Every finding on record at The Gardens of Fairfax Health Care Center

Based on closed record review, review of dialysis center documentation, review of an Emergency Medical Services (EMS) run sheet, interview and review of the facility policy, the facility failed to provide adequate amounts of oxygen to ensure safe breathing. This affected one resident (Resident #60) of one resident requiring oxygen on outside appointments. Facility census was 58. Findings include:Review of Resident #60's closed medical record revealed an admission date of 01/30/26 with diagnoses including end stage renal disease, reduced mobility, insomnia, hypertension, paraplegia, acute and chronic respiratory failure with hypoxia, type two diabetes and unspecified psychosis. Resident #60 discharged to home on [DATE].Review of Resident #60's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #60 was cognitively intact, did not ambulate, used oxygen and received dialysis services.Review of Resident #60's physician's orders revealed an order dated 02/02/26 for dialysis Mondays, Wednesdays and Fridays at [NAME] Shaker with an on time of 11:45 A.M. and an off time of 3:30 P.M. as well as an order dated 02/10/26 for oxygen at five liters via nasal cannula (NC) continuous.Review of a plan of care initiated 02/15/26 revealed Resident #60 required oxygen related to chronic respiratory disease and listed interventions including medications as ordered and observe for signs/symptoms of dyspnea (labored respirations, low oxygen saturation, use of accessory muscles, cyanosis, change in mental status or tachypnea).Review of a dialysis treatment report for Resident #60 dated 02/18/26 revealed treatment was completed from 12:37 P.M. to 3:35 P.M.Review of a progress note dated 02/18/26 at 5:39 P.M. and authored by Licensed Practical Nurse (LPN) #141 revealed at 5:29 P.M. [NAME] called this nurse and stated Resident #60's transportation was delayed to bring him back to the facility. They also stated Resident #60 ran out of the oxygen from the tank that was sent with him and that they did not have any emergency oxygen tanks to send with Resident #60 so they would have to send him to the emergency room (ER). This nurse asked nurse at [NAME] to assess Resident #60's oxygen to see what his measurements were. Nurse stated Resident #60 was at 96 (percent) with two liters via NC and dropped to 80 (percent) without oxygen and was in distress. This nurse also spoke with transportation to see if they could wait for the Assistant Director of Nursing (ADON) to bring a back up oxygen tank and transport hung up on this nurse. [NAME] nurse called back and this nurse informed her that if Resident #60 is in distress then to just send him to the ER.Review of an EMS run report dated 02/18/26 revealed a call placed at 5:39 P.M. for Resident #60 at the dialysis center. EMS arrived at the office on 02/18/26 at 5:46 P.M. Assessment completed on 02/18/26 at 6:05 P.M. revealed Resident #60 had a 97% oxygen saturation from supplemental oxygen. EMS arrived on scene and found Resident #60 sitting in his wheelchair in the lobby of the dialysis center. Resident #60's nurse states that he is not having a medical emergency. Resident #60 is oxygen dependent and is always on oxygen at three liters per minute (3lpm). Resident #60's portable oxygen tank ran out of oxygen while waiting for his ride to get there. The dialysis staff put Resident #60 on their own oxygen concentrator at 3lpm and called his nursing home. The nurse at the nursing home stated that there was no way for them to bring him a replacement oxygen tank; dialysis staff told them that Resident #60 cannot stay at dialysis all night and his ride was not willing to wait and did not have portable oxygen for Resident #60 to use. Nursing home staff told them to call 911. Resident #60 stated that this is not the first time the nursing home staff has sent him out [of the facility] with a partially empty oxygen tank and he has run out of oxygen outside before. EMS and dialysis staff used their Hoyer lift to transfer Resident #60 onto cot, EMS transferred Resident #60 to our oxygen and moved him to the ambulance. Delay on scene due to having to transfer Resident #60 and getting his wheelchair and oxygen tank to fit into the squad. Resident #60 monitored en route to ER. Pt is on four liters per minute on EMS' oxygen and has no complaints. EMS called the nursing home staff en route to ask why they could not bring Resident #60 oxygen; they said that the dialysis staff said Resident #60 could not stay at dialysis and the ride company contracted to bring him to the nursing home was not going to wait, so they could either have nursing home staff bring Resident #60 a full tank of oxygen or call 911, and the nurse in charge of Resident #60's care told them to call 911. EMS informed nurse that Resident #60 will still be out of oxygen when he is discharged from the ER and someone will still have to bring him a full tank because he is oxygen dependent.Review of a dialysis note dated 02/18/26 at 6:13 P.M. and authored by Dialysis Registered Nurse (DRN) #179 revealed Resident #60 completed his treatment awaiting for transportation in the lobby when he began complaining of not getting any oxygen from the oxygen tank provided by his nursing home. Resident #60 is dependent on oxygen and the oxygen tank was noted to be empty at this time. Resident #60 was placed on our unit oxygen concentrator at 2L via NC and felt better with decreased anxiety. Attempts to reach the nursing home unsuccessful ringing without answer. On third attempt I was able to talk to LPN #141 and explained the situation about Resident #60 requiring oxygen. After to and from dialogue about how to get the oxygen tank here at the dialysis center and transportation issues it was decided for Resident #60's safety and well being we would send Resident #60 to the ER via EMS. Resident #60 and sister called later to verify Resident #60's whereabouts.Review of a progress note dated 02/18/26 at 6:21 P.M. and authored by LPN #141 revealed EMS called this nurse stating Resident #60 was in their care and would be taken to Cleveland Clinic Foundation main campus.Review of an after-visit summary from the emergency department for Resident #60 dated 02/18/26 revealed a reason for visit as oxygen. You were seen today for running out of oxygen. An emergency medical condition was not identified at this time.Review of a progress note dated 02/18/26 at 10:54 P.M. and authored by LPN #175 revealed Resident #60 arrived back to the facility from the ER at 10:45 P.M. via stretcher per EMTs with no new orders and alert and oriented times three.Telephone interview on 03/05/26 at 9:55 A.M. with Resident #60 revealed while he was a resident at the facility, he had run out of oxygen and they never gave me enough. Resident #60 stated the facility would give him half-tanks of oxygen which is what happened on 02/18/26. Resident #60 stated he was waiting in the lounge for his ride to come post-dialysis and ran completely out of oxygen. Resident #60 said transportation would not take him due to not having oxygen and he was crying and upset over the whole situation. Resident #60 recalled dialysis staff saying if the facility would not bring him oxygen, he would have to go to the hospital and he ended up going to the hospital that night and then back to the facility.Interview on 03/05/26 at 1:28 P.M. with Registered Nurse (RN)/Assistant Director of Nursing (ADON) #144 revealed an e-tank would last two to three hours when delivered at five liters per minute, as Resident #60 was ordered.Telephone interview on 03/05/26 at 1:37 P.M. with Dialysis Registered Nurse (DRN) #177 revealed she often saw when Resident #60 came in for dialysis he would not have enough oxygen in the tank to get him back to the nursing home. DRN #177 confirmed Resident #60 used a portable oxygen tank which was not full and Resident #60 always ran out as he was waiting in the lobby on oxygen for his ride to leave dialysis.Telephone interview on 03/05/26 at 1:43 P.M. with Dialysis Patient Care Technician (DPCT) #178 revealed she was present with Resident #60 on 02/18/26 and shared Resident #60 came to dialysis with an oxygen tank from the nursing facility. They would take him off of his portable tank and put him on an oxygen concentrator for the duration of the dialysis treatment then Resident #60 went back on his portable oxygen tank after treatment and for transportation home. DPCT #178 recalled on 02/18/26 Resident #60 became upset, crying, huffing and puffing and stated his oxygen stopped. DPCT #178 rolled an oxygen concentrator to the lobby and hooked Resident #60 up to it as his own oxygen tank had no oxygen left in it. DPCT #178 verified Resident #60 did not have oxygen in the tank provided by the nursing home at this time. DPCT #178 stated they called the nursing home as he got off treatment at 3:45 P.M. and his transportation did not show until 5:10 P.M. which was around the time he ran out of oxygen. The nursing home staff (name not given) said they could be there in 20 minutes with an oxygen tank, then his transportation left, then Resident #60's transportation could not get him another ride until 7:00 P.M. At that time, 20 minutes had already elapsed and Resident #60 was offered to wait for the oxygen from the nursing facility or go to the hospital so Resident #60 was sent to the ER. DPCT #178 stated the dialysis center only had one e-tank with the crash cart and the rest of their oxygen were plug-in concentrators so they did not have additional portable oxygen to give to Resident #60.Telephone interview on 03/09/26 at 9:39 A.M. with Dialysis Facility Manager (DFM) #180 revealed she was not present on 02/18/26 when Resident #60 ran out of oxygen in the dialysis center's lobby but heard about it the next day. DFM #180 verified Resident #60 had been sitting in the lobby waiting for his transportation and his oxygen tank had run out. DFM #180 stated the dialysis center closed at 4:00 P.M. and nursing home staff (names not provided) could not arrive at the center until 6:00 P.M. DRN #179 had called and spoken with LPN #141 and the decision was made to send Resident #60 to the ER.During an interview on 03/09/26 at 2:37 P.M. the Administrator and the Director of Nursing (DON) were made aware of the above findings which verified Resident #60 did not have adequate oxygen supplies during dialysis on 02/18/26.Review of the facility policy, Oxygen Administration, revised 07/30/24 revealed oxygen is administered to residents who need it, consistent with professional standards of practice, comprehensive person-centered care plans and the residents' goals and preferences. Oxygen is administered under orders of a physician. The physician will be notified as needed for changes or complications associated with the use of oxygen. The policy did not address the use of oxygen with appointments outside of the facility.This deficiency represents noncompliance investigated under Complaint Number 2748103.

Based on observation, interview, review of meal times, and review of the dining room checklist, the facility failed to maintain effective communication and processes to ensure a timely meal service and ensure adequate portions of the main entree were available. This had the potential to effect all residents receiving meals from the kitchen. The facility identified one Resident (#7) as receiving nothing by mouth (NPO) who did not receive meals from the facility kitchen. The facility census was 61.Findings include: Observations on 02/11/26 of the lunch meal service revealed service began at 11:55 A.M. in the main kitchen area to serve residents who would be eating in their room. The menu included meatloaf, corn, and mashed potatoes. There were three insulated carts delivered. Following delivery of the carts, [NAME] #804 loaded trays of food from the steamtable into a heated cart and took the cart to the second floor servery at 12:34 P.M. [NAME] #804 unloaded trays onto another steamtable and began to take temperatures of each food item. There was a large spill of creamed corn on the floor which required clean up before meal service could continue. [NAME] #804 had forgotten the tray of meatloaf on the steam table in the main kitchen. There was no noted communication method with the main kitchen such as a walkie talkie or phone in the servery. [NAME] #804 asked a dietary aide who was assisting in the dining room to return to the main kitchen and retrieve the meatloaf. The dietary aide returned with the meatloaf. [NAME] #804 then realized there was only one plate available for serving in the plate warmer. [NAME] #804 again asked the dietary aide to return to the kitchen to retrieve plates. At 12:55 P.M., [NAME] #804 was able to serve the first plate to residents in the dining room. A puree diet served in bowls was ordered and [NAME] #804 did not have enough bowls in the servery. [NAME] #804 requested the dietary aide return to the main kitchen to retrieve bowls. Three hamburgers were requested from the alternate menu, however, [NAME] #804 had not brought hamburgers from the main kitchen. [NAME] #804 requested Dietary Manager (DM) #868 return to the kitchen to retrieve hamburgers for three alternate requests. Continued observation revealed [NAME] #804 had run out of the main entree of meatloaf. [NAME] #804 was unable to continue serving as the hamburgers had not arrived and she had run out of the main entree. [NAME] #804 and the dining room servers remained at the second floor servery waiting for the return of DM #868. At 1:24 P.M., [NAME] #838 brought up three hamburgers for the ordered alternates. At 1:31 P.M., DM #868 returned with additional hamburgers to substitute for main entree meatloaf. Following service in the dining room, there were four additional room trays. There was no meatloaf available for two residents which were served hamburgers as a substitute. The lunch meal service was completed at 1:42 P.M. There was not a method of communication with the main kitchen located in the servery. There was not a method of cleaning and sanitizing dishes located in the servery.Interview on 02/11/26 at 2:01 P.M. with DM #868 revealed she had worked at the facility for approximately one year. DM #868 stated there were only 30 residents when she started due to ongoing renovations. DM #868 stated the renovations were completed in October 2025 and they had been steadily gaining census. DM #868 stated they had been working on a process to serve room trays and the dining room. DM #868 stated the process was trial and error and she had to make several revisions in the process to date. DM #868 confirmed the current process was to serve residents who wished to eat in their room first from the main kitchen, then transfer the food to the servery on the second floor to serve the dining room. DM #868 confirmed there was not a method to clean and sanitize dishes in the second floor servery so all dishes had to be returned to the main kitchen after each meal. DM #868 confirmed there was no plates or bowls available at the start of the lunch meal service on 02/11/26. DM #868 confirmed there was not a current method of communication between the servery and the main kitchen such as a phone or handheld radio. DM #868 confirmed [NAME] #804 had run out of meatloaf as [NAME] #804 had used the preparation sheets for the wrong census. DM #868 indicated the preparation sheets were from the previous menu cycle which did not account for the increased census.Review of facility meal times undated revealed lunch was served from 11:45 A.M. to 12:30 P.M. It was noted meal times could vary by 15 minutes. Lunch was to be served to the 100 hallway at 11:45 A.M., to the 200 hallway at 12:00 P.M., to the 300 hallway at 12:15 P.M., and to the main dining room at 12:30 P.M.Review of Dining Room Set Up Checklist for lunch dated 02/10/26 revealed stocking plates and bowls to the servery was not included.

Based on resident record review and staff interview, the facility failed to ensure pharmacy recommendations approved by the physician were implemented in a timely manner. This affected one resident (#4) of five residents reviewed for pharmacy reviews. The facility census was 61.Findings include: Review of the medical record for Resident #4 revealed she was admitted to the facility on [DATE] with diagnoses of atrial fibrillation, schizophrenia, and type 2 diabetes mellitus with hyperglycemia.Review of the facility document titled Pharmacist Medication Regimen Review (MRR) dated 04/24/25 and 06/23/25 revealed Resident #4's medical records were reviewed and the consultant Pharmacist recorded the Medication Review Results referenced to see recommendations. Review of the facility document titled Note to Attending Physician/Prescriber (APP) dated 04/24/25 and 06/23/25 revealed the consultant Pharmacist made recommendations on both dates for laboratory testing, including Valproic Acid Level (VALs) and Liver Function Test (LFTs) to be completed. Both recommendates were signed by a physician as agree with the recommendations for Resident #4 to have the [NAME] and LFT laboratory testing completed. Review of the National Institute of Health (NIH) via www.nih.gov revealed LFTs included alanine transaminase (ALT), aspartate transaminase (AST), alkaline phosphatase (ALP), gamma-glutamyl transferase (GGT), serum bilirubin, prothrombin time (PT), the international normalized ratio (INR), total protein and albumin.Review of the laboratory drawings dated 10/08/24 through 08/13/25 revealed Resident #4 had laboratory draws for VALs, but lacked draws for LFTs. Continued review of the laboratory drawings dated 10/08/24 through 08/13/25 revealed Resident #4 did not have laboratory drawings for LFTs until 08/13/25, approximately four months after the initial request and two months after the second request. Review of the physician orders revealed no current, completed or discontinued orders for laboratory draws related to Resident #4's LFTs.Interview on 02/12/26 at 3:15 P.M. with the Director of Nursing (DON) confirmed and verified the above findings at the time of the interview.

Based on observation, interview, record review and facility policy review, the facility failed to ensure Resident #49's allegation of missing funds was reported to the State Agency. This affected one resident (Resident #49) out of three residents reviewed for misappropriation. The facility census was 61.Findings include: Review of Resident #49's medical record revealed an admission date of 01/19/26 and diagnoses included cerebral infarction due to embolism of the left vertebral artery, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and vascular dementia.Review of Resident #49's care plan dated 01/20/26 included Resident #49 required maximal assistance with ADL's (Activity of Daily Living)'s and might be at risk of developing complications associated with decreased ADL self-care performance related to decreased mobility, CVA with hemiparesis and dementia. Resident #49 would have his ADL needs met through his next review date. Interventions included Resident #49 required total care for grooming including nails, shaving, and hair.Review of Resident #49's admission Minimum Data Set (MDS) assessment dated [DATE] included Resident #49 had moderate cognitive impairment. Resident #49 had impairment on one side of the upper extremity and no impairment of the lower extremities, and used a wheelchair. Resident #49 was dependent for toileting hygiene, bathing, and dressing. Resident #49 required partial to moderate assistance for personal hygiene. Resident #49 did not reject care during the seven-day assessment look-back period.Review of Resident #49's progress notes dated 01/29/26 at 11:14 P.M. included Resident #49 asked staff to use his debit card to order food, and was informed that the staff could not use his card to order food. Resident #49's son and daughter were unable to be contacted, and the nurse notified the Supervisor regarding Resident #49's request. While giving report, Resident #49 activated his call light and told an aide someone stole his card and his money. The nurse and the on-coming nurse talked to Resident #49 and were told his card wasn't stolen but it was his money totaling $8000.00 that was stolen. Resident #49 showed the nurse his debit card, declined to have the card locked in the nurses cart, and wanted the police called about his missing $8000.00. Review of Resident #49's progress notes dated 01/30/26 at 6:39 A.M. revealed Resident #49 called the police and the police came tot he facility and interviewed him. Resident #49 continued to state he was missing $8,000.00 off his bank card. The police advised Resident #49 to call his bank and they opened a theft report on his behalf. Review of Resident #49's late entry progress note dated 01/30/26 at 10:15 A.M. included a follow up investigation was completed regarding Resident #49's concern related to missing funds. Resident #49 stated he was not accusing staff or the facility of taking his money and explained that he believed his bank account was compromised. Resident #49 reported that after several attempts to order food by phone his debit card was declined which prompted concern for possible account fraud. Resident #49 and Business Office Manager (BOM) #811 contacted the bank and his account activity was reviewed. Resident #49 never had a balance of 8000.00 in his account and recent transactions were reviewed for potential fraud. The bank locked Resident #49's debit card and advised Resident #49 a replacement card would be issued. Resident #49 confirmed he provided authorization for the facility to debit his account for patient liability payments. Resident #49 voiced no concerns regarding facility billing or staff involvement. The police came to the facility for a follow up visit and spoke with Resident #49 and BOM #811 and were told everything was taken care of with the bank and Resident #49 had no concerns. The police stated they would note the report as closed with no further action requested from the facility. Staff were re-educated regarding abuse prevention, reporting requirements, and proper handling of resident concerns. Resident #49 was provided a lockbox for his debit card which would be used once the replacement debit card was received. Observation on 02/10/26 at 8:38 A.M. of Resident #49 revealed he was lying in bed with the head of his bed elevated. Resident #49 stated he was unhappy at the facility and did not like the food. A breakfast tray was on his bedside table and was untouched except for a small bite out of a piece of toast. When asked if he told anyone he was unhappy at the facility Resident #49 stated he did not know what they knew, they stole my money and the police came twice.Interview on 02/10/26 at 3:49 P.M. with the Administrator revealed Resident #49 stated he was missing $8000.00. The Administrator stated she knew Resident #49 from other facilities and how much money he received monthly and he could not have had $8000.00 in his account. The Administrator stated before he was admitted to the facility he paid his patient liability and that was how she knew how much money he had in his account. The Administrator stated she contacted Resident #49's bank to inquire about the missing funds and Social Services Director (SSD) #810, BOM #811 and Resident #49 were present for the conversation. The bank staff confirmed Resident #49's account was hacked and the stolen money was refunded to his account. Resident #49 needed to go to the bank so he could update his address in person and then the bank would send a replacement debit card. The Administrator stated it was more of an identity theft and that was why she did not report the incident to the State Agency. The Administrator confirmed Resident #49's debit card was compromised and he had out of town charges on his debit card totaling $504.48. Resident #49 was not liable for the charges and his debit card was refunded the money. The Administrator indicated Resident #49 needed to go to the bank in person to change his address and then a new card would be mailed. The Administrator stated the facility did not consider it abuse because Resident #49 was not accusing anyone at the facility of stealing his money, it was a cyber attack and she did not think since she knew what happened that an SRI (Self-Reported Incident) needed initiated. Observation on 02/11/26 at 2:02 P.M. revealed Resident #49 was out of the facility and Licensed Practical Nurse (LPN) #802 stated SSD #819 accompanied him to the bank.Interview on 02/11/26 at 3:37 P.M. of SSD #819 confirmed she took Resident #49 to the bank and he said some of the charges on his account were not his. Resident #49 changed his address from the previous facility he resided in to the facility and his replacement card would be mailed within seven to ten days. SSD #819 stated she did not know details about Resident #49's missing money.Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated 11/21/16 included it was the facility policy to investigate all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of a resident, or Misappropriation of Resident Property, including Injuries of Unknown Source. Additionally the facility should immediately report all such allegations to the Administrator and the State Agency. In cases where a crime was suspected staff should also report the same to local law enforcement. Misappropriation of Resident Property was the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. 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 source and misappropriation or resident property, are reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the Administrator or designee of the facility and to other officials, including the State Survey Agency in accordance with State law.

