Every finding on record at St Leonard HCC

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure dependent residents received bathing services as scheduled. This affected four (Residents #7, #56, #114, and #130) of five residents reviewed for bathing. The facility census was 124 residents.Findings include: 1.Review of the medical record for Resident #7 revealed an admission date of 12/19/25 with diagnoses including myelodysplastic syndrome, hypokalemia, and iron deficiency anemia. Review of the Minimum Data Set (MDS) assessment for Resident #7 dated 02/10/26 revealed the resident had severe cognitive impairment and required assistance with activities of daily living (ADLs), including bathing and dressing. Review of the care plan for Resident #7 dated 02/11/26 revealed the staff would meet the resident's ADL needs and the resident was fully dependent on staff to provide baths. Review of the shower documentation for Resident #7 revealed she had scheduled showers on Monday and Thursday evenings. Further review of the shower documentation dated 01/01/26 to 04/01/26, revealed no documentation of showers being completed on the following dates: 01/08/26, 01/15/26, 01/26/26, 01/29/26, 02/05/26, 02/09/26, 02/12/26, 02/16/26, 02/23/26, 02/26/26, 03/05/26, 03/16/26, 03/19/26, 03/23/26. During an interview on 04/01/26 at 12:48 P.M., Resident #7's family member stated the resident did not receive baths on a consistent basis. 2. Review of the medical record for Resident #56 revealed an admission date of 04/17/25 with diagnoses including chronic kidney disease, hypertension, and peripheral vascular disease. Review of the MDS assessment for Resident #56 dated 03/19/26 revealed resident had intact cognition and required assistance with ADLs, including bathing and dressing. Review of the shower documentation for Resident #7 revealed he had scheduled showers on Monday and Thursday evenings. Further review of the shower documentation dated 01/01/26 to 04/01/26, revealed no documentation of showers being completed on the following dates: 01/08/26, 01/22/26, 01/26/26, 02/05/26, 02/09/26, 03/23/26, 03/26/26, 03/30/26. 3.Review of the medical record for Resident #114 revealed an admission date of 02/01/26 with diagnoses including diabetes mellitus type two, encephalopathy, and hypertension. Review of the MDS assessment for Resident #114 dated 02/04/26 revealed the resident had intact cognition and required assistance with ADLs. Review of the care plan for Resident #114 dated 02/06/26 the resident was at risk for an ADL self-care performance deficient and required substantial or maximal assistance of staff with bathing or showering. Staff were to provide a sponge bath when the resident could not tolerate a full bath or shower. Review of the shower documentation for Resident #114 revealed she had scheduled showers on Monday and Thursday during day shift. Further review of the shower documentation dated 02/01/26 to 04/01/26, revealed no documentation of showers being completed on the following dates: 02/23/26, 02/26/26, 03/19/26, 03/23/26, 03/26/26, 03/30/26. 4.Review of the medical record for Resident #130 revealed an admission date of 10/20/25 with diagnoses including acute kidney failure, hypertension, and osteoarthritis and a discharge date of 03/20/26. Review of the MDS assessment for Resident #130 dated 01/23/26 revealed the resident had intact cognition and required assistance with ADLs. Review of the care plan for Resident #130 dated 02/13/26 revealed the resident was at risk for an ADL self-care performance deficient and required substantial or maximal assistance by staff with bathing or showering. Staff were to provide a sponge bath when the resident could not tolerate a full bath or shower. Review of the shower documentation for Resident #130 revealed she had scheduled showers on Wednesday and Saturday nights. Further review of the shower documentation dated 01/01/26 through 03/20/26 revealed no documentation of showers being completed on 01/03/26, 01/07/26, 01/10/26, 01/21/26, 01/28/26, 01/31/26, 02/04/26, 02/07/26, 02/21/26, 02/25/26, 02/28/26, 03/04/26, 03/07/26, 03/11/26, 03/14/26. Interview on 04/01/26 at 9:55 A.M. with Assistant Director of Nursing (ADON) #347 confirmed residents are scheduled to receive showers twice weekly unless otherwise indicated. ADON #347 stated if a resident refused a shower, the Certified Nursing Assistant (CNA) was to notify the nurse, and the nurse should re-offer the shower. If the resident continued to refuse, the refusal was to be documented. ADON #347 verified the missing shower documentation for Residents #7, #56, #114, and #130. Review of facility policy titled Resident Showers dated 12/01/25 revealed residents would be provided showers as per request of as per facility schedule protocols. This deficiency represents noncompliance investigated under Complaint Number 2697589 and Complaint Number 2694588

Based on medical record review, review of a facility (self-reported incident), observations, staff interview and facility policy review, the facility failed to provide adequate interventions and/or supervision to ensure a resident who was assessed as being at risk for elopements did not elope from the facility. This affected one (#205) out of three residents reviewed for elopement risk. The facility census was 116. Findings include: Review of Resident #205's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include Alzheimer's disease, dementia and traumatic brain injury. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #205 was severely cognitively impaired, required moderate assistance with dressing, toileting and bathing. Review of Resident #205's care plan dated 06/29/25 revealed the resident was at risk for falls, self-care performance deficit and elopement. Interventions included Resident #205 to be one on one with someone. Review of Resident #205's nursing progress notes dated 06/26/25 identified as a late entry, revealed the resident was placed on a one-on-one on 06/25/25 due to wandering. A wander guard was in place. An aide left Resident #205 to answer a call light and resident left front door with emergency medical services (EMS). Review of a facility SRI dated 06/26/25 revealed for neglect revealed Resident #205 was found outside the facility on the facility grounds by an independent living resident. On 06/25/25 at approximately 7:15 P.M. Resident #205 was assumed to be missing. A headcount was done immediately which confirmed that Resident #205 was not in the facility. Staff initiated a search of the premises. The nurse on duty concluded that Resident #205 was following someone out the main entrance, the Wanderguard system did not sound an alarm. The resident was last seen at 7:00 P.M. in the common area on by Certified Nursing Assistant (CNA) #12. CNA #12 went into another resident's room to provide resident care and when she came back to the common area at 7:15 P.M., Resident #205 was no longer there. Security was notified. At 7:25 P.M., an anonymous caller reported to security that Resident #205 was seen standing in the backyard of one of the Independent Living Cottages. Security personnel was immediately dispatched and successfully returned the resident to the facility. The nurse on duty completed a head-to-toe assessment; the resident was free of injury. The facility conducted an investigation and determined the allegation to be substantiated. Observation on 09/17/25 at 1:41 P.M. revealed when the code to exit door is placed in or when button to unlock front door by receptionist desk, this stops the wander guards from alarming for 60 seconds. Interview on 09/17/25 at 10:48 A.M. with Administrator verified Resident #205 eloped the facility on 06/26/25 approximately 7:15 P.M. Resident #205 was a one on one with Certified Nursing Assistant (CNA) #400. CNA #400 left Resident #205 and answered another resident's light. When CNA #400 returned, Resident #205 was no longer in the common area and a search was started The Administrator stated the facility determined the ambulance was transferring another resident out of facility at the time of Resident #205's elopement. The Administrator stated an anonymous caller on 06/26/25 at 7:24 P.M. reported Resident #205 was found in independent living yard. The Administrator confirmed Resident #205 was assessed and was not injured. Interview on 09/17/25 at 10:48 A.M. with Director of Nursing (DON) verified the facilities security system is currently being changed from x-mark to secure care. New wiring is currently being placed in the facility. The DON stated a secure care will not allow a wandergaurd to pass doorways at anytime without alarming. The DON confirmed with the current system, if a staff or visitor presses the button at the receptionist desk this silences the alarm. Review of facility policy, Elopement and Wandering Residents, dated 05/22/25 revealed residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. This deficiency represents non-compliance investigated under Complaint Number 1323869 (OH00167528).

Based on observation, medical record review, staff interview, and policy review, the facility failed to administer medications as ordered to be free from errors not five (5) percent (%) or greater. There were two medication errors observed out of 27 opportunities for a medication error rate of 7.41%, This affected two (#66 and #71) of two residents observed during medication administration. The facility census was 110. Findings Included: 1. Review of Resident #71's medical record revealed the resident was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease and osteoporosis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 was cognitively intact. Review of a physician order dated 04/25/25 revealed Resident #71 was ordered supplemental calcium 600 milligrams (mg) to be given once daily. Observation on 05/28/25 at 6:40 A.M. with Licensed Practical Nurse (LPN) #270 revealed the nurse was administering medication to Resident #71. At the time of the observation, calcium 600 mg was not available in the medication cart. Interview on 05/28/25 at 7:00 A.M. with LPN #270 verified she did not have calcium 600 mg available for Resident #71 and stated it was a special order and needed to be ordered. Interview on 05/28/25 at 7:39 A.M. with the Director of Nursing (DON) confirmed calcium 600 mg was not available in the facility. The DON stated the facility only had calcium 600 mg with vitamin D3 available. 2. Review of Resident #66's medical record revealed an admission date of 10/01/23. Diagnoses included Parkinson's disease and chronic obstructive disease. Review of the MDS assessment dated [DATE] revealed Resident #66 had intact cognition. Review of a physician order dated 10/11/24 revealed Resident #66 had an order for budesonide-formoterol fumarate inhalation aerosol 160-4.5 micrograms per actuation (mcg/act) with instructions to give two puffs inhaled orally two times a day related to chronic obstructive pulmonary disease. Observation on 05/28/25 at 7:50 A.M. with LPN #398 revealed the nurse was preparing medications for Resident #66 and did not have budesonide-formoterol fumarate available in the medication cart to administer to Resident #66. Interview on 05/28/25 at 8:02 A.M. with LPN #398 verified Resident #66 did not have budesonide-formoterol fumarate inhalation aerosol 160-4.5 mcg/act available in the medication cart to administer to the resident. Interview on 05/28/25 at 8:10 A.M. with the DON stated the facility had a medication dispensing machine that only carried narcotic medications and the facility did not carry aerosols in stock. The DON stated all aerosol medications needed to be specially ordered. Review of the facility medication administration policy, dated 12/20/24, revealed the medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. This deficiency represents non-compliance investigated under Complaint Number OH00164611.

Based on medical record review, staff interview, review of electronic mail (email) documents, and facility policy review, the facility failed to ensure residents were free from significant medication errors. This affected two (#112 and #113) of four residents reviewed for medications. The facility census was 110. Findings Included: 1. Review of Resident #112's medical record revealed an admission date of 04/16/25. Diagnoses included depression, hyperkalemia, fluid overload, thrombocytopenia, peripheral vascular disease, protein-calorie malnutrition, chronic obstructive pulmonary disease, acute diastolic heart failure, and congestive heart failure. The resident was discharged on 04/24/25. Review of Resident #112's physician orders revealed an order dated 04/20/25 for the diuretic furosemide 20 milligrams (mg) with instructions to take two tablets by mouth once a day for hypertension. This order was discontinued on 04/24/25. Review of Resident #112's physician orders revealed an order dated 04/21/25 for furosemide 60 mg once a day for edema and was discontinued on discontinue on 04/24/25. Review of Resident #112's medication administration record (MAR) for April 2025 revealed Resident #112 was administered furosemide 20 mg two tablets on 04/22/25 and 04/23/25 and also received furosemide 60 mg on 04/22/25 and 04/23/25. Interview on 05/28/25 at 3:00 P.M. with Director of Nursing Assisted Living ([NAME]) #693 stated the previous DON at the facility was who handled all investigations but [NAME] #693 had been working with her. [NAME] #693 verified Resident #112's order for furosemide 20 mg two tablets daily was not discontinued before starting the new order of furosemide 60 mg and the medications should not have been given together. 2. Review of Resident #113's medical record revealed the resident was admitted on [DATE]. Diagnoses included type two diabetes, autistic disorder, symbolic dysfunctions, and paranoid schizophrenia. Resident #113 was alert with periods of confusion. The resident was discharged on 05/12/25. Review of Resident #113's physician orders revealed an order dated 04/30/25 for the medication to treat high blood pressure and fluid retention hydrochlorothiazide 50 mg by mouth three times a day. The order was discontinued on 05/05/25. Review of Resident #113's physician orders revealed an order dated 05/05/25 for the blood pressure medication hydralazine 50 mg by mouth three times a day. Review of Resident #113's nursing progress note dated 05/05/25, written by Licensed Practical Nurse (LPN) #301, revealed Medical Director (MD) #350 ordered to discontinue hydrochlorothiazide 50 mg due to a decrease in weight and start hydralazine 50 mg three times a day. Review of Resident #113's MAR for May 2025 revealed Resident #113 received hydrochlorothiazide 50 mg on 05/01/25, 05/02/25, 05/03/25, and 05/04/25 three times a day at 9:00 A.M., 2:00 P.M., and 9:00 P.M. Further review of the May 2025 MAR revealed Resident #113's hydralazine 50 mg was started on 05/05/25 at 12:00 P.M. and hydrochlorothiazide was discontinued. Review of an email dated 05/28/25 at 12:43 P.M. by [NAME] #693 revealed confirmation Resident #113's provider originally ordered hydralazine 50 mg three times a day to be administered, but an order initiated by a nurse for the resident to receive hydrochlorothiazide 50 mg three times a day instead. The prescribing provider and the resident's family were promptly notified and no adverse effects were observed. Resident #113 remained stable with vital signs within normal range. Interview on 05/28/25 at 3:00 P.M. with [NAME] #693 stated a nurse put in the incorrect medication (hydrochlorothiazide 50 mg) in Resident #113's physician orders on 04/30/25 and the order was supposed to be for hydralazine 50 mg. [NAME] #693 confirmed this was a medication error because the wrong medication was initiated and administered to Resident #113. [NAME] #693 stated the nurse that placed the incorrect medication in Resident #113's record as an order was provided education. Interview on 05/28/25 at 5:00 P.M. with the Director of Nursing (DON) stated she expected her nurses to make sure they check the five rights of medication administration to prevent medication errors and provides education right away on any medication errors at the facility. Review of the facility medication administration policy, dated 12/20/24, revealed medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. This deficiency represents non-compliance investigated under Complaint Number OH00164611.

