Every finding on record at University Manor Health & Reha

Based on observation, record review and interview, the facility did not maintain an ambient temperature in resident rooms and common areas. This finding had the potential to affect all 42 residents residing on the second floor and all 25 residents residing on the third floor. The facility census was 143. Findings include: Interview on 01/22/25 at 4:11 P.M. with Security #801 stated he felt it was cold in the facility the last two days. Interview on 01/22/25 at 4:15 P.M. with the Administrator indicated the problems with the heat started with the boiler system in the basement. The Administrator indicated she was aware the temperatures were off. Interview on 01/22/25 at 4:16 P.M. with the Director of Nursing (DON) indicated it was cold in the facility on 01/21/25. The DON stated the facility put heaters at the end of the halls. Interview on 01/22/25 at 4:23 P.M. with Resident #38 indicated it was cold in the facility on 01/21/25 and 01/22/25. Interview on 01/22/25 at 4:25 P.M. with Resident #110 revealed the facility had been cold. Observation of the resident at the time of the interview revealed she was in the first-floor smoking lounge with a coat and hat on at the time of the observation. Staff were observed sitting in a chair outside of the smoking lounge. Telephone interview on 01/22/25 at 4:27 P.M. with Heating Services #802 indicated their company was in the facility on 01/08/25 because the basement flooded with sewage. Heating Services #802 stated their company cleaned the burners, repaired two circuit boards, four flame sensors, four pilot assemblies and two gas valves. He stated the compression tank was repaired and the pressure regular valve (auto fill valve) was repaired. He stated he was obtained temperatures on 01/21/25 the temperature on the second floor was 68 degrees Fahrenheit. Observation on 01/22/25 at 4:42 P.M. with Mobile Administrator #803 who used a temperature gun and obtained a temperature near the first-floor smoke room revealed the temperature was 61 degrees Fahrenheit (first floor). Observation on 01/22/25 at 4:45 P.M. with Mobile Administrator #803 who used a temperature gun and obtained a temperature of Residents #25 and #26's resident room revealed the temperature was 67 degrees Fahrenheit (second floor). Observation on 01/22/25 at 4:45 P.M. with Mobile Administrator #803 who used a temperature gun and obtained a temperature of Resident #38's resident room revealed the temperature was 64 degrees Fahrenheit (second floor). Observation on 01/22/25 at 4:47 P.M. with Mobile Administrator #803 who used a temperature gun and obtained a temperature of Residents #12 and #13's resident room revealed the temperature was 66 degrees Fahrenheit (second floor). Interview on 01/22/25 at 5:07 P.M. with Receptionist #804 indicated the first floor was administration offices except for the smoking room. Interview on 01/22/25 at 5:08 P.M. with Registered Nurse (RN) Assistant Director of Nursing (ADON) #805 indicated it had been cold in the facility for the last twenty-four to forty-eight hours. Observations on 01/22/25 at 5:10 P.M. revealed three mobile air and power rental units on the 2nd floor (one on the end of each hall plus one in the common lounge). Interview on 01/22/25 at 5:12 P.M. with LPN #807 indicated she had worked most days from 01/19/25 to 01/22/25 and the facility started getting cold 01/20/25 or 01/21/25. Observations on 01/22/25 at 5:15 P.M. revealed three mobile air and power rental units on the third floor (one on the end of each hall plus one in the common lounge). Interview on 01/22/25 at 5:26 P.M. with Mobile Administrator #803 confirmed the second floor did not meet the required ambient temperatures within the range of 71 to 81 degrees Fahrenheit. Mobile Administrator #803 indicated he would move one of the mobile heaters from the third floor to the second floor to increase the ambient temperature of the second floor. Review of the Floor Plan Master Audit Sheet dated 01/21/25 at 11:00 A.M. of the second and third floor temperatures revealed the facility Residents #3 and #4's room temperature was 65 degrees Fahrenheit; Residents #8 and #9's room was 69 degrees Fahrenheit; Resident #20's room temperature was 66 degrees Fahrenheit; Residents #27 and #28's room temperature was 68 degrees Fahrenheit; Resident #33's room temperature was 67 degrees Fahrenheit; Resident #43's room temperature was 67 degrees Fahrenheit; Resident #47's room temperature was 68 degrees Fahrenheit; Resident #57's room temperature was 69 degrees Fahrenheit; Resident #66's room temperature was 69 degrees Fahrenheit; and Resident #69's room was 68 degrees Fahrenheit. Review of the Floor Plan Master Audit Sheet dated 01/21/25 at 3:30 P.M. of the second and third floors revealed Residents #3 and #4's room temperature was 64 degrees Fahrenheit; Residents #8 and #9's room temperature was 64 degrees Fahrenheit; Resident #14's room temperature was 65 degrees Fahrenheit; Residents #18 and #19's room temperature was 64 degrees Fahrenheit; Residents #23 and #24's room temperature was 64 degrees Fahrenheit; Residents #31 and #32's room temperature was 67 degrees Fahrenheit; Resident #38's room temperature was 68 degrees Fahrenheit; Resident #43 and #44's room temperature was 65 degrees Fahrenheit; Resident #46's room temperature was 68 degrees Fahrenheit; Resident #50's room temperature was 69 degrees Fahrenheit; Resident #61's room temperature was 69 degrees Fahrenheit; Resident #65's room temperature was 68 degrees Fahrenheit; Resident #68's room was 69 degrees Fahrenheit; and Resident #70's room temperature was 66 degrees Fahrenheit. Review of the Floor Plan Master Audit Sheet dated 01/21/25 at 9:15 P.M. of the second and third floors revealed Residents #1 and #2's room temperature was 65 degrees Fahrenheit; Residents #6 and #7's room temperature was 66 degrees Fahrenheit; Residents #12 and #13's resident room was 64 degrees Fahrenheit; Residents #15 and #16's room temperature was 64 degrees Fahrenheit; Resident #17's room temperature was 65 degrees Fahrenheit; Resident #20's resident room temperature was 64 degrees Fahrenheit; Residents #23 and #24's room temperature was 63 degrees Fahrenheit; Residents #29 and #30's room temperature was 66 degrees Fahrenheit; Residents #34 and #35's room temperature was 67 degrees Fahrenheit; Resident #38's room temperature was 64 degrees Fahrenheit; Resident #43's room temperature was 64 degrees Fahrenheit; Residents #35's room temperature was 67 degrees Fahrenheit; Resident #47's room temperature was 68 degrees Fahrenheit; Resident #52's room temperature was 68 degrees Fahrenheit; Resident #53's room temperature was 67 degrees Fahrenheit; Resident #55's room temperature was 68 degrees Fahrenheit; Resident #59's room temperature was 65 degrees Fahrenheit; Resident #61's room temperature was 67 degrees Fahrenheit; Resident #63's room temperature was 65 degrees Fahrenheit; Resident #65's room temperature was 65 degrees Fahrenheit; Resident #68's room temperature was 66 degrees Fahrenheit; and Resident #69's room temperature was 63 degrees Fahrenheit. Review of the Floor Plan Master Audit Sheet dated 01/22/25 at 7:15 A.M. of the second and third floors revealed Residents #1 and #2's room temperature was 64 degrees Fahrenheit; Residents #3 and #4's room temperature was 66 degrees Fahrenheit; Residents #10 and #11's room temperature was 63 degrees Fahrenheit; Residents #12 and #13's room temperature was 67 degrees Fahrenheit; Residents #18 and #19's room temperature was 68 degrees Fahrenheit; Residents #23 and #24's room temperature was 64 degrees Fahrenheit; Residents #27 and #28's room temperature was 69 degrees Fahrenheit; Residents #31 and #32's room temperature was 67 degrees Fahrenheit; Residents #34 and #35's room temperature was 66 degrees Fahrenheit; Residents #39 and #40's room temperature was 68 degrees Fahrenheit; Residents #44 and #45's room temperature was 68 degrees Fahrenheit; Resident #47's room temperature was 66 degrees Fahrenheit; Resident #50's room temperature was 63 degrees Fahrenheit; Resident #55's room temperature was 62 degrees Fahrenheit; Resident #58's room temperature was 62 degrees Fahrenheit; Resident #62's room temperature was 62 degrees Fahrenheit; Resident #67's room temperature was 64 degrees Fahrenheit; and Resident #69's room temperature was 64 degrees Fahrenheit. Review of the Floor Plan Master Audit Sheet dated 01/22/25 at 2:15 P.M. of the second and third floors revealed Residents #1 and #2's room temperature was 68 degrees Fahrenheit; Resident #5's room temperature was 65 degrees Fahrenheit; Residents #6 and #7's room temperature was 68 degrees Fahrenheit; Residents #8 and #9's room temperature was 66 degrees Fahrenheit; Residents #10 and #11's room temperature was 68 degrees Fahrenheit; Residents #12 and #3's room temperature was 65 degrees Fahrenheit; Resident #14's room temperature was 67 degrees Fahrenheit; Residents #15 and #16's room temperature was 65 degrees Fahrenheit; Resident #17's room temperature was 67 degrees Fahrenheit; Residents #23 and #24's room temperature was 65 degrees Fahrenheit; Residents #25 and #26's room temperature was 65 degrees Fahrenheit; Residents #27 and #28's room temperature was 64 degrees Fahrenheit; Residents #31 and #32's room temperature was 65 degrees Fahrenheit; Resident #33's room temperature was 62 degrees Fahrenheit; Residents #34 and #35's room temperature was 62 degrees Fahrenheit; Residents #36 and #37's room temperature was 62 degrees Fahrenheit; Residents #38's room temperature was 62 degrees Fahrenheit; Residents #39 and #40's room temperature was 62 degrees Fahrenheit; Resident #43 and #44's room temperature was 60 degrees Fahrenheit; Resident #50's resident room temperature was 68 degrees Fahrenheit; Resident #51's room temperature was 68 degrees Fahrenheit; Resident #53's room temperature was 67 degrees Fahrenheit, Resident #54's room temperature was 68 degrees Fahrenheit; Resident #56's room temperature was 68 degrees Fahrenheit; Resident #57's room temperature was 68 degrees Fahrenheit; Resident #58's room temperature was 66 degrees Fahrenheit; Resident #62's resident room temperature was 67 degrees Fahrenheit; Resident #63's room temperature was 68 degrees Fahrenheit; Resident #65's room temperature was 66 degrees Fahrenheit; Resident #67's room temperature was 68 degrees Fahrenheit; Resident #69's room temperature was 67 degrees Fahrenheit; and Resident #70's room temperature was 64 degrees Fahrenheit. Review of the undated facility Extreme Weather Heat or Cold policy revealed to monitor and obtain updates on weather conditions; contact the utility company for restoration of power and/or vendors for needed equipment such as heaters and coolers; monitor the situation in coordination with local response authorities; communicate with local emergency management and state survey agency regarding nursing home situation status, critical issues and resource requests; inform staff, residents and families/representatives of the situation and provides updates as needed, assess residents frequently for changes in condition; identify residents who may require a transfer; ensure continuation of resident care and essential services; distribute appropriate comfort equipment throughout the nursing home such as fans or blankets as needed, complete repairs and restoration activities. This deficiency represents non-compliance investigated under Complaint Number OH00161830.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and interview, the facility failed to ensure Resident #74 was free from physical abuse. This finding affected one (Resident #74) of four residents reviewed for abuse. Findings Include: Review of Resident #701's medical record revealed the resident was admitted on [DATE] and discharged on [DATE] with diagnoses including schizoaffective disorder, diabetes and vascular dementia. Review of Resident #701's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #701's progress note dated 01/04/25 at 9:30 A.M. (recorded as a late entry on 01/05/25 at 2:45 A.M.) authored by Licensed Practical Nurse (LPN) #814 revealed the writer was informed of resident involvement in a physical altercation with Resident #74. The resident was removed from the room and placed in staff view. An assessment was completed with no injuries noted to Resident #701. Upon an interview of Resident #701, she stated she informed Resident #141 of Resident #74 taking her belongings. The two then went to Resident #74's room to confront him and started a physical altercation with the resident. No new orders were obtained, and the emergency contacts were notified. Review of Resident #701's progress note dated 01/04/25 at 9:30 P.M. (recorded as a late entry on 01/05/25 at 3:04 A.M.) authored by LPN #814 revealed the writer was informed of resident involvement in a physical altercation with Resident #74. The resident was removed from the room and placed in staff view. An assessment was completed with no injuries noted to Resident #701. Upon interview of Resident #701, she stated she informed Resident #141 of Resident #701 taking her belongings. The two then went to Resident #74's room to confront him and started a physical altercation with the resident. No new orders were obtained, and the emergency contacts were notified. Review of Resident #701's progress note dated 01/05/25 at 4:05 A.M. authored by LPN #815 indicated Resident #701 along with another resident (Resident #141) initiated a physical altercation with a third resident (Resident #74). Resident #701 did not sustain any injuries from the altercation and an attempt was made to contact the next of kin. Review of Resident #701's progress note dated 01/06/25 at 11:31 A.M. authored by Social Services (SS) #816 revealed the resident had a history of making false allegations. In particular, she targeted another male resident (Resident #74) and accused him of entering her room and taking some money. She was unsure how much. Staff monitors this resident and her room closely. No one was observed entering her room and staff also stated that she had no money. The resident was very delusional, paranoid and psychotic. Will continue to monitor. Review of Resident #701's progress note dated 01/06/25 at 5:40 P.M. authored by LPN #817 indicated staff had been observing the resident on the unit. Resident #701 went into Resident #74's room yelling and screaming at him. The unit manager and staff followed the resident. Resident #701 went into Resident #74's room with an ink pen and stabbed him in the left and right arm. Both residents were immediately separated, and the family were made aware of the event. The resident continued to use inappropriate words threatening to kill Resident #74. The resident was sent to the emergency room . Resident #701 did not return to the facility. Review of Resident #141's medical record revealed the resident was admitted on [DATE] and discharged on [DATE] to home with diagnoses including diabetes, essential hypertension and cellulitis of the lower right limb. Review of Resident #141's Admission MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #74's medical record revealed the resident was admitted on [DATE] with diagnoses including schizophrenia, difficulty in walking and muscle weakness. Review of Resident #74's Quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #74's Physical Abuse Self-Reported Incident (SRI) Form Tracking #255777 dated 01/05/25 revealed on 01/04/25 at approximately 10:00 P.M., Resident #141 and Resident #701 entered Resident #74's room accusing him of stealing from Resident #701. The confrontation resulted in both Resident #141 and Resident #701 striking Resident #74. Staff immediately separated the residents. Resident #141 had been referred for further psychiatric evaluation and would remain on one to one until further notice while in the facility. The unit nurse completed skin and pain assessments on all residents. Resident #74 was noted to have sustained multiple scratches, red eyes, and a bloody mouth. Resident #74 was refusing further medication evaluation and treatment and would continue to be monitored for any change in condition. Resident #74 would be moved to another floor to ensure continued safety. The SRI conclusion revealed the allegation was unsubstantiated as the evidence was inconclusive. Abuse, neglect or misappropriation was suspected. Review of Resident #74's Observation Detail List Report form (skin assessment) dated 1/04/25 at 11:38 P.M. revealed two 15 cm (centimeter) scratches on the left side of the back with several small scratches on the face and blood shot red eyes. Review of Resident #74's Physical Abuse SRI Form Tracking Number #255828 dated 01/06/25 revealed a resident-to-resident altercation took place. On 01/06/25 at approximately 5:30 P.M., Resident #701 entered Resident #74's room without permission and accused him of taking her belongings. As Resident #701 approached Resident #74, she began poking him in both the right and left arm with a pen which resulted in a break of the resident's skin. Resident #701 was pink slipped to the hospital for a psychiatric evaluation and Resident #74 was sent to the hospital for further medical evaluation and treatment. The resident returned the same day after evaluation and a tetanus shot. The conclusion revealed the allegation was substantiated. Review of Resident #74's hospital After Visit Summary form dated 01/06/25 revealed the resident had a left penetrating forearm wound and a superficial injury of the right forearm. The medications administered included a tetanus booster vaccine. Review of Resident #74's Observation Detail List Report form (skin assessment) dated 01/07/25 at 3:17 P.M. revealed the resident had scratches on his back and bilateral arms. Interview on 01/30/25 at 11:51 A.M. with Security Director #810 indicated he was called up to the floor on 01/06/25 when Resident #701 had accused Resident #74 of stealing something and she stabbed him with a fork. Interview on 01/30/25 at 11:59 A.M. with Resident #74 revealed Resident #701 came in his room and hit him with a pen in his arms. He stated he had one drop of blood in his left arm, and he went to the hospital. He did not report any other concerns. Interview on 01/30/25 at 1:36 P.M. with Registered Nurse (RN) Unit Manager (UM) #818 indicated she was coming down the hall and heard a resident say no to Resident #701. She stated she walked into Resident #74's room and observed Resident #701 stab him with a pen. Telephone interview on 01/30/25 at 1:42 P.M. with LPN #814 with RN UM #818 in attendance revealed Resident #701 had jumped onto Resident #74's back while Resident #141 was in front of the resident during the altercation which occurred on 01/04/25. She stated the residents were separated. LPN #814 stated she did not know why she documented the same altercation between Residents #74, #141 and #701 on 01/04/25 at 9:30 A.M. and 9:30 P.M. but confirmed the actual events occurred on 01/04/25 at 9:30 P.M. Telephone interview on 01/31/25 at 1:51 P.M. with LPN #817 with RN UM #818 in attendance revealed on 01/06/25 at 5:11 P.M., Resident #74 walked down to his room and stayed there. LPN #817 stated she heard shouting and RN UM #818 as well as the CNA were in the resident's room. She confirmed that Resident #701 had stabbed Resident #74 in the right and left arm with a pen and Resident #701 was walked back to the common area to be monitored. Resident #74 was sent to the hospital. Interview on 01/30/25 at 2:03 P.M. with SS #816 indicated Resident #701 had a large psychiatric history and targeted males. He also stated on the 01/04/25 incident involving Residents #74, #141 and #701, Resident #74 was the aggressor when Residents #141 and #701 went into the resident's room. Interview on 01/30/25 at 2:09 P.M. with the Administrator and SS #816 indicated the facility investigated the allegation of abuse on 01/04/25 between Residents #701, #141 and #74 and Resident #701 definitely did not jump on Resident #74's back at any point. The Administrator stated they felt the allegation was unsubstantiated because Residents #701 and #141 went into Resident #74's room but Resident #74 was the person who started the altercation with the other two residents. The Administrator confirmed the second abuse allegation on 01/06/25 between Residents #74 and #701 was substantiated. A second telephone interview on 01/30/25 at 2:14 P.M. with LPN #814 with the Administrator and SS #816 in attendance revealed she had heard that Resident #701 jumped on Resident #74's back but she had not witnessed the event. Telephone interview on 01/30/25 at 2:15 P.M. with Certified Nursing Assistant (CNA) #819 revealed he was coming up the stairs and had observed Resident #74 fending off Resident #141 and Resident #701. He stated Resident #141 was in front of Resident #74 and Resident #701 was behind the resident scratching at the resident's back. CNA #819 indicated Resident #74 was bleeding from his face with blood on the wall and on the floor and blood appeared on his face near his mouth and right eye. CNA #819 revealed both Residents #141 and #701 were attacking Resident #74 when he entered the room. Review of the Ohio Resident Abuse Policy revised 07/11/24 revealed the facility would not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. The deficient practice was corrected on 01/24/25 when the facility implemented the following corrective actions: Resident #74 was sent to the hospital for evaluation on 01/06/25 and received a tetanus vaccine. The resident returned to the facility and was moved to a different floor. Resident #701 was sent to the hospital for a psychiatric evaluation and did not return to the facility. Resident #141 was put on a one-to-one supervision from 01/04/25 until discharge to home on 01/30/25. From 01/06/25 to current, SS #816 began behavior huddles with the nursing staff including the nurse and CNA for all residents with any type of report behaviors. The huddles discuss a plan of action to make sure resident behaviors do not escalate and de-escalation techniques to ensure the plan succeeds. The Abuse, Neglect and Misappropriation policy was reviewed by the Administrator on 01/07/25. On 01/07/25 through 01/09/25, Mobile Administrator #803 educated 11 staff members on abuse and behavior management with quizzes following the education including LPNs #806, #807, #814, #884, #964; CNAs #702, #863, #875; Security #846; Environmental Services #843, #848, #874, #970; and Maintenance #878, #919. On 01/08/25, the Administrator conducted an inservice on Abuse Education and Resident to Resident Altercations. The Inservice Sign-Off Sheet revealed LPNs #708, #814, #820, #825, #891, #895, #917, #964, #968; CNAs #827, #833, #838, #839, #841, #844, #847, #853, #863, #864, #872, #875, #883, #902, #908, #931, #933, #940, #946, #956, ##962; Food #821, #876, #885, #958, #971, #974; Environmental Staff Members #843, #879, #924, #959, #970; Security Staff Members #845, #846, #871, #912; RN UM #813; SS #869; Maintenance #919; Administration Staff Members #920, #941; SS #816; RN Assistant Director of Nursing (ADON) #805; Clinical Support #942; Receptionist #954; and RN MDS #963 received the inservice. On 01/08/25, the Administrator emailed education to all staff members regarding abuse, neglect and behavior management. The Administrator revealed this was for all staff members, including those who did not make it to the education sessions in person. On 01/10/25, a Quality Assurance and Performance Improvement (QAPI) meeting was held with RN MDS #963; Administration #941 (admissions); Environmental Services Director #959; Clinical Support #942 (central supply and medial records); RN ADON #805; the Director of Nursing (DON); SS #816; and the Administrator on abuse, neglect and behavior management. On 01/16/25, Mobile Administrator #803 educated 13 staff members on abuse and behavior management with quizzes following the education including RN MDS #965; CNAs #828, #832, #833, #840, #875, #904, #906, #933, #940; Food #957; Administration #920; Social Services Designee #869 (prior); and Environment #843, #959. On 01/24/25, Mobile Administrator #803 and the DON educated 15 staff members on abuse and behavior management with quizzes following the education including Security #892; CNAs #706, #707, #808, #841, #857, #952; Life Enrichment #850; RN UMs #813, #818; Administration #941; RN MDS #963; Office Support #954; LPN #820; and Clinical Support #942. This deficiency represents non-compliance investigated under Complaint Number OH00161562.

