Every finding on record at Strongsville Healthcare and Rehabilitation

Based on record reviews, observations, interviews, and review of facility policies, the facility failed to ensure proper implementation of required infection control practices. Specifically, the facility did not ensure staff consistently followed Enhanced Barrier Precautions (EBP) for residents with indwelling devices, did not properly don and doff required Personal Protective Equipment (PPE) when caring for a resident on droplet isolation for COVID 19, did not use appropriate protective clothing during laundry handling, and did not maintain required procedures to prevent the growth of Legionella bacteria within the facility's water system. These deficient practices affected two residents (Residents #24 and #53) and had the potential to affect all residents in the facility. The facility census was 95.Findings include: 1. Record review for Resident #24 revealed an admission date of 04/02/24. Diagnoses included hemiplegia and hemiparesis following intracerebral hemorrhage affecting the left dominant side, neuromuscular dysfunction of bladder, and need for assistance with personal care. Review of the physician order for Resident #24 dated 12/15/25 revealed an order for an indwelling Foley urinary catheter due to obstructive uropathy. An additional order dated 01/06/26 included EBP: gloves and gown to be worn when providing dressing, bathing/showering, transferring, providing hygiene care, changing linens, changing briefs or assisting with toileting.Review of the Annual Minimum Data System (MDS) 3.0 assessment dated [DATE] revealed Resident #24 was cognitively intact. Resident #24 had an indwelling urinary catheter and required partial/moderate assistance with toileting hygiene, bed mobility, and substantial/maximal assistance with chair/bed to chair transfer.During an interview on 06/14/26 at 10:30 A.M., Resident #24 revealed, They never put a gown on when they do my catheter care or any care, are they supposed too?Observation on 06/14/26 at 10:41 A.M. of incontinence care for Resident #24 provided by Certified Nursing Assistant (CNA) #403 revealed CNA #403 never donned an isolation gown at any time during the care which included turning and repositioning in bed and incontinence of stool care. After incontinence care was completed, CNA #403 revealed she needed a second person to transfer Resident #403 from the bed to the chair. CNA #403 then exited the room to find additional staff.Observation on 06/14/26 at 10:47 A.M. revealed CNAs #403 and #478 returned to Resident #24's room and transferred Resident #24 from his bed to his chair using a slide board. Resident #24 was then transferred to the bathroom and CNAs #403 and #478 then transferred Resident #24 from his chair to the toilet. Observation revealed neither CNA donned an isolation gown while providing hands on care for Resident #24.During an interview on 06/14/26 at 10:54 A.M., CNA #478 stated staff were to donn an isolation gown only if they were providing catheter care. The isolation gown was not required for incontinence care or transfers. During an interview on 06/14/26 at 10:57 A.M., CNA #403 stated staff were only required to wear an isolation gown if the resident had COVID-19 or an infection. CNA #403 confirmed she never had donned an isolation gown while providing care for Resident #24.Observation on 06/14/26 at 10:59 A.M. of CNA #403 and Licensed Practical Nurse (LPN) #603 transfer Resident #24 from the toilet, provide incontinence care, place a brief on and transfer Resident #24 back to his chair revealed neither LPN #603 nor CNA #403 donned an isolation gown.During an interview on 06/14/26 at 11:04 A.M., LPN #603 confirmed she never donned an isolation gown (during the observation) while transferring and providing personal care for Resident #24. LPN #603 confirmed Resident #24 had an EBP sign outside his doorway and confirmed she should have applied an isolation gown while providing hands on care for Resident #24.2. Record review for Resident #53 revealed a re-admission date of 06/09/26. Medical diagnosis included COVID-19.Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #53 was moderately cognitively impaired. Resident #53 required assistance with activities of daily living.Review of the physician orders for Resident #53 revealed an order dated 06/11/26 for droplet isolation precautions due to a diagnosis of COVID-19. All services and meals to be provided in resident's private room every shift for diagnosis of COVID-19. Observation on 06/15/26 at 9:26 A.M. revealed Resident #53 had a sign on his door for droplet precautions. A three-drawer container was sitting outside the doorway that had PPE inside. Inside were sufficient isolation gowns, N-95 masks, gloves and one pair of goggles. Observation revealed LPN #487 donned an isolation gown, N-95 mask and gloves. LPN #487stated Resident #53 had COVID-19, and she was going into his room to administer his medications. LPN #487 entered the room with a medication cup with medications inside but never donned goggles. During an interview on 06/15/26 at 12:16 P.M., LPN #487 confirmed she did not donn goggles when she went into Resident #53's room during medication administration at 9:26 A.M. LPN #487 confirmed there were only one pair of goggles in the isolation cart and revealed they should be thrown away after each use. LPN #487 then walked away and returned at 12:19 P.M. and revealed with those goggles you would clean them after each use with Sani wipes.During an observation and interview on 06/15/26 12:20 P.M., LPN #491 confirmed there were no Sani-wipes in or on Resident #53's isolation cart.Observation on 06/15/26 at 12:22 P.M. of CNA #411 donn an isolation gown and an N-95 mask revealed the lower strap of the mask was left dangling under his chin. CNA #411 stated he was going in Resident #53's room to provide his Foley catheter care, check his brief, and apply cream to buttocks. CNA #411 confirmed Resident #53 was in isolation for COVID-19. He then entered Resident #53 's room with the N-95 strap dangling under his chin, no goggles, and carrying one pair of gloves while entering the room. At 12:42 P.M., CNA #411 exited Resident #53's room, confirmed he drained Resident #53's indwelling catheter drainage bag, applied a fresh brief fresh brief, barrier cream and repositioned Resident #53. CNA #411 confirmed he did not secure the bottom strap of the N-95 mask stating it was too tight and confirmed that he did not wear goggles while providing care for Resident #53.Observation on 06/15/26 at 12:37 P.M. of CNA #460 donn PPE revealed Registered Nurse (RN) Infection Preventionist (IP) #604 stopped and reminded CNA #460 to also donn goggles when entering Resident #53's room. CNA #460 then donned all appropriate PPE including goggles and entered Resident #53's room. At 12:41 P.M., CNA #460 exited Resident #53's room, removed the goggles and tossed them in the top drawer of the isolation cart with clean PPE. CNA #460 confirmed she removed the goggles and placed them directly in the isolation cart without sanitizing them.During an interview on 06/15/26 12:46 P.M., RN IP #604 confirmed Resident #53 was on droplet isolation due to a diagnosis of COVID-19. RN IP #604 confirmed staff should donn an isolation gown, gloves, mask, and goggles before entering Resident #53's room and should make sure both N-95 straps were secured. Goggles were to be cleaned after each use with Sani wipes and left to air dry.3. Observation on 06/15/26 at 1:37 P.M. revealed the laundry area and process with the Director of Nursing (DON) revealed Housekeeping/Laundry Assistants #740 and #745 both revealed they did not know which clothes or linen were from which residents' rooms. When they received laundry to wash, the isolation rooms laundry was not separated from the other residents. Housekeeping/Laundry Assistants #740 and #745 both confirmed they never donned an isolation gown or apron when sorting or washing any of the residents' laundry. RN IP #604 revealed not all staff understand the infection control process.During an interview on 06/15/26 at 1:55 P.M., Regional Clinical Director #725 revealed when staff sort/wash laundry of residents who are on isolation precautions, they should wear gloves and an apron. 4. Record review and interview on 06/15/26 at 4:19 P.M. with Assistant Director of Property Management #750 and Maintenance Supervisor #408 confirmed there was no diagram or description to identify the areas in the water system (needing routinely flushed) that could encourage the growth and spread of Legionella. Maintenance Supervisor #408 revealed there were four eye wash stations that he flushed once a month and confirmed he was unaware of any other areas in the building that needed flushed. Maintenance Supervisor #408 confirmed the facility had empty resident rooms, ice machines, hoses, etc. and revealed he did not know he was supposed to.Review of the undated facility policy titled, Enhanced Barrier Precautions revealed the purpose was to prevent the spread of novel or targeted multidrug-resistant organisms (MDROs). EBP expand the use of PPE beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high contact resident care activities that provide opportunities for MDROs to staff hands and clothing. High contact resident care activities include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use or wound care. EBP apply to all residents with any of the following: Infection or colonization with a novel or targeted MDRO, wounds or an indwelling medical device (i.e.- central line, urinary catheter, feeding tube, trach or vent) regardless of MDRO colonization status.Review of the undated facility policy titled, Covid-19; SARS-CoV-2 revealed the COVID- 19 control plan set forth in this policy is based according to regulatory guidance for resident health and safety. Health care providers who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection should donn an N-95 respirator, gown, gloves and eye protection (goggles or face shield that covers the front and sides of the face).Review of the undated facility policy titled, Laundry Procedures for the Avenue Buildings revealed each piece of equipment provided for the use by the laundry has many purposes such as infection control, operational efficiency as well as providing for a safe working environment for the laundry staff. The expectation is that the equipment provided and the procedures described below will be followed in each Avenue facility operated by Progressive Quality Care. The infection control policy will apply to this procedure, which at a minimum will require gloves and quite possibly a gown or apron to prevent the soiled material from touching or contaminating the clothing of the laundry person.Review of the facility policy titled, Legionella Water Management Program, revised September 2022, revealed the facility is committed to the prevention, detection, and control of water borne contaminants, including Legionella. The water management program includes a detailed description and diagram of the water system in the facility, including receiving, cold water distribution, heating, hot water distribution, and waste. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria including storage tanks, water heaters, filters, aerators, showerheads and hoses, misters, atomizers, air washers, humidifiers, hot tubs, fountains, and medical device equipment.

Based on staff interview, review of staff education, review of Centers for Medicare and Medicaid (CMS) Regulatory Update dated 05/31/23 titled Educate and Offer and review of the facility policy, the facility failed to educate/offer all eligible staff the COVID 19 vaccination. This had the potential to affect all 95 residents residing at the facility.Findings include:During an interview on 06/15/26 at 9:04 A.M., Certified Nursing Assistant (CNA) #494 stated the fall of 2024 was the last time the facility educated/offered the staff the COVID-19 vaccine.During an interview on 06/15/26 at 10:10 A.M., Infection Preventionist (IP) Registered Nurse (RN) #604 confirmed facility staff were not educated/offered the COVID-19 vaccine in 2025 or 2026 and revealed she did not know she was supposed to. Review of staff education related to COVID-19 on 06/15/26 at 11:58 A.M. with IP RN #604 for 2025/2026 confirmed staff were not educated on COVID-19 vaccine benefits, risks and potential side effects.During an interview on 06/16/26 at 2:03 P.M. with Regional Director of Clinical Operations (RDCO) #725 confirmed staff were to be offered COVID-19 vaccines annually. Review of the CMS Regulatory Update, dated 05/31/23, revealed Federal staff vaccine mandate was rescinded. CMS finalized a rule that removed the COVID 19 staff vaccination requirement originally imposed by the November 2021 interim final rule. CMS no longer enforces mandatory staff vaccination for COVID 19 in nursing homes. Educate and offer requirement remains. CMS retained the Education and Offer provisions from the May 2021 interim final rule. Nursing homes must continue to: Educate staff about COVID 19 vaccines (benefits, risks, and side effects) and offer vaccines actively, either on site or by referring staff to off site providers or pharmacies,Review of the facility policy titled, Employee Infection and Vaccination Status, dated January 2024, revealed employees are offered or provided with vaccinations per state or local agency policies/regulations. Employees are provided with educational materials to make informed decisions for non-mandated vaccines. If declined, a declination form is completed and placed in the employees' health record. The facility obtains and/or administers vaccinations required for pre- and post - exposure to infectious diseases in the workplace.