Based on medical record review, review of laboratory results, review of a facsimile (fax) document, staff interview, and review of a facility policy, the facility failed to notify the physician of critical laboratory values in a timely manner. This affected one (#112) of three residents reviewed for laboratory services. The facility census was 110. Findings Included: Review of Resident #112's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included depression, hyperkalemia, fluid overload, thrombocytopenia, peripheral vascular disease, protein-calorie malnutrition, chronic obstructive pulmonary disease, acute diastolic heart failure, and congestive heart failure. The resident was discharged on 04/24/25. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #112 had intact cognition, required setup for meals, and required substantial maximal assistance for bathing, personal hygiene, dressing the lower body, and placing shoes on and off the feet. Review of a physician order dated 04/03/25 revealed Resident #112 had an order for laboratory values to be completed including a complete blood count (CBC) and basic metabolic panel (BMP) one time only related to hyperkalemia. Review of a plan of care dated 04/08/25 revealed Resident #112 had impaired cardiac output related to acute diastolic congestive heart failure, hypertension, heart disease, and coronary angioplasty status. Interventions included to monitor for shortness of breath, sudden weight gain, take medications as ordered, and laboratory work will be drawn as ordered and the physician notified of abnormal laboratory values. Review of laboratory results dated [DATE] revealed Resident #112 had CBC and BMP laboratory values that revealed a sodium level of 132 milliequivalents per liter (mEq/L) (normal range was 136 to 145 mEq/L), chloride was 82 mEq/L (normal range was 98 to 110 mEq/L), carbon dioxide was 37 micromoles per mole (µ[NAME]/[NAME]) (normal range was 21 to 33 µ[NAME]/[NAME]), blood urea nitrogen (BUN) was 31 milligrams per deciliter (mg/dL) (normal range was 6-25), platelets were 137 microliters (mcL) (normal range was 150 to 450 mcL), monocytes were 13.7 percent (%) (normal range was 2.0 to 12.0%), and potassium was 4.9 mEq/L (normal range was 3.5 to 5.3 mEq/L). Review of a physician order dated 04/18/25 revealed Resident #112 had an order for Digoxin 125 microgram (mcg) one time a day for systolic heart failure and was discontinued on 04/24/25. Review of a physician order dated 04/21/25 revealed Resident #112 had an order for BMP, CBC, and Digoxin level laboratory values with orders to obtain laboratory levels one time only for abnormal laboratory values for two days. Review of the laboratory results dated [DATE] revealed Resident #112 had a BMP, CBC, and a Digoxin level with a collection time of 1:21 P.M. and was reported at 7:04 P.M. The report was provided to the facility at 7:04 P.M. of the following critical laboratory values: Digoxin level of 3.50 nanograms per milliliter (ng/mL) (normal level was 0.8 to 2.0 ng/mL), BUN of 107 mg/dL, chloride of 82 mEq/L, and potassium was 7.0 mEq/L. Review of the laboratory document titled, Fax Report History, for Resident #112 revealed dates and times of laboratory result for BMP, CBC, and Digoxin level reporting. On 04/23/25, there were failed fax transmissions at the times of 3:37 P.M., 4:04 P.M., and 7:02 P.M. On 04/24/25, failed fax transmission times of 1:02 A.M. and at 2:23 A.M. were noted. The facility ultimately received the fax transmission on 04/24/25 at 5:43 A.M. Interview on 05/28/25 at 3:15 P.M. with Medical Director (MD) #350 stated the laboratory company never reported the laboratory values for Resident #112 to the facility by fax and he did not receive notification of the critical laboratory values obtained on 04/23/25 from the laboratory company. Interview on 05/29/25 at 7:05 P.M. with Licensed Practical Nurse (LPN) #263 stated she never received the laboratory values by fax or telephone of Resident #112's critical laboratory values until the laboratory called her on 04/24/25 at 5:43 A.M. LPN #263 verified she never told the on-call physician about Resident #112's critical laboratory values until the resident was not longer in the facility. LPN #263 stated she would have called the on-call physician if the critical laboratory values were reported to the facility. Review of the facility policy titled, Physician, Physician Assistant, Nurse Practitioner, or Clinical Specialist Lab Notification, dated 02/2023, revealed it was the policy of the facility to timely notify the physician, physician assistant, nurse practitioner, or clinical nurse specialists of lab results. This deficiency represents an incidental finding investigated under Master Complaint OH00165855.

Based on record review and staff interviews, the facility failed to notify family/Power of Attorney (POA) of an appointment scheduled for the resident and the facility sent the resident, who has Alzheimer's disease, to the appointment alone. This affected one (Resident #110) of three residents reviewed for appointments. The facility census was 123. Findings include: Record review revealed Resident #110 was admitted to the facility on [DATE]. Diagnoses included vascular dementia with psychotic disturbance and Alzheimer's disease with early onset. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #110 had severe cognition impairment. Resident #110 required supervision assistance from with ambulation. Resident #110 required substantial assistance from staff with toileting and transfers. Review of the hospital's Discharge Instructions dated 07/22/24 revealed an order stating: Follow-up with spine surgery in the clinic. Call to make an appointment. Resident #110 needs to follow with Neurosurgery, Spine Surgery for spine surgery follow up with Physician #500 and contact information including physical address and telephone number. Review of the physician orders and progress notes revealed there was no order or documentation for an appointment on 08/23/24. Review of the Order Listing Report - Appointments, dated 08/22/24 through 10/31/24 revealed no appointments for Resident #110. Review of the Facility Appointment Calendar dated 08/23/24 revealed an appointment at 11:45 A.M. with Physician #500, with a pick-up time of 10:45 A.M. Interview on 10/22/24 at 12:52 A.M. with Administrative Assistant (AA) #330 stated when there was a new admission with an appointment already scheduled, the nurses will put an order in the system, complete a transportation paper and tell the nurse manager. The paper comes to AA #330 to schedule transportation. If the resident has a certain insurance or Medicare, then that will depend on what type of transportation they take. The facility has their own transportation vans and drivers so 90% of the appointments were scheduled to go through the facilities transportation. If the resident uses the facilities transportation, the form was forwarded to the transportation manager to schedule transport. If the appointment conflicts with another transport, they will call and get the appointment rescheduled for when transportation is available. AA #330 confirmed she did not call the family or POA for Resident #110 to inform her of the appointment and transportation on 08/23/24. Interview on 10/22/24 at 3:08 P.M. with Transportation Staff #560 revealed scheduling puts order into system for appointment and transportation pick up and appointment time. An appointment schedule was also placed at the nurse's station at the end of each day. Transportation Staff #560 confirmed she did not call the family or POA for Resident #110 to inform her of the appointment and transportation on 08/23/24. Transportation Staff #560 confirmed Resident #110 was taken to her appointment on 08/23/24 and left in the waiting area alone. Transportation Staff #560 confirmed Resident #110 does have dementia and should not have been left alone, but Resident #110 was not marked as needing an escort to the appointment. Interview on 10/22/24 at 3:38 P.M. with the Director of Nursing (DON) confirmed Resident #110 admitted on [DATE] with an order on her discharge paperwork to schedule an appointment with Physician #500 as soon as possible. The DON confirmed the facility made the appointment and should have notified the POA/family. The DON stated there was no policy for scheduling of appointments or notification of appointments. This deficiency represents non-compliance investigated under Complaint Number OH00157702.

Based on record review, observations, interviews, review of the information from the National Pressure Ulcer Advisory Panel (NPUAP), and policy review, the facility failed to ensure timely treatments and interventions were done for a resident's pressure ulcer. This resulted in actual harm when Resident #95's pressure ulcer to his left heel deteriorated in condition and developed osteomyelitis from the delay in treatment. This affected one (Resident #95) of two residents reviewed for pressure wounds. The facility census was 112. Findings include: Review of the medical record for Resident #95 revealed an admitted [DATE]. Diagnoses included acute kidney failure, peripheral vascular disease, and pressure ulcer of sacral region, unspecified stage. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #95 had moderate cognitive impairment. Resident #95 was dependent on staff for toileting, bathing and transfers and required substantial assistance from staff for bed mobility. Resident #95 did not have any rejection of care during the look-back period of the assessment. Review of the plan of care created on 05/21/24 revealed Resident #95 had a pressure ulcer to the left heel related to recent medical diagnoses and noncompliance with off-loading area. Intervention included wearing off-loading boots as tolerated. Review of the Skin Observation Tool assessment dated [DATE] revealed Resident #95 had a wound to the left heel, and it was a deep tissue injury (DTI) (purple or maroon area of discolored intact skin due to damage of underlying soft tissue). There were no measurements present. Review of the Treatment Administration Record (TAR) for May 2024 revealed on 05/17/24, skin preparation to the left heel was applied once daily through 05/21/24. Review of the [NAME] Wound Evaluation and Management Summary dated 05/21/24 revealed Resident #95 had a pressure area to the left heel, and it was an unstageable (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar) due to necrosis measuring 3.0 centimeter (cm) in length by 3.0 cm in width by 0.1 cm in depth. Physician #213 ordered treatment changed to Alginate calcium w/silver apply once daily, foam silicone bordered dressing and apply once daily for 30 days. The recommendation was to float heels in bed and wear pressure off-loading boots. Review of the TAR revealed there was no treatment applied to the wound on 05/22/24 and the new treatment was not implemented until two days later on 05/23/24. This treatment remained in place until 06/19/24 and there was one missed treatment to the left heel on 06/03/24. Review of the physician order dated 06/14/24 revealed an order for two-view x-ray of the left heel due to an odor on the left heel. Review of the progress note dated 06/14/24 at 11:49 A.M. revealed Resident #95 had a positive x-ray confirming the resident had osteomyelitis in the left heel. Review of the radiology results report dated 06/14/24 revealed the conclusion of the x-ray was suspect posterior calcaneal osteomyelitis. Review of the [NAME] Wound Evaluation and Management Summary dated 06/18/24 revealed a pressure area to left heel was presenting at a stage IV measuring 4.0 cm in length by 4.0 cm wide by 0.2 cm in depth. Physician #213 ordered treatment changed to cleanse with normal saline, dampen gauze with 0.25% Dakin's solution, then pack wound with Dakin's dampened gauze. Cover with abdominal pad and wrap with kerlix every day. Further review of the TAR and physician orders revealed the treatment was not changed until two days later on 06/20/24. On 06/28/24, there was an order for Doxycycline Monohydrate (antibiotic) 100 milligrams (mg) capsule, administer one capsule by mouth two times a day for osteomyelitis until 07/28/24. This order was 14 days after the initial diagnosis of osteomyelitis on 06/14/24. Review of the TAR for July 2024 revealed there were two missed treatments to the left heel on 07/05/24 and 07/07/24. The treatment to the left heel was to cleanse with normal saline, dampen gauze with 0.25% Dakin's solution, then pack wound with Dakin's dampened gauze. Cover with abdominal pad and wrap with kerlix every day was not documented as being done. Review of the Skin Observation Tool assessment dated [DATE] revealed the wound to left heel presented as a stage IV pressure wound full thickness wound and measured 3.5 cm in depth by 3.0 cm length by 0.2 cm in depth. The surface area was 10.50 cm. Observation and interview on 07/15/24 at 10:27 A.M. revealed Resident #95 was lying in bed with bilateral heels laying directly on his mattress and the heels were not floating off the mattress and he was not wearing any pressure off-loading boots. There was a low air loss mattress in place. The left heel wound had gauze wrap present. Observations on 07/15/24 at 1:39 P.M. and 3:17 P.M. and on 07/16/24 at 9:00 A.M., 12:22 P.M., and 3:46 P.M. revealed Resident #95 continued to lay in bed with bilateral heels laying on the mattress and the heels were not floating off the mattress and he was not wearing any pressure off-loading boots. Interview on 07/17/24 at 3:14 P.M. with Assistant Director of Nursing (ADON) #22 confirmed there was not a physician order to float bilateral heels in bed or for pressure off-loading boots as noted on the [NAME] Wound Evaluation and Management Summary dated 05/21/24. ADON #22 confirmed there was no documentation that Resident #95's heels have been floated or that pressure off-loading boots had been implemented. ADON #22 confirmed Resident #95's treatment of osteomyelitis which was diagnosed on [DATE] was not implemented until 06/28/24. ADON #22 stated the facility was behind on reviewing the wounds' recommendations and transcribing accordingly. Telephone interview on 07/17/24 at 3:39 P.M. with Physician #213 confirmed Resident #95 has a stage IV pressure area to the left heel. Physician #213 confirmed Resident #95 had arterial doppler in November 2023 and the vascular studies were normal. Physician #213 stated she was surprised Resident #95 ended up with a stage IV wound and osteomyelitis in the left heel. Physician #213 confirmed Resident #95 was to wear pressure off-loading boots. Review of the Wound Treatment Management policy dated 11/23/22 revealed it is the policy of the facility to promote wound healing for various types of wounds, and to provide evidence-based treatments in accordance with current standards of practice and physician orders. Review of the information from the NPUAP revealed a deep tissue pressure injury is intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage Three or Stage Four). Do not use deep tissue pressure injury to describe vascular, traumatic, neuropathic, or dermatologic conditions. Further review of the NPUAP revealed staff should assess pressure points, such as the sacrum, coccyx, buttocks, heels, ischium, trochanters, elbows and beneath medical devices, implement interventions to ensure that the heels are free from the bed and use heel offloading devices or polyurethane foam dressings on individuals at high-risk for heel ulcers.