Based on observation, interview, and review of facility policy, the facility failed to ensure medications were prepared and administered for one resident at a time. This had the potential to affect the 35 residents living on the fifth floor (Resident #8, #10, #13, #15, #20, #23, #25, #28, #31, #38, #40, #43, #50, #57, #59, #60, #64, #66, #71, #72, #74, #80, #82, #83, #84, #87, #90, #91, #97, #98, #107, #108, #114, #124, and #126). The total census was 144. Findings include: Observation on 01/02/25 at 9:06 A.M. of the fifth floor medication carts with Licensed Practical Nurse (LPN) #901 revealed LPN #901 had assembled 13 medication cups containing varying amounts of pills and wrote resident names on the cups with marker so she could later administer those pills to the respective residents. These cups were set on the high and low medication carts for the fifth floor, and LPN #901 was working at these medication carts removing the pills and placing them into the labeled cups. Interview with LPN #901 at the time of the above observation confirmed the above findings. LPN #901 said she did this to help keep track of the medications, as she recently switched to working day shift and it was much busier than during the night. LPN #901 said was the nurse for all residents on the fifth floor. Review of the facility's medication administration policy, revised 11/15/24, revealed medications were only to be prepared for one resident at a time.

Based on observation and interview the facility failed to ensure the resident environment on the fourth floor was maintained in good repair. This had the potential to affect all 42 residents (#1, #3, #6, #7, #11, #12, #16, #36, #37, #39, #45, #49, #51, #52, #56, #57, #60, #64, #72, #73, #77, #80, #83, #85, #87, #89, #92, #98, #106, #108, #109, #111, #112, #114, #120, #128, #133, #137, #140, #144, #145, and #148) who resided on the fourth floor. The facility census was 148. Findings include: Observation on 12/03/24 at 12:04 P.M. revealed Resident #72 was in bed. The wall the bed was against was caved in and in disrepair. Interview at the time of the observation with Certified Nurse Aide (CNA) #300 verified the observation and stated the damage to the wall was from the bed. CNA #300 asked Resident #72 how long the wall had been that way and the resident responded it was like that when he moved to this room about four months ago. Observation of the shower room on the fourth floor located to the right of the vending machine on 12/03/24 at 1:07 P.M. revealed the back of the sink was not affixed to the wall and slightly leaning forward. Interview on 12/03/24 at 1:13 P.M. with CNA #451 verified the observation and stated all the residents on the unit used the shower room. Observation of Residents #1 and #3's room on 12/03/24 at 1:20 P.M. revealed a missing ceiling tile above the toilet exposing the pipes. The ceiling tile was on the floor near the toilet. Several missing floor tiles were observed around the toilet. There was a large white patch on the wall above the soap dispenser that needed to be painted. Interview at this time with CNAs #300 and #451 verified the observations and they stated that the bathroom had been that way greater than five months During observation of the fourth floor on 12/05/24 from 11:03 A.M. to 11:20 A.M. with Director of Maintenance (DOM) #341 the DOM #341 verified the back side of sink in the shower room was not affixed to the wall and sightly leaning forward. During the observation of Residents #1 and #3's bathroom, DOM #341 stated he was not aware of the missing ceiling or floor tiles but stated he was aware of the patched wall and needed to get paint. DOM #341 stated he was not sure when the hole was patched because there were so many holes they had patched because of the resident population. During the observation of Resident #72's room, DOM #341 stated he was aware of wall next to bed and stated he was not sure when the damage occurred. Additional observation of Resident #72's room with DOM #341 revealed a baseball size hole in wall across from and facing the foot of the bed. DOM #341 stated he was not aware of that hole. Review of the facility census report dated 12/02/24 revealed 42 residents (#1, #3, #6, #7, #11, #12, #16, #36, #37, #39, #45, #49, #51, #52, #56, #57, #60, #64, #72, #73, #77, #80, #83, #85, #87, #89, #92, #98, #106, #108, #109, #111, #112, #114, #120, #128, #133, #137, #140, #144, #145, and #148) resided on the fourth floor.

Based on record review, interview and review of monthly pharmacy recommendations, the facility failed to ensure pharmacy recommendations were addressed by the physician timely. This affected four residents (Residents #10, #19, #75, and #92) of five residents reviewed for medication regimen reviews. The facility census was 148. Findings include: 1. Review of the medical record for Resident #10 revealed an admitted [DATE]. Diagnoses included but were not limited to diabetes mellitus, paranoid schizophrenia, gastroesophageal reflux disease, convulsions, restlessness and agitation, and post traumatic stress disorder. Review of the 10/30/24 significant change Minimum Data Set (MDS) 3.0 assessment for Resident #10 revealed he was cognitively intact, and was receiving insulin, antipsychotics, anticonvulsant, and antidepressants. Resident #10 was noted to have delusions and rejection of care. The last gradual dose reduction (GDR) for antipsychotics was attempted on 09/24/13 and the last time a GDR was indicated as contraindicated was 04/22/24. Review of the pharmacy consultation report for Resident #10 dated 12/18/23 revealed Resident #10 received Seroquel extended release 800 milligram (mg) per day, trazadone 50 mg at night and divalproex 1000 mg at night. The recommendation indicated to consider a GDR or provide documentation to support if a GDR was clinically contraindicated. The form did not have a physician response. Review of pharmacy consultation reports for Resident #10 dated 12/18/23 and 03/15/24 revealed the most recent hemoglobin A1c ( measures average blood sugar levels over the past three months) was nine percent. The recommendation indicated to consider increasing Metformin to 1000 mg twice daily. The form did not have a physician response. Review of pharmacy consultation report for Resident #10 dated 05/22/24 revealed the most recent hemoglobin A1c was 8.4 percent. The recommendation indicated to consider increasing Metformin to 1000 mg twice daily. The form did not have a physician response. Review of pharmacy consultation reports for Resident #10 dated 04/22/24 and 06/17/24 revealed the resident received divalproex sodium extended release (ER) but did not have a trough concentration documented in the medical record within the past six months. The recommendation indicated to monitor a valproic acid trough concentration on the next convenient lab day and every six months. Review of the medical record revealed no evidence of the valproic acid trough being completed as recommended. Review of pharmacy consultation report for Resident #10 dated 06/17/24 and 08/20/24 revealed the resident received omeprazole 40 mg once daily. The recommendation indicated to consider a trial reduction to 20 mg daily. The form did not have a physician response. Review of Resident #10's active physician orders revealed orders dated 09/11/24 for divalproex (anticonvulsant) 500 milligrams (mg) one tablet, Seroquel (antipsychotic) 400 mg two tablets at bedtime, trazadone (antidepressant) 50 mg one tablet at bedtime, Metformin (antiheperglycemic) 750 mg extended-release twice daily, and omeprazole (reduces amount of acid stomach makes) 40 mg delayed release once daily. Review of a physician order dated 09/22/24 revealed an order for benztropine (anti-tremor) 0.5 mg twice daily. Interview on 12/04/24 at 2:21 P.M. with Regional Registered Nurse #467 revealed the facility was unable to provide evidence that the above pharmacy recommendations were addressed within 30 days as required. Regional Registered Nurse #467 also confirmed the labs for valproic acid were not completed as recommended on 04/22/24 and 06/17/24. Follow up interview on 12/05/24 at 11:30 A.M. with Regional Registered Nurse #467 confirmed there were no diagnoses listed for benztropine, Metformin, omeprazole, Seroquel and trazadone for Resident #10. 2. Review of the medical record for Resident #75 revealed an admitted [DATE]. Diagnoses included but were not limited to morbid obesity, hepatic encephalopathy, cirrhosis of the liver, esophageal varices with bleeding and depression. Review of the 09/30/24 quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #75 revealed the resident was cognitively intact. Resident #75 was noted to have received antipsychotics, antidepressants, anticoagulant and a diuretic. The Last gradual dose reduction was noted to be 02/05/24 and the last noted contraindicated gradual dose reduction was noted on 04/11/24. Review of physician orders dated 01/28/24 for Resident #75 revealed an order for Eliquis five milligram (mg) (blood thinner) one tablet by mouth two times daily for hypertension. Review of the pharmacy consultation reports for Resident #75 dated 02/25/24, 04/12/24, 06/16/24, and 08/15/24 revealed the following irregularities were noted on the electronic medication administration record /prescriber order sheets: Diagnosis inappropriate (Medication): Eliquis diagnosis listed in the electronic medication administration record as hypertension. Eliquis is an anticoagulant. The recommendations indicated to please clarify or correct these items. The form did not have a physician response. Interview on 12/04/24 at 2:21 P.M. with Regional Registered Nurse #467 revealed the facility was unable to provide evidence the above identified pharmacy recommendations were addressed within 30 days as required. 39969 3. Review of the medical record for Resident #92 revealed an admitted [DATE]. Diagnoses included schizoaffective disorder, bipolar disorder, major depressive disorder, and personal history of other venous thrombosis and embolism. Review of the physician orders for December 2024 revealed active orders for Seroquel (antipsychotic) tablet 50 milligrams (mg) by mouth at bedtime. Review of the consultation report from the pharmacist dated 09/17/24 revealed a recommendation for an initial attempt at a gradual dose reduction (GDR). The recommendation indicated to consider reducing Seroquel to 25 milligram (mg) at bedtime or to provide a rationale as to why a GDR was contraindicated. The report was marked declined, signed by the physician, and dated 09/19/24. There was no documentation on the report regarding the rationale for declining the recommendation. Further review of Resident #92's medical record revealed there was no documentation as to the rationale for declining the GDR for the Seroquel. Interview on 12/05/24 at 8:56 A.M. with Regional Registered Nurse #467 verified there was no documented rationale from the physician for declining the GDR recommendation for the Seroquel. 34297 4. Review of Resident #19's medical record revealed the resident was admitted on [DATE] with diagnoses including schizoaffective disorder, bipolar disorder and generalized anxiety. Review of Resident #19's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem. Review of Resident #19's physician orders revealed an order dated 02/17/23 (discontinued 01/29/24) for Meloxicam 7.5 milligrams (mg) give one tablet one time a day for inflammation of the right leg. Review of Resident #19's Pharmacy Consultation Report form dated 12/16/23 indicated the resident was started on Meloxicam 7.5 mg daily on 02/17/23. The recommendation indicated to please discontinue the Meloxicam and consider initiating an alternative analgesic. The form did not have a physician response. Review of Resident #19's physician orders revealed an order dated 01/29/24 (discontinued 09/24/24) for Meloxicam 7.5 mg one tablet by mouth one time a day for inflammation of the right leg. Review of Resident #19's Pharmacy Consultation Report form dated 02/29/24 revealed the resident was started on Meloxicam 7.5 mg daily on 02/17/23. The recommendation indicated to please discontinue Meloxicam and consider initiating an alternative analgesic. The form did not have a physician response. Review of Resident #19's Pharmacy Consultation Report dated 06/17/24 indicated the resident was started on Meloxicam 7.5 mg daily on 02/17/23. The recommendation indicated to discontinue the Meloxicam and consider initiating an alternative analgesic. The physician response to the recommendation indicated to check a basic metabolic panel (BMP) blood level with the next lab draw. Interview on 12/04/24 at 9:31 A.M. with Regional Registered Nurse #467 confirmed Resident #19's pharmacy recommendations were not acted upon in a timely manner. Review of the Medication Regiment Review policy revised 06/01/24 revealed the consultant pharmacist would document medication record reviews (MRRs) and would make recommendations based on the information made available in the residents' health record. The consultant pharmacist would provide required recipients of residents' MRRs on the MRR report to the Director of Nursing and/or the attending physician, and to the Medical Director.

Based on observation, record review and interview, the facility failed to ensure residents who resided on the fifth floor were provided activities as scheduled. This affected 34 residents (Residents #2, #4, #9, #14, #18, #19, #21, #22, #23, #24, #26, #27, #29, #31, #34, #38, #41, #43, #44, #46, #58, #61, #65, #68, #78, #79, #90, #91, #93, #97, #102, #107, #119 and #123) who resided on the fifth floor secured unit. The facility census was 148. Findings include: Observation on 12/02/24 at 2:01 P.M. revealed Activity Director (AD) #459 counting money for residents on the fifth floor. Residents were observed in their rooms and in the common area. The television was on and music was playing in the common area. No formal activities were observation the fifth floor in the afternoon. Interview on 12/03/24 at 11:45 A.M. with AD #459 revealed she was the only activity staff member working on 12/02/24 and the afternoon/evening activities were not completed as scheduled for the fifth floor residents including the 2:00 P.M. Hydration Hour, 3:00 P.M. Griddle Goodies and 6:00 P.M. Table Games. AD #459 stated she had recently terminated an activity staff. The current activity staff consisted of AD #459, one activity staff member who worked during the week and one activity staff who worked the weekend. Review of the Activity Calendar for 12/02/24 revealed activities including 10:00 A.M. coffee cafe, 11:00 A.M. What's in the news?, 11:30 A.M. Hidden Picture Puzzles; 1:00 P.M. room/virtual visits, 2:00 P.M. Hydration Hour, 3:00 P.M. Griddle Goodies and 6:00 P.M. Table Games. Review of the facility census revealed 34 residents resided on the fifth floor secured unit including Residents #2, #4, #9, #14, #18, #19, #21, #22, #23, #24, #26, #27, #29, #31, #34, #38, #41, #43, #44, #46, #58, #61, #65, #68, #78, #79, #90, #91, #93, #97, #102, #107, #119 and #123. Review of the Life Enrichment Programming Policy revised 05/04/23 revealed an ongoing resident-centered Life Enrichment Program, based on comprehensive assessments and care plans, would be provided. The program would be designed to meet the interests and abilities of each resident including their physical, mental, emotional, social, spiritual, psychosocial and leisure needs.

Based on record review, interview, and review of the facility policy and procedure the facility failed to ensure advanced directives were accurate and readily available. This affected three residents (#87, #99 and #143) of four residents reviewed for advanced directives. The facility census was 148. Findings include: 1. Review of the medical record for Resident #87 revealed an admitted [DATE]. Diagnoses included chronic respiratory failure, hypertension, chronic kidney disease stage three, edema, and obstructive sleep apnea. Review of Resident #87's physician orders for December 2024 revealed an active order for code status of Do Not Resuscitate Comfort Care Arrest (DNRCC-A) dated 07/17/24. Further review of Resident #87's medical record revealed there was not a completed and signed Do Not Resuscitate (DNR) form. Interviews on 12/03/24 at approximately 9:20 A.M. and 3:52 P.M. with Licensed Practical Nurse (LPN) #308 verified a completed and signed DNR form was not in Resident #87's medical record. LPN #308 stated she talked with Resident #87 and asked if he wanted any changes to his advance directive as per physician order and the resident said no. LPN #308 stated she then contacted the nurse practitioner to complete a DNR form reflecting the resident's advance directives as per physician order. Review of the facility policy titled Advanced Care Planning Protocol, revised 10/01/24 revealed in the event there were legal documents to be obtained, the patient, family, and facility staff would coordinate as a team to obtain such documents and place in the clinical record. 42733 2. Review of Resident #99's medical records revealed an admitted [DATE]. Diagnoses included adult failure to thrive and chronic kidney failure. Review of the care plan dated 09/11/24 revealed Resident #99's advanced directive was Do Not Resuscitate Comfort Care Arrest (DNR-CCA). A DNR-CCA allows for life saving treatments until the resident's heart or breathing stops after which only comfort care is provided. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #99 had intact cognition. Review of Resident #99's physician orders for December 2024 revealed an order for DNR-CCA. Review of the signed DNR paperwork dated 10/24/24 revealed Resident #99's advanced directive indicated DNR-CC (comfort care only). Interview on 12/03/24 at 12:21 P.M. with Licensed Practical Nurse (LPN) #357 confirmed Resident #99's signed DNR-CC paperwork and confirmed the electronic medical records indicated Resident #99 as having a DNR-CCA advanced directive. Review of the facility policy titled Advanced Care Planning Protocol, revised 10/01/24 revealed in the event there were legal documents to be obtained, the patient, family, and facility staff would coordinate as a team to obtain such documents and place in the clinical record. 3. Review of Resident #143's medical records revealed an admitted [DATE]. Diagnoses included stroke with right sided weakness, drug abuse and dysphasia (difficulty swallowing). Review of the Minimum Data Set assessment dated [DATE] revealed Resident #143 had impaired cognition. Review of the care plan dated 10/31/24 revealed Resident #143 had a full code status (all life saving measures were to be performed). Review of Resident #143's physician orders for December 2024 revealed a full code order. Review of Resident #143's paper chart revealed hospital paperwork dated 10/07/24 indicating Resident #143 was a presumed full code, however staff were unable to contact next of kin for confirmation. Review of Resident #143's electronic medical records revealed there was not a code status indicated on the main screen. Interview on 12/03/24 at 12:21 P.M. with Licensed Practical Nurse (LPN) #357 revealed a resident's code status should be displayed on the main screen in the electronic medical record. LPN #357 also confirmed Resident #143's code status was blank on the main screen. Interview on 12/04/24 at 10:19 A.M. with Regional Registered Nurse #467 confirmed a resident's code status should be displayed on the main screen in the resident's electronic medical record. Review of the facility policy titled Advanced Care Planning Protocol, revised 10/01/24 revealed in the event there were legal documents to be obtained, the patient, family, and facility staff would coordinate as a team to obtain such documents and place in the clinical record.

Based on record review and interview, the facility failed to provide Residents #29, #43 and #47 and/or their resident representatives, at the time of transfer or in cases of emergency transfer within 24 hours, written information which explained the duration of the bed-hold and the reserve bed payment policy including the resident's return to the next available bed. This affected three (Residents #29, #43 and #47) of four residents reviewed for hospitalization . Findings include: 1. Review of Resident #29's medical record revealed the resident was admitted on [DATE] with diagnoses including schizophrenia, anxiety disorder and violent behavior. Further review of Resident #29's medical record revealed the resident's insurance payor source was Medicaid. The medical record did not reveal evidence Resident #29 or the resident's representative were provided a bed hold notice upon the residents transfer to the hospital on 10/14/29. Review of Resident #29's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #29's progress note dated 10/14/24 timed 12:00 P.M. revealed the nurse observed the resident with difficulty breathing and Resident #29 was transferred to the hospital. Review of Resident #29's progress note dated 10/28/24 timed 4:37 A.M. revealed Resident #29 arrived from the hospital to the facility around 10:45 P.M. Interview on 12/03/24 at 1:15 P.M. with Regional Registered Nurse #467 confirmed Resident #29 was not provided a bed-hold notice which identified the bed-hold policy with bed-hold days and included the policy for returning to the facility with the reserve bed payment policy upon transfer. Review of the Bed Hold Letter Policy revised 09/26/20 revealed it was the policy of the facility to track Medicaid bed hold days and notify the appropriate parties via Medicaid Bed Hold Letter. 2. Review of Resident #43's medical record revealed the resident was admitted on [DATE] with diagnoses including bipolar disorder, epilepsy and anemia. Further review of the medical record revealed Resident #43's insurance payor source was Medicaid. The medical record did not reveal evidence Resident #43 or the resident's representative were provided a bed hold notice upon transfer to the hospital on 10/05/24. Review of Resident #43's quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #43's progress note dated 10/05/24 timed 3:44 P.M. revealed Resident #43 approached the nurse and stated her right hand hurt. Upon assessment, the dorsal part of the right hand was edematous. Resident #43 was transferred to the hospital. Review of Resident #43's progress note dated 10/06/24 timed 1:26 A.M. revealed Resident #43 returned from the hospital around 10:52 P.M. Review of Resident #43's progress note dated 10/10/24 timed 2:36 P.M. revealed Resident #43 sustained a fall on 10/05/24 and was diagnosed with a right fifth metacarpal and right fifth proximal phalanx fracture. Interview on 12/03/24 at 1:15 P.M. with Regional Registered Nurse #467 confirmed Resident #43 was not provided a bed-hold notice upon transfer to the hospital which identified the bed-hold policy with bed-hold days and included the policy for returning to the facility with the reserve bed payment policy. Review of the Bed Hold Letter Policy revised 09/26/20 revealed it was the policy of the facility to track Medicaid bed hold days and notify the appropriate parties via Medicaid Bed Hold Letter. 3. Review of Resident #47's medical record revealed the resident was admitted on [DATE] with diagnoses including multiple sclerosis, vascular dementia and bipolar disorder. Further review of the medical record revealed Resident #47's insurance payor source was Medicaid. The medical record did not reveal evidence Resident #47 or the resident representative were provided a bed hold notice upon Resident #47's discharge to the emergency roiagnom on [DATE]. Review of Resident #47's Minimum Data Set 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #47's progress note dated 09/15/24 timed 4:08 P.M. revealed Resident #47 and another resident were fighting over an orange dehydration unit and Resident #47 fell to the floor with the dehydration unit. Review of Resident #47's progress note dated 09/15/24 timed 8:00 P.M. revealed Resident #47 had a bruise to the left shoulder which was tender to the touch. Resident #47 was discharged to the emergency room . Review of Resident #47's progress note dated 09/17/24 timed 2:58 P.M. revealed Resident #47 sustained a fall on 09/15/24 and was diagnosed with a dislocation of the left shoulder with no surgical intervention. Review of Resident #47's progress note dated 09/20/24 timed 7:33 A.M. revealed Resident #47 returned from the hospital. Interview on 12/03/24 at 1:15 P.M. with Regional Registered Nurse #467 confirmed Resident #47 was not provided a bed-hold notice upon transfer which identified the bed-hold policy with bed-hold days and included the policy for returning to the facility with the reserve bed payment policy. Review of the Bed Hold Letter Policy revised 09/26/20 revealed it was the policy of the facility to track Medicaid bed hold days and notify the appropriate parties via Medicaid Bed Hold Letter.

Based on observation, record review and interview, the facility failed to ensure assessment and monitoring of a wound to Resident #79's left great toe. This affected one (Resident #79) of four residents reviewed for wounds. Findings include: Review of Resident #79's medical record revealed the resident was admitted on [DATE] with diagnoses including Huntington's disease, acute respiratory failure with hypoxia and muscle weakness. Review of Resident #79's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #79's physician orders revealed an order dated 10/22/24 to cleanse the great toe of the left foot with normal saline, pat dry, apply an abdominal dressing and wrap with a gauze roll until healed once daily on night shift. Further review of Resident #79's medical record revealed no evidence of monitoring or assessment of Resident 79's left great toe wound. Observation of Resident #79 on 12/02/24 at 11:50 A.M. with Licensed Practical Nurse (LPN) #364 revealed no evidence Resident #79 had a dressing on the inner aspect of the left great toe. Interview on 12/03/24 at 9:55 A.M. with Interim LPN Wound Nurse #308 revealed the staff did not tell her that Resident #79 had a wound on the inner aspect of the great toe and wound assessments and monitoring were not completed. Interview on 12/04/24 at 12:24 P.M. with Wound Nurse Practitioner (NP) #468 revealed Resident #79's left great toe wound was an abrasion and their first evaluation of the wound was on this date (12/04/24). Review of the Skin and Wound Care Best Practices policy revised 11/05/24 revealed the facility would provide evidence based preventative skin care and wound treatment to prevent unavoidable skin complications.

