealed she acknowledged the facility was cold and added this is the worst it has ever been. Resident #10 shared she had on two layers of pants, shirts and socks on and it should not be necessary to do just to stay warm. Interview on 01/27/26 at 11:33 A.M. with Licensed Practical Nurse (LPN) #100 revealed measures to fix the heating unit started on 01/23/26 when the cold temperatures were noticed. LPN #100 stated resident room doors were kept closed in an attempt to keep residents warm. Interview on 01/27/26 at 11:36 A.M. with Certified Nursing Assistant (CNA) #101 revealed the cooler temperatures in the facility were noted after a recent cold snap and acknowledged the facility remained cold. Observation with Maintenance Technician (MT) #104 on 01/27/26 between 1:26 P.M. and 2:00 P.M. of facility revealed the [NAME] Hall temperatures were between 53.1 degrees Fahrenheit (F) and 55.4 degrees F, the nurse station was 55.6 degrees F, the dining room was 63.9 degrees F and the common area was 69.6 degrees F. Resident room temperatures were as follows: Resident #16 room was 53.8 degrees F; Residents #17 and #18 room was 56.8 degrees F; Resident #18 room was 56.8 degrees F; Resident #10 room was 56.8 degrees F; Residents #34 and #35 room was 55.4 degrees F; and Residents #19 and #20 room was 58.8 degrees F. The East Hall nurses station was 61.2 degrees F, the East Hall temperatures were between 57.6 degrees F and 61 degrees F. Room temperatures were as follows: Resident #13 room was 59.4 degrees F; Residents #36 and #37 was 58.6 degrees F; Resident #18 room was 63.0 degrees F; Resident #17 room was 63.3 degrees F; Resident #16 room was 62.6 degrees F; and Resident #38 room was 70.5 degrees F. Interview on 01/27/26 at 1:37 P.M. with MT #104 while obtaining facility temperatures revealed the facility had recently installed a new heat system. The heat system began blowing cold air over the last week and the department notified the Gas Company, mechanical company and the installer to assess the issue. At the time of the interview, the source of the heating issue had not been discovered. Interview on 01/27/26 at 3:00 P.M. with the Administrator revealed there was no plan of action for the low temperatures at the facility and added, I do not know what they want me to do. The Administrator stated she would contact Corporate to see what she should do. A second interview on 01/28/26 at 3:44 P.M. with the Administrator revealed contact had been made with the Regional Director of Operations (RDO) #105 and delivery of four portable heaters had been placed. Delivery time had yet to be verified, but the Administrator added it should be delivered that day. Observation on 01/27/26 from 3:20 P.M. to 3:29 P.M. revealed there were five random residents in the [NAME] Hall common area wearing jackets and or multiple layers of clothing. There was a notable decrease in temperature when entering the East side of the facility. There were four random residents in the common area wearing coats, two staff members were observed at the nurse's station wearing coats and hats and one resident was walking in the hall wearing a coat. Interview on 01/28/26 at 8:19 A.M. with Maintenance Director (MD) #103 revealed he was not at the facility on 01/27/28 and was not aware prior to his arrival that morning of the need for portable heaters. MD #103 explained he was on his way to get the heaters. Observation on 01/28/26 at 9:22 A.M. revealed no portable space heaters were observed in the facility. Observation with MT #104 on 01/28/26 at 9:39 A.M. of facility revealed [NAME] Hall temperatures were between 66.0 degrees F and 72.3 degrees F. Room temperatures were as follows: Residents #26 and #27 room was 67.8 degrees F; and Residents #25 room was 50.4 degrees F. The East Hall nurses station was 58.6 degrees F, the East Hall temperatures were between 58.3 degrees F and 60.1 degrees F. Room temperatures were as follows: Residents #34 and #35 room was 59.5 degrees F; Residents #10 room was 60.4 degrees F; Resident #58 room was 58.8 degrees F; Residents #17 and #18 room was 61.3 degrees F; and Resident #16 room was 61.2 degrees F. Interview and record review with the Administrator on 01/28/26 at 10:05 A.M. of the Performance Improvement Action Plan (PIAP) revealed the air temperature issue was noted on 01/23/26. The action/intervention was for residents to be provided with extra blankets and clothing. MD #103 was responsible for twice daily temperature checks in areas identified as having temperature concerns until the temperatures were between 71.0 degrees F and 81.0 degrees F. The Administrator verified MD #103 was aware of the twice daily temperature log requirement. Interview on 01/28/26 at 12:30 P.M. with CNA's #109 and CNA #110 revealed the facility had been cold in the past, but it had been really bad since Friday, 01/23/26. CAN #109 and CAN #110 acknowledged residents had complained about the cold temperature. Each stated they offered extra blankets, warm beverages and encouraged the residents to stay in bed where it was warm. Interview on 01/28/26 at 2:30 P.M. with RDO #105 revealed MD #103 had gone to the store to purchase four space heaters. RDO #105 explained and offered documentation he had ordered seven space heaters online to be delivered to the facility on [DATE], but the store cancelled the order. The four larger portable units were scheduled to arrive by 5:00 P.M. on 01/28/26. Observation on 01/28/26 from 2:35 P.M. to 2:43 P.M. revealed there were two room sized space heaters on the [NAME] Hall. Four residents were in the [NAME] Hall common area. Three random residents were observed wearing sweatshirts and one wore a coat. There was a notable decrease in temperature upon entering the East side of the facility. There were two room sized space heaters on the East Hall. Five random residents were observed in the common area, three were wearing coats. Three staff members were at the nurse's station all were wearing coats, two had on hats. Interview on 01/28/26 at 3:16 P.M. with LPN #106 revealed residents had been complaining about the cold temperatures in the facility and management was aware. During an interview on 01/28/26 at 3:19 P.M. Resident #13 was observed in bed under three blankets. Resident #13 acknowledged her room was cold and she needed the extra blankets to stay warm. Resident #13 added the staff offered her hot chocolate throughout the day. During an interview on 01/28/26 at 3:30 P.M. Resident #11 had voiced frustration to CNA #107 because she was unable to go outside to smoke. CNA #107 explained management informed staff the residents could not go outside to smoke due to the cold temperatures outside. Resident #11 replied it was cold inside the facility, feel my hands. CNA #107 did not respond to Resident #11 and left the room. Resident #11 acknowledged it was cold in her room and the staff had supplied extra blankets and had offered her hot chocolate. Interview on 01/28/26 at 4:02 P.M. with RDO #105 revealed if the portable heaters did not arrive by 5:00 P.M. as scheduled, he would have MD #103 go uptown to purchase more portable space heaters. Discussion was had regarding the results of the morning temperatures, and a request was made for the second set of temperatures as the PIAP plan required. RDO #105 explained he would contact MD #103 to provide them. Interview on 01/28/26 at 5:00 P.M. with MD #103 revealed he had not taken temperatures since the morning walk through. MD #103 voiced frustration at taking a second set of temperatures. The PIAP document was shown to MD #103 and he denied knowledge of the document, or of receiving instruction to take temperatures twice daily. Observation on 01/29/26 at 8:12 A.M. of the facility temperatures with MT #104 revealed [NAME] Hall temperatures were between 67.3 degrees F and 69.4 degrees F. Approximately seven feet from one hall space heater the temperature was 64.9 degrees F. MT #104 acknowledged the space heaters were meant to be used in rooms and not the square footage of the unit. Resident rooms were as follows: Resident #38 room was 67.6 degrees F; Resident #39 and #40 room was 66.6 degrees F; Resident #41 and #43 room was 67.3 degrees F; and Resident #25 room was 46.4 degrees F. The East Hall nurse station was 61.2 degrees F, the hall temperatures were between 57.6 degrees F and 61.0 degrees F. The Resident rooms were as follows: Resident #13 room was 59.4 degrees F; Residents #36 and #37 room was 58.6 degrees F; Resident #18 room was 63.0 degrees F; Resident #17 room was 63.3 degrees F; Resident #16 room was 62. 6 degrees F; and Resident #38 room was 70.5 degrees F. Interview on 01/29/26 at 8:50 A.M. with MD #103 revealed he had not been made aware until 7:43 A.M. the portable heaters had not arrived at the facility. MD #103 stated he had left the facility around 5:30 P.M. to 5:45 P.M. on 01/28/26. MD #103 verified the portable heater had not been delivered and he had not purchased more portable space heaters. MD #103 then explained after he arrived at the facility he had been notified by a staff member one large portable heater had arrived at some point last night and he requested to end the interview to locate it. Interview on 01/29/26 at 9:17 A.M. with RDO #105 revealed one portable heater was delivered at some point last night, but it was not set up because there was no maintenance staff present to set it up. RDO #105 stated he did not have maintenance purchase additional space heaters on 01/28/26 because the portable heaters were scheduled to arrive. RDO #105 acknowledged he left the faciity on [DATE] prior to the arrival of an additional heat source. During an interview on 01/29/26 at 11:00 A.M. Resident # 14 was observed in the East Hall in front of the nurse's station, in a wheelchair wearing a thick flannel shacket. Resident #14 stated even with the heaters on, the facility was still cold. An interview and observation on 01/29/26 at 11:30 A.M. with MD #103 revealed there were two residents with air-conditioning units in their windows. MD #103 stated he was not aware there were two resident rooms who had air-conditioning units in the windows. MD #103 acknowledged the units should be removed with the current heat issue at the facility. Interview on 01/29/26 at 12:13 P.M. with Resident #12 revealed the facility had been extremely cold for some time. Resident #12 added the temperature had gotten better but it was still cold. An interview with RDO #105 was completed on 01/29/26 at 2:18 P.M. which revealed RDO #105 reached out to his procurement team on 01/26/26 for the rental of four portable heaters. RDO #105 verified the order was not placed until 01/27/26 with an anticipated delivery date of 01/28/26 by 5:00 P.M. Additional space heaters were purchased online for an additional heat source. RDO #105 stated the provider cancelled the order, and on 01/28/26 MD #103 was sent uptown to purchase space heaters for the facility. RDO #105 acknowledged when he left the faciity on [DATE] no additional space heaters or portable heaters had been provided as an additional heat source. Review of the facility policy titled Temporary Heat Policy dated 10/01/25 documented the facility would maintain safe indoor temperatures and implement temporary heat measures when the primary heat system was not functioning or the temperatures fell below acceptable temperature. The facility would make every reasonable effort to maintain a temperature of at least 71 degrees F in resident care areas. When temperatures fall below acceptable levels, temporary heating interventions would be initiated immediately. Resident support measures included providing additional blankets and layered bedding, encouraging layered clothing, monitoring residents for signs of cold stress and increased monitoring and rounding as needed. This deficiency represents non-compliance investigated under Complaint Number 2727504.