Based on observation, interview, medical record review, and facility policy review, the facility failed to ensure residents who were dependent on care received the appropriate assistance. This affected three Residents (#5, #21, and #49) of four residents reviewed for activities of daily living (ADL) assistance. The facility census was 61.Findings include: 1. Review of the medical record for Resident #21 revealed an admission date of 08/16/22 and diagnoses included metabolic encephalopathy, diabetes mellitus, chronic obstructive pulmonary disease, and altered mental status. Review of plan of care dated 01/20/25 revealed Resident #21 may require assistance with ADLs due to cognitive impairment and disease process. Interventions included provide assistance with bathing and grooming which included nail care, shaving, and hair care. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #21 had a moderate cognitive impairment and was dependent on staff for ADLs including bathing and personal hygiene. Review of bathing forms from 01/07/26 to 02/07/26 revealed Resident #21 received a shower twice per week on Wednesdays and Saturdays. Resident #21 was last documented to have received assistance with shaving on 01/17/26. Observation on 02/10/26 at 10:05 A.M. revealed Resident #21 had hair growth on her chin which appeared to be between one eighth and a quarter of an inch in length. Observation on 02/11/26 at 9:12 A.M. revealed Resident #21 was in her wheelchair returning from the dining room on the second floor. Resident #21 continued to have facial hair on her chin. Interview on 02/11/26 at 2:20 P.M. with Certified Nursing Assistant (CNA) #800 revealed residents received shaving assistance on shower days. CNA #800 stated Resident #21 did not refuse care. CNA #800 observed Resident #21 and confirmed Resident #21 had facial hair growth. CNA #800 offered Resident #21 shaving assistance and Resident #21 agreed to receive shaving assistance. CNA #800 stated Resident #21 was due to have a shower that day and would provide shaving care during shower assistance. 2. Review of Resident #49's medical record revealed an admission date of 01/19/26 and diagnoses included cerebral infarction due to embolism of the left vertebral artery, hemiplegia and hemiparesis following cerebral infarction (CVA) affecting the right dominant side, and vascular dementia. Review of Resident #49's care plan dated 01/20/26 included Resident #49 required maximal assistance with ADLs and might be at risk of developing complications associated with decreased ADL self-care performance related to decreased mobility, CVA with hemiparesis, and dementia. Resident #49 would have his ADL needs met through his next review date. Interventions included Resident #49 required total care for grooming including nails, shaving, and hair. Review of Resident #49's admission MDS assessment dated [DATE] included Resident #49 had a moderate cognitive impairment. Resident #49 had impairment on one side of the upper extremity and no impairment of the lower extremities, and used a wheelchair. Resident #49 was dependent for toileting hygiene, bathing, and dressing. Resident #49 required partial to moderate assistance for personal hygiene. Resident #49 did not reject care during the seven-day assessment look-back period. Review of Resident #49's shower sheets dated 02/04/26 revealed Resident #49 was given a bed bath but refused to be shaved. There was no evidence on 02/04/26 an additional attempt was made to shave Resident #49. Review of Resident #49's shower sheet dated 02/07/26 revealed there was no evidence Resident #49 was shaved, encouraged to be shaved, or refused to be shaved. Observation on 02/10/26 at 11:11 A.M. of Resident #49 revealed he was lying in bed and a scruffy, scraggly beard could be seen with the hair about three quarters of an inch long. Resident #49 stated he would like to have his beard shaved, but no one had shaved his beard or offered to shave it for him. Interview on 02/10/26 at 2:56 P.M. of CNA #851 confirmed Resident #49 needed to be shaved and the hair of his beard was about three-quarters of an inch long. CNA #851 stated she had been off work for three days and was not at the facility to shave Resident #49. CNA #851 stated depending on who the aide was, Resident #49's care might or might not be done. CNA #851 indicated she was preparing to shave Resident #49 now. CNA #851 stated if Resident #49 needed care, she gave the care needed. Interview on 02/11/26 at 1:45 P.M. of CNA #807 revealed sometimes Resident #49 did not want to have his care provided when she offered, but if she went back to his room in about 15 minutes he was fine and would allow the care to be completed. CNA #807 stated Resident #49 allowed her to shave him and cut his fingernails. Interview on 02/11/26 at 2:13 P.M. of CNA #851 revealed Resident #49 allowed her to shave him on 02/10/26 and there were no issues. Interview on 02/11/26 at 2:41 P.M. of CNA #805 revealed Resident #49 required total care, he fed himself but needed help with everything else. CNA #805 indicated Resident #49 sometimes needed a lot of convincing to allow him to provide showers. CNA #805 stated shaving and nail care were provided as needed. CNA #805 revealed he worked on Saturday 02/07/26, Resident #49 was in his resident care assignment and he wanted a bed bath. CNA #805 confirmed he did not shave Resident #49 on 02/07/26 and there was no specific reason he was not shaved other than it was a busy day. 3. Review of the medical record for Resident #5 revealed he was admitted to the facility on [DATE] with diagnoses that included hypertensive heart disease without heart failure, hyperlipidemia, retention of urine, and dementia. Review of the MDS assessment dated [DATE] revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 11 that indicated he was alert and oriented with cognition impairment. Review of the MDS assessment revealed Resident #5 was dependent on staff for ADLs. Review of the physician orders dated 08/19/25 revealed an order for transfers via mechanical lift with assistance of two. Review of the care plan dated 05/02/23 revealed Resident #5 required assistance with ADLs and was at risk for alteration in elimination, completely incontinent of bladder and frequently incontinent of bowel with interventions that included provide incontinence care as needed. Interview and observation on 02/09/26 at 8:16 P.M. revealed Resident #5 seated in his wheelchair next to the right side of his bed, adjacent to the door. Upon entering Resident #5's, a strong odor consistent with urine was noted and was present in the immediate vicinity of the resident. Resident #5 stated staff don't check on me. I need help getting in and out of bed and help going to the bathroom. When I press the call light, they tell me not to press it, and they'll get to me when they can. Observation revealed Resident #5's call light was activated. Observation on 02/09/26 at 8:22 A.M. revealed multiple staff on the unit, near the nursing station. No staff was observed rounding the unit or assisting Resident #5 with his care. Interview and observation on 02/11/26 at 8:15 A.M. revealed Resident #5 seated on the edge of his bed, undressed from the waist down attempting to get dressed. Resident #5 stated I've been stuck in bed all morning and the staff is not worried about me. I didn't do anything wrong. Resident #5 revealed he informed Licensed Practical Nurse (LPN) #802 he wanted to get dressed and out of bed before his breakfast tray arrived. Resident #5 revealed he did not like eating his meals in his night clothes. Interview on 02/11/26 at 8:17 A.M. with LPN #802 revealed Resident #5 was dependent on staff for ADLs. LPN #802 revealed there were two CNAs assigned to assist on Resident #5's unit. LPN #802 revealed she informed CNA #805 of Resident #5's request and continued with the medication pass. Observation on 02/11/26 at 8:25 A.M. revealed LPN #802 entered Resident #5's room and exited a short time after. LPN #802 was then seen approaching CNA #805 and informed him that Resident #5 wanted to get cleaned up, dressed, and in his wheelchair to eat his breakfast. CNA #805 was observed entering Resident #5's room with a breakfast tray and exited the room without the breakfast tray. Interview on 02/11/26 at 8:30 A.M. with CNA #805 revealed breakfast trays had to be delivered before care could be provided to ensure all residents received their meals. CNA #805 revealed Resident #5 would be provided care after tray pass and when another CNA was present due to needing a 2-person assist. Review of the facility document titled Bathing: Bed Bath revised April 2002, revealed the facility had a policy in place to ensure residents receive clean, comfortable care that produced a sense of well-being. Review of the document revealed the facility did not implement the policy. Review of the facility policy titled Bathing: Bed Bath revised 04/2002 included the purpose was to provide cleanliness and comfort, to produce a sense of well-being, to stimulate circulation and relaxation and observe the condition of the resident.

Based on interview, record review, and review of the facility policy, the facility failed to ensure Resident #60's dialysis access site was immediately monitored upon her return to the facility from dialysis for bleeding and other complications. This affected one resident (#60) out of two residents reviewed for dialysis. The facility census was 61.Findings include: Review of Resident #60's medical record revealed an admission date of 12/25/25 and diagnoses included end stage renal disease (ESRD), type two diabetes mellitus with hypoglycemia, polyneuropathy and dependence on renal dialysis.Review of Resident #60's care plan dated 12/27/25 included Resident #60 was at risk for complications due to hemodialysis treatments three times weekly for ESRD. Resident #60 would receive hemodialysis treatments as scheduled with monitoring of disease process. Interventions included dialysis treatments were every Tuesday, Thursday and Saturday; monitor right upper chest tunneled dialysis catheter every shift and notify the physician of abnormalities. There was no evidence of an intervention to immediately monitor Resident #60's dialysis access site when she returned from dialysis for bleeding and other complications.Review of Resident #60's admission Minimum Data Set assessment dated [DATE] included Resident #60 was cognitively intact. Resident #60 had no impairment of the upper extremities and impairment on one side of the lower extremities and used a wheelchair. Resident #60 required supervision or touching assistance for toileting and personal hygiene, partial to moderate assistance with bathing, and substantial to maximal assistance for lower body dressing. Resident #60 required dialysis.Review of Resident #60's progress notes and assessments tab dated 01/12/26 through 02/04/26 did not reveal evidence Resident #60 was monitored immediately upon her return from dialysis including her dialysis access site.Review of Resident #60's Medication Administration Record and Treatment Administration Record dated 01/23/26 through 02/04/26 revealed Resident #60's right upper chest tunneled dialysis catheter was checked every shift. There no times documented, and a check mark was used, indicating the check was completed two times a day, sometime during the day shift and sometime during the night shift. Review of Resident #60's progress notes dated 02/04/26 at 9:09 P.M. revealed Resident #60 was transported to the ER for fluid overload.Interview on 02/11/26 at 9:42 A.M. of Licensed Practical Nurse (LPN) #802 revealed Resident #60 was non compliant with her diet and ate anything she wanted and that probably contributed to her hospital admission for fluid overload. LPN #802 stated Resident #60 had dialysis on Tuesdays, Thursdays and Saturdays. LPN #802 indicated she was not working when Resident #60 was admitted to the hospital for fluid overload, but a few days before that she had a stuffy nose, her appetite was poor, and STAT labs and a chest x-ray were ordered. LPN #802 stated when Resident #60 returned from dialysis her Dialysis Communication Form was placed in her dialysis binder and post dialysis vital signs were documented at the dialysis center. LPN #802 stated vital signs and Resident #60's access port did not need to be checked when she returned from dialysis because they were done at the dialysis center post dialysis. LPN #802 indicated she just found out there was a tab for dialysis assessment in the electronic record and she would be using it going forward. Interview on 02/11/26 at 12:15 P.M. of the Director of Nursing (DON) revealed a communication form was sent to the dialysis center with Resident #60 on her dialysis days. The DON stated the nurses documented vital signs and noted any concerns on the communication form before Resident #60 was transported to the dialysis center. The DON indicated the dialysis facility completed pre-dialysis and post-dialysis vital signs, medications administered during dialysis, and pertinent comments before Resident #60 was sent back to the facility. The DON stated the nurses should check vital signs and complete an assessment when Resident #60 returned from dialysis and the assessment should be in the progress notes. The DON indicated she would check Resident #60's medical record for evaluations completed when Resident #60 returned from dialysis including monitoring of Resident #60's dialysis access site. Interview on 02/11/26 at 2:30 P.M. of the DON revealed Resident #60 had her right upper chest tunneled dialysis catheter checked twice a day by the nurses. The DON confirmed there was no evidence Resident #60's dialysis catheter was monitored immediately upon her return from dialysis, the check twice a day could be anytime during the shift and could be hours after Resident #60 returned from dialysis. The DON stated Resident #60's blood pressure and pulse were checked three times a day in the morning, at lunch and at dinner.Review of the facility policy titled Dialysis Management dated 10/11/18 included the facility would assess, monitor for complications and provide adequate intervention in the management of those receiving hemodialysis based on physician orders and plan of care. The following might be included on the resident's plan of care including the resident's target pre and post weights, vital signs, or other monitoring required during the provision of the dialysis treatment.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLAINCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of the closed medical record, interview, review of the facility's investigation, interviews with facility staff, and review of the facility policy on elopement, facility failed to ensure staff provided adequate supervision to prevent Resident #50 from leaving the facility unsupervised. This affected one resident (#50) of three residents reviewed for elopement and supervision. The facility census was 47. Findings include: Review of the closed medical record for Resident #50 revealed an admission date of 05/14/24 and a discharge date of 09/16/25. Diagnoses included emphysema, malignant neoplasm of the cecum, malignant neoplasm of the upper left female breast, and personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits. Review of the Minimum Data Set (MDS) (modified) annual assessment, dated 06/12/25, revealed Resident #50 had severely impaired cognition. The resident was independent for mobility, transfers, toileting, ambulation, upper and lower body dressing, and donning and doffing footwear. Resident #50 had no episodes of recorded wandering. Review of mood revealed she had total severity score of 13, indicating moderate depression. Review of the care plan dated 06/12/25 revealed Resident #50 was at risk for elopement as she had exit-seeking behaviors and unaware of safety needs. Interventions included a wanderguard to the right ankle and chair, redirect as needed, and follow the facility elopement policy and procedures. Review of Resident #50's physician orders revealed an order dated 07/15/25 for Resident #50 to have a wanderguard (a wearable bracelet-like device used to monitor and prevent residents at risk for wandering from leaving designated areas. It is part of a larger system which includes sensors on doors which alarm and lock the doors when a resident approaches a monitored exit) on at all times to the right ankle and an additional order to check the placement and function of the wanderguard device every shift. Review of Resident #50's Treatment Administration Record (TAR) dated 07/15/25 through 09/22/25 revealed the resident's wander guard was documented as being on at all times to the right ankle and placement and function was documented as checked daily on both day and night shifts. Review of Resident #50's elopement risk assessment dated [DATE] revealed she was an elopement risk and scored a 4.0 as she had a history of eloping and had a lack of awareness of safety needs. Listed interventions in place were the wanderguard and safety checks. Review of Resident #50's nurse progress note dated 09/14/25 at 2:30 P.M. authored by Licensed Practical Nurse (LPN) #120 revealed the nurse was alerted by Certified Nursing Assistant (CAN) #151 that Resident #50 was missing. LPN #120 and other staff began looking for Resident #50 checking all rooms and bathrooms, checking the whole facility and outside. During the search for Resident #50, the resident's daughter and the hospital administrator called the facility and stated Resident #50 was at a local hospital emergency department (ED). The facility Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) was notified. Review of a witness statement dated 09/14/25 authored by CNA #151 revealed she was not assigned to Resident #50 but observed the resident in her wheelchair, rolling back and forth down the hallway, as she normally did. Later that morning, Resident #50 laid back down. When lunchtime came around, Resident #50 was informed it was time for lunch and stated she was not hungry. CNA #151 told her she would check back. About 1:45 P.M., she went to ask Resident #50 if she wanted to come down for church services and that's when she reported to the nurse that Resident #50 was not in her room. Review of a witness statement dated 09/14/25 authored by LPN #120 revealed she was assigned to Resident #50. Around noon, while administering a tube feeding to Resident #50's roommate, she observed Resident #50 lying in bed. After caring for the roommate, LPN #120 proceeded with passing scheduled medications and completing skilled charting at the nurse's station. Approximately 1:25 P.M., LPN #120 went on lunch break. Upon returning, a (unnamed) CNA informed her that another resident required her assistance and she provided that care. Shortly thereafter, a (unnamed) CNA informed her Resident #50 was not in her room. LPN #120 stated she immediately stopped what she was doing and initiated the facility's elopement policy. While conducting a search for Resident #50 and attempting to contact her family, the hospital called informing Resident #50 was in the emergency room (ER) requesting to be seen. LPN #120 explained to hospital staff that she did not send her and would go across the street to the ER and follow up with the resident. In addition, several attempts were made to contact Resident #50's daughter with no response. Review of a witness statement dated 09/14/25 from CNA #132 revealed he was alerted by another CNA that Resident #50 was not in her room. The nurse in charge gave instructions for the search and the elopement protocol was followed. CNA #132 searched the exterior part of the building. While doing so, he received a call instructing him to head across the street to a local hospital ER. Once there, he spoke with the security guard, who informed him that Resident #50 checked herself into the hospital. CNA #132 was escorted to her room where he observed her. He called her name, and she responded and recognized him. Hospital personnel informed him they reached out to her daughter to come and pick her up. CNA #132 immediately left the hospital, returned to the facility, and reported to the charge nurse. Prior to this, the last time he saw Resident #50 was at lunchtime, at approximately 12:30 P.M. He was not assigned to care for Resident #50 that day. Review of the witness statement dated 09/14/25, authored by Registered Nurse (RN) #137 revealed on 09/14/25, she observed Resident #50 in the morning after she finished her breakfast. At that time, RN #137 encouraged her to get dressed as she was still wearing her nightgown. Resident #50 was pleasant, agreed and proceeded to her room. Later that day, around lunchtime, RN #137 noticed Resident #50 in the common area with other residents. No distress was noted. RN #137 was not assigned to Resident #50 but was responsible for the 300 hall during her shift. At approximately 2:15 P.M., RN #137 was notified by a nurse aid that Resident #50 was not in her room. At that time, the elopement protocol was followed. RN #137 spoke with the family member in an attempt to provide details regarding the situation; however, she was unable to do so because the family member hung up during the conversation. Review of the witness statement dated 09/14/25 from CNA #118 revealed she was not assigned to Resident #50 however, she did observe her at lunchtime in the main dining room. During her shift, she was assigned to a separate hall and provided care for those residents. When informed by the nurse of a missing resident, she began looking for Resident #50. Review of the witness statement dated 09/14/25 from CNA #129 revealed she was assigned to Resident #50 and assisted her with morning care. Resident #50 was pleasant, and they had a good conversation. During lunch time, Resident #50 was encouraged to finish eating her food. After that, CNA #129 proceeded to provide resident care in another room. An interview on 09/22/25 at 3:56 P.M. with the DON verified Resident #50 had gotten out of the facility undetected after the resident followed the family member onto the elevator and out the front door of the facility. Review of the video surveillance footage from 09/14/25, viewed on 09/23/25 at 9:10 A.M., revealed Resident #50 was on the first floor exiting the double doors behind a family member who allowed Resident #50 on the coded elevator. The family member was seen exiting the double doors and turning left. She did not look behind her. Resident #50 was observed exiting the double doors and going to the right. Review of the facility investigation dated 09/14/25 and timed 2:15 P.M. revealed at approximately 1:45 P.M., CNA #151 notified RN #137 that Resident #50 was missing. The missing resident procedure was initiated, and staff began searching the facility. At approximately 1:54 P.M., RN #137 received a call from the hospital, located across the street from the facility, that Resident #50 had walked to and checked herself into the emergency department. Notifications were completed, Resident #50 was noted to be uninjured, and Resident #50's daughter requested the emergency department aid in finding placement in an alternate nursing facility. The facility investigation concluded that Resident #50 had followed another resident's visiting family member onto the elevator and out the front door of the facility. The investigation noted that initial audits, education, and ongoing monitoring were implemented following the incident. Interviews conducted on 09/22/25 at 2:50 P.M. with the Administrator confirmed Resident #50 eloped from the facility on the afternoon of 09/14/25. The Administrator reported the facility policy on elopement was followed but the event was not reported to the State Agency. The Administrator confirmed following the elopement occurrence, the elopement was investigated and corrective action was implemented. Review of the facility policy titled Elopement and Unsafe Wandering, with a revision date of 04/28/21, revealed elopement was defined as a resident leaving the premises or a safe area without authorization and/or necessary supervision to do so. The policy noted the facility will assess the resident's risk to elope and will implement measures to protect the resident when the resident is no longer able to make sound decisions. The deficient practice was corrected on 09/15/25 when the facility implemented the following corrective actions: On 09/14/25 at approximately 1:45 P.M., facility staff completed a facility head count immediately with all other residents accounted for. On 09/14/25 at approximately 1:46 P.M., RN #137 initiated the missing resident procedure, directing staff to search resident rooms, shower rooms, etc. and the perimeter of the facility. On 09/14/25 at approximately 1:54 P.M., RN #137 received a call from the hospital across the street saying that Resident #50 was there and safe. On 09/14/25 at approximately 2:00 P.M., Resident #50's responsible party was notified of the incident. On 09/14/25 at approximately 2:15 P.M., Medical Director #500 was notified. On 09/14/25 at approximately 2:20 P.M., CNA #132 went across the street and verified the presence of Resident #50. Hospital staff confirmed Resident #50 was uninjured, safe and reported her daughter requested hospital assistance with placement to a new facility with a memory care unit. On 09/14/25 at approximately 2:45 P.M. the Administrator and DON interviewed eight staff members and two visitors as part of the investigation into how Resident #50 exited the building. Staff members including CNAs #129, #132 and #151 reported she was last observed in the dining room toward the end of lunchtime at approximately 12:30 P.M. A visiting family member stated during an interview that on 09/14/25 at approximately 1:00 P.M. that Resident #50 entered the elevator with her and exited the elevator on the first floor near the facility entrance. The family member reported she was unaware Resident #50 could not leave the floor and did not witness her exiting the facility. On 09/14/25 at approximately 2:45 P.M. the DON or designee verified all wander guard devices were properly placed and functioning for eight residents. All were placed and functioning properly. On 09/14/25 at approximately 7:50 P.M. the DON or designee contacted all resident representatives (44 in total) to re-educated them on the importance of speaking with staff before permitting residents to use the elevator with them. On 09/14/25 at approximately 8:00 P.M., the Administrator or designee re-educated 60 staff via message system and four staff via phone, on not sharing the facility door or elevator codes with family members or visitors and the appropriate response to alarms and actions to take if a door is found ajar or malfunctioning. All staff were notified. On 09/14/25 at approximately 8:30 P.M., the Administrator and Maintenance Director #230 completed an environmental safety risk assessment. All potential egress points were inspected and confirmed secured with no concerns noted. All doors and sensors were checked with no concerns noted. On 09/14/25 at approximately 9:30 P.M., an outside vendor inspected the front door to ensure proper functioning. No concerns were identified. On 09/14/25 at approximately 10:00 P.M., the DON or designee completed elopement assessments on all 43 residents and validated appropriate care plans were indicated. On 09/14/25 by 10:00 P.M., the DON or designee re-educated all 64 staff members on identifying signs and symptoms of exit-seeking behaviors. All staff were educated. On 09/15/25, an ad hoc Quality Assurance (QA) committee meeting was held to review the incident investigation, complete root cause analysis, internal action plan and audit plan. Attendees included the Medical Director #500, the Administrator, the DON, Assistant Director of Nursing (ADON) #152, ADON #153, admission Director #250, Medical Record #270, Social Worker #220, Activities Director #290, Human Resources Director #280, Therapy Director #260, Dietary Manager #240, Maintenance Director #230 and Dietician #300. Beginning on 09/15/25, a staff member was assigned to sit at the front desk from 7:00 A.M. to 7:00 P.M. daily to answer calls and monitor the front door. Beginning 09/15/25, elopement drills/audits will be completed by the DON, Administrator or designee weekly for two weeks or until otherwise directed by the QA committee. Beginning 09/15/25, the Maintenance Director #230 or designee will audit the elevator, door alarms and locks five times weekly for two weeks or until otherwise directed by the QA committee. Beginning 09/15/25 the DON or designee will conduct weekly audits on all residents with elopement risk per assessment, checking if the Wanderguard's in place and functioning, five times a week for two weeks or until otherwise directed by the QA committee. Ad hoc QA committee meetings will continue weekly for two weeks to review the effectiveness of the action plan and further needs for audits, changes, or further committee meetings.This deficiency represents non-compliance investigated under Complaint Number 2621167.