Based on interview and record review the facility failed to ensure pre and post dialysis communication was completed. This affected two residents (#100 and #133) of two residents reviewed for dialysis. The facility census was 148. Findings include: 1. Review of Resident #100's medical records revealed an admitted [DATE]. Diagnoses included end stage renal disease and acute kidney failure. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #100 had intact cognition. Review of the care plan dated 11/18/24 revealed Resident #100 required dialysis. Review of physician orders for December 2024 revealed an order to complete Resident #100's dialysis observation tool prior to dialysis and print and send with resident to dialysis. Interview on 12/04/24 at 8:05 A.M. with Licensed Practical Nurse (LPN) #425 revealed dialysis communication was to be completed prior to residents leaving for dialysis and was to be sent with the residents. Review of dialysis communication forms for Resident #100 on 12/04/24 at 2:37 P.M. with Regional Registered Nurse (RRN) #467 revealed communication forms had not been completed with each dialysis treatment as required. Review of the facility policy titled Hemodialysis revised 08/24/23 revealed the policy indicated to document pre-assessments on the dialysis communication tool including vital signs, pre-treatment weight, medications administered before treatment and any additional alerts or information. The policy further indicated to print the tool and send with the residents. The Post dialysis processes included received report from the dialysis provider and post dialysis information was to include vital signs, post treatment weights and any new orders. 39969 2. Review of the medical record for Resident #133 revealed an admitted [DATE]. Diagnoses included post-traumatic stress disorder, end stage renal disease, dependence on renal dialysis, and schizophrenia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #133 had intact cognition, behaviors that included delusions and hallucinations, physical behaviors, verbal behaviors, and rejection of care that occurred daily. The assessment also indicated the resident was dependent on staff for transfers and received dialysis. Review of the physician orders for December 2024 revealed and active order for dialysis on Mondays, Wednesdays, and Fridays at the dialysis center. Review of a 30 day look back of the dialysis communication tools revealed communication tools dated 11/06/24, 11/11/24, 11/18/24, and 12/02/24 sent to dialysis but nothing was documented under the section to be completed by dialysis staff. There was no dialysis communication tools for the days the resident attended dialysis on 11/15/24, 1/22/24, and 11/27/24. Resident #133 refused to go to dialysis on 11/04/24, 11/08/24, 11/13/24, 11/20/24, and 11/29/24. Interview on 12/05/24 at 10:04 A.M. with Regional Nurse #467 verified dialysis did not send back the communication completed with the dialysis center information and that there were days that the communication tool was not sent at all outside of the days Resident #133 refused to go. Review of the Hemodialysis Care Policy, revised 08/24/23 revealed licensed staff with demonstrated competence would care for residents who required hemodialysis (via onsite third party providers or who traveled to an outpatient setting). Communication between the dialysis provider and facility staff would occur before and after hemodialysis treatment and as needed.

Based on record review and interview, the facility failed to ensure Resident #19's as-needed antipsychotic medications were limited to fourteen days until the physician evaluated the resident, and non-pharmacological interventions were attempted prior to administering as-needed antipsychotic medications. This affected one (Resident #19) of five residents reviewed for medication administration. Findings include: 1. Review of Resident #19's medical record revealed the resident was admitted on [DATE] with diagnoses including schizoaffective disorder, bipolar disorder and generalized anxiety. Review of Resident #19's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem and received antipsychotic medications. Review of Resident #19's physician orders revealed an order dated 11/11/24 for olanzapine (antipsychotic) 2.5 mg intramuscularly (IM) every six hours as needed for agitation. There was no stop date on the order. Review of Resident #19's Pharmacy Consultation Report dated 11/15/24 revealed the resident was ordered olanzapine antipsychotic medications without a stop date. The physician response dated 11/26/24 indicated to initiate the stop date to 14 days (stop date 11/26/24). Review of Resident #19's medication administration records from 11/04/24 to 12/04/24 revealed no evidence the resident received the olanzapine IM during this time frame. Interview on 12/04/24 at 9:44 A.M. with Regional Registered Nurse (RN) #467 confirmed Resident #19's IM olanzapine did not have an appropriate stop date. 2. Review of Resident #19's medical record revealed the resident was admitted on [DATE] with diagnoses including schizoaffective disorder, bipolar disorder and generalized anxiety. Review of Resident #19's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem and received antipsychotics. Review of Resident #19's physician orders revealed an order dated 11/27/24 (discontinued 12/09/24) for olanzapine 2.5 mg give one tablet by mouth every six hours as needed. Review of Resident #19's medication administration records revealed the resident was administered the olanzapine antipsychotic on 11/27/24 at 1:26 P.M., 11/27/24 at 8:04 P.M. and 11/28/24 at 9:19 P.M. The medical record did not have evidence non-pharmacological interventions were implemented prior to administering the antipsychotic medication. Interview on 12/04/24 at 9:31 A.M. with Regional Registered Nurse #467 confirmed Resident #19's medical record did not have evidence non-pharmacological interventions were implemented prior to administering Resident #19's as needed antipsychotic medication. Review of the Psychoactive Medication Policy revised 05/10/24 revealed all residents receiving psychoactive medications would have their behaviors, effectiveness of interventions (pharmacological and non-pharmacological) and potential for a gradual dose reduction of psychoactive medications monitored and documented.

Based on record review, interview, and policy review the facility failed to ensure Resident #198's monies from the authorized resident fund account (RFA) were dispersed timely upon the resident's death. This affected one (Resident #198) of five residents reviewed for resident funds. Findings include: Review of Resident #198's medical record revealed an admitted [DATE] and diagnoses including other specified schizophrenia and pulmonary heart disease. Resident #198 expired in the facility on [DATE] at 12:28 A.M. Review of Resident #198's medical record revealed the RFA dispersal check was dated [DATE]. Interview on [DATE] at 11:25 A.M. with Business Office Manager (BOM) #402 confirmed Resident #198's RFA monies were not dispersed timely upon the resident's death as required. Review of the Resident Personal Funds Management Policy revised [DATE] revealed if the resident expired, personal funds deposited, would be refunded within 30 days with an accounting of these funds to the individual, probate jurisdiction administering the resident's estate, or other entities or individuals as required by State law or regulation.

Based on observation, record review, and interview the facility failed to ensure the coordination of services to make certain residents received the correct diets. This affected two residents (#19 and #29) of seven residents (#19, #29, #31, #100, #119, #134, and #143) reviewed for nutrition. The facility census was 148. Findings include: Observation of lunch on 12/02/24 at 12:50 P.M. revealed Resident #29's meal ticket indicated regular double protein diet and listed beef stew, mixed vegetables, biscuit, margarine, tropical fruit cup, whole milk, and beverage of choice. Observation of Resident #29's meal revealed no double protein. Medical record review revealed Resident #29 was to receive double protein with meals. Interview on 12/02/24 at 12:55 P.M. with Agency Certified Nurse Aide (CNA) #500 confirmed Resident #29 did not have double protein for his meal. Observation of lunch on 12/03/24 at 12:30 P.M. revealed Resident #19's meal ticket indicated regular, renal diet and listed cheese pizza, salad garden with dressing, fortified potatoes, chocolate chip cookie, two percent milk, hot chocolate, margarine, beverage of choice, salt, pepper, and sugar. Observation of Resident #19's meal revealed she received noodles, a plain hamburger, and milk. Medical record review revealed Resident #19 was to receive fortified potatoes and was not ordered a renal diet. Interview on 12/03/24 at 12:33 P.M. with CNA #347 verified the observation of Resident #29's lunch meal.

Based on record review, interview, and policy review the facility failed to ensure Resident #95 was provided education and offered the influenza and pneumococcal vaccines. This affected one (Resident #95) of five residents reviewed for immunizations. Findings include: Review of Resident #95's medical record revealed the resident was admitted on [DATE] with diagnoses including essential hypertension, other chronic pain and history of falling. Review of Resident #95's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Further review of Resident #95's medical record did not reveal evidence the resident was offered or educated on the influenza and pneumococcal vaccines. Interview on 12/05/24 at 11:03 A.M. with Registered Nurse Infection Preventionist #320 and Regional Registered Nurse #467 confirmed Resident #95 was not offered or educated on the influenza or pneumococcal vaccines. Review of the Influenza Vaccine Policy (Resident) revised 08/19/20 revealed all residents would be offered an influenza vaccine beginning in October of each year, unless medically contraindicated or the resident had already been vaccinated. The facility would provide the most recent vaccine information statement from the Centers for Disease Control and Prevention and an opportunity to ask any questions they may have before consenting to the vaccination. Review of the Pneumococcal Vaccine Policy (Resident) revised 08/19/20 revealed all residents would be offered the pneumococcal vaccine to aid in preventing pneumococcal infections. The facility would provide educational information regarding the significant risks and benefits of the vaccine to the resident and/or residents' representative on admission and prior to administration of the vaccine.

Based on record review and staff interview the facility failed to notify the appropriate state agency (The Ohio Department of Mental Health) of a significant change in a resident's mental health condition as required. This affected one resident (#106) of one resident reviewed for preadmission screening and resident review (PASARR). The facility census was 148. Findings include: Review of the medical record for Resident #106 revealed an admitted [DATE] with a diagnosis of dementia. Further review of the resident's diagnosis list revealed diagnoses including bipolar disorder, current episode depressed, mild or moderate severity dated 05/21/23, bipolar disorder, current episode mixed, moderate dated 05/23/23, schizoaffective disorder dated 07/26/23, and paranoid schizophrenia dated 10/24/23. Further review of a Notice of PASARR level II outcome dated 04/21/22 revealed Resident #106 was ruled out from further PASARR review related to dementia, Alzheimer's or other neurocognitive disorder. There were no other PASARR reviews after this date. Interviews on 12/03/24 at 1:50 P.M. and at 2:26 P.M. with the Administrator revealed they checked the Healthcare Electronic Notification System ([NAME]) and there were no other PASARRs other than the one from 2022. The Administrator stated they submitted a PASARR today (12/03/24) to include the diagnoses from 2023.

Based on record review, interview, and policy review, the facility failed to ensure Resident #44's care plans were updated to reflect the resident's behaviors and interventions which required the resident to sleep on a flat yoga mat on the floor with no furniture in the room. The facility also failed to ensure Residents #13 and #29's care conferences were conducted at least quarterly. This affected three (Residents #13, #29 and #44) of four residents reviewed for care plans. Findings include: 1. Review of Resident #29's medical record revealed the resident was admitted on [DATE] with diagnoses including paranoid personality disorder and schizophrenia. Further review of the medical record revealed Resident #29 had a legal guardian who was the emergency contact and responsible for the resident's finances. Review of Resident #29's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #29 exhibited severe cognitive impairment. Review of Resident #29's Care Conference Report form dated 05/06/24 revealed the interdisciplinary team (IDT) was present for the care conference at 11:00 A.M. and the legal guardian was not present after three notifications. Interview on 12/03/24 at 9:08 A.M. with Resident #29's legal guardian revealed she had not been invited to a care conference in greater than three months. Interview on 12/03/24 at 1:15 P.M. with Licensed Social Worker (LSW) #373 confirmed care conferences for Resident #29 were not conducted quarterly. 2. Review of Resident #44's medical record revealed the resident was admitted on [DATE] with diagnoses including schizoaffective disorder, bipolar disorder, antisocial disorder and generalized anxiety. Review of Resident #44's annual MDS 3.0 assessment dated [DATE] revealed the resident exhibited moderate impairment in cognitive skills for daily decision making. Review of Resident #44's Violent Behavior Care Plan dated 04/12/24 revealed interventions including follow up with psychiatric services, if agitation/aggression behaviors, leave in a safe situation and return in five to ten minutes, encourage to participate in care and activities of choice. Review of Resident #44's Behaviors Care Plan dated 10/23/24 revealed behaviors such as pacing, aggressiveness, hallucinations, and delusions. The care plan had interventions including refer to psychiatrist or psychologist, provide support and reassurance, offer choices to feel more independent, observe for and report to provider behavior issues, monitor/record mood, if resident disruptive, remove from situation and attempt to calm down; identify what helps calm resident; explain all care and procedures before assisting, ensure a safe environment, encourage activity and attempt to redirect. Interview on 12/03/24 at 1:15 P.M. with Regional Registered Nurse #467 confirmed Resident #44's care plans were not updated to reflect interventions for the resident's behaviors including removing the furniture in the resident's room to prevent the resident from throwing the furniture out of the windows and providing the resident a thin blue yoga mat to sleep on per the resident's preference. 45442 3. Review of the medical record for Resident #13 revealed an admitted [DATE]. Diagnoses included but were not limited to epileptic seizures, dysphagia, flaccid hemiplegia affecting right dominant side, bipolar disorder, dementia and paranoid schizophrenia. Further review of the medical record did not reveal any documentation of a care conference being held within the past twelve months. Review of Resident #13's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 had moderate cognitive impairment and was dependent upon staff for all activities of daily living (ADLs). Phone interview on 12/02/24 at 1:58 P.M. with Resident #13's guardian revealed she was unsure when the last care conference was held as she had not been contacted to attend. Interview on 12/04/24 at 9:46 A.M. with Regional Registered Nurse #467, the Director of Nursing and Assistant Director of Nursing revealed they were unable to provide evidence of a care conference being held for Resident #13 in the past 12 months. Regional Registered Nurse #467 stated the facility identified the concern in October 2024 but had not held a care conference since identifying the concern. Review of the facility's Comprehensive Care Planning Policy with a revision date of 03/02/21 revealed an interdisciplinary plan of care would be established for every resident and updated in accordance with state and federal regulatory requirements and on an as needed basis. The facility was to develop a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessments. A resident care plan conference was to be scheduled at least weekly. Residents scheduled for the resident care conference included new admissions whose MDS was completed within the previous seven days, residents who returned from the hospital in the past week, residents with a significant condition change and MDS was completed in the past week, and residents with 90-day review assessments or an annual full assessment completed within the previous seven days.

Based on record review, interview, and review of the facility policy and procedure, the facility failed to ensure individualized care plans were developed and accurate for three residents (#40, #92, and #133) of 29 sampled residents whose care plans were reviewed. The facility census was 148. Findings include: 1. Review of the medical record for Resident #133 revealed an admitted [DATE]. Diagnoses included post-traumatic stress disorder (PTSD), end stage renal disease, dependence on renal dialysis, and schizophrenia. Further review of Resident #92's medical record on 12/03/24 at 8:56 A.M. revealed no care plan related to PTSD. On 12/04/24 the facility provided a copy of Resident #133's plan of care. Review of this plan of care revealed it was created on 12/04/24 and indicated Resident #92 had a diagnosis of PTSD. The care plan indicated Resident #40 (another resident) has or had potential for intrusive thought, flashbacks, avoidance behaviors, negative changes in mood and cognition. The care plan indicated Will follow up with psych/behavior management as needed. Interview on 12/04/24 at 1:57 P.M. with Minimum Data Set (MDS) Registered Nurse (MDSRN) #356 revealed it was brought to her attention that Resident #133 did not have a care for PTSD, so she ran a report and added a PTSD care plan to those residents who did not. MDSRN #356 verified she created the care plan for Resident #133 today (12/04/24) and that it included Resident #40. MDSRN #356 stated she had created a template from Resident #40's care plan and copied and pasted it to Resident #133's care plan and that was why Resident #40's name was in the PTSD care plan for Resident #133. 2. Review of the medical record for Resident #92 revealed an admitted [DATE]. Diagnoses included schizoaffective disorder, bipolar disorder, major depressive disorder, and personal history of other venous thrombosis and embolism. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #92 had intact cognition and received an antidepressant, antipsychotic, and anticoagulant. The assessment indicated Resident #92 received an antipsychotic on routine basis. Review of the physician orders for December 2024 revealed active orders for risperidone (antipsychotic) tablet two milligrams (mg) by mouth at bedtime; Seroquel (antipsychotic) tablet 50 mg by mouth at bedtime; trazodone (antidepressant) tablet 50 mg by mouth at bedtime; and Eliquis (anticoagulant) tablet five mg by mouth twice a day. Interview on 12/04/24 at 3:28 P.M. with Regional Nurse #467 verified there were no care plans for Resident #92's use of psychotropic or anticoagulant medication. 45442 3. Review of the medical record for Resident #40 revealed an admitted [DATE]. Diagnoses included but were not limited to bipolar disorder, suicidal ideations, altered mental status, schizoaffective disorder, panic disorder and post-traumatic stress disorder (06/29/23). Review of Resident #40's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 had mild cognitive impairment and required supervision for eating, oral hygiene, toileting hygiene and rolling 150 feet in her wheelchair. Resident #40 required moderate assistance for dressing and personal hygiene and maximum assistance from staff for bathing. Review of Resident #40's care plan revealed it was last reviewed on 11/04/24 and revealed no evidence of a care plan or interventions for post-traumatic stress disorder (PTSD). Interview on 12/04/24 at 9:28 A.M. with Social Services #317 confirmed there was no PTSD care plan for Resident #40. Interview on 12/04/24 at 9:46 A.M. with Regional Nurse #467 confirmed there was no care plan addressing PTSD despite Resident #40 having a diagnosis of PTSD since 06/29/23. Review of the facility's Comprehensive Care Planning Policy with a revision date of 03/02/21, revealed the facility must develop a comprehensive Person-Centered Care Plan for each resident that included measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessments.

Based on medical record review, bathing/showering documentation review, facility policy review and interview, the facility failed to ensure bathing/showering was completed as required for one Resident #110 who required total assistance with activities of daily living. This affected one (#110) of one resident reviewed for bathing. The facility census was 148. Findings include: Review of the medical record for Resident #110 revealed an admitted [DATE]. Diagnoses included but were not limited to acute respiratory failure, chronic obstructive pulmonary disease, and atrial fibrillation. Review of Resident #110's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #110 had intact cognition and was dependent for all activities of daily living (ADLs) including bathing. Review of Resident #110's care plan last reviewed on 11/18/24 revealed Resident #110 had a self-care deficit and required total assistance with ADLs. The care plan did not include specific information related to bathing type preference or frequency for bathing. Interview on 12/02/24 at 10:32 A.M. with Resident #110 revealed he had not been offered a shower in two months, he was sometimes offered a bed bath but not consistently. Review of the undated facility shower rotation sheet for the second floor (the floor Resident #110 resided) revealed Resident #110 was to receive a shower or bed bath on Wednesdays and Saturdays. Review of Resident #110's shower sheets for the past 90 days revealed four shower sheets dated 08/14/24, 08/21/24, 12/02/24 and one which was undated. Interview on 12/04/24 at 1:05 P.M. with the Director of Nursing revealed she was unable to provide any other shower sheets for Resident #110 for the past 90 days and he should have been bathed twice weekly. Review of the facility's Resident Bath Showering Scheduling Policy with a revision date of 09/09/22 revealed each resident would be scheduled to receive bathing a minimum of two times per week unless they preferred less frequent baths. When the bath or shower was complete, the nursing assistant was to document the activity on the shower sheet or the electronic medical record.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, facility self-reported incident (SRI) review, and facility policy review the facility failed to prevent an incident of staff to resident emotional abuse, based on the reasonable person concept, when State tested Nurse Aide (STNA) 314 posted a video showing Resident #5 on social media. This affected one resident (#5) of six residents reviewed for abuse. The facility census was 144. Findings include: Review of the medical record revealed Resident # was admitted to the facility on [DATE] with diagnoses including severe intellectual disabilities, seizures, schizophrenia, and dementia The resident was discharged on [DATE] to a group home. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition. Resident #5 had behaviors including delusions, physical behavioral symptoms directed at others, verbal behavioral symptoms directed at others, other behavioral symptoms not directed at others, rejection of care, and wandering. Review of the SRI allegation background revealed on 09/12/24 at approximately 7:10 P.M., the Director of Nursing (DON) was notified of a video that was posted on social media by STNA #314. The video was captioned Everyday it is something new with my clients. STNA # was heard on the video making the statement what the [expletive], and then the camera view pans to a resident walking with their brief/pull up around their ankles. The resident's face was momentarily visible although unclear in the video. The video was posted without the consent of the resident. Review of SRI tracking number 251842 dated 09/12/24 revealed on 9/12/2024 at 7:30 P.M., the Administrator was made aware that STNA #314 posted a video on social media that had a blurred image of Resident #5. When STNA #314 was interviewed, she stated the image was of Resident #5. The post was deleted, and the staff member was suspended pending investigation. A message was left for Resident #5's guardian regarding this investigation. Staff were being educated on the facility's abuse and social [NAME] policies. Staff were being interviewed to determine if there was knowledge of any other videos that were posted on social media that have a resident's image. Residents were being interviewed to determine if they had knowledge of any additional posting that may have a resident's image. Resident #5 had no change in condition. The compliance division was notified of the potential breech and will initiate its own investigation. The investigation revealed the DON, Regional Director of Clinical Services (RDCS) #303, and Regional [NAME] President of Operations (RVPO) #302 were immediately made aware of the allegation. A referral was placed to the organization's compliance department to also investigate. Resident #5 was assessed and had no injuries. Due to the resident's cognitive ability, the resident had no awareness of what occurred and there were no signs of being negatively impacted. Two voicemail messages were left for the guardian to alert her of the allegation, as of 9/18/24, no return call had been received, another call was placed to the legal guardian on 9/18/24 and another voicemail message was left. When STNA #314 was interviewed, she stated she had no intention of causing any harm, distress, or pain to any resident and was simply posting a video of her work life. She stated that no other employee was part of the post, and no employee liked or commented on the post. She stated she had posted the video on 09/09/24 and only to the Tik Tok site. The post was deleted, and the staff member was suspended pending investigation. She stated the video was created on Tik Tok, was only posted to Tik Tok, and there were no copies of the video. All staff were interviewed on 09/12/24 and 09/13/24 regarding having any knowledge of this or any other breach of the social media policy, and no additional violations were committed. All residents that were able, were interviewed on 09/12/24 and 09/13/24, and no residents had any knowledge of any video of them or any other resident being taken and/or placed on social media. All staff were educated by the Administrator / Designee on the facility's Health Insurance portability and Accountability Act (HIPAA), Abuse, and Social Media policies on 09/12/24 and 09/13/24. Resident #5 has shown no change from baseline that would be indicative of any distress or harm. Social services will continue to monitor. STNA #314 was terminated. Interviews on 10/08/24 at 2:02 P.M. with the DON and Assistant Director of Nursing (ADON) #310 and on 10/09/24 at 8:21 A.M. with the Administrator verified the administrator had heard about the social media posting incident on 09/12/24, the video had been posted a couple days prior. STNA #314 was interviewed and immediately suspended. The facility worked with their corporate ethics to ensure they did everything needed to address the issue. Review of the personnel record for STNA #314 revealed the last day worked was 09/12/24. The STNA was terminated 09/19/24. Review of the Ohio Resident Abuse Policy, dated 07/11/24, revealed no concerns in relation to the allegation. The facility followed its policy. STNA #314 did not follow the policy and was terminated. Review of the undated facility [NAME] Media policy included that if an employee posted information on the Internet in any fashion, they were expected to do so responsibly and must adhere to the following guidelines: employees' communications concerning the facility must not violate any facility policies, employees may not post any material that is obscene, defamatory, libelous, threatening, harassing, abusive or hateful. Employees should expect the facility to monitor compliance with this policy, including accessing any information posted, created, or exchanged on social media, without prior notice to the employee, to the extent permitted by law. Failure to comply with these policies will lead to discipline up to and including termination. The deficient practice was corrected on 09/13/24 when the facility implemented the following corrective actions: On 09/12/24 the DON notified the Administrator, ADON #310, and RDCS #303 of the video that was posted by staff. The Administrator notified RVPO #302. On 09/12/24 the DON called the facility and spoke with STNA #314, asked about the video, and informed her she was suspended, and security escorted her from the facility. STNA #314 was terminated on 03/1/24. 09/12/24 the Administrator called STNA #314 and instructed her to delete the video and remove the post from social media. It was determined during this conversation that the video was posted for approximately three days prior to the facility having knowledge. On 09/12/24 the DON verified the video was removed from social media 09/12/24 Resident #5 was assessed, as the resident was not able to participate in an interview. There were no negative findings. 09/12/24 the Administrator called Resident #5's legal guardian, left a voicemail explaining the situation and requesting a call back. On 09/12/24 the Administrator completed the initial SRI for alleged emotional abuse and submitted it to the state agency. On 09/12/24 the Administrator notified the corporate compliance officer via email of the alleged HIPAA violation. On 09/12/24 current residents who were able to participate were interviewed by the Administrator or designee related to any staff seen taking pictures or videos of them without consent, there were no negative findings. On 09/12/24 all staff were interviewed by the Administrator or designee related to any staff seen taking pictures or videos of residents without consent. The staff interviews were completed on 09/13/24 at 1:00 P.M. There were no negative findings. Beginning on 09/12/24, the Administrator initiated all staff education related to abuse and neglect prevention and reporting along with the social media policy and the HIPAA policy. Education for all staff was completed on 09/13/24 at 1:00 P.M. On 09/13/24 the Administrator called to speak with Resident #5's legal guardian again and was informed by the office that she is off. He did leave another voicemail. On 09/13/24 Resident #5 was seen by a clinical counselor, and there was no indication of any emotional impact related to the situation. Beginning on 09/13/24, the Administrator or designee will interview five residents three times per week for four weeks and then monthly for two months to determine if they have seen any staff taking pictures or videos of residents, or if they have heard anything of pictures or videos containing residents being posted to social media platforms. Results of the interviews will be submitted to the Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. Beginning on 09/13/24, the Administrator or designee will interview five staff three times per week for four weeks and then monthly for two months to determine if they have seen any staff taking pictures or videos of residents, or if they have heard anything of pictures or videos containing residents being posted to social media platforms. Results of the interviews will be submitted to the QAPI committee for further review and recommendations. An Ad Hoc was held on 09/1324 with the Medical Director in attendance via phone to review the event and the QAPI plan implemented by the facility. This deficiency represents past non-compliance from Self-Reported Incident Control Number OH00158085.