Based on observations, staff interviews and policy review, the facility failed to implement an effective pest control program for the eradication of pests and rodents. This had the potential to affect all 58 residents residing in the facility. The facility census was 58. Findings include: Observation on 01/28/26 at 8:19 A.M. revealed the facility cat was observed in the facility on the west side of the front desk. The cat was playing with a mouse, swiping at it. Maintenance Technician (MT ) #103 and Maintenance Director (MD) #104 were also observed walking down the same hall when they stopped beside the cat and mouse. The mouse was lying still with the cat right beside it. MT #103 bent down and grabbed the mouse and walked off to dispose of it. MD #104 verified the mouse had been in the facility. Observation on 01/29/26 at 9:20 A.M. revealed a random resident was overheard to say, the cat got another one. The same cat was observed to the east of the front lobby hunched over in a corner and eating a mouse. This was verified with Housekeeping Supervisor #111, who stated she would mop and disinfect the area after the cat ran off. Review of the facility policy, Pest Control Program revised 2025 documented the facility would maintain an effective pest control program which eradicated common household pests and rodents. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on observations and staff interviews, the facility failed to ensure a safe, clean, and homelike environment. This had the potential to affect all 63 residents residing in the facility. The facility census was 63. Findings include: Observation on 05/20/25 at 10:45 A.M. of the [NAME] Hall shower room revealed the flooring was peeled up along the walls and a hole in the drywall near the baseboard of the wall near the shower. The observation revealed the drywall was protruding from the wall and some drywall chunks were laying on the floor near the shower entrance. The observation also revealed two ceiling tiles with large circular brownish colored marks. Interview on 05/20/25 at 10:50 A.M. with Registered Nurse (RN) #138 confirmed the shower room on the [NAME] Hall had a hole in the drywall near the shower with drywall protruding from the wall, drywall chunks on the floor, and stained ceiling tiles in the shower. RN #138 stated the shower room has had the issues with drywall broken, a hole in the wall, and stained ceiling tiles for several months. RN #138 stated all the residents on the [NAME] Hall utilize the shower room. Interview on 05/21/25 at 4:20 P.M. with Maintenance #147 confirmed the [NAME] Hall shower room has had a hole in the drywall and stained ceiling tiles for over one year. Maintenance #147 stated the facility had a company provide the facility for an estimate for repairs but have not received the quote yet. Observation with interview on 05/21/25 at 4:45 P.M. with Maintenance #147 revealed the employee entrance door to the facility, located in the basement, did not fit the doorframe and would not close. The observation revealed the employee entrance door was open at all times and staff were not able to securely close the door. Interview with Maintenance #147 confirmed the employee entrance door did not close because the door did not fit the doorframe and had been that way for quite some time. Maintenance #147 stated residents can come down to the basement via the elevator and he had seen residents from the nursing home in the basement. Maintenance #147 stated he was not aware of any residents leaving the facility through the employee entrance door. Maintenance #147 confirmed a person from the community could enter the employee entrance door and enter the facility at any time. This deficiency represents non-compliance investigated under Complaint Numbers OH00165645, OH00165398, OH00164655, and OH00163547.

Based on medical record review, staff interviews, and policy review, the facility failed to ensure a resident was provided written notification prior to a room change. This affected one (#10) out of three residents reviewed for room changes. The facility census was 63. Findings include: Review of the medical record for Resident #10 revealed an admission date of 03/22/22 with medical diagnoses of cerebral infarction with left hemiplegia, aphasia, ischemic cardiomyopathy, obesity, congestive heart failure, and chronic kidney disease stage III. Review of the medical record revealed Resident #10 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the medical record for Resident #10's quarterly MDS assessment, dated 05/02/25, indicated Resident #10 had severely impaired cognition, not able to make needs known, and was dependent upon staff for all ADL's including eating. The MDS indicated Resident #10 did not receive any by mouth (PO) intake and received 51%-100% nutrition via tube feeding. Review of the medical record for Resident #10 revealed under the Census Tab in the electronic medical record revealed the resident was moved in April 2025. Further review of Resident #10's medical record revealed there was no evidence the resident received written notification of the room change. Interview on 05/15/25 at 11:53 A.M. with Licensed Practical Nurse (LPN) #150 stated Resident #10 was moved from in April 2025 in order to consolidate beds. LPN #150 stated Resident #10 was not happy with the room change and stated Resident #10 enjoyed his prior room his bed was by the window and he could look outside and his bed in room [ROOM NUMBER] was by the door and he couldn't look out the window. Interview on 05/20/25 at 2:30 P.M. with admission #103 confirmed Resident #10 was moved rooms in April 2025. Admissions #103 stated Resident #10 was moved rooms to consolidate rooms due to the facility was running out of female beds. Admissions #103 stated she did not show Resident #10 or his representative of the room prior to the room change or provide written notice of the room change. admission #103 stated the facility never provided written notice of room changes. Review of the facility policy titled, Change of Room or Roommate, revised 03/01/25 stated the facility must inform the resident, consult with the resident's physician, and/or notify the resident's family member or legal representative when there is a change requiring notification. The policy stated circumstances which required notification included accidents, significant change in the resident's physician, mental, or psychosocial condition such as a deterioration in health, mental or psychosocial status. This deficiency was an incidental finding discovered during the course of the complaint investigation.

Based on medical record review, staff interview, and policy review, the facility failed to reconcile medications following a hospital re-admission. This resulted in Actual Harm when Resident #210 was admitted to the psychiatric hospital on 03/25/24 and upon return to the facility on [DATE], the facility failed to continue the psychiatric medications resulting in a change in condition and hospitalization . This affected one (Resident #210) of one resident reviewed for medication reconciliation. The facility census was 61. Findings include: Review of the medical record for Resident #210 revealed an admitted [DATE]. Diagnoses included schizophrenia, bipolar disorder, type two diabetes mellitus without complications, chronic obstructive pulmonary disease, anxiety disorder, anemia, major depressive disorder, schizoaffective disorder, heart failure, hypokalemia, and hypothyroidism. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #210 had intact cognition. Resident #210 had delusions and displayed verbal behaviors towards others. Resident #210 was assessed to require setup assistance for eating, oral hygiene, bathing, dressing, and personal hygiene, and was independent for toileting, bed mobility, and transfer. Review of the plan of care revised 04/29/24 revealed Resident #210 had diagnoses of schizophrenia, anxiety, and depression. Resident #210 also had a history of suicidal thoughts and hearing voices, refusing medications, being religiously preoccupied and verbally inappropriate with others. Interventions included administer medications as ordered, allow to vent thoughts and feelings, always approach in a calm and relaxed manner, attempt to re-direct when resistive to care, attempt to set limits on behavior by trying to re-direct, re-focus when experiencing altered thoughts, moods, or behaviors, and send for mental health evaluation as needed. Review of the progress note dated 03/25/24 revealed Resident #210 was sent to a psychiatric hospital for evaluation following an increase in behaviors. Review of the progress note dated 04/04/24 revealed Resident #210 was readmitted to the facility on this date from the psychiatric hospital. Review of the discharge medication list dated 04/04/24 revealed Resident #210 was to take alogliptin 25 milligram (mg) once daily for diabetes, metformin 1,000 mg twice a day for diabetes, paliperidone 6 mg extended release once daily for schizoaffective disorder, ziprasidone 80 mg every evening for psychosis, ziprasidone 20 mg once daily for psychosis, divalproex sodium extended release 1,000 mg at bedtime for schizoaffective disorder, and hydroxyzine pamoate 25 mg twice a day for anxiety. Review of the physician orders from 04/04/24 to 04/12/24 revealed the above orders were not entered into the electronic health record following Resident #210's re-admission to the facility. Review of the progress notes dated 04/06/24 and 04/07/24 revealed Resident #210 had an increase in verbal outbursts. Review of the progress notes dated 04/11/24 revealed Resident #210 was experiencing religious ideations, manic behaviors, and having verbal outbursts with redirection unsuccessful. Resident #210 was to be transferred for a psychiatric evaluation but refused and became combative. Review of the progress note dated 04/12/24 revealed Resident #210 continued to have behaviors and was noted to be on less medications since returning to the facility from the psychiatric hospital on 04/04/24. Review of the progress note dated 04/12/24 revealed Resident #210's medications were not reconciled following discharge from the psychiatric hospital and re-admission to the facility on [DATE]. The note indicated the orders were verified and confirmed with the physician, and Resident #210's guardian was notified. Review of the progress notes dated 04/13/24 and 04/14/24 revealed Resident #210 continued to have behaviors, which included screaming at others and pinching her arms until they bruised. The police were called, and Resident #210 was transported to the emergency room for evaluation. Review of the progress notes from 04/14/24 through 04/20/24 revealed Resident #210 was admitted to a psychiatric hospital and returned to the facility on [DATE]. Interview on 05/21/24 at 2:32 P.M. with the Director of Nursing (DON) verified Resident #210's medications were not reconciled and continued upon re-admission. Interview on 05/30/24 at 11:22 A.M. via phone with the DON confirmed Resident #210 was transferred to the local emergency roiagnom on [DATE] and then transferred to a psychiatric hospital after the medications had not been reconciled. Review of the facility policy titled, Consulting Physician/Practitioner Orders, dated 01/01/24, revealed the attending physician should authenticate orders for the care and treatment of residents. The policy indicated the nurse was to contact the attending physician to verify orders received from consulting physicians/practitioners and follow facility procedures that included noting the order, submitting to the pharmacy, and transcribing to the administration record.