Based on record review and interview, the facility failed to ensure accurate comprehensive assessments were completed as required. This finding affected three residents (Residents #107, #109 and #111) and had the potential to affect all six residents (Residents #103, #105, #107, #108, #109 and #111) who were transferred to the facility from a sister facility following a fire. The facility census was 95. Findings include: 1. Review of Resident #111's medical record revealed the resident was admitted to the facility 03/13/26 as a transfer from a sister facility with diagnoses including paraplegia, essential hypertension and legal blindness. Review of Resident #111's medical record revealed an admission Minimum Data Set (MDS) 3.0 Comprehensive assessment dated [DATE] with a description of Inactivation of Entry. The MDS did not have evidence that the home conducted a comprehensive, accurate, and standardized assessment of the resident's functional capacity. Telephone interview on 06/15/26 at 12:27 P.M. with Medicaid Representative #705 confirmed that their office did not instruct any facility to not complete MDS assessments as required. Interview on 06/15/26 at 12:40 P.M. with Regional Registered Nurse (RRN) #710 confirmed Resident #111's medical record did not have evidence of an admission MDS or any subsequent MDS assessments because the resident was a transfer from a sister facility who had a fire, and he was educated by the corporate office that the MDS assessments did not have to be completed for Resident #111 since she was a transfer. Email interview on 06/16/26 at 9:15 A.M. with the Administrator confirmed the facility followed the Resident Assessment Instrument (RAI) manual on completing assessments. The Administrator confirmed that six residents were transferred to the facility following a fire at a sister facility including Residents #103, #105, #107, #108, #109 and #111. 2. Review of the medical record for Resident #107 revealed an admission date of 03/13/26 with diagnoses including dementia, schizophrenia and atrial fibrillation. Review of the MDS 3.0 Comprehensive Assessment list revealed Resident #107 did not have any MDS assessments completed by the facility since admission. It was noted she had an entry MDS initiated on 03/13/26 but then it was inactivated. She also had an admission assessment dated [DATE] which was also inactivated. Review of emails provided by RRN #710 dated from 03/20/26 through 06/02/26 revealed direction given from Medicaid staff on 03/25/26 was for the originating facility to submit MDS's based on their routine schedule. Interview on 06/15/26 at 8:29 A.M. with Registered Nurse (RN) #715 revealed Resident #107 was a transfer from one of their sister facilities who had a fire and had to perform an evacuation. He stated Resident #107 had been at the facility for three months. He verified there were no MDS's completed per directive from his management team. Interview on 06/15/26 at 9:16 A.M. with RRN #710 revealed MDS assessments for Resident #107 were not being completed by the facility or the sister facility (originating facility). He stated he had received directive from management that the assessments did not have to be completed until they returned to the originating facility by a Medicaid representative. Interview on 06/15/26 at 10:09 A.M. with RRN #710 where he presented documentation from Centers for Medicare and Medicaid Services (CMS) related to Frequently Asked Questions for Provider Survey and Certification for Declared Public Health Emergencies and All Hazards Health Standards and Quality Issues. He stated he had received this document from Medicaid Representative #705 on 03/27/26. Review of the document with him revealed when a resident returns to the evacuating facility within 30 days from the evacuation date, the facility would continue with the MDS cycle as though the resident was never transferred/discharged . However, if the evacuating facility determined the resident would not be able to return in the 30-day time frame, the evacuating facility should discharge the resident by completing a discharge assessment within the 30-day time frame. The receiving facility would then admit the resident if it was the resident's choice to stay there. RRN #710 verified the facility did not follow the documentation's guidance. Interview on 06/15/26 at 12:27 P.M. with Medicaid Representative #705 revealed she had spoken to the facility and its representatives. She verified she had not stated to the facility to not do the MDS assessments for the residents who had been evacuated. She stated they should have been doing the MDSs as directed by the guidance she had sent them on 03/27/26. Email interview on 06/16/26 at 9:15 A.M. with the Administrator confirmed the facility followed the RAI manual on completing assessments. The Administrator confirmed that six residents were transferred to the facility following a fire at a sister facility including Residents #103, #105, #107, #108, #109 and #111. 3. Review of the medical record for Resident #109 revealed an admission date of 03/13/26 with diagnoses including quadriplegia, depression and anxiety. Review of the MDS 3.0 assessment list revealed Resident #109 did not have any MDSs completed by the facility since admission. It was noted she had an entry MDS initiated on 03/13/26, but it was inactivated. Review of emails provided by RRN #710 dated from 03/20/26 through 06/02/26 revealed direction given from Medicaid staff on 03/25/26 was for the originating facility to submit MDSs based on their routine schedule. Interview on 06/15/26 at 8:29 A.M. with RN #715 revealed Resident #109 was a transfer from one of their sister facilities who had a fire and had to perform an evacuation. He stated Resident #109 had been at the facility for three months. He verified there were no MDSs completed per directive from his management team. Interview on 06/15/26 at 9:16 A.M. with RRN #710 revealed MDSs for Resident #109 were not being completed by the facility or the sister facility (originating facility). He stated he had received directive from management that the assessments did not have to be completed until they returned to the originating facility by a Medicaid representative. Interview on 06/15/26 at 10:09 A.M. with RRN #710 where he presented documentation from CMS related to Frequently Asked Questions for Provider Survey and Certification for Declared Public Health Emergencies and All Hazards Health Standards and Quality Issues. He stated he had received this document from Medicaid Representative #705 on 03/27/26. Review of the document with him revealed when a resident returns to the evacuating facility within 30 days from the evacuation date, the facility would continue with the MDS cycle as though the resident was never transferred/discharged . However, if the evacuating facility determined the resident would not be able to return in the 30-day time frame, the evacuating facility should discharge the resident by completing a discharge assessment within the 30-day time frame. The receiving facility would then admit the resident if it was the resident's choice to stay there. RRN #710 verified the facility did not follow the documentation's guidance. Interview on 06/15/26 at 12:27 P.M. with Medicaid Representative #705 revealed she had spoken to the facility and its representatives. She verified she had not stated to the facility to not do the MDS assessments for the residents who had been evacuated. She stated they should have been doing the MDSs as directed by the guidance she had sent them on 03/27/26. Email interview on 06/16/26 at 9:15 A.M. with the Administrator confirmed the facility followed the RAI manual on completing assessments. The Administrator confirmed that six residents were transferred to the facility following a fire at a sister facility including Residents #103, #105, #107, #108, #109 and #111.

Based on record review and interview, the facility failed to ensure comprehensive assessments were completed timely. This finding affected three (Residents #107, #109 and #111) and had the potential to affect all six residents (Residents #103, #105, #107, #108, #109 and #111) who were transferred to the facility from a sister facility following a fire. The facility census was 95. Findings include: 1. Review of Resident #111's medical record revealed the resident was admitted to the facility 03/13/26 as a transfer from a sister facility with diagnoses including paraplegia, essential hypertension and legal blindness. Review of Resident #111's medical record revealed the admission Minimum Data Set (MDS) 3.0 Comprehensive assessment dated [DATE] with a description of Inactivation of Entry. The MDS did not reflect the resident's medical, functional, and psychosocial conditions. This included identifying the resident's strengths and needs to maintain or improve the resident's overall status using the appropriate Resident Assessment Instrument (RAI), such as a comprehensive, quarterly, or significant change assessment. The facility did not ensure the accuracy and integrity of the resident's assessment including proper documentation, qualified professional involvement, and adherence to observation periods. Telephone interview on 06/15/26 at 12:27 P.M. with Medicaid Representative #705 confirmed that their office did not instruct any facility to not complete MDS assessments as required. Interview on 06/15/26 at 12:40 P.M. with Regional Registered Nurse (RRN) #710 confirmed Resident #111's medical record did not have evidence of an accurate MDS assessment because the resident was a transfer from a sister facility who had a fire, and he was educated by the corporate office that the MDS assessments did not have to be completed for Resident #111 since she was a transfer. Email interview on 06/16/26 at 9:15 A.M. with the Administrator confirmed the facility followed the Resident Assessment Instrument (RAI) manual on completing assessments. The Administrator confirmed that six residents were transferred to the facility following a fire at a sister facility including Residents #103, #105, #107, #108, #109 and #111. 2. Review of the medical record for Resident #107 revealed an admission date of 03/13/26 with diagnoses including dementia, schizophrenia and atrial fibrillation. Review of the MDS 3.0 assessment list revealed Resident #107 did not have any MDS's completed by the facility since admission. It was noted she had an entry MDS initiated on 03/13/26 but then it was inactivated. She also had an admission assessment dated [DATE] which was also inactivated. The MDS did not reflect the resident's medical, functional, and psychosocial conditions. This included identifying the resident's strengths and needs to maintain or improve the resident's overall status using the appropriate RAI, such as a comprehensive, quarterly, or significant change assessment. The facility did not ensure the accuracy and integrity of the resident's assessment including proper documentation, qualified professional involvement, and adherence to observation periods. Review of emails provided by RRN #710 dated from 03/20/26 through 06/02/26 revealed direction given from Medicaid staff on 03/25/26 was for the originating facility to submit MDS assessments based on their routine schedule. Interview on 06/15/26 at 8:29 A.M. with Registered Nurse (RN) #715 revealed Resident #107 was a transfer from one of their sister facilities who had a fire and had to perform an evacuation. He stated Resident #107 had been at the facility for three months. He verified there were no MDS assessments completed per directive from his management team. Interview on 06/15/26 at 9:16 A.M. with RRN #710 revealed MDS's for Resident #107 were not being completed by the facility or the sister facility (originating facility). He stated he had received directive from management that the assessments did not have to be completed until they returned to the originating facility by a Medicaid representative. Interview on 06/15/26 at 10:09 A.M. with RRN #710 where he presented documentation from Centers for Medicare and Medicaid Services (CMS) related to Frequently Asked Questions for Provider Survey and Certification for Declared Public Health Emergencies and All Hazards Health Standards and Quality Issues. He stated he had received this document from Medicaid Representative #705 on 03/27/26. Review of the document with him revealed when a resident returns to the evacuating facility within 30 days from the evacuation date, the facility would continue with the MDS cycle as though the resident was never transferred/discharged . However, if the evacuating facility determined the resident would not be able to return in the 30-day time frame, the evacuating facility should discharge the resident by completing a discharge assessment within the 30-day time frame. The receiving facility would then admit the resident if it was the resident's choice to stay there. RRN #710 verified the facility did not follow the documentation's guidance. Interview on 06/15/26 at 12:27 P.M. with Medicaid Representative #705 revealed she had spoken to the facility and its representatives. She verified she had not stated to the facility to not do the MDS assessments for the residents who had been evacuated. She stated they should have been doing the MDS's as directed by the guidance she had sent them on 03/27/26. Email interview on 06/16/26 at 9:15 A.M. with the Administrator confirmed the facility followed the RAI manual on completing assessments. The Administrator confirmed that six residents were transferred to the facility following a fire at a sister facility including Residents #103, #105, #107, #108, #109 and #111. 3. Review of the medical record for Resident #109 revealed an admission date of 03/13/26 with diagnoses including quadriplegia, depression and anxiety. Review of the MDS 3.0 Comprehensive Assessment list revealed Resident #109 did not have any MDS assessments completed by the facility since admission. It was noted she had an entry MDS initiated on 03/13/26 but then it was inactivated. The MDS did not reflect the resident's medical, functional, and psychosocial conditions. This included identifying the resident's strengths and needs to maintain or improve the resident's overall status using the appropriate RAI, such as a comprehensive, quarterly, or significant change assessment. The facility did not ensure the accuracy and integrity of the resident's assessment including proper documentation, qualified professional involvement, and adherence to observation periods. Review of emails provided by RRN #710 dated from 03/20/26 through 06/02/26 revealed direction given from Medicaid staff on 03/25/26 was for the originating facility to submit MDS assessments based on their routine schedule. Interview on 06/15/26 at 8:29 A.M. with RRN #715 revealed Resident #109 was a transfer from one of their sister facilities who had a fire and had to perform an evacuation. He stated Resident #109 had been at the facility for three months. He verified there were no MDS assessments completed per directive from his management team. Interview on 06/15/26 at 9:16 A.M. with RRN #710 revealed MDS assessments for Resident #109 were not being completed by the facility or the sister facility (originating facility). He stated he had received directive from management that the assessments did not have to be completed until they returned to the originating facility by a Medicaid representative. Interview on 06/15/26 at 10:09 A.M. with RRN #710 where he presented documentation from the Centers for Medicare and Medicaid Services (CMS) related to Frequently Asked Questions for Provider Survey and Certification for Declared Public Health Emergencies and All Hazards Health Standards and Quality Issues. He stated he had received this document from Medicaid Representative #705 on 03/27/26. Review of the document with him revealed when a resident returns to the evacuating facility within 30 days from the evacuation date, the facility would continue with the MDS cycle as though the resident was never transferred/discharged . However, if the evacuating facility determined the resident would not be able to return in the 30-day time frame, the evacuating facility should discharge the resident by completing a discharge assessment within the 30-day time frame. The receiving facility would then admit the resident if it was the resident's choice to stay there. RRN #710 verified the facility did not follow the documentation's guidance. Interview on 06/15/26 at 12:27 P.M. with Medicaid Representative #705 revealed she had spoken to the facility and its representatives. She verified she had not stated to the facility to not do the MDS assessments for the residents who had been evacuated. She stated they should have been doing the MDS's as directed by the guidance she had sent them on 03/27/26. Email interview on 06/16/26 at 9:15 A.M. with the Administrator confirmed the facility followed the RAI manual on completing assessments. The Administrator confirmed that six residents were transferred to the facility following a fire at a sister facility including Residents #103, #105, #107, #108, #109 and #111.

Based on record review, interview, and review of the facility policy, the facility failed to ensure care planning conferences were completed at least quarterly. This affected two (Residents #10 and #111) of five residents reviewed for care planning. The facility census was 95. Findings include: 1. Review of Resident #10's medical record revealed the resident was admitted on [DATE] with diagnoses including dementia, bipolar disorder and essential hypertension.Review of Resident #10's medical record revealed a care conference was conducted on 09/30/25.Review of Resident #10's medical record revealed a care conference was conducted on 02/20/26.Review of Resident #10's Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment.Telephone interview on 06/14/26 at 10:32 A.M. with Resident #10's family member revealed she had missed the care conference and tried to reschedule, but the facility had never returned her phone calls. Telephone interview on 06/15/26 at 12:12 P.M. with Prior Social Service Designee (SSD) #701 confirmed Resident #10's care conferences were not completed at least quarterly.2. Review of Resident #111's medical record revealed the resident was admitted to the facility 03/13/26 as a transfer from a sister facility with diagnoses including paraplegia, essential hypertension and legal blindness.Review of Resident #111's medical record revealed a MDS 3.0 assessment dated [DATE] with a description of Inactivation of Entry.Review of Resident #111's social service progress note dated 05/14/26 at 11:20 A.M. revealed the clinical and administrative team gathered for a care conference at the daughter's request. The team waited for up to 15 minutes and the daughter did not show. A call was made in an attempt to reach the daughter at this time to enquire if she would still arrive that day and no answer was obtained.Telephone interview on 06/14/26 at 12:09 P.M. with Resident #111's family member revealed a care conference was not completed since the resident's transfer to the facility from a sister facility. The family member indicated she was told a care conference would be completed and the staff did not contact her to conduct one.Telephone interview on 06/15/26 at 12:12 P.M. with Prior SSD #701 confirmed Resident #111 was transferred from a sister facility on 03/13/26 and the medical record did not have evidence a care conference was completed since admission.Review of the Advanced Care Planning policy, revised 12/2022, revealed the Interdisciplinary Team (IDT) will coordinate with the resident and/or their responsible party, an appropriate plan of care for the resident's needs or wishes specific to person centered care based on the assessment and reassessment process within the required time frames.

