Every finding on record at The Pavilion at Edgefield for Nursing and Rehabili

Based on observation, interview, and facility policy review, the facility failed to ensure snack items were available at all times for residents. This had the potential to affect all 61 residents who received meals/snacks from the kitchen. Findings Include:Observations on 05/11/26 from 9:00 A.M. to 9:41 A.M. during the initial facility tour revealed no snack trays/storage visible anywhere on all three residential hallways.Observation on Monday, 05/11/26, during the kitchen tour at 10:10 A.M. revealed in the dry food stock room the shelf was empty of snack items for the residents.Interview on 05/11/26 at 10:15 A.M. with the Dietary Manager #260 confirmed the shelf in the dry food stock room was empty of snack items. The Dietary Manager #260 stated food ordering was completed on Mondays, and the food delivery was on Thursdays, with the food items being stocked and put away in the kitchen on Thursdays. There were snack items available as of last Friday, though the Dietary Manager stated they were not sure why the shelf was empty of snack items for the residents.Interview on 05/11/26 at 1:13 P.M. with Resident #12 revealed there were no snacks available this past Saturday or Sunday. Resident #12 stated there were snacks after supper and before bedtime and the staff would pass the snacks out or they could get them from the nurse's area, though Resident #12 stated she had to purchase her own snacks sometimes since they didn't give them snacks on a regular basis.Interview on 05/11/26 at 1:31 P.M. with Licensed Practical Nurse (LPN) #282 revealed the evening snacks for the residents were not available routinely. LPN #282 stated the kitchen staff were to deliver the snack trays around 7:00 P.M. Sometimes the trays came out later, and sometimes the trays don't come out at all. When the snack trays were delivered, they were kept at the nurse's desk and passed out by the night shift staff.Review of the facility's policy titled Frequency of Meals dated 2001 revealed evening snacks will be offered routinely to all residents.This violation represents non-compliance investigated under Complaint Number 2995524.

Based on observation, interview, and facility policy review, the facility failed to maintain a clean and sanitary area around the dumpsters and failed to ensure facility trash was placed in the dumpsters. This deficient practice had the potential to affect all 61 residents residing in the facility. Findings Include: Observation on 05/11/26 at 10:40 A.M. revealed a fenced area with two large dumpsters inside the fence. There were multiple full clear trash bags around the outside base of the two dumpsters laying on the ground and partially under the dumpsters. There was also a small couch sitting next to the dumpster fence that was not wrapped in plastic.Interview on 05/11/26 at 10:45 A.M. with the Dietary Manager #260 confirmed the multiple clear trash bags on the ground around and under the dumpsters and the small couch which was not wrapped in plastic. The Dietary Manager #260 stated the dietary staff and the housekeeping staff monitor the dumpster area and clean up around it as needed.Review of the facility's policy titled Grounds dated 09/2008 revealed facility grounds shall be maintained in a safe and attractive manner.This violation represents non-compliance investigated under Complaint Number 2995524.

Based on observation, interview and review of facility policy, the facility did not ensure infection control practices were maintained in three of three linen closets for sanitary linen storage. This had the potential to affect all 64 residents residing in the facility. Findings include:An observation was conducted on 02/17/26 at 10:50 A.M. with Certified Nursing Assistant (CNA) #329 of the second floor clean storage linen closet. A very large pile of socks was on the ground in the closet with a dirty pair of shoes on top of the socks. Multiple items of clothing, hospital gowns and bedsheets were on the ground, and various items of trash were sitting on shelving units with clean linens. An interview with CNA #329 at the time of the observation confirmed the findings. An observation on 02/17/26 at 11:00 A.M. with Licensed Practical Nurse (LPN) #382 of the first floor 100 hall clean linen closet revealed there were multiple bedsheets, trash bags and various Styrofoam cups and plastic bags on the ground. There were also Styrofoam cups and plastic bags of trash sitting on the shelves with the clean linens. LPN #382 verified the findings at the time of the observation. Further observation on 02/17/26 at 11:02 A.M. with LPN #382 of the first-floor linen closet on the 400-hall revealed various Styrofoam cups and plastic bags on the floor. The shelves that held clean linens had various dirt and splatter stains all over the shelves. Multiple sheets had black lint on them. LPN #382 verified the findings at the time of the observation and placed a call to housekeeping to get linen closets cleaned. An interview on 02/18/26 at 12:30 P.M. with the Administrator confirmed all residents use the linens and towels from the facility linen closets. Review of facility policy Departmental (Environmental Services) Laundry and Linen, dated January 2014, revealed soiled and clean linen should be separated at all times. Clean linen will remain hygienically clean through measures designed to protect it from environmental contamination and reprocess any linen that is not visibly clean upon completion of the cycle or any linen that falls onto the floor.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on observation, medical record review, review of witness statements, review of mechanical lift manual, interview, and review of facility plan of correction documentation, the facility failed to ensure mechanical lift equipment was maintained in a safe and working condition to prevent an avoidable fall for Resident #23. This affected one (Resident #23) of three residents reviewed for falls. The facility census was 64.Findings include:Review of the medical record for Resident #23 revealed an admission date of 04/25/16 with diagnoses which included schizoaffective disorder bipolar type, metabolic encephalopathy, obesity, pseudobulbar affect, altered mental status, generalized anxiety disorder, major depressive disorder, and chronic pain syndrome.Review of the activities of daily living (ADL) care plan revised on 02/02/21 revealed Resident #23 had an ADL self-care performance deficit related to anxiety, behaviors, congestive heart failure, generalized weakness, history of falls, impaired vision, obesity, pain, poor balance, psychoactive drug use and hypothyroidism with interventions including that the resident was dependent on chair-to-bed or bed-to-chair transfers and mechanical lift for transfers with two-person assistance.Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #23 was cognitively intact, used a wheelchair for mobility, was totally dependent on staff for toileting, bathing, personal hygiene, and transferring.Review of the late entry nurse note dated 12/05/25 timed 11:50 A.M. created on 12/06/25 timed 2:50 A.M. authored by Registered Nurse (RN) #72 revealed the aide informed the nurse that during the process of hoisting a resident, the Hoyer (mechanical lift) pad broke, and the resident fell on his buttocks. They grabbed another Hoyer pad and continued. The hydraulics failed with the Hoyer machine; this time, the resident fell and sustained a small injury on the forehead, close to the bridge of the nose, and on the left hand. The resident said the Hoyer pad broke, and he fell. The second time, he was unable to explain what happened, but he said I fell down from the Hoyer again, claimed he hit his forehead, right knee and left hand hurt. Vital signs checked immediately: 139/101 blood pressure, 90 pulse, 20 respirations and 97.8 temperature. Range of motion completed. The resident complained of pain in the right knee and forehead. Physical assessment from head to toe. The was an injury on the left hand, particularly at the back of the hand, and one close to the bridge of the nose. Had his scheduled pain medications before the incident. The wound was cleaned and dressed. Said he did not want any other pain medications because he was sure the hospital will give him pain medication again. Physician aware and ordered to send him to the emergency room (ER). He was taken to the emergency room.Review of the hospital discharge documentation dated 12/06/25 timed 12:51 A.M. revealed Resident #23 was diagnosed with a fall and had no post-acute orders. Additional information revealed to follow-up with the doctor, keep wound clean and dry, return if worsening or concerning symptoms.Review of the nurse note dated 12/06/25 timed 5:47 A.M. revealed Resident #23 was brought back from the ER with no other new orders. Vitals were checked and recorded and neurological checks continued.Review of the eMAR Medication Administration Note dated 12/06/25 timed 9:08 A.M. revealed Resident #23 was administered Acetaminophen oral tablet 500 milligrams (mg) with instructions to give 1000 milligrams (mg) every eight hours as needed for mild pain related to chronic pain syndrome. Resident complained of generalized pain and left knee pain; 10 out of 10 on the pain scale.Review of the eMAR Medication Administration Note dated 12/06/25 timed 9:10 A.M. revealed Resident #23 was administered Cyclobenzaprine HCl (a muscle relaxant medication) oral tablet with instructions to give 10 mg orally every eight hours as needed for muscle spasms. Resident #23 complained of generalized pain and left knee pain; 10 out of 10 on the pain scale.Review of the nurse note dated 12/06/25 timed 7:00 P.M. revealed Resident #23's representative returned the call for notification of the resident's fall on 12/05/25. No concerns were voiced at this time.Review of the fall care plan revised on 12/06/25 revealed Resident #23 was at risk for falls related to behaviors: hoarding items in room, history of falls, medications, obesity, poor balances, psychoactive drug use with interventions which included: implement preventative fall interventions/devices and inspect Hoyer pad prior to use/transfer.Review of Resident #23's witness statement obtained via telephone by the Administrator dated 12/06/25 revealed Resident #23 was picked up from his chair to be put in bed and the strap broke. The resident's back hit the side of the bed and then buttock on the floor. The second time Resident #23 was lifted, the resident thought the strap broke again. Resident #23 did not see the staff switch the lift, but the staff did nothing different than any other time they assisted the resident. There were two aides (Certified Nursing Assistant (CNA) #72 and CNA #73) and the nurse came in after the first fall.Review of CNA #72's witness statement obtained via telephone by the Administrator dated 12/06/25 revealed CNA #72 was in the room with CNA #73 to lift Resident #23 into bed. CNA #73 removed the chair from the area and CNA #72 moved the lift in front of Resident #23's chair. The lift was in the proper position with the legs open and the sling loops on green and purple. As the staff were lifting him, the strap broke on the sling and Resident #23 fell. His back hit the edge of the bed and then his bottom landed on the floor. The nurse, RN #74, came in to assess the resident following the fall. At this time, CNA #72 obtained another pad to lift the resident. The staff were lifting the resident and the piston on the Hoyer gave out. The resident started to quickly drop to the floor again. The resident was not swaying or tipping and was equally balanced on both attempts. The resident had an injury on his forehead, nose and knee following the second fall. The staff were able to get him up on a third attempt using a different lift.Review of CNA #73's witness statement obtained via telephone by the Administrator dated 12/06/25 revealed CNA #73 was in the room with CNA #72 assisting Resident #23 to bed from his chair. CNA #73 was controlling the lift and CNA #72 was in the back. The first time the staff tried to lift him, the strap broke and was still attached to hooks of the lift. The aides got a second sling while the nurse was in the room with the resident. The aides tried to get the resident up from the floor and had to roll him to either side to get the new pad under him. The aides got the lift all the way down to pick him a second time. The resident was almost the same level as the bed and then the lift started to shake then the resident went down to the floor quickly. The aides called the nurse again to the room. The nurse checked the resident and the resident complained of pain in his left knee. The aides brought in a second lift, lowered the bed to the lowest position and assisted him to bed. Each time we attempted to lift the resident the legs were open and he was balanced. At no time did the resident sway, rock or tip while in lift.Observation on 12/22/25 at 8:40 A.M. revealed Resident #23 was lying in bed on his side then rolled to his back. Interview, during the observation, with Resident #23 revealed he had fallen twice during a mechanical lift transfer from his chair to his bed when the strap broke twice. Resident #23 stated two staff members were assisting with the mechanical lift transfer when he fell. The first fall, Resident #23 fell back against the bed and landed on his buttocks. The second fall, Resident #23 fell on his face and was able to brace himself with his hands. Resident #23 stated the same mechanical lift was used during both transfers however a different mechanical lift pad was used on the second transfer. Resident #23 stated he was sent to the hospital and did not have any broken bones and returned to the facility the same day.Observation on 12/22/25 at 11:15 A.M. with the Administrator revealed the mechanical lift (Serial #4A13020093), used to transfer Resident #23 when he fell twice on 12/05/25, was behind a locked door stored in the maintenance workroom. There was a lock applied to a cable preventing usage.Interview on 12/22/25 at 11:35 A.M. with CNA #72 revealed CNA #72 and CNA #73 attempted to transfer Resident #23 from his wheelchair to his bed when he fell twice from a mechanical lift. During the first fall, one of the bottom straps broke near the residents foot and Resident #23 hit the bed and then landed on his buttocks on the floor. CNA #72 reported CNA #72 and CNA #73 had inspected the straps prior to the transfer to ensure the straps were not frayed or torn. CNA #73 ran and got Registered Nurse (RN) #74 to assess the resident and obtain another mechanical lift pad. The staff rolled Resident #23 on to the other mechanical lift pad and used the same mechanical lift to lift the resident off the floor when the machine's hydraulics gave out and Resident #23 fell on his face. CNA #72 reported Resident #23 was approximately waist height when he fell from the mechanical lift during both falls.Interview on 12/22/25 at 12:00 P.M. with RN #74 revealed two CNA's were transferring Resident #23 from his wheelchair to the bed when one of the straps on mechanical lift pad broke. RN #74 assessed the resident and left the room to call the physician. The CNA's obtained another mechanical lift pad and was transferring the resident off the floor when the hydraulics went out on the mechanical lift causing the resident to fall again, hitting his head. Resident #23 reported he wasn't in too much pain.Interview on 12/22/25 at 3:05 P.M. with CNA #73 revealed Resident #23 fell twice during a mechanical lift transfer. The first time, one of the straps broke on the mechanical lift pad. During the second fall, CNA #73 wasn't sure what happened. CNA #73 stated Resident #23 had a bump on his head from the second fall.Review of the Drive Medical Electric Patient Lift Item #13240 manual revealed it was extremely important that the lift be inspected before each use.The deficient practice was corrected on 12/09/25 when the facility implemented the following corrective actions: - On 12/05/25 at 11:40 P.M., CNA #72 and CNA #73 removed the mechanical lift pad from the floor.- On 12/05/25 at 11:50 P.M., CNA #72 and CNA #73 removed the mechanical lift from the floor.- On 12/06/25, Maintenance Director #75 removed the malfunctioned mechanical lift from operation behind a locked door and locked the cords to prevent usage.- On 12/06/25, the Administrator disposed of the mechanical lift pad with a broken strap into the garbage. - On 12/06/25 at 10:30 A.M., an AD HOC Quality Assurance and Performance Improvement (QAPI) meeting was conducted with the Administrator, Maintenance Director #75, the Director of Nursing (DON), Assistant Director of Nursing (ADON) #76, Regional Nurse Consultant #77 and Regional Director of Operations #78.- On 12/06/25, Maintenance Director #75 inspected all seven mechanical lifts for mobile lift safety without any negative findings.- On 12/06/25, Laundry/Housekeeping Director #79 educated all laundry staff on proper laundering of the mechanical lift pads and what to do if a mechanical lift pad was damaged.- By 12/08/25, the DON completed a mechanical lift competency evaluation with all nurses and CNA's without any negative findings.- By 12/09/25, the DON and ADON #76 educated all nurses and CNA's on inspecting the mechanical lift pad and proper mechanical lift techniques.- On the week of 12/07/25 and 12/14/25, Laundry/Housekeeping Director #79 audited all 23 mechanical lift pads for integrity without any negative findings. Maintenance Director #75 or the DON/designee would continue to inspect all mechanical lift pads five times weeks for two additional weeks.- On the week of 12/07/25 and 12/14/25, Maintenance Director #75 audited all mechanical lifts without any negative findings. Maintenance Director #75 would continue the audit for two additional weeks.- On the week of 12/07/25 and 12/14/25, the DON audited four nursing staff perform a mechanical lift transfer with inspecting the sling prior to use without any negative findings. The DON/designee would continue the audit for two additional weeks.- On 12/15/25, the Administrator ordered 10 new size large mechanical lift pads and six new extra-extra-large mechanical lift pads.- On 12/17/25, the Administrator audited and disposed of 12 mechanical lift pads in circulation and replaced the pads with 21 new mechanical lift pads.- On 12/22/25, CNA #70, CNA #71, CNA #72, CNA #73, and RN #74 were interviewed and verified mechanical lift and pad education and mechanical lift competency evaluation were completed after Resident #23's falls.This deficiency represents non-compliance investigated under Complaint Number 2690320.