Based on observation, interviews with facility staff and resident representatives, medical record review, review of a facility investigation, review of hospital records, and review of the facility policy on elopement, the facility failed to provide adequate supervision for Resident #60, who had severely impaired cognition and had a history of exit seeking behaviors. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death when Resident #60 displayed a change in condition, began having exit seeking behaviors identified by the facility staff on [DATE], and a physician order was requested for fifteen-minute checks related to Resident #60's newly identified behavior of pushing on exit doors and attempting to exit the facility unsupervised. On [DATE], Resident #60 left the facility without staff's knowledge through one alarmed interior door and a second exterior door, and by the time staff responded to the elopement, Resident #60 had propelled himself in a wheelchair through both doors, down a winding sidewalk and fell down approximately 11 stairs. Consequently, the resident sustained trauma related injuries, was transferred to the local hospital emergency room (ER), then transferred to a higher level of care (level one trauma center) where Resident #60 was admitted to the intensive care unit (ICU) for trauma related injuries including an open [NAME] III fracture (skull fracture where the cranial/facial are separated), right femur fracture, rib fractures, facial lacerations/bruising, left humerus fracture, Thoracic -1 (T-1) endplate compression fracture (acute), and atrial fibrillation (chronic and on Eliquis) and the resident subsequently expired on [DATE] from the injuries sustained from the elopement/fall. This affected one (Resident #60) of seven residents reviewed for elopements/accident hazards. The facility identified twenty-one current residents (#09, #10, #29, #30, #31, #32, #35, #36, #38, #41, #42, #45, #46, #47, #48, #49, #50, #51, #53, #55, and #59) who were at risk for elopement. The facility census was 59. On [DATE] at 4:30 P.M., the Administrator, Director of Nursing (DON), and Divisional Clinical Specialist (DCS)/Registered Nurse (RN) #400 were notified Immediate Jeopardy began on [DATE] when the facility identified Resident #60 began having exit seeking behaviors on [DATE] and the facility obtained a new order from the physician for 15-minute checks related to Resident #60's attempts to exit the facility unsupervised. The investigation revealed Resident #60 continued to have exit seeking behaviors from [DATE] through [DATE]. On [DATE] at approximately 4:15 P.M., Resident #60 eloped from the facility and was found outside the facility on the third step from the bottom of fourteen concrete steps with his wheelchair on top of him. He was transferred to the hospital and admitted to the ICU for trauma related injuries and eventually expired on [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE], Licensed Practical Nurse (LPN) #109 completed a head count on current residents to ensure all residents were accounted for. There were no negative findings. On [DATE], LPN #109 and the DON checked all door alarms and windows for proper functioning. There were no negative findings. On [DATE], (East Unit) and [DATE] (West Unit), the DON reviewed current resident elopement scores with no negative findings and on [DATE], the entire facility was reviewed by LPN #115. On [DATE] through [DATE], education was provided to staff to prevent elopement from recurring. The DON/designee (LPN #115) educated staff on elopement education and abuse/neglect. The DON/designee (LPN #115) educated staff on identifying exit seeking behaviors, implementation of interventions, completion of elopement assessments, review of the elopement policy, physician notification of behaviors/exit seeking behaviors and change in conditions, abuse, and neglect, and notifying of the DON. Education was completed on [DATE] and staff not educated, would complete education prior to their next scheduled shift. On [DATE], the elopement binder was reviewed by the DON with no negative findings. On [DATE], the DON rechecked all door alarms for proper functioning. There were no negative findings. On [DATE] through [DATE], elopement drills were conducted on each of the three shifts. Drills were conducted by nursing and staff responded appropriately. On [DATE], the DON/designee (LPN #115), completed resident interviews on those residents who were able to be interviewed related to abuse/neglect. There were no negative findings. On [DATE], an ad hoc Quality Assurance Performance and Improvement (QAPI) committee meeting was held with the DON, LPN/Unit Manager #115, Licensed Nursing Home Administrator (LNHA), and the Medical Director (MD) #300. Results of observations, drills, and reviews to be forwarded to the facility QAPI committee for further review and recommendations. On [DATE], to monitor and maintain ongoing compliance, the DON/designee will complete five resident interviews on those residents who are able to be interviewed, weekly for four weeks, then monthly for two months related to abuse/neglect. On [DATE], to monitor and maintain ongoing compliance, the DON/designee will complete five resident body checks weekly for four weeks, then monthly for two months related to any signs of abuse/neglect. On [DATE], to monitor and maintain ongoing compliance, Maintenance Director Supervisor (MDS) #98 or designee will check door alarms for proper functioning weekly for 12 weeks. On [DATE], to monitor and maintain ongoing compliance, MDS #98 or designee will conduct an elopement drill three times monthly (on different shifts) for three months, then monthly thereafter. On [DATE], the DON/designee (LPN#115) completed resident body checks related to any signs of abuse/neglect. There were no negative findings. On [DATE], the DON /designee (LPN#115) reviewed the previous 72-hours of progress notes to identify any issues with exit seeking. There were no negative findings. On [DATE], the DCS/RN #400 educated the DON and LNHA on review of elopement, identifying exit seeking behaviors, physician notification of behaviors/exit seeking behaviors and change in conditions, implementation of interventions, completion of elopement assessments and abuse/neglect. Education was completed [DATE]. On [DATE], to monitor and maintain ongoing compliance, the DON/designee will review progress notes weekly for 12 weeks to identify any residents with exit seeking behavior. On [DATE], MDS #98 completed window checks and door alarm checks. Any issues were corrected as needed. On [DATE], to monitor and maintain ongoing compliance, the DON/designee will review residents at risk for elopement weekly for four weeks, then monthly for two months. Review to include, but not limited to, risk assessment accuracy, interventions appropriate, in place and functional, documentation of applicable interventions and validation that functional testing being completed. On [DATE] and [DATE], surveyor completed review of the medical records for Residents #09, #10 and #45, and revealed no concerns related to actual elopement from the facility, elopement risk assessments were current and accurate, and care plans were initiated and updated with appropriate interventions to prevent elopement. On [DATE] and [DATE] between 8:00 A.M. and 5:00 P.M., LPNs #102, #107 and #109 and State tested Nurse's Aides (STNAs) #77, #108, and #110 verified they were educated on resident elopement and wandering as well as responding to resident alarms. All staff members interviewed were knowledgeable of the content of each education provided by the facility. On [DATE], Exit Stopper exit alarms (model number STI-6400) were installed on the East end hallway (unsecured unit), and East nurse's station exit door (unsecured unit) with the alarm volume programmed by MDS #98 to sound for 180 seconds while the door was opened and would alarm for three seconds once the door closes. The door alarms were also equipped with strobe lights to flash when opened. Staff secured the doors until the alarms were installed. On [DATE], MDS #98 installed two Door/Window entry alarms on the main entrance/front door (model: YL - 323). The alarm volume sounded continuously until closed. Staff secured the main entrance until the alarm was installed. 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 was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings Include: Review of Resident # 60's medical record revealed an admitted [DATE] and was discharged to the hospital on [DATE] with the resident expiring at the hospital on [DATE]. His diagnoses included, but were not limited to, acquired absence of right leg above the knee (AKA) acquired absence of left leg above the knee (AKA), hyperlipidemia, depression, chronic conjunctivitis, essential primary hypertension, and chronic obstructive pulmonary disease (COPD). Review of the quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #60 had severely impaired cognition. Further review of the MDS assessment, revealed Resident #60 required extensive assistance from staff with transfers and locomotion. Review of the Brief Interview for Mental Status (BIMS) assessment dated [DATE], revealed the resident was assessed as a four, which indicated the resident had severely impaired cognition. Review of the new admission wandering risk assessment dated [DATE], revealed Resident #60 was at low risk for elopement related to no history of wandering or exit seeking. No other wandering or elopement risk assessments were completed. Review of the physician visit notes dated [DATE], revealed Resident #60 was seen related to a fall. The physician's (#301) notes did not mention or address any behaviors related to exit seeking. Review of Nurse Practitioner (NP) #300's visit note dated [DATE], revealed Resident #60 was seen related to a fall, weakness, heart arrhythmia and hypertension. NP #300 visit notes did not mention or address any behaviors related to exit seeking. Review of NP #300 visit note dated [DATE] revealed the resident was seen related to a hematoma and to check residents blood pressure. NP #300 visit notes did not mention or address any behaviors related to exit seeking. Reviewed of physician orders dated [DATE] at 3:29 P.M. by LPN #109, revealed Resident #60 was ordered to receive fifteen- minute checks every shift for exit seeking behavior. Review of the nurse's progress note dated [DATE] at 9:48 A.M., revealed Resident #60 was ordered to have 15-minute checks for 72 hours and the residents' wife was notified. Review of the nurse's progress notes dated [DATE] at 2:24 P.M., revealed Resident #60 was ambulating in his wheelchair and exit seeking. Notes indicated resident wheeled to the east wing door and pushed the door open and the resident was redirected. Review of nurse's progress notes dated [DATE] at 6:47 A.M., revealed Resident #60 was repeatedly exit seeking, disrobing and urinated on the floor twice during the shift. Review of nurse's progress notes dated [DATE] at 9:28 A.M. revealed Resident #60 opened the exit door by the nurse's station and tried to go out. Resident #60 asked the nurse what time he was able to go out and the resident was directed to stay inside, and his wife would be here to visit. The progress notes indicated the resident was sitting by the nurse's station. Review of facility documents titled Resident Observation/Monitoring Tool revealed Resident #60 had 15-minute checks recorded daily which started on [DATE] through [DATE]. Review of nurse's progress notes dated [DATE] at 6:03 P.M. revealed Resident #60 was exit seeking and pushed open the doors. Review of nurse's progress notes dated [DATE] at 4:11 A.M., revealed Resident #60 was exit seeking and the resident was redirected and 15-minute checks were in place and being completed. Review of the Interdisciplinary Team (IDT) meeting progress notes dated [DATE] at 2:41 P.M., revealed facility staff spoke with the residents' wife about the exit seeking behaviors, and at the time, the resident was an elopement risk, behaviors usually occurred in evenings after wife left, resident had dementia, was in a wheelchair, on 