Based on interview, record review, and facility policy review, the facility failed to ensure an elopement was reported to the State Agency. This affected one resident (#50) of three residents reviewed for elopement. The facility census was 47.Findings include:Review of the medical record for Resident #50 revealed an admission date of 05/14/24 and a discharge date of 09/16/25. Diagnoses included emphysema, malignant neoplasm of the cecum, malignant neoplasm of the upper left female breast, and personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits. Review of the Minimum Data Set (MDS) (modified) annual assessment, dated 06/12/25, revealed Resident #50 had severely impaired cognition. The resident was independent for mobility, transfers, toileting, ambulation, upper and lower body dressing, and donning and doffing footwear. Resident #50 had no episodes of recorded wandering. Review of mood revealed she had total severity score of 13, indicating moderate depression. Review of the care plan dated 06/12/25 revealed Resident #50 was at risk for elopement as she had exit-seeking behaviors and unaware of safety needs. Interventions included a wanderguard to the right ankle and chair, redirect as needed, and follow the facility elopement policy and procedures. Review of Resident #50's physician orders revealed an order dated 07/15/25 for Resident #50 to have a wanderguard (a wearable bracelet-like device used to monitor and prevent residents at risk for wandering from leaving designated areas. It is part of a larger system which includes sensors on doors which alarm and lock the doors when a resident approaches a monitored exit) on at all times to the right ankle and an additional order to check the placement and function of the wanderguard device every shift. Review of Resident #50's Treatment Administration Record (TAR) dated 07/15/25 through 09/22/25 revealed the resident's wander guard was documented as being on at all times to the right ankle and placement and function was documented as checked daily on both day and night shifts. Review of Resident #50's elopement risk assessment dated [DATE] revealed she was an elopement risk and scored a 4.0 as she had a history of eloping and had a lack of awareness of safety needs. Listed interventions in place were the wanderguard and safety checks. Review of Resident #50's nurse progress note dated 09/14/25 at 2:30 P.M. authored by Licensed Practical Nurse (LPN) #120 revealed the nurse was alerted by Certified Nursing Assistant (CAN) #151 that Resident #50 was missing. LPN #120 and other staff began looking for Resident #50 checking all rooms and bathrooms, checking the whole facility and outside. During the search for Resident #50, the resident's daughter and the hospital administrator called the facility and stated Resident #50 was at a local hospital emergency department (ED). The facility Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) was notified. Review of the State Agency's Certification and Licensure System (CALS) revealed no facility self-reported incident (SRI) had been submitted regarding Resident #50's elopement. An interview on 09/22/25 at 2:50 P.M. with the Administrator revealed she did not know she needed to report an elopement to the State Agency and was unaware where on the computer she was to report the incident. Review of facility policy titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 11/21/16, revealed it is the facility's policy to investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of resident property. Additionally, the facility should immediately report all allegations to the Administrator and to the Ohio Department of Health.

Based on observation, medical record review, review of a facility Self-Reported Incident (SRI), staff statements, local police incident report, National Centers for Environmental Information, the [NAME] Cleveland Ohio Neighborhood Guide, the facility's Elopement policy and procedure and interviews, the facility failed to provide adequate supervision to Resident #1, who was assessed to be cognitively impaired and at risk for elopement, to prevent the resident from exiting the facility without staff knowledge. This resulted in Immediate Jeopardy and the likelihood for serious harm, injury, or death on [DATE] between 3:30 P.M. and 4:10 P.M. when Resident #1 exited the facility without staff knowledge. Resident #1 was wearing a wanderguard bracelet (a device that activates an alarm and locks armed doors when the wearer approaches within a set parameter of the door) that failed to lock the doors or set off an alarm to alert facility staff. Resident #1's whereabouts were unknown until approximately 7:20 P.M. when a family member reported he had been found and was currently at a family member's home. This affected one resident (#1) of seven residents who were identified by the facility as being at risk for elopement. The facility census was 44. On [DATE] at 4:50 P.M., the Administrator was notified Immediate Jeopardy began on [DATE] at 4:10 P.M. when staff identified Resident #1, who was severely cognitively impaired and at high-risk for elopement, could not be located. Facility staff and the resident's son/power of attorney (POA) were unaware of how Resident #1 exited the facility. The resident traveled to an alleged location ,d+[DATE] minutes driving distance away from the facility. Resident #1's son reported the resident traveled on a bus to the alleged location where he was allegedly found by friends/family. At the time of the incident, Resident #1 had a care plan in place for being at high risk for falls, wandering behaviors, and at risk for elopement. The resident was wearing a wanderguard device at the time of the incident, however it was determined to be not functional. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at approximately 9:00 P.M. Resident #1 was returned to the facility by his son. The resident was assessed by Registered Nurse (RN) #110 and was determined not to have any injuries. The resident was placed on hourly checks by staff based following a physician's order. These checks would continue indefinitely. The resident's wanderguard bracelet was changed for a new bracelet that was working properly. On [DATE] by 10:30 P.M., all other residents at risk for elopement (Resident #7, #8, #9, # 10, #12 and #13) had their wanderguard bracelets checked by Social Worker (SW) #111. It was determined all bracelets were working properly. Although the bracelets were functioning properly each bracelet was changed because it was time to change them based on the manufacturer's 90-day recommendation. Moving forward, all wanderguard bracelets would be checked weekly for functionality by the SW #111. A spreadsheet was created to document the weekly monitoring of the wanderguard bracelets. The Administrator would audit the weekly check list once each month for four months and report findings during quality assurance Quality Assurance Performance Improvement (QAPI) meetings. On [DATE], the Director of Nursing (DON) reviewed the care plans of all residents at risk for elopement, Resident #1, #7, #8, #9, # 10, #12 and #13 to ensure the care plans reflected the current behavior and needs of the residents. On [DATE], the DON reviewed the elopement books posted at each nursing station to ensure that they were up-to-date and reflected those residents at risk for elopement. The DON also reviewed the elopement book and elopement policy with all nurses. On [DATE] at 10:30 A.M., during a stand-up meeting the interdisciplinary team including the Administrator, DON, SW #111, the Minimum Data Set (MDS) Nurse, and Director of Environmental Services performed a root cause analysis. It was determined Resident #1's elopement was caused by a nonperforming wanderguard bracelet. On [DATE] Resident #1's wanderguard bracelet was changed upon return to facility, and it was determined the wanderguard bracelets the other residents at risk for elopement were wearing were working as designed. It was verified that all exit alarms were working properly, and they had been previously checked on [DATE]. The Elopement policy was reviewed and determined to be appropriate with no changes required. On [DATE], the receptionists who monitor the entrance doors received training by the administrator. The training was designed to make monitoring the main entrance doors the number one priority on the list of responsibilities for receptionist. The facility Scheduler/Administrative Assistant #104 was also included in the training to provide backup coverage. SW #111 and the DON would be responsible for monitoring the receptionists' performance and would provide a quarterly performance evaluation. The human resource coordinator would audit the receptionists' performance evaluations quarterly for one year. On [DATE], the DON posted signs at the two entrance doors alerting residents, families, and friends of residents that staff must be notified, and residents must be signed-out before leaving the building. On [DATE], the administrator began training sessions for all staff on all shifts. This training included the use of elopement books, the elopement policy, the wanderguard system, and wandering and exit seeking behaviors. Each training session included an elopement drill. Ongoing training regarding elopement will be completed weekly for four weeks. Review of sign-in sheets dated [DATE] revealed 25 staff members across all shifts had attended the training. On-going training would continue for staff as they arrived to work each shift. On [DATE] at 2:00 P.M., a QAPI meeting was held to review the Elopement Abatement Plan. The QAPI members present included the Administrator, DON, Maintenance Director, Administrative Assistant (AA) #104 and SW#111. It was determined no changes were necessary and the QAPI committee would continue to monitor the implementation of the abatement plan to determine if any modification needed each month for four months. Although the Immediate Jeopardy was removed on [DATE], the deficiency remained at a Severity Level 2 (no actual harm with the potential for minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #1 revealed an admitted [DATE] with diagnoses including bipolar disorder, current episode manic severe with psychotic features, unspecified dementia, without behavioral disturbance, and schizophrenia. Review of the resident's plan of care revealed the following plans, dated [DATE]: Resident #1 was at risk for elopement and wandering aimlessly. Interventions included distracting Resident #1 from wandering by offering pleasant diversions, structured activities, food, conversation, and watching television. Resident #1 had impaired cognitive function/dementia or impaired thought processes related to impaired decision making, psychotropic drug use, short term memory loss. Interventions included cue, reorient, and supervise as needed. Resident #1 was at high risk for falls related to gait/balance problems. Interventions included anticipating and meeting the resident's needs and ensuring the resident wears non-skid socks/shoes when ambulating. On [DATE] an intervention was added to monitor Resident #1's location and activity every hour. On [DATE] an intervention was added to assess Resident #1 for activity of choice and enable him to engage in that activity when possible. On [DATE] an intervention was added to explain to Resident #1 that he must sign out with a staff member or person authorized to remove him from the facility, and to redirect resident from exits. Review of Wandering Risk Scale assessments dated [DATE] and [DATE] revealed Resident #1 was at risk for wandering. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment, dated [DATE], revealed Resident #1 was severely-cognitively impaired with a Brief Interview of Mental Status score of three (out of 15). The assessment revealed the resident was independent with walking in his room and on the units. Resident #1 was alert to self only. Review of a nursing progress note dated [DATE] timed 10:43 P.M. revealed Resident #1 wandered out of the facility without staff or family knowledge. Resident #1 was oriented to self only. The resident's wanderguard bracelet was replaced, and the resident was moved to the second floor. Resident #1 was placed on one-hour checks per physician orders. Review of the facility SRI report dated [DATE] revealed Resident #1 was last observed in the facility on [DATE] at approximately 3:30 P.M. Staff noticed Resident#1 missing around 4:10 P.M. when delivering dinner trays. Staff began a search for Resident #1 throughout the facility. The staff notified the Administrator Resident #1 was missing on [DATE] at 4:50 P.M. The Administrator assigned staff to search the outside of the facility and surrounding neighborhood. The Administrator notified the police Resident #1 was missing on [DATE] at 6:15 P.M. and notified the son/POA at 6:30 P.M. The son/POA suggested some locations the resident might go. The son/POA contacted the facility at 6:45 P.M. stating Resident #1 was found and was with family. The facility offered to pick Resident #1 up to return him to the facility, but the son/POA declined to provide the resident's location. The son/POA returned Resident #1 on [DATE] at 9:00 P.M. The SRI report indicated the resident's wanderguard bracelet Resident #1 was wearing did not alarm when he returned to the facility and staff replaced the wanderguard bracelet immediately. Resident #1 returned to the facility without signs/symptoms of stress or injury. Registered Nurse (RN) #110 questioned Resident #1 about his whereabouts and Resident #1 stated his son picked him up and they drove around. The SRI report indicated following the investigation, it was surmised Resident #1 either eloped from the building between 3:30 P.M. and 4:00 P.M. or a family member escorted the resident out without staff knowledge. The facility believed Resident #1 had no money or cognitive ability to negotiate public transportation or make pick-up arrangements. The facility also believed the family entered the facility and escorted Resident #1 out when visitors attending an activity were leaving the facility. The facility receptionist was distracted by all the activity going on and assisting visitors to the door. Review of State tested Nurse Assistant (STNA) #113's untimed statement dated [DATE] revealed STNA #113 last observed Resident #1 on the unit around 3:30 P.M. on [DATE]. STNA #113 indicated she noticed Resident #1 was missing around 4:00 P.M. and reported it to the nurse. Review of RN #110's statement dated [DATE] timed 7:05 P.M. revealed RN #110 observed Resident #1 attending the church service on the second floor. RN #110 stated she was informed later that Resident #1 was missing and she notified the Administrator. Review of AA #104's untimed statement dated [DATE] revealed AA #104 asked Resident #1 how he got away from the facility and Resident #1 stated, my son picked me up. Review of a police report revealed an incident date and time of [DATE], 6:49 P.M. The incident type was missing person-handicapped. The notification was received via a 911 call. The search was completed at 6:49 P.M. The call comments indicated Resident #1 was last seen around 3:30 P.M. and located at 7:20 P.M. at a family member's home and states he was safe. The family called to notify the facility. Interview on [DATE] at 8:32 A.M. with AA #104 revealed Resident #1 told her his son came and got him and they went riding around. AA #104 stated the son told her Resident #1 had a bus pass and took the bus to where the resident was allegedly found. AA #104 further stated the facility did not give out bus passes, Resident #1 had no money, and the nearest bus stop was 15 blocks from the facility. AA #104 said Resident #1's wanderguard was not functioning properly when he returned to the facility. Interview on [DATE] at 8:56 A.M. with SW #111 revealed Resident #1's wanderguard was not functioning properly when he returned to the facility. Interview on [DATE] at 8:41 A.M. with RN #110 revealed Resident #1's son told RN #110 that Resident #1 walked to a bus stop and took the bus to a family member's house. However, RN #110 said Resident #1 had no money, and the facility did not provide bus passes. RN #1 stated Resident #1 required assistance with dressing and had an unsteady gait. RN #110 stated she felt there was no way Resident #1 could walk 15 blocks to catch a bus or request to exit at a specific destination. Interview on [DATE] at 9:29 A.M. with the Administrator revealed staff completed an internal and external search of the property and the surrounding neighborhood when looking for Resident #1. The Administrator said Resident #1's wanderguard bracelet had not functioned properly which allowed exit without alarms sounding. Interview on [DATE] at 10:29 A.M. with Receptionist #112 revealed the day Resident #1 eloped was a busy day with two church services and bingo. The last church service ended around 4:15 P.M. and there were many visitors and residents who needed assistance on and off the elevator. Receptionist #112 stated she was distracted and was not always seated at the front desk. Interview on [DATE] at 10:51 A.M. with Resident #1's son/POA revealed a family member observed Resident #1 walking on the sidewalk of a street which was approximately ten minutes from the facility. The son/POA also suggested Resident #1 took the bus using a bus pass. The son stated he called the facility to report Resident #1 was with family, but he did not tell the facility where Resident #1 was or who found him. Observations on [DATE] at 1:30 P.M. revealed Resident #1 was dressed in street clothes and lying in bed. A follow up interview on [DATE] at 2:11 P.M. with SW #111 revealed wanderguard bracelets needed to be replaced every 90 days according to the manufacture's guidelines. Prior to [DATE] when Resident #1's wanderguard was replaced upon his return to the facility, his wanderguard bracelet had been changed on [DATE] (92 days prior). Interview on [DATE] at 3:39 P.M. with STNA #113 revealed when Resident #1 returned to the facility he did not appear anxious or injured. STNA #113 stated Resident #1 was wearing a shirt, pants, shoes, and a jacket. During an interview with Resident #1 on [DATE] at 7:44 A.M. he stated he was picked up by his niece, they went to see a movie called Days of Our Lives, and then he went to see his son. After further conversation Resident #1 was asked again what movie they watched and he replied, Days of Our Lives. Interview on [DATE] at 8:47 A.M. with the Director of Nursing (DON) revealed Resident #1's family was not contacted on [DATE] until 2.5 hours after Resident #1 was identified as missing. The DON indicated the resident's family was not called earlier because staff were busy searching Resident #1. Observations on [DATE] at 10:00 A.M. revealed Resident #1 walking down the second-floor hall near the wall; he had a slow shuffling gait. Review of the National Centers for Environmental Information revealed on [DATE] the temperature in Cleveland Ohio was 60 degrees Fahrenheit (F). Review of the [NAME] Cleveland Ohio Neighborhood guide dated 2024 revealed the neighborhood in which the facility was located and where Resident #1 was found had a high-crime history. Review of the facility Elopement policy, dated 2022, revealed nursing staff would check placement of wanderguard daily and staff would check the functionality weekly. The policy also stated the administrator, DON and the resident's responsible party would be notified immediately if a resident was not found within ,d+[DATE] minutes. This deficiency represents non-compliance investigated under Self-Reported Incident Investigation Control Number OH00152178.