Based on interview and record review, the facility failed to ensure accurate care plans were initiated and updated for two residents (Resident #20 and #24) of 25 residents reviewed for care planning. The facility census was 95.Findings include:1. Record review for Resident #24 revealed an admission date of 04/02/24. Diagnoses included hemiplegia and hemiparesis following intracerebral hemorrhage affecting the left dominant side, neuromuscular dysfunction of bladder and need for assistance with personal care. Review of the physician order for Resident #24 dated 12/15/25 revealed an order for Foley (indwelling) urinary catheter due to obstructive uropathy. An additional order dated 01/06/26 included Enhanced Barrier Precautions (EBP): Gloves and gown to be worn when providing dressing, bathing/showering, transferring, providing hygiene care, changing linens, changing briefs or assisting with toileting.Review of the Annual Minimum Data System (MDS) 3.0 assessment dated [DATE] revealed Resident #24 was cognitively intact. Resident #24 had an indwelling catheter and required partial/moderate assistance with toileting hygiene, bed mobility, and substantial/maximal assistance with chair/bed to chair transfer.Review of the medical record for Resident #24 revealed there was no care plan initiated for the indwelling urinary catheter and for EBP.During an interview and medical record review on 06/16/26 at 1:03 P.M., the Director of Nursing (DON) confirmed Resident #24 had no care plan for the indwelling urinary catheter or EBP initiated until after the surveyor inquired about the care plan on 06/15/26.2. Record review for Resident #20 revealed an admission date of 05/04/23. Diagnoses included type II diabetes mellitus, chronic kidney disease, and lack of coordination.Review of the Annual MDS 3.0 assessment dated [DATE] revealed Resident #20 was moderately cognitively impaired. Resident #20's vision was adequate with corrective lenses. Review of the medical record for Resident #20 revealed no care plan was initiated for vision or corrective lenses.During an interview on 06/15/26 at 9:13 A.M., Resident #20 was sitting up in his chair in his room with glasses on. Resident #20 revealed he cannot see well even with the glasses, he can only see movement, he cannot even see letters to read. During a record review and interview 06/15/26 at 11:12 A.M., Registered Nurse (RN) Unit Manager (UM) #604 confirmed Resident #20 did not have a care plan for vision or corrective lenses.During an interview on 06/16/26 at 12:40 P.M., Resident #20's daughter confirmed he had seen the eye doctor, received new glasses but his vision had progressively continued to worsen, and he had expressed concerns several times that he cannot see well even with the new glasses. She confirmed that his vision was expected to continue to worsen due to his disease process.During an interview on 06/16/26 at 1:19 P.M, RN UM #425 confirmed Resident #20 expressed concerns with her regarding his poor vision even with glasses.

Based on review of medical records, hospital records, and staff interviews, the facility failed to ensure that appropriate immediate care was provided to Resident #84 following a fall. Staff moved the resident despite her complaints of pain and before notifying the physician or Certified Nurse Practitioner (CNP) for further direction. Resident #84 was later found to have sustained multiple fractures. This affected one resident (Resident #84) of four residents reviewed for accidents. The facility census was 95.Findings include:Record review for Resident #84 revealed an admission date of 10/24/24. Diagnoses included metabolic encephalopathy, dementia, and muscle weakness.Review of the Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #84 was rarely or never understood. Resident #84 used a wheelchair for mobility, required supervision or touch assistance for meals, substantial/maximal assistance for toileting hygiene, bathing, bed mobility, lying to sitting on the side of the bed, had not attempted sit to stand and was dependent on staff for chair/bed to chair transfer. Resident #84 had no falls since admission. Review of the fall risk assessment dated [DATE] for Resident #84 revealed a score of 15 indicating Resident #84 was at risk for falls.Review of the care plan initiated on 09/25/25 and revised 06/03/26 revealed Resident #84 had an actual fall and was at risk of further falls. Interventions included assessing the resident's footwear for safety, encouraging non-slip socks and appropriate footwear to promote safety, defined parameter air mattress, encouraging the use of the call light to call for staff assistance and to wait for staff to arrive, and a floor mat to the right side of the bed. Review of the progress note for Resident #84 dated 06/03/26 at 6:20 A.M. completed by Licensed Practical Nurse (LPN) #468 revealed, Aide notified this nurse that she found resident on the floor beside her bed. This nurse entered room and resident was lying on her back with her head at the foot of the bed, and legs towards head of bed. No visible injury. Resident does state my legs hurt. She was lifted via 2-person assistance into bed. Neuro checks started. LPN #468 indicated that the CNP was notified and ordered a STAT (immediate or at once) x-ray of the pelvis and bilateral femurs.Review of the Medication Administration Record (MAR) revealed Resident #84 received Tylenol 325 milligrams (mg) (analgesic) on 06/03/26 at 4:31 A.M. and 11:38 A.M. Review of the MAR and progress notes for May and June 2026 for the two weeks prior to the fall on 06/03/26 revealed no indication of Resident #84 having pain.Review of the progress note dated 06/03/26 at 11:57 A.M. revealed Resident #84's x-ray results included a left femur fracture. A new order was received to send her to the emergency department (ED) for evaluation and treatment.Review of the progress note dated 06/03/26 at 1:28 P.M. revealed Resident #84 was sent out to the ED at this time.Review of the Hospital Notes from Care Team/Discharge Summary for Resident #84 attestation signed 06/09/26 at 12:11 P.M. by Medical Doctor (MD) #730 revealed ED to hospital admission on [DATE]. Reasons for hospitalization included trauma, acute pain due to trauma, closed displaced supracondylar fractur with intracondylar extension of lower end of right femur, closed displaced supracondylar fractur without intracondylar extension of lower end of left femur. Hospital Course information included questionable right radial neck fracture, and subacute T5/T12 compression fracture. Resident #84 was admitted under trauma services. Single shot bilateral femoral nerve blocks with exparel were done. Medical decision making confirmed by MD #735 revealed during the hospital stay the patient (Resident #84) was found to have multiple traumatic injuries including bilateral distal femurs, and right proximal radial head. There were additional age indeterminate fractures appreciated on imaging. Resident #84 reports significant discomfort throughout her body. During the course of the ED evaluation, she was given intravenous (IV) fluids and a small dose of morphine. She ultimately underwent splinting with assistance of the orthopedic team. Given polytrauma and concern for possible neglect by the facility, Resident #84 was recommended for hospitalization for trauma tertiary assessment, pain management. The case was discussed with family who opted for non-operative management.Review of the progress note dated 06/05/26 at 1:03 A.M. revealed Resident #84 was hospitalized for multiple fractures.Review of the progress note dated 06/07/26 at 4:17 P.M. revealed Resident #84 returned to the facility.During a telephone interview on 06/16/26 at 7:55 A.M., Certified Nursing Assistant (CNA) #602 confirmed she was the CNA who found Resident #84 on the floor on 06/03/26 and reported it to the nurse. She recalled Resident #84's fall on 06/03/26 and stated that in the morning she was in the room next door providing care at approximately 4:15 A.M. She heard shouting from Resident #84, finished providing care, which took about 10 to 15 minutes, and then went to see why Resident #84 was yelling. She found her on the floor, went to get the nurse, and reported that the resident had fallen. The nurse and the CNA assisted in returning Resident #84 to bed. The resident said her knees were hurting and was yelling out in pain. They used a bath blanket, lifting the resident back into bed. The nurse informed her that the resident had also fallen out of bed the previous week.During a telephone interview on 06/16/26 at 8:10 A.M., Licensed Practical Nurse (LPN) #468 reported that shortly after 4:00 A.M., CNA #602 called out to her from down the hall. When she went to the room, she found Resident #84 lying directly beside the bed, with the resident's head positioned near the foot of the bed and her feet near the head of the bed. Resident #84 asked what she should do. LPN #468 stated she did not observe any bruising; the resident's knees were bent, and she complained of pain in her legs. LPN #468 explained that she checked Resident #84's vital signs and completed neurological checks while the resident was still on the floor. She then turned the resident and placed a sheet underneath her. CNA #602 held two corners of the sheet, and LPN #468 held the other two so they could lift the resident back into bed.LPN #468 reported that she then contacted the Nurse Practitioner because she believed the resident would need an X ray due to the leg pain. She added that the resident continued to complain of discomfort, so she administered Tylenol and noted that it was unusual for Resident #84 to report pain.During a telephone interview on 06/16/26 at 9:33 A.M., MD #720 explained that when a resident experiences a fall, the decision to move them depends on whether the clinical setting is safe. If there is any medical concern, emergency medical services (EMS) should be called.During an interview on 06/16/26 at 1:33 P.M., the Regional Director of Clinical Operations #725 and the Director of Nursing (DON) confirmed that when a resident falls and reports pain, staff should not move the resident until the physician or CNP has been notified and provides direction on how to proceed with the transfer.

Based on record review, observation, interview, and review of the facility policy, the facility failed to ensure expired medications were discarded and insulin vials were appropriately dated and discarded as appropriate. This finding affected two (Residents #4 and #19) of two residents identified during the audit of three medication administration carts. The facility census was 95.Findings include:1. Review of Resident #4's medical record revealed the resident was admitted on [DATE] with diagnoses including Parkinson's disease with dyskinesia, essential hypertension and type II diabetes mellitus without complications.Review of Resident #4's physician orders revealed an order dated 03/09/26 (discontinued 03/10/26) for Lantus long-acting insulin inject 10 units subcutaneously at bedtime for diabetes; an order dated 03/10/26 (discontinued 04/20/26) for Lantus long acting insulin inject 10 units subcutaneously at bedtime for diabetes; and an order dated 5/07/26 for Glargine Solostar (Lantus) long acting insulin inject 10 units subcutaneously at bedtime for diabetes. Notify the physician for a blood sugar less than 70 or greater than 400.Review of Resident #4's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.During observation on 06/14/26 from 1:30 P.M. to 1:36 P.M. of three medication administration carts and medication storage rooms with the Director of Nursing (DON) revealed the East Hall Long Term Medication Cart B, Resident #4's Lantus KwikPen long-acting insulin was opened and used with no open date and no expiration date.During an interview on 06/15/26 at 1:30 P.M., the DON also confirmed Resident #4 received the Lantus KwikPen long-acting insulin from the East Hall Medication Cart B which was not dated, and she was unable to determine if the insulin was expired. 2. Review of Resident #19's medical record revealed the resident was admitted on [DATE] with diagnoses including rheumatoid arthritis, essential hypertension and muscle weakness.Review of Resident #19's physician orders revealed an order dated 03/10/25 for COQ10 capsule 100 milligrams (mg) give 100 mg by mouth in the morning for supplement.Review of Resident #19's Quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment.During observation 06/14/26 from 1:30 P.M. to 1:36 P.M. of the South Hall Medication Cart, an over-the-counter bottle of CQ10 100 mg expired on 04/2026.During an interview on 06/14/26 at 1:36 P.M., the DON confirmed Resident #19 was the only resident who received CQ10 100 mg from the South Hall Medication Cart. Review of the Medication Storage policy, revised 08/2014, revealed medications and biologicals were stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply was accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on medical record review, resident interview, and staff interview, the facility failed to honor resident preferences for getting out of bed. This affected one (Resident #37) of three residents reviewed for resident rights. The census was 87.Findings Include:Resident #37 was admitted to the facility on [DATE]. Her diagnoses were heart failure, chronic obstructive pulmonary disease, mild protein calorie malnutrition, infection and inflammatory reaction due to internal left knee, acute and chronic respiratory failure, acute kidney failure, pulmonary hypertension, encephalopathy, anemia, atrial fibrillation, cardiomegaly, major depressive disorder, muscle weakness, other bacterial infections of unspecified site, dysphagia, pneumonitis, and diverticulitis of intestine. Review of her minimum data set (MDS) assessment, dated 08/02/25, revealed she was cognitively intact.Review of Resident #37's MDS assessment, section GG, dated 08/02/25, revealed she needed substantial/maximum physical assistance to perform rolling in bed, and was dependent on staff for chair/bed to chair transfers.Review of Resident #37's care plan revealed the following: Resident #37 at times refuses treatment such as having labs drawn, taking medications, refusals of bathing and/or showering and allowing further care activities to be performed, which was dated 03/07/25. Interventions for this care plan included for the facility to document all refusals of showers, medications, treatments and care activities. Inform clinical leadership as deemed appropriate, and If resident refuses notify physician for alternate treatment or elimination of order, which was implemented on 03/06/25. Resident #37 had an additional care plan focus which documented: Resident #37 has demonstrated consistent noncompliance with acts of care, treatments and medication administration, which was implemented on 07/15/24. Intervention for this care plan included for the facility to document all refusals in Resident #37 clinical chart. Resident #37's care plan also revealed Resident #37 had the right to make decisions regarding their everyday lifestyle while residing in this skilled nursing facility (SNF), which was implemented on 02/04/25. Intervention for this care plan included for the facility to make every reasonable effort to meet the resident's stated preferences. Resident #37's care plan included Resident #37 was at risk for a self care deficit and/or decreased ADL performance related to their diagnosis of heart failure, COPD, respiratory failure, hypertension, metabolic encephalopathy, major depressive disorder (MDD), atrial fibrillation, anemia, weakness, dysphagia and bilateral knee osteoarthritis, which was implemented on 08/09/24. Interventions for this care plan included for the facility to assist of two via use of mechanical lift for transfers, and Resident #37 has historically self-limited due to unrealistic requests of clinical and therapy staff. Multiple instances of education have been provided as to the requests for records that Resident #37/her brother would need to make regarding feasibility of therapy. These interventions were added on 09/26/25.Review of Resident #37's progress notes, dated 05/01/25 to 09/26/25, revealed no documentation to support the behavior of refusing to get out of bed.Review of Resident #37's behavior logs, dated 08/27/25 to 09/26/25, revealed no documented behaviors to support her refusals to get out of bed.Interview with Resident #37 on 09/26/25 at 11:30 A.M. and 3:55 P.M. confirmed that she is never offered to get out of bed. She stated she will ask at times, but no one will assist her. She confirmed she gets frustrated by having to ask, that there are times she doesn't ask because she is frustrated.Interview with Certified Nursing Aide (CNA) #140 on 09/26/25 at 4:10 P.M. confirmed that Resident #37 does refuse to get out of bed. But, when asked if staff offer to get her out of bed, she stated, we probably don't offer to get her out of bed as often as we should, because of her history of refusing to get out of bed. When asked if the aides capture the refusals in documentation, she confirmed they do not.This deficiency represents non-compliance investigated under Complaint Numbers 2590124 and 2564784.