15-minute checks, wife preferred to have a referral sent to Northwood which was a single level, and had a wander guard system versus having the resident placed in the secured memory care unit at their facility. The notes indicated social services were aware to send the referral, resident would remain on 15-minute checks and the physician was made aware. The notes further indicated the DON, Assistant DON #104, LPN Unit Manager #115, Director of Rehabilitation (DOR) #450, LPN/MDS #99 and Social Services Director (SSD) #71 were all present during the meeting. Review of the [DATE] updated care plan for Resident #60, revealed the resident was at risk for elopement and the interventions for the care plans included 15-minute checks, calmly redirect resident, divert resident, and relocate resident to a different area. Review of nurse's progress notes dated [DATE] at 12:14 A.M., revealed Resident #60 was exit seeking early in the shift and needed continued redirection throughout the shift for disrobing. Review of nurse's progress notes dated [DATE] at 10:31 A.M., revealed Resident #60 was yelling out, was exit seeking, and resident wheeled up to the east door and pushed the door open. Review of nurse's progress notes dated [DATE] at 5:15 P.M., revealed Resident #60 was exit seeking, resident set off door alarm to the east side door at the end of the hallway, then set off the alarm to the door by the nurse's station. The progress notes indicated resident then wheeled to the front door/main entrance by the receptionist desk and attempted to open the door leading to the main steps to the building. Resident #60 was yelling profanities and the resident had become difficult to redirect. Review of nurse's progress notes dated [DATE] at 12:07 A.M., revealed resident #60 was exit seeking and staff was sitting with resident one-on-one to prevent resident from exiting, and exit seeking attempts continued throughout the shift and redirection was ineffective. Review of nurse's progress note dated [DATE] at 1:57 P.M., revealed Resident #60 was exit seeking and pushed opened the double set of exit doors on the East unit. The notes indicated the resident went out the first door and attempted to go out the second door when staff redirected Resident #60 back inside the facility. The notes indicated the resident was exit seeking more and more daily. Review of nurse's progress note dated [DATE] at 3:05 P.M., revealed Resident #60 again tried to exit out the double doors at the end of the east end hallway. The notes indicated the resident was yelling out extremely loud they tricked me, they trapped me here. Review of nurse's progress note dated [DATE] at 4:50 P.M., revealed LPN #109 returned to the unit from passing medications on the second floor (assisted living unit) at approximately 4:15 P.M. and spoke to the other nurse and went into the medication room. The notes indicated LPN #109 heard one of the STNAs yell out he got out, he fell on the steps. The notes indicated LPN #109 immediately ran outside and the resident was on the ground (stairs) with the wheelchair upside down. The notes indicated the nurse started first aid, while an STNA called 911. The notes indicated LPN #109 also called 911 to explain resident's condition. The notes indicated Emergency Medical Services (EMS) arrived at 4:40 P.M. and a second EMS unit arrived at 4:45 P.M., the resident was removed and transported to the local hospital, his wife was contacted at 4:50 P.M. and the DON was contacted at 4:55 P.M. Review of the hospital notes dated [DATE] at 9:41 P.M. revealed the resident was attempting to flee his extended care facility (ECF) when he fell down some concrete stairs striking his head. Resident #60 was diagnosed with rib fractures, left proximal humerus fracture, T-1 fracture and [NAME] III fracture. The notes indicated the resident had swelling in both eyes where pupils were unable to be visualized, had dried blood in nares, bruising on left shoulder, resident was noted to be in atrial fibrillation at a rate of ,d+[DATE] beats per minute (elevated) (normal ,d+[DATE]) and resident was admitted to the trauma ICU. Interview on [DATE] at 3:21 P.M. with the DON revealed the facility failed to complete a new elopement risk assessment after the facility identified Resident #60's exit seeking behaviors on [DATE]. The DON verified the facility should have completed another elopement risk assessment following the exit seeking behaviors and when the IDT met on [DATE] to update Resident #60's care plan. The DON indicated the documentation regarding Resident #60's incident of elopement could have been better. Interview on [DATE] at 3:39 P.M. with MDS/LPN #99, confirmed she updated Resident #60's care plan after the IDT team met on [DATE] to discuss the concerns with Resident #60's exit seeking behaviors and plans were suggested to move Resident #60 to the secure unit. Interview on [DATE] at 4:03 P.M. with LPN #109, revealed she was tasked with caring for Resident #60 on [DATE] from 7:00 A.M. to 7:00 P.M. LPN #109 stated the previous shift reported to her, Resident #60 had been up all night and was exit seeking throughout the previous day. LPN #109 stated Resident #60 was on 15-minute checks, and she documented each time Resident #60 would attempt to elope. LPN #109 confirmed the 15-minute checks started on [DATE] and continued through [DATE]. LPN #109 stated Resident #60 attempted to exit out the double doors at the end of the hallway. LPN #109 stated staff would encourage resident to remain at the nurse's station so they could keep an eye on him. LPN #109 stated resident attempted to elope again and was redirected. LPN #109 stated she left the unit around 3:45 P.M. to administer medications on the Assisted Living (second floor) unit, which left two STNAs and one LPN remaining on the unit. LPN #109 stated around 4:15 P.M., as she was reentering the unit, she could hear STNA #120 yelling from outside, he is outside. LPN #109 stated she ran outside and observed Resident #60 lying at the bottom of the concrete steps with blood coming from his face and eye socket. LPN #109 provided care to Resident #60 while EMS was called. LPN #109 stated Resident #60 was taken to the hospital by EMS. LPN#109 verified she did not hear the door alarm due to being off the unit. Interview on [DATE] at 4:19 P.M. with SSD #71, confirmed during the IDT meeting on [DATE], she was asked by family to send a referral to another facility where the resident could be housed on a secured unit. SSD #71 indicated she sent one referral but verified she had no documented evidence of sending the referral or any follow-ups. SSD #71 stated she sent the referral but never followed up. Interview on [DATE] at 4:25 P.M. with STNA #77, revealed she was informed at the beginning of her shift ([DATE] at 3:00 P.M.), that Resident #60 had been up throughout the previous night and exit seeking. STNA #77 stated Resident #60 was on 15-minute checks and attempted to exit the double doors on the back hallway; however, he was redirected. STNA #77 stated she was sitting with Resident #60 at the nurse's station, and he fell asleep. STNA #77 stated another nurse asked for her assistance in a resident's room at the end of the east hallway. STNA #77 stated it had been less than five minutes when she was coming out of the resident's room, and she could hear the other STNA yelling that Resident #60 was on the ground outside. STNA #77 confirmed she did not hear the alarm of the door going off. STNA #77 verified Resident #60 had eloped and had fallen down the steps outside. Interview on [DATE] at 5:19 P.M. with the DON, indicated the facility never placed Resident #60 on a one-on-one for supervision. The DON additionally indicated the facility never referred Resident #60 for any psychological services and never transferred the resident to another other facility per family's request. Additionally, the DON stated the family told her they wanted Resident #60 to stay at the facility and the other facility denied his admission. Interview on [DATE] at 8:21 A.M. with the DON, indicated the facility protocol was to notify the physician of any new or increased behaviors. The DON confirmed the facility failed to notify the physician when Resident #60's new and increased behaviors of exit seeking and attempts to elope began. Interview on [DATE] at 2:40 P.M. with the Administrator, confirmed the Assisted Living residents would exit the steps from the second floor, near the east nurse's station to smoke. The Administrator stated the Assisted Living residents walked past the east nurse's station, pushed on the door while a door magnet alarm sounded and walked out the door to smoke unsupervised. The Administrator verified the hazards of having 14 steps next to the door. Interview on [DATE] at 2:45 P.M. with Resident #401, revealed she observed Resident #60 sitting in his wheelchair near the nurse's station and the exit doors on [DATE] prior to the incident. Resident #401 stated she walked past Resident #60, pushed on the door which alarmed and went out to smoke. Resident #401 stated she was outside with Resident #402, and when they rang the bell to reenter the facility, Resident #60 pushed through the two doors, and she had to step to the side when Resident #60 came out the doors and rolled passed her like he was on a mission. Resident #401 stated she went in and told STNA #120 in the dining room about Resident #60 being outside. Interview on [DATE] at 2:50 P.M. with Resident #402, stated she was outside smoking with Resident #401, and they had decided to go in. Resident #402 stated they pushed the bell to go in, and she observed Resident #60 open the east unit door and wheel himself outside. Resident #402 stated she got out of his way because she had health problems and did not want to get ran over by a man in a wheelchair. Interview on [DATE] at 3:16 P.M. with LPN #107, revealed she observed Resident #60 go up to the door and push on it during the shift. LPN #107 stated Resident #60 would sit by the nurse's station and exit seek throughout the shift. LPN #107 stated she was told the resident was going to be moved but the resident never did. LPN #107 stated she was seated at the nurse's station on [DATE] and overheard Resident #60's spouse tell the resident to stop trying to exit the door because he was going to roll down the steps and die. Interview on [DATE] at 8:07 A.M. with Nurse Practitioner (NP) #300 regarding Resident #60, revealed she refused to answer any surveyor questions regarding Resident #60. NP #300 was very hostile and stated she did not interview with the state and would listen to questions but would not answer any. NP #300 stated she was contracted to work with the facility and the physician. NP #300 refused to confirm any information regarding Resident #60. Interview on [DATE] at 11:07 A.M. with STNA #120, confirmed she worked on [DATE] from 3:00 P.M. to 11:00 P.M. and was told in her shift report, Resident #60 was up all night. STNA #120 stated she was told Resident #60 was exit seeking and attempted to exit the door by pushing it open and looking for his wife. STNA #120 stated on [DATE] at the time of the elopement, she had left the unit to help in the dining room, LPN #109 was upstairs in the Assisted Living administering medications, and the other STNA and the other nurse was in a resident's room. STNA #120 stated an Assisted Living resident came into the dining area and stated Resident #60 was outside. STNA #120 stated she ran outside and saw Resident #60 lying on the bottom of the steps and began yelling. STNA #120 stated she attempted to call 911; however, the nurse came out and took over the call. Review of the facility policy titled, Elopement/Unauthorized Absence Policy, dated [DATE], revealed the facility would identify residents with potential and/or actual risk for elopement and protect the resident through development and implementation of safety interventions. In the event of a resident elopement the facility will implement its policies and procedures promptly to locate the resident in a timely manner. This deficiency represents non-compliance under Complaint Numbers OH00138658 and OH00138621.