Based on interview and review of medical record, Self-Reported Incident report/investigation, and the facility's abuse policy and procedure the facility failed to implement their abuse policy and procedure related to an injury of unknown origin. This affected one (Resident #14) of seven residents reviewed for abuse and neglect. Findings include: Review of the medical record for Resident #14 revealed an admitted [DATE]. Diagnoses included end stage renal disease, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. Resident #14 was receiving hospice services. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/23/24, revealed Resident #14 had impaired cognition. Review of progress note dated 02/24/24 timed 8:00 A.M. authored by Licensed Practical Nurse (LPN) #106 revealed State tested Nurse Assistant (STNA) #105 observed Resident #14 had a black eye. LPN #106 entered Resident #14's room and observed the eye. Resident #14 told LPN #14 that it happened at night. When LPN #106 asked if the injury occurred as a result of an accident or if it was purposeful, Resident #14 responded by shrugging his shoulders. Receptionist #112 told LPN #106 that Resident #14's eye did not look like that the day before. STNA #105 and Receptionist #112 asked Resident #14 again if someone had hit him, Resident #14 shook his head indicating yes. The Administrator was notified. Review of Self-Reported Incident number 244523 dated 02/24/24 timed 10:55 A.M. revealed an injury of unknown origin was reported by LPN #106 (an agency nurse). LPN #106 immediately contacted the Administrator. LPN #106 had interviewed Resident #14 and identified STNA #101 as a potential perpetrator and STNA #101 was immediately suspended. The Director of Nursing (DON) was notified on 02/25/24 at 10:30 A.M. Resident #14 was out of the building for a dialysis treatment when the DON arrived at the facility. Resident #14 was assessed and interviewed by the DON on 02/25/24. The facility conclusion indicated Resident #14 had a burst blood vessel in the right eye and the dark discoloration beneath the eye was not bruising but a common side effect from receiving an iron tablet daily for iron deficiency anemia which was present beneath both eyes. Review of the facility investigation revealed statements from STNA #101, Receptionist #112, Resident #14, and the administrator. Interview on 03/26/24 at 9:57 A.M. with the DON revealed she did not interview any residents who received care from STNA #101 on 02/24/24. The DON did not obtain statements from any other staff than those listed above and indicated the progress note LPN #106 authored dated 02/24/24 timed 8:00 A.M. served as her statement. Review of the facility policy Abuse, Neglect, and Misappropriation, dated 2023 revealed the actions the facility would take when abuse was alleged including the following. 1. Thoroughly investigate suspicious bruising of residents, and any other occurrences, injuries, patterns and/or trends that resemble abuse. 2. Thoroughly investigate any evidence of suspected abuse, neglect, or misappropriation of property. 3. Use video, photographs, witness statements, staffing patterns, interviews with residents, staff, and visitors to investigate allegations of abuse or neglect.

Based on observation, interview, medical record review, Self-Reported Incident report/investigation review and abuse policy and procedure review, the facility failed to thoroughly investigate an allegation of physical abuse. This affected one (Resident #14) of seven residents reviewed. Findings include: Review of the medical record for Resident #14 revealed an admitted [DATE]. Diagnoses included end stage renal disease, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. Resident #14 was receiving hospice services. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/23/24, revealed Resident #14 had impaired cognition. Review of progress note dated 02/24/24 timed 8:00 A.M. authored by Licensed Practical Nurse (LPN) #106 revealed State tested Nurse Assistant (STNA) #105 observed Resident #14 had a black eye. LPN #106 entered Resident #14's room and observed the eye. Resident #14 told LPN #14 that it happened at night. When LPN #106 asked if the injury occurred as a result of an accident or if it was purposeful, Resident #14 responded by shrugging his shoulders. Receptionist #112 told LPN #106 that Resident #14's eye did not look like that the day before. STNA #105 and Receptionist #112 asked Resident #14 again if someone had hit him, Resident #14 shook his head indicating yes. The Administrator was notified. Review of Self-Reported Incident number 244523 dated 02/24/24 timed 10:55 A.M. revealed an injury of unknown origin was reported by LPN #106 (an agency nurse). LPN #106 immediately contacted the Administrator. LPN #106 had interviewed Resident #14 and identified STNA #101 as a potential perpetrator and STNA #101 was immediately suspended. The Director of Nursing (DON) was notified on 02/25/24 at 10:30 A.M. Resident #14 was out of the building for a dialysis treatment when the DON arrived at the facility. Resident #14 was assessed and interviewed by the DON on 02/25/24. The facility conclusion indicated Resident #14 had a burst blood vessel in the right eye and the dark discoloration beneath the eye was not bruising but a common side effect from receiving an iron tablet daily for iron deficiency anemia which was present beneath both eyes. Review of Receptionist #112's statement dated 02/24/24 timed 10:45 A.M. revealed the receptionist was assisting Resident #14 in his wheelchair to the door to leave for dialysis. Receptionist #112 indicated she observed Resident #14 had a black eye that was not there the night before. The receptionist asked if someone had hit him in the eye, Resident #14 nodded his head yes. The receptionist told Resident #14 she was going to report the incident, and Resident #14 started saying no no. Review of an STNA #101's untimed statement dated 02/24/24 revealed STNA #101 had worked the night before and repositioned Resident #14 several times while the resident was in bed. STNA #101 denied observing swelling or discoloration on his face. Review of Resident #14's statement dated 02/25/24 timed 12:56 P.M. revealed when the DON asked Resident #14 what happened. Resident #14 curled his hand into a fist and directed his fist toward his eye. The DON asked Resident #14 was someone helping you at the time, Resident #14 responded yeah. The DON asked Resident #14 if it was a staff member, Resident #14 responded yeah. The DON asked if it was a male or female, Resident #14 responded female. The DON asked if the female was short or tall, Resident #14 put his hand out to indicate the staff was short. The DON asked Resident #14 again about the staff being a male or female, Resident #14 responded a lady. The DON asked if it happened at night, Resident #14 responded yes. Resident #14 demonstrated poor eye contact during the interview and presented with a flat affect, no smiling nor grimacing were observed. Review of the Administrator's untimed statement dated 02/26/24 revealed STNA #101 stated Resident #14 was fidgety and placed himself upside down in bed three times. STNA #101 stated LPN #106 assisted each time the resident needed repositioned. STNA #101 stated Resident #14 threw himself on the floor and seemed very confused. STNA#101 mentioned that she had not noticed a problem with Resident #14's eye, but in her opinion, Resident #14 eyes were dark frequently and his face was swollen due to needing dialysis. STNA #101 denied having any accidents or confrontations with Resident #14. Interview on 03/26/24 at 9:57 A.M. with the DON revealed she did not interview any residents who received care from STNA #101 on 02/24/24. The DON did not obtain statements from any other staff than those listed above and indicated the progress LPN #106 authored served as her statement. Observation of Resident #14 on 03/26/24 at 11:00 A.M. revealed Resident #14 was lying in bed fully clothed. An attempt to interview Resident #14 was unsuccessful; he was unable/unwilling to answer questions. Observation revealed the skin beneath both eyes was darkened. Review of the timecard report dated 02/18/24 through 03/02/24 revealed STNA #101 did not work on 02/24/24, 02/25/24 due to scheduled time off. STNA #101 returned to work on 02/26/24 after meeting with the Administrator. Interview on 03/26/24 at 4:24 P.M. with Receptionist #112 revealed she thought Resident #14 had a black eye, but she was mistaken. Receptionist #112 stated the resident had a history of having a swollen face. Receptionist #112 stated when she told Resident #14 she was going to report the incident he began to back pedal stating no no. Receptionist #112 confirmed the statement she had written on 02/24/24. Review of the facility policy Abuse, Neglect, and Misappropriation, dated 2023 revealed the actions the facility would take when abuse was alleged included the following. 1. Will thoroughly investigate suspicious bruising of residents, and any other occurrences, injuries, patterns and/or trends that resemble abuse. 2. Will thoroughly investigate any evidence of suspected abuse, neglect, or misappropriation of property. 3. Will use video, photographs, witness statements, staffing patterns, interviews with residents, staff, and visitors to investigate allegations of abuse or neglect.

Based on medical record review, observation, and interview the facility failed to provide feeding assistance in a timely manner for dependent residents. This affected one (Resident #14) of seven residents reviewed. The census was 44. Findings include: Review of the medical record for Resident #14 revealed an admitted [DATE]. Diagnoses included end stage renal disease, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. Resident #14 was receiving hospice services. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/23/24, revealed Resident #14 had impaired cognition and required supervision or hands on assistance for eating. Review of the plans of care revealed no plan related to nutrition or assistance needed for eating. Review of the nutritional assessment dated [DATE] revealed Resident #14 received a liberal renal pureed diet with nectar thickened liquid. Resident #14 required supervision, set-up, and assistance with eating. Resident #14 was at risk for altered laboratory results, fluid imbalance related to end stage renal disease, diabetes, and difficulty swallowing as evidenced by the need for a therapeutic mechanical altered foods and fluids. Observation on 03/26/24 at 8:32 A.M. revealed Resident #14 seated in wheelchair in his room eating independently. There was no staff present to provide assistance or verbal cueing. The bowls and cups holding Resident #14's food and beverages were scattered haphazardly on the tray and the bottom of the tray was filled with the beverages that had been spilled. Interview on 03/26/24 at 8:36 A.M. with Registered Nurse (RN) #110 revealed due to call offs administrative staff were assisting residents as needed on the unit but she did not know their current location or who they were assisting. RN #110 said when a resident required supervision and/or hands on assistance staff were to stay with the resident while eating to observe, prompt, guide, and assist with needs. RN #110 stated she was assisting Resident #14 but left to go to another resident's room. RN #110 verified the spilled beverages and haphazard set up the bowls on Resident #14's meal tray. Interview on 03/26/24 at 9:22 A.M. with the Director of Nursing (DON) revealed staff were to stay with Resident #14 during meals to assist and cue as needed.

Based on record review and interview the facility failed to develop a person-centered baseline care plan for one resident (#48) of two residents reviewed for baseline care plans. The facility census was 47. Findings include: Review of the medical record for Resident #48 revealed an admitted [DATE]. Medical diagnoses included hypertension, chronic atrial fibrillation, dementia, encephalopathy, gastro-esophageal reflux disease, and pressure ulcer of sacral region. Review of the physician orders for Resident #48 revealed an order dated 11/01/23 that stated to cleanse right lateral calf wound with normal saline, pat dry, apply oil emulsion gauze and cover with abdominal pad and wrap with Kerlix gauze every night shift every Monday, Wednesday, and Friday and as needed. Further review of the physician orders revealed an order dated 11/01/23 that stated to cleanse sacral wound with normal saline, pat dry, pack wound with Vashe moistened gauze and cover with foam every night shift. Review of Resident #48's care plan dated 11/01/23 revealed no care plan for wound care or skin integrity. Interview on 12/05/23 at 3:02 P.M. with Licensed Practical Nurse (LPN) #335 confirmed Resident #48's baseline care plan did not include wound care or skin integrity.

Based on record review and interview the facility failed to develop a person-centered care plan for one resident (#9) of two residents reviewed for comprehensive person-centered care plans. The facility census was 47. Findings include: Review of the medical record for Resident #9 revealed an admitted [DATE]. Medical diagnoses included Alzheimer's disease, pulmonary hypertension, moderate protein-calorie malnutrition, chronic kidney disease, and chronic diastolic congestive heart failure. Review of the physician orders for Resident #9 revealed an order dated 05/26/20 for Do Not Resuscitate Comfort Care (DNR-CC). Review of Resident #9's care plan dated 05/11/20 revealed the care plan did not include residents code status wish. Interview on 12/05/23 at 3:02 P.M. with Licensed Practical Nurse (LPN) #335 confirmed Resident #9's comprehensive person-centered care plan did not reflect that Resident #9 had a DNR-CC in effect.

Based on observation, record review and interview the facility failed to ensure a clean and sanitary laundry service, privacy curtains were changed when visibly dirty, a comprehensive legionella program, and yearly screening for tuberculosis. This affected all 45 residents residing at the facility. Findings Include: 1. Observation on 05/10/23 at 10:29 A.M. with Building Manager #226 revealed in the soiled area of the laundry processing area there were two large washing machines and one smaller washing machine. The smaller washing machine had clothing inside. An attempt to open the door of the smaller washing machine revealed it would not open. The tops of both large washers had sticky liquid spills, and dust. Interview at the time of the observation with Building Manager #226 revealed he was unsure how long the small washer had not been in service nor how long the clothes locked inside had been there. Further observation of the clean side of the laundry processing area revealed a bath robe and additional clothing items on hangers hanging from a metal pipe just below the ceiling. A wheeled cart that held additional clothing items on hangers, and unorganized, unfolded clothing items on the bottom of the cart. The cart also had folded blankets sitting on top. On the floor, in front and to the right of the cart were numerous clear plastic bags full of clothing items. Some of the bags were open and overflowing with the contents spilling onto the floor. An interview at the time of the observation with Maintenance Director #226 revealed the items on the cart were ready to be returned to the residents and the bags on the floor were clean resident clothing items and mismatched socks that needed to be sorted. An additional observation in the clean laundry area revealed a large table that had a laminate cover with uneven edges exposing the particle board beneath the top of the table and a brown, sticky dried liquid spill located just in front of the clean, folded blankets and washcloths. Observation in the entrance to the clean and dirty laundry rooms revealed the flooring was in disrepair with broken, uneven pieces of cement. Multiple areas of drywall in the clean laundry area were observed to have gouges and missing pieces. Interview at the time of the observation with Maintenance Director #226 confirmed the sticky spill, indicated the items on the table were overflow items, and confirmed the flooring was uneven and there were areas of disrepair in the drywall as it was an older building. Review of the undated facility policy titled Quality Assessment and Assurance Program revealed functions of the quality assessment and assurance program were to: evaluate care delivery to resident in accordance to established regulations and rules, quality indicators, quality measures, professional standards and facility based criteria, identify any quality deficiencies that deviate from the established regulations and rules, and assess the overall environment as it related to the comfort, safety and infection control of residents. It was the responsibility of all department heads to assure the quality assessment and assurance program was followed at all times. 2. Observation on 05/07/23 at 10:10 A.M. of Resident #26's privacy curtain revealed numerous unidentifiable dark spots on the bottom section of the curtain. Interview at the time of the observation with Resident #26 revealed the curtain had not been changed in at least the last six months. Observation on 05/09/23 at 9:52 A.M. in Resident #26's room revealed unidentified soiling in multiple spots on the privacy curtain on both sides. Interview at the time of the observation with Building Manager #226 confirmed the observation. Observation on 05/09/23 at 9:56 A.M. in Resident #6's room revealed numerous unidentified brown spots on the lower section of the privacy curtain. Interview at the time of the observation with Building Manager #226 confirmed the observation. Interview on 05/10/23 at 1:03 P.M. with Housekeeper #237 revealed there was not a specific frequency for washing the privacy curtains. Review of the 02/22/16 facility policy titled [NAME] Place Environmental Services Housekeeping Procedures revealed it provided no information for staff regarding cleaning frequency or changing of privacy curtains. 38522 3. Review of the facility's legionella environmental assessment form dated 02/25/20 revealed the facility had municipal water and did not monitor incoming water parameters, such as disinfectant or temperature. Only hot water temperatures were measured at the point of use. Review of the facility's water management plan, no date, revealed cold water was distributed directly to the water fountain in the lobby area, ice machine in the kitchen and faucets in resident rooms and tub rooms. Cold water was heated to 120 degrees Fahrenheit (F) by a water heater. A diagram was noted on a sheet titled, How to Monitor Your Control Measures and indicated to check temperatures (marked by a red c in a pentagon) at the kitchen appliances, water heater (#1, #2), water heater (#3 kitchen), sinks/showers (floors one and two) at both the cold water distribution and the hot water distribution points and after receiving water from the municipality. The plan indicated the facility would complete yearly testing of their water supply and follow the water management program. Review of a water testing request form dated 03/04/20 revealed four water samples were taken to be tested for legionella. Results dated 03/12/20 indicated no legionella was detected. No further water testing results were available for review. Review of the facility water temperature log book revealed water temperatures were done quarterly for 18 resident rooms sampled in the morning and again in the afternoon. For 2023, temperatures were obtained on 03/14/23 and 05/10/23. Interview on 05/15/23 at 8:51 A.M. with Building Manager (BMA) #226 revealed hot water temperatures were collected quarterly. When asked about what the facility did for vacant rooms, such as the 2-south wing, BMA #226 stated he ran the hot water and flushed the toilets in those rooms monthly but did not document this practice. BMA #226 stated the 2-south wing had been closed since 12/31/22. Follow-up interviews on 05/15/23 at 9:11 A.M. and 9:55 A.M. with BMA #226 revealed he moved hot water temperatures from monthly to quarterly due to not having enough help. BMA #226 verified the water management plan and legionella policy were incomplete and did not match as hot water temperatures were being taken from resident rooms, not in shower rooms or other areas identified on the water management plan. BMA #226 confirmed the provided documentation did not address water in rooms not in use nor provide a timeframe for this monitoring and documentation. Review of the facility policy, Legionella, no date identified risks within the facility including: hot and cold-water storage tanks, water heaters, expansion tanks, water filters, electronic and manual faucets, showerheads and hoses, eyewash stations, ice machines, decorative fountains and cooling towers. The policy did not indicate what the facility would monitor or provide a frequency for monitoring to minimize the risk of legionella. 4. Review of 14 personnel records on 05/10/23 starting at 12:29 P.M. with Human Resource Coordinator (HRC) #202 revealed the following concerns: a. Review of State tested Nursing Assistant (STNA) #231's personnel file revealed a date of hire of 02/15/80. The file did not contain evidence an annual tuberculosis (TB) questionnaire had been completed with the most recent questionnaire available dated 05/12/22. Interview on 05/10/23 at 12:29 P.M. with HRC #202 verified she did not have an annual TB questionnaire for STNA #231. b. Review of STNA #223's personnel file revealed a date of hire of 04/29/94. The file did not contain evidence an annual TB questionnaire had been completed with the most recent questionnaire available dated 03/10/22. Interview on 05/10/23 at 12:29 P.M. with HRC #202 verified she did not have an annual TB questionnaire for STNA #223. c. Review of STNA #201's personnel file revealed a date of hire of 06/02/14. The file did not contain evidence an annual TB questionnaire had been completed. Interview on 05/10/23 at 12:29 P.M. with HRC #202 verified she did not have an annual TB questionnaire for STNA #201. d. Review of Dietary Aide (DA) #204's personnel file revealed a date of hire of 02/10/23. The file did not contain evidence an initial TB test had been completed. Interview on 05/10/23 at 12:29 P.M. with HRC #202 verified she did not have evidence of an initial TB test completed for DA #204. e. Review of STNA #217's personnel file revealed a date of hire of 04/07/23. The file did not contain evidence an initial TB test had been completed. Interview on 05/10/23 at 12:29 P.M. with HRC #202 verified she did not have evidence of an initial TB test completed for STNA #217. Review of the facility policy, TB Testing for New Employees, dated 12/28/22 revealed all new employees not having documentation of a two-step TB skin test within the last year before start of employment shall receive a two-step TB skin test upon employment and must have one negative test result prior to resident contact. All employees shall answer the questionnaire annually thereafter.