Based on record review, policy review, and staff interview the facility failed to ensure the comprehensive care plan included a vision and hearing plan for Resident #107 and a indwelling urinary catheter for Resident #95. This affected two (Resident #95 and #107) of six residents reviewed for care plans. The facility census was 112. Findings include: 1. Review of medical record for Resident #107 revealed admitted [DATE]. Diagnoses included macular degeneration of the right eye and hearing loss, unspecified ear. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #107 had impaired cognition. His vision was documented as impaired, and his hearing was documented as adequate. Review of Resident #107's care plan revealed there was no documentation of a hearing or vision concern. Interview on 07/15/24 at 11:44 A.M. with Resident #107 revealed he did have an issue with his hearing, and he was blind in his right eye. Interview on 07/18/24 at 2:08 P.M. with MDS Nurse #214 verified there was no care plan in place for Resident #107's hearing and vision concern. 48570 2. Review of the medical record for Resident #95 revealed an admitted [DATE]. Diagnosis included benign prostatic hyperplasia with lower urinary tract symptoms. Review of the physician orders for Resident #95's indwelling urinary catheter revealed an order dated 01/21/24 for a privacy bag at all times every shift for dignity, irrigate with 60 cubic centimeters (cc) of normal saline (NS) for leaking or non-functioning every 12 hours as needed, may change as needed when unable to irrigate every 12 hours as needed for dysuria, change collection bag with sediment or as needed every shift. An order dated 03/01/24 to change the urine collection bag every two months on day shift An order dated 03/14/24 may use leg bag when out of bed as tolerated every shift. An order dated 05/01/24 for a catheter strap to leg as tolerated every shift. Review of Resident #95's care plan revealed no documentation on the resident's indwelling urinary catheter. Interview on 07/17/24 at 3:14 P.M. with Assistant Director of Nursing (ADON) #1 confirmed Resident #95 had a indwelling urinary catheter and verified Resident #95's plan of care did not include the care and services of the indwelling urinary catheter. Review of the facility policy titled Comprehensive Care Plan dated 10/24/22 revealed the facility would develop a comprehensive and person-centered care plan for each resident that included measurable objectives and time frames.

Based on record review, staff interview, and policy review, the facility failed to ensure fall interventions were timely added to the care plan. This affected one (#66) of five residents reviewed for falls. The facility census was 112. Findings include: Review of the medical record for Resident #66 revealed an admitted [DATE]. Diagnoses included dementia, congestive heart failure, anxiety disease, chronic kidney disease, delusional disorders, and osteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 had severely impaired cognition. Review of the interdisciplinary team (IDT) note dated 07/10/24 revealed Resident #66 had a fall on 06/17/24 in her room and was found in front of her wheelchair. The new intervention was to place Dycem in the wheelchair. The IDT note dated 07/11/24 revealed Resident #66 had a fall on 06/21/24 in her room and was found near her bed. The new intervention was a fall mat to the side of the bed. Review of the plan of care revised on 07/15/24 revealed Resident #66 was at risk for falls and injury related to confusion, incontinence, psychoactive drug use, anxiety, insomnia, impaired mobility, gout, peripheral vascular disease, and neuropathy. Interventions included fall mat to side of bed while in bed, which was initiated on 06/21/24 and added to the care plan on 07/16/24, low bed, place Dycem to wheelchair, which was initiated on 06/17/24 and added to the care plan on 07/10/24, ensure appropriate footwear when out of bed, and make sure floor/path is clutter free and properly lighted. Interview on 07/18/24 at 1:34 P.M. with the Director of Nursing (DON) confirmed the new fall interventions for Resident #66 were not added to Resident #66's care plan timely. Review of the facility policy titled Fall Prevention Program, revised 07/17/24, revealed the facility would review the resident's care plan and update as indicated.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure the physician treatment orders were followed and implemented timely for the residents. This affected two (Residents #60 and #108) of two residents reviewed for un-pressure related skin conditions. The facility census was 112. Findings include: 1. Review of the medical record for Resident #60 revealed admitted [DATE]. Diagnoses included encounter for orthopedic aftercare, infection and inflammatory reaction due to internal joint prosthesis and vascular dementia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 had significantly impaired cognition. Review of the care plan revealed Resident #60 had skin breakdown due to right hip surgical incision. Interventions included to administer treatments as ordered and for enhanced barrier precautions. Review of the physician orders dated 06/18/24 revealed an order to cleanse the right hip surgical site with normal saline, pat dry and apply dry dressing daily and as needed. Observation and interview on 07/18/24 at 11:52 A.M. with Licensed Practical Nurse (LPN) #107 and Infection Control Preventionist #3 revealed they were going to complete a wound treatment for Resident #60. Upon exposing the right hip of Resident #60, the dry dressing was dated 07/15/24. LPN #107 verified this date was three days old and LPN #107 verified the physician order was to change the dressing daily. 48570 2. Review of the medical record for Resident #108 revealed an admitted [DATE] with diagnoses of hypertensive heart disease without heart failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #108 had severe cognitive impairment. Review of [NAME] Wound Initial Wound Evaluation and Management summary dated 07/16/24 revealed Resident #108 had a wound of the left, lower, lateral shin due to infection and a wound of the right, upper, medial calf due to infection. The resident developed cellulitis, has chronic issues with lower extremity (LE) edema, and developed multiple blisters. The dressing treatment plan was to apply Alginate calcium with silver apply once daily for 30 days and apply gauze roll (kerlix) 4.5 inch, apply once daily for 30 days. Review of Resident #108's physician orders for July 2024 revealed there were no treatment orders initiated to apply calcium alginate with silver, apply once daily for 30 days and to apply kerlix daily for 30 days. Interview on 07/18/24 at 10:00 A.M. with Assistant Director of Nursing (ADON) #1 confirmed the wound rounds completed on 07/16/24 had physician orders to change the treatments to resident's right lower extremity and left lower extremity and confirmed the physician orders were not initiated for Resident #108.

Based on record review, observations, staff interview, and policy review, the facility failed to ensure physician orders for oxygen administration were followed. This affected one (Resident #7) of one resident reviewed for respiratory care. The facility census was 112. Findings include: Review of the medical record of Resident #7 revealed an admitted [DATE]. Diagnoses included acute and chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease (COPD). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact, was dependent on staff assistance for activities of daily living, and utilized oxygen therapy. Review of the care plan revealed Resident #7 has oxygen therapy related to COPD, chronic respiratory failure with hypoxia, obstructive sleep apnea, congestive heart failure, and morbid obesity. Intervention included providing oxygen as ordered. Review of Resident #7's physician order dated 07/18/23 revealed an order to administer oxygen at two to three liters per minute per nasal cannula to keep saturations greater than 90% every shift for shortness of breath (SOB) related to COPD. Observation on 07/15/24 at 2:11 P.M. revealed Resident #7's oxygen level was set on 3.5 to four liters. Subsequent observation on 07/16/24 at 3:14 P.M. revealed Resident #7's oxygen level set to four liters. Interview on 07/16/24 at 3:15 P.M. with Assistant Director of Nursing (ADON) #1 confirmed Resident #7's oxygen was set at four liters per minute via nasal cannula and should not be set that high. ADON #1 confirmed Resident #7's oxygen should be set at two to three liters per minute per nasal cannula. Review of the Oxygen Administration policy dated 10/2010 revealed the purpose is to provide safe oxygen administration and verify that there is a physician's order for the procedure.

Based on record review, resident and staff interviews, and policy review, the facility failed to schedule dental services for teeth extractions per physician orders for a resident. This affected one (Resident# 54) of one resident reviewed for dental services. The facility census was 112. Findings include: Review of the medical record for Resident #54 revealed an admitted [DATE] with diagnoses of major depressive disorder and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 was cognitively intact and required substantial assistance with oral hygiene. Resident #7 did not have broken or loosely fitting full or partial dentures and did not have mouth or facial pain, discomfort or difficulty with chewing. Review of the physician orders dated 12/14/23 revealed an order for Resident #54 to have order to extract broken teeth and root tips. The resident was planned for upper complete denture and lower partial. Resident #54 would like to keep tooth #17 and #22 to #27 for partial support. Please see scheduler to set up appointment. There was an additional order dated 02/21/24 to please contact Cleveland Dental Institute and schedule appointment for Resident #54 to extract broken teeth and root tips and the resident would like to keep tooth #17 and #22 to #27. The physician cleared Resident #54 to have local anesthesia and discontinue when done. Review of the care plan dated 04/08/24 revealed Resident #54 was at risk for oral/dental health problems to rule out partial dentures. Interventions included to coordinate arrangements for dental care, transportation as needed/as ordered and monitor for signs and symptoms of oral/dental problems needing attention: pain (gums, toothache, palate), abscess, debris in mouth, lips cracked or bleeding, teeth missing, loose, broken, eroded, decayed, tongue (black, coated, inflamed, white, smooth), ulcers in mouth, and lesions. Interview on 07/15/24 at 9:50 A.M. with Resident #54 revealed she had broken teeth that needs removed and had a consultation done 02/02/24. Resident #54 stated there had been no follow up since February 2024 and reported she has pain with movement and touching of the areas. Interview on 07/17/24 at 10:40 A.M. with Administrative Assistant/Scheduler (AA/S) #20 confirmed she schedules appointments for the residents. AA/S #20 stated she was not aware an appointment needed scheduled to have Resident #54's teeth extracted. AA/S #20 stated no one gave her the paperwork to schedule the appointment and verified Resident #54 has not been scheduled or sent out to have teeth extracted. Review of the Dental Services policy, undated, revealed routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and care plan.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure proper enhanced barrier precautions (EBP) were followed for Resident #60 and the facility failed to ensure gloves were worn when administering eye drops for Resident #26. The facility census was 112. Findings include: 1. Review of the medical record for Resident #60 revealed admitted [DATE]. Diagnoses included encounter for orthopedic aftercare and infection and inflammatory reaction due to internal joint prosthesis. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 had significantly impaired cognition. Review of the care plan dated 06/27/24 revealed Resident #60 had skin breakdown due to right hip surgical incision. Interventions included to administer treatments as ordered and EBP. Observation on 07/18/24 at 11:51 A.M. revealed there was a sign taped on the door of Resident #60's room which documented EBP were required. This included the need for gloves and gowns for high resident contact. Just inside the room to the right of the doorway was a plastic cabinet with three drawers which contained gloves and disposable yellow gowns. Observation and interview on 07/18/24 at 11:52 A.M. with Licensed Practical Nurse (LPN) #107 and Infection Control Preventionist (ICP) #3 revealed they entered Resident #60's room to complete wound treatment. LPN #107 washed her hands and donned gloves. LPN #107 did not don a gown. LPN #107 proceeded to assist Resident #60 to pull down her pants, unfasten her incontinent product and expose her dressing. After removing the dressing using proper procedure, she provided wound treatment and redressed the wound. During an interview directly following the wound treatment, LPN #107 acknowledged Resident #60 required EBP but denied knowledge of the need for any other Personal Protective Equipment (PPE) except her gloves. Interview on 07/18/24 at 12:23 P.M. with ICP #3 revealed a gown was required during the wound treatment for Resident #60 and verified LPN #107 did not wear a gown to perform wound treatment on Resident #60. Review of the undated facility policy titled Enhanced Barrier Precautions documented it was the policy of the facility to implement EBP for the prevention of transmission of multidrug-resistant organisms. Staff were expected to comply with all designated precautions. 48570 2. Review of the medical record for Resident #26 revealed an admitted [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of the physician orders revealed an order for Artificial Tears one drop in each eye daily. Observation on 07/17/24 at 8:46 A.M. revealed Licensed Practical Nurse (LPN) #110 administered Resident #26's Artificial Tears one drop in each eye without wearing gloves. Interview on 07/17/24 at 8:54 A.M. with LPN #110 confirmed she did not use gloves to administer Resident #26's Artificial Tears one drop in each eye.

Based on record review, staff interview, and policy review, the facility failed to ensure influenza and pneumococcal immunizations were offered to residents. This affected four (#19, #51, #66, and #74) out of five residents reviewed for immunizations. The facility census was 112. Findings include: 1. Review of the medical record for Resident #19 revealed an admitted [DATE]. Diagnoses included other sequela of cerebral infarction and type two diabetes mellitus. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had severely impaired cognition. Further review of the medical record revealed no evidence that the facility offered the pneumococcal immunization or provided education to the resident or resident representative. Interview on 07/18/24 at 1:30 P.M. with the Director of Nursing verified the lack of immunization documentation for Resident #19. 2. Review of the medical record for Resident #51 revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had intact cognition. Further review of the medical record revealed no evidence that the facility offered the pneumococcal immunization or provided education to the resident or resident representative. Interview on 07/18/24 at 1:30 P.M. with the Director of Nursing verified the lack of immunization documentation for Resident #51. 3. Review of the medical record for Resident #66 revealed an admitted [DATE]. Diagnoses included dementia, congestive heart failure, and atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 had severely impaired cognition. Further review of the medical record revealed no evidence that the facility offered the influenza or pneumococcal immunization or provided education to the resident or resident representative. Interview on 07/18/24 at 1:30 P.M. with the Director of Nursing verified the lack of immunization documentation for Resident #66. 4. Review of the medical record for Resident #74 revealed an admitted [DATE]. Diagnoses included congestive heart failure, asthma, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #74 had intact cognition. Further review of the medical record revealed no evidence that the facility offered the influenza or pneumococcal immunization or provided education to the resident or resident representative. Interview on 07/18/24 at 1:30 P.M. with the Director of Nursing verified the lack of immunization documentation for Resident #74. Review of the facility policy titled Influenza Exposure Control, dated 03/01/23, revealed the current season's influenza vaccine would be offered to residents. Review of the facility policy titled Pneumococcal Vaccine, dated 03/02/23, revealed each resident would be offered a pneumococcal immunization unless it is medically contraindicated, or the resident has already been immunized.