Based on observation, interview and review of facility policy, the facility did not ensure garbage was properly disposed of to prevent the harborage pests. This had the potential to affect all 144 residents. The facility census was 144. Findings include: Observation on 08/28/24 at 9:30 A.M. with Maintenance Director #539 revealed the three outside dumpsters near the facility kitchen doors did not have lids covering trash, a sour smell permeated around the dumpsters with wet boxes and leaf and twig debris piled up around the dumpsters. Maintenance Director #539 verified the findings on 08/28/24 at 9:30 A.M. and stated it was difficult to get behind the dumpsters to pick up the boxes and clean the area, and there should be lids to cover the trash. Interview with Exterminator #646 on 08/28/24 at 12:31 P.M. revealed garbage containment and sanitation was important to prevent and control pests. Review of the facility policy titled Pest Control dated 8/12/18 revealed routine pest control would be placed to prevent pest infiltration. Maintenance of the garbage storage area to prevent harboring and feeding of pests. Outside dumpsters doors and lids would be kept shut and secure. This deficiency represents noncompliance as an incidental finding during the investigation of Complaint Number OH00157080.

THIS DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THE ON-SITE INVESTIGATION Based on medical record review, staff interview, resident representative interview, law enforcement interview, review of facility self-reported incidents (SRIs), review of police reports, review of police body camera footage, review of emergency medical services (EMS) run reports, review of hospital records, review of the Facility Assessment, and review of facility policies, the facility failed to ensure Resident #1 was free from physical abuse from Resident #2. This resulted in Immediate Jeopardy and serious life-threatening harm on 03/12/24 at approximately 5:00 A.M. when Resident #1 was found on the floor in a prone position (face down on the stomach) in his room with blood coming out of the left side of his head and face. The resident was transported to the emergency room . Upon further investigation by hospital staff and law enforcement, it was determined Resident #1 was physically assaulted by Resident #2, who had a documented history of violent behaviors and was Resident #1's roommate. Resident #1 sustained numerous blows to the head and abdomen and injuries including scattered abrasions about the head, significant swelling to the left side of the face mostly over the left eyelid with a laceration present in the area, bleeding on the brain, and a fractured sacrum. This affected one resident (#1) reviewed for physical abuse and had the potential to affect 42 additional residents (#3, #4, #5, #6, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #37, #38, #39, #40, #41, #42, #43, #44, #45 and #46) who resided on the secure dementia unit were Resident #2 resided. The facility census was 143. On 04/11/24 at 5:05 P.M., the Administrator and Corporate Registered Nurse (CRN) #116 were notified Immediate Jeopardy began on 03/12/24 at approximately 5:00 P.M. when Resident #1 was found on the floor in the prone position in his room with blood coming out of the left side of his head and face. The injuries were determined to be a result of an incident of physical abuse/assault by Resident #2. The facility did not begin corrective action until 03/18/24 when law enforcement arrived at the facility and informed facility staff Resident #1 alleged the assault by Resident #2, leaving the 43 additional residents residing on the unit at risk for physical abuse from Resident #2 between 03/12/24 and 03/18/24. The Immediate Jeopardy was removed and corrected on 03/21/24 when the facility implemented the following corrective actions: On 03/12/24 Resident #1 was transferred to the hospital and did not return to the facility. On 03/18/24, Resident #2 was placed on one-to-one supervision until discharged to the hospital. On 03/18/24, the Director of Nursing (DON) notified Resident #2's guardian and physician and orders were received to send the resident to a hospital for a psychological evaluation. Resident #2 was hospitalized from 03/18/24 to 03/21/24. On 03/18/24, the Administrator initiated a facility Self-Reported Incident (SRI) and an investigation for resident-to-resident physical abuse involving Resident #1 and Resident #2 that occurred on 03/12/24. On 03/18/24, the DON/Designee completed interviews with all interviewable residents who could potentially be affected regarding abuse and neglect. There were no negative findings from the resident interviews. On 03/18/24, Assistant Director of Nursing (ADON) #249, Licensed Practical Nurse (LPN) Unit Manager #298, and Registered Nurse (RN) #288 completed skin assessments on all non-interviewable residents to identify any signs or symptoms of abuse. There were no negative findings from the skin assessments. On 03/19/24, the interdisciplinary team (IDT) consisting of the Administrator, ADON #249, Social Service Designee (SSD) #220, RN #257, Regional Director of Clinical Services (RDCS) #350, and LPN Unit Manager #298 reviewed residents with like behaviors, including review of care plans and interventions, and review of all residents and their roommates for compatibility. As a result of the meeting, it was determined Resident #2 was moved to a private room upon readmission to the facility on [DATE]. There were no concerns found with the other residents during the review. On 03/18/24, the Administrator/Designee began education with all staff on abuse, neglect, aggressive behaviors, and violent behaviors. The education was completed face-to-face for facility staff working in the facility and via telephone for staff members not present in the facility. Newly hired staff/agency staff were to be educated upon hire and upon assignment to the facility. All education of current staff members was completed on 03/19/24. On 03/18/24, the DON/designee began audits to include interviews with five staff members three (3) times weekly for four (4) weeks and then monthly for two (2) months to monitor and assess residents for any signs and symptoms of abuse. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations. All audits through 04/01/24 revealed no concerns. On 03/18/24, the DON/Designee began audits to include interview with 10 residents who were interviewable and skin assessments on non-interviewable residents 3 times weekly for 4 weeks and then monthly for two months to assess for signs and symptoms of abuse. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations. All audits through 04/01/24 revealed no concerns. On 03/18/24, the DON/Designee began audits to review all residents with aggressive and violent behaviors to ensure appropriate interventions are implemented and/or updated to reflect current resident status. All residents will be audited weekly for 4 weeks and then monthly for 2 months to ensure compliance. All audits through 04/01/24 revealed no concerns. On 03/19/24, the DON/Designee began audits of new admissions and readmissions to the facility to monitor for aggressive and violent behaviors to ensure appropriate interventions are implemented upon admissions. Review of the audits through 04/01/24 revealed no concerns. On 03/21/24 Resident #2 was readmitted to the facility and placed in a private room as an intervention to decrease the risk for resident-to-resident abuse by Resident #2. Review of SRIs on 04/09/24, revealed the facility had submitted no additional allegations of resident-to-resident physical abuse since 03/18/24. Interview with State tested Nurse Aide (STNA) #215, STNA #302, LPN #257, and LPN #298, on 04/15/24 between 8:35 A.M. and 8:55 A.M. revealed all staff members interviewed had been educated regarding abuse, neglect, aggressive behaviors, and violent behaviors. All staff members interviewed confirmed they retained knowledge regarding the content of the education provided. Findings Include: Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included seizures, depression, and post-traumatic stress disorder. Resident #1 shared a room with Resident #2 on admission and remained roommates until Resident #1 was discharged to a local hospital on 03/12/24 and did not return to the facility. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 was assessed as cognitively intact and required limited assistance from one staff person for completing his activities of daily living. Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia, paranoid personality disorder, anxiety disorder, and violent behavior. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #2 was assessed as cognitively intact, had active delusions, and required the assistance of one staff person for completing his activities of daily living. Review of Resident #2's admission paperwork prior to arriving at the facility on 02/18/20 revealed Resident #2 was placed in a psychiatric hospital for physically assaulting another resident and staff person at another nursing facility, causing broken arms in both the staff person and the other resident. Review of the care plan for Resident #2, initiated on 02/18/20 and revised on 05/24/23, revealed a care plan focus that indicated Resident #2 had a mood problem related to paranoid schizophrenia. Resident #2 had the potential to express himself using verbal or physical violence when he was experiencing elevated feelings. Goals for the care plan focus were for Resident #2 to have improved mood through the next review date. Interventions included administering medications as ordered, monitoring/documenting for side effects and effectiveness, assessing/monitoring/recording/reporting to the medical doctor (MD) as needed for risk for harming others, assessing/recording/reporting to the MD as needed acute episodes or significant changes in mood, assessing/record/reporting to the MD as needed mood patterns signs and symptoms of depression, anxiety, mood as per facility behavior monitoring protocols, behavioral health consults/psychiatric consult as needed or per orders, encouraging the resident to express feelings, allowing them time to talk as needed, allowing for Resident #2 to express himself using active listening, maintaining eye contact, speaking in a calm manner, not challenging him while he was in an elevated emotional state, acknowledging and rephrasing what was frustrating Resident #2 so he was aware that he has been heard, and observing for signs and symptoms of mania or hypomania racing thoughts or euphoria; increased irritability; frequent mood changes; pressured speech; flight of ideas; marked change in need for sleep; agitation or hyperactivity. The care plan included no other interventions to specifically address Resident #2's specific behaviors, triggers, or other concerns to prevent violent and aggressive behaviors. Review of the Ohio Department of Health's Enhanced Information Dissemination Collection (EIDC) system revealed Resident #2 was involved in 16 separate incidents resulting in facility SRIs across four different nursing facilities being reported to the State agency since 2014. Notable SRIs which occurred in Resident #2's current facility in the reported SRIs investigations included, on 10/23/23, Resident #2 placed Resident #15 in a choke hold during a physical altercation which resulted in Resident #15 biting Resident #2's finger. Review of an SRI on 12/13/23 revealed Resident #2 and Resident #17 were roommates and Resident #17 was noted with swelling and redness to the right cheek. When a nurse attempted to assess Resident #17, the resident indicated he wanted to be left alone. Resident #2 was interviewed about the incident and stated, I punched him (Resident #17) for no reason. Review of an additional SRI on 02/07/24 revealed Resident #2 struck Resident #449, who at the time were roommates, in the lip causing Resident #449 to have a swollen lip. Review of psychiatrist progress notes from the facility noted the facility's psychiatrist was unwilling to reduce Resident #2's psychiatric medications due to ongoing behaviors. Resident #2 had been most recently seen by facility's psychiatrist for a medication review on 01/17/24 at which time Resident #2 was noted with impaired judgement and incoherent thought process. Resident #2 was documented with medical history of schizophrenia, paranoid personality, violent behavior, anxiety, and schizoaffective disorder. Further review revealed adjustments made since the last visit included an increase in Resident #2's antipsychotic medication Haldol to 300 milligrams every three weeks. Resident #2 was noted to not be a candidate for a dose reduction because of continuing target symptoms and a high risk of relapse if medication was lowered. Review of a nursing progress note dated 03/12/24 at 8:09 A.M. revealed Resident #1 was discovered on the floor of his room at 5:00 A.M. Resident #1 was laying in the prone position with his head turned to the right and blood coming from the left side of his head. Further review of the progress note revealed staff documented prior to a fall Resident #1 was walking around looking for his wheelchair. The progress note indicated Resident #1 was alert and oriented and able to maintain a conversation with the nurse. Resident #1 was transferred to the hospital for evaluation. Review of an EMS run report dated 03/12/24 revealed EMS personnel arrived at the facility at 5:07 A.M. Resident #1 was found lying on the ground in his bedroom with a laceration to the back of the head and his left eye was swollen shut. Nursing staff reported to EMS personnel that they did not know what happened, but assumed Resident #1 fell , but confirmed it was unwitnessed incident. Further review of the EMS run report revealed multiple pools of blood were noted on the doorway of Resident #1's room. As EMS transported Resident #1 to the facility's elevator, Resident #1 told the EMS personnel he did not just fall but was kicked in the face (multiple times) by another resident (#2) who lived in the facility. Review of hospital documentation dated 03/12/24 revealed Resident #1 admitted to the emergency room (ER) with a primary diagnosis of trauma and a left eyelid laceration and intracranial hemorrhage. Resident #1 was brought to the ER as a limited trauma after nursing staff found the resident on the ground, but Resident #1 reported to EMS he was assaulted and kicked multiple times in the head and body. Resident #1 reported to EMS personnel while enroute to the ER that he was assaulted by his roommate and named Resident #2. Resident #1 was alert and oriented to person, place, and time and reported pain throughout his body. Resident #1 was assessed with dried blood on his scalp with scattered abrasions without lacerations identified on his head. Resident #1 had significant swelling to the left side of the face mostly over the left eyelid with an approximate five millimeters long laceration present in the area. The laceration was treated and repaired with sutures. Assessment of Resident #1's abdomen produced some guarding. Review of Resident #1's history revealed the resident had a previous subdural craniotomy (a temporary flap surgically created to the skull) and a flap on the right side of his head where there was no skull. Review of a computed tomography (CT) image of Resident #1's pelvis revealed a nondisplaced acute fracture involving the caudal sacrum. Review of the police body camera footage during an interview with Resident #1 on 03/12/24 at 8:56 A.M., from the ER that Resident #1 was transferred to after the incident, revealed Resident #1 was lying flat on his back with a cervical collar on. Resident #1's face was covered in scratches and bruises with a significant amount of dried blood noted across his face. Photos taken during the interview by the police officer on the body camera footage also noted numerous bruises on Resident #1's abdomen. Resident #1 was noted stating to the officer that he was beat up by his roommate (Resident #2). The body camera footage also noted Resident #1's hospital nurse explained to the officer that Resident #1 suffered bleeding on his brain, a broken sacrum, and was going to be transferred to the hospital trauma intensive care unit (ICU) for further medical care. Review of the police body camera footage dated 03/18/24 at 12:39 P.M. revealed Resident #2 was interviewed regarding the incident by Detective #300 at the nursing facility. Resident #2 stated Resident #1 was reaching for a religious picture that belonged to Resident #2, and he then stuck his foot out to block Resident #1 from touching the religious picture. Resident #2 stated Resident #1 bumped into his foot, Resident #2 took offense to Resident #1 bumping his foot and proceeded to strike Resident #1 with a closed fist. Review of the police body camera footage dated 03/18/24 at 1:23 P.M. in the ICU of the hospital revealed Resident #1 was interviewed by Detective #300. Resident #1 revealed he was thrown out of his wheelchair during the incident and was stomped multiple times on the ground by Resident #2. As a result of being thrown to the ground, Resident #1 suffered a broken tailbone. Resident #1 was informed that based on Detective #300's investigation, Resident #1 was the victim of felonious assault (defined as causing or attempting to cause serious physical harm to another person, or to their unborn child, with a deadly weapon or dangerous ordnance). Detective #300 further explained that after consultation with the county's prosecutor, the county would like to proceed with criminal charges. Resident #1 stated he would like to press charges for the incident with Resident #2. Detective #300 educated Resident #1 that the case would be brought to the county's grand jury to secure formal indictments against Resident #2. Review of a facility self-reported incident (SRI) dated 03/18/24 revealed Resident #1 was discovered on the floor in his room (on 03/12/24) at 5:00 A.M. Resident #1 was laying on the floor of his room in the prone position with his head turned to the right and bleeding from the left side of his head. The SRI included that while being assessed for injuries, Resident #1 informed his nurses that he fell looking for his wheelchair. After assessment, Resident #1 was transported to a local hospital for evaluation. While being evaluated in the hospital, Resident #1 informed hospital staff that he was assaulted by Resident #2. The facility was contacted related to the situation and then began an investigation into the incident. Interview on 04/09/24 at 2:47 P.M. with Resident #1's guardian revealed Resident #1 was nothing like he used to be before the incident on 03/12/24 and has periods of impaired cognition. Interview on 04/09/24 at 5:30 P.M. with the Administrator and DON verified Resident #2's history of physically aggressive behaviors toward other residents, and confirmed the facility did not develop individualized interventions to prevent Resident #2 from physically abusing other residents, including Resident #1. Interview with Detective #300 on 04/11/24 at 9:33 A.M. verified local law enforcement were moving ahead with charges of felonious assault against Resident #2 related to the incident with Resident #1 on 03/12/24. Detective #300 also commented the facility was visited often by law enforcement for incidents of resident-to-resident abuse and other similar incidents. Interview with STNA #215 on 04/15/24 at 8:44 A.M. revealed he was the staff person who found Resident #1 after the incident on 03/12/24. STNA #215 revealed Resident #1 was sitting on his knees on the floor with a large amount of blood coming from the left side of his head. STNA #215 noted Resident #2 was in the room lying awake in his bed and did not speak to STNA #215. Interview with STNA #302 on 04/15/24 at 8:50 A.M. revealed Resident #2 had numerous instances of violent behavior toward staff and others. STNA #302 further noted Resident #2's behaviors were often exacerbated when he had a roommate. Interview with LPN #257 on 04/15/24 at 8:55 A.M. revealed Resident #2's behaviors were often more extreme during the evening and late-night hours. Interview with Psychologist #900 on 04/15/24 at 2:35 P.M. revealed Resident #2 was very territorial in his behaviors, and if Resident #2's personal space and routine were changed/violated, he would very likely retaliate against others. Interview with Resident #2's guardian on 04/15/24 at 1:05 P.M. revealed Resident #2 had a long history of violent behaviors at numerous nursing homes and estimated Resident #2 was placed at over a half dozen nursing homes in the state over the last seven to ten years. Review of the Facility assessment dated [DATE], under the subsection of Mental health and behavior, revealed the facility would manage the medical conditions and medication-related issues causing psychiatric symptoms and behaviors, and identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/post-traumatic stress disorder, and other psychiatric diagnoses. Review of the policy titled, Secured Resident Unit Policy, dated 05/12/22, revealed the facility's secured unit was meant to improve quality of life via enhanced safety and maintenance or improvements in the level of functioning. Review of the policy titled, Abuse, Neglect, and Exploitation, dated 08/30/23 revealed the facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. Further review of the police revealed, in order to prevent and identify abuse, the facility will assessment, care plan, and monitors residents with needs and behaviors which might lead to conflict or neglect. This deficiency is based on incidental findings discovered during the course of the complaint investigation.