Based on observation, interview and record review the facility failed to ensure a clean and sanitary kitchen. This affected 44 residents receiving food from the kitchen. Resident #25 was ordered nothing-by-mouth. The facility census was 45. Findings Include: Observation of the kitchen on 05/07/23 from 8:54 A.M. to 9:45 A.M. with Cook #209 revealed the following concerns: The walk-in cooler lacked an internal thermometer. On the shelves, two bags of shredded mozzarella cheese, a lemon meringue pie and a strawberry cream pie did not have dates on them. On the bread cart, four loaves of bread had a use by date of 04/24/23 and two loaves of bread had a use by date of 05/02/23. Buns and wraps were present but also undated. On a pull cart, three packs of ham were undated. In the freezer, a bag of unidentifiable meat was not dated and had a lot of ice buildup. On the shelf, 11 pans of macaroni and cheese lacked a date. There was also no internal thermometer inside the freezer. In the dry stock room, cans did not have a date received to ensure appropriate rotating. A bottle of lemon juice was noted with an expiration date of 12/03/21. In the second-floor refrigerator, a container of potato salad was noted dated 03/11/23. An internal thermometer was present but broken. A red-gray material covered the bottom of the refrigerator. On the shelf, three halves of peanut butter and jelly sandwiches were present but lacked dates. Interview with Cook #209 verified the above areas of concern at the time of observation. Cook #209 stated the pans of macaroni and cheese were made 05/04/23 and confirmed the pans should have had the date made written on them. Cook #209 indicated all foods should have a date on them when pulled such as the ham or when received such as the cans in the stock room. Cook #209 agreed the second floor refrigerator was not clean and reiterated all foods under refrigeration should have a date on them. Review of the facility policy, Food Receiving and Storage, dated December 2008 revealed refrigerators must have working thermometers and be monitored for temperature according to state-specific guidelines. Food services or other designated staff would maintain clean food storage areas at all times. All foods stored in the refrigerator or freezer would be covered, labeled and dated (use by date).

Based on observation, interview and record review the facility failed to ensure food was served at safe and appetizing temperatures. This affected 44 residents receiving food from the kitchen. Resident #25 was ordered nothing-by-mouth. The facility census was 45. Findings Include: Review of the Fall/Winter Week Two menu for Monday corresponding to 05/08/23 revealed the meal to be served for lunch included Salisbury steak, garlic mashed potatoes, stewed tomatoes, wheat bread, margarine, coconut cream pie and beverage of choice. Observation on 05/08/23 at 11:37 A.M. revealed Cook #209 was taking temperatures for lunch tray service with the facility's self-calibrating electronic thermometer. Food temperatures obtained were as follows: sour cream (on ice) 33.5 degrees Fahrenheit (F); Salisbury steak, 203 degrees F; baked potato, 191 degrees F; stewed tomatoes, 173 degrees F; and mashed potatoes 196 degrees F. Trayline started 11:46 A.M. At 12:03 P.M. staff started making trays for the two carts for the first floor and a test tray was requested. The test tray was made at 12:22 P.M., on the cart at 12:23 P.M. and left the kitchen at 12:24 P.M. The carts arrived on the floor at 12:24 P.M. and trays began to be passed at 12:25 P.M. The test tray was sampled at 12:49 P.M. with Dietary Manager (DM) #200 and Assistant Dietary Manager (ADM) #205. Temperatures were taken with the facility's self-calibrating electronic thermometer with temperatures as follows: Salisbury steak, 128.1 degrees F; potato, 124.5 degrees F; tomatoes, 109.5 degrees F and lemon curd dessert, 50 degrees F. DM #200 and ADM #205 stated the potatoes were cold to touch and the tomatoes were also cold. ADM #205 stated the tomatoes should have been served in a disher to better retain heat but the facility did not have enough dishers for service. DM #200 and ADM #205 verified the potato and tomatoes were not at a palatable temperature and indicated the ideal temperature for point of service was 135 to 140 degrees F which the test tray did not meet.

Based on interview and record review the facility failed to ensure a Registered Nurse (RN) was on-site eight hours a day, seven days a week as required. This had the potential to affect all 45 residents in the facility. Findings Include: 1. Review of posted staffing sheets from 04/01/23 to 05/06/23 revealed a RN was not in the facility on 04/01/23, 04/02/23, 04/03/23, 04/06/23, 04/07/23, 04/08/23, 04/09/23, 04/10/23, 04/13/23, 04/14/23, 04/15/23, 04/16/23, 04/17/23, 04/20/23, 04/21/23, 04/22/23, 04/23/23, 04/27/23, 04/28/23, 04/29/23 and 05/06/23. Interview on 05/09/23 at 9:14 A.M. with Scheduler #220 verified the identified dates did not meet the required eight hours of RN coverage as required. 2. Review of the staffing schedules for 04/30/23 to 05/06/23 with Scheduler #220 on 05/09/23 at 12:05 P.M. revealed the facility did not have an RN onsite on any shift on 05/06/23. Interview on 05/09/23 at 4:31 P.M. with the Administrator revealed if RN #235 was not working the facility tried to obtain an RN through a staffing agency but at times, staffing was tight. The Administrator was made aware at the time of the interview the facility did not have an RN onsite in the facility as required on 05/06/23.

Based on record review, facility policy review, personnel file review and interview, the facility failed to implement the screening component of their abuse policy and procedure to ensure all potential new hires were checked against the state Nurse Aide Registry (NAR) to ensure no employee had findings concerning abuse, neglect, exploitation or misappropriation of residents' property. The facility also retained staff after 30 days when background check results were not received. This affected six out of 14 employees whose personnel files were reviewed and had the potential to affect all 45 residents in the facility. Findings Include: Review of 14 personnel records on 05/10/23 starting at 12:29 P.M. with Human Resource Coordinator (HRC) #202 revealed the following concerns: a. Review of State tested Nursing Assistant (STNA) #218's personnel file revealed a re-hire date of 04/11/23. The file contained no evidence of STNA #218 being checked against the NAR and no evidence background checks had been completed upon re-hire. b. Review of Dietary Aide (DA) #204's personnel file revealed a hire date of 02/10/23. The file contained no evidence of DA #204 being checked against the NAR on hire. c. Review of Licensed Practical Nurse (LPN) #219's personnel file revealed a hire date of 05/31/22. LPN #219's NAR check was completed on 04/20/23. d. Review of STNA #211's personnel file revealed a re-hire date of 05/21/22. STNA #211's NAR check was completed on 06/18/22. e. Review of Unit Secretary (US) #206's personnel file revealed a hire date of 06/10/22. The file contained no evidence background checks had been received. f. Review of STNA #217's personnel file revealed a hire date of 04/07/23. The file contained no evidence background checks had been received. Interview on 05/10/23 at 12:29 P.M. with HRC #202 verified the above background and NAR checks were not completed on or before each employee's date of hire to ensure no employee had a finding concerning abuse, neglect, exploitation or misappropriation of residents' property. HRC #202 verified US #206 and STNA #217 continued to work at the facility even as 30 days had passed and their background check results had still not been received by the facility. Review of the facility policy, Abuse, Neglect and Misappropriation, revised 09/29/22 revealed as part of the employment screening process, Ohio's NAR portal was used to confirm a STNA's eligibility to work in a long-term care setting. As part of the employment screening process, the Ohio Board of Nursing was used to confirm as nurse's eligibility to work in a long-term care setting. Once a conditional offer of employment was given to a potential employee, he/she would be provided with information to attain a criminal background check at the individual's expense. Potential employees were encouraged to complete this process as soon as possible, preferably prior to the start of orientation. [Facility name] must receive results of this check prior to the completion of one month of employment. New hires must stop working after one month until [facility name] received the results from the background check.