Based on record review, staff interview, and policy review, the facility failed to ensure COVID-19 immunizations were offered to residents. This affected three (#19, #66, and #74) out of five residents reviewed for immunizations. The facility census was 112. Findings include: 1. Review of the medical record for Resident #19 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus and hypertensive heart disease with heart failure. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had severely impaired cognition. Further review of the medical record revealed no evidence that the facility offered the COVID-19 vaccine or provided education to the resident or resident representative. Interview on 07/18/24 at 1:30 P.M. with the Director of Nursing verified the lack of immunization documentation for Resident #19. 2. Review of the medical record for Resident #66 revealed an admitted [DATE]. Diagnoses included dementia, congestive heart failure, atrial fibrillation, and pulmonary hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 had severely impaired cognition. Further review of the medical record revealed no evidence that the facility offered the COVID-19 vaccine or provided education to the resident or resident representative. Interview on 07/18/24 at 1:30 P.M. with the Director of Nursing verified the lack of immunization documentation for Resident #66. 3. Review of the medical record for Resident #74 revealed an admitted [DATE]. Diagnoses included congestive heart failure and asthma. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #74 had intact cognition. Further review of the medical record revealed no evidence that the facility offered the COVID-19 vaccine or provided education to the resident or resident representative. Interview on 07/18/24 at 1:30 P.M. with the Director of Nursing verified the lack of immunization documentation for Resident #74. Review of the facility policy titled COVID-19 Vaccination, revised 05/09/23, revealed COVID-19 vaccinations would be offered to residents when available unless medically contraindicated, the resident has already been immunized, or refuses the vaccine.

Based on interview, record review, and policy review, the facility failed to act in a timely manner to protect residents from abuse. This affected one (Resident #10) of five residents reviewed for abuse. The facility census was 102. Findings include: Review of the medical record for Resident #10 revealed an admitted [DATE]. Diagnoses included atherosclerotic heart disease, dysphagia, and the need for assistance with personal care. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition, had no behaviors, did not reject care, and did not wander. Review of the progress note dated 02/24/24 at 6:23 P.M. revealed staff heard screaming from the hallway. Upon entering Resident #10's room, Licensed Practical Nurse (LPN) #122 and State tested Nurse Aide (STNA) #103 observed the resident's daughter forcing food into Resident #10's mouth. The daughter stated she was wiping blood from the resident's mouth. The nurse assessed, but could not locate a source of bleeding. The daughter was observed to be stuffing goldfish crackers into the resident's mouth and trying to give soda to help the resident swallow. The soda was spilling down the resident's chest. Further review of the medical record revealed no documentation of an incident between Resident #10 and the resident's daughter on 03/01/24. During an interview on 03/18/24 at 2:50 P.M., STNA #131 stated she had not been present when the incident on 02/24/24 occurred, however, on 03/01/2025 around 5:30 P.M., she witnessed Resident #10's daughter trying to force noodles into the back of the resident's mouth with a butter knife. STNA #131 stated she reported the observation to the nurse. STNA #131 and the nurse returned to the resident 's room and overheard Resident #10's daughter screaming at the resident and crying hysterically. STNA #10 verified staff did not intervene or ask the resident's daughter to leave for either incident. During an interview on 03/19/24 at 4:51 P.M., LPN #106 verified on 02/24/24, an aide saw and reported Resident #10's daughter was forcibly shoving food into the resident's mouth and the facility took no action at the time to remove the family member from the resident's room. LPN #106 stated a second incident happened three weeks ago, on 03/01/24 at dinnertime when Resident #10's daughter had a butter knife and was trying to push noodles down Resident #10's throat. LPN #106 went to the room with STNA #131 and heard Resident #10's daughter scream at the resident, Why don't you just die? repeatedly. LPN #106 stated she made a voice recording of this incident and and played it for supervisor, Unit Manager (UM) #25. LPN #106 stated she entered the room and asked if everything was ok. LPN #106 stated she confronted the family member about her behavior, told the family member the behavior was unacceptable, but left the room with the family member still seated at the resident's bedside. During an interview on 03/19/24 at 8:56 A.M., UM #25 stated on 03/01/24 she was working an assignment on the evening shift. STNA #131 reported shortly after dinner she witnessed Resident #10's daughter trying to force the resident to eat and put a butter knife in the patient's mouth. About 20 minutes later, LPN #106 reported something about the knife and being held to Resident #10's throat. UM #25 stated she was busy passing medications and did not go to check on the patient or intervene in any way except to text the Director of Nursing (DON), who had already left for the evening. The DON texted back she was already aware and had contacted the Executive Director (ED). UM #25 stated she did not call campus security to have the family member removed because she did not think it rose to that level. UM #25 stated at the time it was reported to her, the incident was over, and she was not concerned about the resident's safety at that time. The aide reported the incident on her way to take trash out after dinner was already over. UM #25 stated she walked by the resident's room and peaked in around 6:00 P.M. and Resident #10 was in her room alone. It would have been handled differently had it been reported staff was treating a patient that way. UM #25 stated she did not feel the need to intervene because the staff made conflicting statements about what had happened and UM #25 was too busy to go because she was involved with a fall at the time. UM #25 stated she was never questioned by management about the incident and verified she did not document the incident. During interviews on 03/19/24 at 9:48 A.M., the Administrator and DON each stated they were unaware of any incident of alleged abuse with Resident #10 on 03/01/24. The Administrator stated he had completed an investigation and filed a Self-Reported Incident (SRI) involving Resident #10 and her daughter for alleged physical abuse on 03/08/24. The DON stated she did not believe Resident#10's daughter intended any harm to Resident #10 and stated staff were blowing things out of proportion because they did not like how the daughter interacted with the resident. The DON and Administrator agreed that if a staff member had overheard anyone making a statement, Why don't you just die? to a resident, that would have been considered verbal abuse. During an interview on 03/19/24 at 1:57 P.M., LPN #106 verified there was no progress note in Resident #10's medical record regarding the incident on 03/01/24. Review of policy titled, Abuse, Neglect, And Exploitation, dated 10/24/22 revealed staff were educated to identify possible indicators of abuse including staff reports of abuse, physical injury to a resident from an unknown source, verbal abuse of a resident overheard, and physical abuse of a resident observed. The facility made efforts to ensure all residents were protected from abuse by responding immediately to protect the alleged victim from additional abuse. This deficiency represents non-compliance investigated under Complaint Number OH00152007.

Based on review of the medical record, staff interviews, and policy review, the facility staff failed to report allegations of abuse in a timely manner. This affected one (Resident #10) of five residents reviewed for abuse. The facility census was 102. Findings include: Review of the medical record for Resident #10 revealed an admitted [DATE]. Diagnoses included atherosclerotic heart disease, dysphagia, and the need for assistance with personal care. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition, had no behaviors, did not reject care, and did not wander. Review of the progress note dated 02/24/24 at 6:23 P.M. revealed staff heard screaming from the hallway. Upon entering Resident #10's room, Licensed Practical Nurse (LPN) #122 and State tested Nurse Aide (STNA) #103 observed the resident's daughter forcing food into Resident #10's mouth. The daughter stated she was wiping blood from the resident's mouth. The nurse assessed, but could not locate a source of bleeding. The daughter was observed to be stuffing goldfish crackers into the resident's mouth and trying to give soda to help the resident swallow. The soda was spilling down the resident's chest. Further review of the medical record revealed no documentation of an incident between Resident #10 and the resident's daughter on 03/01/24. During an interview on 03/18/24 at 2:50 P.M., STNA #131 stated she had not been present when the incident on 02/24/24 occurred, however, on 03/01/2025 around 5:30 P.M., she witnessed Resident #10's daughter trying to force noodles into the back of the resident's mouth with a butter knife. STNA #131 stated she reported the observation to the nurse. STNA #131 and the nurse returned to the resident 's room and overheard Resident #10's daughter screaming at the resident and crying hysterically. STNA #10 verified staff did not intervene or ask the resident's daughter to leave for either incident. During an interview on 03/19/24 at 4:51 P.M., LPN #106 verified on 02/24/24, an aide saw and reported Resident #10's daughter was forcibly shoving food into the resident's mouth and the facility took no action at the time to remove the family member from the resident's room. LPN #106 stated a second incident happened three weeks ago, on 03/01/24 at dinnertime when Resident #10's daughter had a butter knife and was trying to push noodles down Resident #10's throat. LPN #106 went to the room with STNA #131 and heard Resident #10's daughter scream at the resident, Why don't you just die? repeatedly. LPN #106 stated she made a voice recording of this incident and and played it for supervisor, Unit Manager (UM) #25. LPN #106 stated she entered the room and asked if everything was ok. LPN #106 stated she confronted the family member about her behavior, told the family member the behavior was unacceptable, but left the room with the family member still seated at the resident's bedside. During an interview on 03/19/24 at 8:56 A.M., UM #25 stated on 03/01/24 she was working an assignment on the evening shift. STNA #131 reported shortly after dinner she witnessed Resident #10's daughter trying to force the resident to eat and put a butter knife in the patient's mouth. About 20 minutes later, LPN #106 reported something about the knife and being held to Resident #10's throat. UM #25 stated she was busy passing medications and did not go to check on the patient or intervene in any way except to text the Director of Nursing (DON), who had already left for the evening. The DON texted back she was already aware and had contacted the Executive Director (ED). UM #25 stated she did not call campus security to have the family member removed because she did not think it rose to that level. UM #25 stated at the time it was reported to her, the incident was over, and she was not concerned about the resident's safety at that time. The aide reported the incident on her way to take trash out after dinner was already over. UM #25 stated she walked by the resident's room and peaked in around 6:00 P.M. and Resident #10 was in her room alone. It would have been handled differently had it been reported staff was treating a patient that way. UM #25 stated she did not feel the need to intervene because the staff made conflicting statements about what had happened and UM #25 was too busy to go because she was involved with a fall at the time. UM #25 stated she was never questioned by management about the incident and verified she did not document the incident. During interviews on 03/19/24 at 9:48 A.M., the Administrator and DON each stated they were unaware of any incident of alleged abuse with Resident #10 on 03/01/24. The DON stated she did not receive any written witness statements from staff regarding an incident of alleged abuse on 03/01/24. During an interview on 03/19/24 at 1:51 P.M., the Executive Director stated he was not notified and was unaware of an incident of alleged abuse which occurred on 03/01/24 involving Resident #10 and her daughter. During an interview on 03/19/24 at 1:57 P.M. LPN #106 stated UM #25 told her, STNA #131, and LPN #140 to write statements before leaving and place them under the door to the DON's office. LPN #106 stated she documented the incident in a progress note in Resident #10's medical record. LPN #106 verified there was no progress note in Resident #10's medical record regarding the incident on 03/01/24. Review of Self-Reported Incidents (SRI) revealed no SRI completed for incidents between Resident #10 and the resident's daughter on 02/24/24 and 03/01/24. Review of policy titled, Abuse, Neglect, And Exploitation, dated 10/24/2022 revealed all allegations involving abuse were reported to the administrator within two hours after the allegation was made. This deficiency represents non-compliance investigated under Complaint Number OH00152007.

Based on medical record review, staff interviews, and policy review, the facility failed to investigate allegations of abuse. This affected one (Resident #10) of five residents reviewed for abuse. The facility census was 102. Findings include: Review of the medical record for Resident #10 revealed an admitted [DATE]. Diagnoses included atherosclerotic heart disease, dysphagia, and the need for assistance with personal care. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition, had no behaviors, did not reject care, and did not wander. Review of the progress note dated 02/24/24 at 6:23 P.M. revealed staff heard screaming from the hallway. Upon entering Resident #10's room, Licensed Practical Nurse (LPN) #122 and State tested Nurse Aide (STNA) #103 observed the resident's daughter forcing food into Resident #10's mouth. The daughter stated she was wiping blood from the resident's mouth. The nurse assessed, but could not locate a source of bleeding. The daughter was observed to be stuffing goldfish crackers into the resident's mouth and trying to give soda to help the resident swallow. The soda was spilling down the resident's chest. Further review of the medical record revealed no documentation of an incident between Resident #10 and the resident's daughter on 03/01/24. During an interview on 03/18/24 at 2:50 P.M., STNA #131 stated she had not been present when the incident on 02/24/24 occurred, however, on 03/01/2025 around 5:30 P.M., she witnessed Resident #10's daughter trying to force noodles into the back of the resident's mouth with a butter knife. STNA #131 stated she reported the observation to the nurse. STNA #131 and the nurse returned to the resident 's room and overheard Resident #10's daughter screaming at the resident and crying hysterically. STNA #10 verified staff did not intervene or ask the resident's daughter to leave for either incident. During an interview on 03/19/24 at 4:51 P.M., LPN #106 verified on 02/24/24, an aide saw and reported Resident #10's daughter was forcibly shoving food into the resident's mouth and the facility took no action at the time to remove the family member from the resident's room. LPN #106 stated a second incident happened three weeks ago, on 03/01/24 at dinnertime when Resident #10's daughter had a butter knife and was trying to push noodles down Resident #10's throat. LPN #106 went to the room with STNA #131 and heard Resident #10's daughter scream at the resident, Why don't you just die? repeatedly. LPN #106 stated she made a voice recording of this incident and and played it for supervisor, Unit Manager (UM) #25. LPN #106 stated she entered the room and asked if everything was ok. LPN #106 stated she confronted the family member about her behavior, told the family member the behavior was unacceptable, but left the room with the family member still seated at the resident's bedside. During an interview on 03/19/24 at 8:56 A.M., UM #25 stated on 03/01/24 she was working an assignment on the evening shift. STNA #131 reported shortly after dinner she witnessed Resident #10's daughter trying to force the resident to eat and put a butter knife in the patient's mouth. About 20 minutes later, LPN #106 reported something about the knife and being held to Resident #10's throat. UM #25 stated she was busy passing medications and did not go to check on the patient or intervene in any way except to text the Director of Nursing (DON), who had already left for the evening. The DON texted back she was already aware and had contacted the Executive Director (ED). UM #25 stated she did not call campus security to have the family member removed because she did not think it rose to that level. UM #25 stated at the time it was reported to her, the incident was over, and she was not concerned about the resident's safety at that time. The aide reported the incident on her way to take trash out after dinner was already over. UM #25 stated she walked by the resident's room and peaked in around 6:00 P.M. and Resident #10 was in her room alone. It would have been handled differently had it been reported staff was treating a patient that way. UM #25 stated she did not feel the need to intervene because the staff made conflicting statements about what had happened and UM #25 was too busy to go because she was involved with a fall at the time. UM #25 stated she was never questioned by management about the incident and verified she did not document the incident. During interviews on 03/19/24 at 9:48 A.M., the Administrator and DON each stated they were unaware of any incident of alleged abuse with Resident #10 on 03/01/24. The DON stated she did not receive any written witness statements from staff regarding an incident of alleged abuse on 03/01/24. During an interview on 03/19/24 at 1:51 P.M., the Executive Director stated he was not notified and was unaware of an incident of alleged abuse which occurred on 03/01/24 involving Resident #10 and her daughter. During an interview on 03/19/24 at 1:57 P.M. LPN #106 stated UM #25 told her, STNA #131, and LPN #140 to write statements before leaving and place them under the door to the DON's office. LPN #106 stated she documented the incident in a progress note in Resident #10's medical record. LPN #106 verified there was no progress note in Resident #10's medical record regarding the incident on 03/01/24. During interviews on 03/20/24 at 10:10 A.M., the Administrator and DON stated they could not investigate allegations of abuse if staff did not report allegations of abuse to them. When asked, the DON confirmed nursing management were responsible to review progress notes routinely. The DON confirmed the nursing progress note on 02/24/24, which documented Resident #10 was heard screaming, staff witnessed food being forced into Resident #10's mouth, and there was bleeding from an injury of unknown source, contained indications of potential physical abuse that was never investigated. Review of Self-Reported Incidents (SRI) revealed no SRI completed for an incident between Resident #10 and the resident's daughter on 02/24/24 and 03/01/24 indicating no investigations were completed. Review of the policy titled, Abuse, Neglect, And Exploitation, dated 10/24/22 revealed staff were educated to identify different types of abuse and possible indictors of abuse included the physical injury of a resident from an unknown source, verbal abuse of a resident overhead, and physical abuse of a resident observed. All allegations involving abuse were immediately investigated to determine if abuse had occurred, to what extent abuse had occurred, and why abuse had occurred. This deficiency represents non-compliance investigated under Complaint Number OH00152007.