Based on medical record review, resident interview, and staff interview, the facility failed to honor resident preferences for getting out of bed. This affected one (Resident #37) of three residents reviewed for resident rights. The census was 87.Findings Include:Resident #37 was admitted to the facility on [DATE]. Her diagnoses were heart failure, chronic obstructive pulmonary disease, mild protein calorie malnutrition, infection and inflammatory reaction due to internal left knee, acute and chronic respiratory failure, acute kidney failure, pulmonary hypertension, encephalopathy, anemia, atrial fibrillation, cardiomegaly, major depressive disorder, muscle weakness, other bacterial infections of unspecified site, dysphagia, pneumonitis, and diverticulitis of intestine. Review of her minimum data set (MDS) assessment, dated 08/02/25, revealed she was cognitively intact. Review of Resident #37's MDS assessment, section GG, dated 08/02/25, revealed she needed substantial/maximum physical assistance to perform rolling in bed, and was dependent on staff for chair/bed to chair transfers. Review of Resident #37's care plan revealed the following: Resident #37 at times refuses treatment such as having labs drawn, taking medications, refusals of bathing and/or showering and allowing further care activities to be performed, which was dated 03/07/25. Interventions for this care plan included for the facility to document all refusals of showers, medications, treatments and care activities. Inform clinical leadership as deemed appropriate, and If resident refuses notify physician for alternate treatment or elimination of order, which was implemented on 03/06/25. Resident #37 had an additional care plan focus which documented: Resident #37 has demonstrated consistent noncompliance with acts of care, treatments and medication administration, which was implemented on 07/15/24. Intervention for this care plan included for the facility to document all refusals in Resident #37 clinical chart. Resident #37's care plan also revealed Resident #37 had the right to make decisions regarding their everyday lifestyle while residing in this skilled nursing facility (SNF), which was implemented on 02/04/25. Intervention for this care plan included for the facility to make every reasonable effort to meet the resident's stated preferences. Resident #37's care plan included Resident #37 was at risk for a self care deficit and/or decreased ADL performance related to their diagnosis of heart failure, COPD, respiratory failure, hypertension, metabolic encephalopathy, major depressive disorder (MDD), atrial fibrillation, anemia, weakness, dysphagia and bilateral knee osteoarthritis, which was implemented on 08/09/24. Interventions for this care plan included for the facility to assist of two via use of mechanical lift for transfers, and Resident #37 has historically self-limited due to unrealistic requests of clinical and therapy staff. Multiple instances of education have been provided as to the requests for records that Resident #37/her brother would need to make regarding feasibility of therapy. These interventions were added on 09/26/25. Review of Resident #37's progress notes, dated 05/01/25 to 09/26/25, revealed no documentation to support the behavior of refusing to get out of bed. Review of Resident #37's behavior logs, dated 08/27/25 to 09/26/25, revealed no documented behaviors to support her refusals to get out of bed. Interview with Resident #37 on 09/26/25 at 11:30 A.M. and 3:55 P.M. confirmed that she is never offered to get out of bed. She stated she will ask at times, but no one will assist her. She confirmed she gets frustrated by having to ask, that there are times she doesn't ask because she is frustrated. Interview with Certified Nursing Aide (CNA) #140 on 09/26/25 at 4:10 P.M. confirmed that Resident #37 does refuse to get out of bed. But, when asked if staff offer to get her out of bed, she stated, we probably don't offer to get her out of bed as often as we should, because of her history of refusing to get out of bed. When asked if the aides capture the refusals in documentation, she confirmed they do not. This deficiency represents non-compliance investigated under Complaint Numbers 2590124 and 2564784.

Based on observation, record review, interview and review of the facility's' payroll-based journal (PBJ) data, the facility failed to ensure sufficient staffing to meet the needs of residents. This affected seven residents (#1, #6, #8, #34, #49, #76, #82) of eight residents reviewed for sufficient staffing and had the potential to affect all residents. The facility census was 93. Findings include: 1. Review of the medical record for Resident #1 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included cellulitis, right below the knee amputation, generalized muscle weakness, difficulty walking, diabetes and chronic pain. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 was cognitively intact. He was continent of bowel and bladder, independent in eating, oral and personal hygiene and required supervision for toileting and showering. Review of the fall risk assessment dated [DATE] revealed Resident #1 was not at risk for falls. Observation and interview on 03/05/25 at 1:09 P.M. with Registered Nurse (RN) #207 revealed the activated call light system indicated which call lights had been activated and how long they remained unanswered. She confirmed Resident #1's call light had remained unanswered for 19 minutes. She revealed all call lights should be answered in less than 15 minutes. She confirmed there was not enough staff to complete all daily tasks, including showers and answering call lights timely. 2. Review of the medical record for Resident #6 revealed an admitted [DATE]. Diagnoses included cancer of the urinary system, weakness and hypertension. Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #6 was severely cognitively impaired. He was always incontinent of bowel and bladder and required setup help for eating, supervision for oral and personal hygiene, partial to moderate assistance for showering and was dependent on staff for toileting. Review of the fall risk assessment dated [DATE] revealed Resident #6 was at risk for falls. Review of the shower sheets dated 02/02/25 through 03/03/25 revealed Resident #6 received a bed bath on 02/20/25, 02/27/25, and 03/3/25. He refused a shower on 02/24/25 but requested a bed bath. Interview on 03/05/25 at 9:02 A.M. with Certified Nursing Assistant (CNA) #203 revealed most residents were supposed to receive a shower at least twice per week; she confirmed showers were not always provided consistently. Interview on 03/05/25 at 10:09 A.M. with Resident #6 and his son revealed Resident #6 had not received a shower since his admission to the facility; he only received bed baths, and it often took staff hours to respond to Resident #6's call light. He felt these issues were due to a lack of staff availability. 3. Review of the medical record for Resident #34 revealed an admitted [DATE]. Diagnoses included heart disease, irritable bowel syndrome, constipation and macular degeneration. Review of the quarterly MDS assessment data 12/31/24 revealed resident #34 was moderately cognitively impaired. She was frequently incontinent of bowel and bladder, required setup help for eating and partial to moderate assistance for oral hygiene, toileting, showering, dressing and personal hygiene. Review of the fall risk assessment dated [DATE] revealed Resident #34 was at risk for falls. Observation on 03/05/25 at 10:03 A.M. revealed resident #34's call light had been activated. CNA #204 answered Resident #34's call light after 21 minutes. Interview at the time of the observation with CNA #204 confirmed the activated call light system revealed Resident #34's call light remained unanswered for 21 minutes. CNA #204 revealed call lights should be answered as soon as possible, but within approximately five minutes. CNA #204 revealed it was especially difficult to respond to call lights during mealtime due to lack of staffing. 4. Review of the medical record for Resident #8 revealed and admitted [DATE]. Diagnoses included morbid obesity, heart failure, respiratory failure, weakness, difficulty walking and lack of coordination. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #8 was moderately cognitively impaired. He was incontinent of bowel and bladder, required set of help for eating, supervision for oral and personal hygiene, substantial or maximum assistance for showering almost dependent for toileting. Review of the fall risk assessment dated [DATE] revealed resident #8 was at risk for falls. Observation and interview on 03/05/25 at 1:09 P.M. with RN #207 revealed the activated call light system indicated which call lights had been activated and how long they remained unanswered. She confirmed Resident #8's call light had remained unanswered for 49 minutes. She stated all call lights should be answered in less than 15 minutes. She confirmed there was not enough staff to complete all daily tasks, including showers and answering call lights timely. 5. Review of the medical record for Resident #49 revealed an admitted [DATE]. Diagnoses included dementia, repeated falls, heart failure, depression, difficulty walking and weakness. Review of the quarterly MDS assessment dated [DATE] revealed Resident #49 was severely cognitively impaired. She was always incontinent of bladder and required setup help for eating, partial to moderate assistance for toileting and showering and substantial to maximal assistance for oral and personal hygiene. Review of the fall risk assessment dated [DATE] revealed Resident #49 was at risk for falls. Observation and interview on 03/05/25 at 1:09 P.M. with RN #207 revealed the activated call light system indicated which call lights had been activated and how long they remained unanswered. She confirmed Resident #49's call light had remained unanswered for 47 minutes. She stated all call lights should be answered in less than 15 minutes. She confirmed there was not enough staff to complete all daily tasks, including showers and answering call lights timely. 6. Review of the medical record for Resident #76 revealed an admitted [DATE]. Diagnoses included multiple sclerosis, paralysis of the left side, tremors and depression. Review of the quarterly MDS assessment dated [DATE] revealed Resident #76 was cognitively intact. She was always incontinent of bowel and bladder and required partial to moderate assistance for eating and oral care and substantial or maximum assistance for toileting, showering and personal hygiene. Review of the fall risk assessment dated [DATE] revealed Resident #76 was not at risk for falls. Interview on 03/05/25 at 8:57 A.M. with Resident #76 revealed she was given a shower less than once per week. She preferred a shower, not a bed bath. Interview on 03/05/25 at 9:02 A.M. with CNA #203 revealed most residents were supposed to receive a shower at least twice per week; she confirmed showers were not always provided consistently. Interview on 03/05/25 at 1:00 P.M. with CNA #203 confirmed she had written on the shower sheet for Resident #76 on 02/04/25 she could not complete four showers. (The shower sheet did not specify the other three residents affected). She stated it was due to lack of staffing. Interview on 03/05/25 at 1:09 P.M. with RN #207 revealed she was informed by CNA #203 on 02/04/25 she could not complete a shower for Resident #76, and agreed there were times showers were not completed due to lack of staff. Review of the shower sheets dated 02/04/25 through 03/04/25 revealed Resident #76 received a bed bath 02/04/25 and 02/25/25 and a shower on 02/07/25, 02/21/25, 02/28/25, 03/04/25. She refused a shower on 02/11/25. Review of the CNA shower tasks dated 02/07/25 through 03/04/25 revealed Resident #76 received a bed bath or shower on 02/07/25, 02/11/25, 02/14/25, 02/18/25, 02/28/25 and 03/04/25. (The shower sheets stated Resident #76 refused a shower on 02/11/25). Interview on 03/06/25 at 11:12 A.M. with the Director of Nursing (DON) confirmed information on resident shower sheets and CNA tasks was inconsistent. She could not confirm which information was accurate. 7. Review of the medical record for Resident #82 revealed an admitted [DATE] with diagnoses including unspecified injury of the head, hypoventilation, heart failure, hypoxia, and malnutrition. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #82 was cognitively intact. She was frequently incontinent of bladder and occasionally incontinent of bowel. She required partial to moderate assistance for eating and toileting and supervision or touch assistance for showering and personal hygiene. Review of the fall risk assessment dated [DATE] revealed Resident #82 was at risk for falls. Observation on 03/05/25 at 8:57 A.M. revealed Resident #82's call light had been activated for 24 minutes. At 9:06 A.M. an unknown aide entered Resident #82's room and assisted her out of her room and down the hall. Observation of the activated call light system confirmed Resident #82's call light remained unanswered for 33 minutes. Interview on 03/05/25 at 2:00 P.M. with Residents #82 and #85 (present for the interview with Resident #82) revealed call response was quite lengthy most of the time, and Resident #85 believed they did not have enough staff, which she attributed to the long call response. 8. Review of the PBJ data submitted by the facility for the fourth quarter of 2024 (July 1 - September 30), revealed the facility had a one-star staffing rating. Interview on 03/05/25 at 8:10 A.M. with CNA #201 revealed call lights were often not answered timely due to lack of staff, and staff often worked past their scheduled work hours in order to complete their job duties. Interview on 03/05/25 at 8:57 A.M. with CNA #203 revealed the facility would send employees home if they felt there were too many people working. She was often asked to stay over and pick up additional shifts to help with staffing issues. She normally worked through her lunch break in order to complete all tasks, and there were times she could not complete showers due to staffing issues. Interview on 03/06/25 at 9:37 A.M. with CNA #201 revealed she was assigned 18 residents for the day, ten of them required every two-hour check and change for incontinence. She was also responsible for getting people out of bed and making sure residents were turned and repositioned every two hours. She revealed the workload was often too much for one person to complete all tasks, and some tasks were left uncompleted. Interview on 03/06/25 at 9:59 A.M. with Scheduler #206 and the Administrator revealed the facility was staffed based on census and acuity. The administrative team met daily and made changes to the schedule as necessary, reaching out to employees who were not working and offering additional shifts. The Administrator revealed she had no knowledge of concerns from staff, residents or families regarding insufficient staff. She attributed the one-star rating for the PBJ to the use of agency staff at the time and believed the rating had improved since the report had been submitted. This deficiency represents noncompliance investigated under Master Complaint Number OH00162396 and Complaint Number OH00161454.