Based on observation, record review, review of the facility Elopement/Unauthorized Absence policy and procedure and interviews, the facility failed to provide adequate supervision and individualized and comprehensive interventions to prevent Resident #101 from eloping from the facility. This resulted in Immediate Jeopardy and the likelihood of actual harm on 08/29/23 at approximately 9:48 A.M. when Resident #101, who was cognitively impaired and assessed to be at high risk for elopement, exited the facility grounds without staff knowledge, during a supervised smoke break. Staff failed to identify Resident #101 was missing until approximately 12:15 P.M. when the resident was not available for lunch. On 08/29/23 at 5:14 P.M. Resident #101 was found by police, approximately 2.8 miles away from the facility on a street corner. The resident was transported to the hospital for evaluation. This affected one resident (#101) of three sampled residents reviewed for accidents. This facility identified 14 residents (#3, #24, #27, #45, #46, #76, #86, #90, #98, #101, #124, #130, and #131) who were smokers and elopement risks. The facility census was 138. On 08/30/23 at 5:11 P.M. the Administrator, Regional Nurse Consultant, Director of Nursing and Administrator in Training were notified Immediate Jeopardy began on 08/29/23 when Resident #101, who was cognitively impaired, exited the facility grounds without staff knowledge during a supervised smoke break. Resident #101 was found on a street corner approximately 2.8 miles from the facility by police and was transferred to the local hospital for evaluation. The Immediate Jeopardy was removed on 08/31/23 when the facility implemented the following correction actions: On 08/29/23 at 12:15 P.M. Resident #101 was identified as having eloped from the facility when he was not present in the dining room for lunch. Licensed Practical Nurse (LPN) #558 informed Licensed Social Worker (LSW) #403, immediately had the receptionist call Code Green 512W. LSW #403 immediately notified the Administrator and Director of Nursing (DON). The administrator notified the Regional [NAME] President of Operations (RVPO) #559 and the Regional Director of Clinical Services #560. Upon hearing the Code Green, facility staff conducted a head count on all floors and a facility sweep as well as the immediate area outside the facility. Several other staff members used their vehicles to begin searching for the residents in the surrounding neighborhoods, checking bars, convenient stores, and other areas of interest. All residents were accounted for by 12:30 P.M. except for Resident #101. On 08/29/23 at 12:30 P.M. the DON notified the physician of Resident #101 leaving the facility. Attempts were made to notify the family of Resident #101; however, the attempts were not successful until 08/30/2023 at 2:00 P.M. On 08/29/23 at approximately 12:30 P.M. all local hospitals and satellite emergency room s were notified by clinical leadership. The receptionist contacted Cleveland Police Department (CPD) third district and Regional Transit Authority (RTA) police. LSW #403 called University Circle police and Case Western police. The Cleveland Police Department contacted all other local affiliate police departments and emergency medical services (EMS). On 08/29/23 at 12:30 P.M. Administrator and Human Resource Director (HR) #495 reviewed camera footage. Resident #101 was last observed outside smoking in a supervised smoking group that was being conducted by State tested Nursing Assistant (STNA) #526. Resident #101 was last seen on camera at 9:48 A.M. smoking with other residents. Resident #101 was not observed entering the facility when smoke break was over. On 08/29/23 at 12:45 P.M. LSW #403 and the Administrator provided CPD a description of Resident #101, full body picture of Resident #101 and Resident #101's face sheet for pertinent contact information. On 08/29/23 at 5:14 P.M. CPD located Resident #101 at 5:14 P.M. at Forty Fifth Street and Cedar Avenue, approximately 2.8 Miles from the facility, and took Resident #101 to the hospital for evaluation. LPN #515 and Assistant Director of Nursing (ADON) #492 met the resident at the emergency room (ER). ADON #492 stayed at the ER until 11:15 P.M. when informed by personnel at the ER that they would watch the resident until his transportation arrived back to the facility at approximately 3:00 A.M. or 4:00 A.M. on 8/30/2023. On 08/29/23 at 1:00 P.M. until 2:00 P.M, RDCS #560 reviewed progress notes for the last 72 hours for any resident changes in condition with no negative findings. On 08/29/23 from 2:00 P.M. to 10:00 P.M. the DON and/or Designee completed new elopement assessments for all current residents. Residents who were identified as high risk for elopement had their care plan and Kardex information updated. The facility ensured appropriate interventions were put in place if needed. On 8/29/2023 at 3:20 P.M. the Administrator and RDCS #560 updated the process of outdoor group activities for residents with supervised leave of absences (LOAs) to reflect two staff must accompany residents for outdoor activities, no more than 15 residents at a time, and residents must be signed out and signed in when returning inside. This process went into effect on 8/31/2023. There was no outdoor supervised smoking after the event on 8/29/2023 and 8/30/2023. All residents were assisted smoking inside. On 08/29/23 and 08/30/23 education was provided to all staff on the facility's elopement policy, outdoor smoking policy for residents with supervised leave of absences (LOA), and the new process on expectations of signing residents in and out when they are participating in an outdoor supervised group as well as clarifying the expectations of staff members who are taking responsibility for the security and safety of an outside group. Training was completed in person, telephone, email, and via text message system. On 08/29/23 at 11:45 P.M., Licensed Practical Nurse (LPN) Supervisor # 431 completed an elopement drill. LPN Supervisor #431 noted staff response was very good. Staff searched and followed the policy properly. On 08/29/23 at 5:00 P.M. a Quality Assurance Performance Improvement (QAPI) was held via telephone with the Administrator, DON, Regional [NAME] President of Operations (RVPO) #559, Regional Director of Clinical Services (RDCS) #560 and Medical Director (MD) #556. The QAPI minutes and findings were reviewed with the facility interdisciplinary team (IDT) and Medical Director during clinical morning meeting on 8/30/2023 at 9:45 A.M. Beginning 08/29/23 the administrator/or designee would conduct elopement drills, one on each shift weekly for four weeks and then monthly for two months. Elopement drills will be evaluated, and education would be completed as needed. Beginning 08/29/23 the Director of Nursing (DON) /or designee would complete audits of five residents who were at high risk for elopement or have had a change of condition three times per week for four weeks then monthly for two months. The Director of Nursing (DON) /or designee would review assessments, care plans and Kardex information to ensure that orders were accurate, and revisions made as needed. Beginning 08/29/23 the Administrator/or Designee would conduct audits three times weekly for four weeks and then monthly for two months for new admissions and re-admissions to ensure elopement risks were completed appropriately. Residents who were identified at risk would have their face sheet and picture placed in the elopement binders located on each unit and reception desk. On 08/30/23 at 5:45 A.M. Resident #101 returned to facility. Resident #101 was assessed with no signs of pain or discomfort. For safety the resident was kept on his secured unit and smoking opportunities were provided on the unit. The facility arranged for an interpreter to interview the resident regarding the incident and during the interview the resident voiced suicidal ideations. The nurse practitioner was notified, and an order was received to send the resident to the hospital for psychological evaluation. One to one (1:1) was provided for safety to resident until he was transferred at 2:00 P.M. on 8/30/2023. Beginning 08/30/23 the Administrator/or designee would complete an audit five times per week for four weeks and then monthly for two months for all residents taken out to smoke are signed out/in by staff and are accounted for upon returning to the unit. The results of all audits would be forwarded to the facility QAPI committee for review and correction actions would be made. On 08/30/23 at 10:00 A.M., Registered Nurse (RN) #501 completed an elopement drill and noted staff did an excellent job. A suggestion was made to add color code to the back of name tags. On 08/30/23 at 12:00 P.M. the facility elopement binder was updated and placed on each floor and at the receptionist desk. On 08/30/23 at 3:30 P.M., Registered Nurse (RN) #501 completed an elopement drill. RN #501 noted staff searched appropriately inside and outside. On 08/30/23 at 11:45 P.M. Licensed Practical Nurse (LPN) Supervisor #431 completed an elopement drill. Licensed Practical Nurse (LPN) Supervisor #431 noted staff overall did a good job. A list of common codes was to be given to staff to place with name tags. On 08/31/23 at 9:30 A.M. Registered Nurse (RN) #540 completed an elopement drill. Registered Nurse (RN) #540 noted staff were very responsive and went through all rooms and areas. Staff given copies of policy. Interviews on 08/31/23 from 8:00 A.M. through 11:30 A.M. with State tested Nursing Assistant (STNA) #507, Licensed Practical Nurse (LPN) #491, STNA #480, Housekeeper #443, STNA #550, LPN #517, Physical Therapist Aide (PTA) #561 and LPN #504 confirmed they were educated and knowledgeable of the elopement and smoking policies and procedures. Although the Immediate Jeopardy was removed on 08/31/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #101 revealed an admitted [DATE] with diagnoses including dementia without behavioral disturbance, alcohol dependence, epilepsy, and human immunodeficiency virus (HIV) disease. Review of the elopement assessment dated [DATE] at 4:32 P.M. revealed Resident #101 was at high risk for elopement. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/23/23 revealed Resident #101 had severely impaired cognition and was independent for mobility, transfers, and ambulation. Review of Resident #101's comprehensive care plan revealed no evidence goals and/or interventions were identified to address the resident's high risk of elopement or exit seeking behaviors. Review of the physician's orders for August 2023 revealed an order indicating Resident #101 may go on leave of absence (LOA) with supervision. Review of the smoking assessment dated [DATE] at 9:44 A.M. revealed Resident #101 required supervision by staff, volunteer, or family member always when smoking. Review of the nurse's note dated 05/06/23 at 4:03 P.M. revealed Resident #101 had previous exit seeking behavior after being moved from the facility fifth floor to the fourth floor. Resident #101 stated I want to leave and go home during the shift, and was standing near the elevator, got on the elevator as the doors opened and went to the main floor lobby. The resident was encouraged by staff to return to the assigned unit, he finally agreed, and was seen flicking a lighter. The resident agreed to hand it (the lighter) to this nurse. The family of the resident came in for a visit and voiced concerns about the resident's current room and requested he be transferred back to the fifth floor. The resident agreed to the move, and a supervisor and Director of Nursing (DON) were made aware. Resident #101 moved then moved back to the fifth floor. Review of the nurse's note dated 08/29/23 at 12:36 P.M. revealed Resident #101 was not in the dining area and not in his room. An overhead page was sent, and staff surveyed the facility. Resident #101 was noted to be out of the building. The physician was notified and attempted to notify the family but there wasn't a working number. Review of the nurse's note dated 08/29/23 at 7:32 P.M. revealed during lunch tray pass at/or around 12:45 P.M. Resident #101 was unable to be located on the unit. The DON and Administrator were made aware, and complete search of facility and surrounding grounds was completed by staff. Local police departments were notified and given description of resident, surrounding hospitals called, staff out in vehicles searching area. On 08/29/23 at approximately 5:15 P.M. CPD notified facility that Resident #101 was located and taken to hospital for medical evaluation. Review of the care plan dated 08/30/23 revealed Resident #101 was at risk of elopement because he believed he was in Philadelphia instead of Cleveland. Interventions included but were not limited to complete elopement assessments upon admission, quarterly and as needed, resident information in elopement binder, and staff to follow procedures for elopements, if applicable to ensure safe return. Review of the facility investigation dated 08/30/23 at 10:53 A.M. revealed Resident #101 exited the facility grounds while out on 08/29/23 during the 9:18 A.M. supervised smoke break without staff knowledge and was found by police, approximately 2.8 miles away, on the corner of Forty Fifth Street and Cedar Avenue on 08/29/23 at 5:14 P.M. Interview on 08/30/23 at 7:15 A.M. with State tested Nursing Assistant (STNA) #526 revealed on 08/29/23 she took Resident #101 outside to smoke and get fresh air. She stated she did not realize Resident #101 was not with the group when they re-entered the building. STNA #526 revealed she regularly took Resident #101 outside for smoke breaks without difficulty. Observation on 08/30/23 at 7:20 A.M. confirmed Resident #101 returned to the facility. Resident #101 was observed walking the halls with a towel around his waist. Security Officer #545 observed Resident #101 and got an aide to assist him back to his room for a shower. Interview on 08/30/23 at 8:56 A.M. with LSW #403 confirmed Resident #101 eloped from the facility after not receiving adequate supervision during a smoke break. LSW #403 revealed he was notified at approximately 12:30 P.M. Resident #101 got away from the smoking group at approximately because he was not available for meal pass. LSW #403 called surrounding police departments, gave description of the resident, and reported Resident #101 missing. Human Resources (HR) #495 reviewed camera footage and Resident #101 was last seen at 9:48 A.M. on 08/29/23. The facility staff searched the facility and grounds as well as started driving around. Police came to the facility and were given Resident #101's medical record face sheet. The Police Department called the facility on 08/29/23 at 5:14 P.M. and stated Resident #101 was found approximately 2.8 miles away, on the corner of Forty Fifth Street and Cedar Avenue on 08/29/23 at 5:14 P.M. A nurse went to the hospital and brought the resident back. Interview on 08/30/23 at 11:21 A.M. with the Assistant Director of Nursing (ADON) revealed when he received notification Resident #101 was at the hospital the ADON retrieved fresh clothes and went to the hospital. The hospital wanted the ADON him to stay with Resident #101. The ADON stated he waited until 11:00 P.M. and that transportation would not be there for a couple more hours, but the hospital stated the ADON could leave. The ADON indicated Resident #101 had no bruises, and all tests completed came back negative. Interview on 08/31/23 at 8:54 A.M. with Receptionist #527 revealed smokers who required a supervised leave of absence (LOA) must be accompanied by staff. The list gets updated weekly and Resident #101 was on the list. Receptionist #527 stated she assisted in calling places looking for Resident #101 after the resident was noted to be missing. Review of Resident #101's progress notes revealed on 08/30/23 at 11:06 A.M. Resident #101 was interviewed by LSW #403, LPN #515 and a phone interpreter (OPI) to understand Resident #101's thoughts on why he left the facility unsupervised on 08/29/23. Resident #101 could state his basic needs but when dialogue was more complex, he understood better with his native language. According to LSW #403, Resident #101 stated he was unsatisfied with the facility, and they were not providing for him the amenities he felt that he should have (cigarettes). Resident #101 was unfamiliar with his diagnoses but did identify he was forgetful and that his memory fails him often. Resident #101 stated he left the facility because he wanted more cigarettes because he was not given any more by the facility. Resident #101 was not oriented to place or time during the conversation and insisted he was in Philadelphia. The resident insisted he was in a prison during the interview. Resident #101 did make homicidal and suicidal statements during the interview. LPN #515 notified the resident's physician, and the resident was sent for a psychological evaluation and admitted . Review of the sign out sheet dated 08/29/23 revealed STNA #526 signed out Resident #63, #75, #86, #88, #98, #124 and a resident that was not residing in the facility. The sign out sheet had no time out or time in documented. Resident #101 was not included on the sign out sheet. On 09/07/23 at 9:50 A.M. observation of the smoking area for residents revealed there were chairs and a bench located on the side of the building. Human Resources Director # 495 was outside and stated they believed Resident #101 went around the building and exited on the driveway that connected the facility and condominiums next door. Review of facility policy dated 09/2008 with a revision date of 03/18/22 titled, Elopement/Unauthorized Absence Policy, revealed the facility would identify residents with potential and/or actual risk factors for elopement and protect the resident through development and implementation of safety interventions. In the event of a resident elopement the facility would implement its policies and procedures promptly to locate the resident in a timely manner. This deficiency is an example of noncompliance investigated under Master Complaint Number OH00145983 and Complaint Number OH00145980.

Based on medical record review, review of hospital documentation and interview the facility failed to ensure Resident #138 was provided timely and adequate urinary catheter care to prevent a urinary tract infection. The facility also failed to timely re-assess Resident #54's need for an indwelling urinary catheter following an evaluation in the emergency room . Actual harm occurred on 03/04/23 when Resident #138, who was dependent on staff for all activities of daily living was transferred to the hospital and admitted with a urinary tract infection (UTI) requiring intravenous antibiotic treatment. Hospital staff identified the catheter had aged sediment and crusting in the catheter line and on the resident's urethral meatus (the opening of the urethra) at tip of the penis reflective of a lack of proper care. This affected two residents (#54 and #138) of three residents reviewed for urinary catheters. Findings include: 1. Review of Resident #138's closed medical record revealed an admitted [DATE] with a readmitted [DATE] with diagnoses including chronic kidney disease, anoxic brain damage, and indwelling catheter. The resident was discharged on [DATE] (to the hospital and did not return to the facility). Review of the physician's orders revealed an order dated 01/31/23 for an indwelling urinary catheter for muscle spasticity. In addition, there was a physician order, (dated 01/31/23) to document catheter output every shift and an order to provide catheter care every shift and as needed. Record review revealed no assessment for the use of the indwelling urinary catheter. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed the resident had intact cognition. The assessment indicated the resident had an indwelling urinary catheter and was dependent on staff for activities of daily living. Review of Resident #138's plan of care revealed no care plan had been developed related to the resident's urinary catheter. There were no orders or plan to monitor for signs/symptoms of urinary tract infection or care plan to direct staff in the necessary care/treatment of the catheter. Review of the February 2023 treatment administration record (TAR) revealed staff did not document urine output on 02/06/23 or 02/07/23, during the second shift on 02/10/23, or during the second shift on 02/26/23, 02/27/23, or 02/28/23. Review of the nursing progress notes from 02/01/23 to 03/04/23 revealed no information documented related to the resident's indwelling urinary catheter. Review of a nursing progress note, dated 03/04/23 at 4:48 P.M. revealed family members of Resident #138 visited and became upset stating they wanted the resident to be sent to the emergency room . The resident's family was upset regarding the condition of the resident's catheter and overall appearance. Review of hospital notes, dated 03/04/23 revealed Resident #138's indwelling catheter had aged sediment and crusting in the line and urethral meatus (the opening of the urethra) at tip of the penis. The catheter was draining purulent urine and needed to be replaced. Hospital staff collected laboratory work to check for a urinary tract infection (UTI). The resident vital signs included temperature 97.7 degrees Fahrenheit, heart rate 75 beats per minute, respirations 16 per minute and blood pressure was 121/81. The resident was admitted for a UTI and received intravenous antibiotics including Ciprofloxacin 500 milligrams (mg) every 12 hours and Ceftriaxone one gram with dextrose. On 04/11/23 at 1:37 P.M. interview with the Director of Nursing (DON) verified the facility had not implemented a comprehensive and individualized plan of care related to the resident's urinary catheter. On 04/11/23 at 4:19 P.M. interview with the social worker from the hospital revealed Resident #138 was admitted to the hospital with a urinary tract infection, the resident's indwelling catheter had crusting in the line and at the tip of penis. On 04/12/23 at 9:00 A.M., interview with Licensed Practical Nurse (LPN) #211 revealed (urinary) catheter lines get crusty when there is a lack of cleaning. The LPN indicated aged sediment and crusting don't happen overnight, it takes time to develop. On 04/12/23 at 8:26 A.M., interview with the Nurse Practitioner (NP) revealed she was not aware of concerns with the resident's catheter. The NP stated sediment and crusting take time to develop and staff should have observed it when providing care daily. Review of facility policy titled Indwelling Urinary Catheter Care Procedure, dated 2022 revealed staff were to start cleaning around the urethral meatus where the catheter enters the resident using warm soapy washcloth. Use a new cloth to cleanse the entire catheter from point of entry at the meatus to about four inched below. 2. Review of the medical record for Resident #54 revealed an admitted [DATE] with diagnoses including other psychoactive substance abuse with intoxication, neuromuscular dysfunction of bladder, bipolar disorder, and chronic kidney disorder. Review of a plan of care, dated 09/28/22 revealed the resident had an indwelling catheter related to obstructive uropathy. Interventions included to assess and document output as per facility policy, provide catheter care per routine, and position catheter bag and tubing below the level of bladder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. The assessment indicated the resident had an indwelling urinary catheter. The resident was independent for activities of daily living except toileting. Review of a nursing progress note, dated 02/26/23 at 5:18 P.M. revealed Resident #54 pulled her (urinary) catheter out, staff tried to reinsert but were unable. The resident was sent to the hospital. A note dated 02/27/23 at 4:38 A.M. revealed the resident returned to the facility without a urinary catheter in place. There was no evidence the physician was notified or that the need for a urinary catheter was evaluated at that time. Review of a nursing progress note, dated 02/27/23 at 3:15 P.M. revealed the resident had been incontinent almost constantly throughout the day per the resident and staff. The resident had been dyspneic (difficulty breathing with minor exertion) with frequent changing of briefs. The nurse practitioner (NP) was contacted and provided an order to have an indwelling catheter reinserted at that time. Review of a skin assessment dated [DATE] revealed Resident #54 had new onset moisture associated skin damage (MASD) to right and left iliac crest (hip bone), groin, and labia folds. On 04/10/23 at 1:17 P.M., an interview with Resident #54 revealed the hospital staff did not reinsert the catheter on 02/26/23 and the facility staff had to provide care and change her all day. Resident #54 indicated staff had to look for a catheter because they didn't have any. Resident #54 could not identify the staff involved in looking for the catheter. On 04/12/23 at 11:00 A.M. interview with the Director of Nursing (DON) revealed Resident #54 had been transferred to the emergency roiagnom on [DATE] to have her urinary catheter re-inserted. However, the resident returned without a catheter because she stated the hospital indicated the resident didn't need one. The DON verified staff should have contacted the physician/NP upon the resident's return to the facility to discuss the need for a catheter and/or to obtain an order to have a new catheter inserted. This deficiency represents non-compliance investigated under Complaint Number OH00140892 and Complaint Number OH00140731.