Based on observations, staff interviews, review of kitchen staff education, review the owner's manual for the facility dishwasher, and policy review the facility failed to ensure the kitchen was maintained in a sanitary manner. This had the potential to affect all residents residing in the facility. The facility census was 63. Findings include: Observation on 09/15/25 at 9:55 A.M. of the dishwasher machine revealed the dishwasher was a low temperature dishwasher. When asked if they check the sanitizer of the dishwasher, the surveyor was told no by Dietary Aide #990. Dietary Aide #990 stated she has never checked the sanitizer for the dishwasher since she started. Dietary Aide #990 stated she had worked at the facility for a few months. Interview on 09/15/25 at 10:00 A.M. with Dietary Aide #200 revealed periodically he will check the sanitizer solution, but not every day. He stated when the dishwasher machine gets built up with calcium then he knows the sanitizer solution is out and needs to be changed. Observation on 09/15/25 at 10:05 A.M. of the three-sink sanitizer water revealed Dietary Aide #990 did not know which test strips were to be used to test the sanitizer water and did not know how to test the sanitizer water for correct sanitizer levels. Dietary Aide #990 had to ask Dietary Aide #200 how to check the sanitizer water and which test strips to use. When asked how often the sanitizer water is changed, Dietary Aide #200 stated at each meal. Observation of a sign on the wall by the three-sink that stated change water every two hours. Dishwasher #200 stated there is no record on when the dishwasher sanitizer or the three-sink sanitizer are checked. Dishwasher #200 verified the dishwasher and sanitizer water are not being checked every two hours or every day. Observation on 09/15/25 at 10:15 A.M. of the kitchen also revealed dishes are being put away wet. There was 20 plus plate lids, 20 plus plates, 20 plus bowls, 20 plus cups and all of the serving trays were staked and put away wet. Interview on 09/15/25 at 10:19 A.M. with [NAME] #100 verified all wet dishes that were stacked and put away wet and instructed staff to rewash the dishes. [NAME] #100 verified that dishes and cookware are not to be put away wet due to sanitation concerns. Review of the facility policy Sanitization, dated 2001 revealed the chemical solution is maintained at the correct concentration, based on periodic testing, at least once per shift, effective contact time according to manufacturer's guidelines. Facilities must have appropriate and adequate testing equipment, such as test strips and thermometers, to ensure adequate washing and sufficient concentration of sanitizing solution is present to effectively clean and sanitize dishware and kitchen equipment. Review of the owner's manual for the low temperature dishwasher model 1.05C 07-2022 revealed staff should test the bottom of the glasses with litmus paper (test strips). The concentration should be 50 parts per million (p.p.m.) minimum to 100 p.p.m. maximum and if concentration is incorrect contact your chemical supplier. Review of the staff education sheet (undated) for proper use of sanitizer test strips revealed the purpose was for all dietary staff to properly test and document sanitizer concentrations to maintain compliance with infection control and food safety standards.

Based on record review and staff interviews, the facility failed to provide required and complete bed hold and Ombudsman notifications for transferred and/or discharged residents. The affected four (#04, #56, #79, and #81) of four residents reviewed for bed hold and ombudsman notifications. The facility census was 63.Findings include:1.Review of medical record of Resident #04 revealed admission to facility on 11/07/23 with diagnoses including heart failure, lung disease, contracture (deformity) of right hand, heart disease, anemia (low blood count), chronic back pain, high blood pressure, degenerative joint disorder of cervical (neck) and lumbar (mid back) regions. Review of the medical record for Resident #04 revealed transfer and admission to the hospital on [DATE], 07/26/25, and 08/24/25. Further record review revealed notification of bed hold status provided to the resident's representative and Resident #04 via certified mail for the hospitalization on 05/24/25 and 08/24/25. Review of the Bed Hold Days document provided on 05/27/25 to Resident #04 revealed Resident's name, date of discharge: [DATE], days used: 01, days remaining: 29, date delivered: 05/27/25 and signed by the Business Office Manager, (BOM) #370. Review of the Bed Hold Days document provided on 08/24/25 to Resident #04 revealed Resident's name, date of discharge: [DATE], days used: 09, days remaining: 21, date delivered: 08/25/25 and signed by the BOM #370. Review of medical record for Resident #04 revealed there was no transfer form completed or sent with the resident to the hospital at time of transfer for the 05/24/25 hospital admission. Interview on 09/22/25 10:22 A.M. with BOM #370, revealed she was on vacation during the week of 7/26/25 - 08/02/25 and the bed hold notice was not sent to Resident #04 Representative or Resident #04. Further interview revealed it was the responsibility of the Social Worker, who no longer works for facility, to complete the notification during the time the business office manager was on vacation. The BOM #370 verified she only sends the bed hold notice of current days available to residents and does not provide the bed hold policy or cost of bed hold to residents at time of transfer. Interview on 09/22/25 at 1:24 P.M. with the Director of Nursing, (DON), revealed the transfer form was not completed for Resident #04 for the 5/24/25 hospitalization. Further interview with the DON revealed the transfer process as follows: The facility completes the transfer form and sends with the transport team and resident to the hospital. The nurse providing care calls reports to the hospital for a one-on-one nurse report. The medical provider and family are notified via phone calls of transfer to hospital if not done so already and this is documented in the progress notes. The Business Office Manager completes the bed hold notice of available days and sends via certified letter to the resident and their representative. The Social Worker is responsible for completing the ombudsman notification for all transferred and discharged residents usually via an email notification. Interview on 09/22/25 at 1:56 P.M. with the Administrator revealed the facility had not been notifying the Ombudsman office of transfer and discharges of residents. Further interview revealed this was the responsibility of the prior Social Worker who was terminated. The Administrator verified that there was no notification to the ombudsman for the three hospitalizations for Resident #04 on 5/24/25, 07/26/25, and 08/24/25. Review of the facility policy Transfer or Discharge, Facility -Initiated dated October 2022 revealed the following statements 4. Notice of Transfer is provided to the residents and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable (e.g., in a monthly list of residents that includes all notice content requirements). 5. Notice of Facility Bed-Hold and Return policies are provided to the resident and representative within 24 hours of emergency transfer. 6. Notices are provided in a form and manner that the resident can understand, taking into account the resident's educational level, language, communication barriers, and physical or mental impairments. Review of the facility policy Bed-Holds and Returns undated revealed the following statement, The written bed-hold notices provided to the residents/representatives explain in detail: the duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the facility; the reserve bed payment policy as indicated by the state plan (for Medicaid residents); the facility policy regarding bed-hold periods; the facility per-diem rate required to hold a bed (for non-Medicaid residents), or to hold a bed beyond the state bed-hold period (for Medicaid residents); and the facility return policy. 2. Review of Resident #79's medical record revealed a 04/24/25 admission and a 07/13/25 discharge to the hospital. Diagnoses included malignant neoplasm of tongue, acute respiratory failure, type 2 diabetes, severe protein malnutrition, congestive heart failure and hemiplegia. On 07/13/25 at 6:53 A.M. nurse notes included the resident appeared to be having a seizure. Upon assessment resident was not responding but breathing. Resident assisted into bed, oxygen applied. Resident then stopped breathing and cardiopulmonary resuscitation started. The resident was transported to the hospital. Review revealed a certified letter was sent with the bed hold days available. It did not contain the cost of the room or reason for transfer/discharge. The facility did not provide ombudsman notification. Interview on 09/22/25 at 10:22 A.M. with the Business Office Manager, (BOM), #370 revealed she was on vacation during the week of 7/26/25 - 08/02/25 and the bed hold notice was not sent to Resident Representative or Resident #79. Further interview revealed it was the responsibility of the social worker, who no longer works for facility, to complete the notification during the time the business office manager was on vacation. The BOM verified she only sends the bed hold notice of current days available to residents and does not provide the bed hold policy or cost of bed hold to residents at the time of transfer. Interview on 09/23/25 at 1:06 P.M. with the Administrator verified the facility did not send the ombudsman notification of the transfer/discharge. Further, verified they did not include the cost of the room on their bed hold letters and the transfer/discharge reason. He indicated the former social worker was to be completing these duties and had not been. On 09/25/25 at 3:48 P.M. the Administrator emailed the facility sent February through July bed holds to notify the Ombudsman on 08/07/25 The August notification was 09/02/25. However, the paperwork sent did not indicate which residents the Ombudsman was notified about and the reason for the transfer/discharge, Interview with the Administrator at the time of the email verified the ombudsman notification was not timely and did not indicate which residents were included. Review of the Transfer or Discharge, Facility Initiated policy (revised 10/2022) included notice of transfer is provided to the resident and representative as soon as practicable before the transfer and to the long term care (LTC) ombudsman when practicable (e.g. in a monthly list of residents that includes all notice content requirements. Notice of Facility Bed Hold and Return policies are provided to the resident and resident representative within 24 hours of emergent transfer. The facility will send a copy of the discharge notice to a representative of the Office of the State LTC ombudsman Review of the facility's Bed-Holds and Returns policy revised October 2022 included the facility per-diem rate required to hold a bed and facility return policy. 3.Review of the medical record for Resident #81 revealed she was admitted to the facility on [DATE]. She was admitted from home with diagnoses that included, but were not limited to, malignant neoplasm of unspecified bronchus, secondary malignant neoplasm of liver and intrahepatic bile duct, secondary malignant neoplasm of bone, diabetes, peripheral vascular disease, left hip arthritis, history of pulmonary embolism, acquired absence of lung, and anxiety disorder. At the time of admission, Resident #81 was a hospice patient. Review of the medical record for Resident #81 revealed a form titled PHC-Recapitulation of Stay, dated 06/23/25. The form contained only information from social services and a weight was included in the dietary information. The Recapitulation failed to provide course of illness, treatment, therapy, pertinent labs, and radiology reports for Resident #81. This was confirmed by the Director of Nursing (DON) on 09/23/25 at 3:15 P.M. Review of the medical record for Resident #81 revealed a form titled PHC-Interdisciplinary Discharge summary dated [DATE]. The form failed to provide a discharge summary which included: Identification and demographic information; customary routine; cognitive patterns; communication; vision; mood and behavior patterns; physical functioning and structural problems; continence; disease diagnoses and health conditions; dental and nutritional status; skin condition; activity pursuit; medications; special treatments and procedures; discharge planning (as evidenced by most recent discharge care plan); documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the MDS; and Documentation of participation in assessment. This was confirmed by the DON on 09/23/25 at 3:15 P.M. Review of the medical record for Resident #81 failed to reveal any information had been communicated to the receiving nursing facility. The record also failed to reveal any communication of discharge information being sent within 30 days of discharge to the Ombudsman. This was confirmed by the DON on 09/23/25 at 3:15 P.M. An Interview with the Administrator (AD), on 09/22/25 at 1:56 P.M., revealed the facility had not been notifying the ombudsman of transfer and discharges. This was the responsibility of the prior social worker and reason he was terminated. An interview with the AD on 09/23/25 at 4:00 P.M., confirmed the record for Resident #81 contained incomplete discharge information. After review of the record, he confirmed it did not contain a complete discharge summary, recapitulation, or notice to the Ombudsman. 4. Review of the medical record for Resident #56 revealed an admission date of 07/11/25. Diagnoses included anemia, cellulitis of right upper limb, lymphedema and abnormal gait. Review of the progress note dated 09/15/25 revealed Resident #56 had critical labs and was sent to the hospital. Review of the bed hold days notification sent to Resident #56 representative dated 09/16/25 revealed Resident #56 used one day and still had 29 days left. Interview on 09/22/25 at 1:58 P.M. with the Business of Manager (BOM) #370 stated Resident #56's bed hold days was sent to POA on 09/16/25 stating how many days have been used and how many days are left. The BOM verified she only sends the bed hold notice of current days available to residents and does not provide the bed hold policy or cost of bed hold to residents at time of transfer.