Based on medical record review, observations, staff interviews and review of facility policy, the facility failed to ensure interventions and treatment orders were in place for a resident admitted to the facility with a stage three pressure ulcer to the coccyx. This resulted in the Actual Harm when Resident #10's stage three pressure ulcer, present upon admission, did not receive timely treatment and there was deterioration of the pressure ulcer to a stage four (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer. Additionally, the facility also failed to ensure skin assessments were completed as ordered for Resident #14 who was at risk for pressure ulcer development and who developed an unavoidable pressure ulcer, this placed the resident at potential risk for more than minimal harm for Resident #14. This affected two (#10 and #14) of four residents reviewed for skin breakdown. The facility census was 113. Findings included: 1. Review of medical record for Resident #10 revealed an admitted [DATE]. Diagnoses include right tibia fracture, diabetes mellitus type two, colostomy, reflux, depression, anxiety and alcohol induced pancreatitis. Review of Resident #10's care plan revealed the resident had a pressure ulcer to the sacrum. The care plan was initiated on 09/28/23 with interventions which included to assess/monitor/record wound healing frequency; measure length, width and depth when possible; assess the wound perimeter, wound bed and healing process; report improvements and declines to the physician; and encourage frequent repositioning and encouragement to turn side to side in bed when tolerated. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10's Brief Interview for Mental Status (BIMS) score was 15 out 15 indicating intact cognition. Resident #10 was independent with eating, dependent for toileting, and transfers were not attempted. Resident #10 had an indwelling catheter and ostomy present. Resident #10 had a stage three pressure ulcer present upon admission. Review of the admission assessment/orders for Resident #10 revealed the resident had a documented stage three (full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon or muscle are not exposed) pressure ulcer. On 09/27/23, the area measured 4.0 centimeters (cm) by (x) 3.5 cm x 0.5 cm. Wound surface area was 14 cm. The admission wound care order was to apply Vashe (wound cleanser) moistened gauze and border foam dressing to change daily and as needed. Review of Resident #10's physician orders revealed there were no admission orders entered for the treatment of a stage three pressure ulcer. Review of the admission skin assessment dated [DATE] revealed an open wound was documented to the coccyx. There was no identification, or measurements of the wound. Review of the progress notes for Resident #10 revealed no documentation the physician was contacted for treatment orders for an open wound to the coccyx. Review of Resident #10's September 2023 Treatment Administration Record (TAR) revealed there was no documentation or treatment for coccyx wound care. Review of Resident #10's skin assessment dated [DATE] revealed documentation of a coccyx wound was described as an unstageable pressure wound. Peri wound noted with intact edges, moderate serosanguinous drainage noted with foul smelling odor, wound bed red and moist. The physician was notified, and a new treatment order was obtained. Review of Resident #10's physician orders dated 10/02/23 revealed an order to cleans the coccyx with wound cleanser, pack with calcium alginate (wound), then cover with xeroform then apply foam dressing twice daily and as needed. Review of Resident #10's October 2023 TAR revealed there was no documentation for coccyx wound care until 10/02/23 on the night shift. Review of Resident #10's wound physician notes dated 10/03/23 documented coccyx wound to be a stage four (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer. Measurements were 5.0 cm x 4 cm x 0.5 cm. Wound surface area was 20.0 cm. with 30 percent (%) slough (nonviable tissue). Observation of Resident #10's coccyx dressing change with Licensed Practical Nurse (LPN) #42 on 10/11/23 at 12:33 P.M. revealed wound care was completed as ordered and per standards of care. Resident #10's old dressing was removed from the coccyx which revealed drainage was minimal with no signs of infection, no odor present. Resident #10's coccyx wound base appeared beefy red, and wound perimeters were intact without concern for infection. Resident #10 denied pain when asked. The area was described as a healing stage four pressure ulcer. Interview on 10/16/23 at 1:44 P.M. with the Director of Nursing (DON) revealed Resident #10's admitting nurse was a Licensed Practical Nurse (LPN) who cannot stage a wound. The DON acknowledged Assistant Director of Nursing (ADON) #09 and weekend nurse managers were each Registered Nurses. The DON verified measurements were not taken of the coccyx wound upon admission and the wound treatment admission orders were not initiated as ordered and caused a delay in the treatment of a stage three pressure injury. The DON confirmed Resident #10's coccyx pressure ulcer deteriorated from a stage three to a stage four. 2. Review of medical record for Resident #14 revealed an admitted [DATE] and admitted to hospice on 09/01/23. Diagnoses include vertebrogenic low back pain, second lumbar and sacrum fracture, anxiety, delusions, anemia and scoliosis. Resident #14 was receiving hospice services. Review of the significant change MDS assessment dated [DATE] revealed Resident #14 had a BIMS score of five out of 15 which indicated significant cognitive impairment. Resident #14 required extensive two-person assistance for bed mobility, transfers, toileting and one person assistance for eating. Resident #14 had no pressure ulcers documented. Review of Resident #14's skin assessment dated [DATE] revealed the resident's skin was intact. There was no further skin assessment until 09/12/23. Review of Resident #14's September 2023 TAR revealed an order to complete a head-to-toe assessment and note any current and new area under skin observation assessment. The start date was 08/05/23; however, there was no documentation of completion of a skin assessment until 09/20/23. Review of Resident #14's Wound Physician note dated 09/12/23 revealed documentation of a pressure ulcer to the coccyx. The area measured 1.7 cm x 1.9 x 0.1 cm. Treatment was collagen sheet daily cover with gauze island with foam border. Review of the September 2023 TAR revealed an order to wash coccyx area and pat dry, cover with collagen and cover with gauze island with border dressing daily with a start date of 09/17/23. Review of Resident #14's Wound Physician note dated 09/19/23 revealed documentation of a pressure ulcer to the coccyx. The area measured 2.0 cm x 1.5 x 0.1 cm. Improved as evidenced by a 7.1 % decrease in surface size. No change in treatment. Interview on 10/16/23 at 1:44 P.M. with the DON verified skin assessments had not been done weekly or as ordered for Resident #14. The DON confirmed Resident #14 was at risk for pressure ulcer development and weekly skin assessments should have been done/documented for the resident. The DON shared a new position for a treatment nurse had recently been filled and an admission nurse position had recently been approved and was hopeful this would allow the floor nurses to have more time to ensure assessments were provided as ordered. Review of the facility policy titled Pressure Ulcer/Skin Breakdown last revised 04/2018 revealed the nurse shall describe and document a full assessment of pressure sore including location, stage, length, width, depth and presence of exudate of necrotic tissue. This deficiency represents non-compliance investigated under Complaint Number OH00147182.

Based on record review and staff interview, the facility failed to ensure a residents colostomy care was completed as ordered. This affected one (#10) of three residents reviewed. The facility census was 113. Findings include: Review of medical record for Resident #10 revealed admitted [DATE]. Diagnoses include right tibia fracture, diabetes mellitus type two, colostomy, reflux, depression, anxiety and alcohol induced pancreatitis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had a a Brief Interview Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. Resident #10 was independent for eating, dependent for toileting, transfers were not attempted. Documentation revealed Resident #10 had an indwelling catheter and ostomy present. Record review of the physician orders revealed orders to apply skin barrier to surrounding skin as a protectant with no start date. A second order to gently clean the stoma with soap and water and to change pouching system every three to seven days and as needed also with no start date. Review of the October 2023 Treatment Administration Record (TAR) revealed there was an X in each daily box for the order to apply skin barrier to surrounding skin as a protectant and order to gently clean the stoma with soap and water and to change pouching system every three to seven days and as needed. Further record review for Resident #10 revealed there was no documentation regarding colostomy care. Interview on 10/16/23 at 1:44 P.M. with the Director of Nursing (DON) revealed she was unable to explain why there was an X marked daily on Resident #10's TAR, but it appeared to be a technical error. The DON added Resident #10 had excessive output in the colostomy and noted the facility had to order extra supplies to ensure supplies were available. The DON believed the orders had been followed but verified she was unable to provide the documentation. This deficiency represents non-compliance investigated under Complaint Number OH00147182.