Based on record review and staff interview, the facility failed to implement a comprehensive antibiotic stewardship program. This had the potential to affect all 45 residents residing at the facility including Residents (#9, #15, #23, #27, #39 and #40) who received antibiotics between March 2023 and May 2023. Findings Include: Interview on 05/09/23 at 9:24 A.M. with the Director of Nursing (DON) revealed the facility kept a log of resident infections in a notebook which was tracked by type of organism, type of antibiotic used and mapped by room to identify potential patterns. If a physician ordered an antibiotic prior to obtaining culture and sensitivity results, the nurse wrote a progress note that McGreer's criteria (antibiotic surveillance definitions specific for benchmarking appropriate antibiotic usage) had not been met and the physician was notified. When an antibiotic was started prior to obtaining the culture and sensitivity results, and the lab results indicated the current antibiotic was an inappropriate antibiotic, the physician was notified. The DON stated the medical director had been made aware of concerns related to antibiotics being ordered prior to identification of the organism but had declined to address this with other physicians. Follow up interview on 05/10/23 at 12:14 P.M. with the DON revealed each physician had a notebook with information regarding their residents. Results of culture and sensitivity reports were placed in the physician notebooks. The DON indicated she did not speak directly with the physicians regarding the results including when the culture and sensitivity results indicated the antibiotic currently in use was not sensitive to the bacteria identified. The DON was unsure if the physicians reviewed the antibiotic information in the notebook for their residents. The DON stated the physicians did not meet to discuss antibiotic stewardship and indicated a team approach would be better at ensuring appropriate antibiotic stewardship was achieved. Review of the facility infection control log for the months of March 2023 through May 2023 revealed eight residents (Residents #9, #15, #19, #23, #27, #39, #40, and #46), received antibiotics. Review of the monthly medical director reports revealed the Medical Director checked off a box indicating he was reviewing the monthly infection control logs. Review of the 09/01/18 facility policy titled Antibiotic Stewardship Policy revealed since antibiotics were frequently over and inappropriately prescribed, an effort to decrease or eliminate inappropriate use could make a big impact on resident safety and the reduction of adverse events. Antibiotic stewardship consisted of coordinated interventions aimed at treating infections while promoting appropriate antibiotic use. Further review of the policy revealed the facility was to have physician, nursing, and pharmacy leads responsible for promoting and overseeing antibiotic stewardship activities. Regular feedback on antibiotic use and resistance to prescribing clinicians, nursing staff and other relevant staff. The Antibiotic Stewardship Team (AST) was to monitor antibiotic use and other data to ensure that the policies and procedures of the Antibiotic Stewardship Policy were followed and refined as needed and would include, at minimum, the Medical Director, the Director of Nursing, and the consultant pharmacist. The policy indicated providers were to use the McGreer criteria when considering initiation of antibiotics. Consistent with these criteria, the standardized suspected urinary tract infection (UTI) Situation Background Assessment and Recommendations (SBAR) form would be used for all residents suspected of having a UTI. The completed form should be provided to or information communicated with the provider. The medical director and medical staff were to perform quality of care functions including, but not limited to review of minutes of the facility's Quality Assessment and Assurance Committee meeting for minutes for items which needed medical consideration, further investigation or new policies and procedures.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memos, Nursing Home Guidance from the Centers for Disease Control (CDC), data contained on the State of Ohio's coronavirus.ohio.gov dashboard, observations, record reviews, review of the facility Coronavirus (COVID-19) policy, review of the facility's timeline, interview with the local health department and staff and resident interview, the facility failed to implement effective and recommended infection control practices including proper isolation of residents and the appropriate use of personal protective equipment (PPE) to prevent the spread of COVID-19 throughout the facility. This resulted in Immediate Jeopardy on 07/21/20 at 8:22 A.M. when Resident #1 had a temperature of 100.1 degrees Fahrenheit (F). New orders were received to send the resident to the emergency room (ER). A follow up nurses ' note dated 07/21/20 at 6:53 P.M. revealed Resident #1 was admitted to the hospital for COVID-19. The lack of investigation and effective infection control practices and prevalence of continued positive cases in the facility placed all residents in the facility at risk for harm, complications and/or death related to the facility's failure to control the COVID-19 outbreak. In addition, the facility failed to ensure consistent and timely infection control interventions were in place to promptly identify and isolate residents with potential exposure to staff members who tested positive for COVID-19, failed to ensure a root cause analysis was determined related to the COVID-19 outbreak in the facility, failed to ensure all staff received education on infection control and PPE use, failed to create and maintain an effective infection control program and failed to consistently have a qualified infection control preventionist. The facility census was 44 residents. From 07/21/20 through 08/01/20, there were 10 residents positive for COVID-19 (Residents #1, #3, #5, #6, #9, #10, #11, #12, #13 and #14) and two presumptive-positive residents (Resident #7 and Resident #21). In addition, three staff members tested positive for COVID-19. Through investigation including the use of a facility timeline as well as through interviews it was determined the facility failed to coordinate with the local health department in a timely manner to prevent and contain the spread of COVID-19 within the facility. The facility's previous Director of Nursing (DON)/Registered Nurse (RN) #109, who also served as the facility's infection control preventionist, was no longer employed by the facility as of 07/01/20. The current DON/RN #123 started her employment with the facility on 07/27/20. On 08/05/20 at 1:37 P.M. the Administrator and the current DON/RN #123 were notified by phone that Immediate Jeopardy began on 07/21/20 when Resident #1 was sent to the hospital and tested positive for COVID-19. No resident testing was completed as a result of the positive COVID-19 case and no quarantine or COVID unit was available for use at the facility prior to 07/21/20. The facility failed to have a policy regarding Coronavirus (COVID-19) until 08/04/20, failed to have any evidence of an infection control log or COVID-19 timeline list until 08/04/20 and failed to appropriately cohort residents by infection status. No contact tracing for residents or staff had been completed with any COVID-positive residents. On 08/04/20, 08/06/20, 08/07/20 and 08/10/20 onsite observations and interviews revealed ongoing infection control concerns including but not limited to the following: the 1-North unit contained positive COVID-19 cases, presumptive cases and exposed residents, where the same staff would serve all residents on the unit. Observations and interviews revealed staff were provided with one N95 mask and one face shield or set of goggles for use during the entire shift. PPE was not readily available outside residents ' rooms. Housekeeping staff wore the same set of PPE as rooms with COVID-19 positive, presumptive positive and exposed residents were cleaned. Through observation and interview, staff were not knowledgeable about isolation precautions or PPE use. Through record review, all residents were not appropriately screened for symptoms of coronavirus. The Immediate Jeopardy was removed on 08/12/20 when the facility implemented the following corrective action: · On 07/30/20 the Ohio National Guard tested staff for COVID-19. Those who were not tested were not allowed to work until they provided the facility with a negative test result. These individuals were pulled from the schedule and sent letters on 08/04/20. In an effort to identify anyone who might be infecting others, the facility will continue to test staff with a goal of twice per month. · On 07/30/20 and 07/31/20 DON/RN #123 conducted a training for 30 staff on PPE use and location of supplies. · On 08/05/20 and continuing through 08/09/20 DON/RN #123 provided morning and afternoon education sessions to 42 of 65 staff on hand hygiene, donning and doffing PPE and signs/symptoms of respiratory illness. These sessions will continue until 8/14/20 for staff who have not attended the training. Staff will not be able to work until training has been received. · On 08/06/20, a COVID-19 policy and procedure notebook was developed by DON/RN #123. The books were introduced to all staff and are available for staff use at each of the nurses ' stations. · On 08/06/20 at 4:00 P.M. a sealed plastic barrier wall with a zipper entrance was set up to separate the one known COVID-positive patient from other suspected COVID patients near the end of the hallway on the 1-North unit, creating a COVID-positive unit of four rooms. · On 08/07/20 all 41 residents in-house were tested for COVID-19 · On 08/07/20 DON/RN #123 developed a paper COVID-19 screening tool that will be used daily to evaluate each resident in the building and verbally shared the tool with staff. Feedback from the tool will be gathered from staff and presented at the September Quality Assurance (QA) meeting. · On 08/08/20 at 3:00 P.M. resident COVID-19 test results were received and allowed the facility to accurately separate residents into three distinct units (positive on the 1-North unit; suspect on the 2-South unit; negative on the 2-North unit). · On 08/08/20 starting at 4:00 P.M. 15 residents were moved according to the COVID-19 test results. · On 08/08/20 at 7:00 P.M. the plastic barrier was moved on the 1-North unit to accommodate a full COVID-positive unit due to facility need. Signage posted by DON/RN #123 on the entrance of the 1-North unit indicated that N95 masks and face shields were required. · On 08/08/20 at 8:00 P.M. PPE was stocked at the entrance and inside of the 1-North/COVID-positive unit, with appropriate signage placed to indicate droplet and contact precautions. · On 8/08/2020 at 8:00 P.M. the Administrator installed hooks in each resident bathroom on the COVID-positive unit for staff to hang their isolation gowns when they leave a resident ' s room. · On 08/09/20 the local City Health Department was notified of the resident COVID testing results and helped to set up a Tele-ICAR meeting (an infection prevention and control assessment and response program that is conducted via phone or video conferencing). · On 08/10/20 at 4:30 P.M. the Administrator had a conference call with the State Agency to discuss the Bridge Team as a staffing resource. · On 08/11/20 at 10:00 A.M., the DON and the Administrator had a meeting with the Tele-ICAR team. · On 08/11/20 the Administrator had a call with MetroHealth to obtain more PPE supplies and an order for [REDACTED].>· On 08/11/20 from 11:09 A.M. to 11:25 A.M. and on 08/13/20 from 11:23 A.M. to 11:55 A.M. interviews with State tested Nursing Assistant (STNA) #107, Housekeeper #126, STNA #115, Licensed Practical Nurse (LPN) #104, Dietary Staff (DS) #103, LPN #127, Licensed Social Worker (LSW) #105 and Manager of Environmental Services (MES) #128 revealed staff were knowledgeable on PPE use, the COVID resource books and hand washing protocols. · On 08/11/20 the facility reached out to a staffing agency to hire four nurses for an eight-week contract. After eight weeks, the facility will re-evaluate the need for supplemental staff. · On 08/11/20 the facility interviewed three LPNs, which are moving through the hiring process. · On 08/12/20 an electronic COVID-19 Screening was placed into Point Click Care, the facility's electronic medical record. This screening was to be completed three times a day for residents on the COVID-19 unit and once a day for all other residents. Although the Immediate Jeopardy was removed on 08/12/20, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: 1. Review of the Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memo QSO 20-20-ALL dated 03/20/20 revealed The Centers for Medicare & Medicaid Services (CMS) is committed to taking critical steps to ensure America's health care facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (COVID-19). As part of CMS guidance the Focused Infection Control Survey was made available to every provider in the country to make them aware of Infection Control priorities during this time of crisis, and providers and suppliers may perform a voluntary self-assessment of their ability to meet these priorities. The QSO Memo included additional instructions to Nursing Homes. We are disseminating the Infection Control survey developed by CMS and CDC so facilities can educate themselves on the latest practices and expectations. We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of COVID-19. This document may be requested by surveyors, if an onsite investigation takes place. We also encourage nursing homes to voluntarily share the results of this assessment with their state or local health department Healthcare-Associated Infections (HAI) Program. Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and whom possible incidents of communicable disease or infections should be reported (42 CFR 483.80(a)(2)(i) and (ii)). On 08/07/20 at 2:08 P.M. interview with the DON/RN #123 and the Administrator confirmed the CMS voluntary self-assessment had not been completed. 2. Review of the Centers for Disease Control and Prevention (CDC) website updated 07/22/20 revealed Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 07/15/20. To limit health care personnel (HCP) exposure and conserve PPE, facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection. Dedicated means that HCP are assigned to care only for these patients during their shift. Limit transport and movement of the patient outside of the room to medically essential purposes. Assign dedicated HCP to work only on the COVID-19 care unit. At a minimum this should include the primary nursing assistants (NAs) and nurses assigned to care for these residents. HCP working on the COVID-19 care unit should ideally have a restroom, break room, and work area that are separate from HCP working in other areas of the facility. Information obtained as part of the COVID-19 Focused Infection Control Survey between 08/03/20 and 08/13/20 from the Administrator and DON/RN #123 revealed the first resident (Resident #1) tested positive on 07/21/20 while at the hospital. The following concerns were identified as part of the survey: a. Review of Resident #1's closed medical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of admission physician's orders [REDACTED]. Review of census data indicated Resident #1 resided on the 1-North unit as a new admission and discharged to the hospital on [DATE]. A nurses' note dated 07/21/20 at 8:22 A.M. revealed the physician was notified Resident #1 had a temperature of 100.1 degrees Fahrenheit (F). New orders were received to send the resident to the emergency room . A follow up nurses' note dated 07/21/20 at 6:53 P.M. revealed Resident #1 had an admitting [DIAGNOSES REDACTED]. Review of the corresponding timeline, no date, listed 12 staff that had come into contact with Resident #1. On 07/22/20, the facility reported the case to the CDC and spoke with the staff that had been in contact with the resident. On 07/23/20 the facility reached out to the (City) Department of Public Health (CDOPH) and Public Health Outbreak Practice Coordinator (PHOPC) #111. On 07/24/20, State tested Nursing Assistant (STNA) #117 called off of work with symptoms and was told to not report to work until she was tested . STNA #117 was one of the staff listed that had cared for Resident #1. On 08/05/20 at 9:00 A.M. phone interview with the Administrator revealed no COVID or isolation area had been in place at the facility prior to 07/21/20 so he made the 1-North unit the isolation hall. The Administrator stated prior to the isolation unit, new residents were isolated in a private room but not on a designated unit in the facility. The Administrator verified no in-house resident COVID-19 testing had been done at the time of the interview. In a follow-up interview on 08/10/20 at 10:55 A.M. the Administrator revealed no contact tracing had been done with residents or staff when positive COVID-19 cases occurred and there had been no root cause analysis of cases within the facility. The Administrator stated it could have been Resident #1 that brought COVID into the facility as a new admission or Resident #14, who was a [MEDICAL TREATMENT] patient, but he didn't know. b. Review of electronic mail (e-mail) communication between the Administrator and the CDOPH dated 07/26/20 at 8:53 P.M. revealed the facility requested PHOPC #111 come to the facility to review how the positive COVID-19 case was being handled. On 08/06/20 at 5:24 P.M. phone interview with PHOPC #111 revealed during July 2020 the facility had their first COVID-19 case, then had three or four cases over a span of a few days so she was asked to visit the facility. PHOPC #111 shared the facility was trying to come up with an isolation area and a quarantine area and spoke of sectioning off an empty wing for sick residents. PHOPC #111 stated at the time of her visit on 07/29/20, the facility had not decided what to do regarding those residents coming back from the hospital especially if they were COVID-positive. PHOPC #111 stated she educated DON/RN #123, the Administrator and Licensed Social Worker (LSW) #105 on quarantine, isolation and PPE and discussed getting more resources. PHOPC #111 recommended cohorting residents including exposed residents in one area and positive/symptomatic residents in another area with dedicated staff for each of the negative, quarantine and isolation areas. PHOPC #111 stated for residents returning from the hospital, a 14-day quarantine was recommended and full PPE including a N95 respirator mask, gown, gloves and eye protection was needed for both positive residents and new admissions. PHOPC #111 explained each nursing home in Ohio was assigned to an organization within their zone and region and stated the facility was assigned to (named hospital) as well as a laboratory provider; if a facility had a shortage of COVID testing or PPE supplies, they were directed to contact the hospital organization. PHOPC #111 verified the facility had not reached out to her regarding any testing or PPE needs as of 08/06/20. On 08/06/20 at 9:32 A.M. interview with the Administrator verified the facility did not follow the recommendations PHOPC #111 provided to the facility regarding three separate areas with dedicated staff as they were ideal recommendations. c. Continued review of the undated facility timeline indicated on 07/31/20 the facility contacted Metro Health Nurse (MHN) #122 to request immediate testing of all residents; MHN #122 could not authorize this but would speak to a supervisor. On 08/08/20 at 12:51 P.M. interview with the Chief Quality Officer for the designated hospital (CQO) #118 confirmed the facility had made contact regarding COVID testing on 07/31/20. CQO #118 verified COVID testing for in-house residents was not completed until 08/07/20. CQO #118 stated a webinar had been provided to all facilities assigned to their hospital that discussed how to contact the hospital if needs arose. CQO #118 verified the facility had not requested PPE or reached out for testing supplies prior to 07/31/20. On 08/10/20 at 11:25 A.M. e-mail from CQO #118 and General Counsel (GL) #125 indicated as of 08/10/20 the facility did not have a contract in place for routine testing of residents and staff. 3. On 08/04/20 from 10:02 A.M. to 12:12 P.M. onsite observations and interviews conducted at the facility revealed the following concerns: a. Review of the previous DON,RN #109's personnel file revealed a start date of 02/05/20 for the DON position. A personnel change form dated 07/01/20 revealed RN #109 resigned and did not give proper notice of resignation. RN #109's license was valid and current. No infection control preventionist training was available for review. Review of DON/RN #123's personnel file revealed a hire date of 07/27/20. DON/RN #123's license was valid and current. Infection preventionist training was completed and available for review. Interview with DON/RN #123 on 08/04/20 at 10:35 A.M. revealed she was newly employed with the facility. When asked for a COVID timeline list or infection control log, DON/RN #123 revealed no infection control log, surveillance or infection control policies were available from the previous DON. Phone interview with the Administrator on 08/05/20 at 9:00 A.M. revealed the facility's previous DON, RN #109 filled the infection preventionist (IP) role but did not have the formal training. The Administrator stated RN #109 was the IP for three or four months but could not provide dates. The Administrator verified between RN #109 and DON/RN #123 there was a span of time where the facility did not have a DON or an IP. b. Interview with DON/RN #123 on 08/04/20 at 10:35 A.M. revealed the facility was running low on gowns, so they were to be hung up in the resident's bathroom. For isolation residents, staff were to use a gown, surgical mask and gloves. As Resident #6 readmitted to the facility on [DATE], staff were required to use a N95, face shield, gown and gloves when providing care to this resident as Resident #6 was on contact/droplet isolation. Interview with Licensed Practical Nurse (LPN) #104 on 08/04/20 at 10:53 A.M. revealed both exposed residents and positive residents were to be on Contact Airborne Droplet isolation precautions and this required a N95 respirator, gown, face shield and gloves. However, to enter the isolation unit on the 1-North hall only a N95 respirator was required. Interview with State tested Nursing Assistant (STNA) #107 on 08/04/20 at 11:22 A.M. revealed they had not received infection control training since March 2020 and no training on PPE at all from the facility. Review of education dated 07/21/20 to 07/25/20 revealed 46 out of 58 staff completed training on handwashing and PPE use. c. Review of an infection control map for July 2020, provided on-site, identified eight residents with respiratory infection. No log was available for review with this infection control map to indicate which residents had been affected, what symptoms they had or what course of action was taken. Observation of the 1-North isolation unit with the DON/RN #123 on 08/04/20 at 11:41 A.M. revealed Resident #6's door had signage indicating isolation status. PPE carts were sporadically placed throughout the hall. All doors on the unit did not have isolation signage and it was not clear what residents were under isolation and what PPE was required to enter these rooms. Review of a resident census list dated 08/04/20 requested by the surveyor while on-site to determine spread of infection throughout the facility and provided by DON/RN #123 revealed the facility had identified one positive resident (Resident #6), two presumptive positive residents P (Resident #7 and #21) and eight residents who tested positive for COVID at the hospital (Residents #1, #3, #5, #9, #10, #11, #13, #14) as well as one resident on contact droplet airborne precautions (Resident #8). The census document itself indicated five residents on isolation (Residents #2, #6, #8, #21 and #25). Phone interview with the Administrator and DON/RN #123 on 08/04/20 at 4:21 P.M. revealed there was no facility policy regarding COVID-19 and no COVID timeline list available for review at the time of interview. The Administrator and DON/RN #123 stated all residents on the first floor had been exposed. Both the Administrator and the DON/RN #23 verified all residents on the 1-North unit were to be considered presumptive positive. Review of the facility's Coronavirus policy, dated 08/04/20 and received by e-mail on 08/04/20 at 6:57 P.M. revealed guidance for positive and presumptive positive residents. For positive residents, an isolation period would commence, [MEDICATION NAME] 10-14 days (to be determined by DON). Positive or presumptive positive residents would have two signs on the door a) keep door closed and b) Contact/Droplet precautions. All staff must wear N95 masks, gown and gloves while giving patient care. A face shield must be worn if possible splash should occur. Gowns and gloves must be taken off and appropriate hand hygiene performed before leaving room. Dedicated equipment would be utilized in caring for positive and presumptive positive residents and cleaned with [MEDICATION NAME] alcohol or bleach wipes between use. Disposable dining products would be utilized in positive and presumptive positive rooms. The policy did not address exposed residents, new residents or readmissions or where these different groups of residents would reside within the facility. Review of an infection control log for July 2020, provided to the surveyor via e-mail on 08/04/20 at 6:57 P.M. revealed 10 residents with COVID-19 and three staff. There was one positive case on 07/21/20 (Resident #1), two positive cases on 07/24/20 (Resident #9 and Resident #14), one positive case on 07/25/20 (Resident #5), two positive cases on 07/26/20 (Resident #10 and Resident #12) and four positive cases on 07/31/20 (Residents #3, #6, #11, and #13). Residents identified as presumptive positive on the census document (Resident #7 and Resident #21) were not on the infection control log. Record review completed on 08/04/20 revealed 11 residents on the 1-North unit (Residents #2, #4, #14, #15, #16, #17, #18, #19, #20, #22 and #23) did not have orders for isolation precautions and a presumptive positive resident (Resident #7) did not have orders for isolation precautions. Phone interview with the Administrator on 08/05/20 at 9:00 A.M. confirmed the 1-North isolation unit had not been in place prior to 07/21/20. New admissions were being isolated in a private room but did not go to a designated unit, 2-South, until 07/24/20. The Administrator verified the city health department had been contacted and had suggested keeping separate units of non-exposed residents, suspected residents and positive residents but due to not enough COVID tests, the facility held off on creating these units. The Administrator verified the facility had placed a COVID-positive resident amongst presumptive positive and exposed residents on the 1-North hall. Review of the CDC's Responding to Coronavirus (COVID-19) in Nursing Homes (https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html) revised 04/30/20 revealed residents with suspected or confirmed COVID-19 were to be cared for using all recommended COVID-19 PPE (N95 or higher-level respirator, eye protection, gloves, and gown). If a resident was confirmed to have COVID-19 regardless of symptoms they should be transferred to the designated COVID-19 care unit. Roommates of residents with COVID-19 should be considered exposed and potentially infected. Health care providers should use all recommended COVID-19 PPE for the care of all residents on affected unit including asymptomatic and symptomatic residents. Record review of the facility's positive and presumptive COVID cases revealed the following concerns: i. Review of Resident #9's closed medical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of physicians' orders revealed an order dated 04/14/20 for temperature and lung sounds each shift and as needed notify DON if temperature at 99 (degrees F) or higher every evening shift related to COVID-19. Review of the July 2020 Medication Administration Record [REDACTED]. A nurses' note dated 07/23/20 at 10:22 P.M. revealed the resident had a moist productive cough but was afebrile. A nurses' note dated 07/24/20 at 3:17 P.M. revealed Resident #9 was sent to the emergency room for increased shortness of breath, decreased pulse oximetry and hypertension. Interview with the DON on 08/10/20 at 12:34 P.M. verified nursing staff should have followed the order as written and notified the DON and/or the physician of Resident #9's elevated temperature as well as documented this in the medical record. ii. Review of Resident #21's medical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Review of the July 2020 and August 2020 MARs revealed no evidence the COVID test had been completed as ordered. Review of a nurses' note dated 07/27/20 revealed the resident was aware she was to be tested for COVID-19. Review of a nurse practitioner note dated 08/05/20 indicated Resident #21 was not positive for COVID-19 but was on precautions as her roommate had tested positive for COVID-19. Interview with the DON on 08/10/20 at 12:34 P.M. revealed the facility was sent several COVID-19 testing swabs but they had not been used. No resident COVID testing had been completed in-house prior to 08/07/20. The DON was made aware there was no evidence of Resident #21's COVID-19 swab in the electronic medical record and stated it may have not been done. iii. Review of Resident #11's medical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Review of the July 2020 and August 2020 MARs revealed no evidence the COVID test had been completed as ordered. Review of nurses' notes revealed on 07/30/20 at 1:01 P.M. the nurse practitioner was informed Resident #11 had a change condition with poor appetite, lethargy and was shaking; new orders included a COVID-19 swab and to start intravenous (IV) fluids along with urinalysis and lab work. A nurses' note dated 07/31/20 at 1:00 P.M. revealed Resident #11 discharged to the hospital and tested positive for COVID. Interview with the DON on 08/10/20 at 12:34 P.M. revealed the facility was sent several COVID-19 testing swabs but they had not been used. No resident COVID testing had been completed in-house prior to 08/07/20, including Resident #11. iv. Review of Resident #7's medical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of current physician's orders [REDACTED]. Review of a nurses' note dated 08/01/20 at 4:48 P.M. revealed Resident #7's white blood count (can detect hidden infections in the body) was 2.9 (low) and Resident #7 was suspected positive for COVID and in isolation. Review of the July 2020 infection tracking log revealed Resident #7 was not listed as suspected COVID-positive. The Administrator was made aware of these concerns during interview on 08/06/20 at 9:32 A.M. v. All 28 resident records reviewed (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27 and #126) were noted to lack evidence of COVID-19 symptom monitoring. Review of physician orders [REDACTED]. No other assessments were available for review in the medical records. Interview with the Administrator on 08/06/20 at 9:32 A.M. revealed nursing staff completed pulse oximetry to monitor residents for COVID-19 but was unsure if any other assessment was completed. Review of CMS memorandum, QSO-20-30-NH dated 05/18/20 revealed 100% of residents were to be screened with temperature checks and questions about/observation for other signs and symptoms of COVID-19 at least daily. 4. Phone interview with the Administrator on 08/05/20 at 9:00 A.M. revealed the facility had not had a medical director since 01/01/20 and was using facility physicians for guidance relating to COVID-19. Review of the facility's roster of medical staff, undated, revealed no medical director was listed. A phone interview with Physician #110 on 08/10/20 at 12:08 P.M. confirmed he resigned as medical director in October 2019. Physician #110 stated he had suggested three or four weeks ago that the facility test all residents and staff for COVID-19. A phone interview with Physician #120 on 08/11/20 at 3:17 P.M. denied the facility had asked him for any guidance regarding COVID-19. An e-mail was sent to Physician #112 on 08/12/20 at 10:16 A.M. requesting an interview but no return contact was received. A phone interview with Physician #119 on 08/12/20 at 10:21 A.M. denied the facility had asked him for any guidance regarding COVID-19. 5. On 08/06/20 from 9:19 A.M. to 12:41 P.M. onsite observations and interviews conducted at the facility revealed the following concerns: a. Observation of the facility's PPE supplies with the Administrator on 08/06/20 starting at 10:26 A.M. revealed in the conference room there were five jugs plus partial containers of alcohol to make hand sanitizer; six containers plus partial containers of hand sanitizer; 1000 extra large gloves; 1400 small gloves; 240 N95 respirators plus partial packs; 1450 surgical masks; 18 face shields; a partially opened large box of goggles; 60 isolation gowns. Observation of the facility's PPE storage on the (TRUNCATED)