Based on observation, policy review, and interview, the facility failed to ensure the facility maintained a clean environment free of cigarette butts, trash, damaged drywall, molding, wallpaper and dirty floors. This affected five residents (#5, #12, #13, #27 and #67) of 63 residents residing in the facility. The census was 63.Findings include: 1. Observation on 09/15/25 at 11:20 A.M. of Resident #5's room revealed the molding in the bathroom was coming off the wall by the shower and door. The wall was marred. Observation on 09/18/25 at 9:24 A.M. of Resident #5's room revealed the molding was coming off the wall in the bathroom to the left of the shower and the right wall walking in. There was a plastic surface on the wall that was coming off and taped with thick silver duck tape. The wall was plastered white and not painted to the left of the medicine cabinet. The lower wall sink side was scraped up. The wall was also damaged and scraped up with the paint off. Interview on 09/18/25 at 9:44 A.M. with Licensed Practical Nurse (LPN) #770 verified the molding, plastic wall surface and drywall damage affecting Resident #5 who resided in the room. 2. Observation on 09/16/25 at 12:40 P.M. of the bathroom between rooms [ROOM NUMBERS] revealed there were holes in the wall behind the commode, molding off wall and wallpaper coming off the wall. Observation and interview on 09/16/25 at 4:50 P.M. with the Administrator verified the hole in the wall behind the toilet, the molding off the wall to the right of the sink and wallpaper peeling off the wall in front of the toilet. The Administrator verified Resident's #12 and #13 resided in the adjoining rooms. 3. Observation on 09/17/25 at 3:33 P.M. of the administration of an intravenous medication for Resident #67 in room [ROOM NUMBER] revealed his bathroom floor was sticky. When in the bathroom to wash hands with Licensed Practical Nurse (LPN) #780 shoes could be heard sticking to the floor when walking. There was a sticky sound. The bathroom floor was smeary soiled with blackened streaks. Interview 09/17/25 at 3:44 P.M. with LPN #780 verified the bathroom floor in room [ROOM NUMBER] was sticky sounding with a dirty appearance affecting Resident #67. LPN #780 thought maybe it was because the resident was in isolation and the cleaning time was altered. 4.On 09/16/25 at 9:55 A.M., an observation of outdoor smoking area revealed cigarette butts were in the cracks of the sidewalk. There were cigarette butts in and under the bushes, as well as right beside the Smoker's Outpost (a closed cigarette butt disposal). This was confirmed at the time of observation by Activities Aide (AA) #400. At the time of the observation, an interview with AA #400 revealed the outdoor area surrounding the smoking structure was littered with cigarette butts. She reported the area behind the structure usually had cigarette butts and debris from employees who would smoke outside behind the smoking structure. 5. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including cellulitis of right lower limb, chronic ulcer of right lower limb, chronic heart failure, multiple sclerosis, and anxiety. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #27, dated 08/21/25, revealed the Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The assessment revealed the resident required staff assistance with activities of daily living (ADLs). Observation on 09/15/25 at 3:14 P.M. of Resident #27's bathroom, revealed the trash can was full and overflowing onto the floor. Further observation revealed the floor was sticky and black shoes imprints were visible. Interview on 09/15/2025 at 3:32 P.M. with Certified Nurse Aide (CNA) #840 confirmed the trash was overflowing and the floor appeared soiled. Interview on 09/15/2025 at 3:51 P.M. with Administrator revealed he would notify housekeeping immediately to remove the trash and clean the floor. Review of the Resident Council Minutes, dated 05/21/25, revealed resident concerns related to trash being picked up every two to three days. Review of the facility's policy titled, Safe and Homelike Environment, undated, revealed in accordance with residents' rights, the facility will provide a safe, clean, comfortable, and home-like environment. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment.

Based on record review, policy review, and interview the facility failed to ensure accuracy of code status and educate staff on the location of the resident current code status. This affected six (#01, #10, #12, #15, #27 and #32) of 24 residents reviewed. The census was 63.Findings include: 1. Review of Resident #15's medical record revealed a 05/01/25 admission date with diagnoses including dementia, fracture of left femur, emphysema, severe protein calorie malnutrition, disorders of psychological development, Alzheimer's disease, ataxia, muscle weakness, varus deformity left hip, bradycardia, joint implants, vitamin D deficiency, abnormal findings of lung fields, major depressive disorder, osteoarthritis, cataract, elevated white blood cell count, anxiety, cataracts, constipation, gastroesophageal reflux disease, tremor, insomnia, scoliosis, kyphosis, tremor, history of falling, and hypothyroidism. Review of a 06/26/25 Quarterly Minimum Data Set Assessment included the resident was severely impaired for daily decision making. Physician orders included a 05/02/25 order for Do Not Resuscitate Comfort Care (DNRCC) (a medical directive where a patient chooses to receive only measures that promote comfort and relieve pain and suffering, rather than emergency treatments like cardiopulmonary resuscitation (CPR) to restart their heart or breathing if they stop). The miscellaneous section of the electronic medical record included DNRCC's signed on 04/29/24 and 05/11/25. Interview on 09/16/25 at 11:34 A.M. with Licensed Practical Nurse (LPN) #360 included they did not have a paper code record on the unit for guidance. Certified Nurse Aide (CNA) #560 stated they did have a code binder and pulled it off the nurse station desk. CNA #560 said the binder is what they would look at for a code status. Resident #15's code status was not in the binder. LPN #360 verified she was not aware the facility kept code status binders on the units. LPN #360 verified at the time of the observation Resident #15 did not have a code status located in the binder. 2. Review of Resident #12's medical record revealed a 05/17/25 admission with diagnoses including dementia, cerebral infarction, attention and concentration deficit, chronic kidney disease stage 2, abscess of breast and nipple, leiomyoma of uterus, restlessness and agitation, hypothyroidism, anemia, hypercholesterolemia, cognitive communication deficit, Vitamin D deficiency, anxiety disorder, difficulty in walking, essential hypertension, major depressive disorder, insomnia, muscle weakness, and chronic pain. Review of the 05/23/25 admission Minimum Data Set Assessment (MDS) revealed the resident was severely impaired for daily decision making, inattention continuously, behaviors continuously present for disorganized thinking and altered level of consciousness. Review of the physician orders revealed a 05/18/25 order that identified the resident's code status as Full Code and admit to the secured unit. Review of the secured unit code binder revealed there was not a code status in the binder for Resident #12. Interview on 09/16/25 at 12:01 P.M. with Registered Nurse (RN) #500 verified the code binder did not contain a code status for Resident #12. Review of the plans of care revealed there was not a code plan of care developed until 09/16/25 when it was determined the code binder was not up to date and did not contain the resident's code status. Interview on 09/17/25 at 5:41 P.M. with the Director of Nursing (DON) included they should not be using the code binder. She doesn't know who taught the staff to look in them for the code status. She verified there were code binders on the units. She agreed everyone needed to be on the same page as to where to find resident code status. She stated the staff is to look in the electronic documentation to find the resident code status. Review of the facility's Advance Directive policy (revised September 2022) included if the resident or the residents representative has executed one or more advanced directives, or executes one upon admission, copies of these documents are obtained and maintained in the same section of the residents medical record and are readily retrievable by any facility staff. The resident's wishes are communicated to the resident's direct care staff and physician by placing the advanced directive documents in a prominent, accessible location in the medical record and discussing the resident's wishes in care planning meetings. 3. Review of Resident #32's medical record revealed a readmission [DATE] with diagnoses including Alzheimer's disease, dementia, epilepsy, severe protein malnutrition, chronic kidney disease stage 3, and malignant prostate. Physician orders included a 02/18/25 order for a full code. Review of the Annual MDS dated [DATE] revealed the resident was severely impaired for cognition, the resident was dependent on staff for all care. Review of the second floor code status binder revealed there was no code status in the binder for Resident #32. Interview on 09/16/25 at 12:01 P.M. with RN #500 verified the code binder did not contain a code status for Resident #32. 4. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including cerebrovascular disease, dementia, diabetes mellitus, congestive heart failure, chronic kidney disease, and adult failure to thrive. Review of Resident #10's electronic medical record (EMR) indicated his code status was (Advanced Directives) Do Not Resuscitate – Comfort Care Arrest (DNR-CCA). Further review revealed a DNR Order Form, signed by the physician, which indicated the code status of DNR-CCA. Observation on 09/16/25 at 11:30 A.M. of Resident #10's code status sheet located in the [NAME] titled Do Not Resuscitate (DNR) Code Status, revealed Resident #10 was a Full Code. Interview on 09/16/25 at 11:35 A.M. with LPN #780 stated Resident #10's code status sheet located in the binder titled Do Not Resuscitate (DNR) Code Status, revealed Resident #10 was a Full Code, however, his EMR indicated he was a DNR-CCA. LPN #780 further stated staff could access either the EMR or the binder located at nurse's station to verify a resident's code status. Interview on 09/16/25 at 11:57 A.M. with the Assistant Director of Nursing (ADON) confirmed Resident #10's code status sheet indicated he was a Full Code; however, the EMR revealed the resident was a DNR-CCA, which was correct. The ADON confirmed the resident's code status should be the same in both locations. 5. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including cellulitis of right lower limb, chronic ulcer of right lower limb, chronic heart failure, multiple sclerosis, and anxiety. Review of Resident #27's electronic medical record (EMR) indicated his code status was (Advanced Directives) Do Not Resuscitate – Comfort Care Arrest (DNR-CCA). Further review revealed a DNR Order Form, signed by the physician, which indicated the code status of DNR-CCA. Observation on 09/16/25 at 11:31 A.M. of the binder titled Do Not Resuscitate (DNR) Code Status, revealed the binder was absent of any advanced directive documents for Resident #27. Interview on 09/16/25 at 11:37 A.M. with LPN #780 revealed the DNR Code Status binder did not contain any advanced directive documents for Resident #27, however, the EMR indicated the resident was a DNR-CCA. LPN #780 further revealed staff could access either the EMR or the binder located at nurse's station to verify a resident's code status. Interview on 09/16/25 at 11:57 A.M. with the Assistant Director of Nursing (ADON) confirmed Resident #27's EMR revealed the resident was a DNR-CCA, which was correct; however, the DNR Code Status binder did not contain any advanced directive documents. The ADON confirmed the resident's code status should be the same in both locations. Review of the facility's policy titled, Advance Directives, (undated), revealed the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. If the resident has an advance directive, copies of these documents are obtained and maintained in the same section of the residents medical record and are readily retrievable by any facility staff. 6. Review of medical record for Resident #01 revealed admission to the facility on [DATE] with diagnoses including pneumonia related to inhalation of food and vomit, diabetes, vascular disease, heart disease, kidney disease, fatty liver, high blood pressure, attention deficit hyperactivity disorder, overactive bladder, anxiety, fibromyalgia (chronic pain to nerve endings), and anemia (low blood count). Review of medical record for Resident #01 revealed on 09/16/25 the code status listed in the electronic medical record (EMR) list as Do Not Resuscitate – Comfort Care Arrest (DNR-CCA). Further review of the EMR revealed a signed copy by the medical provider for an ordered code status of DNR-CCA. Interview on 09/16/25 at 11:10 A.M. with Licensed Practical Nurse, (LPN) #780, revealed there was no code status sheet or order in the book titled Do Not Resuscitate (DNR) Code Status, located at the nurse's station, for Resident #1. Interview further revealed staff could access either EMR or the book at nurse's station to verify Residents code status.