Based on medical record review, observations, interview with staff, residents and family, review of hospital records, review of the facility's Self-Reported Incidents (SRI), review of staff statements, review of facility maps, review of a weather report, and review of facility policy, the facility failed to accurately assess and develop a care plan regarding the cognitive status, wandering or elopement risk factors, and level of supervision for Resident #85, resulting in the resident eloping from the facility without staff knowledge. This resulted in Immediate Jeopardy with the potential for serious life-threatening harm, injuries, and/or death on [DATE] at approximately 6:15 P.M. when Resident #85 eloped from the facility without staff knowledge. State tested Nurse Aide (STNA) #500 found Resident #85 lying in the middle of the facility's road by the parking lot at approximately 6:59 P.M. Resident #85 was taken to the hospital for a superficial skin tear on his right elbow. Staff were unaware Resident #85 was gone until STNA #500 brought the resident back into the facility. Additionally, the facility failed to update their elopement binders to include Resident #85's information following his elopement and failed to conduct a thorough investigation of Resident #85's elopement to prevent the same action, situation, and/or practice from occurring in the future. This affected one (#85) out of four residents reviewed for elopements. The facility's census was 129. On [DATE] at 10:32 A.M., the Administrator was notified Immediate Jeopardy began on [DATE] at approximately 6:15 P.M. when Resident #85 eloped from the facility without staff knowledge. STNA #500 found Resident #85 around 6:59 P.M. lying by his wheelchair in the middle of the facility road by the parking lot. The temperature was 19 degrees Fahrenheit (F), and the ground was snow covered. Resident #85 did not have a coat or shoes on and was shivering. Resident #85 was taken to the hospital for evaluation and treatment, including the treatment of a superficial skin tear on his right elbow. Resident #85 returned to the facility on [DATE]. Agency Licensed Practical Nurse (LPN) #511 reported she was assigned to care for Resident #85 on the evening of [DATE]. When Agency LPN #511 arrived for her shift on [DATE] at approximately 6:15 P.M., she heard a bed or chair alarm and told an unknown STNA to investigate where the alarm was coming from. Agency LPN #511 and the unknown STNA investigated resident rooms and found nothing out of the ordinary and the alarm stopped, so they stopped looking for anything suspicious. Agency LPN #511 reported they did not check exterior doors because she was adamant the alarm was a bed or chair alarm, even though she had knowledge the facility did not use bed or chair alarms during this incident. Agency LPN #511 reported at around 7:00 P.M., Resident #85 was being pushed down the hallway in his wheelchair by STNA #500 and she was told he was found lying outside. Staff were not aware Resident #85 had left the building or was missing. Additionally, the facility failed to ensure Resident #85 was assessed properly for elopement/wandering status and cognitive status, failed to update the care plan to address wandering behaviors in a timely manner, and failed to update elopement binders. Lastly, the facility failed to conduct a thorough investigation of Resident #85's elopement to prevent the same action, situation, and or practice from occurring in the future. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE], Resident #85 was sent to the hospital for evaluation per physician orders. · On [DATE], Assistant Director of Nursing (ADON) #600 placed a Wanderguard device on Resident #85. · On [DATE], Resident #85 was seen by his physician for an evaluation and medication review regarding his increased exit seeking behaviors. · On [DATE], a care conference for Resident #85 was held with his family, the Administrator, and Director of Social Services #611. Resident #85 had his care plan reviewed and updated to reflect wandering and elopement risk by ADON #600. Additionally, Resident #85 was placed on increased monitoring by facility staff and family would be at his bed side during wake hours. · On [DATE], the Administrator updated the door where Resident #85 eloped to ensure it was locked with a code. · On [DATE], ADON #600 added Resident #85's picture and information to the facilities elopement binder. Additionally, the facilities elopement binders with resident's pictures were also updated with resident information. · On [DATE], ADON #600 audited all active residents with Wanderguard devices to ensure they were in place and working. · On [DATE], ADON #600 conducted new elopement risk assessments on all current residents. · On [DATE], Director of Social Services #611 audited all residents' Brief Interview for Mental Status (BIMS) assessments to ensure they were completed. · On [DATE], Minimum Data Set (MDS) Nurse #622 reviewed all residents care plans regarding wandering/elopement risk and updated the care plans as needed. MDS Nurse #622 would monitor daily for new Wanderguard placement and would update care plan accordingly. · On [DATE], the Administrator and/or designee completed education to all staff regarding the facilities elopement policy and procedure and how to handle residents with wandering or exit seeking behaviors. The education was completed for all staff on duty on [DATE] and staff would not be allowed to return to work without the training. The education will be completed by [DATE]. · The Quality Assurance and Performance Improvement (QAPI) committee would meet monthly for the next three months and quarterly following to ensure compliance and provide ongoing monitoring of the areas listed above. The Administration would continue to oversee the audits and education were completed. · On [DATE] from 3:18 P.M. to 3:57 P.M., interviews with LPN #599 and STNA #505 verified they received recent training prior to their shifts regarding the facility's expectations on how to respond to elopements and were knowledgeable on the facility's elopement policy. · Medical record reviews for three additional residents (#65, #92, and #200) revealed elopement and cognition assessments were completed and care plans were accurate. · On [DATE], review of the facilities elopement binder revealed the binder was updated with Resident #85's information. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimum 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 included: Review of Resident #85's medical record revealed an admitted [DATE]. Diagnoses included, urinary tract infection, hypoxemia, [CONDITION(S)], unspecified injury of head, laceration with foreign body of right elbow, repeated falls, altered mental status, [CONDITION(S)] disorder, dementia, [CONDITION(S)], [CONDITION(S)], pulmonary hypertension, seizures, [CONDITION(S)], [CONDITION(S)], and history of Coronavirus Disease 2019 (COVID-19). Review of Resident #85's Elopement assessment dated [DATE] revealed Resident #85 was not at risk for elopement. Review of Resident #85's Baseline Care Plan dated [DATE] revealed Resident #85 was cognitively impaired and was not considered an elopement risk. Resident #85 utilized a wheelchair. Review of Resident #85's history and physical dated [DATE] revealed Resident #85 had a history of dementia. Resident #85 was aware of month and year and that he was in a place for exercise, but confusion was still present. Resident #85 did not know the name of the facility, day or the week, or date. Review of the care plan for Resident #85 dated [DATE] revealed it contained no documentation or interventions regarding the resident's cognitive and functional status and did not address the level of supervision needed for the resident. Review of Resident #85's admission Minimum Data Set (MDS) assessment completed [DATE] revealed a BIMS score was not assessed and the MDS documented the resident had no wandering behavior. Resident #85 required extensive assistance of one staff member with Activities of Daily Living (ADL's) including transfers, bed mobility, toileting, and walking. Review of Resident #85's quarterly MDS assessment dated [DATE] revealed a BIMS score was not assessed, and the resident had no wandering behavior. Resident #85 required limited assistance of one staff member with ADL's including transfers, bed mobility, toileting, and walking. Review of Resident #85's progress notes revealed the following: · On [DATE] at 2:36 P.M., Resident #85 was restless and walking around confused. · On [DATE] at 4:22 P.M., Resident #85 was wandering around the unit trying to find his car keys so he could leave. Later in the evening around 11:00 P.M., Resident #85 was walking down the hallway using his roommate's wheelchair to support himself as he was heading toward an exit. Staff attempted redirection and Resident #85 became aggressive. Staff were able to get Resident #85 redirected back into his room eventually. Approximately 40 minutes later, Resident #85 was walking down the hallway using his roommate's wheelchair as support. Resident #85 was attempting to enter other resident rooms and exit doors in an attempt to leave the facility. Resident #85 became angry when redirected. · On [DATE] at 11:23 P.M., Resident #85 was brought back to the unit by staff and a security officer. Resident #85 was spotted in the parking lot/drive by staff. Resident #85 was assessed for injuries and a small skin tear was noted to his right elbow and vital signs were within normal limits. Resident #85 was sent to the hospital. Resident #85 returned from the hospital around 10:30 P.M. with his son. Resident #85's son was assured an investigation had been started and interventions were being implemented to ensure Resident #85's safety. · On [DATE] at 10:45 A.M., Resident #85 was up and trying to leave, stating he was going home. Redirection was unsuccessful and medication interventions were utilized. Family arrived to sit with Resident #85. · On [DATE] at 6:42 P.M., Resident #85's daughter requested a Wanderguard be placed on Resident #85. A Wanderguard bracelet was applied to Resident #85's right ankle. Review of Resident #85's hospital records revealed on [DATE] at 8:00 P.M. Resident #85 presented with a right elbow injury. Resident #85 was found outside the facility for an unknown length of time. Resident #85 was confused at baseline due to dementia. Resident #85 stated he did not know why he was outside, but probably because he was trying to escape. Resident #85 does not know what happened or what is going on. Resident #85 was unable to provide any other historical information. Resident #85 did not have any pain, other than reports of pain to his head and right elbow. Resident #85 was unsure what medications he took. Resident #85 was treated for his superficial skin tear on his right elbow, which did not require sutures. A Computerized Tomography (CT) scan of his head and neck was completed with no negative or acute findings. Review of Resident #85's physician orders dated [DATE] revealed orders to check Wanderguard function daily and to check Wanderguard placement every shift to right ankle. Review of Resident #85's care plan revealed the document was updated on [DATE] to reflect the resident being at risk for elopement due to confusion and exit seeking behaviors and wandering. Interventions in place included, apply Wanderguard to alert staff when near an exit door, check placement daily to right ankle, and check Wanderguard function daily. Review of Resident #85's Elopement assessment dated [DATE] revealed the assessment was not completed accurately as the assessment did not reflect Resident #85's recent elopement on [DATE]. There were no other additional Elopement Assessments completed. Review of facility SRI completed on [DATE] revealed on [DATE], Agency LPN #511 reported around 6:20 P.M. she was giving report to another staff person when she heard what she thought was a bed or chair alarm. When Agency LPN #511 was walking down the 400 Hall to investigate the alarm, the alarm turned off. Agency LPN #511 was unable to determine where the alarm was coming from. At 6:50 P.M., STNA #500 who was arriving for her shift, found Resident #85 propelling himself in his wheelchair toward the main building. STNA #500 flagged down Security Officer (SO) #533 who was passing by and assisted with pushing Resident #85 back to the building. Resident #85 was assessed for injuries and a small skin tear to the right elbow was found with no other injuries. Vital signs were taken and within normal limits. The physician was notified and ordered Resident #85 be sent to the hospital. Resident #85 returned to the facility on [DATE] at 10:30 P.M. After further investigation that night, the nurse supervisor was able to determine that Resident #85 exited through the fire escape door located between the chapel and 100 Hall. The nurse supervisor found that the door alarms when opened, but silences when the door closed. The nurse supervisor and security audited remaining doors to find all remaining doors alarmed until reset with a code. A Wanderguard was placed on Resident #85 upon return. Interview on [DATE] at 11:10 A.M. with the Administrator and ADON #600 verified Resident #85 was cognitively impaired. On [DATE] at 12:51 P.M., an interview with the Administrator and ADON #600 to review the investigation from the SRI completed [DATE] revealed the Administrator and ADON #600 did not appear to be prepared or have much knowledge regarding the incident of Resident #85 eloping on [DATE]. The Administrator attended the meeting with one document and was unable to determine all staff members involved in the incident on [DATE]. The Administrator left and said he would be back with additional information. Observation on [DATE] at 1:52 P.M. revealed Resident #85 was resting quietly in bed with family present. Interview on [DATE] with LPN #522 verified Resident #85 wandered often and was not easy to redirect. Interview on [DATE] at 2:21 P.M. with Resident #85 revealed he was cognitively impaired. Resident #85 was able to have simple conversation and report how he was feeling, but he did not remember any incidents of him leaving the facility or going to the hospital on [DATE]. Resident #85's family members were visiting and verified on [DATE] they were notified Resident #85 got out of the facility through the door by the chapel. Resident #85 was outside in the cold and snow without a coat and wearing only a t-shirt. Resident #85's family was upset and could not understand how staff did not realize he was gone. Interview on [DATE] at 2:29 P.M., the Administrator and ADON #600 verified Resident #85 was cognitively impaired and struggled in the evenings with wandering when his family left. On [DATE], Resident #85 exited the facility through the door located between the chapel and 100 Hall. Resident #85 made it to the stop sign out front of the nursing home, just past the parking lot. A door alarm did sound; however, Agency LPN #511 thought it was a bed or chair alarm, even though the facility did not utilize those types of alarms. Agency LPN #511 was unable to locate the source of the alarm. The Administrator and ADON #600 were unable to decipher when the last time staff laid eyes on Resident #85 during the evening of [DATE] prior to his elopement, but thought it was during dinner time at around 5:30 P.M. Resident #85 was found outside at 6:59 P.M. by STNA #500 who was arriving to the facility for her shift. The Administrator explained the door Resident #85 exited through was the only door in the facility that was not locked with a code. The door was alarmed, and would sound when opened, but the alarm would turn off once the door was closed. The Administrator confirmed on [DATE], the door where Resident #85 eloped was updated to be locked with a code. So, if the alarm sounded, staff would have to physically go to the door and put the code in for the alarm to turn off. The Administrator verified all doors in the facility were locked with a code and would alarm when exited after holding the handle for 15 seconds. The Administrator provided staff statements and reported he did not have evidence of staff education being completed. During the interview, the Administrator also confirmed the facility did not have evidence Resident #85's elopement was investigated, including completed staff education, and identifying like residents to ensure assessments were up to date and accurate. The Administrator confirmed there were limited staff statements collected following Resident #85's elopement. Interview on [DATE] at 2:54 P.M., ADON #600 reported every unit in the facility had an elopement binder, which identified residents who were at risk for elopement with their picture and other important healthcare information to be used in the event of an elopement. During the interview, ADON #600 reviewed the facility elopement binder with the surveyor, which did not include Resident #85's picture or information. ADON #600 reported she had not added Resident #85 to the elopement binder yet due to her finishing up printing his pictures and her printer running out of colored ink. ADON #600 verified Resident #85 had elopement assessments completed on [DATE] and [DATE], but there was no other assessments completed in-between. ADON #600 confirmed Resident #85 should have had an elopement assessment completed after his elopement incident on [DATE]. Furthermore, ADON #600 verified Resident #85's elopement assessment completed on [DATE] was completed incorrectly and did not reflect accurate information as the assessment did not reflect the resident's elopement and/or consider the resident's diagnosis of dementia or exit seeking behaviors. Observation on [DATE] at 3:25 P.M., the Administrator showed the surveyor the door Resident #85 exited from on [DATE] when he eloped. The door was located between the chapel and 100 Hall, which was quite a way from where Resident #85 resided. The Administrator verified Resident #85 made it quite a way from his room to the door. The Administrator confirmed Resident #85 traveled down the hallway where he resided, down the 400 Hall, passed the chapel, down a small hallway, and out the door. Interview on [DATE] at 3:31 P.M., Agency LPN #511 verified she was working on [DATE] and was assigned to care for Resident #85. Agency LPN #511 stated when she arrived for her shift around 6:15 P.M. she heard what she thought to be a chair or bed alarm. Agency LPN #511 stated she told an unknown STNA to investigate the alarm. Agency LPN #511 and the unknown STNA checked resident rooms and were unable to locate the source of the alarm. The alarm turned off, so staff stopped looking. Agency LPN #511 reported staff did not check exterior doors because, Why would we check exterior doors if we thought it was a bed or chair alarm? Agency LPN #511 stated on [DATE] at around 7:00 P.M., an unknown staff member was wheeling Resident #85 down the hallway in his wheelchair and reported he had been found outside, so Agency LPN #511 called 911. Agency LPN #511 reported she was aware the facility did not utilize bed or chair alarms when this event took place because a week or two prior to Resident #85's elopement, she had requested a chair alarm for a different resident and was told the facility did not utilize those types of alarms. Observation on [DATE] at 4:08 P.M. revealed Resident #85 had a Wanderguard band placed on his ankle. Interview on [DATE] at 4:43 P.M., Resident #85's family member verified Resident #85 had elopement behaviors prior to his elopement on [DATE]. Resident #85's family member stated the facility staff were aware of Resident #85's wandering behaviors. Resident #85's family member reported she had requested a Wanderguard device be placed on Resident #85 days prior to the elopement on [DATE] and it was never placed. Resident #85's family member stated the family had to demand the Wanderguard device be placed on [DATE] and could not believe it was not placed when he returned from the hospital on [DATE] after the elopement. Interview on [DATE] at 5:03 P.M., STNA #500 verified on [DATE] at approximately 6:59 P.M. she was arriving for her shift and noticed an object blocking the road. It was dark and snowing and she thought it was an animal. STNA #500 realized the blockage in the road was a person and was in shock. STNA #500 stated she parked her car in the middle of the road because there was no room to drive around the person. STNA #500 stated she discovered Resident #85 was lying in the middle of the road next to his wheelchair. STNA #500 stated Resident #85 had no coat or shoes on and was shivering. STNA #500 stated the grounds were snow covered and it was cold. STNA #500 stated Resident #85 had an indwelling urinary catheter and the catheter bag was attached to his wheelchair and there was tension with the catheter tubing. STNA #500 stated she called for help. STNA #500 stated two unknown staff members were leaving their shift and assisted STNA #500 with getting Resident #85 back into his wheelchair and back into the facility. STNA #500 reported she almost ran Resident #85 over with her car and could not believe staff had not noticed he was gone. Interview on [DATE] at 9:00 A.M., Registered Nurse (RN) #577 verified Resident #85's cognition level did not appear to be assessed throughout his stay. Resident #85 was admitted on [DATE]. Interview on [DATE] at 4:26 P.M., SO #533 reported during the early evening of [DATE] he received a call from a staff member reporting Resident #85 had been found outside on the ground, away from his wheelchair. SO #533 stated when he arrived to assist, Resident #85 was already back into the facility, and he gathered staff statements, and wrote his own statement. Interview on [DATE] at 4:50 P.M., LPN #588 reported she was the nurse manager working on [DATE]. LPN #588 stated on [DATE] at around 6:45 P.M., Resident #85 was being brought back into the facility from being found outside. LPN #588 reported she spoke with Agency LPN #511, who reported she heard an alarm sound around 6:15 P.M. and she thought it was a bed or chair alarm. LPN #588 stated before anyone could find the source, the alarm stopped, and staff stopped looking for the source of the alarm. LPN #588 reported she began investigating Resident #85's elopement and found the door Resident #85 exited by finding wheelchair and footprint marks in the snow. LPN #588 thought Resident #85 self-propelled from his wheelchair when he eloped because that was his main mode of transporting himself. Review of e-mail from the Administrator on [DATE] revealed Resident #85 traveled approximately 612 feet from his bedroom to where he was found outside. Review of STNA #500's undated written statement revealed when she was arriving for her shift at 6:59 P.M., she saw a Caucasian, elderly male sitting on the ground next to his wheelchair with no one in sight. The resident was alone and had no coat, a blanket covering his head, and only socks on his feet, but he was fully clothed. STNA #500 approached the resident and called the facility to alert them of the wandering resident, who was discovered unattended in inclement weather. Resident #85 reported he was outside about 20 minutes, and he was trying to escape. Resident #85's catheter was stretching from the wheelchair while he was on the ground. Review of LPN #588's statement revealed she interviewed Agency LPN #511. Agency LPN #511 reported on [DATE] at 6:15 P.M. while completing report with the day shift nurse, she heard what she thought to be a bed or chair alarm. The alarm was not very loud, and Agency LPN #511 told a nurse aide to investigate the sound. The alarm stopped while looking for the source. STNA #500 found Resident #85 outside in the drive while reporting to work at 6:59 P.M. STNA #500 called for help. LPN #588 found Resident #85's wheelchair marks and footprints in the snow leaving the door next to the chapel. LPN #588 tested the door and realized the alarm is not as loud as other doors and the alarm stopped as soon as the door was closed. Review of SO #533's statement dated [DATE] revealed on [DATE] at approximately 7:00 P.M. security received a phone call from nursing home staff reporting a resident had fallen out of his wheelchair and was lying on the ground on Schervier Court, about 100 feet away from the main entrance. Security arrived at approximately 7:05 P.M. and the resident was back in his wheelchair and being pushed back into the nursing home. The resident was identified as Resident #85. Security assisted staff and Resident #85 back to Unit #02 station. Not a single staff member was aware Resident #85 was gone. Nursing staff called 911. SO #533 noticed Resident #85 had blood coming from his elbow. He rolled back the sleeve to check the wound and noticed it was a skin tear actively bleeding. SO #533 asked nursing staff to clean and dress the wound. At first, no one would help. SO #533 had to ask several times until an unknown aide agreed to help clean and dress the wound. At approximately 7:40 P.M., emergency services arrived and took Resident #85 to the hospital. LPN #588 told emergency service members Resident #85 needed to be evaluated and that he was a flight risk with physical aggression when attempting to elope in the past. Review of the weather report from wunderground.com revealed on [DATE] at 6:56 P.M. it was 19 degrees F with light snow. Additionally, according to the weather report the sunset on [DATE] at 6:11 P.M. Review of the facility policy titled, Elopement Search and Rescue Plan, revised [DATE] revealed residents would be kept safe and residents at risk of elopement would not leave the facility unaccompanied. The facility would have elopement binders kept at each nursing station and reception desk including face sheets with photographs of all residents with Wanderguards or exit seeking behaviors. Review of the facility policy titled, Wandering/Exit Seeking Unsafe Resident, revised [DATE] revealed facility staff would identify residents who were at risk for harm because of unsafe wandering or exit seeking. Staff would assess at-risk individuals for interventions to manage risk factors and the care plan would indicate if the resident was at risk for elopement. This deficiency substantiates Complaint Number OH 454.