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure adequate interventions were implemented to prevent the development of a pressure ulcer for Resident #3. Actual Harm occurred on 09/01/21 when Resident #3 who required extensive assistance from staff for bed mobility and transfers was found to have an unstageable pressure ulcer (a wound caused by pressure that had full thickness tissue loss in which the base of the ulcer was covered by slough (nonviable dead tissue that is white or yellow in appearance) or eschar (dead tissue that was usually black) to the left ischial lower and back part of his hip. Initial measurements of the pressure revealed the area to the left ischial measured five centimeters (cm) in length by 4.5 cm width with 100% necrotic tissue. This affected one of three residents reviewed for pressure ulcers. The facility identified four current residents (Residents #1, #3, #10 and #11) with pressure ulcers. Findings Include: Review of the medical record for Resident #3 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Braden Scale Pressure Ulcer Risk Assessment, dated 10/29/18 revealed Resident #3 was at low risk for pressure ulcers. The assessment form indicated the resident had no impairment with his sensory perception, was very moist, chair fast and he had a potential problem with friction and shear. Review of care plan, dated 02/06/18 revealed Resident #3 had an activities of daily living self-care performance deficit related to [CONDITION(S)] and he was wheelchair bound. Interventions included physical assistance with transfers, bathing, showering, hygiene and dressing. Review of care plan, dated 02/06/18 revealed Resident #3 had a potential for impairment to skin integrity related to occasional urine incontinence and limited mobility that was related to his [CONDITION(S)]. Interventions included encourage good nutrition and hydration, keep skin dry and clean, turn and reposition every two hours while in bed, and cushion to wheelchair to protect the skin while up in wheelchair. Review of an Admission/ Readmission Evaluation- V3 form, dated 07/02/21 revealed Resident #3 was at risk for pressure ulcers as he was slightly limited with sensory perception, constantly moist, chair fast and had potential for friction and shear. Review of quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/13/21 revealed Resident #3 had impaired cognition. The assessment revealed the resident required extensive assistance from one staff for bed mobility, transfers and dressing. The resident was totally dependent of one staff for toileting and unable to ambulate. The assessment identified the resident was at risk for pressure ulcers. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident also had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Braden Scale Pressure Ulcer Risk Assessment, dated 09/01/21 revealed Resident #3 was at high risk for pressure ulcers because he was very limited with sensory perception, very moist, chair fast, very limited with mobility and had a problem with friction and shear. Review of a nursing note, dated 09/01/21 at 1:13 A.M. and authored by Licensed Practical Nurse (LPN) #610 revealed Resident #3 continued to state, My Butt Hurts. The LPN completed an assessment at that time and observed a pressure ulcer to the area. LPN #610 documented the resident's left ischial lower and back part of his hip bone had a circular area that measured 5.0 centimeter (cm) in length and 4.5 cm in width. The LPN noted the area contained black eschar (dead tissue). Resident #3's physician was notified at that time and ordered a treatment, weekly weights, dietary consult and wound consult. Review of facility form labeled, Weekly Wound Assessment V1-V5 dated 09/01/21 and completed by Assistant Director of Nursing (ADON)/ Wound Nurse #603 revealed Resident #3 had a pressure wound that was unstageable to his left ischium that measured four cm in length by four cm in width, with a depth that could not be determined. The area was described as in house acquired and was first identified on 09/01/21. The assessment revealed there was 100 percent thick adherent devitalized necrotic tissue. The assessment included to off load and reposition, air mattress and limit the resident's chair time to two hours at a time. Review of wound progress note labeled, Wound Evaluation and Management Summary, dated 09/01/21 and authored by Wound Physician #609 revealed Resident #3 had an unstageable pressure ulcer due to necrosis to his left ischium and the wound bed had moderate serous drainage. Wound Physician #609 described the wound as a pressure ulcer that measured four cm in length by four cm width with an undetermined depth. Wound Physician #609 revealed the wound had 100 percent thick adherent devitalized necrotic tissue that required her to surgically debride the wound to establish margins of viable tissue. She ordered treatment to the area, Santyl (a [MEDICATION(S)] agent) and calcium alginate once daily. On 09/07/21 at 11:47 A.M. interview with ADON/ Wound Nurse #603 verified Resident #3's pressure ulcer to his left ischium area was found as an unstageable pressure ulcer. The ADON revealed LPN #610 had notified her of the wound as it was black with necrotic tissue. The ADON revealed she had Wound Physician #609 evaluate the resident the same day (09/01/21) and Wound Physician #609 classified the pressure wound as unstageable and she surgically debrided the area as the area contained black necrotic eschar. On 09/07/21 at 12:05 P.M. interview with Resident #3 revealed care concerns. The resident revealed sometimes staff turn him every two hours and sometimes they did not. The resident reported he felt sometimes he did not see any staff for a long period of time. The resident was unsure how long he would remain on one side (without repositioning) but indicated it seemed like a long time as he revealed his butt usually started to hurt. On 09/07/21 at 1:02 P.M. LPN #600 was observed providing wound care for Resident #3. During the observation, LPN #600 described Resident #3's wound as unstageable and approximately four cm in length by four cm in width. She revealed she was unable to determine the depth of the area as the area contained white/yellow material inside the wound bed. LPN #600 revealed she was not sure if the wound had improved or if the wound had declined as this was the first time she had seen the wound. LPN #600 completed the dressing change as ordered. On 09/07/21 at 1:10 P.M. interview with ADON #604 revealed there were days when there were not enough staff to ensure residents were turned and repositioned every two hours. She revealed the residents get turned it just may not be every two hours as it may be delayed, and the residents may not get turned then timely. This may have contributed to the development of Resident #3's unstageable pressure ulcer as the resident was at high risk for skin breakdown and required staff assistance to turn and reposition in bed. On 09/07/21 at 4:16 P.M. interview with State tested Nursing Assistant (STNA) #608 revealed she does not feel there was enough staff to turn and reposition residents including Resident #3 every two hours as there were just too many residents on her assignment. She revealed this happened frequently, at least a few times a week where she was unable to turn and reposition residents timely. Review of facility policy titled, Skin and Wound Care best Practices, dated 03/12/21 revealed the purpose of the policy was to prevent unavoidable skin complications by providing pressure reduction and redistribution for those residents at risk by reposition at a frequency determined by risk assessment to avoid pressure to bony prominences. This deficiency substantiates Complaint Number OH 296.

Based on observations, review of the medical record, facility investigation, policy and procedure on elopement, interview with staff, legal guardian and the elevator contractor, the facility failed to provide appropriate supervision to prevent the elopement from the secured behavior unit for one resident, Resident #25, who was assessed as having delusions and [DIAGNOSES REDACTED].M. when Resident #25 exited the facility without staff knowledge. The likelihood of actual harm that was Immediate Jeopardy occurred when Resident #25 got onto the unsecured freight elevator from the fifth-floor secured behavior unit and exited the facility. The likelihood of actual harm, serious injury or death occurred as Resident #25's location was unknown to the facility, family, and police from 09/19/20 until he was found on 09/26/20 due to delusional behavior, illogical thought processes and cognitive impairment while unsupervised in the urban environment. This affected one of three residents reviewed for elopement risk. The facility identified 16 additional residents (Residents #6, #15, #17, #39, #46, #93, #94, #99, #100, #101, #108, #109, #111, #113, #120, and #126) at risk for elopement. The facility census was 129. On 09/23/20 at 3:50 P.M., the Administrator, Director of Nursing (DON), and Regional Nurse #503, were notified a situation of Immediate Jeopardy was identified which began on 09/19/20 at 10:35 P.M. when Resident #25, who resided on a secured behavior unit and exhibited exit seeking behaviors was identified as missing from the facility. Resident #25 exited via the freight elevator, which had been left unlocked. Resident #25 was subsequently located by a family member on 09/26/20 at approximately 3:00 P.M. and was transported to the hospital for assessment and admission to the psychiatric unit. The Immediate Jeopardy was removed on 09/25/20 when the facility implemented the following corrective actions: · On 09/19/20 at approximately 10:25 P.M. Resident #25 was last observed by Stated tested Nurse Aide (STNA) #401 on the fifth floor behavior unit. · On 09/19/20 at approximately 10:35 P.M. Resident #25 was identified as missing from the fifth floor and an immediate search of the facility was performed. Licensed Practical Nurse (LPN) #451 and Registered Nurse (RN) #500 searched the basement, first, and second floors. RN #471 also searched the second floor. RN #468 and LPN #465 searched the fifth floor. RN #468 and STNA #488 performed a two-block radius search outside the facility at approximately 11:00 P.M. · On 09/19/20 at 11:15 P.M. the DON was notified of Resident #25's elopement by RN #471. · On 09/19/20 at 11:30 P.M. a head count was performed to account for all residents by RN #471, RN #500, RN #468, and RN #470. · On 09/19/20 at 11:30 P.M. all exit doors and windows were checked to identify proper function by RN #471 in the basement and third floor, by RN #500 on the first and second floors, by RN #468 on the fourth floor, and by RN #470 on the fifth floor. · On 09/19/20 at 11:40 P.M. the kitchen coolers and freezers were checked by the DON. · On 09/19/20 at 11:45 P.M. the temperature was 45 degrees Fahrenheit, verified by Regional Clinical Nurse (RCN) #502. · On 09/19/20 at 12:15 A.M. the local police department was notified, and a report was completed at the facility. · On 09/19/20, notification was attempted via text message and voicemail message to Resident #25's guardian at 12:21 A.M. and to the physician at 12:30 A.M. · On 09/19/20 at approximately 1:00 A.M., a second search of the facility was conducted by the DON in the basement and first floor, by LPN #458 on the second floor, by RN #468 on the third floor, by STNA #488 on the fourth floor, and by RN #470 on the fifth floor. · On 09/20/20 at 8:00 A.M. all exit doors and windows were inspected again to ensure proper function by Activity Staff (AS) #401. Two door issues were identified, a door on the secured fifth floor unit was sticking and a door on the unsecured skilled unit on the third floor was not alarming when opened. On 09/20/20 at 8:30 A.M., staff were designated to remain at the identified points of concern until repairs were made on 09/23/20 at 10:00 A.M. · On 09/20/20 at 9:00 A.M., AS #401 started operational checks of the elevator security function which were to be conducted daily. · On 09/20/20 at approximately 9:00 A.M. review of the Elopement Binder was conducted by the Social Services Designee (SSD) #406. · On 09/20/20 at 11:00 A.M. the DON performed a daytime search for Resident #25 on the facility grounds. · On 09/20/20 at 11:00 A.M. the elevators were inspected by the contracted elevator company who identified debris in the key mechanism which allowed the key to turn but prevented the mechanism from engaging and locking. The debris was removed. · On 09/20/20 and 09/21/20 all current staff were re-educated on the elopement policy and procedure by the DON, RN #473, and LPN #499. Staff unable to report to the facility were educated by phone. · On 09/20/20 elopement drills were conducted at 1:00 P.M. with nine staff members; at 5:45 P.M. with seven staff members; and at 1:15 A.M. with nine staff members. · On 09/21/20 at approximately 7:00 A.M. review of the daily door inspection log by RCN #502 revealed no abnormalities. · On 09/21/20 from 8:00 A.M. to 1:00 P.M. elopement risk assessments were completed for all residents by the DON, RN #473, LPN #465, LPN #455, LPN #459, LPN #463, LPN #454, and LPN #466. Sixteen residents were identified at risk for elopement. · On 09/21/20 from 9:00 A.M. to 12:00 P.M. the Admissions Director (AD) #402 made calls to local hospitals trying to locate Resident #25. · On 09/21/20 at 1:00 P.M. review of the 16 residents at risk for elopement was completed by the Interdisciplinary Team (IDT). The review included an elopement risk assessment, physician orders, and interventions. · On 09/23/20 at approximately 4:00 P.M. adjustments were made to the video camera system to ensure proper placement for observation of the interior areas of the basement. · On 09/24/20 interviews from 11:41 A.M. to 12:04 P.M. with Housekeeper (HSK) #438, HSK #436, LPN #455, LPN #464, LPN #454, STNA #491, and Security Staff (SS) #413 revealed they were all in-serviced on elopement. · On 09/24/20 at 1:42 P.M. an observation of the facility elevators was conducted. Environmental Services Director (ESD) #434 pushed the call button for the standard set of elevators on the secured second floor unit, without using a key to unlock the elevator. The elevator button lit up red and came to the unit. ESD #434 obtained the elevator key from floor staff and was observed to lock the elevator to prevent unauthorized access. ESD #434 confirmed the elevator had been left unlocked. · On 09/24/20 at 3:00 P.M. all elevator keys for the secured units were to be limited to the charge nurse and security staff. Key retrieval from all other staff members was implemented. · On 09/24/20 by 8:30 P.M., all staff were educated on elevator security by the DON, Dietary Manager (DM) #433, ESD #434, Director of Rehabilitation (DOR) #503, and the Administrator. · Beginning on 09/25/20 audits of staff knowledge regarding elevator security were conducted and would continue five days a week for four weeks and then two times monthly by the Administrator. · Elopement drills were conducted on 09/20/20 and would continue weekly for four weeks with all staff required to participate in one of the weekly drills. Findings to be reviewed by the Quality Assurance and Performance Improvement (QAPI) committee to determine continued frequency. · Elopement assessments would continue to be performed upon admission, quarterly, and as needed. Residents identified at risk, which is a score of four or greater, would have their face sheet and picture placed in the elopement binder maintained at the front desk. The resident's physician would be notified of their elopement risk and recommended interventions. · On 09/28/20 at 10:19 A.M. on the secured fifth floor unit and on the second floor at 10:39 A.M., staff were observed monitoring the standard set and freight elevators on each of these units. · On 09/28/20 from 10:20 A.M. to 10:32 A.M. interviews with two LPNs, one security staff, one STNA, and one housekeeper revealed that they were all in-serviced on elevator security. They verified only the nurse and security staff have keys to the elevators on the three secured units, the second floor, the fourth floor and the fifth floor. · On 09/28/20 at 2:58 P.M. interview with RCN #502 revealed all the elevator keys had been collected from staff except for the nurse on the unit and security staff. RCN #502 stated they planned to change the locks on all the elevators for the secured units. RCN #502 stated the elevator company needed to obtain parts, so in the meantime staff were stationed at the elevators until the locks were changed. Although the Immediate Jeopardy was removed on 09/25/20, the deficiency remained at a Severity Level 2 (no actual harm with the potential for minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #25's medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had intact cognition but also had delusions. He required supervision for ambulation on and off the unit. Resident #25 was independent for bed mobility, transfers, toilet use, eating, and walking in his room. The September 2020 physician orders [REDACTED]. Review of the care plan for Resident #25 initiated on 08/27/20 revealed he had altered cognitive function related to his [MEDICAL CONDITION] [DIAGNOSES REDACTED]. Review of the nursing progress notes revealed an admission note dated 09/18/20 at 11:01 P.M. which indicated Resident #25 was readmitted from a local hospital psychiatric unit on 09/18/20 at 4:45 P.M. His [DIAGNOSES REDACTED]. There were no other progress notes recorded from 09/18/20 through 09/23/20 and no documentation related to his elopement from the facility on 09/19/20. Telephone interview on 09/22/20 at 3:45 P.M. with Resident #25's Legal Guardian (LG) revealed she had received a phone call from the facility and a text message on 09/19/20 at approximately 11:20 P.M. to contact the facility. The LG stated when she woke up the next morning, she called the facility. She wasn't sure of the time but stated it was early. The LG stated she talked with the Administrator who informed her that her brother, Resident #25, was missing. The LG stated the Administrator said they were unsure how Resident #25 had gotten out of the facility. She said the video cameras were checked but there was no evidence found and they were still investigating the incident. The LG stated she went to the police station on 09/20/20 at approximately 9:45 A.M. to file a missing person report but learned the facility had already contacted the police earlier that morning. Interviews on 09/23/20 beginning at 8:14 A.M. with LPN #466 and STNA #491 revealed they heard there was an elopement over the previous weekend but were not working the day of the incident. They said they heard Resident #25 had eloped from the facility on 09/19/20 on second shift but had no other details. Interview on 09/23/20 with Security Staff, SS #412, at 8:27 A.M. verified he heard about Resident #25's elopement but he wasn't working at the time. SS #412 stated he last saw Resident #25 when the resident handed him his lunch tray on 09/19/20 approximately 10 minutes before his shift ended at 3:00 P.M. SS #412 stated the facility had video cameras in the basement. Interview on 09/23/20 at 8:59 A.M. with the Administrator verified Resident #25 eloped on 09/19/20 and he had not been found. The Administrator stated she was notified of the elopement on 09/20/20 at about 2:00 A.M. by the DON who also said the police had been contacted. Interview on 09/23/20 at 9:09 A.M. with the DON revealed they determined Resident #25 pushed the button to call the freight elevator to the fifth floor. The elevator came to the secured fifth floor and he was able to get on the elevator. The DON stated the STNA noticed Resident #25 was in the hall by the elevator prior to him leaving. He was not wearing a shirt or mask and the STNA directed him to his room to get a shirt and mask. The DON stated the STNA went to the bathroom and when he came back, another resident told the STNA that Resident #25 got on the freight elevator. The DON stated the elevators are normally kept locked and staff had to use a key to unlock them. The DON stated the contracted elevator company came out and found something, but the elevator appeared to be locked. The DON stated the elevator wasn't locking and was able to be called to the secured unit. The DON stated she didn't know where Resident #25 exited the facility but said there was a staff member stationed at the front desk 24 hours a day and he did not go out that door. The DON stated there were video cameras at the front desk but the cameras outside of the front entrance did not work. The DON stated she was told the basement camera was also broken. The DON stated the Administrator would have checked the video surveillance. Interview with the Administrator on 09/23/20 at 9:18 A.M. revealed she didn't get an invoice for the elevator service provided on 09/20/20 but said there was a piece of plastic in the elevator lock that kept the elevator unlocked. The Administrator stated the elevator was last serviced a month ago, but it was something unrelated. The Administrator stated she viewed the video recordings from the back of the building, but there was nothing on it. The Administrator stated the camera worked but it was pointed toward the door and they couldn't get it to stay in the proper place. The Administrator stated she didn't check the video recording from the camera at the front desk as this area was manned and they verified during interview with that staff person that no one left the building through the front entrance. On 09/23/20 at 9:25 A.M., review of the local police department website revealed a missing person page which contained Resident #25's information and it reported he went missing on 09/20/20. Review of the undated facility investigation revealed each unit did a head count for their residents and witness statements were obtained. Staff searched the grounds, facility, and the surrounding neighborhood for a two-block radius and Resident #25 was not located. The DON and Administrator were made aware Resident #25 was missing. The physician and family ware notified. The police were notified and completed a report at the facility. Review of a handwritten witness statement dated 09/19/20, authored by STNA #489, revealed he was working on the fifth floor. He said there was no nurse or security personnel on the unit. He said at about 10:25 P.M., he observed Resident #25 go to the elevator without a shirt or face mask. STNA #489 told Resident #25 he needed a shirt and mask then he went to the restroom. When he returned, Resident #7 told him he saw Resident #25 get on the freight elevator, which was about 10:35 P.M. STNA #489 said he went to the basement to see if he could see the resident but didn't so then he informed the nurse. Review of a handwritten signed statement by Resident #7, dated 09/20/20 at approximately 12:30 P.M., revealed he saw a guy by the elevator he had never seen before. He said he told the STNA he saw the guy get on the freight elevator and the next thing you know, he was gone. Telephone interview on 09/23/20 at 11:30 A.M. and 11:45 A.M. with Elevator Contractor #600 revealed they serviced the freight elevator on the fifth floor on 09/20/20. He was not in the office and couldn't recall the exact time. He said the elevator key switch had something in it and couldn't be locked. The contractor stated nothing needed to be replaced and it was considered customer damage. The contractor stated the position of the lock (open or locked) would stay in place once something was lodged into the locking mechanism. He stated a key wouldn't work to lock the elevator once this occurred. Interview on 09/23/20 at 12:53 P.M. with STNA #489 revealed he had seen Resident #25 walk out of his room with no shirt or mask on going toward the elevators. STNA #489 stated he asked the resident where he was going and Resident #25 stated he need some air, needed to go walk to get some air. STNA #489 stated he told Resident #489 that he was on the floor alone and couldn't take him for a walk. He then asked him to go put on a shirt and mask. STNA #489 stated as he was going to the restroom, he saw Resident #25 walking back up the hall wearing a face mask and a white shirt, but he proceeded to the restroom. STNA #489 stated when he returned Resident #7 said, as he pointed to the freight elevator, that guy got on the elevator. STNA #489 stated he asked Resident #7 what guy and the Resident #7 stated that guy that was trying to get on the elevator. STNA #489 said he then notified the nurse. STNA #489 stated there wasn't a nurse or security on the unit at that time. STNA #489 stated there was a nurse that came up to pass medications around dinner time, but he wasn't sure if it was before or after dinner. STNA #489 stated he didn't go search the basement until around 11:00 P.M. STNA #489 said around that time, security personnel came to the floor and pushed the button to call the freight elevator and it came right up to the floor. He said the security personnel stated that's how he got out. Interview on 09/24/20 at 9:47 A.M. with Facility Scheduler (FS) #409 revealed she does the schedules for the STNA's, nurse's and security staff. FS #409 stated she schedules two security staff, one for the fourth floor and one for the fifth floor for all three shifts. FS #409 stated on the fifth floor she schedules two nurses and one aide on first and second shifts and one nurse and one aide for the third shift. FS #409 stated on the evening of 09/19/20 she only had one call off and that was the security staff. FS #409 stated she didn't know why the nurse scheduled wasn't on the unit. FS #409 stated the fifth floor only needed one aide as the residents were pretty much independent or required minimal staff assistance. Interviews on 09/28/20 from 10:20 A.M. to 10:32 A.M. with LPN #454, SS #412, STNA #483, LPN #463, and HSK #436 revealed they were all in-serviced on elevator security. They all stated the only staff to have elevator keys were security staff and the nurses working on the locked units. Interview with the Administrator on 09/28/20 at 10:28 A.M., revealed Resident #25 was found by his sister on 09/26/20 and was currently in the hospital. The Administrator said Resident #25 was okay and that was all the information she had been given. Interview with Nurse Practitioner (NP) #610 on 09/28/20 at 12:52 P.M. revealed she was contacted on 09/20/20 but wasn't sure of the time. She said she was informed Resident #25 had eloped from the facility. NP #610 stated she hadn't seen the resident since he was readmitted from the hospital on [DATE]. Interview with the DON on 09/30/20 at 11:04 A.M. revealed there was a staffing issue identified on 09/19/20, the day Resident #25 eloped from the facility. She indicated the nurse scheduled to work on the secured fifth floor had reported off, but they found a replacement nurse. The DON said she later found out the replacement nurse did not report to work and did not report off to anyone. The scheduler then directed two nurses working on different floors to go and cover the fifth floor as needed for the second shift. The only staff person working the secured fifth floor unit for the entire second shift on 09/19/20 was STNA #489. Review of the facility's policy titled, Elopement/Unauthorized Absence Policy, revised on 10/03/19 revealed the facility would identify residents with potential and/or actual risk factors for elopement and protect the resident through development and implementation of safety interventions. This deficiency substantiates Complaint Number OH 978.

Based on record review, interview and review of manufacturer guidelines the facility failed to ensure a mechanical lift (Hoyer) sling was maintained in good repair resulting in the Hoyer strap breaking causing a fall to Resident #2. Resident #2 sustained actual harm when he suffered a fracture of the right hip and right femur. This affected one of three residents reviewed for falls. Findings include: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment completed on 01/27/17 revealed the resident was totally dependent on staff for bed mobility, transfers, locomotion, dressing, eating, toilet use, personal hygiene and bathing. An activity of daily living care plan dated 09/13/16 revealed the resident had self-care deficits due to dementia and subdural hemorrhage and required the use of a Hoyer lift for transfers. A fall care plan dated 09/13/16 revealed the resident was at risk for falls related due to a history of falls and functional deficits. A Hoyer lift was required for all transfers. Review of a nurse's note dated 04/22/17 at 12:30 P.M. revealed Resident #2 had a fall with injury. State tested Nurse Aides (STNA) #24 and #37 called for assistance from the nurse. Resident #2 was found on the floor on his right side, and his head was bleeding. The resident was alert and complained of back pain. The STNAs said the resident had fallen during the Hoyer lift transfer. The resident's head was cleansed and bandaged. A call was placed to 911 and at 12:45 P.M., Resident #2 was transferred to the hospital. A nurse's note dated 04/23/17 at 2:45 A.M. revealed the hospital was contacted and hospital staff informed the facility Resident #2 had been admitted with [DIAGNOSES REDACTED]. Review of the fall investigation revealed on 04/22/17 at 12:30 P.M. STNA #24 and STNA #37 called for assistance. When LPN #36 arrived Resident #2 was on the floor in his room on his right side with his legs resting on the base of the lift, and his head was bleeding. STNA #24 and #37 said the resident fell during transfer. A call was placed to 911 and at 12:45 P.M. the resident was transferred to the hospital. Witness statements obtained from STNA #37 and STNA #24 on 04/22/17 revealed both stated while they were transferring the resident from the chair to the bed the strap at the bottom of the sling broke and Resident #2 fell to the floor. Review of the manufacturers' General Guidelines for the Hoyer/mechanical/ lift revealed the slings would accommodate from 350 to 600 lbs. Care instructions indicated the slings should be inspected after each laundering for wear, tear, and loose stitching. Bleached, torn, cut, frayed, or broken slings were unsafe, could result in injury and should be discarded immediately. Review of the facility's undated Mechanical Lift Transfer Procedure revealed instructions on how to transfer a resident but did not include checking the straps on the sling for wear and tear prior to use. On 05/02/17 at 4:35 P.M. the Administrator and Director of Nursing (DON) verified on 04/22/17 during a Hoyer lift transfer a strap broke off the sling causing Resident #2 to fall out of the sling onto the floor. The resident was transferred to the hospital and admitted with fractures of the right hip and femur. They verified manufacturer instructions indicated the straps on the slings should be checked after each laundering and discarded for signs of wear and tear to prevent possible injury. The slings were able to accommodate from 350 to 600 lbs. and the resident weighed 127 lbs. which was well under the weight limit. Both verified the strap on the sling would have had to been worn or damaged to have torn off during the Hoyer transfer. On 04/24/17 the facility initiated a Hoyer sling audit. Prior to 04/24/17 there was no evidence straps on the slings were checked for wear and tear and discarded as needed. This deficiency substantiates Complaint Number OH 949.