Based on observation, record review and interview, the facility failed to ensure call lights were answered in a timely manner. This affected five residents (#1, #8, #34, #49 and #82) of six residents reviewed for timely call light response. The facility census was 93. Findings include: 1. Review of the medical record for Resident #1 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included cellulitis, right below the knee amputation, generalized muscle weakness, difficulty walking, diabetes, and chronic pain. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 was cognitively intact. He was continent of bowel and bladder, independent in eating, oral and personal hygiene, and required supervision for toileting and showering. Review of the fall risk assessment dated [DATE] revealed Resident #1 was not at risk for falls. Observation and interview on 03/05/25 at 1:09 P.M. with Registered Nurse (RN) #207 revealed the activated call light system indicated which call lights had been activated and how long they remained unanswered. She confirmed Resident #1's call light had remained unanswered for 19 minutes. She revealed all call lights should be answered in less than 15 minutes. 2. Review of the medical record for Resident #8 revealed and admitted [DATE]. Diagnoses included morbid obesity, heart failure, respiratory failure, weakness, difficulty walking, and lack of coordination. Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #8 was moderately cognitively impaired. He was incontinent of bowel and bladder, required setup help for eating, supervision for oral and personal hygiene, substantial or maximum assistance for showering, and was dependent on staff for toileting. Review of the fall risk assessment dated [DATE] revealed Resident #8 was at risk for falls. Observation and interview on 03/05/25 at 1:09 P.M. with RN #207 revealed the activated call light system indicated which call lights had been activated and how long they remained unanswered. She confirmed Resident #8's call light had remained unanswered for 49 minutes. She stated all call lights should be answered in less than 15 minutes. 3. Review of the medical record for Resident #34 revealed an admitted [DATE]. Diagnoses included heart disease, irritable bowel syndrome, constipation, and macular degeneration. Review of the quarterly MDS 3.0 assessment data 12/31/24 revealed Resident #34 was moderately cognitively impaired. She was frequently incontinent of bowel and bladder, required setup help for eating and partial to moderate assistance for oral hygiene, toileting, showering, dressing and personal hygiene. Review of the fall risk assessment dated [DATE] revealed Resident #34 was at risk for falls. Observation on 03/05/25 at 10:03 A.M. revealed Resident #34's call light had been activated. Certified Nursing Assistant (CNA) #204 answered Resident #34''s call light after 21 minutes. Interview at the time of the observation with CNA #204 confirmed the activated call light system revealed Resident #34's call light remained unanswered for 21 minutes. CNA #204 revealed call lights should be answered as soon as possible, but within approximately five minutes. 4. Review of the medical record for Resident #49 revealed an admitted [DATE]. Diagnoses included dementia, repeated falls, heart failure, depression, difficulty walking, and weakness. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #49 was severely cognitively impaired. She was always incontinent of bladder and required setup help for eating, partial to moderate assistance for toileting and showering, and substantial to maximal assistance for oral and personal hygiene. Observation and interview on 03/05/25 at 1:09 P.M. with RN #207 revealed the activated call light system indicated which call lights had been activated and how long they remained unanswered. She confirmed Resident #49's call light had remained unanswered for 47 minutes. She stated all call lights should be answered in less than 15 minutes. 5. Review of the medical record for Resident #82 revealed and admitted [DATE]. Diagnoses included arthritis, difficulty walking, muscle weakness, hypothyroidism, osteoporosis, depression, cataracts, repeated falls, and artificial knee joints. Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #82 was cognitively intact. She was frequently incontinent of bladder and occasionally incontinent of bowel. She required partial to moderate assistance for eating and toileting and supervision or touch assistance for showering and personal hygiene. Review of the fall risk assessment dated [DATE] revealed Resident #82 was at risk for falls. Observation on 03/05/25 at 8:57 A.M. revealed Resident #82's call light had been activated for 24 minutes. At 9:06 A.M. an unknown aide entered Resident #82's room and assisted her out of her room and down the hall. Observation of the activated call light system confirmed Resident #82's call light remained unanswered for 33 minutes. Interview on 03/06/25 at 8:13 A.M. with the Administrator confirmed the expectation was for call lights to be answered in approximately 10 minutes. Review of the facility policy titled Resident call system dated March 2023 revealed resident call lights would be responded to in a timely manner. This deficiency represents noncompliance investigated under Complaint Number OH00161454.

Based on observation, interview, record review and facility policy review, the facility failed to ensure Resident #76 had access to a call light within their functional abilities. This affected one resident (#76) of three reviewed for call light accessibility and had the potential to affect six residents (#18, #21, #27, #61, #74 and #76) identified by the facility as using a modified call light. The facility census was 93. Findings include: Review of the medical record for Resident #76 revealed and admitted [DATE]. Diagnoses included Multiple Sclerosis, paralysis of the left side, tremors, and depression. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #76 was cognitively intact. She required partial to moderate assistance for eating and oral care and substantial or maximum assistance for toileting, showering, and personal hygiene. Review of the care plan dated 02/26/25 revealed Resident #76 who is at risk for a self-care deficit. Interventions included considering the need for assistive devices and determining factors that hindered the residents' limitations for movement, and encourage the resident to use the call light for staff assistance. Interview on 03/05/25 at 8:57 A.M. with Resident #76 revealed she had a call light pad lying on her chest. She revealed she could not push the pad. Observation at the time of the interview with Certified Nursing Assistant (CNA) #203 revealed Resident #76 could not touch the call pad with her hand. CNA #203 moved to the pad closer to Resident #76 and attempted to assist her in touching the call light pad. CNA #203 confirmed Resident #76 could not activate the call light to call for assistance. She said Resident #76 used the call light in the past; however, there was no documented evidence that she was able to use it. The Administrator stated she was going to place an order for an occupation therapy (OT) evaluation to determine an appropriate call light for Resident #76. Interview on 03/6/25 at 9:59 A.M. with the Administrator revealed she had no knowledge of Resident #76 being unable to use the call light pad. Review of the facility policy titled Resident Call System, dated March 2023, revealed the facility would provide an environment which assisted in meeting the residents' needs, including responding to call lights. This deficiency represents noncompliance investigated under Complaint Number OH00161454.