Based on medical record review, observation, resident and staff interviews, and review of facility pain policy, the facility failed to ensure a resident with an unstageable pressure ulcer received pain medication prior to or during a treatment. This resulted in actual harm to Resident #89 who complained of pain during a pressure ulcer treatment. This affected one Resident (#89) of two reviewed for pain. The census was 145. Findings include: Medical record review revealed Resident #89 was admitted on [DATE]. Medical [DIAGNOSES REDACTED]. Review of admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #89 was cognitively intact. Review of the care plan dated 01/15/19 revealed the resident was at risk for developing pain. Interventions included to monitor non-verbal gestures and or facial expressions related to pain. Further review of the care plan for unstageable pressure ulcer to left proximal buttock revealed to manage the pain associated with the wound. Review of the Medication Administration Record [REDACTED]. Review of wound notes dated 01/29/19 revealed the resident had an unstageable pressure ulcer to the left proximal buttock that measured 2.9 centimeters (cm) by 1.4 cm by 0.1 cm. The wound was described as having a small amount of yellow, clear exudate. There was no odor noted, 10% granulation, area was red and moist, and had 90% yellow necrotic [MEDICATION NAME] or slough. Further review of the wound notes revealed the treatment for [REDACTED]. Observation of wound care on 01/30/19 at 11:35 A.M. with Licensed Practical Nurse (LPN) #321 and State tested Nursing Assistant (STNA) #379 revealed the resident had stool when the staff turned him. STNA #379 used a bath blanket to wipe the stool off of the resident, and he moaned in pain when she touched the pressure ulcer. The old dressing was no longer covering the pressure ulcer leaving the area exposed. STNA #379 commented she was sorry and she knew the area hurt. As LPN #321 began the treatment to the resident's left buttock, he moaned. He was observed with facial grimacing, and he flinched when LPN #321 touched his buttocks. LPN #321 continued the treatment. Resident #89 commented, goodness gracious. LPN #321 did not stop the treatment nor offer to medicate the resident. Interview with LPN #321 on 01/30/19 at 11:50 A.M. revealed she had asked Resident #89 if he needed any pain medication 30 minutes before beginning the treatment but the resident refused. She stated the resident knew the treatment was gong to be painful, but he refused to be medicated. A subsequent interview with LPN #321 at 12:24 P.M., verified there was no current order for pain medication routine or as needed. Interview with Resident #89 on 01/31/19 at 8:19 A.M. stated the dressing changes were painful. He denied the staff had ever asked him if they could medicate him for pain. He further stated he wished they would. A subsequent interview with the resident at 10:05 A.M., revealed he didn't understand the pain scale, but stated the treatment hurt pretty bad. When asked if the pain was mild, moderate or severe, he said severe. Review of policy entitled Pain Assessment and Management Policy and Procedure dated (MONTH) (YEAR) revealed to assess each resident's individual pain through direct observation and use of the nursing assessment process withe the goal to identify pain and develop a management protocol in order to maximize each residents capabilities and quality of life. If resident is unable to express feelings of pain the pain identification shall be based on behavioral factors such as: presence of crying, facial expressions, and body posture.