Based on record review and interview, the facility failed to ensure the transfer and discharge of a resident was documented in the medical record. The facility also failed to communicate appropriate information to the receiving facility. This affected one (#81) of four residents reviewed for inappropriate discharge. The facility census was 63. Findings include:Review of the medical record for Resident #81 revealed she was admitted to the facility on [DATE]. She was admitted from home with diagnoses that included, but were not limited to, malignant neoplasm of unspecified bronchus, secondary malignant neoplasm of liver and intrahepatic bile duct, secondary malignant neoplasm of bone, diabetes, peripheral vascular disease, left hip arthritis, history of pulmonary embolism, acquired absence of lung, and anxiety disorder. At the time of admission, Resident #81 was a hospice patient. Review of the medical record for Resident #81 revealed a care plan dated 06/09/25. The care plan did not address discharge planning for the resident. This was confirmed by the Director of Nursing (DON) on 09/23/25 at 3:15 P.M. Review of the progress notes in the medical record for Resident #81 failed to reveal any communication or planning with the resident or the resident's representative for a discharge to another nursing facility. This was confirmed by the DON on 09/23/25 at 3:15 P.M. An interview with the Administrator on 09/23/25 at 4:00 P.M., confirmed the medical record for Resident #81 did not contain the necessary care planning and discharge planning. He reviewed the medical record and confirmed there was no care planning for discharge, and no communications with the resident or the resident's representative which would indicate the facility assisted with arrangements for the resident to go to another nursing facility.

Based on record review, observation and interview, the facility failed to ensure residents were safe from accidents, hazards and adequate supervision was provided as needed to residents. The facility failed to properly secure Resident #22 in his wheelchair during transportation and failed to provide safety measures and neurological checks for Resident #15 following a fall. This affected two (#15, #22) of five residents reviewed for accidents. The facility census was 63.Findings include: 1.Review of the medical record for Resident #22 revealed an admission date of 02/20/17. Diagnoses included but were not limited to atherosclerotic heart disease of native coronary artery without angina pectoris, multiple fractures of ribs, left side, seizures, mild cognitive impairment, chronic lymphocytic leukemia of B-Cell type in remission, small cell B-Cell lymphoma, need for assistance with personal care, muscle weakness, essential tremor, major depressive disorder, vascular dementia unspecified without behavior disturbance, personal history of healed traumatic fracture, and generalized anxiety disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 14. A BIMS score 13 to 15 points indicated cognitive intactness. Section E of the MDS did not reveal any behavioral concerns. Functionally, he was identified to need set up assistance for eating, oral hygiene, showering, and personal hygiene. He was identified as independent with all other tasks and able to ambulate up to 150 feet independently. Review of a care plan for Resident #22, dated 01/15/25, revealed a focus area which indicated the resident was at risk for falls, related to a history of falls, decreased safety awareness, medications, poor balance, psychoactive drug use, non-compliant with safety interventions at times, and leukemia. The goal was to minimize risk for falls/minimize injuries related to falls. Another focus for fall risk was noted to include decreased safety awareness, medications, poor balance, psychoactive drug use, non-compliance with safety interventions and leukemia. Interventions for these focus items included education, therapy evaluations and safety equipment. Review of a progress note dated 12/02/24 at 2:56 P.M., revealed Resident #22 was out of the facility for a physician appointment at Tri-county hematology and was being transported by the facility driver. Review of a progress note, marked as a late entry, dated 12/02/24 at 3:20 P.M., revealed a call was received from Bus driver, who reported Resident #22 had a fall on the bus. Physician (MD) #2000 wanted the resident sent to the Emergency Department (ED) for eval and treatment d/t resident is on Plavix. Review of an ED note, dated 12/02/24, revealed Resident #22 arrived at the hospital at 4:35 P.M., with a History of Present Illness (HPI) indicating the resident had returned to the ED for a recurrent injury. The note indicated the resident reported he was in the transportation van and was in his wheelchair when the driver pressed on the brakes too fast and caused him to fall from his wheelchair. He does state that the wheelchair was secured, he was belted, however for an unclear reason, this did not hold and he subsequently fell forward striking the desk part of the van. He did fall completely out of his chair; he has symptoms of a mild and generalized frontal headache as well as upper mid substernal chest discomfort. The ED note further indicated on physical exam, Resident #22 was alert, oriented, and interactive. He was diagnosed by computed tomography (CT) as having mildly displaced rib fractures of the left fifth through seventh ribs. Review of a document titled Fall Investigation Timeline revealed the resident experienced falls two days in a row. According to the report, the resident called for help, was found lying and was not using an assistive device. If further indicated the device being used was according to manufacturer's specifications and resident's needs. The form failed to reveal how many falls the resident had in the past 30 days or the last 31-180 days. The report indicated the resident had not been injured, the physician was notified on 12/02/24 at 3:45 P.M., and the family was notified at 12/02/24 at 4:00 P.M. Review of a form titled Witness Statement, dated 12/02/24, completed by Certified Nurse Aide (CNA) #660 revealed the resident was on the bus, strapped down in the wheelchair. The witness statement read: I was driving down the road an(d) I heard [Resident #22] yell out help I pulled over at [NAME] ('s), parked the bus and got out of the bus to help him up a(nd) he got up and got up and got in his chair. I called the nurse to let them know that he had fell and he said that he was ok. I unstrapped the wheelchair and put him back in the chair an(d) strapped him back down and took him to his appointment. Review of a form titled Demonstration Checklist Securing Wheelchairs in Transport Van, dated 12/03/24, revealed the DON trained CNA #660 on Pre-loading, Loading and Positioning, Securing the Wheelchair, Securing the passenger, Final Safety check, and Unloading. The form was signed and dated by the DON and CNA #660. Review of a pamphlet titled QRT-360 4-Point Wheelchair Securement System (a system of four-point securement device with retractors or manual belts along with occupant securements [passenger lap and shoulder belts] and four separate anchor points on the floor of the vehicle), revealed how to properly secure a passenger in a wheelchair without a permanent lap belt. The user should pull the shoulder belt over the occupant's chest and buckle shoulder belt pelvic connector to the removable pelvic belt. The shoulder belt height should then be adjusted so that it would rest on the passenger shoulder. The removable pelvic belt pin connector should be connected to the rear retractor closest to the aisle. On 09/18/25, the Regional Director of Operations (RDO) confirmed this was not how he instructed CNA #660 to secure a wheelchair when he trained him on 09/17/25. On 09/17/25 at 2:42 P.M., CNA #660 revealed he had been doing transportation of residents for the past two years. He was trained at that time by a former activity director for two days. There was no manual or workbook provided to him for the operation and safety of the wheelchair securement system, only what he was shown in the two days of bus orientation he had. CNA #660 reported on 12/02/24, he was taking Resident #22 to a scheduled appointment in [NAME], OH. He strapped Resident #22 into the van in a wheelchair. CNA #660 explained Resident #22 usually walked with a walker, however that day he was in a wheelchair. Resident #22 was the only one on the bus that day. CNA #660 hooked two straps to the small front wheels and two straps to the back wheels (metal framing). There was a shoulder strap and a lap belt that was then connected. As CNA #660 was driving down the street he heard Resident #22 call out hey, hey and looked in the rearview mirror and the resident was on the floor. All of the straps were still connected. He was unsure how the resident came out of the seat. On 09/18/25 at 10:48 A.M., an interview with the DON revealed on 12/02/24, CNA #660 called her from the [NAME]'s parking lot and advised her that Resident #22 had fallen out of the wheelchair while being transported to a physician appointment. She indicated CNA #660 told her the resident appeared to be fine, she could hear [Resident #22] in the background and he (Resident #22) told her he was fine. She felt a CNA was able to make a decision of whether or not a resident had an injury, and since nothing was broke it had been acceptable to move the resident and continue to transport him to his physician appointment. On 09/18/25 at 11:00 A.M., an interview and observation of CNA #660 revealed how he would secure wheelchair bound residents into facility van prior to education completed by the Regional Director of Operations (RDO) on 09/17/25. At that time, he demonstrated attaching J-Hooks of floor anchors near each of four wheels of the wheelchair. He would then place the shoulder belt over the resident's chest and attach to another belt coming from the floor to the front right side of the resident. He reported he now knew that to be incorrect. He reported on 09/17/25, he was educated the correct way, which he demonstrated to connect the J-Hooks to the frame of the wheelchair, instead of near the wheels. RDO confirmed this was the instruction given to CNA #660. On 09/18/25 at 12:48 P.M., an interview with the facility Administrator revealed he had just obtained the Q'straint QRT-360 user instructions via the website that day. He confirmed no one in the facility had training using these guidelines. He was uncertain which employees were trained to complete resident transports using the facility transport van. On 09/18/25 at 1:00 P.M., an observation of RDO securing a resident into the transportation vehicle revealed the securement floor anchoring system had been improperly installed. He had to remove the floor anchors and reposition them in the correct position for transporting a single wheelchair. With the anchoring system in the incorrect position, the pelvic strap, which kept wheelchair passengers from sliding out of a wheelchair during transportation, could not be properly fastened/secured. During interview he confirmed he had incorrectly educated CNA #660 on 09/17/25. The facility failed to provide any evidence of transportation logs, staff in-service or training logs regarding the wheelchair securement system, or maintenance logs for the wheelchair securement system. Review of an undated facility policy, titled Transporting a Resident (Facility Van), revealed the purpose of the policy was to provide residents safe, non-emergency transportation to doctor's appointments, activity outings, and any other trips the facility deemed necessary. The policy guidelines required attendance to be taken prior to departing the facility and the destination. The van would be well-maintained and equipped with safety features. Each resident would be secured in a seat with a seatbelt or in their wheelchair secured with wheelchair tie-downs. The policy further indicated staff authorized to drive the van would have necessary training and licensure to operate the vehicle as well as knowledge on van safety features. 2. Review of Resident #15's medical record revealed a 05/01/25 admission date with diagnoses including dementia, fracture of left femur, emphysema, severe protein calorie malnutrition, disorders of psychological development, Alzheimer's disease, ataxia, muscle weakness, varus deformity left hip, bradycardia, joint implants, vitamin D deficiency, abnormal findings of lung fields, major depressive disorder, osteoarthritis, cataract, elevated white blood cell count, anxiety, cataracts, constipation, gastroesophageal reflux disease, tremor, insomnia, scoliosis, kyphosis, tremor, history of falling, and hypothyroidism. Review of a 02/09/21 Fall Risk plan of care revealed the resident was at risk related to generalized weakness, history of falls, impaired cognition with decreased safety awareness, poor balance, poor communication/comprehension, psychoactive drug use, unsteady gait and a history of falls. A 07/31/24 intervention was to encourage resident to wear non skid footwear at all times. a. Review of a fall on 02/13/25 at 10:10 P.M. included the resident was found in her room beside the bed transferring unassisted. Neurological checks were initiated for the unwitnessed fall. Review of the neurological checks revealed there were three consecutive sets of neurological checks not completed between 02/14/25 at 1:00 P.M. and 02/15/25 at 10:00 A.M. Interview 09/23/25 at 5:46 P.M. Registered Nurse (RN) #1000 verified the neurological checks were not completed as ordered. b. Review of a fall on 03/29/25 at 12:45 A.M. fall investigation revealed the resident fell in her room transferring unassisted. The resident had a raised hematoma to head. The immediate intervention was to apply gripper socks. Review of witness statements included the resident was last seen about 7:00 P.M. using the bathroom bare foot. A second witness statement included the resident was last seen at medication pass lying in bed with nothing on her feet. A third witness statement included the resident was last seen at 11:00 P.M. lying in bed with nothing on her feet. A sock was placed on the right foot. Review of a 6/26/25 Quarterly Minimum Data Set Assessment included the resident was severely impaired for daily decision making, dependent on staff to put footwear on, dependent for chair transfer and did not walk. The resident required substantial maximum assist for putting on/taking off footwear. The resident had no falls since last assessment. Observation on 09/16/25 at 11:38 A.M. revealed the resident was lying in bed with a patient gown on and bare feet. Interview on 09/23/25 at 4:44 P.M. with the Director of Nursing verified witness statements revealed the resident did not have non skid footwear on when last observed. Two of the statements revealed no mention of footwear applied. One statement included a sock was placed on the right foot only. The Director of Nursing verified there was a previous intervention for non skid footwear at all times that were not applied. The Director of Nursing verified non skid footwear was not applied at all times.