Based on record review, interview and facility policy review, the facility failed to ensure Residents #6, #74, and #76 received showers on a consistent basis. This affected three residents (#6, #74 and #76) of three residents reviewed for showers and had the potential to affect all residents. The facility identified all residents required assistance with showers. The facility census was 93. Findings include: 1. Review of the medical record for Resident #6 revealed an admitted [DATE]. Diagnoses included cancer of the urinary system, weakness, and hypertension. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 was severely cognitively impaired. He required setup help for eating, supervision for oral and personal hygiene, partial to moderate assistance for showering and was dependent for toileting. Review of the shower sheets dated 02/02/25 through 03/03/25 revealed Resident #6 received a bed bath on 02/20/25, 02/27/25, and 03/3/25. He refused a shower on 02/24/25 but requested a bed bath. Interview on 03/05/25 at 10:09 A.M. with Resident #6 and his son revealed Resident #6 had not received a shower since his admission to the facility; he only received bed baths. Resident #6's son revealed he would like to see his dad receive a shower one to two times a week; Resident #6 nodded in agreement. 2. Review of the medical record for Resident #74 revealed an admitted [DATE]. Diagnoses included stroke, paralysis, hypertension, and muscle weakness. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #74 was moderately cognitively impaired. He required partial to moderate help for eating, oral and personal hygiene and substantial to maximum assistance for toileting, showering, and dressing. Review of the shower sheets dated 01/07/25 through 02/28/25 revealed Resident #74 received a bed bath on 01/07/25 and a shower on 02/14/25. He refused a shower on 02/04/25 and 02/28/25. Review of the certified nursing assistant (CNA) shower tasks dated 02/04/25 through 03/05/25 revealed Resident #74 received a shower on 02/04/25, 02/18/25 and 02/22/25. (The shower sheet stated Resident #74 refused a shower on 02/04/25). 3. Review of the medical record for Resident #76 revealed and admitted [DATE]. Diagnoses included multiple sclerosis, paralysis of the left side, tremors, and depression. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #76 was cognitively intact. She required partial to moderate assistance for eating and oral care and substantial or maximum assistance for toileting, showering and personal hygiene. Review of the shower sheets dated 02/04/25 through 03/04/25 revealed Resident #76 received a bed bath 02/04/25 and 02/25/25 and a shower on 02/07/25, 02/21/25, 02/28/25, 03/04/25. She refused a shower on 02/11/25. Review of the CNA shower tasks dated 02/07/25 through 03/04/25 revealed Resident #76 received a shower on 02/07/25, 02/11/25, 02/14/25, 02/18/25, 02/28/25 and 03/04/25. (The shower sheet stated Resident #76 refused a shower on 02/11/25). Interview on 03/05/25 at 8:57 A.M. with Resident #76 revealed she was given a shower less than once per week. She preferred a shower, not a bed bath. Interview on 03/05/25 at 9:02 A.M. with CNA #203 revealed most residents were supposed to receive a shower at least twice per week; she confirmed showers were not always provided consistently. Interview on 03/06/25 at 11:12 A.M. with the Director of Nursing (DON) confirmed information on resident shower sheets and CNA tasks was inconsistent. She could not confirm which information was accurate. Review of the facility policy titled Bathing-Personal Care, dated August 2024, revealed residents would be offered a shower or bath twice a week and as needed. This deficiency represents noncompliance investigated under Complaint Number OH00161454.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, review of local police report, resident, family, and staff interviews, local police detective interview, review of the National Weather Service forecast, review of the facility Elopement Policy and Procedure, review of camera footage, the facility failed to provide adequate supervision to prevent Resident #37, who had a diagnosis of dementia, post- traumatic stress disorder (PTSD) and severe cognitive impairment, from leaving the facility without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious harm, injury, or death when Resident #37 was seen (by camera footage) on 11/23/24 at 11:07 P.M. standing inside the facility in front of the main door when a visiting family member entered from outside, punched in the door code and let Resident #37 out of the building without notifying staff. The resident's whereabouts remained unknown until 11/24/24 at 12:20 A.M. when a concerned citizen called the local police department after finding a confused male (later identified as Resident #37) sitting on the curb of a five-lane, heavily traveled street with speeds of 25 miles per hour (mph) to 35 mph approximately 0.6 miles from the facility. On 11/24/24 at 12:30 A.M. the police arrived and found Resident #37 confused with an abrasion to his left hand due to a fall. The squad transported Resident #37 to the emergency room (ER) for further evaluation. On 11/24/24 at 12:50 A.M. Licensed Practical Nurse (LPN) #423 received a call from the local police department stating Resident #37 was transported to the ER. The resident was missing from the facility for approximately one hour and 45 minutes without the knowledge of staff. The ambient air temperature outside on 11/23/24 was between 43 and 47 degrees Fahrenheit (F). This affected one resident (#37) of five residents reviewed for elopement. The facility identified 20 residents, #9, #19, #27, #37, #41, #44, #47, #49, #50, #52, #58, #59, #62, #63, #74, #75, #76, #83, #85, #90, who were at risk for elopement. The facility census was 89. On 12/03/24 at 1:30 P.M., the Administrator, Director of Nursing (DON), and Regional Director of Clinical Services (RDCS) #300 were notified Immediate Jeopardy began on 11/23/24 at 11:07 P.M. when the facility failed to provide adequate supervision to prevent resident elopement. Resident #37 was seen at the front door standing by the keypad when another resident's family member punched in the code and let Resident #37 out of the building and did not notify staff. A staff member reported hearing the door alarm sound, but did not respond as the staff member assumed the alarm was activated by staff member retrieving food. The Immediate Jeopardy was removed and deficiency corrected on 11/25/24 when the facility implemented the following corrective actions: On 11/24/24 at 12:43 A.M. the facility was alerted by the local police department Resident #37 was missing from the facility On 11/24/24 at 12:45 A.M. the door alarms were checked by LPN #500. On 11/24/24 at 1:00 A.M. RDCS #300 reviewed the facility elopement policy with no changes being made to the policy. On 11/24/24 at 1:00 A.M. the Administrator and DON were re-educated on the facility elopement policy by RDCS #300. On 11/24/24 at 3:11 A.M., upon return from the local ER, Resident #37 was placed on 1:1 supervision with Certified Nursing Assistant (CNA) #581. On 11/24/24 at 3:14 A.M., Resident #37 was assessed by the DON upon his return from the local ER. On 11/24/24 at 3:30 A.M., Resident #37's care plan was updated by Registered Nurse (RN) Minimum Data Set (MDS) Coordinator #350. The update included the addition of 1:1 supervision. On 11/24/24 at 11:30 A.M. Resident #37's 1:1 supervision was discontinued, and the resident was transferred to the facility secured memory care unit. Elopement risk assessments were completed on all 89 residents who resided in the facility. This was completed on 11/24/24 at 6:00 A.M. by RN Unit Manager #524. The assessments noted 20 residents were identified at high risk for elopement. All residents at high risk of elopement resided on the secured memory care unit. Subsequent elopement assessments would be completed on a quarterly and as-needed basis by the nursing leadership team. The Administrator re-educated all staff on 11/24/24 at 10:07 A.M. on the facility's elopement policy and procedure. Residents at high risk of elopement were listed in an elopement binder kept at the front desk. The binder was updated on 11/24/24. The binder included the resident's demographics, including a photograph. The elopement binder would be reviewed 5 times weekly and updated as needed by the Administrator or designee. The front door entrance code was changed on 11/24/24 by Maintenance Director #499. The facility implemented a plan for the door code to be changed weekly for six months, then as needed to address family members having the access codes. Resident #37's daughter and Visiting Family Member #375 were re-educated on the facility's elopement policy, visitation, and door access on 11/24/24 by the Administrator. An elopement drill was completed on 11/24/24 at approximately 1:00 A.M. This was coordinated by Director #499. The facility implemented a plan for ongoing elopement drills to be completed to verify staffs understanding and implementation of the facility elopement policy on alternate shifts monthly for six months, then quarterly thereafter. This would be completed by Maintenance Director #499 and overseen by the Administrator. On 11/25/24 at 9:00 A.M., signage was placed at the front entrance for families, visitors, and residents stating, Visiting Hours are 8am-8pm. Doors are locked in off-hours to ensure the safety of our residents. Call [PHONE NUMBER] for after-hour assistance. Questions may be directed to the Administrator. This was completed by the Administrator. On 11/25/24 at 9:30 A.M, an ad hoc Quality Assessment and Performance Improvement (QAPI) meeting was held. The Administrator presented the QAPI Team with investigation and all findings for discussion and review. Discussion included an action plan from the (elopement) incident involving Resident #37. Staff in attendance included the Administrator, DON, RN Unit Manager #524, RN MDS Coordinator #350, Social Service Designee (SSD) #710, Therapy Director #715, Activity Director #720, Maintenance Director #499, Housekeeping/Laundry Director #730, Food Service Director #735, Medical Director #765, Human Resources Director #755, Business Office Manager (BOM) #740, Admissions Coordinator #745, Pharmacy Consultant #760, and Scheduler #750. The facility implemented a plan for ongoing audits to monitor elopement risk to be completed on each unit and include a random sample of 3-5 residents weekly for four weeks, then randomly thereafter. The audits would include monitoring for residents who were exhibiting signs or symptoms which could be indicative of an increased elopement risk such as residents wandering aimlessly, with cognitive impairments, behavior patterns, packed belongings, statements of wanting to leave the facility, and/or staying near an exit door as well as auditing door codes and staff response time for door alarms. The audits would be completed by the Administrator, DON, or designee. The results of the audits would be reviewed in QAPI. The facility implemented a plan for all new employees to receive education on the facility's elopement policy upon hire during orientation by HR Director #755 or designee, then annually and as needed thereafter. Findings include: Review of the medical record for Resident #37 revealed an admitted [DATE] with diagnoses including dementia, chronic kidney disease Stage IV, depression, and PTSD. Review of the most recent elopement assessment dated [DATE] revealed the assessment did not identify the resident to be at risk for elopement. A care plan dated 09/03/24 revealed Resident #37 was an elopement/wander risk related to impaired safety awareness. Interventions included distracting the resident from wandering by offering pleasant diversions, structured activities, food conversation, television, or books. The care plan additionally instructed staff to provide structured activities including toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Resident #37 required supervision with eating, toileting and transfers. The assessment also noted the resident required set-up assistance with walking 50 feet. Review of the National Weather Service forecast at www.weather.gov revealed the weather in the Cleveland area on 11/23/24 included a high temperature of 47 degrees Fahrenheit (F) and low of 43 degrees F. Review of a police report dated 11/24/23 at 12:20 A.M. revealed a call was received from a concerned citizen that an elderly confused male was found sitting on the curb of the apron in front of a business. The citizen stated she would stand by in a white jeep with her flashers on until the police arrived. The police arrived on 11/24/24 at 12:30 A.M. and found the elderly male confused and had bleeding to his left hand. Officer #575 provided first aid and called for an ambulance. The elderly male was identified as Resident #37. The resident told police he lived in [NAME], Wisconsin and believed he was still there. Resident #37 stated he was out for a walk and fell . Resident #37 was sent by squad to the ER for further evaluation. Dispatch reached out to several nursing homes in the area and verified the nursing facility where Resident #37 resided. On 11/24/24 at 12:50 A.M. Resident #37's daughter was notified Resident #37 was in the ER. Review of the hospital discharge summary dated 10/24/24 at 2:52 A.M. revealed Resident #37 had imaging completed including computed tomography (CT) scan of the head, cervical spine, and an x-ray of the left hand. No acute findings were seen. Resident #37 had no complaints of neck pain. There was no evidence of a traumatic injury to the head, however there was an abrasion to his left hand which was cleaned at the ER. Review of a progress note dated 11/24/24 at 1:13 A.M. revealed another nurse received a phone call stating a male resident (later identified to be Resident #37) was found outside and taken to the ER. A head count was initiated, and all doors were checked to ensure doors and alarms were working properly. The ER called and reported the resident (#37) was okay and received imaging which resulted in negative findings. On 12/02/24 at 4:20 P.M. review of video footage with the Administrator revealed the video was a copy of a video taken on a computer screen. There was no date, but the time stamp read 11:07 P.M. The Administrator revealed the original video had a date of 11/23/24 and was no longer available. The video was viewed partially from a computer monitor and then from the Administrator's cell phone to get a clearer picture. In the video, Resident #37 was viewed standing in the lobby in front of the first set of doors with his right hand by the keypad located to the right of the sliding door. The lobby door opened (by a visiting female from the outside) and Resident #37 walked through the lobby door and stood in the vestibule between the entrance to the inside lobby and the outside main door for several seconds. A visiting female was then seen watching Resident #37 exit the vestibule through the outside door of the building. The visiting female walks through the lobby door turns around and was seen looking out of the doors, the lobby door was still open. The visiting female punched in a code and the lobby doors closed. The visiting female proceeds several feet through the lobby, pauses and turns one more time to look out the door of the lobby and proceeded to walk into the building. An attempted interview on 12/03/24 at 9:29 A.M. with Resident #37 revealed the resident stated it was a secret that he had left the facility. Resident #37 believed it happened in [NAME], Wisconsin. The resident then appeared to be agitated and ended the interview. Interview on 12/03/24 at 11:59 A.M. with Certified Nursing Assistant (CNA) #581 revealed on 11/23/24 she heard a door alarm sounding for a short period, then it went silent. CNA #581 revealed she did not respond to the alarm and reported she figured it was somebody getting food delivered. She stated she was unaware Resident #37 was missing until the facility received calls from Resident #37's daughter and the police. At 12:57 A.M. she completed a head count. CNA #581 stated she was assigned to provide one on one supervision to Resident #37 when he got back from the ER. Resident #37 was extremely tired and did not mention any information about the incident. CNA #581 assisted the resident to change his clothes, and then the resident went to bed. Resident #37 was wearing a hat fleece jacket socks and house shoes, and his hand was bandaged up. Interview on 12/02/24 at 12:20 P.M. with Resident #37's Power of Attorney (POA) #580 revealed she received a call from the police on 11/24/24 at 12:42 A.M. stating her father was found approximately a half mile down the street sitting on the curb and he did not have his rollator walker with him. Resident #37 told her he fell three times after he exited the facility. During the interview, POA #580 revealed she was extremely upset that someone let her father out of the facility. POA #580 stated her father often woke up at night due to PTSD and would call her. She would then tell him to go back to sleep. She believed her father awoke and could not find staff and started wandering down the hall to the lobby door and started banging on the door. She reported that while Resident #37 was out of the building, he had on his slippers and a fleece zippered jacket. Interview on 12/03/24 at 2:06 P.M. with CNA #316 revealed he was assigned to Resident #37 on 11/23/24, the night of the elopement. The CNA revealed the last time he had seen the resident, prior to the elopement was between 9:30 P.M. and 10:00 P.M. The resident was in his room, fully dressed. CNA #316 reported he knew Resident #37 to frequently sleep in his clothes. Resident #37 was lying in bed watching television. CNA #316 stated he had been providing care to other residents, and at approximately at 12:00 A.M. he was notified by another unnamed CNA that Resident #37 was missing from the facility. A head count was initiated. Resident #37 was not in his room at that time. CNA #316 viewed the camera footage and Resident #37 appeared to be pushing the keypad when a visitor came up to the front door, entered a code, opened the door and entered the facility, talked to Resident #37 and then the door closed with Resident #37 exiting the facility. Interview on 12/03/24 at 3:56 P.M. with LPN #500 revealed she was assigned to the memory care and west unit on 11/23/24, the night Resident #37 eloped. Resident #37 resided on the west unit. LPN #500 stated she was in the memory care unit when the elopement occurred. CNA # 316 was the only CNA assigned to the west unit. LPN #500 did not see Resident #37 until he came back from the emergency room and at that time, she assessed Resident #37. Resident #37 was placed on one-on-one supervision with CNA #581 following the incident. Interview on 12/03/24 at 4:06 P.M. with LPN #426 revealed she administered Resident #37 his medications on 11/23/24 at 8:45 P.M. LPN #426 stated she had last seen Resident #37 on 11/23/24 walking around the hall with other residents after dinner. Interview on 12/04/24 at 8:20 A.M. with Visiting Family Member (VFM) #375 revealed on 11/23/24 Resident #37 was standing at the door when she entered the building (after punching in a code). The VFM revealed Resident #37 stated he was an employee and wanted to leave. VFM #375 stated it was not her right to question or keep the person in the facility due to being an employee who worked in the facility. After letting Resident #37 out of the building she stated she punched in the code to close the lobby door. She reported the code to the door was common knowledge. Interview on 12/04/24 at 10:24 A.M. with the DON revealed on 11/23/24 the nurse was contacted by police and the Resident #37's daughter. After the notification, staff completed a head count and checked all doors to ensure proper function. The DON reviewed the camera footage and interviewed staff. Resident #37 was seen on camera going out the front door (on the video). The resident was evaluated in ER and upon return was placed on 1:1 supervision with a staff member. The next day Resident #37 was moved to the facility secured unit. Through her investigation, it was determined that staff did not report hearing the lobby door alarming. However, following the incident the facility conducted a Quality Assurance Performance Improvement (QAPI) meeting, placed a sign at the entrance of new visiting hours and all staff were re-educated. Interview on 12/05/24 at 7:05 A.M. with Officer #575 revealed on 11/23/24 he arrived on the seen and found an elderly man who was confused and who had an abrasion to the hand that was bleeding. The man stated he was from [NAME], Wisconsin. Officer #575 stated he provided first aid and called the squad. Dispatch began calling nursing homes in the area. Officer #575 verified the elderly man was Resident #37 and resided at this facility. Officer #575 revealed at the time of the incident Resident #37 was wearing a sweater and pants and should have had a warmer jacket. He stated the weather was approximately 40 degrees F. Interview on 12/05/24 at 1:00 P.M. with LPN #423 revealed on 11/23/24 she received a call from Resident #37's POA who was frantic and stated You guy did not know he was gone?. LPN #423 stated at the time she was talking to Resident #37's POA the police called. Staff then verified Resident #37 was missing and initiated a search and a head count. LPN #423 revealed she viewed the video and saw Resident #37 was trying to unlock the door from the top and push the keypad. LPN #423 stated she was in a room providing care to another resident and did not hear any alarm at the time Resident #37 eloped. Interview on 12/09/24 at 11:30 A.M. with a concerned citizen (Citizen #582), revealed she was driving down the road with her family and found a male (identified to be Resident #37) sitting in the middle of an apron, close to the street. The area was not well lit. She stated she initially drove past the resident before she turned around and entered the parking area through another entrance. Citizen #582 activated her hazard lights and called the police. Resident #37 tried getting up and fell . Citizen #582 stayed with the resident until the police arrived. Review of the facility's policy titled Elopement, revised October 2022 revealed the purpose of the policy was to identify a resident's risk for elopement, prevent a resident from exiting the facility without the knowledge of the staff and to delineate the reporting process if an elopement occurs. This deficiency represents non-compliance investigated under Master Complaint Number OH00160219 and Complaint Number OH00160218.