Based on observation, review of the medical record, facility Self-Reported Incident (SRI), the National Center for Environmental Information, local news station articles, facility policy and procedure and interviews the facility failed to ensure adequate supervision to prevent the elopement of one resident (Resident #1) who was assessed as severely cognitively-impaired and at risk for elopement. Resident #1 left without staff knowledge through a service door that had the audible alarm deactivated by a staff member. This resulted in Immediate Jeopardy and the likelihood for serious harm, injury or death to Resident #1 when the resident exited the facility unsupervised and was found wandering on the sidewalk headed away from the facility by Resident #1's family member in a busy, high risk neighborhood. This affected one of three sampled residents reviewed for risk of elopement. The facility identified seven (#1, #2, #3, #4, #5, #6 and #7) residents as being at risk for elopement. The facility census was 62. On 12/30/19 at 2:49 P.M., the Administrator, and the interim Director of Nursing (DON), were notified Immediate Jeopardy began on 12/08/19 at 12:51 P.M. when Resident #1, who was assessed as high-risk for elopement, was observed via recorded video footage, exiting the facility, unsupervised and was found wandering off facility property at 1:05 P.M. by his family member. The facility was not aware he had left the facility until the family member advised them. According to National Centers for Environmental Information, the average temperature was 40.1 degrees Fahrenheit (F) to 50 degrees F on 12/08/19. Per local news station articles, the facility's neighborhood has a high-crime history. The Immediate Jeopardy was removed on 12/10/19 when the facility implemented the following corrective actions: · On 12/08/19 between 2:30 P.M. and 3:30 P.M., the DON educated 12 nurses and state tested nurse aides (STNAs) on the location of the elopement book, residents at-risk for elopement, door alarms and individual staff responsibility (STNA #14, STNA/Receptionist #15, Licensed Practical Nurse (LPN) #16, STNA #17, STNA #18, STNA #19, STNA #20, LPN #12, STNA #21, LPN #22, LPN #23 and Registered Nurse (RN) #24). · On 12/08/19 at 3:30 P.M., the Administrator conducted a door alarm inspection of the seven doors that were alarmed but not connected with the Wander guard system (a system that involves a resident wearing a bracelet that automatically locks and alarms a monitored door upon approach of the resident). No concerns were noted. · On 12/09/19 between 9:00 [NAME]M. and 3:30 P.M., the DON educated an additional nine nurses, STNAs and housekeepers on the location of the elopement book, residents at-risk for elopement, door alarms and individual staff responsibility (Housekeeper #27, Housekeeper #28, Housekeeper #29, Housekeeper #30, STNA #25, LPN #26, STNA #4, STNA #6, and LPN #31). · On 12/09/19 by 9:56 [NAME]M., the DON and LPN #12 reassessed the six residents (Residents #2, #3, #4, #5, #6 and #7) who the facility identified as being at risk for elopement and care plans were updated as indicated. Moving forward, elopement assessments will be completed on every new admission, quarterly and following any significant change in condition. A resident's care plan will reflect the needs identified in the assessment. Each admission will be reviewed by a nurse manager within 48 hours after admission. The nurse manager will check for an elopement assessment and a care plan that reflects the needs of the resident. · On 12/09/19 at 10:00 [NAME]M., Manager of Building Services (MBS) #8 conducted a video assessment to determine how Resident #1 exited the building. · On 12/09/19 at 1:00 P.M., MBS #8 changed the code for the service door, which Resident #1 exited, so only the cooks could deactivate and reactivate the service door alarm. When a cook was not in the building, the dietary aides would use the rear entrance doors which were Wander guard protected to remove the trash. · On 12/09/19 at 2:15 P.M., the Administrator provided additional education to four housekeeping employees on the elopement policy, elopement book, door alarms and individual staff responsibility (Housekeeper #26, Housekeeper #27, Housekeeper #28 and Housekeeper #29). · On 12/09/19 at 3:00 P.M., the DON implemented 30-minute interval nursing checks on Resident #1 through 12/18/19 at 3:30 P.M. · On 12/09/19 at 3:30 P.M., MBS #8 checked all exit doors to ensure the alarms were functioning properly. No concerns were noted. · On 12/09/19 by 4:00 P.M., Director of Resident Services #11 reviewed all seven residents at-risk for elopement to ensure their Wander guards were working. · On 12/09/19 at 5:00 P.M., the DON reviewed and updated the elopement book at each nurses' station which contained information and pictures of the seven residents at risk for elopement. Moving forward, The DON will be responsible to ensure the Elopement Assessment books are audited once each month to make sure they are up to date. Additionally, the information in the books will be reviewed with the licensed nurses at least quarterly in regular nurse staff meeting. The licensed nurses will have an opportunity to offer any updates based on their experience with the residents on their unit. · On 12/13/19 at 2:30 P.M., the Administrator conducted another door alarm inspection of the seven doors that were not connected with the Wander guard system. All doors and alarms were properly engaged and functional. · On 12/13/19 by 3:30 P.M., Dietary Manger #10 reeducated all dietary employees on the elopement policy and use of the service door exit. · On 12/20/19 at 4:00 P.M., MBS #8 conducted a door alarm inspection of the seven doors that were not connected with the Wander guard system. All doors and alarms were properly engaged and functional. · On 12/30/19 at 11:20 [NAME]M., MBS #8 conducted a door alarm inspection of the seven doors that were not connected with the Wander guard system. All doors and alarms were properly engaged and functional. · On 12/31/19 at 9:30 [NAME]M., MBS #8 conducted a door alarm inspection of the seven doors that were not connected with the Wander guard system. All doors and alarms were properly engaged and functional. Door alarm inspections would continue weekly. · On 12/31/19 at 10:45 [NAME]M., LPN #13 conducted an elopement drill with staff representing all shifts. Staff responded appropriately. · On 12/31/19 between 7:55 [NAME]M. and 11:01 [NAME]M. interviews with Cook #1, Dietary Aide #2, STNA #3, LPN #5 and STNA #6 revealed they were educated and knowledgeable on the elopement policy and procedure and on the location of the elopement binders. · On 01/06/19 at 3:00 P.M. the DON began education via phone regarding the elopement policy, elopement book, door alarms and individual staff responsibility for all staff that had not attended an in-service in person. If phone contact with staff unsuccessful, staff education would be provided prior to beginning next scheduled shift by the nurse manager. Although the Immediate Jeopardy was removed, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 admission assessment, dated 11/19/19, revealed Resident #1 was severely-cognitively impaired, required supervision with walking in his room and the corridor and had wandering behaviors one to three days during the assessment. Review of the elopement risk/wanderer care plan, created on 11/19/19, revealed Resident #1 was at risk for elopement/wandering due to impaired safety awareness. Review of the impaired cognitive function care plan, created on 11/19/19, revealed Resident #1 had impaired thought processes related to [MEDICAL CONDITION] and short-term memory loss. An intervention to ensure Resident #1's safety included to cue, reorient and supervise the resident as needed. Review of the wandering risk scale assessment, dated 11/20/19, indicated Resident #1 was at risk to wander and stated he wanted to go through the double doors on the front floor. Review of the wandering risk scale assessment, dated 12/06/19, indicated Resident #1 was at high risk for wandering. Review of the (MONTH) 2019 physician orders [REDACTED]. Resident #1 was also ordered a Wander guard device for elopement risk. Review of the behavior note, dated 12/08/19, timed 1:41 P.M., recorded as a late entry indicated at 1:05 P.M., Resident #1's family member entered the facility, irate and stated she had found the resident walking down the street and she had picked him up. Resident #1's family member stated, he's in my car and not coming back here. Review of the nursing progress note, dated 12/08/19, timed 2:22 P.M. indicated a call was placed to Resident #1's responsible party to inform her of Resident #1 leaving the facility. Resident #1's family member found him on the street and stated the resident was not returning to the facility. Review of the behavior note, dated 12/08/19, timed 3:15 P.M., recorded as a late entry indicated Resident #1 returned with his wife to the facility at that time. Resident #1 was alert and oriented to self and immediate surroundings. Resident #1 was ambulatory with step, shuffle gait and refused head-to-toe assessment stating, girl, leave an old man alone. The note further indicated Resident #1 was being monitored at 15-minute intervals and was in bed, asleep, at this time. Review of the SRI submitted to the State Agency, dated 12/09/19, indicated Resident #1 eloped from the building at 12:51 P.M. and returned to the building at 1:02 P.M. by a family member. The SRI indicated on Sunday, 12/08/19, Resident #1 departed the dining room on the first floor and headed South towards the kitchen instead of North towards his room and the resident lounge. The resident went beyond the kitchen and exited the building at 12:51 P.M. through a service entrance used for deliveries and trash removal. The door was routinely alarmed except when being used. At the time, the door alarm was off because a porter in the kitchen was emptying the trash (Dietary Aide #7). The resident maneuvered his way to the front exterior of the building where he could no longer be observed by the camera. A family member was approaching the nursing home in a car and spotted him. The family got out of the car and helped the resident into the car. She then pulled up to the facility and entered the building about 1:02 P.M., leaving the resident in the car. The family member expressed anger at finding the resident outside the building and said she was taking him home. Review of the witness statement, written by STNA #4, dated 12/08/19, indicated Resident #1 was sitting in the dining room about 12:45 P.M. and at 1:05 P.M., his family member walked in the building and stated the resident was in her car and she found him walking down the street. Review of the witness statement, written by LPN #5, dated 12/08/19, indicated at 1:05 P.M., Resident #1's family member entered the building, irate, stating that she found the resident walking down the street. She picked him up and stated, he's in my car and not coming back here. Review of the witness statement, written by STNA #6, dated 12/08/19, indicated STNA #6 saw Resident #1 sitting in the dining room eating. STNA #6 came down the hall to help another STNA and when they completed their task, about 1:00 P.M., Resident #1's family member came in and stated the resident was in the car and she saw him walking down the street and she was taking him home. There were no witness statements from Dietary Aide #7 or any other dietary aide or cook in the SRI investigation file. Observation on 12/30/19 at 7:50 [NAME]M. revealed Resident #1 lying in bed with his head at the foot of the bed and his feet at the head of the bed. Resident #1 was wearing an adult incontinence brief, hospital gown, and blue jeans. Resident #1 had a Wander guard bracelet on his right wrist, he was bare foot and his eye glasses were on the floor. An attempt to interview Resident #1 was unsuccessful as his responses were mumbled and unclear. Observation on 12/30/19 at 8:00 [NAME]M. of the service door near the kitchen revealed the door led into a stairwell with access to the second floor and an exit door. The door alarmed when opened. The sidewalk path headed East and West. If headed West, the sidewalk path led to the front of the building through an iron gate. If headed East, the sidewalk led to a side road connected to the facility through a metal gate. Within seconds of the service door alarming, Cook #1 and Environmental Services Director (ESD) #2 responded to the alarm. Cook #1 showed the surveyor the keypad on a wall inside the kitchen which controlled the alarm to the service door. Observation upon exiting the front entrance of the facility on 12/30/19 at 8:50 [NAME]M. revealed a residential neighborhood. A very large, sprawling campus of a nationally-renowned hospital was one city-block away from the facility and could be seen from the sidewalk in front of the facility. Interview on 12/30/19 at 8:55 [NAME]M. with Dietary Aide #3 revealed she was educated on the elopement policy and she knew the code to deactivate the service door exit in case a cook called off. Observation on 12/30/19 at 9:09 [NAME]M. revealed Resident #1 sitting on the side of his bed without a shirt and wearing blue jeans. Interview on 12/30/19 at 9:10 [NAME]M. with STNA #4 revealed she had last seen Resident #1 sitting in the dining room, chatting with another resident at 12:45 P.M. on 12/08/19. Resident #1 had previously verbalized he wanted to go home and wanted to get out of here. STNA #4 did not hear a door alarm sound on 12/08/19. Interview on 12/30/19 at 9:15 [NAME]M. with LPN #5 revealed she had last seen Resident #1 sitting in the dining room at 12:45 P.M. on 12/08/19. LPN #5 stated when Resident #1 was first admitted , he attempted to exit the building. LPN #5 stated Resident #1 was wearing jeans, shoes and a [NAME]et on 12/08/19. LPN #5 did not hear a door alarm sound on 12/08/19. Interview on 12/30/19 at 9:18 [NAME]M. with STNA #6 revealed Resident #1 had previously attempted to exit the building. Resident #1 was last seen sitting in the dining room on 12/08/19; however, STNA #6 did not know the time of the observation. STNA #6 did not hear a door alarm sound on 12/08/19. Observation on 12/30/19 at 10:10 [NAME]M. revealed Resident #1 remained seated on the side of his bed without a shirt. Interview on 12/30/19 at 11:00 [NAME]M. with the Administrator revealed the video footage of Resident #1 exiting the building had since been erased. The Administrator verified a written witness statement was not obtained from Dietary Aide #7 who allegedly was emptying the trash and left the door unsecured. Interview on 12/30/19 at 11:01 [NAME]M. with Dietary Aide #7 revealed when he arrived to work on 12/08/18 at 11:00 [NAME]M., Resident #1 had already exited the building. Dietary Aide #7 stated he had not emptied trash when Resident #1 exited the facility and he did not empty the trash until 1:00 P.M. or 2:00 P.M. Dietary Aide #7 stated he did not see any resident exit the building while he was emptying the trash. Dietary Aide #7 stated he knew how to deactivate the alarm on the service door. Interview on 12/30/19 at 11:05 [NAME]M. with the Administrator revealed Dietary Aide #7 had a learning disability and he did not understand what happened with Resident #1. The Administrator said he did not watch the recorded video footage of Resident #1 exiting the building, MBS #8 viewed the video footage. Interview on 12/30/19 at 11:15 [NAME]M. with MBS #8 revealed at 12:51 P.M. on 12/08/19, Resident #1 exited out of the dining room and turned left to walk towards the service door. Next, the resident was seen on another camera in the stairwell after exiting the first service door. Resident #1 then was seen on an exterior camera walking out the second service door exiting the facility. Resident #1 followed the sidewalk, heading West toward the front entrance then the resident went out of view of the camera. MBS #8 stated he did not see Resident #1 follow any staff member out of the service door nor did he see any staff members outside emptying the trash. MBS #8 indicated he did not rewind the video footage to see who the last staff member was exiting the service door prior to Resident #1 eloping from the facility. MBS #8 said there was no audio from the video footage, only visual footage. Observation on 12/30/19 at 11:20 [NAME]M. with MBS #8 revealed when the surveyor opened the North double doors at the side of the building an alarm activated throughout the facility. Interview, during the observation, with MBS #8 revealed the front and back facility entrances were the only doors which were linked to the Wander guard system. The door(s) in the resident lounge, the chapel, activities/dining room, therapy gym, and the North stairwell were not Wander guard protected; they were equipped with 15-second delayed egress hardware designed to continuously alarm when the exit bar was engaged until the alarm was de-activated by entering a code on a key pad. The keypad to activate and deactivate those doors was behind the first-floor nursing station. MBS #8 explained the service door alarm could only be activated and deactivated by the keypad located in the kitchen. Once the service door alarm was deactivated by inputting a numerical code into the keypad, the service door alarm would have to be reactivated by a staff member by inputting the same code into keypad. During an interview on 12/30/19 at 11:25 [NAME]M. with STNA #4 and STNA #6 they stated they would not have realized Resident #1 was missing until they completed their 2:00 P.M. resident checks on 12/08/19. Interview on 12/30/19 at 11:35 [NAME]M. with the Administrator revealed he assumed Dietary Aide #7 was the staff member who deactivated the service door. Interview on 12/30/19 at 11:40 [NAME]M. with Dietary Aide #9 revealed he was in the laundry room when Resident #1 eloped and was not aware of what Dietary Aide #7 was doing at the time. Observation on 12/30/19 at 12:20 P.M. revealed Resident #1 sitting in the dining room, feeding himself lunch. A second attempt to interview Resident #1, at the time of observation, was unsuccessful. His responses were mumbled, and the words unclear. Interview on 12/30/19 at 3:30 P.M. with Dietary Manager (DM) #10 indicated she assumed a cook had deactivated the service door alarm since the cooks were the only dietary employees who knew the code to the service door. Interview on 12/30/19 at 3:55 P.M. with Resident #1's family member indicated she was driving South on the street which the facility's main entrance faced when she observed Resident #1 walking, unsupervised, outside on the sidewalk, heading South. Resident #1 was standing outside of an iron fence that enclosed a grassy area, midway the length of the fence which was not located on facility property. Resident #1 was wearing jeans, another resident's shirt, a [NAME]et, sneakers and socks. Resident #1 told the family member that he was by himself and he was cold. Interview on 12/30/19 at 4:00 P.M. with Resident #1's wife revealed she arrived at the facility after attending church services on 12/08/19. She did not remember what time she arrived at the facility but her husband, Resident #1 was not at the facility when she arrived. Facility staff notified her that Resident #1 had exited the facility and was with a family member. Observation on 12/30/19 at 4:10 P.M. of a photograph of Resident #1 distributed by Resident #1's family member revealed Resident #1 standing, midway of the length of an iron fence that enclosed a grassy area, on the sidewalk of the street which the facility main entrance faced. Resident #1 was wearing jeans, a zipped up beige [NAME]et and glasses. The photograph did not show Resident #1's feet. Review of a local news station article, dated 11/03/19, indicated a [AGE] year old man was shot in the groin late Saturday (11/02/19) in the facility's neighborhood. Review of a local news station article, dated 12/08/19, indicated a [AGE] year old man was stabbed at about 10:00 P.M. on Saturday (12/07/19) in the facility's neighborhood. Review of the facility's undated missing resident policy revealed facility staff should check the whereabouts of any resident at risk of wandering off or those who would deliberately attempt to leave the facility frequently throughout the shift. This deficiency substantiates Self-Reported Incident Investigation Control Number OH 956.

Based on record review, interview and self reported incident (SRI) review, the facility failed to ensure Resident #19 was transferred appropriately via a Hoyer (mechanical) lift. Actual harm occurred when Resident #19 sustained a left [MEDICAL CONDITION] during transfer. This affected one of three sampled residents. Findings include: Review of the medical record for Resident #19 revealed an admission date of [DATE]. Admitting [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment and was dependent on staff for most activities of daily living. Review of an incident report dated 06/24/19, revealed on 06/24/19 at around 11:00 A.M. Licensed Practical Nurse (LPN) #113 and Occupational Therapy Assistant (OTA) #114 were transferring Resident #19 via a mechanical lift. During the transfer the resident hit her left knee on the lift bar. The resident complained of left knee pain. No swelling or bruising of the knee was noted. The resident was given pain medication and the nurse practitioner and family were notified. An x-ray of the left knee on 06/24/19 was negative for fracture. Review of the facility investigation revealed on 06/27/19, LPN #113 reported to the Director of Nursing (DON) that on 06/24/19 the resident bumped her knee on the lift bar while being lowered into a chair via the Hoyer lift. An incident report was completed and an x-ray of the left knee revealed no evidence of a fracture. LPN #113 indicated the resident, who was in the Hoyer lift, was quick released into her chair. LPN #113 indicated she was not sure but she thought the resident hit her knee when released into the chair. LPN #113 did not report the incident because she did not think the resident fell into the chair that hard. Other residents were interviewed regarding the incident and they did not see anything happen. However, Resident #42 did state that later that day she talked to Resident #19 who was crying due to being in extreme pain. Resident #42 reported Resident #19's pain to LPN #113 who informed her that she would check on Resident #19. Review of OTA #114's statement dated 06/27/19 timed 5:00 P.M. revealed during the Hoyer transfer on 06/24/19 Resident #19 started to look uncomfortable so she hit the emergency release to get her into the chair quickly and the resident fell into the chair. The statement indicated the resident hit the chair hard when the quick release button was activated. The resident complained of pain to her left knee. An attempt to interview Resident #19 on 08/01/19 at 9:40 A.M. was unsuccessful because she was not lucid enough to answer questions. Interview with LPN #113 via telephone on 08/01/19 at 3:30 P.M. revealed that when assisting OTA #114 use the Hoyer lift to transfer Resident #19 from her bed to a chair, OTA #114 hit the quick release button and the resident hit the chair hard. LPN #113 said the resident continued to complain of pain to the knee area in the following days. The nurse practitioner came in to reassess the resident on 06/27/19 and upon examination of the resident the nurse practitioner asked LPN #113 what could have happened to cause the resident to be in so much pain. LPN #113 explained OTA #114 used the emergency release on the Hoyer during a transfer and the resident fell into the chair. The nurse practitioner ordered x-rays of the pelvis and left femur and added an order for [REDACTED]. Review of the hospital record from 06/27/19 to 07/06/19 confirmed Resident #19 had an intertrochanteric left femoral fracture with mild apex angulation (indicating the top of the femoral head was not straight) and mild soft tissue swelling. The report indicated with the resident's co-morbidities she was not a surgical candidate and it was decided to treat the fracture medically. The resident was released back to the facility on [DATE]. Review of the operators manual for the Invacare Hoyer lift dated (YEAR) revealed there were emergency release buttons on the lift. The manual did not indicate when the emergency button should be used or why. Interview with an Invacare representative via telephone on 08/01/19 at 1:26 P.M. revealed when the quick release was used the resident would not be automatically dropped but would be slowly lowered.