Based on closed medical record review, observations, family interview, staff interview, review of a facility investigation, review of the National Service Weather report, and policy review, the facility failed to provide adequate supervision to prevent the elopement of a cognitively impaired resident who was assessed as being at risk for elopement. This resulted in Immediate Jeopardy when Resident #220 was placed at risk for serious harm and injury when the resident eloped from the facility without staff knowledge and was missing for approximately fifteen minutes before being found by staff wandering in a field near a wooded area approximately 0.3 miles from the facility. The outside temperature according to the National Weather Service Report was 25 degrees Fahrenheit (F). This affected one (#220) of four residents (#64, #71 and #81) reviewed for risk of elopement. The facility identified nine current residents at risk for elopement on the secured unit (#45, #49, #51, #56, #61, #64, #71, #72, and #81). The facility census was 87. On 02/27/18 at 3:01 P.M., Nursing Home Administrator (NHA) #90, the Director of Nursing (DON), and the Senior Regional Director of Clinical Services Registered Nurse #88 were notified Immediate Jeopardy began on 01/28/18 at 11:30 P.M. when Resident #220, who was assessed to be at risk for wandering and exhibited exit seeking behaviors almost daily, exited the secured unit of the facility by climbing out his window, which was missing the bolts to prevent the window from opening more than six inches. State tested Nursing Assistant (STNA) #1 located the resident in the field behind the facility near the wooded area, wearing pajama bottoms with a thermal shirt and anti-slip socks. The resident was noted to have dirt on his clothes, face and hands and he was shivering from the cold. STNA #1 escorted the resident back to the secured unit to his room at approximately 01/28/18 at 11:50 P.M. The Immediate Jeopardy was removed on 01/29/18 at 1:00 P.M. when the facility implemented the following corrective actions: · On 01/28/18 at 11:50 P.M., STNA #1 located Resident #220 approximately 0.3 miles from the facility near a wooded area and was assisted back to the facility and returned to the secured unit. · On 01/29/18 at 12:15 A.M., LPN #71 notified Medical Director #1 of Resident #220's elopement. The Medical Director ordered one-to-one supervision. The one-to-one supervision was implemented immediately. · On 01/29/16 at 4:00 A.M., LPN #71 completed an elopement assessment for Resident #220, as per facility policy, to be done on admission and when a resident elopes from the facility. The elopement assessment dated [DATE] for the resident revealed a score of eight compared to the admission elopement assessment dated [DATE] with a score of four. The facility's elopement policy revised 12/13/17 revealed any resident with a score of four or higher was at high risk for elopement. · On 01/29/18 at 8:00 A.M., LPN #55 and Assistant Director of Nursing (ADON) #55 reviewed and updated Resident #220's care plan, added a new intervention for one-to-one supervision to continue until resident discharge. · On 01/29/18 at 8:30 A.M., the DON, Registered Nurse (RN) #39, Activity Director #75, Dietary Manager #98, Night Shift Supervisor LPN #83 began education of all staff on elopement, resident observations, one-to-one with residents, and monitoring residents' windows with emphasis on elopement and resident observation. Staff were not allowed to return to work without the in-service training. The in-service training was completed by 02/01/18. · On 01/29/18 at 12:00 P.M., Social Service Director (SSD) #68 sent a referral to Behavioral Health Facility #22 for psychological evaluation and treatment. · On 01/29/18 at 1:00 P.M., Maintenance Director #58 replaced the bolts in Resident #220's window. · On 01/29/18 at 1:05 P.M., Maintenance Director #58 completed a facility audit of all resident's windows and found no other residents windows missing bolts on the secured unit. The non-secured unit had bolts installed on all the windows at this time. Daily audits of all windows were implemented and continued to be checked daily for 30 days then weekly starting the first week of 03/2018. All department managers were assigned a day and were responsible for daily window checks. Daily window audit sheets were completed by the specified department manager for that day and submitted to the DON daily. · On 01/29/18 at 4:10 P.M., the DON and RN #39 initiated an elopement drill and then multiple elopement drills were conducted to include multiple shifts: on 01/30/18 at 1:30 P.M., 01/31/18 at 6:28 A.M., 01/31/18 at 1:20 P.M., 02/01/18 at 2:05 P.M. and 10:00 P.M., 02/02/18 at 2:00 P.M. and 4:30 P.M., 02/03/18 at 6:12 A.M. and 2:30 P.M. and 10:45 P.M., 02/04/18 at 6:40 A.M. and 9:55 A.M., 02/05/18 at 6:40 A.M. and 3:30 P.M., 02/06/18 at 12:00 A.M., 11:19 A.M., and 4:16 P.M., 02/07/18 at 6:45 A.M., 02/08/18 at 6:35 A.M., 02/12/18 at 3:15 P.M., 02/27/18 at 4:00 P.M. There were no negative findings as of 02/27/18. The facility will continue with monthly elopement drills. · On 01/30/18 at 12:00 P.M., a Quality Assurance and Performance Improvement (QAPI) meeting was held and attended by all department managers which included FNHA #92, ADON #55, Human Resources Director (HRD) #28, Medical Records (MR) #76, Director of Environmental Services #49, RN #24, Business Office Manager (BMO) #67, SSD #68, Maintenance Director #58, Nurse Manager LPN #6, and Medical Director. The root cause was determined to be a suspected window air conditioner unit which was removed by maintenance at an undetermined time and maintenance failed to replace the bolts in the window to restrict the window opening to only a six-inch gap. · On 01/30/18 at 2:30 P.M., East Wing Nurse Manager #6, and West Wing Secured Unit Nurse Manager #55 conducted elopement assessments for all residents. The elopement assessments for all 74 residents were completed on 1/30/18. Care plans for all residents at risk for elopement (#45, #49, #51, #56, #61, #64, #71, #72 and #81) were reviewed and required no updates. Care plan reviews were completed on 01/30/18. · Resident #220 was discharged from the facility on 02/01/18 to Behavioral Health Facility #22 · Review of Quality Assurance Audit Sheets (QA) for window audits from 01/31/18 through 02/26/18 revealed no negative findings. · Observation on 02/27/18 at 8:30 A.M. with Maintenance Director #58 revealed all residents' rooms in the facility had bolts in both windows, 26 rooms on the east hall and 22 rooms on the secured unit. · Interviews on 02/27/18 between 3:05 P.M. and 3:30 P.M. with Maintenance Director #58 and LPNs #6 and #23 revealed they were knowledgeable about the procedure to follow if a resident eloped from the facility. · Interviews on 02/28/18 between 8:00 A.M. and 8:30 A.M. with RN #24 and STNAs #14, #40 and #51 revealed they were knowledgeable about the procedure to follow if a resident elopes from the facility. Although the Immediate Jeopardy was removed, 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 action plan and monitoring to ensure on-going compliance. Findings include: Closed medical record review revealed Resident #220 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's comprehensive admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment, disorganized thinking, delusions, wandering/exit seeking behaviors, and required limited assist with locomotion. Review of the resident's elopement risk evaluation dated 01/17/18 revealed Resident #220 was physically capable of leaving the building, wandered daily within the facility, and had a previous history of attempted elopement/exit seeking. Review of the resident's care plan dated 01/17/2018 revealed Resident #220 was at risk for elopement related to poor safety awareness. Interventions included activities to keep the resident occupied, calmly redirect the resident, divert the resident's attention, and relocate the resident to a different area. Review of a daily skilled charting note dated 01/28/18 at 11:30 P.M. revealed LPN #71 documented staff found Resident #220's window open and screen removed, the resident was not in his room, and he was last seen by LPN #71 at 11:05 P.M. when administering the resident's medications. STNA #1 heard a noise from Resident #220's room at 11:30 P.M., felt cold air upon entering the room and discovered the window open. Code Green (elopement code) was initiated, staff went outside to check for the resident. Resident #220 was found by STNA #1 near the woods behind the facility at 11:50 P.M. The resident was brought into the facility at 11:50 P.M. and an abrasion was noted on the palm of his right hand. Medical Director #1 was notified and new orders were received to place the resident on one-to-one supervision on 01/28/18 at 11:50 P.M. Review of the National Weather Service Report for the night of 01/28/18 revealed the temperature was 25 degrees Fahrenheit (F). Review of the facility's investigation revealed on 01/29/18 FNHA #92 conducted an interview with Maintenance Director #58 and documented Maintenance Director #58 went into Resident #220's room to assess the windows; the assessment of the resident's windows rendered the possibility that bolts were installed in the windows and in (YEAR) were removed when the air conditioners on the unit were removed. Resident #220 had two windows that were side-by-side. One window had bolts but the other window did not. There was evidence that the window the resident kicked the screen out of had bolts at one time. FNHA #92 and Maintenance Director #58 assessed the area where