Based on interview, record review, review of facility video footage, review of the Ohio Department of Health (ODH) Certification and Licensure System (CALS) and review of the facility policy, the facility failed to ensure an allegation of potential neglect was reported to the State Survey Agency as required. This affected one (Resident #37) of six residents reviewed for neglect. Findings include: Review of the medical record for Resident #37 revealed an admitted [DATE] with diagnoses including dementia, chronic kidney disease Stage IV, depression, and post traumatic stress disorder (PTSD). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 had severe cognitive impairment. Review of a care plan dated 09/03/24 revealed Resident #37 was an elopement/wander risk related to impaired safety awareness. Interventions included distracting the resident from wandering by offering pleasant diversions, structured activities, food conversation, television, or books. The care plan additionally instructed staff to provide structured activities including toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Review of a police report dated 11/24/23 at 12:20 A.M. revealed a call was received from a concerned citizen that an elderly confused male was found sitting on the curb of the apron in front of a business. The citizen stated she would stand by in a white jeep with her flashers on until the police arrived. The police arrived on 11/24/24 at 12:30 A.M. and found the elderly male confused and had bleeding to his left hand. Officer #575 provided first aid and called for an ambulance. The elderly male was identified as Resident #37. The resident told police he lived in [NAME], Wisconsin and believed he was still there. Resident #37 stated he was out for a walk and fell . Resident #37 was sent by squad to the emergency room (ER) for further evaluation. Dispatch reached out to several nursing homes in the area and verified the nursing facility where Resident #37 resided. On 11/24/24 at 12:50 A.M. Resident #37's daughter was notified Resident #37 was in the ER. Review of a progress note dated 11/24/24 at 1:13 A.M. revealed another nurse received a phone call stating a male resident (later identified to be Resident #37) was found outside and taken to the ER. A head count was initiated, and all doors were checked to ensure doors and alarms were working properly. The ER called and reported the resident (#37) was okay and received imaging which resulted in negative findings. On 12/02/24 at 4:20 P.M. review of video footage with the Administrator revealed the video was a copy of a video taken on a computer screen. There was no date, but the time stamp read 11:07 P.M. The Administrator revealed the original video had a date of 11/23/24 and was no longer available. The video was viewed partially from a computer monitor and then from the Administrator's cell phone to get a clearer picture. In the video, Resident #37 was viewed standing in the lobby in front of the first set of doors with his right hand by the keypad located to the right of the sliding door. The lobby door opened (by a visiting female from the outside) and Resident #37 walked through the lobby door and stood in the vestibule between the entrance to the inside lobby and the outside main door for several seconds. A visiting female was then seen watching Resident #37 exit the vestibule through the outside door of the building. The visiting female walks through the lobby door turns around and was seen looking out of the doors, the lobby door was still open. The visiting female punched in a code and the lobby doors closed. The visiting female proceeds several feet through the lobby, pauses and turns one more time to look out the door of the lobby and proceeded to walk into the building. Review of the ODH CALS website revealed no Self-Reported Incident (SRI) of potential neglect had been reported regarding Resident #37's elopement from the facility. Interview on 12/03/24 at 9:00 A.M. with the Administrator stated she did not complete a SRI report to the State Survey Agency. The Administrator stated she received guidance from corporate stating elopements are not reportable. Review of the policy Abuse, Prohibition revised October 2022 revealed in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation is make, if the events that cause the allegation involve abuse or results in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures. This deficiency represents an incidental finding while investigating Complaint Number OH00160218.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, record review, review of an employee personnel file, review of video surveillance, review of a policy report, review of facility policy and interview, the facility failed to ensure Resident #1, a resident with cognitive impairment, was free from staff to resident abuse when Certified Nursing Assistant (CNA) #813 physically abused the resident while providing care. This resulted in Immediate Jeopardy and actual physical and psychosocial harm as a result of the physical abuse incident which occurred on 10/29/24 at approximately 9:30 P.M. when CNA #813 took Resident #1 to the bathroom and the CNA could he heard hitting (audio of skin to skin contact sounding like two smacks) could be heard on the surveillance video and the resident was heard crying out. Continued video surveillance showed CNA #813 coming out of the bathroom with Resident #1 and putting the resident back in bed at which time CNA #813 was observed hitting Resident #1 in the face. Resident #1 was observed on the surveillance video crying in emotional distress. This affected one resident (#1) of three sampled residents reviewed for abuse. The facility identified 23 residents residing on the secured memory care unit (SMCU), Resident #1, #4, #11, #18, #23, #31, #36, #40, #43, #46, #48, #49, #51, #53, #58, #62, #63, #74, #75, #76, #83, #85 and #89 at the time of the incident. The facility census was 89. On 11/12/24 at 2:27 P.M., the Administrator, Registered Nurse (RN) Corporate Director of Clinical Services (CDCS) #920 and the Director of Nursing (DON) were notified Immediate Jeopardy began on 10/29/24 when the facility failed to protect Resident #1's right to be free from physical and emotional/mental abuse by CNA #813. Video surveillance captured the incidents of abuse that occurred while the CNA was providing personal care services to the resident and video surveillance also captured the resident's emotional distress as a result of the incident. The Immediate Jeopardy was removed and corrected on 10/30/24 when the facility implemented the following corrective actions: On 10/29/24 at 10:17 P.M. following family notification of the incident observed on video surveillance to the local police, CNA #813 was taken into police custody by the police department. CNA #813's employment was terminated on 10/29/24. On 10/29/24 at 11:00 P.M. Resident #1 was assessed by RN Unit Manager (UM) #808. On 10/30/24 at 10:00 A.M. Resident #1's care plans were reviewed and updated by RN Minimum Data Set (MDS) #914 to include the following new behavioral focus interventions: Any incident of combativeness while providing care must be immediately reported to appropriate clinical management; Any instances of providing hands-on care to Resident #1 now required two qualified staff members, without exception; And assure resident, staff and visitor safety to the best of the staff's ability and within reason. On 10/29/24 from 11:00 P.M. to 10/30/24 at 1:00 A.M. RN UM #808 assessed all residents on the SMCU for evidence of abuse which included skin checks and pain assessments. On 10/30/24 from 10:00 A.M. to 12:00 P.M. all resident, including the 23 residents on the SMCU (Residents #1, #4, #11, #18, #23, #31, #36, #40, #43, #46, #48, #49, #51, #53, #58, #62, #63, #74, #75, #76, #83, #85 and #89) were reviewed by RN MDS #914 to ensure they were accurate to meet the residents' needs. On 10/30/24 at 10:00 A.M. the facility abuse policy was reviewed by RN CDCS #920 with no updates or changes being made. On 10/29/24 at 10:15 P.M. RN CDCS #920 re-educated the Administrator and the DON on the facility abuse policy and procedure. On 10/30/24 at 10:00 A.M. a new procedure was developed by the DON: Residents on the SMCU Become a Two-Person Assist During an Episode of Combative Behavior. Compliance would be monitored by the DON and Administrator three to five days per week for four weeks then quarterly thereafter. All findings of concern would be immediately addressed and reported to the Quality Assurance Performance Improvement (QAPI) committee for further review and prompt response and resolution. On 10/29/24 from 10:42 P.M. to 10/30/24 at 2:00 P.M. the Administrator re-educated all staff on the Abuse Policy and the new procedure for Residents on the SMCU Become a Two-Person Assist During an Episode of Combative Behavior. Re-education was provided to a total of five RNs, 19 Licensed Practical Nurses (LPNs), 36 CNAs, 17 dietary Staff, two Activity Staff, 13 Housekeeping/Laundry Staff and 20 therapy staff (all staff in the building). Beginning on 10/29/24 at 9:00 A.M. and continuing through 10/30/24 at 2:00 P.M all current staff were educated on facility's dementia-focus program, Compass Training, by the Administrator. New employees would receive dementia focused training, Compass Training, upon hire during orientation by Activity Director #815 and/or designee, then annually and as necessary thereafter. On 10/30/24 at 11:00 A.M., the Administrator presented the QAPI team with the abuse investigation and all findings were discussed and reviewed. The discussion included an action plan from the incident regarding Resident #1 and the staff to resident abuse. Staff in attendance included the DON, RN UM #808, RN MDS #914, Social Service Designee (SSD) #916, Therapy Director #921, Activity Director #815, Maintenance Director #814, Housekeeping/Laundry Director #842, Dietary Manager #834, Pharmacy Consultant #922, the Medical Director, Human Resources #907 and Business Office Manager (BOM) #848. On 10/30/24 at 3:00 P.M. an audit was completed by the Administrator and DON to monitor compliance of the abuse education. The audit included monitoring skin assessments for injuries of unknown origin on cognitively impaired residents and interviews of non-cognitively impaired residents for allegations of abuse. On 10/30/24 the facility implemented a plan for the Administrator, DON and/or designee to conduct an audit on three to five residents per week for four weeks, and randomly thereafter. The audit included monitoring skin assessments for injuries of unknown origin on cognitively impaired residents and interviews of non-cognitively impaired residents for allegations of abuse. All findings of concern would be immediately addressed and reported to the QAPI committee for further review and prompt response and resolution. Findings include: Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with late onset, senile degeneration of the brain and unspecified dementia without behavioral disturbance. The resident resided on the facility SMCU. Review of Resident #1's behavioral care plans revealed (with a revision date of 04/21/23) revealed the resident had a behavior problem related to throwing clothes at times, was resistant to care due to dementia, rummages through things. Interventions included to administer medications as ordered, anticipate and meet the resident's needs, provide opportunity for positive interaction and attention, discuss resident's behaviors, praise any indicate of the resident's progress/improvement in behavior, provide a program of activities that was of interest and accommodates the resident's status. Review of Resident #1's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident exhibited a memory problem, was occasionally incontinent of urine, always continent of bowel, and required setup or clean-up assistance with toilet hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). Review of Resident #1's progress note dated 10/29/24 at 4:43 P.M. revealed the resident had restless periods during the day. However, she did not have any incidents of aggressive behavior towards staff, visitors, other residents or family members documented. Review of a facility Self-Reported Incident Investigation (SRI) Tracking Number 253495 dated 10/29/24 revealed the facility reported an incident of physical abuse involving Resident #1. The SRI included at approximately 10:15 P.M. the police were onsite at the request of the resident's family member after witnessing CNA #813 hit Resident #1 on the room surveillance camera. The police arrested and removed CNA #813 from the facility at the time of the incident. The facility immediately suspended CNA #813 pending an investigation and the resident's safety was maintained. CNA #813 was terminated as a result of the facility investigation. The facility substantiated the allegation/incident of abuse. Review of a police department report revealed abuse occurred on 10/29/24 at 9:33 P.M. The synopsis section of the form indicated on 10/29/24 at approximately 9:34 P.M., the police were dispatched to the facility for an assault that had recently occurred between a patient (Resident #1) and a staff member (CNA #813). The staff member was arrested and charged with patient abuse which was a fourth-degree felony. The documentation reflected surveillance video which was four minutes and 13 seconds long. During the first three minutes and 15 seconds of the video, the resident and CNA #813 seemed to be inside the restroom. At two minutes and thirteen seconds into the video surveillance, CNA #813 asked Resident #1 what she was doing. At two minutes and seventeen seconds into the surveillance video, CNA #813 told Resident #1 to put her underwear on. At two minutes and twenty-five seconds into the surveillance video, CNA #813 tells Resident #813 to stand up and at two minutes twenty-six seconds into the surveillance video, the resident said she was not standing up. A smacking sound was heard on the surveillance video. At two minutes and twenty-eight seconds into the surveillance video, another smacking sound was heard and then Resident #813 was heard sobbing and saying oh, my God many times. At three minutes and fifteen seconds into the surveillance video, CNA #813 and Resident #1 were observed walking out of the restroom and the resident was guided by the CNA towards the bed while the resident was sobbing. At three minutes and 29 seconds into the surveillance video, CNA #813 placed Resident #1's legs on the bed while the resident was striking the CNAs shoulder. At three minutes and thirty-one seconds into the surveillance video, CNA #813 hit the resident's face with her open palm which caused the resident to cover her face and state oh, my God and start to sob. At four minutes and thirteen seconds into the surveillance video, CNA #813 turned off the lights and opened the door of the room. Review of Resident #1's progress note dated 10/29/24 at 11:00 P.M. revealed the resident was resting quietly in bed with her eyes closed. The nurse assessed the resident and the resident's pulse oximetry on room air and the resident had not voiced any complaints of pain/discomfort at the time. Vital signs were obtained with a blood pressure at 144/55, pulse 65 beats per minute (BPM) and respirations 18 breaths per minute. The resident's temperature was 97.6 degrees Fahrenheit. Review of Resident #1's progress note dated 10/30/24 at 6:51 A.M. revealed the resident returned to the facility with the daughter at this time and had dinner on leave of absence (LOA). Observation on 11/12/24 at 5:31 A.M. revealed Resident #1's door was shut. The resident was observed in a room on the facility SMCU. Observation on 11/12/24 at 5:57 A.M. revealed Resident #1 was in the dining room and small lounge off the dining room (directly beside the nursing station) on the SMCU. She appeared clean and was ambulatory. The resident was wearing nonskid socks and her hair was combed. No bruising was noted to the resident's face, head or neck area. However, due to the resident's cognitive impairment she was not interviewable or able to answer questions related to the incident of abuse. Interview on 11/12/24 at 6:12 A.M. with RN UM #808 revealed she was called on 10/29/24 by the DON and told to go to the facility because something happened. She stated she arrived approximately ten minutes after the call and was informed the police had arrested CNA #813. RN UM #808 stated the police and CNA #813 were already gone from the facility when she clocked in on 10/29/24 at 10:54 P.M. She denied Resident #1 had any new (visible) injuries, but stated she did have a yellow area on the right cheek from a prior fall and a bruise on her thigh from a prior fall. RN UM #808 stated at that time, the police, CNA #813 and (resident's)family were in the parking lot, but the resident's family members declined to come in the building. Interview on 11/12/24 at 6:35 A.M. with RN #812 (dayshift on the SMCU) revealed he had worked an extra four hours on the SMCU on 10/29/24 from approximately 6:30 P.M. to 10:25 P.M. and was unaware of any abuse concerns until the police walked up to the nursing station and addressed CNA #813. RN #812 indicated Resident #1 was in the main dining area on 10/29/24 around 9:15 P.M. when CNA #813 took the resident to her room for resident care and finished at an unknown time. RN #812 stated CNA #813 was sitting behind the nursing desk playing on her phone when the police came into the SMCU on 10/29/24 around 10:15 P.M. and addressed the CNA specifically. RN #812 stated the police did not talk to him and asked CNA #813 if she was aware of what was on video footage. RN #812 stated CNA #813 told the police she was trying to hold the resident's head down and the police told the CNA that was not evidenced per the video. RN #812 stated the police told CNA #813 that if Resident #1's family pressed charges, they were taking the CNA to jail. RN #812 stated the police then asked CNA #813 to walk with them and they left the unit. RN #812 stated he had assessed Resident #1 who was in bed sleeping and did not identify injuries to the resident per his assessment. Interview on 11/12/24 at 7:25 A.M. with the DON indicated she received a call from RN #816, the nightshift supervisor who stated the police were in the building to arrest CNA #813. The DON stated RN #816 had watched the video surveillance provided by Resident #1's family which confirmed physical abuse. The DON stated she had watched the video surveillance at a later (unknown) time and stated CNA #813 put Resident #1 in bed and the resident was patting the CNA on her shoulder. The DON stated after CNA #813 put the resident in bed, she hit her in the forehead with an open palm. The DON stated the facility provided documentation including the type of camera approved by the facility and costs for installing/mounting the camera as well as release forms per Esther's Law on 10/28/24 but was unaware the family had put a camera in the room by the resident's bed for video surveillance. Telephone interview on 11/12/24 at 8:12 A.M. with CNA #817 revealed CNA #813 was working on the SMCU by herself, and she came in on 10/29/24 around 11:00 P.M. after the police had arrested CNA #813. CNA #817 stated she did not see any physical injuries when she had provided care to Resident #1 following the abuse incident. CNA #817 confirmed following the incident, she received education on abuse. Telephone interview on 11/12/24 at 9:40 A.M. with Resident #1's daughter confirmed she had viewed STNA #813 hitting her mother on the video surveillance (on 10/29/24) in the resident's room. Observation on 11/12/24 at 10:36 A.M. of the video surveillance provided by Resident #1's daughter and power-of-attorney (POA) for healthcare and financial revealed a clock in the surveillance video on the wall in the resident's room stated it was 9:27 P.M./ 9:28 P.M. The surveillance video confirmed two smacking sounds could be heard while Resident #1 and CNA #813 were in the bathroom followed both times by the resident's crying in emotional distress. Further observation revealed CNA #813 and Resident #1 walked out of the bathroom, the CNA roughly pushed the resident onto the bed, swung her legs up in the bed and hit the resident in the face. The resident was observed holding her face and crying out in emotional distress as a result of the incident. Interview on 11/12/24 at 11:38 A.M. with the DON revealed only full-time staff members who worked on the SMCU were provided Compass Dementia training the facility had implemented several months prior. The DON revealed CNA #813 was not a full-time staff member on the SMCU and therefore she had not been provided the Compass Dementia training although the employee was scheduled to work on the unit. Telephone interview on 11/13/24 at 9:22 A.M. with CNA #813 revealed she had provided care to Resident #1 and the resident was always hitting and kicking. When asked if she or anyone else hit or called Resident #1 names, she denied the allegation. The CNA then stated she would not discuss anything else with the surveyor unless her lawyer was present. Review of CNA #813's employee file revealed a hire date of 06/12/24 with a signed Job Description form dated 06/12/24. The Job Description form revealed to perform all duties within the guidelines of quality of care always including following resident rights policies and report any concerns to the licensed nurse. The employee's file included an Employee Corrective Action Form dated 10/29/24 which included the employee was terminated due to performance/policy violation and conduct issues. The termination was issued via the telephone. Observations during the onsite investigation revealed there were four units in the facility with a total census of 89 residents. The Special Care Unit (secured memory care unit or SMCU) had 23 residents residing on it which included, Resident #1, #4, #11, #18, #23, #31, #36, #40, #43, #46, #48, #49, #51, #53, #58, #62, #63, #74, #75, #76, #83, #85 and #89. Review of the facility undated Abuse Prohibition policy revealed each resident had the right to be free from abuse, neglect, and corporal punishment of any type by anyone. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also included the deprivation by an individual, including a caretaker, of goods or services that were necessary to attain or maintain physical, mental, and psychosocial well-being. Review of the facility Behavior Management; Dementia policy revised 02/2023 revealed the purpose of the policy was to ensure each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompassed a residents whole emotional and mental well-being, which included, but was not limited to, the prevention and treatment of mental and substance use disorders. This deficiency represents non-compliance investigated under Complaint Number OH00159638 and Complaint Number OH00159450.