Based on record review, interview and self reported incident (SRI) review, the facility failed to ensure Resident #19's pain was appropriately treated from 06/24/19 to 06/27/19. Actual harm occurred as evidenced by complaints of extreme pain and no pain medication administered after sustaining a left [MEDICAL CONDITION]. This affected one of three sampled residents. Findings include: Review of the medical record for Resident #19 revealed an admission date of [DATE]. Admitting [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment and was dependent on staff for most activities of daily living. Review of an incident report dated 06/24/19, revealed on 06/24/19 at around 11:00 A.M. Licensed Practical Nurse (LPN) #13 and Occupational Therapy Assistant (OTA) #114 were transferring Resident #19 via a Hoyer (mechanical) lift. During the transfer Resident #19 hit her left knee on the lift bar. The resident complained of left knee pain. No swelling or bruising of the knee was noted and the resident was given pain medication. An x-ray was completed and was negative for fracture. Review of the facility investigation dated 06/27/19 revealed on 06/27/19, LPN #113 reported to the Director of Nursing that on 06/24/19 Resident #19 bumped her knee on the lift bar while being lowered in to her chair via the Hoyer lift. An incident report was completed and an x-ray of the left knee was performed and revealed no evidence of a fracture. The investigation included interview with other residents regarding the incident. The other residents had no knowledge of the incident but Resident #42 did state that later that day she talked to Resident #19 who was crying due to being in extreme pain. Resident #42 reported this to LPN #113 who informed her that she would check on Resident #19. An attempt to interview Resident #19 on 08/01/19 at 9:40 A.M. was unsuccessful because the resident was not lucid enough to answer questions. When asked if she was in pain, she stated yes but was unable to provide a pain rating. Interview with LPN #113 via telephone on 08/01/19 at 3:30 P.M. revealed that when assisting OTA #114 with using the Hoyer lift to transfer Resident #19 from her bed to a chair, OTA #114 hit the quick release button and the resident hit the chair hard. LPN #13 said the resident continued to complain of pain to the knee area in the following days. The nurse practitioner came in to reassess the resident on 06/27/19 and upon examination of the resident the nurse practitioner asked LPN #113 what could have happened to cause the resident to be in so much pain. LPN #113 explained OTA #114 used the emergency release on the Hoyer during a transfer and the resident fell into the chair. The nurse practitioner ordered x-rays of the pelvis and left femur and added an order for [REDACTED].#113 could not remember if she medicated Resident #19 after the Hoyer transfer or after Resident #42 reported the resident was in pain. Review of Resident #19's medical record revealed no documentation in the nursing progress notes indicating Resident #19 was assessed for pain or received pain medication after the transfer via the Hoyer lift where she fell into the chair or after receiving the report from Resident #42 that the resident was in extreme pain. Review of Resident #19's daily pain check documentation revealed on 06/24/19 she rated her pain at a level of nine and then on night shift she rated her pain six (on a scale of zero to 10, zero = no pain, 10= the most pain imaginable). Review of the resident's Medication Administration Record [REDACTED]. Additional review of the MAR indicated [REDACTED].M. for a pain rating of eight. This was the only pain medication documented as administered to Resident #19 during between 06/24/19 and 06/27/19. Further review of Resident #19's medical record revealed on 06/27/19 the nurse practitioner evaluated the resident and the resident complained of pain. The nurse practitioner ordered [MEDICATION NAME] (narcotic pain reliever) 50 milligram (mg) two times a day. Review of Resident #19's MAR indicated [REDACTED] Review of the hospital record from 06/27/19 to 07/06/19 revealed Resident #19 had an intertrochanteric left femoral fracture with mild apex angulation (indicating the top of the femoral head was not straight) and mild soft tissue swelling. The report indicated with the resident's co-morbidities she was not a surgical candidate and it was decided to treat the fracture medically. The resident was released back to the facility on [DATE]. Review of the physician's orders [REDACTED]. Interview with LPN Supervisor #103 on 07/31/19 at 4:50 P.M. revealed the facility had to wait for an actual hard copy signed order to send to the pharmacy before they could obtain and administer the [MEDICATION NAME] to Resident #19. LPN Supervisor #103 said she contacted the physician numerous times and the physician said he sent the prescription but she did not receive it. Once she received the prescription she had the pharmacy drop ship it immediately. The resident received her first dose of [MEDICATION NAME] 25 mg on 07/08/19 at 5:40 A.M. for complaints of pain that she rated an eight.

Based on observation, record review and interview, the facility failed to ensure accurate assessments and weekly wound tracking was completed for Residents #78 and #94's pressure ulcers and failed to ensure appropriate pressure relieving interventions were implemented and in place for Residents #78 and #94. The facility failed to address a decline in Resident #78's coccyx/left buttock pressure ulcer from a Stage II to a Stage IV and failed to provide incontinence care to her during the dressing change observation. This affected two of three residents reviewed with pressure ulcers. The facility census was 94. Findings include: 1. Resident #78 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. During the initial tour of the facility with Licensed Practical Nurse (LPN) #4 on 11/16/11 at 10:15 A.M Resident #78 was observed in bed on her back and appeared very thin/frail. She did not open her eyes or respond when spoken to. A special air mattress was on her bed and LPN #4 indicated she was dependent on staff for all aspects of her care/activities of daily living and needed to be turned every two hours. LPN #4 indicated she currently had open areas only on her buttocks. LPN #4 pulled back the sheet and verified that pressure relieving boots were supposed to be on both feet/lower legs, but only the left one was in place. The right boot was observed on her recliner chair. Review of the admission nurse's note dated 02/18/11 indicated Resident #78 was lethargic and could not respond to commands or communicate her needs. The note indicated Resident #78 had a Stage I pressure ulcer on her right buttock, with measurements of 1.5 centimeters (cm) by 1 cm. A Stage I pressure ulcer is defined as non blanchable redness of intact skin and in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues. Resident #78's right upper buttock was documented with a Stage III pressure ulcer measuring 4.3 cm by 3.0 cm. A Stage III pressure ulcer is defined as a full thickness tissue loss in which subcutaneous fat may be visible but bone, tendon or muscle is not exposed, slough may be present but does not obscure the depth of tissue loss and there may be undermining or tunneling. Resident #78's left buttock was documented as having a Stage IV pressure ulcer with an area measuring 6.0 cm by 4.5 cm. A Stage IV pressure ulcer is defined as a full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar may be present on some parts of the wound bed and often includes undermining and tunneling. A care plan was initiated on 02/23/11 for impairment of skin integrity related to Resident #78 being bedfast, urine/bowel incontinence, disease process and immobility. The initial care plan did not reflect the findings of a Stage I, Stage III and a Stage IV pressure ulcer as documented in the admission nurse's note. Interventions for the risk of pressure ulcer development included assessing skin daily and reporting changes, keeping the resident clean and dry, changing wet linens, minimizing pressure on bony prominences and turning every two hours. The care plan was updated on 02/25/11with no further updates. Review of the pressure ulcer tracking grid revealed the following assessments for the left buttock/cleft area pressure ulcer: On admission of 02/18/11 Stage IV pressure ulcer measuring 6.0 cm by 4.5 cm with no wound description. 02/25/11 Stage II pressure, no description, no measurements. 03/04/11 Stage II pressure, 9.0 cm by 3.0 cm with 30% slough, (slough is indicative of a Stage II pressure ulcer). Additional documentation through 06/17/11 indicated the area was Stage II pressure ulcer. 06/21/11 and 07/01/11 indicated the area was resolved. 08/19/11 Stage II, 1.0 cm by 1.0 cm. 08/26/11 no documentation. 09/02/11 Stage II, 6.0 cm by by 1.0 cm with serous drainage. 09/23/11 3.5 cm by 1.5 cm with no staging or wound description. 10/07/11 Stage II, 1.8 cm by 1.2 cm, macerated. 10/14/11 Stage II, 4.0 cm by 4.0 cm, no description. 10/21/11 no documentation. 10/28/11 7.0 cm by 3.0 cm with 75% necrotic tissue, Stage II. Necrotic tissue is indicative of a Stage III or Stage IV pressure ulcer. 11/04/11 6.5 cm by 3.5 cm, no description or staging. 11/11/11 6.0 cm by 4.0 cm Stage II, no description or staging. The pressure ulcer tracking for Resident #78's current open areas indicated she had a Stage IV on her left hip. The tracking for the left hip pressure ulcer indicated the area developed on 08/08/11 as a Stage I. No measurements were recorded until 08/12/11 and indicated the area was 1.5 cm by 1.5 cm and the treatment listed was [MEDICATION NAME]. On 08/19/11 the area opened and was documented as being a Stage II and measuring 2.0 cm by 1.0 cm with serous drainage, the amount was not noted. No depth measurement was recorded and no other descriptive assessment of the wound was documented including the appearance of the wound bed, the surrounding tissue or peri-wound and the presence or absence of an odor. The treatment was changed to an Allevyn dressing. There was a dated entry on a line for 08/26/11 but no assessment of the pressure ulcer was completed. The next entry on 09/02/11 indicated the left hip pressure ulcer was a Stage II with measurements of 3.0 cm by 2.0 cm and no depth recorded. The only description listed indicated there was 50% necrotic tissue present. There was no evidence the physician was notified or the treatment was changed. There was no pressure ulcer documentation recorded on 09/09/11 and on 09/16/11 the tracking indicated there was no open area and it had resolved. An additional pressure ulcer tracking sheet for a left hip area pressure ulcer was reviewed and the first measurements on 09/30/11 indicated it was a Stage IV/unstageable pressure ulcer measuring 3.0 cm by 3.0 cm and 1.5 cm deep with 100% necrotic tissue. However, a note at the top corner indicated the odorous pressure ulcer was sharply debrided at the bed side on 09/28/11 and there was undermining present. The pressure ulcer was not identified until it was unstageable and no assessment was documented for two days. The documented assessment on 09/30/11 did not indicate any undermining was present and did not include an assessment of the peri-wound, pain, drainage or odor. The treatment ordered was Santyl ointment and a dressing twice a day. The pressure ulcer measurements were recorded on 10/07/11 and 10/14/11 but did not include any description of the pressure ulcer except to indicate there was 30% necrotic tissue present. The treatment was changed to [MEDICATION NAME] silver dressing twice a day on 10/14/11 and the measurements were 3.0 cm by 4.0 cm by 1.5 cm deep. There was no assessment of the pressure ulcer on 10/21/11. The assessment of 10/28/11 indicated the wound was 4.5 cm by 3.5 cm and 1.5 cm deep with 20% necrotic tissue and some granulation tissue. There was documentation of tunneling/undermining which was 3.5 cm deep at 11:00. The next assessment on 11/04/11 indicated the wound was 5.0 cm by 3.0 cm and 1.5 cm deep and the tunneling/undermining was 5.0 cm at 9:00. There was 20% necrotic tissue with some granulation. No other drainage or wound descriptions were documented. On the wound sheet for the 11/11/11 entry line there was a note indicating the treatment was changed to Santyl ointment and a dressing was to be changed on Monday, Wednesdays and Fridays. There was no assessment or measurement of the pressure ulcer on this date or since 11/04/11. Pressure ulcer treatments were observed on 11/17/11 at 9:55 A.M. with the treatment nurse, LPN #5 and Nursing Supervisor (NS) #6. Upon entrance to the room, Resident #78 was observed positioned on her left hip. Resident #78 was uncovered and turned to her right side. The dressing was intact to her left hip and was observed with serosanguinas drainage saturating the dressing. The dressing was removed by LPN #5 while NS #6 held her over on her right side. The pressure ulcer was approximately 4 cm in diameter with some slough and granulation tissue in the wound bed. There was undermining present and visible when the wound was cleaned and packed with Santyl ointment on gauze, a [MEDICATION NAME] window dressing was applied and gauze was applied over the window and secured. No wound measurements were taken by LPN #5. The left buttock/cleft area was observed with a large triangular dressing on the coccyx. The bottom edges were pulled away from the skin and the dressing appeared saturated with drainage, yellow in color with a small amount of black and red material. The dressing did not contain a date indicating when it had last been changed. The surveyor was at the foot of the bed and upon removal of the dressing a strong, foul odor was noted. The nurses were asked if the odor was from the pressure ulcer and they both indicated they did not know. NS #6 indicated the odor might be from the bed pad under Resident #78. The nurses verified the presence of urine on the bed pad and said that may be the source of the odor. The wound appeared to be approximately two and one half to three inches long and two inches wide with apparent tunneling/undermining. The wound bed contained blackened and yellow tissue. The pressure ulcer was cleaned with normal saline, Santyl ointment, gauze and an Allevyn dressing was applied by LPN #5. After the dressing was completed a new bed pad was positioned under Resident #78 and the old one was removed. Resident #78 was repositioned onto her left hip, where the other pressure ulcer was, and covered with a sheet. LPN #5 told Resident #78 they were all done. LPN #5 was tying the trash bag and indicated she could smell the foul odor from the bag and maybe the odor was from the pressure ulcer since the soiled dressing was in the bag. She indicated she would check the pressure ulcer tracking from last week to see if there had been an odor at that time. The room was left at 10:07 A.M. Upon leaving the room, LPN #5 indicated she did not know if Resident #78 was care planned to not be positioned on her left hip but indicated it would not be appropriate to put her on the left side. LPN #5 verified Resident #78 had been on her left side when we entered the room for the treatment and that she and NS #6 had repositioned Resident #78 back onto her left hip after the treatment. LPN #5 verified no incontinence care had been done but then stated she never said there was urine on the bed pad. NS #6 joined the interview and verified they had identified the presence of urine on Resident #78's bed pad and they had not provided any incontinence/skin care to Resident #78. The findings were shared with the director of nursing, (DON) on 11/17/11 at 10:40 A.M. On 11/17/11 at 12:00 P.M. the DON and LPN #4 removed Resident #78's dressing to the left buttock/cleft area for assessment and measurement. LPN #5 and NS #6 verified there was no date on the dressing to indicate when it was last changed. The strong foul odor from the wound was verified at that time. The measurements obtained revealed the wound was 6.8 cm long, 5.0 cm wide and 2.0 cm deep. At 12:00 on a face clock there was 1.0 cm undermining. LPN #4 verified the pressure ulcer was a Stage IV. Review of the medical record revealed no documentation that the physician had been notified of the decline in Resident #78's wound to her left buttock/cleft area since 11/11/11. He was not made aware of a Stage IV pressure ulcer with tunneling, drainage and foul odor. The skin impairment care plan had not been followed since LPN #5 and NS #6 did not assist Resident #78 with hygiene and general skin care when Resident #78 was incontinent of urine and they positioned her back onto her left hip, which is a bony prominence and was compromised with skin breakdown. The DON was interviewed on 11/17/11 at 10:40 A.M. and the findings were verified. The DON called LPN #5 to the meeting at 10:50 A.M. LPN #5 indicated the pressure ulcer was a Stage II and indicated she had not measured the area. The DON agreed to obtain staff and remove the dressing for an observation and measurement. At 12:00 P.M., the DON and LPN #4 observed and measured Resident #78's left buttock/cleft pressure ulcer. The strong foul odor was verified when the dressing was removed. The measurements obtained were 6.8 cm long, 5 cm wide, and 2 cm deep at 11:55 (on a clock face). There was 1.0 cm undermining at 12:00. LPN #4 verified the pressure ulcer was a Stage IV. There was no evidence found to indicate the physician had been notified of the declining status in the pressure ulcer since it was documented as a Stage II on 11/11/11 without odor, necrotic tissue, drainage or depth. 2. Resident #94 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. Resident #94 was readmitted on [DATE] and the nurse's notes/admission assessment indicated she was lethargic, oriented to self but was unable to communicated her needs. Resident #94 had a Stage II pressure ulcer on her coccyx. Review of the state tested nursing assistant (STNA) flow record for November, 2011 revealed Resident #94 was dependent on staff for grooming, eating, bathing, toileting, mobility and repositioning in bed. The dressing change to Resident #94's coccyx was observed on 11/17/11 at 9:10 A.M. with LPN #5 and STNA #7. Resident #94 was in bed on her back and when she was uncovered her feet and heels were directly on the bed surface. LPN #5 and STNA #7 verified Resident #94 was dependent on staff for all of her care. There were no pillows or heel protectors observed. Resident #94 was turned to her left side and no dressing was in place on her coccyx pressure ulcer. LPN #5 indicated she had removed it in preparation for the treatment. LPN #5 verified there was no way for the surveyor to know if the dressing had been dated or if there had been drainage present from the pressure ulcer. STNA #7 indicated she could confirm they had removed the dressing earlier that morning. When asked the reason for removal, STNA #7 indicated it was in preparation of the treatment observation. The treatment to the pressure ulcer was completed and Resident #94 was placed back on her back. STNA #7 covered Resident #94 with her sheets. STNA #7 was asked if they used anything under Resident #94's heels to relieve pressure. STNA #7 indicated she did not know because this was the first time on this assignment but she would check and she left the room. LPN #5 returned to the room and she indicated she did not know if Resident #94's heels were to be elevated off of the bed. At 9:21 A.M., STNA #7 returned and indicated the nursing supervisor, NS #6, told her they did not use pillows under a person's legs or feet unless they were swollen. At 9:25 A.M., NS #6 told the surveyor there was no physician order to elevate Resident #94's heels/feet. Asked if a resident, such as Resident #94, who is at risk for skin impairment, had skin impairment and was dependent of staff for mobility could have her feet/heels elevated per nursing. NS #6 then stated it would be up to the nursing assistant if they felt the resident needed their feet/heels elevated. Then NS #6 verified it should be a nurse completing an assessment and determining appropriate pressure relief interventions. NS #6 indicated she did not know if heel/foot elevation was part of Resident #94's pressure ulcer plan of care or on the STNA flow sheet to direct nursing assistants as to what a resident needs. With the assistance of LPN #8, the STNA flow record was observed on the computer. There was a section directing the nursing assistants to place pillows under Resident #94's heels in bed. This intervention was listed on two different sheets for November, 2011 and not all of the spaces had been initialed by staff to indicate it was done. LPN #8 verified it is the responsibility of the nursing assistant to find out the care needs of a resident if they are unfamiliar with them. This observation and concern was reviewed and verified with the DON on 11/17/11 at 10:40 A.M. The skin impairment care plan was reviewed with her. It indicated pressure relieving devices were to be used in the bed and chair, but the care plan was not individualized and specific to what Resident #94 needed. This citation substantiates Complaint Number OH 050.