Based on record review, observation and interview, the facility failed to refer residents with lost or damaged dentures for dental services, or provide documentation of why a referral did not take place within three days. The facility also failed to provide a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility. This affected one (#22) of two residents reviewed for dental concerns. The facility census was 63.Findings include:Review of the medical record for Resident #22 revealed an admission date of 02/20/2017. Diagnoses included but were not limited to atherosclerotic heart disease of native coronary artery without angina pectoris, multiple fractures of ribs, left side, seizures, mild cognitive impairment, chronic lymphocytic leukemia of B-Cell type in remission, small cell B-Cell lymphoma, need for assistance with personal care, muscle weakness, essential tremor, major depressive disorder, vascular dementia unspecified without behavior disturbance, personal history of healed traumatic fracture, and generalized anxiety disorder.Review of a care plan for Resident #22 revealed a focus of dental problem related to upper and lower dentures. He would be referred for dental services as needed. The care plan history indicated the resident had received bottom dentures 2/22/21, on 11/08/24 the bottom dentures did not fit well, and on 12/06/24 the update indicated the bottom dentures were not present. That was the last care plan update noted.Review of a document titled Summary Report for [Resident #22], dated from 01/06/21-09/23/25, revealed multiple visits from 06/30/22 through 07/09/24 where resident complained of lower dentures not fitting correctly (too loose). On 07/09/24, the resident presented to dentist with broken dentures. The note from that visit indicated the dentures were sent to dental lab for repair and would be back in two weeks. There was no note following that indicated the dentures were ever returned and fit for resident.The Summary Report also revealed a visit on 12/17/24 where Resident #22 was identified as edentulous (no teeth). It indicated dentures were n/a (not applicable).That was the last note for dental treatment.Review of a nursing progress note, dated 12/05/24 revealed Resident #22 only had upper dentures.Review of a Minimum Data Set (MDS) progress note, entered 05/27/25, revealed Resident #22 was edentulous. He had upper dentures and lower dentures that did not fit. This was done as part of the MDS assessment.Review of a Minimum Data Set (MDS) progress note, entered 08/19/25, revealed Resident #22 was edentulous. He had upper dentures and lower dentures that did not fit. This was done as part of the MDS assessment.On 09/16/2025 at 12:10 P.M., an interview with Resident #22 revealed he had uppers but not downers. He thought maybe he went to the dentist to have new bottom dentures made, but he was not sure. Feels like it had been a really long time since that happened. Observed resident with upper dentures only. He reported he did not believe he even had bottom dentures anymore.On 09/23/25 at 10:00 A.M., an interview with Registered Nurse (RN) #670 revealed she had assessed Resident #22 to complete his MDS assessments on both 05/27/25 and 08/19/25. At that time, the resident had expressed concerns over ill fitting bottom dentures.On 09/23/25 at 4:00 P.M., an interview with Administrator revealed it was the responsibility of social services to arrange dental services for residents. The previous social service representative was terminated. A new social service representative had been with the facility for just one week.Review of an undated facility policy titled Dental Services revealed routine and emergency dental services were available to meet the resident's oral health services in accordance with the resident's assessment and plan of care.The policy interpretation and implementation indicated the select dentists must be available to provide follow up care. Social services were to assist resident's with appointments. Dentures would be protected from loss or damage to the extent practicable, and lost or damaged dentures would be replaced at the resident's expense. The policy did not provide for how the facility would handle dentures that were lost or damaged at the facility's responsibility.

Based on record review and staff interviews, the facility failed to ensure medical provider follow-up to monthly pharmacist recommendation for gradual dose reduction (GDR). This affected three (#01, #03, and #04) of five residents reviewed for GDR. The facility census was 63.Findings include:Review of the medical record of Resident #01 revealed admission to facility on 06/25/25 with diagnoses including pneumonia related to inhalation of food and vomit, diabetes, vascular disease, heart disease, kidney disease, fatty liver, high blood pressure, attention deficit hyperactivity disorder, overactive bladder, anxiety, fibromyalgia (chronic pain to nerve endings), and anemia (low blood count).Review of the electronic medical record (EMR) of Resident #01 revealed monthly pharmacy reviews completed on 06/26/25, 07/09/,25, 08/05/25, and 09/02/25 with recommendations made by pharmacist on 06/26/25, 07/09/25, and 09/02/25. Further review revealed detailed recommendations made by the pharmacist to the medical provider on 06/26/25 for Resident #01. There was no documentation of the specific recommendations by the pharmacist for 07/09/25 or 09/02/25. There was no documentation provided that the medical provider was notified of recommendations by pharmacist for 07/09/25 or 09/02/25 for Resident #01Interview on 09/23/25 at 2:00 P.M. with the Director of Nursing (DON), revealed she had provided all documentation related to the monthly pharmacy reviews that required medical provider review for Resident #01. That included medical provider follow up on 06/27/25 to pharmacist recommendations made on 06/26/25. The DON further confirmed there was no documentation for what was specifically recommended for Resident #01 by the pharmacist 07/09/25 and 09/02/25 and no documentation of medical provider review and follow up for 07/09/25 and 09/02/25.Review of the medical record of Resident #03 revealed admission to facility on 03/13/25 with diagnoses including intestinal fistula, aftercare for joint replacement, urinary tract infection, diabetes with neuropathy (loss of sensation of hands and feet), history of right breast cancer, low back pain, nicotine dependence, depression, high blood pressure, blood clots in legs, and anemia (low blood count).Review of the medical record of Resident #03 revealed monthly pharmacy medications reviews completed on 03/14/25, 04/07/25, 04/27/25, 05/06/25, 06/02/25, 07/09/25, 08/05/25, and 09/02/25. Review of the EMR further revealed pharmacist recommendations made on 03/14/25, 04/07/25, 04/27/25, 06/02/25, 07/09/25, and 09/2/25. The recommendations were addressed by a medical provider acknowledging review, changes made, or no changes made with rationale on 04/24/25 for recommendations made on 04/07/25, on 04/27/25 for recommendations made on 04/27/25, on 06/02/25 for recommendations made on 06/02/25, on 07/28/25 for recommendations made on 07/09/25, and on 09/15/25 for recommendations made on 09/02/25. There was no documentation of the specific medication recommendations made on 03/14/25. There was no documentation of medical provider acknowledgement or changes made or rationale if not changed for the recommendation made on 03/14/25.Interview on 09/23/25 at 2:00 P.M. with the Director of Nursing (DON) revealed she had checked with the pharmacy team and had provided all documentation related to the monthly pharmacy reviews that required medical provider review for Resident #03. The DON further confirmed there was no documentation of the medical provider review and follow-up for the pharmacist recommendations made on 03/14/25 for Resident #03.Review of the medical record of Resident #04 revealed admission to facility on 11/07/23 for diagnosis including heart failure, lung disease, contracture (deformity) of right hand, heart disease, anemia (low blood count), chronic back pain, high blood pressure, degenerative joint disorder of cervical (neck) and lumbar (mid back) regions.Review of the medical record for Resident #04 revealed monthly pharmacy medication reviews completed monthly as required for the last twelve months. Further review of the electronic medical record (EMR) revealed pharmacist recommendations for drug regimen review by the medical provider occurred on 01/12/25, 03/13/25, 05/06/25, 05/28/25, 06/26/25, 08/04/25, and 08/29/25. The recommendations were addressed by a medical provider acknowledging review, changes made, or no changes made with rationale on 02/13/25 for recommendations made 01/12/25, on 04/02/25 for recommendations made on 03/13/25, on 05/19/25 for recommendations made on 05/06/25, on 08/05/25 for recommendations made on 08/04/25, on 09/09/25 for recommendations made on 08/29/25. There was no documentation provided for the review by the medical provider for recommendations made on 05/28/25.Interview on 09/23/25 at 2:00 P.M. with the Director of Nursing (DON) revealed she had checked with the pharmacy team and had provided all documentation related to the monthly pharmacy reviews that required medical provider review for Resident #04. The DON further confirmed there was no documentation of the medical provider review and follow-up for the pharmacist recommendations made on 05/28/25 for Resident #04.

Based on record review, interview and observation, the facility failed to recognize and address pain promptly when there was a change in condition. This affected one (#73) of one resident reviewed for pain management. The facility census was 63. Findings include:Review of the medical record for Resident #73 revealed an admission date of 04/24/25 . Diagnoses included but were not limited to acute diastolic heart failure, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, acute pulmonary edema, ulcerative pancolitis without complications, Alzheimer's Disease with late onset, atrial fibrillation, osteoarthritis right shoulder, mood disorder, and dementia in other diseases.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15. A score of 13-15 would indicate cognitive intactness. The resident was assessed to have no behavioral issues or wandering behaviors. The MDS revealed him to be occasionally incontinent. The resident was assessed to have frequent, severe pain.Review of a progress note dated 09/18/25 at 9:54 P.M. revealed the resident received Hydrocodone-Acetaminophen (a narcotic pain medication) 5-325 milligrams (mg) one tablet by mouth as ordered every eight hours as needed for pain. The note did not indicate a pain level or interventions provided to resident prior to medication administration. This was confirmed by the Director of Nursing on 09/23/25 at 3:45 P.M.A progress note dated 09/18/25 at 11:12 P.M. revealed a progress note which indicated the administration of Hydrocodone-Acetaminophen had been effective and the resident's pain was zero. A document titled PHC-Pain Tool, dated 09/19/25 at 12:05 A.M., revealed a comprehensive pain assessment for Resident #73. This assessment did not include location, type, duration or frequency of pain. It did not indicate whether pain was continuous or intermittent. The assessment further indicated Resident #73 had no pain. Pain did not affect the resident's activities of daily living. It reported the only medication, treatment or modality effective in managing pain was rest. This assessment was completed three hours after pain medication had been administered to the resident.Review of a care plan dated 04/04/25 and updated 05/02/25, revealed a focus for risk of pain related to depression, cardiac disease, ulcerative colitis, heterogenous liver, degenerative changes in spine, and osteoarthritis with a target date of 07/29/25. The interventions for pain were to monitor for pain and notify the physician of any complaint of pain.The record failed to reveal any orders for non-narcotic pain medications or interventions. On 09/23/25 at 2:20 P.M., interview with Resident #73 revealed he did not believe his pain was being managed. He had pain in the base of his right great toe and at the base of his right thumb, which began about three weeks ago. The right great toe appeared red and swollen. The resident reported it was painful to touch and shooting in nature. He indicated he had been given a medicated gel for this pain and it did not work. He also reported chronic back pain. He moved to Ohio from Texas and prior to the move he had been going to pain management and had his pain mostly controlled. He reported he talked to the nurses about it. He reported the as needed narcotic medication he was taking was not effective to manage his current pain. On 09/23/25 at 2:35 P.M. an interview with Licensed Practical Nurse (LPN) #930 revealed the resident frequently gets pain medications. She indicated the intervention provided for pain prior to medication administration was he is able to reposition himself and if that doesn't work we give him the medication. She reported the physician had assessed the resident on 09/18/25, and would see residents when there was a change in their condition. She reported the resident had been complaining of pain in his right great toe and right thumb for at least two weeks. Prior to that time, all of his pain was in his knee and his back. She did not think any medications had been change with the new complaints of pain.An interview with the Director of Nursing (DON) on 09/23/25 at 3:45 P.M. revealed nurses document pain on the medication administration record. This information was requested from the facility at the time of this interview, however the facility did not provide this information.During this interview, physician notes were also requested for Resident #73. The DON indicated physician documentation was downloaded to the system, and recent notes were not in the system. The facility failed to provide the requested physician notes to determine if pain assessment by physician had been completed.Review of a policy titled Pain-Clinical Protocol, revised October 2022 required the physician and staff to identify individuals who had pain or were at risk for having pain. This should have also included a review for any treatments the resident was receiving for pain, including complementary and non-pharmacologic treatments.The policy indicated the nursing staff would assess each individual for pain on admission, at the quarterly review, and whenever there was a significant change in condition, and when there was an onset of new or worsening of existing pain.The staff and physician would evaluate how pain was affecting mood, activities of daily living, sleep and the resident's quality of life. The physician would help identify causes of pain by examining the resident directly, reviewing the resident's history and by discussion with the resident and staff.