Resident #220 kicked the screen out. The screen was on the ground outside the room. There were no visible traces of bolts removed and/or kicked out with the screen. All windows on the secured unit were assessed by Maintenance Director #58 and verified two three-inch lag bolts or 2 three and one-half inch dry wall screws were in place in every window on the secured unit. The missing bolts were replaced on 01/29/18 at 1:00 P.M. The non-secured unit at the time of the assessment did not have bolts in the windows and would be installed on that day (01/29/18) to ensure this incident did not happen on that unit. Further review of Resident #220's medical record revealed there were resident observation/monitoring sheets completed from 01/29/18 at 12:00 A.M. through 02/01/18 at 12:15 P.M. when the resident was discharged to Behavioral Health Facility #22. The documentation indicated the resident continued on one-to-one supervision and staff documented his status every fifteen minutes. The resident's care plan was updated on 01/28/18 to include the new intervention of one-to-one supervision for the resident. On 02/27/18 at 8:30 A.M., an interview with Maintenance Director #58 on 02/27/18 at 8:30 A.M. stated he could not be certain and had no record indicating Resident #220's room had a window air conditioning unit in the window or that bolts were in the window to prevent the window from opening. Maintenance Director #58 stated when he assessed Resident #220's room on 01/29/18, he verified there were no bolts in one window where the air conditioning unit had been and he installed bolts on 01/29/18 at 12:00 P.M. On 2/27/18 at 2:00 P.M., an observation was made of the field behind the facility where Resident #220 was found after he eloped from the facility. The wooded area was located approximately 0.3 miles from the facility. Observation of Resident #220's window from the outside of the building revealed the distance from the resident's window ledge to the ground was four feet and two inches. On 02/28/18 at 1:00 P.M., during a telephone interview with LPN #17, she revealed the resident was sitting in his chair in his room at 11:05 P.M. when she administered his scheduled 12:00 A.M. medications. LPN #71 stated at 11:30 P.M. STNA #1 alerted her the resident was not in his room and the window was open. A Code Green alert was initiated immediately. The LPN stated she was on the phone with the emergency 9-1-1 operator to report the incident to the police, when at 11:50 P.M. STNA #1 returned to the unit with Resident #220. The resident was wearing pajama bottoms and a thermal shirt with anti-slip socks. She assessed the resident and noted a small abrasion to his right hand and no signs or symptoms of hypothermia. On 02/28/18 at 1:13 P.M., during a telephone interview with STNA #1, she revealed Resident #220 had been pacing the halls as he always did and was easily directed when he attempted to exit the doors on the secured unit. STNA #1 stated at approximately 11:30 P.M. she heard a noise coming from the resident's room. When she opened the door to his room, she felt cold air and observed the window open and she immediately notified LPN #71. STNA#1 started checking the immediate area and left the facility to search outside while other staff searched the building. STNA #1 stated she located the resident in the field behind the facility near the wooded area, wearing pajama bottoms with a thermal shirt and anti-slip socks. STNA #1 stated the resident had dirt on his clothes, his face and his hands and he was shivering. STNA #1 stated she escorted him back to the secured unit to his room at approximately 11:50 P.M. On 02/28/18 at 4:39 P.M., during a telephone interview with Resident #220's son, he revealed family visited the facility daily and had discussed with staff, although he could not recall their names, the possibility his father would try to elope, such as watching staff enter the door codes or going out the window. Review of the facility's policy entitled Elopement Policy and Resident Safety revised 12/13/17 revealed the facility would identify residents with potential and/or actual risk factors for elopement and protect the resident through development and implementation of safety interventions. In the event of a resident elopement, the facility would implement its policy and procedures immediately to locate the resident in a timely manner. This deficiency substantiates Complaint Number OH 430.

Based on medical record reviews, closed medical review, staff interviews, resident interviews, review of staff statements, review of the facility abuse policy, review of a Self-Reported Incident (SRI), and local police department report, the facility failed to ensure a cognitively impaired Resident (#12) was free of sexual assault. This resulted in Immediate Jeopardy and actual harm when Resident #22, with a known history of verbal and aggressive behaviors, held his hand over Resident #12's mouth and sexually assaulted her putting her at risk for serious injury. On 11/30/17 at 3:12 P.M., the Licensed Nursing Home Administrator (LNHA), Regional Director of Operations (RDO) and the Director of Nursing (DON) were notified Immediate Jeopardy began on 11/21/17 at 6:00 A.M. when Resident #22 was found lying on top of Resident #12 and both residents' pants were pulled down. The facility's failure to supervise and implement measures to protect residents from Resident #22, who had a known history in the facility of verbal and aggressive behaviors, allowed Resident #22 to sexually abuse Resident #12. The Immediate Jeopardy was removed on 11/30/17 when the facility implemented the following corrective actions: · On 11/21/17 at 6:00 A.M., Residents #12 and #22 were separated by Registered Nurse (RN) #4 and RN #4 stayed with Resident #12 interviewing her and completing a head to toe assessment. No injuries were found on Resident #12. · On 11/21/17 at 6:00 A.M. Resident #22 was placed on one to one direct supervision until the local Sheriff's Department took him into custody on 11/21/17 at 9:30 A.M. · On 11/21/17 at 8:10 A.M. a self-reported incident (SRI) was submitted to the State Agency. · On 11/21/17 at 6:20 A.M. Residents #12 and #22's physician, #107, was notified of the incident. · On 11/21/17 at 7:20 A.M. Resident #12 was transported to a nearby hospital for additional examination and returned to the facility at approximately 11:49 A.M. with no new orders. · On 11/21/17 at 9:00 A.M. education was initiated by the DON and Unit Managers with staff regarding abuse, supervision, resident rights and specifically stopping any witnessed abuse, making residents safe, providing supervision and monitoring for increasing behaviors. By 11/30/17 all 101 staff were educated. · On 11/21/17 at 10:00 A.M., the remaining 27 residents residing on the secured unit were interviewed by Admissions Director #110, Human Resource Director #111, and Activities Director #109, with no issues regarding abuse. Three of the 30 residents who were non-interviewable had assessments completed by RN #4 and there were no findings. · On 11/21/17 at 10:30 A.M. facility department managers initiated staff interviews regarding knowledge of abuse and the alleged incident. · On 11/21/17 at 12:00 P.M. Resident #22's guardian was served immediate discharge notice from the Administrator and Admission Director #110. The facility notified the guardian by phone and certified letter. · On 11/21/17 at approximately 12:30 P.M. Resident #12 was referred to counseling services. · On 11/21/17 at 12:30 P.M. the state Ombudsman office was notified by Social Services of the sexual assault. · On 11/21/17 at 1:22 P.M., Counseling Service, the Administrator and DON met with Resident #12 for interview. · On 11/21/17 at 2:30 P.M. the facility clinical team assessed all residents on the secured unit for sexual behaviors and none were noted. · Social Services conducted one to one visits with Resident #12 on 11/21/17 through 12/08/17. The visits were daily, Monday through Friday. · On 11/27/17 a Resident Council Meeting was held by the Administrator to educate the residents on Resident Rights and what to do in abuse situations. Sixteen (16) residents were in attendance. Interviewable residents on the secured unit were interviewed and educated on abuse. · On 11/30/17 Regional Director of Clinical Services #113 educated the Administrator and DON on abuse reporting, investigations, supervision and immediate interventions for residents exhibiting behaviors. · On 11/30/17 all other residents with physical and verbal behaviors had their care plans reviewed and updated as indicated. A total of nine residents were identified with the potential for physical and/or verbal aggression. The Interdisciplinary team reviewed care plans and updated them if required on 11/30/2017. · Unit Managers #226, #227 and #228 will conduct a minimum of three resident interviews and a minimum of three staff interviews twice weekly for four weeks then weekly for two additional months to ensure ongoing compliance. · Corporate Social Service Director #14 and /or designee will conduct facility wide training on dealing with behaviors specifically verbally and physically abusive residents by 12/07/17. · Interviews with state tested nursing assistants (STNA's) #6, #9 and #11 and RN #4 on 12/01/17 at various times of the morning revealed they were aware of what to report, when to report an abuse situation and were given education just recently on abuse. Although the Immediate Jeopardy was removed on 11/30/17, 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: Medical record review for Resident #12 