Based on review of a facility Self Reported Incident, interview and medical record review, the facility did not implement planned interventions to prevent the occurrence of abusive resident to resident behaviors. Actual Harm occurred to Resident #5 who sustained a broken tooth and lacerations to her lip that required sutures after she was pushed to the floor by another resident. This affected one of three residents reviewed for behaviors, of 85 residents in the facility who had behaviors. Findings include: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #5 had verbal behavioral symptoms directed toward others that occurred every day and significantly interfered with her social interactions and disrupted her living environment. Resident #5 wandered about the unit and intruded on the privacy of others. A plan of care to address Resident #5's behaviors of spitting on other residents, starting altercations with other residents and displaying verbal aggression with staff and other residents was initiated on 03/03/16. Interventions included allowing Resident #5 to express her thoughts and venting of feelings, encouraging her to participate in care and referring her to psychiatric services as needed. A facility Self Reported Incident dated 06/29/16 revealed that on 06/28/16 at 11:30 P.M., Resident #5 disturbed Resident #7 by following him around when he wanted to be left alone. Resident #7 then pushed Resident #5 and she fell . Resident #5 sustained a small cut inside her mouth. She was transferred to the hospital for an evaluation. Review of the hospital emergency department Patient Visit Information dated 06/29/16 revealed Resident #5 was treated for [REDACTED].#5's front tooth broke and became embedded into her lower lip when she fell after being pushed down by Resident #7. The tooth was removed and Resident #5 received sutures to the inside and outside of her lower lip. During an interview on 07/06/16 at 4:15 P.M., the director of nursing (DON) indicated the incident between Resident #5 and Resident #7 occurred on 06/28/16 at 11:02 P.M., which was during shift change. The DON indicated Resident #5's behaviors escalated into an incident with Resident #7 because the nurses and the security guards on the fifth floor were engaged in shift to shift report at that time and were not actively monitoring the residents on the floor. This deficiency substantiates Complaint Number OH 295.

Based on record review and interview, the facility failed to provide adequate supervision to prevent a resident from wandering into another resident's room and sustaining an injury. Actual Harm of an injury above the nose that required two stitches to close occurred to Resident #59 when she wandered into another resident's room. This affected one of three residents reviewed. Findings include: Review of Self Reported Incident # with date of occurrence of [DATE] documented an alleged physical abuse that was unwitnessed between Resident #59 and Resident #130. Review of the medical record of Resident #59 revealed she was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #59's Minimum Data Set (MDS) 3.0 assessments dated [DATE] and [DATE] revealed the resident was cognitively impaired, had delusions, and had wandering behaviors that occurred daily. The wandering behavior did not significantly intrude on the privacy or activities of others. She was identified to have physical behavioral symptoms directed towards others, including hitting, kicking, pushing, scratching, grabbing, and verbal behavioral symptoms directed towards others, including threatening others, screaming at others, cursing at others, which were assessed to occur daily. Review of Resident #59's behavior care plan revealed the assessed behavior of daily wandering was not identified as a problem with a measurable goal or identified approaches to address wandering behavior. Review of Resident #59's nurses progress note dated [DATE] at 10:16 P.M. documented at 4:20 P.M. Resident #59 was up in wheelchair and wandered into another resident's room (#130). She was seen in the hallway screaming saying " a man hit me". She has a cut beside her left eyebrow and blood all over her face. Ice was applied. Physician notified and ordered to send resident out. The son was notified and the hospital was notified. Vital signs were 98.2 temperature, 60 pulse, respirations 18 and blood pressure ,[DATE] and pulse oxygen level was 98 percent on room air. The resident was transported at 5:25 P.M. Review of Resident #59's psychologist progress note dated [DATE] at 9:51 A.M. documented this resident with late stage dementia and chronic history of schizophrenia, extremely delusional, disoriented, unaware of her own actions, apparently wandered down hallway looking for male friend who had expired. Because of major disorientation she went in Resident #130's room, who had late stage Huntington's Chorea. There were no witnesses, and neither could even remember what occurred and the male resident rarely spoke. It appeared Resident #59 was hit by Resident #130. Review of the medical record revealed Resident #130 was admitted on [DATE]. [DIAGNOSES REDACTED]. The resident received hospice services. Review of the MDS 3.0 assessment dated [DATE] documented overall behaviors did not put others at significant risk of physical injury. Review of Resident #130's MDS 3.0 assessment dated [DATE] identified Resident #130 with a short term and long term memory problem. He was able to identify the location of his room and that he was in a nursing home. He was assessed as having severely impaired cognitive skills for daily decision making. The resident was assessed to have physical behavior symptoms, including hitting, kicking, pushing, grabbing scratching, and verbal behavioral symptoms directed towards others, including threatening others, screaming at others and cursing at others. Nursing progress note dated [DATE] at 4:30 P.M. and written as a Late Entry for Resident #130 documented this writer went to the resident's room, resident was standing there and there was blood on the floor. The nurse was unable to assess resident because of his aggressive behavior. The nurse asked the resident what happened. The resident did not verbalize what happened and stood in his room with a blank stare. The physician was contacted and order given to send to the resident to the hospital. The resident continued to be monitored until his departure. The resident's Power Of Attorney (POA) and hospice were notified. Review of Resident #130's transfer assessment documented the resident can be physical at times, stays to himself, cannot socialize, gets combative when other residents in close proximity. Review of the Resident #130's psychologist progress note dated [DATE] at 10:04 A.M. documented a female resident accidentally walked into Resident #130's room. This resident (Resident #130) who is very easily startled, agitated and reactive either hit or kicked female resident. No witnesses. This resident is in late stage of Huntington's Chorea. He is oriented times zero, most of the time he is totally unaware of his own actions. He also has [DIAGNOSES REDACTED]. He has muscle wasting, lack of coordination, muscle weakness. Due to Huntington's he has [DIAGNOSES REDACTED], impaired ability to carry out motor functions, [DIAGNOSES REDACTED], failure to appropriately recognize or respond to others and disturbance of executive functioning. This apparent act was probably not intentional, he was startled, could not identify who or why someone entered his room, reacted by some physical action as due to his depressed and declining cognition was not only startled which activated his "flight or fight response," as in his mind he felt physically threatened. Non-medication interventions: received phone call, staff to continue to monitor resident as he did not come out of the room, staff also monitored hallway to assure no other resident went down near this room. The psychiatrist was notified. Interview with Licensed Practical Nurse (LPN) # 200 on [DATE] at 6:00 P.M. indicated on [DATE] Resident #59 went into Resident #129 and Resident #170's room. She indicated she would redirect Resident #59 away from Resident #130's room. Interview with LPN #203 on [DATE] at 3:00 P.M. indicated Resident #59 would wander up and down the halls. Interview with State tested Nurse Aide (STNA) #202 on [DATE] at 4:30 P.M. indicated Resident #59 would wander in and out resident rooms. Sometimes she would go in a room and holler. STNA #202 indicated she had not seen Resident #59 in Resident #130's room before. Most of time STNA #202 would catch her near the room or doorway and redirect her. She indicated if anybody would make a loud noise, Resident #130 would walk towards them. She was not aware of any attempt by Resident #130 to hit Resident #59 before. She indicated Resident #59 had a friend that lived across from her room and next to Resident #130's room. She indicated Resident #59 would sit with Resident #170 in the dining room. If she went into his room, he would bring her out. Interview with LPN #201 on [DATE] at 12:15 P.M. indicated she would see Resident #59 wander in and out of resident rooms. She indicated she has observed Resident #59 in the doorway of Resident #130's room but not in the room. She indicated when she observed Resident #59 in Resident 130's doorway or near his room she would redirect Resident #59. She indicated Resident #59 could self propel herself in a wheelchair. Interview with Resident #129 on [DATE] at 12:15 P.M. indicated Resident #59 would come into his room and use his bathroom. Interview with the Administrator on [DATE] at 11:00 A.M. indicated Resident #130 did not have any documented self reported incidents of hitting other residents. Interview on [DATE] at 3:30 P.M. with Resident #59's physician, Physician #1, indicated Resident #59 was hospitalized in the neurological intensive care unit and monitored for subdural hematoma. The resident had three Computerized Axial Tomography scans and all were negative which indicated the resident did not have a subdural hematoma. He indicated the resident received two stitches above the nose on the forehead area and had bruising under the eyes. This deficiency substantiates Complaint Number OH 491.

Based on medical record review, staff interview, and review of the facility elopement policy, incident/accident report, facility's investigation, and the police missing person report, the facility failed to ensure that one resident (Resident #79) from a sample of eleven residents identified at risk for elopement was supervised to prevent elopement from the facility. Resident #79 was assessed as a high risk for elopement and unsafe if away from the facility unsupervised. This resulted in Immediate Jeopardy for Resident #79, whose whereabouts were unknown by facility staff for 24 hours after he left the facility. Facility census was 163. On 06/19/12 at 2:32 P.M., the facility administrator, corporate regional director of operations, director of nursing (DON), assistant director of nursing (ADON), and the administrator in training were notified that Immediate Jeopardy began on 06/17/12 at 3:08 P.M. when Resident #79 was observed walking outside in the parking lot of the facility. Security guards at the front door of the facility did not observe Resident #79 leave. The only door in the facility that was not alarmed was in the basement, which was accessible by an elevator that was left unlocked. The resident's whereabouts were unknown until 06/18/12 at approximately 3:30 P.M., when Resident #79's sister called and informed the administrator the resident was found at their mother's home. Resident #79 was not injured or harmed, but was taken to the hospital by family. The Immediate Jeopardy was removed on 06/20/12 at 2:30 P.M. when the facility implemented the following corrective actions: ? On 06/18/12 at 3:30 P.M., the facility was notified that Resident #79 was sent to the hospital by his family and did not return to the facility. ? On 06/18/12, the DON and nursing staff assessed 163 residents in the facility to determine their correct elopement risk. ? On 06/18/12, the DON reviewed the records of 10 residents identified as at risk for elopement (Resident #6, #26, #33, #41, #53, #75, #113, #120, #133 and #163) and verified care plans were developed and appropriate interventions were implemented. ? On 06/18/12, the DON began educating all facility staff in person or by telephone on the facility elopement policy dated July, 2011; every 30 minute visual check of new admissions, the service elevator policy, and the elevator key policy. As of 06/21/12, eight of 170 employees had not been in-serviced. ? On 06/19/12, staff implemented every 30 minute visual observations of four residents identified by the facility as high elopement risk who resided on a non-secured floor of the facility. ? On 06/19/12, all security staff were educated on security rounds by the staff development nurse, including checking the freight elevator to assure it was locked to prevent access to the basement, stairwells, basement, exits and the delivery door. Auditing tools were developed by the corporate licensed social worker on 06/20/12 to ensure compliance with the monitoring policy. ? On 06/19/12 at 4:00 P.M. an accounting of all elevator keys was completed by the administrator and the maintenance director. ? By 06/20/12, facility policies were revised and implemented that addressed use of the service elevator, locking of the elevator panel to prevent access to the basement, and accountability of elevator keys. ? On 06/20/12 at 9:50 A.M., Security Staff #8 demonstrated that the service elevator was locked to the basement, and indicated the service elevator was for staff only, and only authorized staff had keys. ? On 06/20/12 from 1:20 P.M. to 2:30 P.M., interview with Licensed Practical Nurse (LPN) #9, LPN #12, LPN #15, LPN #16, LPN #19, LPN #20, LPN #22 and State tested Nursing Assistant (STNA) #11, STNA #13, STNA #14, STNA #17, STNA #18 and STNA #21 confirmed their knowledge of the elevator policy, LOA policy, elopement policy, and the procedure to follow in the event of a resident elopement from the facility. Although the Immediate Jeopardy was removed when the facility implemented procedures to supervise residents at risk for elopement and prevent exit from the basement door, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) because all staff have not been in-serviced on the facility elopement policy, every 30 minute visual check of newly admitted residents, the service elevator policy, and the elevator key policy. Findings include: Review of the medical record revealed Resident #79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Court documents dated 06/07/12 revealed the resident was declared incompetent and the resident's mother was appointed guardian by the court. Resident #79's medical record contained an Admission Notification form, dated 06/14/12, that indicated Resident #79's special needs were, " has guardian, no leaves of absence (LOA's)". A Leave of Absence-Safety Assessment form, dated 06/15/12, indicated the resident had a [DIAGNOSES REDACTED]. Based on the assessment it was determined the resident's safety would be significantly compromised by leaving the facility independently. An Elopement Risk Assessment form dated 06/15/12 was in the resident record which assessed Resident #79 as a high risk for elopement. The resident was mobile; had a [DIAGNOSES REDACTED]. A Care Plan dated 06/15/12 indicated the resident was determined to be unsafe for unescorted leaves of absence and must be escorted while on leave. Nurse's notes written by LPN #5 on 06/15/12 revealed Resident #79 was admitted to the floor with confusion and had signs of dementia. Review of Resident #79's Resident Demographic Information Sheet dated 06/17/12 revealed it did not contain a photograph of the resident as required by the facility Elopement Policy (revised July 2011). According to this policy, if a resident was determined to be a high elopement risk, the Resident Demographic Information Sheet would be filled out and would include the resident's name, date of birth, date of admission to the facility, a description of the resident, prior residence and places frequented by the resident, and a current photograph of the resident. On 06/17/12 at 6:35 P.M., LPN #4 documented she saw Resident #79 walking alone in the parking lot at 3:08 P.M. When LPN #4 arrived on the floor to begin work, she notified staff (unidentified) Resident #79 was alone in the parking lot. A search was not initiated until 3:45 P.M. The facility administrator, resident's guardian, and the ADON were notified and the police were called. Review of the facility Incident/Accident Report completed by LPN #4 on 06/17/12 at 6:00 P.M. revealed Resident #79 was seen in the parking lot on 06/17/12 at 3:08 P.M. by LPN #4, who was arriving for work. Registered Nurse (RN) #5 went to administer Resident #79's intravenous medication and was unable to locate him on the floor. On 06/17/12 at 3:45 P.M. a code was called and a search began. Security, the ADON, the administrator, and the guardian were notified. The police were called, and a Missing Person Report was completed by the local police department, which was dated 06/17/12. On 06/17/12, LPN #4 wrote in her witness statement that upon coming to work on 06/17/12 at 3:08 P.M., she observed Resident #79 in the parking lot. Upon arrival to the fourth floor, she notified RN #5 (who was preparing an intra-venous medication) and LPN #7 that Resident #79 was in the parking lot. At 3:45 P.M., RN #5 asked where the resident was and was informed the resident was last seen in the parking lot. At that time security was notified and the search initiated. Review of written witness statements revealed there were two security guards who were working at that time. A witness statement written by Security Staff #1 on 06/17/12 revealed he was working at the front desk on 06/17/12 at 3:00 P.M. and Resident #79 did not pass by him. A written witness statement completed by Security Staff #2 on 06/17/12 revealed he worked on 06/17/12, and was outside the facility talking to a family member at 3:00 P.M. Security Staff #2 stated that he did not see Resident #79. He also discovered the service elevator that went to the basement was not locked, which he then locked at that time. On 06/19/12 at 9:00 A.M., interview with the administrator revealed he was notified on 06/17/12 at approximately 3:45 P.M. that Resident #79 was missing and he arrived at the facility within 25 minutes. He said the police were notified and a search was conducted of the building, grounds and surrounding neighborhood. Resident #79 was not found at that time. The administrator said that on 06/18/12 at approximately 3:30 P.M., Resident #79's sister called and informed the facility that Resident #79 was at their mother's house. The resident was not injured. The family took the resident to the hospital for admission and recertification for readmission to the nursing facility. On 06/19/12 at 9:00 A.M., interview with the administrator revealed there were no other elopements from the facility in the past three months. The administrator said the doors in the facility were alarmed except for the door in the basement. The administrator verified the information documented in the facility Incident/Accident report, and the associated witness statements, and the statement that the service elevator to the basement was unlocked. In a meeting on 06/20/12 at 10:20 A.M., the DON said RN #5 worked the second floor on 06/17/12 and went to the fourth floor where Resident #79 resided to hang an IV medication. She verified that LPN #7 was the staff nurse working on the fourth floor when LPN #4 reported at 3:10 P.M. that Resident #79 was in the parking lot. The DON verified that neither RN #5 nor LPN #7 initiated a search for the resident when they were notified by LPN #4 at 3:10 P.M. that Resident #79 was outside the facility in the parking lot. This deficiency substantiates Complaint Number OH 994.