Based on medical record review and staff interview, the facility failed to provide education on psychotropic drug use, risk, benefits, and side effects to residents. This affected one (#01) of the five residents reviewed for psychotropic drug use. The facility census was 63.Findings include:1. Review of the medical record of Resident #01 revealed admission to facility on 06/25/25 with diagnoses including pneumonia related to inhalation of food and vomit, diabetes, vascular disease, heart disease, kidney disease, fatty liver, high blood pressure, attention deficit hyperactivity disorder, overactive bladder, anxiety, fibromyalgia (chronic pain to nerve endings), and anemia (low blood count).Review of the medical record for Resident #01 revealed a general psychotherapies consent signed on admission to facility on 06/25/25 by Resident #01. The consent stated medication management may involve the risk of physical side effects, which may increase over time and/or persist after the conclusion of my treatment. I understand that I am encouraged to talk to my treating clinician(s) about any side effects or other adverse effects I am experiencing. There was no documentation related to the specific medications prescribed for Resident #01 including risk, benefits, and side effects. The prescribed psychotropic medications for Resident #01 included: Bupropion (anti-depressant) prescribed on 06/25/25, Duloxetine (anti-depressant) prescribed on 06/25/25, and Nortriptyline (antidepressant) prescribed on 06/25/25, Adderall (stimulant) prescribed on 06/27/25, Ativan (anti-anxiety) prescribed on 06/26/25. Review of medication side effect resource Medscape www.medscape.com revealed side effects for these medications included: Bupropion (dry mouth, sore throat, dizziness, nausea, vomiting, ringing in the ears, headache, decreased appetite, weight loss, constipation, trouble sleeping, increased sweating, or shaking). Duloxetine (Nausea, dry mouth, constipation, loss of appetite, tiredness, drowsiness, or increased sweating, light headedness, increased blood pressure, confusion, easy bleeding/bruising, decreased interest in sex, changes in sexual ability, muscle cramps/weakness, shaking (tremor), difficulty urinating, signs of liver problems, black stool, bloody vomit, seizure, eye pain swelling and redness, vision changes, blurred vision, fast heartbeat, hallucinations, loss of coordination, fever, agitation, restlessness). Nortriptyline (fatigue, sleepiness, sedation, weakness, dry mouth, constipation, blurred vision, agitation, anxiety, headache, inability to sleep, nausea, vomiting, sweating, low blood pressure, heart rhythm changes, dizziness, high heart rate, confusion, ringing in ears, rash, sexual dysfunction, seizure, increased liver function, low white blood cell counts, excessive urination). Adderall (loss of appetite, headache, inability to sleep, abdominal pain, weight loss, anxiety, vomiting, nervousness, high heart rate, fever, nausea, infection, emotional changes, dizziness, diarrhea, fatigue, dry mouth, indigestion). Ativan (drowsiness, depression, headache, constipation, diarrhea, dry mouth, impaired coordination, increased appetite, fatigue, memory impairment, irritability, cognitive disorders, lightheadedness, difficulty speaking, decreased appetite, weight changes, difficulty urinating, menstrual disorder, decreased sexual libido, tremors, leaking urine). Review of the medical record for Resident #01 revealed signed physician progress notes dated 06/26/25, 06/30/25, and 07/21/25 had no documentation of education of benefits, risk, or side effects of medications prescribed for Adderall, Bupropion, Nortriptyline, or Ativan. Review of the medical record for Resident #01 revealed nursing progress notes dates 06/25/25 through 09/16/25 did not indicate education was provided to Resident #01 regarding psychotropic medication use, risk, benefits, or side effects. Interview on 09/18/25 at 8:45 A.M. revealed Regional Clinical Consultant, #1000 reported the statement on the psychotherapy consent form was used for education, as it stated if the resident had any questions they were answered by the provider or facility staff. Regional Clinical Consultant #1000 stated prescribers educated residents on medications as part of their standard practice.

Based on record review, policy review, resident and staff interviews, the facility failed to develop comprehensive resident specific care plans and include resident and resident representative involvement in the care planning process. for Residents #04 and #15. The affected two (#04, #15) of 27 residents reviewed for comprehensive care planning. The facility census was 63.Findings include:1.Review of medical record of Resident #04 revealed admission to facility on 11/07/23 with diagnoses including heart failure, lung disease, contracture (deformity) of right hand, heart disease, anemia (low blood count), chronic back pain, high blood pressure, degenerative joint disorder of cervical (neck) and lumbar (mid back) regions. Review of the Minimum Data Sets 3.0 (MDS) assessment tool revealed completion of MDS 3.0 quarterly assessment on 12/24/24, quarterly assessment 03/24/25, annual assessment on 06/04/25, and quarterly assessment on 08/12/25. Review of Resident #04 Care Conference Summary Sheet 2.0 dated 01/07/25 revealed Resident #04's family and Resident #04 were not in attendance; they were invited and declined. Further record review revealed no other care conference summaries completed to coincide with the MDS assessments and care plan revisions. Interview 09/16/25 at 12:10 P.M. with Resident #04's son revealed he has participated in care conference in past but has not been invited to one in a long time. Interview on 09/23/25 at 11:35 A.M. with the Director of Nursing, (DON), revealed verification that there were no care conferences conducted, or care conference notes completed in the medical record in 2025 for Resident #04. Interview further revealed that it was the responsibility of the prior social worker, who was terminated, to conduct and document care conferences. Review of facility policies Care Planning and Interdisciplinary Team and Care Plans, Comprehensive Person-Centered policies both dated March 2022; revealed care conference would occur quarterly for each resident and the facility will attempt to have family and resident present and document reason if not in attendance. 2.Review of Resident #15's medical record revealed a 05/01/25 admission date with diagnoses including dementia, fracture of left femur, emphysema, severe protein calorie malnutrition, disorders of psychological development, Alzheimer's disease, ataxia, muscle weakness, varus deformity left hip, bradycardia, joint implants, vitamin D deficiency, abnormal findings of lung fields, major depressive disorder, osteoarthritis, cataract, elevated white blood cell count, anxiety, cataracts, constipation, gastroesophageal reflux disease, tremor, insomnia, scoliosis, kyphosis, tremor, history of falling, and hypothyroidism. Review of a 02/09/21 Fall Risk plan of care revealed the resident was at risk related to generalized weakness, history of falls, impaired cognition with decreased safety awareness, poor balance, poor communication/comprehension, psychoactive drug use, unsteady gait and a history of falls. Review of a 6/26/25 Quarterly Minimum Data Set Assessment included the resident was severely impaired for daily decision making, dependent on staff to put footwear on, dependent for chair transfer and did not walk. The resident had no falls since last assessment. Review of a 07/14/25 fall in the dayroom included the resident was rising unassisted and landed on her butt in front of her wheelchair. The immediate intervention was to offer her the recliner. Review of physician orders included a 07/14/25 order to offer recliner chair when in lounge. Review of the comprehensive fall plan of care revealed to offer the resident the recliner chair when is the lounge was not added to the plan of care. Interview 09/23/25 at 4:44 P.M. with the Director of Nursing verified the care plan was not updated for the use of the recliner. Review of the facility's Fall and Fall Risk Managing policy revised March 2018 did not include adding interventions to the comprehensive plan of care.

Based on observation, interview and record review the facility failed to provide residents who required supplemental oxygen with the needed support. This affected one (#34) of one resident who was reviewed for respiratory care. The facility census 63. Findings include: Review of the open medical records for Resident #34 revealed a readmission date 10/26/25. Diagnoses included acute and chronic respiratory failure with hypoxia, pleural effusion and shortness of breath. Review of the physician orders for September 2025 revealed continuous oxygen at four liters via nasal cannula every shift. Review of the plan of care dated 04/15/24 revealed Resident #34 had an impaired respiratory status related to hypoxia, respiratory failure, shortness of breath and sleep apnea. Interventions included oxygen via nasal cannula at four liters continuously and treatments as ordered by the physician. Observation on 09/15/25 at 3:04 P.M. of Resident #34 revealed she was lying in bed with her oxygen nasal cannula tubing on. Observation of the oxygen concentrator revealed the oxygen concentrator was not on but set at two liters per minute. Interview on 09/15/25 at 3:05 P.M. with Resident #34 stated she did not realize her oxygen was off. The aide came in around 6:00 A.M. and took the resident's C-pap off and put her oxygen nasal cannula on. Resident #34 stated I guess she did not turn the concentrator on. Interview on 09/15/25 at 3:07 P.M. with Licensed Practical Nurse (LPN) #970 verified Resident #34's oxygen concentrator was not on and was to have her oxygen on at four liters via nasal cannula. LPN #970 checked Resident #34's oxygen saturation with a pulse ox. The pulse ox was 80 percent (%) on room air. LPN #970 told Resident #34 to take some deep breaths and turned the oxygen concentrator on. Resident #34's pulse ox went up to 93%. LPN #970 stated Resident #34 is to be on continuous oxygen for hypoxia. Review of the facility policy Oxygen Administration, dated 2001 revealed review the physician's orders or facility protocol for oxygen administration.

Based on record review, observation, and interview the facility failed to provide personal hygiene care to a resident dependent on staff for provision of care. This affected one (#13) of six residents reviewed for personal hygiene care. The facility census was 63. Findings include: Review of Resident #13's medical record revealed a 11/25/23 admission with diagnoses including Alzheimer's disease, dementia, hypertension and anxiety. The resident had a 11/25/23 activity of daily living self care performance deficit plan of care related to Alzheimer's, anxiety, dementia, and psychoactive drug use. Interventions included the resident will accept assistance during bathing and/or showering. The resident had an 11/21/24 order for placement on secured memory care unit for therapeutic environment. Review of the 07/16/25 Quarterly minimum data set (MDS) assessment revealed the resident was severely impaired for daily decision making. Review of nurse notes May 2025 through September 2025 revealed no bathing or nail care refusals. Review of showers revealed no documented refusals of showers. Observation on 09/16/25 at 8:20 A.M. revealed the resident was ambulating in the hall. Her nails were long. Observation at 1:37 P.M. revealed her finger nails had debris under the nailbeds and her nails were long and jagged. Observation 09/16/25 at 4:38 P.M. with the Administrator of the resident's fingernails revealed the resident's nails were long with dirt under the nail beds bilaterally. The Administrator asked her if she wanted a spa day tomorrow. The resident did not respond. Interview 09/16/25 at 4:45 P.M. with Certified Nurse Aide (CNA) #490 verified they are to trim and clean resident nails with showers if needed. Observation 09/17/25 at 11:44 A.M. of Resident #13 revealed her fingernails remained dirty and jagged bilaterally. Interview 09/17/25 at 12:06 P.M. with Licensed Practical Nurse (LPN) #270 included it was not passed on to her that Resident #13 needed nail care completed.