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was severely cognitively impaired. She was an extensive assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. Review of Resident #12's progress note dated 11/21/17 at 7:00 A.M., revealed Resident #22 was found by RN #4 on top of Resident #12 with his pants pulled down to his knees and he had also removed Resident #12's pants. Resident #22 was removed from her room and placed on one to one supervision. STNA #6 assisted her with dressing in the same clothes, no peri care was provided, the police were called and Resident #12 was taken to hospital for evaluation. At 7:52 A.M. the progress note revealed Resident #12 refused an assessment of her thighs and vaginal area. Closed medical record review revealed Resident #22 was admitted to the facility on [DATE] and discharged on [DATE]. Resident #22 was noted with the [DIAGNOSES REDACTED]. Review of his comprehensive MDS 3.0 assessment dated [DATE] revealed he was cognitively intact. The assessment revealed Resident #22 had delusions, physical and verbal behavioral symptoms towards others. Review of progress notes for Resident #22 revealed he refused care on multiple occasions. On 10/25/17 he was yelling at nurses. On 10/28/17 he was yelling at his roommate and was placed on 15 minute checks. On 11/03/17 he pushed another resident. Resident #22 remained on 15 minute checks with no new interventions. On 11/07/17 he grabbed another resident by the collar and said, I am going to kill you. There were no new interventions and the facility continued 15 minutes checks on the resident. On 11/10/17 he was threatening, yelling and cursing at staff members. On 11/11/17 he was yelling at another resident and again there were no new interventions and the 15 minute checks continued. On 11/12/17 he was calling residents derogatory names. There were no behaviors documented from 11/15/17 through 11/21/17 and he remained on 15 minute checks. Review of a progress note for Resident #22 on 11/21/17 at 6:00 A.M., revealed he was found in Resident #12's room on top of her, in bed with his pants pulled down to his knees and Resident #12's pants were removed as well. The residents were immediately separated and Resident #22 was placed on one-on-one supervision and the police were called. Medical record review for Resident #3, roommate to Resident #12, revealed she was admitted on [DATE] and her [DIAGNOSES REDACTED]. Her comprehensive MDS assessment dated [DATE] revealed she was cognitively intact. Review of the law enforcement arrest report dated 11/21/17 revealed on 11/21/17 Officers #32 and #34 were dispatched at 8:58 A.M. to the facility to escort Resident #22 to the local hospital for an evaluation due to an incident where he was found on top of a female resident (Resident #12) and attempting to have sex with her. They were told Resident #12 was already at the hospital for evaluation. The report revealed Officers #32 and #34 went to the hospital and took a statement of events from Resident #12. The statement revealed Resident #12 reported someone climbed on top of her and when she opened her eyes it was Resident #22. She reported she asked him to get off her several times but he did not. She reported Resident #22 took out his penis and began playing with it and stated he was rubbing his penis on her and attempted to pull her pants down. She stated she told him several more times to stop and she didn't want him doing this. She stated her roommate (Resident #3) yelled for help. Then RN #4 came into the room and removed Resident #22 from on top of her. She reported to officers #32 and #34 several times she was not in a relationship with Resident #22 and did not give permission to do what he did. The document further revealed a warrant was requested on Resident #22 for gross sexual imposition. Review of the facility's self-reported incident (SRI) # 8 dated 11/21/17 at 8:10 A.M. revealed they substantiated the sexual abuse allegation. The SRI revealed Resident #22 was noted on top of Resident #12 around 6:00 A.M. in her room. Resident #3 saw Resident #22 on top of Resident #12 and immediately went to get RN #4. RN#4 came into the room and discovered Resident #22 on top of Resident #12 with his pants pulled down to his knees. Resident #22 was noted to have his back arched and rounded with repeated motions of going back and forth while on top of Resident #12. RN #4 asked Resident #22 what was he doing and he responded, We have a mutual agreement and Resident #12 responded, I did not agree with this. Resident #12 stated to RN #4 there was no penetration and she didn't want the police to be called, however the police were called and she was sent to the emergency room for evaluation. Resident #22 was placed on one to one supervision. Review of the written statement completed on 11/21/17 from RN #4 revealed Resident #3 called him to her room on 11/21/17 at 6:00 A.M. stating there's a man in here on top of her (Resident #12). Upon entering the room, he discovered Resident #22 on top of Resident #12 (performing sexual actions) her. The statement revealed both of the residents were quiet and not saying anything. RN #4 asked Resident #22 what he was doing and he state, we have a mutual agreement. Resident #12 then responded, I didn't agree to this. The statement further revealed Resident #22 had removed his pants and had removed Resident #12's pants. Resident #12 stated there was no penetration. The police were called and Resident #12 was sent to the emergency room . Review of the written statement from STNA #6 revealed Resident #3 alerted staff that Resident #22 was in her room on top of Resident #12. Resident #22 was found on top of Resident #12 {performing sexual actions) her. Resident #22 stated he and Resident #12 had a mutual understanding, however Resident #12 had not consented. The statement revealed the residents were separated and the police were called. Review of hospital records dated 11/21/17 revealed Resident #12 denied any penetration, therefore a Sexual Abuse Nurse Evaluation (SANE) evaluation was not completed. A focused exam was performed by a physician and it was determined the resident was in no acute distress and had no obvious injuries and she was discharged back to the facility. Interview on 11/30/17 at 8:46 A.M. with Resident #3 (Resident #12's roommate) revealed she had gotten up from bed to make a phone call and discovered Resident #22 was on top of Resident #12 and yelled for the nurse to come and help. Interview on 11/30/17 at 9:00 A.M. with Resident #12 stated on 11/21/17 she was in bed when Resident #22 grabbed her by the mouth and she started to yell for help and he put his hand on her mouth and her neck. He was lying on top of her and tried to get her to consent. She stated she couldn't believe he was doing this to her. She stated he tried to get her pants down. She stated she tried to get out of the bed, however his body weight was pushed down on her and she could not. She said her roommate (Resident #3) saw Resident #22 on top of her and called for help and RN #4 came into the room and asked Resident #22 to get off of her. She stated Resident #22 kept saying to her you know we talked about this. Resident #12 said they had never talked about it. She stated she was terrified and felt very used. Interview on 12/01/17 at 6:18 A.M. with RN #4 revealed Resident #3 yelled for help and he went immediately to see what was wrong. He stated upon arriving at the room, he discovered Resident #22 was on top of Resident #12 and both of their incontinence briefs were down to their knees. He stated Resident #22 told him they had a mutual understanding. However, Resident #12 stated she did not agree to it. RN #4 stated Resident #22 was moved away from Resident #12 and was escorted out of Resident #12's room. RN #4 said he stayed in the room with Resident #12. RN #4 confirmed he could not see Resident #22 from Resident #12's room. Resident #22 was placed on one on one supervision. Interview on 12/01/17 at 6:31 A.M. with STNA #6 stated he saw Resident #22 on top of Resident #12 and went in and told him to get off her and to pull his pants up. He stated Resident #22 came out of the room and STNA #7 went down the hall with him. Review of the facility's Abuse Policy and Procedure with a revised date of 03/03/17, revealed the facility will follow state and federal guidelines on preventing abuse, neglect, mistreatment, exploitation and misappropriation of property. The facility defined sexual abuse as including but not limited to sexual harassment, sexual coercion or sexual assault. Reports of abuse will promptly and thoroughly investigated. If abuse is witnessed by a staff member the staff member will first and foremost take whatever action is needed to protect the resident. When an incident or suspected incident of abuse or neglect is reported, the Administrator or designee investigates the incident with the assistance of appropriate personnel. During and after the investigation the residents are protected from harm through supervision by staff. In the case of resident-to-resident suspected abuse the parties are separated from one another until the investigation has been completed. If the abuse is substantiated the incident would be reported to the local law enforcement agency, licensing/certification boards and the attorney general's office for further actions. Any person witnessing or having knowledge of alleged violation involving abuse, neglect, misappropriation or injury of unknown origin of a resident has the responsibility to report the incident to the Administrator or the Direction of Nursing. This deficiency substantiates Control Number OH 849.