Based on observation, record review, policy review, and interview, the facility failed to ensure Resident #1's care planned interventions were implemented related to wandering behavior and her safety was maintained at all times to prevent elopement from the facility. This finding affected one (Resident #1) of three residents reviewed for accidents and hazards. Findings include: Review of Resident #1's medical record revealed the resident was admitted on [DATE] with diagnoses including Alzheimer's disease with late onset, senile degeneration of the brain and unspecified dementia without behavioral disturbance. The resident resided on the secured memory care unit (SMCU). Review of Resident #1's care plans dated 12/27/22 and revised on 09/16/24 revealed the resident was an elopement risk/wanderer related to the resident's cognitive status and disorientation to place. An intervention dated 12/27/22 stated to assess for fall risk; an intervention dated 12/27/22 to distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and books; and an intervention dated 12/27/22 to provide structured activities, toileting, walking strategies including signs, pictures and memory boxes. Review of Resident #1's Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem. Observation on 11/14/24 at 2:08 P.M. of the facility surveillance video (no sound) of the secured memory care unit (SMCU) with the Director of Nursing (DON) revealed on 11/08/24 at 6:29 P.M., Resident #1 put a doll in a chair and pushed the chair across the common lounge then walked out into the hall, turned left and walked down the hall to the 15-second egress door on the left side of the SMCU (only a small portion of the door was observed on the facility surveillance video which was pointed at the common lounge area). The door was observed to open and close. Further observation revealed on 11/08/24 at 6:30 P.M., Registered Nurse (RN) #812 went to the 15-second egress door on the left hand side and opened the door but did not go out of the door to look for Resident #1. RN #812 was observed to walk back up the hall and towards the nursing station. Observation of the surveillance video on 11/08/24 at 6:42 P.M. revealed Laundry Aide #847 walking with Resident #1 back into the SMCU. The resident was outside of the building approximately thirteen minutes. Interview on 11/14/24 at 2:11 PM. with Laundry Aide #847 revealed she was in her car preparing to go home as she had clocked out at 6:32 P.M. when she observed Resident #1 standing on the side of the building by herself with no staff members nearby. Observation on 11/14/24 at 2:15 P.M. with the DON revealed the door on the SMCU in which Resident #1 went out was 101 steps from the window/grassy area where the resident was found (around the side of the building and standing beside the side windows on the property). Telephone interview on 11/14/24 at 2:15 P.M. with RN #812 revealed he thought staff were outside talking to Resident #1 and he thought those staff members would bring the resident back into the building. He was unable to state who the staff members were. RN #812 confirmed he did not go out and retrieve Resident #1 to ensure the resident's safety as indicated in the elopement policy. Interview on 11/14/24 at 2:22 P.M. with the DON confirmed Resident #1 was off the SMCU approximately 13 minutes per the facility surveillance video. The DON confirmed RN #812 should have went through the door to look for Resident #1 when the resident exited the building unsupervised. DON confirmed Resident #1's medical record did not include the resident's elopement. DON revealed they were unaware the resident was out of the building for 13 minutes. Review of the facility provided incident/accident log revealed Resident #1's elopement was not on the log. The facility did not have an investigation of the elopement for review. Review of Resident #1's medical record revealed the facility did not document the resident's 10/29/24 elopement or follow up measures to ensure the residents wellness and safety. Review of the Elopement policy revised 10/2022 revealed the purpose of the policy was to identify a resident's risk for elopement, prevent a resident from exiting the facility without the knowledge of the staff and to delineate the reporting process if an elopement occurs. A situation in which a resident leaves the premises or a safe area without the facility knowledge and supervision, if necessary, would be considered an elopement. The situation represents a risk to the resident's health and safety. If a resident is missing from the facility the facility would take steps including but not limited to the nurse/designee will initiate a full house head count of the residents. The staff member will announce Code Purple over the intercom system to alert the staff that a search will begin for the resident. The staff will report to the nurse's station and await further instructions from the Administrator, DON, or charge nurse. Staff will perform a thorough search of the inside of the facility and outside grounds of the facility. If the resident is located, the license nurses, will perform a head-to-toe body assessment and document the findings. The licensed nurse will complete an incident report with interview statements to reflect an investigation, and document in the nurses' notes. A detailed investigation as to the circumstances surrounding the incident will be completed by the Administrator and DON. The Administrator or DON will assure that an incident report is completed, a copy of the police report is obtained, staff interviews are gathered, interventions to prevent further incident are to be implement, and the care plan will be updated. The interdisciplinary Team will meet following an elopement to determine the resident's further needs. Cases of elopement will have corrective action and tracking by the QAA Committee.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview and facility policy review, the facility failed to ensure a Resident #88 had adequate supply of oxygen to attend an outside doctor's appointment. This affected one resident (#88) of three residents reviewed for respiratory services and had the potential to affect all residents that required oxygen. The facility identified 15 residents (#5, #6, #10, #15, #18, #32, #34, #41, #44, #76, #78, #81, #86, #87, and #88) who were dependent on oxygen. The facility census was 86. Findings include: Review of the closed medical record revealed Resident #88 was admitted to the facility on [DATE] and was discharged on [DATE]. Pertinent diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease, urinary tract infection, anxiety, and obstructive uropathy. Significant orders included, change disposable oxygen equipment weekly, and oxygen at two liters via nasal cannula (a device to deliver oxygen through the nose) as needed to keep oxygen saturation above 92%. Review of the admission assessment dated [DATE] revealed Resident #88 was alert and oriented to person, place, and time. Resident #88 was noted to have oxygen on via nasal cannula at 3.4 liters per minute with an oxygen saturation rate of 98%. Review of the care plan dated 04/02/24 revealed Resident #88 had oxygen related to chronic obstructive pulmonary disease. Interventions included to give medications as ordered by the physician and monitor for signs of respiratory distress. A review of progress notes dated 03/29/24, 04/05/24 and 04/10/24 revealed Resident #88 to be on oxygen at three liters per minute via nasal cannula. Review of the medical record revealed Resident #88 had an appointment with the urologist on 04/11/24 at 10:30 A.M. On 05/06/24 at 9:40 A.M. an interview with Licensed Practical Nurse (LPN) # 205 revealed Resident #88 had a doctor's appointment on 04/11/24 at 10:30 A.M. Between 10:00 A.M. and 10:30 A.M. the facility received a phone call from Resident #88's daughter stating Resident #88's oxygen tank was empty. LPN #205 stated she immediately got an oxygen tank and delivered it to Resident #88 at his doctor's appointment, approximately 15 minutes away. LPN #205 stated Resident #88 was not in distress upon her arrival. On 05/06/24 at 9:59 A.M. an interview with the Administrator and Director of Nursing (DON) revealed Resident #88's oxygen was ordered as needed, and his daughter would run the oxygen despite his needs. On 04/11/24, the resident's daughter called from the doctor's office stating the resident's oxygen tank was empty. The doctor's office was called, and the resident was not in distress. Facility staff (LPN #205) took an oxygen tank to the doctor's office immediately which was about 15 minutes away, and the resident was not in distress upon her arrival. (The doctor's office had oxygen available per the resident's daughter). Review of the medical record revealed Resident #88 had no more complications related to oxygen through his discharge to another facility on 04/19/24 at the request of his daughter. A review of the policy titled; Leave of Absence, dated October 2022, revealed appropriate equipment as necessary will be sent with the resident during appointments. The deficient practice was corrected on 04/13/24 when the facility implemented the following corrective actions: On 04/11/24, LPN #205 delivered an oxygen tank to Resident #88 at the doctor's office immediately after the facility was notified the oxygen tank ran out. Beginning on 04/11/24 the Director of Nursing (DON) in-serviced nursing staff ensuring an appropriate supply of oxygen was sent with residents on leave of absences (LOA) and doctors' appointments. All nurses were in-serviced by 04/13/24. Review of the LOA policy and education on 05/06/24 revealed all nursing staff had signed off on the in-service provided by the DON by 04/13/24. Interviews with LPN #205 and LPN #313 on 05/06/24 between 9:40 A.M. and 2:45 P.M. revealed they had been in-serviced by the DON and were knowledgeable of the policy for ensuring residents going on LOA had all needed equipment, including oxygen. There have been no further incidents. This deficiency represents non-compliance investigated under Complaint Number OH00152982.

Based on observation and interview the facility failed to ensure a home like dining atmosphere on the Memory Care unit. This affected 16 residents (#61, #64, #26, #65, #36, #83, #60, #20, #75, #57, #62, #55, #71, #78, #18, and #59) of 18 residents residing on the unit. The facility census was 86. Findings Include: Observation on 02/28/24 at 12:25 P.M., 16 residents (#61, #64, #26, #65, #36, #83, #60, #20, #75, #57, #62, #55, #71, #78, #18, and #59) were in the dining room eating their lunch. Also present in the dining room were three visiting family members. Maintenance #625 was standing directly across from the dining room. A large white round area was present on the wall. Maintenance #625 had a vacuum which he turned on and started sweeping the wall. After a few minutes the vacuum was turned off. Interview with Maintenance #625 on 02/28/24 at 12:30 P.M. revealed he normally did not vacuum during meals, but it only took a few moments to complete. Maintenance #625 confirmed vacuuming during the meals was disruptive.