Based on record review, observation, and interview, the facility failed to ensure residents received proper assistive devices to maintain hearing abilities. This affected on (#22) of two residents reviewed for communication and sensory issues. The facility census was 63.Findings include:Review of the medical record for Resident #22 revealed an admission date of [DATE]. Diagnoses included but were not limited to atherosclerotic heart disease of native coronary artery without angina pectoris, multiple fractures of ribs, left side, seizures, mild cognitive impairment, chronic lymphocytic leukemia of B-Cell type in remission, small cell B-Cell lymphoma, need for assistance with personal care, muscle weakness, essential tremor, major depressive disorder, vascular dementia unspecified without behavior disturbance, personal history of healed traumatic fracture, and generalized anxiety disorder. Review of care plan for Resident #22 revealed he had impaired communication related to anxiety, cognitive impairment, depression and hard of hearing. A care plan update on [DATE] indicated the resident had received replacement hearing aides. There had been no additional changes to this focus area. Interventions included audiology referral as needed. Review of a progress note from 360Ohio, dated [DATE], revealed resident had possible hearing loss noted with normal conversational tones. The resident had hearing aides that were broken. Warranty expired in 2022. Recommended audiology referral to see if eligible for a new set. There was no follow up with audiology noted after that note. Review of a progress note by Registered Nurse (RN) #670 on [DATE] revealed Resident #21 was minimally hearing impaired. He did not have hearing aides. This assessment was completed during review of Minimum Data Set (MDS) information for the resident. Review of a progress note by RN #670 on 08/19//25 revealed Resident #21 was minimally hearing impaired. He did not have hearing aides. This assessment was completed during review of Minimum Data Set (MDS) information for the resident. On [DATE] at 12:10 P.M., an observation and interview with Resident #22 revealed he was supposed to wear hearing aides in both ears. He had not had them for some time because they broke. He did not know for sure if he had an appointment recently to get them repaired and he was not sure what had happened to them. Observation revealed the resident's television was turned up very loud, and he did not have in any hearing aides in place in either ear. On [DATE] at 10:00 A.M., an interview with RN # 670 revealed during review for MDS she had discussed hearing with resident. She confirmed on [DATE] and [DATE] during MDS review, resident was identified as having minimal hearing loss and he did not have hearing aides. On [DATE] at 4:00 P.M., an interview with Administrator revealed it was the responsibility of social services to arrange hearing or vision exams for residents. The previous social service representative was terminated. A new social service representative had been with the facility for just one week.

Based on observation, record review, and interviews, the facility failed to ensure Resident #44's bilateral lower leg (BLL) wraps were applied as ordered by the physician. This affected one (#44) of two residents reviewed for edema and non-pressure skin conditions. The facility census was 63.Findings include: Review of the medical record for Resident #44 revealed an admission date of 02/13/25 with diagnoses including Alzheimer's disease, dementia, left bundle branch block, lymphedema, edema, anxiety, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/08/25, revealed Resident #44's Brief Interview for Mental Status (BIMS) score was 08, which indicated moderately impaired cognition. The resident required staff assistance with activities of daily living. Review of the Care Plan, dated 3/11/25, revealed Resident #44 was at risk for impaired skin integrity related to edema and fragile skin with the intervention to apply ACE wraps to bilateral lower extremities in the morning and to be removed in the evening, Review of physician order, dated 3/12/25, revealed the order for ACE wraps to be applied to bilateral lower extremities, to be on in the morning and off in the evening. Observation on 09/17/25 at 9:12 A.M. revealed Resident #44 did not have ACE wraps applied to bilateral lower extremities as ordered by the physician. Subsequent observation on 09/17/25 at 11:19 A.M. again revealed the resident did not have ACE wraps applied to her bilateral lower extremities. Interview on 09/17/24 at 11:25 A.M., Licensed Practical Nurse (LPN) #780 confirmed Resident #44 was not wearing ACE wraps on her bilateral lower extremities as ordered by the physician.

Based on observation, interview, and record review, the facility failed to ensure a call light was within reach for a dependent resident. This affected one (#10) of five residents reviewed for activities of daily living (ADLs). The facility census was 63.Findings include: Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including cerebrovascular disease, dementia, diabetes mellitus, congestive heart failure, chronic kidney disease, and adult failure to thrive. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/24/25, revealed the Resident #10 was moderately cognitively impaired and required staff assistance with activities of daily living (ADLs). The resident's mobility device was a wheelchair. Observation on 09/18/25 at 1:26 P.M. revealed Resident #10 was lying in bed. The resident's call light was observed draped over his recliner and not within reach of the resident. Observation on 09/18/25 at 3:28 P.M. revealed Resident #10 was lying in bed, tearful and requesting to be pulled up in his bed. Further observation revealed his call light draped over his recliner and not within reach of the resident. Interview on 09/18/25 at 3:30 P.M. with the Assistant Director of Nursing (ADON) confirmed Resident #10's call light was not within reach of the resident.

Based on record review, observation, resident and staff interview, review of the facility policy, and review of the guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to implement a comprehensive and individualized pressure ulcer prevention program for Resident #25 to prevent the development of an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer. The facility also failed to accurately assess the wound as a facility acquired pressure ulcer. Actual Harm occurred on 11/27/23 when Resident #25, who was at risk for pressure ulcers and required staff assistance for bed mobility and incontinence care was found to have an unstageable pressure ulcer to the sacrum without evidence of adequate interventions to prevent the development or timely identify the pressure ulcer prior to it being unstageable. This affected one resident (#25) of three residents reviewed for pressure ulcers. The facility census was 75. Findings include: Review of the medical record revealed Resident #25 was admitted on [DATE] with diagnoses including a fracture to the left femur, type II diabetes mellitus, spinal stenosis, and intellectual disabilities. Review of the hospital paperwork dated 11/22/23 revealed Resident #25 did not have skin breakdown upon discharge from the hospital. Review of the plan of care dated 11/22/23 revealed Resident #25 was at risk for impaired skin integrity related to the resident being confined to bed or chair most of the time, diabetes, impaired cognition, incontinence of bowel and bladder, pain, and required staff to assist with repositioning. Interventions included assisting Resident #25 with turning and repositioning as needed and completing a skin inspection every seven to ten days and as needed. On 11/29/23, a new intervention of an air mattress was added to the plan of care. Review of the admission note dated 11/22/23 at 4:45 P.M. revealed Resident #25 required two-persons assist for transfers and one-person assist for bed mobility. No skin impairments were observed. The Braden Scale used to determine the risk level for the development of pressure ulcers revealed Resident #25 was able to respond meaningfully to pressure-related discomfort, was rarely moist, was chairfast, had very limited ability to change and control body position, had adequate food intake, had no apparent problem with friction or shearing as evidenced by Resident #25 being able to move in bed/chair independently and had sufficient muscle strength to lift up completely during movement and maintained good position in bed/chair at all times. A Braden Scale assessment, revealed Resident #25 was at low risk for the development of pressure ulcers. Review of the bath sheet dated 11/24/23 revealed Resident #25 was given a bed bath and no skin concerns were noted. Review of an admission functional abilities and goals note, dated 11/27/23 revealed Resident #25 required substantial/maximal assistance for toileting hygiene, from lying to sitting on side of bed, and from sitting to standing. Resident #25 was dependent for chair/bed-to-chair and toilet transfer. Review of the nursing note dated 11/27/23 at 5:29 P.M. revealed a State tested Nursing Assistant (STNA) notified the nurse that Resident #25 had a discolored and scabby area to the buttocks. The area was pink with dark discoloration and was dry. A Braden Scale assessment, dated 11/27/23 at 5:31 P.M. revealed Resident #25 was able to respond meaningfully to pressure-related discomfort, was occasionally moist, was chairfast, had very limited ability to change and control body position, had adequate food intake, and had a potential problem with friction or shearing as evidenced by Resident #25 moved feebly or required minimum assistance with skin probably sliding at some extent against the sheets/chair/devices. Resident #25 was at low risk for the development of a pressure ulcer. Review of the facility's wound evaluation dated 11/27/23 at 6:00 P.M. revealed Resident #25 had an unstageable pressure ulcer to sacrum that measured 8.2 centimeter (cm) long and 11.4 cm wide. The depth was not able to be determined due to slough (yellow/white necrotic tissue) and eschar (necrotic tissue) tissue being present. The wound was documented as a new wound and community acquired (present on admission). A new treatment was ordered. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was cognitively intact. Resident #25 was frequently incontinent of bowel and bladder and had one unstageable pressure ulcer present upon admission. Resident #25 required substantial/maximal assistance for toileting hygiene, lying to sitting, and sitting to standing. Resident #25 was dependent for toilet transfer. Review of the wound physician note dated 11/29/23 at 11:43 A.M. revealed Resident #25 was recently admitted from the hospital for therapy. Resident #25 had an unstageable pressure ulcer to left upper buttock which was present upon admission. The wound measured 3.7 cm long and 2.7 cm wide. The depth was undetermined due to the wound base having 40 percent slough tissue. The wound was debrided (damaged tissue removed) to reduce bacterial load and promote healing. A treatment of Triad (zinc oxide-based hydrophilic paste that adheres to moist wound beds and protects periwound skin) paste to be applied thickly was noted. Interview on 01/17/24 at 7:25 A.M. with Assistant Director of Nursing (ADON) #135 revealed the ADON was the facility wound nurse. ADON #135 verified the area to Resident #25's left buttock was considered present on admission because the wound developed within seven days of the resident's admission. ADON #135 verified the wound to Resident #25's left buttock/sacrum area was discovered five days after Resident #25 had been admitted . An additional interview on 01/17/24 at 10:29 A.M. with ADON #135 revealed Resident #25 had multiple comorbidities which made Resident #25 at risk for pressure ulcers. The ADON stated a skin check was completed upon admission and then weekly. ADON #135 verified the pressure ulcer was not present on admission and should have been documented as facility acquired pressure ulcer. Interview on 01/17/24 at 11:06 A.M. with Resident #25 revealed when the resident was first admitted , she laid on her back in bed most of the time due to pain from staples in her left leg. Resident #25 stated she was incontinent of urine frequently, but staff would only provide incontinence care every two hours. Observation on 01/17/24 at 11:47 A.M. of dressing change for Resident #25 revealed a pink blanchable area to Resident #25's left inner buttock. Wound Nurse Practitioner #500 indicated the pressure ulcer area had healed but preventative treatment would continue. Interview on 01/19/24 at 8:08 A.M. with Therapy Manager #200 revealed at the time of admission (on 11/22/23) Resident #25 required maximum (staff) assist for all activities of daily living except for eating. Review of the facility's policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised April 2018, revealed the staff and practitioner would examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. The nursing staff and practitioner would assess and document an individual's significant risk factors for developing pressure ulcers: for example, immobility, recent weight loss, and a history of pressure ulcer(s). Review of the NPUAP guidelines dated 2014 pages 70-71 at (https://npiap.com/general/custom.asp page=2014 Guidelines) revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominence. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominence's including the sacrum, ischial tuberosity, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. This deficiency represents non-compliance investigated under Complaint Number OH00149774.