Based on medical record review, review of facility incident investigations, review of an emergency room report, review of manufacturer's recommendations for use of the Wander Guard system and interviews with staff, the police and fire departments, the facility failed to ensure residents were adequately supervised and assistive devices were functioning properly to prevent residents at risk for elopement from exiting the facility through the ambulance door. This resulted in Immediate Jeopardy for one (#88) of 18 residents, assessed for potential elopement risk, when Resident #88 exited the facility unsupervised and was found by a neighbor lying in the lawn who then called 911. Additionally, the facility failed to properly transfer one (#25) of 39 residents identified as dependent on staff for transfers. This resulted in actual harm that is not immediate jeopardy to Resident #25 who sustained a sprained ankle as a result of not utilizing a Hoyer lift and two staff per physician order [REDACTED]. On 10/03/12 at 10:39 A.M., the Administrator and Director of Nursing (DON) were notified that Immediate Jeopardy began on 09/23/12 at 4:55 P.M., when Resident #88 was last observed by State tested Nurse Aide (STNA) #38, walking up the 500 hall on the way to the Unit II dining room. Resident #88 then proceeded past the Unit II dining room and exited out the ambulance door of the facility without the Wander Guard alarm sounding. At 5:40 P.M., a 911 call was placed by a community neighbor who found the resident in their front yard lying on the lawn. Resident #88 was taken by emergency medical service personnel to a local hospital, where he was found to have a fractured neck. The Immediate Jeopardy was removed on 09/24/12 at 10:30 P.M. when the facility implemented the following corrective actions: ? On 09/23/12, the DON began in-service training with all nursing staff on use of the Wander Guard system. ? On 09/23/12, the facility reassessed each resident currently utilizing a Wander Guard bracelet. All bracelets were replaced during the 3:00 P.M. to 11:00 P.M. shift. ? On 09/23/12, all exit door stations were checked with an activated bracelet to verify they were in working order. All doors alarmed appropriately. ? On 09/24/12, a new elopement risk assessment was done on every resident in the Health Care Center (HCC). ? On 09/24/12, the Elopement Prevention Policy was reviewed and updated by the Quality Assurance Committee. ? On 09/24/12, an infrared sensor was installed to the current Wander Guard system on Unit II. The infrared system will cause the door to alarm when a resident with a Wander Guard bracelet is within approximately three feet of the door, instead of alarming after the resident crosses the threshold of the door. ? On 09/24/12, new Wander Guard testers were purchased. All nurses were in-serviced on use of the testers and provided an instruction manual. All Wander Guard bracelets to be checked each shift for placement, tested daily and results recorded in the resident ' s record. The bracelet is to be changed every two months. Security staff are to monitor by testing three Wander Guard door stations and delayed egress alarmed doors weekly to verify all are functioning properly. ? On 09/24/12 at 10:30 P.M., all nursing staff had been in-serviced on elopement prevention and proper use of the Wander Guard system. All non-nursing staff were in-serviced by their department head supervisor which addressed immediate response by all staff to Wander Guard alerts, visual search of the area to verify no residents are outside of the building and the alarm should not be reset until it is determined that no resident has exited. ? On 10/02/12 and 10/03/12, STNA's #8, #18, #51, #52, #57, #69, #72, #74, #93 and #99, Licensed Practical Nurses (LPN) #2, #4, #8, #11, #28, #33 and #36 and Registered Nurse (RN) #10 were interviewed and were able to verbalize thorough knowledge of the Wander Guard system and the elopement procedures. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 3 (Actual harm that is not jeopardy) for Resident #25, who suffered pain that interfered with normal activities as a result of an ankle sprain sustained during an improper transfer. Findings Include: 1. Review of Resident #88's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Elopement Risk Assessment (ERA), dated 02/01/12 and 05/01/12, revealed Resident #88 had no actual or potential risk for elopement. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. The assessment identified the resident had difficulty focusing attention and had impaired memory. The activity preferences portion of the assessment documented it was very important to Resident #88 to go outside to get fresh air when the weather is good. His ambulation was assessed as limited assistance with one person. Balance during transitions and walking were assessed as not steady and only able to stabilize with human assistance. The resident was assessed as using a walker. Nurses notes dated 02/18/12 revealed Resident #88 wanted to go out to his Grandpa's car and had his coat and hat on. The resident was re-oriented to place and resident stated he knew where he was but still wanted to go to the car. Nurses notes dated 02/22/12 revealed Resident #88 was sitting in the lobby and wanted to go out to see if the keys were left in Grandpa's car. Nurses notes dated 02/23/12 revealed Resident #88 had increased confusion and thought he was going out of the facility to Grandpa's car. Nurses notes dated 04/01/12 documented Resident #88 was ambulating in the hallways around the full square of the building looking for lockers and staff assisted the resident back to Unit II. The Elopement Risk assessment dated [DATE] revealed the resident was not at actual or potential risk for elopement, although comments noted at the bottom of the assessment revealed Resident #88 had a Wander Guard on due to some increased confusion and exit seeking behaviors. Review of a social service note dated 05/04/12 documented Resident #88 reports trouble concentrating and feeling restless several days but reports it happens when he is bored. There were a few incidents in which Resident #88 wanted to go out to Grandpa's car. Nurses notes on 05/21/12 revealed Resident #88 attempted to leave the building and he was redirected back to his room. Nurses notes dated 05/22/12 revealed the resident was sitting in his chair in his room without any attempts of elopement this morning. Nurses' notes dated 06/11/12 revealed the resident was thinking about his Grandfather's car today and that he had left if five blocks away and he left the keys in the car. The nurse spoke with this resident many times this shift to divert him from trying to walk out the ambulance door. A nurse's note dated 06/13/12 revealed Resident #88 went out the ambulance entrance, walking with a walker. Resident #88 stated he was going out to get his Grandfather's car that he left on the street two blocks away. Staff encouraged Resident #88 to come back inside. Resident #88 sat in the lounge area for a while, then got up and stated he was going out to the car. The nurse took the resident outside for a short walk by the parking lot and Resident #88 reported his Grandfather's car was not in this parking lot but two blocks away. The nurse persuaded Resident #88 he could not walk that far and was able to redirect him back inside the building. Documentation at this time noted the Wander Guard was functioning. The resident was not assessed for elopement risk after this incident. Review of the quarterly MDS, dated [DATE], revealed the resident wandered one to three days of the assessment. The Elopement Risk assessment dated [DATE] revealed Resident #88 was a potential risk of elopement due to having a history of exit seeking behavior with causes being dementia process, searches for people or things, and wandering during disoriented periods. The comments noted on the assessment revealed the resident would attempt to go out of facility unattended. Review of Resident #88's plan of care for cognitive and communication, updated on 07/14/12, documented the resident has intermittent confusion, delusion, and attempts to walk out of the doors and into the parking lot unattended at times. The interventions were to redirect the resident and place a Wander Guard on the resident to alert staff of elopement attempts. Review of social service notes dated 07/24/12 revealed Resident #88 attempted elopement and wears a Wander Guard due to elopement risk. Nurses' notes dated 07/26/12 revealed Resident #88 attempted elopement recently and had a Wander Guard on. Nurses notes dated 09/04/12 revealed Resident #88 was at the nurse ' s station attempting to go outside and look for his car. Nurses' notes dated 09/17/12 revealed Resident #88 was at the nurse's station this morning attempting to exit the facility without assistance. Review of a facility incident investigation report, dated 09/23/12, revealed a witness statement completed by STNA #38 that documented Resident #88 was seen coming out of Room #504 up the hall for dinner on 09/23/12 just before 5:00 P.M. while she and STNA #37 finished caring for Resident #88's roommate. At 5:25 P.M., STNA #38 was checking for empty seats and noticed Resident #88 was missing. STNA #38 went back to the resident's room and then double checked the lobby. She notified Registered Nurse (RN) #4 that Resident #88 was missing and then walked up front to look for the resident. STNA #38 began searching the building asking if anyone had seen the resident. At 5:30 P.M., the staff could not locate the resident. Review of the witness statement completed by STNA #37, dated 09/23/12, revealed on 09/23/12 she went down to the 300 hall and STNA #38 went down the 400 hall searching for Resident #88. They both met at the 100 hall nurse's station, where they informed RN #6 the resident could not be found. STNA #37, STNA #38 and RN #6 went back to Unit II and out the back ambulance door to look for Resident #88. Upon returning in the building, STNA #37 received a telephone call from campus security informing them Resident #88 had been found. STNA #37 forwarded the call to RN #6. STNA #37 documented this all happened between 4:45 P.M. and 6:25 P.M. Review of the witness statement completed by RN #4, dated 09/23/12, revealed Resident #88 was seen at the medication cart about 4:55 P.M. at which time he ambulated down the hall towards the dining area. She was informed by STNA's at approximately 5:30 P.M. that a thorough search of the building needed to be performed and documented she was not aware at this time Resident #88 was missing. Review of a witness statement dated 09/23/12, completed by RN #6, revealed she was told of Resident #88's elopement and went outside of the building to look for him. When she returned to Unit II at approximately 5:50 P.M., she received a phone call from campus security, who reported Resident #88 had been found on Seminary Drive. He had fallen and 911 had been called. Review of the emergency room report dated 09/23/12 revealed Resident #88 was transferred by Emergency Medical Services (EMS) after a fall and Computed Tomography (CT) results revealed the first cervical vertebrae bone in the neck was fractured. The resident was admitted to the hospital, seen by the trauma service and was placed in a hard cervical collar. Review of the Medical Director (MD) Progress note dated 09/25/12 revealed Resident #88 was returning after a hospital stay with a fall and fracture. "The patient apparently went outside the building and he fell in the neighboring plat of the nursing home. At the hospital he was found to have a C-1 fracture and was sent back to the ECF (extended care facility) with an Aspen collar". The MD further wrote there is a very high risk of him having a sudden death from this type of fracture. The resident will need more supervision and make sure he is not falling again. Interview on 10/02/12 at 10:15 A.M. with the DON revealed prior to the resident's elopement on 09/23/12, Wander Guard bracelets were only checked monthly, and the batteries were changed when they were found no longer functioning. The DON confirmed the facility was not following the manufacturer's recommendations that indicated how to safely monitor the use of the Wander Guards for the residents. The DON stated the system would alarm only after the resident passed the door threshold, thus allowing the resident to exit the facility. The alarm did not lock the door, but simply alerted staff that the resident had exited. The DON was unable to provide a written policy regarding the use of the Wander Guard system prior to the incident on 09/23/12. During an interview with the DON on 10/02/12 at 1:14 P.M., she stated she was notified at approximately 5:40 P.M. that Resident #88 was taken by ambulance after he was found on a neighborhood lawn. She then e-mailed the Administrator and Executive Director. She began her investigation and discovered the local Police Department had been called, who in turn notified the facility's campus security department. The DON stated Resident #88 had been sent by Emergency Medical Squad (EMS) to a local hospital after a neighbor had called 911, on 09/23/12 at 5:40 P.M., when they found Resident #88 lying on their lawn. She then began to interview staff to see what had happened and found that no staff heard any alarms sounding. It was discovered the resident was last seen at approximately 4:55 P.M. after STNA #37 and #38 sent him up the hall to the dining room. She further reported Resident #88 was seen on one of the security cameras walking through the parking lot with his walker, away from the ambulance doors on Unit II, then turned toward the neighborhood and that was the last footage they had of him. The DON stated their investigations led them to believe Resident #88 left the facility through the ambulance door. She further stated the ambulance door had a Wander Guard alarm system in place, but the door does not have a key pad and magnetic closure. The alarm only sounded after the Wander Guard bracelet crossed the threshold of the door. The DON stated they believe Resident #88 went out the ambulance doors because they do have a brief video clip of Resident #88 walking with his walker in the back parking lot. He came from the ambulance exit and turned left out of the parking lot, heading into the grass to the pine trees. She was then informed the local Police Department received a 911 call from a neighbor on Seminary Road. A local Township EMS took Resident #88 to the hospital for treatment, where he was found to have sustained a neck fracture. She thought the resident had a Wander Guard attached to his walker, but when Resident #88 returned back to the facility, the walker was missing and Resident #88 did not have a Wander Guard on his person. The DON further reported they were checking the Wander Guards monthly and knew the manufacturer required daily checks. Resident #88 is now on one-on-one supervision with a sitter is in the room at all times due to the neck fracture. A telephone interview on 10/02/12 at 2:44 P.M. with the local Police Department revealed a 911 call was made at 5:40 P.M. and the local Township Fire Department removed an elderly man with injuries. The police department representative stated no report was completed because the incident was not suspicious in nature. On 10/02/12 at 3:00 P.M., a telephone interview with the Chief of the local Township Fire Department would only confirm they responded to an injury on Seminary Drive. He would release no further information. On 10/02/12 at 3:33 P.M., an interview with STNA #37 revealed she did not see Resident #88 after she and STNA# 38 instructed Resident #88 to go to the dining room. She reported she did not tell her nurse on the floor right away because the nurse was busy passing medications on the 400 hall. She further reported she did not hear an overhead call system alerting all staff in the building of the missing resident. Resident #88 was wearing gray sweat pants, a red T-shirt and his black gym shoes. She stated she was asking other resident ' s family members if they had seen Resident #88. STNA #37 stated she was not aware the Wander Guard had to be checked every day prior to the incident. She stated Resident #88 was sent down to the dining room a little before 5:00 P.M. and this is the last time she actually saw him. She could not tell if Resident #88 even had a Wander Guard on and did not have knowledge of where it was placed. On 10/02/12 at 6:10 P.M., interview with RN #4 revealed she last saw Resident #88 at her medication cart at approximately 4:55 P.M. She was busy passing medications and did not recall STNA #38 telling her Resident #88 was missing. Resident #88 would usually give a hint when he was going to try and go or he would sometimes wait and watch at the nurse's station. She could not recall if the overhead system was sounding and she stated she did not hear a door alarm that evening. She stated she last saw Resident #88 at about 5:00 P.M. when she gave medications to Resident #88. She did not actually see Resident #88 go into the dining room or anywhere else. During an interview on 10/02/12, RN #4, STNA #37 and STNA #38, who were the regular staff working on the 500 hall on the day of the incident, were not able to identify if Resident #88 had a Wander Guard bracelet on and if it was located on the walker or on the resident' s body. On 10/03/12 at 1:49 P.M., interview with Certified Nurse Practitioner (CNP), reported the first time she was made aware of Resident #88 attempting to go outside on his own was just recently when he was found outside and had to go to the emergency room . During a telephone interview on 10/03/12 at 4:02 P.M., STNA #38 stated she first noticed Resident #88 was missing in the dining room at about 5:25 P.M. They are not allowed to serve a tray unless the resident is seated in the dining room. Resident #88 was not seated at the table. She went back to the resident's room and started checking all over. She told STNA #37, they split up and checked the halls again. The nurse working the 500 hall and the Nursing Supervisor on the floor were notified. They checked outside and could not find Resident #88. It was close to 6:00 P.M. when STNA #37 and STNA #38 came back in. At this time, campus security had notified RN #6 the resident had been found and taken to the hospital. Review of the Wander Guard Departure alert system revealed the manufacturer recommended before use of the Wander Guard system, the directions should be read and followed carefully. Failure to do so could result in injury or death to a person. Each signaling device should be tested daily and the results should be recorded in the resident's records. The signaling device should not be placed on or next to metal such as wheelchair frames, jewelry, watches, etc. Metal could interfere with the signal sent to the door modules. This information was enclosed in a box labeled "WARNING". In addition, the manufacturer includes the signaling device will permit 90 days of use. An interview with the DON on 10/02/12 at 10:15 A.M. verified prior to the resident ' s elopement on 09/23/12, Wander Guard bracelets were only being checked monthly. 2. Review the medical record of Resident #25 revealed an admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of MDS assessment dated [DATE] identified that Resident #25 was cognitively intact and needed extensive assistance of two staff for transfers. The resident used a wheelchair and was dependent on staff assistance for locomotion. Resident #25 was assessed to have impairments to both sides of her upper extremities and one side of her lower extremities. Review of a care plan for falls, dated 01/25/12, documented the resident has a potential for falls and is dependent with two person assistance for transfer. Review of the MDS dated [DATE] revealed Resident #25 was cognitively intact and was dependent on two staff for transfers and locomotion. On 07/21/12 the care plan documented the resident was unable to bear weight with transfers. The intervention was to use the Hoyer lift with two staff for transfers. Nursing notes dated 09/07/12 documented the resident received an as needed pain medication at lunch time due to complaints of right knee pain from transferring. The resident rated the pain a 7 on a 1-10 scale. The nursing note dated 09/08/12 at 5:40 A.M. documented the pain was of recent onset related to traumatic event with severity of pain 7 on a scale of 1-10. Nurses notes dated 09/08/12 at 11:46 A.M. documented an X-ray was done and was negative. On 09/08/12 at 1:03 P.M., nursing notes documented the resident complained of right knee pain, rating the pain a 2 at resting and 10 with movement on a scale of 1-10. At 2:32 P.M., the nursing note documented at 12:30 P.M. revealed the resident told an STNA that she did not want to get up because her leg was hurting. At 11:46 P.M., nursing notes stated while removing the resident's socks, it was noted that her ankle had some swelling. Review of the facility ' s investigation dated 09/08/12 documented Resident #25 stated STNA #36 transferred her to her chair without the Hoyer lift and twisted her leg. Resident #25 is now complaining of severe pain in the right leg from above the knee to the foot. Resident #25's daughter was interviewed and stated she visited Resident #25 the day of the incident and found Resident #25 " cockeyed " in bed lying right up against the edge of the air mattress and she was very uncomfortable and at risk for falling out of bed with the way STNA #36 left her. Resident #25's daughter revealed that Resident #25 had reported the incident to her and that her leg was in pain, but the daughter thought it was the resident's typical complaint of pain. During the facility ' s investigation, STNA #36 confirmed he transferred Resident #25 without a Hoyer lift. STNA #36 revealed he did not transfer Resident #25 using the Hoyer lift to put the resident into or take her out of the shower chair. The DON told STNA #36 that by not following the doctor's orders, STNA #36 caused harm to Resident #25. Review of STNA #36's termination notice, dated 09/08/12, documented staff did not use proper transfer technique with the resident. The resident had a doctor ' s order for a Hoyer lift for all transfers due to her severe arthritis, fragile skin, and high risk for injuries. STNA #36 was aware of this and transferred her by lifting her around the waist. In the process of the transfer, Resident #25's leg was twisted. On 09/08/12 Resident #25 reports severe pain and was crying out in pain. Review of nursing notes on 09/09/12 at 12:39 A.M., 1:07 A.M., 8:08 A.M., and 8:30 P.M. revealed the resident complained of pain (3/10 and 8/10 on 1-10 scale) and it affected her by limiting mobility, insomnia, and changes in her mood and behavior. On 09/10/12 at 4:40 A.M. and 7:00 A.M., the resident complained of having pain. At 4:12 P.M., the resident complained of right ankle pain and refused to get out of bed. Review of nursing notes dated 09/10/12 revealed the Certified Nurse Practitioner(CNP) assessed the resident and ordered a splint to the right ankle, ice as needed and Lidoderm patch to the ankle for pain. Review of the Medication Administration Record for September 2012 includes an order dated 09/10/12 for Lidoderm patch for right ankle sprain. On 09/11/12 at 5:57 A.M., 11:30 A.M., and 2:43 P.M. nurses notes revealed Resident #25 had pain and reported it with movement to the right ankle. On 09/12/12 at 4:31 A.M., 6:09 A.M., and 10:29 P.M. it was noted the resident complained of pain or discomfort. Review of the Physical Therapy Evaluation and Plan of Treatment signed 09/12/12 revealed the patient was referred to Physical Therapy after sustaining a right ankle sprain during a transfer. The long-term goal was identified for patient to demonstrate right ankle active range of motion to neutral without pain in order for patient to return to prior level of functioning. Review of nurses' notes on 09/13/12 at 10:15 A.M. revealed the resident again complained of pain. Review of the Physical Therapy Progress note signed 09/20/12 revealed the resident required skilled services to increase lower extremity range of motion and strength in order to enhance patient's quality of life by improving ability to return to prior level of functional abilities. During an interview on 10/03/12 at 2:30 P.M., the DON stated Resident #25 was complaining of a lot of pain in her leg. Resident #25 told the DON that STNA #36 had transferred her without the Hoyer lift, so the DON did a physical assessment. The DON stated STNA #36 put Resident #25 in and out of the shower chair without the use of a Hoyer lift. The physician was notified and ordered X-rays and Ultram, a pain medication. The DON called and talked with Resident #25's daughter. Resident #25's daughter had actually known about it the night before (which was the day of the incident). Resident #25 mentioned to her daughter that STNA #36 had moved her without the Hoyer lift. The DON stated Resident #25 had a lot of pain and it got worse. The DON revealed STNA #36 admitted he transferred the resident unsafely and the DON suspended him until an investigation was complete. The DON called STNA #36 and terminated him because he did not follow facility policy. The DON confirmed STNA #36 stood Resident #25 up to transfer her. Resident #25 had an increase in pain after this happened and previously her pain level was maintained so this change in condition alerted staff something was wrong.