Based on medical record reviews, closed medical review, staff interviews, resident interviews, review of staff statements, review of the facility abuse policy, review of a Self-Reported Incident (SRI), and local police department report, the facility failed to implement their abuse policy when a cognitively impaired Resident (#12) was not free of sexual assault. This resulted in Immediate Jeopardy and actual harm when Resident #22, with a known history of verbal and aggressive behaviors, held his hand over Resident #12's mouth and sexually assaulted her putting her at risk for serious injury. On 11/30/17 at 3:12 P.M., the Licensed Nursing Home Administrator (LNHA), Regional Director of Operations (RDO) and the Director of Nursing (DON) were notified Immediate Jeopardy began on 11/21/17 at 6:00 A.M. when Resident #22 was found lying on top of Resident #12 and both residents' pants were pulled down. The facility's failure to supervise and implement measures to protect residents from Resident #22, who had a known history in the facility of verbal and aggressive behaviors, allowed Resident #22 to sexually abuse Resident #12. The Immediate Jeopardy was removed on 11/30/17 when the facility implemented the following corrective actions: · On 11/21/17 at 6:00 A.M., Residents #12 and #22 were separated by Registered Nurse (RN) #4 and RN #4 stayed with Resident #12 interviewing her and completing a head to toe assessment. No injuries were found on Resident #12. · On 11/21/17 at 6:00 A.M. Resident #22 was placed on one to one direct supervision until the local Sheriff's Department took him into custody on 11/21/17 at 9:30 A.M. · On 11/21/17 at 8:10 A.M. a self-reported incident (SRI) was submitted to the State Agency. · On 11/21/17 at 6:20 A.M. Residents #12 and #22's physician, #107, was notified of the incident. · On 11/21/17 at 7:20 A.M. Resident #12 was transported to a nearby hospital for additional examination and returned to the facility at approximately 11:49 A.M. with no new orders. · On 11/21/17 at 9:00 A.M. education was initiated by the DON and Unit Managers with staff regarding abuse, supervision, resident rights and specifically stopping any witnessed abuse, making residents safe, providing supervision and monitoring for increasing behaviors. By 11/30/17 all 101 staff were educated. · On 11/21/17 at 10:00 A.M., the remaining 27 residents residing on the secured unit were interviewed by Admissions Director #110, Human Resource Director #111, and Activities Director #109, with no issues regarding abuse. Three of the 30 residents who were non-interviewable had assessments completed by RN #4 and there were no findings. · On 11/21/17 at 10:30 A.M. facility department managers initiated staff interviews regarding knowledge of abuse and the alleged incident. · On 11/21/17 at 12:00 P.M. Resident #22's guardian was served immediate discharge notice from the Administrator and Admission Director #110. The facility notified the guardian by phone and certified letter. · On 11/21/17 at approximately 12:30 P.M. Resident #12 was referred to counseling services. · On 11/21/17 at 12:30 P.M. the state Ombudsman office was notified by Social Services of the sexual assault. · On 11/21/17 at 1:22 P.M., Counseling Service, the Administrator and DON met with Resident #12 for interview. · On 11/21/17 at 2:30 P.M. the facility clinical team assessed all residents on the secured unit for sexual behaviors and none were noted. · Social Services conducted one to one visits with Resident #12 on 11/21/17 through 12/08/17. The visits were daily, Monday through Friday. · On 11/27/17 a Resident Council Meeting was held by the Administrator to educate the residents on Resident Rights and what to do in abuse situations. Sixteen (16) residents were in attendance. Interviewable residents on the secured unit were interviewed and educated on abuse. · On 11/30/17 Regional Director of Clinical Services #113 educated the Administrator and DON on abuse reporting, investigations, supervision and immediate interventions for residents exhibiting behaviors. · On 11/30/17 all other residents with physical and verbal behaviors had their care plans reviewed and updated as indicated. A total of nine residents were identified with the potential for physical and/or verbal aggression. The Interdisciplinary team reviewed care plans and updated them if required on 11/30/2017. · Unit Managers #226, #227 and #228 will conduct a minimum of three resident interviews and a minimum of three staff interviews twice weekly for four weeks then weekly for two additional months to ensure ongoing compliance. · Corporate Social Service Director #14 and /or designee will conduct facility wide training on dealing with behaviors specifically verbally and physically abusive residents by 12/07/17. · Interviews with state tested nursing assistants (STNA's) #6, #9 and #11 and RN #4 on 12/01/17 at various times of the morning revealed they were aware of what to report, when to report an abuse situation and were given education just recently on abuse. Although the Immediate Jeopardy was removed on 11/30/17, 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: Medical record review for Resident #12 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was severely cognitively impaired. She was an extensive assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. Review of Resident #12's progress note dated 11/21/17 at 7:00 A.M., revealed Resident #22 was found by RN #4 on top of Resident #12 with his pants pulled down to his knees and he had also removed Resident #12's pants. Resident #22 was removed from her room and placed on one to one supervision. STNA #6 assisted her with dressing in the same clothes, no peri care was provided, the police were called and Resident #12 was taken to hospital for evaluation. At 7:52 A.M. the progress note revealed Resident #12 refused an assessment of her thighs and vaginal area. Closed medical record review revealed Resident #22 was admitted to the facility on [DATE] and discharged on [DATE]. Resident #22 was noted with the [DIAGNOSES REDACTED]. Review of his comprehensive MDS 3.0 assessment dated [DATE] revealed he was cognitively intact. The assessment revealed Resident #22 had delusions, physical and verbal behavioral symptoms towards others. Review of progress notes for Resident #22 revealed he refused care on multiple occasions. On 10/25/17 he was yelling at nurses. On 10/28/17 he was yelling at his roommate and was placed on 15 minute checks. On 11/03/17 he pushed another resident. Resident #22 remained on 15 minute checks with no new interventions. On 11/07/17 he grabbed another resident by the collar and said, I am going to kill you. There were no new interventions and the facility continued 15 minutes checks on the resident. On 11/10/17 he was threatening, yelling and cursing at staff members. On 11/11/17 he was yelling at another resident and again there were no new interventions and the 15 minute checks continued. On 11/12/17 he was calling residents derogatory names. There were no behaviors documented from 11/15/17 through 11/21/17 and he remained on 15 minute checks. Review of a progress note for Resident #22 on 11/21/17 at 6:00 A.M., revealed he was found in Resident #12's room on top of her, in bed with his pants pulled down to his knees and Resident #12's pants were removed as well. The residents were immediately separated and Resident #22 was placed on one-on-one supervision and the police were called. Medical record review for Resident #3, roommate to Resident #12, revealed she was admitted on [DATE] and her [DIAGNOSES REDACTED]. Her comprehensive MDS assessment dated [DATE] revealed she was cognitively intact. Review of the law enforcement arrest report dated 11/21/17 revealed on 11/21/17 Officers #32 and #34 were dispatched at 8:58 A.M. to the facility to escort Resident #22 to the local hospital for an evaluation due to an incident where he was found on top of a female resident (Resident #12) and attempting to have sex with her. They were told Resident #12 was already at the hospital for evaluation. The report revealed Officers #32 and #34 went to the hospital and took a statement of events from Resident #12. The statement revealed Resident #12 reported someone climbed on top of her and when she opened her eyes it was Resident #22. She reported she asked him to get off her several times but he did not. She reported Resident #22 took out his penis and began playing with it and stated he was rubbing his penis on her and attempted to pull her pants down. She stated she told him several more times to stop and she didn't want him doing this. She stated her roommate (Resident #3) yelled for help. Then RN #4 came into the room and removed Resident #22 from on top of her. She reported to officers #32 and #34 several times she was not in a relationship with Resident #22 and did not give permission to do what he did. The document further revealed a warrant was requested on Resident #22 for gross sexual imposition. Review of the facility's self-reported incident (SRI) # 8 dated 11/21/17 at 8:10 A.M. revealed they substantiated the sexual abuse allegation. The SRI revealed Resident #22 was noted on top of Resident #12 around 6:00 A.M. in her room. Resident #3 saw Resident #22 on top of Resident #12 and immediately went to get RN #4. RN#4 came into the room and discovered Resident #22 on top of Resident #12 with his pants pulled down to his knees. Resident #22 was noted to have his back arched and rounded with repeated motions of going back and forth while on top of Resident #12. RN #4 asked Resident #22 what was he doing and he responded, We have a mutual agreement and Resident #12 responded, I did not agree with this. Resident #12 stated to RN #4 there was no penetration and she didn't want the police to be called, however the police were called and she was sent to the emergency room for evaluation. Resident #22 was placed on one to one supervision. Review of the written statement completed on 11/21/17 from RN #4 revealed Resident #3 called him to her room on 11/21/17 at 6:00 A.M. stating there's a man in here on top of her (Resident #12). Upon entering the room, he discovered Resident #22 on top of Resident #12 (performing sexual actions) her. The statement revealed both of the residents were quiet and not saying anything. RN #4 asked Resident #22 what he was doing and he state, we have a mutual agreement. Resident #12 then responded, I didn't agree to this. The statement further revealed Resident #22 had removed his pants and had removed Resident #12's pants. Resident #12 stated there was no penetration. The police were called and Resident #12 was sent to the emergency room . Review of the written statement from STNA #6 revealed Resident #3 alerted staff that Resident #22 was in her room on top of Resident #12. Resident #22 was found on top of Resident #12 {performing sexual actions) her. Resident #22 stated he and Resident #12 had a mutual understanding, however Resident #12 had not consented. The statement revealed the residents were separated and the police were called. Review of hospital records dated 11/21/17 revealed Resident #12 denied any penetration, therefore a Sexual Abuse Nurse Evaluation (SANE) evaluation was not completed. A focused exam was performed by a physician and it was determined the resident was in no acute distress and had no obvious injuries and she was discharged back to the facility. Interview on 11/30/17 at 8:46 A.M. with Resident #3 (Resident #12's roommate) revealed she had gotten up from bed to make a phone call and discovered Resident #22 was on top of Resident #12 and yelled for the nurse to come and help. Interview on 11/30/17 at 9:00 A.M. with Resident #12 stated on 11/21/17 she was in bed when Resident #22 grabbed her by the mouth and she started to yell for help and he put his hand on her mouth and her neck. He was lying on top of her and tried to get her to consent. She stated she couldn't believe he was doing this to her. She stated he tried to get her pants down. She stated she tried to get out of the bed, however his body weight was pushed down on her and she could not. She said her roommate (Resident #3) saw Resident #22 on top of her and called for help and RN #4 came into the room and asked Resident #22 to get off of her. She stated Resident #22 kept saying to her you know we talked about this. Resident #12 said they had never talked about it. She stated she was terrified and felt very used. Interview on 12/01/17 at 6:18 A.M. with RN #4 revealed Resident #3 yelled for help and he went immediately to see what was wrong. He stated upon arriving at the room, he discovered Resident #22 was on top of Resident #12 and both of their incontinence briefs were down to their knees. He stated Resident #22 told him they had a mutual understanding. However, Resident #12 stated she did not agree to it. RN #4 stated Resident #22 was moved away from Resident #12 and was escorted out of Resident #12's room. RN #4 said he stayed in the room with Resident #12. RN #4 confirmed he could not see Resident #22 from Resident #12's room. Resident #22 was placed on one on one supervision. Interview on 12/01/17 at 6:31 A.M. with STNA #6 stated he saw Resident #22 on top of Resident #12 and went in and told him to get off her and to pull his pants up. He stated Resident #22 came out of the room and STNA #7 went down the hall with him. Review of the facility's Abuse Policy and Procedure with a revised date of 03/03/17, revealed the facility will follow state and federal guidelines on preventing abuse, neglect, mistreatment, exploitation and misappropriation of property. The facility defined sexual abuse as including but not limited to sexual harassment, sexual coercion or sexual assault. Reports of abuse will promptly and thoroughly investigated. If abuse is witnessed by a staff member the staff member will first and foremost take whatever action is needed to protect the resident. When an incident or suspected incident of abuse or neglect is reported, the Administrator or designee investigates the incident with the assistance of appropriate personnel. During and after the investigation the residents are protected from harm through supervision by staff. In the case of resident-to-resident suspected abuse the parties are separated from one another until the investigation has been completed. If the abuse is substantiated the incident would be reported to the local law enforcement agency, licensing/certification boards and the attorney general's office for further actions. Any person witnessing or having knowledge of alleged violation involving abuse, neglect, misappropriation or injury of unknown origin of a resident has the responsibility to report the incident to the Administrator or the Direction of Nursing. This deficiency substantiates Control Number OH 849.