Based on review of the medical record and facility video monitoring, staff and visitor interview, review of the National Weather Service report, the facility elopement policy and a local electronic news article, the facility failed to provide adequate supervision to prevent the elopement of one cognitively impaired resident, (Resident #33) who resided on the facility secured (memory care) unit and was assessed to be at risk for elopement. This resulted in Immediate Jeopardy when Resident #33 eloped from the facility on [DATE] at 7:59 P.M. without staff knowledge. Actual harm occurred when Resident #33 was found deceased outdoors by the local County Sherriff's Department, 4.3 miles from the facility on [DATE] at 4:10 P.M. This affected one resident of 14 residents identified to be at risk for elopement who resided on the secured unit (Resident #38, #40, #41, #42, #43, #44, #45, #47, #48, #49, #52, #53 and #54). The facility census was 91. On [DATE] at 11:15 A.M., the Nursing Home Administrator (NHA), Director of Nursing (DON), Regional Director of Nursing (RDON) #11 and Regional Director of Operations (RDO) #12 were notified Immediate Jeopardy began on [DATE] at 7:59 P.M. when Resident #33, who was assessed to be at risk for elopement and exhibited exit seeking behaviors, exited the secured unit of the facility by entering the elevator with a visitor. The resident then exited the front entrance with the visitor after being provided assistance with the exit code out the facility main entrance by State tested Nursing Assistant (STNA) #10. Resident #33 was found deceased on [DATE] at 4:10 P.M. by the local County Sheriff's Department, outdoors and 4.3 miles from the facility. The Immediate Jeopardy was removed on [DATE] at 12:00 P.M. when the facility implemented the following corrective actions: · Beginning on [DATE] and completed on [DATE], the DON in-serviced 14 department heads who then in-serviced all remaining staff, including 36 STNAs, 15 Licensed Practical Nurses (LPNs), four Registered Nurses (RNs), 11 housekeeping staff, four maintenance staff, six therapy staff and three activity staff on the following: a. Identifying residents who were at risk for elopement b. Elopement policy c. Resident Leave of Absence sign out procedure d. Importance of verifying residents are signed out prior to them exiting facility e. Reinforce duties and responsibilities of nursing assistants · Elopement drills were completed by Maintenance #14 and Maintenance #21 on [DATE] at 1:51 P.M. and at 4:30 P.M. Twenty four staff members participated including 11 STNAs, four LPNs, four administrative staff (administrator, DON, Business Office Manager and facility social worker), two maintenance staff, one housekeeping staff and two activity staff. · Director of Maintenance #14 completed functional testing of all coded doors including elevators on [DATE] by 8:15 A.M. All doors passed inspection. · On [DATE] and [DATE] elopement assessments for all residents identified to be at risk for elopement, who resided within the secured unit were completed (Residents #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56 and #57 ). The care plans for these residents were updated to reflect the assessments. · On [DATE] the facility receptionist ensured all elopement books (one on each unit and at the front desk) were updated and accurate. On [DATE] at 8:45 A.M., observation of elopement books at each unit and front entrance verified the accuracy. · New signage was posted on [DATE] at 11:00 A.M. on all secured unit exit doors and the secured unit elevator stating PLEASE DO NOT PERMIT ANYONE/RESIDENT TO EXIT THESE DOORS BEFORE CHECKING WITH A STAFF MEMBER FIRST. Signs were observed in place on [DATE] at 8:40 A.M. · On [DATE] the elevator key pad code was changed and a plan to change the code on a monthly basis was implemented for an indefinite time period. · A new facility policy and procedure titled Head Count Protocol was initiated on [DATE]. Staff was to count all residents on their assigned units at the beginning of their shift to ensure all residents were in the facility. · On [DATE] from 8:45 A.M through 8:55 A.M. interviews with LPN #17, LPN #18 and STNA #19 revealed staff members had knowledge on preventing resident elopement and knowledge of the policy and procedure for an actual elopement. · The facility denied any additional resident elopements from the facility had occurred since [DATE]. · The facility identified in the Quality Assurance and Performance Improvement (QAPI) Program the need for ongoing auditing and monitoring including: a. A special QAPI committee meeting was held on [DATE], consisting of the NHA, DON and medical director via phone to discuss the events set forth in the notification of the immediate jeopardy. A special QAPI committee meeting will occur weekly for the next four weeks to discuss audit finding and assess for plan effectiveness. b. DON or designee will monitor for head counts to be completed daily on each shift. Monitoring will continue until otherwise directed by the QAPI committee. c. DON or designee will conduct interview audits of five staff to ensure retention of education, weekly for four weeks. Audits will consist of questions pertaining to items discussed during the in-service. After the initial four weeks, three staff members will be audited for four weeks. d. NHA or designee will conduct elopement drills on random shifts once per week for four weeks with findings reported to the QAPI committee. e. Audit findings will be discussed in the monthly QAPI and the committee will determine the strategies for ongoing compliance. · On [DATE] at 12:00 P.M. LPN #13, STNA #22 and STNA #23, the staff working at the time of the elopement were terminated by the facility for failure to identify Resident #33 was missing between [DATE] at 8:00 P.M. and [DATE] at 5:00 A.M. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level II (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #33's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #33 was moderately cognitively impaired and able to ambulate independently. An elopement risk assessment completed on [DATE] identified Resident #33 as high risk for elopement. Review of Resident #33's care plan, dated [DATE] identified Resident #33 was an elopement risk due to history of attempts to leave the facility unattended, frequent statements of going to try to leave and impaired safety awareness. The care plan identified Resident #33 had impaired cognitive function and was an elopement risk. Care plans also indicated Resident #33 had a history of [REDACTED]. Review of nursing notes revealed Resident #33 displayed exit seeking behavior on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. These included behaviors of wandering the hallways of the secured unit and seeking exits including the elevator and statements made of the desire to leave the facility. Further review of nursing notes revealed no evidence of documentation of the elopement from the facility on [DATE]. The last nursing progress note was dated [DATE]. On [DATE] at 8:20 A.M. interview with the NHA and the DON revealed Resident #33 eloped from the facility on the evening of [DATE]. The NHA and DON revealed on [DATE] at 7:55 A.M., the local police department was notified Resident #33 was missing from the facility. However, the administrative staff revealed they were informed that the police department was unable to provide assistance to the facility as the resident had not been missing for 48 hours. The NHA and DON revealed facility staff members were continuing to search for the resident as of [DATE]. Further interview revealed the facility had electronic video evidence that on [DATE] at 7:57 P.M. Resident #33 eloped from the facility. On [DATE] at 8:35 A.M. and again on [DATE] at 10:10 A.M., observation of the electronic video surveillance with the NHA and the DON revealed on [DATE] at 7:57:23 P.M., Resident #33 was observed standing beside the elevator of the secured unit on the second floor wearing a coat. Visitor #15 approached the elevator, entered the elevator code and waited for the elevator. When the elevator doors opened Visitor #15 and Resident #33 walked into the elevator. At 7:58:19 P.M. Visitor #15 was observed exiting the elevator and going to the front lobby. Resident #33 was not seen on the video at that time. At 7:58:30 P.M. Visitor #15 returned to the elevator area to seek assistance with the code for the front door. At 7:58:54 Resident #33 returned to the elevator area and was standing next to Visitor #15 and talking with Visitor #15. At 7:59:10 STNA #10 was observed walking to the front entrance. Resident #33 and Visitor #15 were observed following STNA #10 towards the front entrance. At 7:59:23 P.M., STNA #10 assisted Visitor #15 and Resident #33 by putting the code into the keypad which unlocked the front door. As STNA #10 held the door open, Visitor #15 and Resident #33 exited the facility. At 7:59:39 STNA #10 then turned around and left the front door area. On [DATE] at 10:07 A.M. telephone interview with Visitor #15 revealed she was in the facility to return Resident #52 from a leave of absence. Visitor #15 added when she was leaving the secured unit she walked to the elevator and saw Resident #33 standing by the elevator. He was wearing a coat and appeared to be leaving. She thought Resident #33 was also a visitor. Visitor #15 stated she entered the code into the elevator and stepped into the elevator when the door opened. Resident #33 stepped into the elevator with her. She stated Resident #33 informed her that he was going to the hospital to visit his sister. When the elevator door opened she turned to the right to exit the building and Resident #33 turned to the left. She went to the front door, but needed a code to get out the door as the door was locked. Visitor #15 returned to the elevator area and saw Resident #33 returning to the elevator area as well. She then found STNA #10 and requested his assistance in helping them out of the front entrance. STNA #10 walked with her and Resident #33 to the front door and entered the code so both her and Resident #33 could exit the facility. On [DATE] at 10:18 A.M., interview with STNA #10 revealed he was approached by Visitor #15 who requested to help us with the code to get outside. STNA #10 further added that he knew it was Resident #33, but assumed he was with the visitor and was going outside with the visitor. STNA #10 further added that he watched Visitor #15 and Resident #33 exit the building onto the sidewalk and he then returned to work. He did not advise any staff members or question any staff members if Resident #33 was going on a leave of absence with Visitor #15. He assumed Resident #33 left the secured unit with Visitor #15 and he was permitted to leave. On [DATE] at 2:55 P.M., interview with LPN #13 revealed on [DATE] a little before 5:00 A.M., she found Resident #33 was not in his room when she was making rounds and administering morning medications. She notified staff on her floor to search for Resident #33, and then alerted other staff in the building to search. She then called the DON to advise her of a missing resident. She added staff members searched the entire facility and outside of the facility and did not locate Resident #33. LPN #33 stated she did not check for Resident #33 prior to 5:00 A.M. and indicated her shift had started on [DATE] at 6:00 P.M. As of [DATE] at 4:00 P.M. according to interview with the NHA and the DON Resident #33 remained missing and staff were continuing to search for the resident. Review of the National Weather Service Report temperatures for Canton Ohio revealed the following temperatures: [DATE] at 7:51 P.M., 55 F [DATE] at 12:51 A.M., 46 F [DATE] at 6:51 A.M., 41 F [DATE] at 12:51 P.M., 36 F [DATE] at 7:51 P.M., 35 F [DATE] at 12:51 A.M., 32 F [DATE] at 8:51 A.M., 31 F [DATE] at 12:51 P.M., 34 F Review of an electronic news article from News 5 Cleveland revealed on [DATE] at 4:10 P.M. Resident #33 was found deceased by the Stark County Sheriff's department. He had been found outdoors at an unoccupied business building, 4.3 miles from the facility. On [DATE] at 9:00 A.M., interview with Regional Director of Nursing (RDON) #11 and Regional Director of Operations (RDO) #12 verified on [DATE] at 4:10 P.M., Resident #33 was found by local law enforcement 4.3 miles from the facility and was deceased . On [DATE] at 9:55 A.M., interview with Physician #20, Resident #33's primary physician revealed Resident #33 had impaired safety awareness as well as delusions and other medical problems. He would have difficulty surviving outside in cold weather for an extended period and also with no medications or nutrition. Review of the resident's current Medication Administration Record [REDACTED] On [DATE] attempts to reach STNA #22 and STNA #23 via telephone were unsuccessful. Review of the facility policy titled, Elopements with a revision date of (MONTH) 2007 revealed staff shall investigate and report all cases of missing residents. Staff shall promptly report any resident who tried to leave the premises or was suspected of being missing to the Charge Nurse or Director of Nursing. If an employee discovered that a resident was missing from the facility, he/she shall: a. Determine if the resident was out on an authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; c. If the resident was not located, notify the Administrator and Director of Nursing Services, the resident's legal representative (sponsor), the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., Emergency Management, Rescue Squads, etc.); d. Provide search teams with resident identification information; and e. Initiate an extensive search of the surrounding area. This deficiency substantiates Master Complaint Number OH 510 and Complaint Number OH 386.

Based on interview, observation, facility policy and record review, the facility failed to coordinate and schedule Resident #80's dental visits for three years. Harm occurred when Resident #80 complained of extreme mouth pain and expressed discomfort by crying and yelling out loud. There was no evidence that Resident #80 received the ordered dental consult for the toothache. Findings include: Review of Resident #80's medical record revealed the resident was admitted to the facility on 06/10/11 with [DIAGNOSES REDACTED]. unspecified [MEDICAL CONDITION] and developmental speech or language disorder. Resident #80 was admitted to Hospice on 11/07/11. Resident #80's brief interview for mental status revealed cognitive impairment. Further review of Resident #80's medical record revealed a physician order [REDACTED]. regarding a toothache. Review of Resident #80's nursing progress notes dated 07/12/15 at 8:25 P.M. stated the resident was crying and yelling out loud. When the nurse asked the resident what was wrong, the resident stated his teeth. The nurse notified Hospice and the physician and obtained orders for [MEDICATION NAME] (antibiotic) 500 milligrams (mgs) by mouth for ten days and a dental consult. Review of Resident #80's Hospice progress note dated 07/12/15 at 10:30 P.M. stated the patient was in bed screaming due to teeth pain with the physician being notified and antibiotics plus a dental consult ordered. Further review of the Hospice progress note stated the facility nurse gave [MEDICATION NAME] (pain medication) 0.5 milliliter (ml) at 08:00 P.M. and 10:30 P.M. plus [MEDICATION NAME] prior to the hospice visit. Review of Resident #80's last dental consult dated 05/08/12 revealed the resident received a teeth cleaning. Interview on 07/15/15 at 12:34 P.M. with Medical Records #16 stated she thought Resident #80's dental visits were coordinated by Hospice and the resident was not on the facility dental list to make an appointment for the resident to see the dentist. Further interview revealed Medical Records #16 was unaware of the physician order [REDACTED].#80 to see the dentist for a toothache and no dental visit was scheduled at the time of the interview. Observation on 07/15/15 at 3:46 P.M. of Resident #80 revealed the resident was in his bed resting quietly and the resident's wife was visiting. Resident #80 had visible plaque on his teeth which was verified by the wife at the time of the observation Interview on 07/15/15 at 4:43 P.M. with Clinical Director of Hospice #15 revealed the facility was to coordinate Resident #80's dental care per the facility policy Review of the facility dental policy dated 02/04/13 stated the provider would schedule appointments for the resident based on the following criteria of an annual dental exam and all Medicaid covered treatment.