Based on observation, medical record review, staff and resident interview and review of the facility smoking policy, review of the Resident and Responsible Party Handbook and review of the smoking violation reports, the facility failed to provide adequate supervision of residents who smoked cigarettes. Four residents (#62, #68, #136 and #101) were found smoking in unapproved and unsupervised areas of the facility. This resulted in Immediate Jeopardy for four (Residents #62, #68, #136 and #101) who required supervision when smoking cigarettes of 68 residents who smoked in the facility, and placed residents on three of five floors at risk for serious injury or death from fire or smoke inhalation. The facility census was 143 residents. On 07/07/11 at 4:30 P.M. the administrator, director of nursing, Regional Consultant (RC) #1, and RC #2 were notified that Immediate Jeopardy began on 02/04/11 at 2:00 P.M. when Resident #101 was first found smoking unsupervised in his bedroom on the fourth floor. Two additional incidents occurred when Resident #68 was found smoking unsupervised in his bedroom and bathroom on the third floor on 05/04/11 and 05/16/11. The Immediate Jeopardy continued on 06/17/11 at 8:30 P.M. when Resident #62 was smoking while in her bed on the third floor with oxygen in use, and continued on 06/22/11 when Resident #136 was found smoking while in bed on the second floor. The Immediate Jeopardy was removed on 06/30/11 when the facility implemented the following corrective actions: ? Between 03/13/11 and 03/21/11 the facility conducted inservices with all staff regarding the facility one to one monitoring policy; the leave of absence policy, which included the smoking rules; and fire safety. ? On 04/15/11 the facility conducted inservices with 42 staff regarding resident use of cigarettes and lighters in the facility. ? On 04/17/11 an additional fire safety inservice was conducted with staff which included safety with residents who smoke. ? On 05/02/11 all smokers signed the facility smoking policy and associated governance steps, and smoking times were reviewed with the residents. ? On 05/03/11 an immediate house sweep to check for cigarette lighters and cigarettes was completed. ? On 05/06/11 the facility began room checks throughout the facility looking for cigarettes and lighters three times each week and as needed. ? On 05/06/11 the facility initiated room checks every shift for residents identified as frequently possessing dangerous items. ? On 05/12/11, Resident #101 was discharged from the facility. ? By 05/18/11 the facility reviewed all residents who smoked for current assessments of their safety and level of supervision needed when smoking. ? On 06/30/11 the facility obtained signed Smoking Violation Search Consent forms from 21 residents identified by the facility as violators of their smoking policy. This was in accordance with the new facility protocol for searching residents, who were identified as frequent violators of their smoking policy, when they return to the facility from a leave of absence in order to prevent smoking materials from being brought into the facility and kept in unapproved areas. Although the Immediate Jeopardy was removed on 06/30/11, the facility remains out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing the following corrective actions: ? A new policy, dated 07/05/11, for Smoking Violations Search, which included a new protocol for searching residents considered as frequent violators of their smoking policy upon their return to the facility from a leave of absence in order to prevent smoking materials from being brought into the facility and kept in unapproved areas. ? Inservices with all facility staff regarding this new protocol, smoking policies and resident safety. Findings include: 1. Review of Resident #101's medical record revealed he had [DIAGNOSES REDACTED]. Review of Resident #101's smoking assessment dated [DATE] revealed he was assessed and was permitted to smoke in designated smoking areas. The assessment also revealed, "per facility policy, resident must request smoking materials from staff and be supervised by staff, volunteer or family member at all times when smoking." However, review of Resident #101's nurses notes revealed multiple occasions when the resident was found smoking in unapproved areas, and with cigarettes and lighters in his possession. On 02/04/11 at 2:00 P.M., LPN #20 documented Resident #101 was found smoking in his room. On 02/11/11 at 7:00 P.M., LPN #21 documented that due to Resident #101's smoking violations, the resident needed to be closely monitored and redirected often. Additional nurses notes revealed Resident #101 continued to smoking in unapproved and unsupervised areas. A nurses note written by LPN #20 on 03/19/11 at 3:10 P.M. revealed Resident #101 was found by the administrator smoking in an unsupervised area. On 04/27/11 at 1:30 P.M., RN #18 wrote that Resident #101 was found smoking with another resident in his room. On 04/29/11 at 4:00 A.M. a nurse's note written by LPN #22 revealed Resident #101 was found smoking in his room with two other residents. Review of a nurse's note written by LPN #31 on 05/06/11 at 10:57 A.M. revealed Resident #101 was found with smoking items in his room, the psychologist was informed and the resident was ordered counseling related to the smoking violation. Review of a nurses note written on 05/12/11 at 5:00 A.M. revealed Resident #101 was discharged from the facility on 05/12/11. Review of a "Smoking Violation Report" dated 05/12/11 at 3:15 A.M. revealed Resident #101 was found smoking in his room. Resident #101 was counseled, his smoking materials were confiscated. On 05/02/11 at 1:53 P.M., interview with the facility administrator revealed Resident #101 was found smoking in unapproved areas without staff supervision, and had cigarette lighters in his possession on many occasions. The administrator also said many residents' smoke in their rooms against the facility's policy. On 06/30/11 at 10:40 A.M. an interview with the director of nursing (DON) verified Resident #101 was found in resident rooms with cigarettes and lighters on 05/06/11 and 05/12/11. The DON revealed she had "no idea" how the resident obtained the lighters and cigarettes but stated Resident #101 was permitted to leave the facility independently on leave of absences (LOA). Further interview with the administrator at this time verified Resident #101 was discharged from the facility on 05/12/11 for his history of smoking violations. 2. Resident #62 was admitted to the facility on [DATE] and readmitted on [DATE]. She had current [DIAGNOSES REDACTED]. The smoking evaluation dated 05/10/11 indicated the resident did not have fine motor skills needed to securely hold a cigarette, and was not able to extinguish a cigarette safely and completely when finished smoking. This evaluation determined the resident may smoke in designated smoking areas, and must wear a smoking apron at all times. These interventions were included in the resident's plan of care for "possible smoking violations." Social service notes in the resident record documented Resident #62's behaviors relative to smoking. On 05/19/11, Licensed Social Worker (LSW) #25 documented that the social worker and assistant director of nursing spoke with the resident in regards to safe smoking. The team felt the resident should wear a smoking apron any time she smoked. The note indicated the resident understood. A social service note written by LSW #25 on 06/10/11 stated the resident was caught outside smoking without the apron. The care plan dated 06/10/11 also reflected the resident was smoking without the apron. A social service note written by LSW #25 on 06/17/11 indicated the resident was found smoking in her bed and would be issued a 30 day notice. Nurses notes written by LPN #21 on 06/17/11 at 8:30 P.M. revealed LPN #21 was notified by State tested Nurse Aide (STNA) #32 that she smelled smoke coming from the room of Resident #62. The note stated LPN #21 found the resident smoking in her bed and security was notified. The care plan dated 06/20/ 11 stated the resident was smoking in her room, however, no new interventions were added to the care plan. Interview with Resident #62 on 06/29/11 at 9:32 A.M. revealed she was caught smoking in bed. She stated an awareness of the smoking policy and the smoking times. She also said she received a discharge notice because she violated the smoking policy five times. On 06/30/11 at 4:00 P.M., interview with STNA #32 revealed she entered the resident's room on 06/17/11 and saw the resident seated upright in bed, and the nasal cannula was in her nose. The resident had a cigarette in her mouth and it looked like she just lit the cigarette. She said the oxygen concentrator was turned on. She said the resident looked shocked when STNA #32 entered the room, and Resident #62 asked her to "keep it quiet" about her smoking in bed. STNA #32 immediately went to the nurses to let them know Resident #62 was smoking in bed. Interview with LPN #21 on 06/29/11 at 12:00 P.M. revealed she was called to the resident's room by STNA #32. She observed the resident in bed smoking a cigarette, and the cigarette was half gone. The resident had an oxygen concentrator in her room that was turned on, and the nasal cannula and tubing were at her side in bed. The resident asked LPN #21 not to report the incident. LPN #21 took the lit cigarette from the resident, but the resident refused to give LPN #21 any other cigarettes. Security was notified by LPN #21. When security came to the resident's room, Resident #62 gave permission for a search of person for smoking materials, and to have her closet searched. Security recovered a pack of cigarettes and a lighter from the resident and additional cigarettes from her closet. LPN #21 stated she did not ask the resident where she obtained the cigarettes or lighter. Interview with the DON on 06/29/11 at 12:15 P.M., revealed the resident was noncompliant with the use of the smoking apron twice on 06/10/11. She stated the resident was given one to one counseling each time, and verified the resident was observed smoking in bed on 06/17/11. The DON said the facility will be issuing a discharge notice because of the severity of the noncompliance. Interview with the administrator on 06/29/11 at 2:35 P.M. revealed he has verbally discussed discharge from the facility with Resident #62 for non-compliance with the facility smoking rules. The administrator said Resident #62 will be discharged on ce a new residence is determined for the resident. The DON added on 06/30/11 at 4:10 P.M. that until Resident #62's discharge occurs, the resident's leave of absences were stopped so that she could not obtain any additional smoking materials. The DON confirmed that a room sweep was done on 06/17/11 which resulted in additional cigarettes being removed from the resident's room. On 06/30/11, the resident signed a Smoking Violation Search Consent form which would permit staff to search the resident upon return from an LOA for any cigarettes or cigarette lighters. The DON said this was done so that the resident may now be able to go out on an LOA, and the facility would be aware if she returned with cigarettes or cigarette lighters. 3. Review of Resident #68's medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He also had a history of [REDACTED]. Resident #68's medical record included a plan of care developed on 01/14/11, relative to Resident #68 smoking in the facility. The goal was for the resident to "enjoy tobacco safely in accordance with (facility) policy." The approaches included staff keeping lighters, and matches at the nurses station/activity department; cigarettes, lighters and matches are to be kept with appropriate staff only; remind/instruct on smoking areas and times; redirect when needed if smoking in appropriate places; and if found smoking in room or any other inappropriate places, initiate a room sweep for smoke materials, lighters, matches, cigarettes, and confiscate all. Review of Resident #68's care card used by the state tested nursing assistants (STNAs), which was last updated on 12/13/10, revealed no evidence of these approaches, or of any other behavioral interventions as written in the plan of care for this resident. Interview with the director of nursing (DON) and the psychologist on 06/09/11 between 12:20 P.M. and 12:45 P.M. revealed the STNAs do not have access to any of the residents' medical records and care plans, and the STNAs were expected to utilize the residents' care cards, and any verbal direction from the nurses or the psychologist, when supervising residents and addressing resident behaviors. The DON and the psychologist confirmed the STNA's would not have had access to Resident #68's behavioral interventions as indicated in the plan of care. Further interview with the psychologist on 06/09/11 between 12:20 P.M. and 12:45 P.M. revealed he was creating care plan books for each resident with behavior care plans for the STNAs to utilize on the units. This was being done as the STNAs did not have access to the plans of care in the residents medical records, and they only utilized resident care cards, which had no evidence of any behavioral interventions to be aware of when supervising these residents. Review of a psychologist progress note, dated 05/16/11, revealed Resident #68 had a "2nd smoking violation." Interview with the psychologist on 06/09/11 at 12:20 P.M. revealed he was made aware from a staff member that Resident #68 was smoking in his room on 05/16/11, and he said this was the resident's second smoking violation. The psychologist said Resident #68 was smoking in the bathroom of his room. He also said there was a previous smoking violation, where Resident #68 was found smoking in his room. He did not present any evidence of the date of the first smoking violation, any counseling with this resident regarding this incident, or any other documentation relative to the first smoking violation. Interview with the DON on 06/09/11 between 12:20 P.M. and 12:45 P.M. revealed she had no reports of any smoking violations for Resident #68 as explained in the psychologist's 05/16/11 documentation. She responded, "Not to my knowledge" when asked if she knew of these smoking violations. After this interview on 06/09/11, the DON presented evidence of Behavior Meeting Minutes, dated 05/04/11, where the column titled "Follow-Up needed" included reference to Resident #68 smoking in his room. She said this was the date of the first smoking violation referenced in the psychologists progress note. The facility provided no evidence that interventions were planned and communicated to the direct care staff relative to Resident #68's behaviors and non-compliance with the facility smoking rules after the 05/04/11 and 05/16/11 incidents where he was found smoking in his room and in violation of the facility smoking rules. Review of the Resident and Responsible Party Handbook (revised September 2006), revealed resident "Rights and Responsibilities" relative to smoking included smoking being prohibited in resident rooms at all times , and only permitted in specific areas designated for smoking and at specific times. This handbook also included "tobacco and related products" were required to be kept in a safe place by the charge nurse or designee and released to the resident during scheduled smoking periods. On 06/30/11 between 9:15 A.M. and 10:00 A.M., the surveyor observed that the nurse aide activity of daily living (ADL) notebooks on the fifth floor secured unit included the resident's care plans relative to their behaviors. However, further review of the nurse aide ADL notebooks on the third floor, where Resident #68 lived, revealed the behavior care plans of residents with behaviors were not included in the ADL notebooks for the nurse aides review. Interview with LPN #13 on 06/30/11 at 3:00 P.M. revealed the behavior care plans were included in the nurse aide ADL notebooks on the secured unit only, and the nurse aides working on the remaining facility units would rely on verbal instruction from the nurses regarding resident's behavioral and supervision needs. On 06/30/11 at 4:30 P.M., interview with the psychologist revealed the facility was planning on including resident behavior care plans in the nurse aide ADL notebooks on all units of the facility. On 07/07/11 at 3:15 P.M., the surveyors reviewed the nurse aide ADL notebooks on the second and third floors. The nurse aide ADL notebooks for residents with behaviors included care plans for their behaviors and/or care plans for their smoking violations. In addition, the nurse aide ADL notebooks included residents' Safe Smoking Evaluations. On 07/07/11 at 3:25 P.M., interview with the psychologist revealed the nurse aide ADL notebooks have been updated on all units in the facility, and subsequent updates will continue to be added as needed relative to resident behaviors and smoking violations. 4. Review of the medical record face sheet revealed Resident #136 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #136 moderately impaired in making decisions related to daily life, required the limited assistance of one staff member for transfers and used a wheelchair for mobility. Review of the "safe smoking evaluation" dated 05/13/11 revealed Resident #136 was permitted to smoke in the designated smoking areas and the resident was informed of the facility's smoking procedures. The resident's care plan with the identified problem of "possible smoking violations" indicated the resident will be educated on the facility smoking program, sign the policy, and be counseled for any violations of the program. The resident will also be asked to give all smoking articles to staff to prevent any danger to the resident or other residents of the facility. The care plan also indicated the resident may be given a discharge notice for continued violations of the facility policy. A nurse's note written by Licensed Practical Nurse (LPN) #26 on 06/22/11 at 12:00 P.M. revealed Resident #136 was found lying on his stomach in bed smoking a cigarette. The note indicated Resident #136 put the cigarette out in a plastic cup and "smoke was pouring out of that cup." The resident attempted to spray deodorizer to mask the smell of the smoke. The nurse immediately counseled the resident and the resident stated, "I know it's wrong but I really needed to smoke and nobody has come in to get me up." The nurse documented that she reported the incident to the social service department. Review of the social service note written by Licensed Social Worker (LSW) #25 dated 06/22/11 revealed Resident #136 was counseled regarding violating the smoking policy and made aware of possible discharge notice. Review of the "Smoking Violation Report" dated 06/22/11 at 12:00 P.M. revealed Resident #136 was found smoking while lying in bed, was counseled and the incident was documented in the medical record. The report had an "administration follow up" section where the number of violations should be tallied and the administrative action should be documented. This section of the form was left blank. Review of a nurse's note dated 06/23/11 at 4:30 A.M. revealed Resident #136 was admitted to the hospital during the survey and so he was unable to be interviewed. On 06/28/11 at 3:15 P.M., the director of nursing (DON) verified Resident #136 was caught smoking in bed on 06/22/11, and said no residents were permitted to have a lighter or cigarettes in their possession and without supervision in the facility. The DON verified the resident's medical record did not contain evidence to indicate how the resident obtained the lighter and cigarettes. An interview with LPN #26 on 06/29/11 at 10:25 A.M. verified she found Resident #136 smoking in bed on 06/22/11. LPN #26 said Resident #136 could not get out of bed without assistance and she did not ask Resident #136 how he obtained the lighter and cigarettes. Further interview of LPN #26 revealed security confiscated the lighter and cigarettes, did a room search and did not find any other accident hazards. Review of the Resident and Responsible Party Handbook (revised September 2006), revealed resident "Rights and Responsibilities" relative to smoking included smoking being prohibited in resident rooms at all times, and only permitted in specific areas designated for smoking and at specific times. This handbook also included "tobacco and related products" were required to be kept in a safe place by the charge nurse or designee and released to the resident during scheduled smoking periods. Review of the current facility policy titled "Smoking" (dated July 2008) revealed the facility permitted smoking of tobacco at designated times and locations as outlined in the associated procedure. The smoking policy procedures indicated residents may smoke in designated locations and at specific times, and all resident smoking materials would be retained and distributed by the facility staff to the residents during the designated smoking times. The procedure stated, "No resident is permitted to maintain or store smoking materials on their person or in their room." This deficiency substantiates Complaint Number OH 988 and Complaint Number OH 565.

This is evidence of continued non-compliance at a higher scope and severity level than the survey conducted on 04/01/2011. Based on medical record review, resident and staff interviews, observations, review of facility incident investigations, and review of the facility's abuse policy, review of Resident/Observation Monitoring Tool, review of Resident Observation/Intervention policy and "One on One Observation" policy, the facility failed to prevent resident to resident physical abuse between Residents #113 and #144, Residents #139 and #95. This resulted in Immediate Jeopardy for Residents #113, #144, #139 and #95, and placed the other 42 residents in the facility's behavioral unit at risk for serious injury from physical abuse or risk of death from being set on fire. The facility's census was 143 residents. On 07/07/11 at 4:30 P.M. the administrator, director of nursing (DON) and the corporate nurse were notified that Immediate Jeopardy began on 03/12/11 at 11:39 P.M. when Resident #144 tried to run Resident #113 over with his electric wheelchair and subsequently tried to attack Resident #113 three (3) times with scissors, resulting in the local police being dispatched to the facility and instructing staff to place Resident #144 on one-to-one supervision. On 03/13/11 at 2:18 A.M., Resident #113 entered Resident #144's room and hit him in the face with a radio. Immediate Jeopardy continued on 03/13/11 at 9:33 A.M. when Resident #144 lit Resident #113's mattress on fire while he (#113) was sleeping. LPN #11 found Resident #113 staggering toward the door with one shoe on, while his mattress, his other shoe, and a pile of clothing were on fire. The Immediate Jeopardy continued on 05/09/11 as the facility failed to prevent another incident of resident to resident abuse when Resident #139, who had a history of [REDACTED]. Resident #95 sustained a fractured jaw requiring treatment at the hospital and a wired jaw. Immediate Jeopardy was removed on 06/01/11 when the facility implemented the following corrective actions: ? On 03/13/11 at approximately 10:00 A.M., the police took Resident #144 to jail and he did not return to the facility. ? On 05/04/11 the facility developed a new " Resident Observation/Intervention " Policy which established three levels of supervision (one to one supervision, every 15 minute observation and every 30 minute observation), and established a documentation tool to use when monitoring residents. ? On 05/10/11 Resident #139 was transferred to the hospital and discharged from the facility. ? On 05/13/11 the facility psychologist initiated weekly staff in-services on behavior management. These weekly in-services will continue to be held weekly on an ongoing basis. ? On 05/20/11 the DON completed in-service training for all staff on the new Resident Observation/Intervention Policy. ? A secured unit was established on 06/01/11 to provide increased observation and therapeutic activities for residents with behaviors. Additional staff hired for the secured unit included an activity director, a unit manager, and security for all three shifts. Although the Immediate Jeopardy was removed, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate jeopardy) as another situation of resident to resident abuse occurred on 06/29/11 which did not result in harm, however, required staff to implement one to one monitoring of Resident #104. Findings include: 1. Review of Resident #144's admission face sheet revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #144 had impaired memory, had disruptive and intrusive behaviors and was not ambulatory but able to transfer himself from a bed to his electric wheelchair. Social Service Progress Notes dated 01/13/11 indicated the resident was a short term placement at the facility. He was easily agitated, unpleasant at times, and had a history of [REDACTED]. He also displayed repetitive physical movements such as, "rolling around in motorized wheelchair at high speeds." Review of Resident #144's care plans revealed a behavior and mood care plan initiated on 11/08/10, which indicated Resident #144 could become verbally and physically abusive towards others. The goal identified for this care plan indicated Resident #144 would not harm himself or others; would not touch any person inappropriately; would express himself in a calm, respectful manner; and would make positive statements. The behavior and mood care plan contained interventions including maintain a consistent routine; 1:1 to allow him to vent feelings in a quiet, private area; encourage him to inform staff if other residents were bothering him; utilize quiet room when needed to help reduce over stimulation; intervene early when there were warning signs and redirect with positive interventions; and provide frequent and consistent supervision. In addition, an abuse care plan was initiated on 11/08/10, which indicated Resident #144 had a history of [REDACTED].#144 would not harm himself or others. The abuse care plan contained interventions to implement after episodes of hitting, kicking or attempting to harm another, which included social service discussing the event with the resident to prevent further episodes; anger management at least weekly with social services; psychiatrist to evaluate as needed; resident to be hospitalized if unable to regain self control and/or presence of psychotic thinking predicts further violent behavior; room change for resident/roommate to resolve conflict; and staff to observe and redirect resident without getting into an argument. Review of the nurse's notes from Resident #144's admission on 10/06/10 until his discharge on 03/13/11 revealed he was frequently noncompliant with his care, and was verbally abusive to staff and other residents. However, there was no evidence that the facility nursing and direct care staff implemented interventions from the resident's plan of care to address these behaviors. A psychiatric evaluation completed on 06/29/10 indicated Resident #144 was admitted to the facility from another nursing home after getting into a fight with the security guard. The resident's record included an Application for Emergency Admission to a hospital, dated 02-15-11, as the resident displayed violent behavior by hitting other residents and threatening to kill the psychologist. Review of the psychologist's progress notes from 01/04/11 through 03/13/11 revealed Resident #144 was counseled for being physically and/or verbally abusive to staff on four occasions and to residents on nine occasions. The Psychological Progress Notes, dated 03/15/11 and 03/17/11, described the resident as being delusional, disoriented, and having disorganized thoughts. Review of Resident #113's MDS quarterly assessment dated [DATE] revealed he had [DIAGNOSES REDACTED]. The assessment revealed Resident #113 frequently refused care and was independently ambulatory. Nurse's note written by LPN #16 on 03/12/11 at 2:30 A.M. revealed Resident #144 threatened to hit a resident (unidentified) with his electric wheelchair, and went down the hall banging on residents ' doors and yelling for the residents to get up. The note continued to indicate, "attempts to redirect not successful." Interview with LPN #16 on 05/14/11 at 10:30 A.M. revealed Resident #144 also threatening to run over Resident #120 with his wheelchair on 03/12/11 at 2:30 A.M. However, there was no evidence in the medical record that the staff attempted any interventions included in the plan of care to address Resident #144's behaviors. Nurse's note written by LPN #15 on 03/12/11 at 11:39 P.M. revealed Resident #144 was involved in an altercation with Resident #113. The notes indicated Resident #144 was yelling, calling Resident #113 names and threatened to run Resident #113 over with his electric wheelchair. Resident #144 went into his room, obtained scissors and attempted to attack Resident #113. The facility's security guard was called and confiscated the scissors. The resident's physician was notified and the physician ordered the staff to place Resident #144 on "one to one" observation. Resident #144 then returned to his room, obtained a second pair of scissors and began to yell at the staff. The facility's staff confiscated the second pair of scissors. Resident #144 returned to his room again and obtained a third pair of scissors. The police were called to the facility (time not documented), confiscated the scissors, and instructed the staff to place Resident #144 on "one to one" observation. The note revealed the physician would be in the facility the next day, and staff "will continue to monitor." There was no evidence that the facility staff implemented any interventions included in Resident #144's plan of care to address his escalating behaviors and repeated attempts to harm Resident #113. Nurse's note written by LPN #17 on 03/13/11 at 2:15 A.M. revealed staff observed Resident #144 and Resident #113 in a physical altercation in Resident #144's room. The residents were separated, the police were called and the physician was notified. Resident #144 refused a transfer to another room. Resident #113's nurse's note written by LPN #17 on 03/13/11 at 2:18 A.M. revealed Resident #113 went into Resident #144's room and hit Resident #144 in the face with a radio. Resident #144 sustained abrasions to the side of his face. There was no evidence in the medical record that the facility staff attempted any planned interventions for both Resident #113 and #144, and provided the level of supervision needed to prevent these behaviors from continuing between these residents. Nurse's note written by LPN #11 on 03/13/11 at 9:33 A.M. revealed at approximately 7:25 A.M., Resident #144 was observed leaving Resident #113's room. Approximately four (4) minutes later the fire alarm sounded and the fire system panel indicated a fire was in Resident #113's room. The staff opened the door to this room and found Resident #113 standing behind the door. Resident #113 was taken to safety by the staff and the police and the fire department arrived. Resident #113 sustained no injuries. Review of a facility's incident investigation dated 03/13/11 revealed Resident #144 entered Resident #113's room on 03/13/11 at approximately 7:45 A.M. Resident #144 took a lighter from Resident #113's desk and lit Resident #113's mattress on fire. The staff observed Resident #144 leaving Resident #113's room and saw smoke a few minutes later. The staff obtained a fire extinguisher and "put out smoldering smoke from mattress." The fire department arrived and broke the windows out of the room to vent the smoke. All of the residents were evacuated to a different hall and Resident #144 was taken into police custody on 03/13/11 at approximately 10:00 A.M. Resident #144 did not return to the facility. On 04/28/11 at 8:47 A.M., an interview with Resident #113 revealed he was asleep in his bed when Resident #144 went into his room and lit his mattress on fire. Resident #113 said he felt the fire on his feet and his feet "felt hot." Resident #113 verified Resident #144 set the fire, and stated Resident #144 "bothered everybody "and was in jail now " On 04/28/11 at 9:05 A.M., interview with LPN #11 revealed she was present during the fire that occurred on 03/13/11 at approximately 7:45 A.M. LPN #11 stated she was told in morning report by LPN #17 (the night shift nurse) that Resident #144 was chasing Resident #113 with scissors and Resident #113 hit Resident #144 in the head with a radio during the night. LPN #11 stated LPN #17 told her Resident #144 was ordered "one on one" observation, but LPN #11 observed Resident #144 exiting Resident #113's room unsupervised just a few minutes before the fire alarm sounded. LPN #11 ran to the room, opened the door and saw flames coming from the mattress. She saw Resident #113 "staggering toward the door." Resident #113 was wearing one shoe, and his other shoe and a pile of clothing were observed on fire on the resident's floor. LPN #11 stated the resident's blankets, mattress and bed were on fire. Additional staff members arrived with fire extinguishers and put out the fire. On 04/28/11 at 9:23 A.M., interview with State tested Nurse Assistant (STNA) #12 revealed he obtained a fire extinguisher and assisted in putting out the fire in Resident's #113's room. STNA #12 said Resident #113's mattress was on fire and there was a lot of smoke. He said it took 10 to 15 minutes for staff to extinguish the fire. Interview with the administrator on 04/28/11 at 10:15 A.M. revealed Resident #144 told the police that he took the lighter from Resident #113's desk and set his mattress on fire. The administrator stated he did not know where Resident #113 got the lighter. The administrator also said the facility staff did not ask Resident #113 how he obtained the cigarette lighter after the fire. On 04/28/11 at 11:52 A.M., interview with LPN #13 revealed he arrived for work on 03/13/11 at approximately 7:00 A.M. and upon his arrival, he passed STNA #10 as she was leaving the facility to go home. LPN #13 said he was informed after the fire that STNA #10 was assigned the "one on one" observation of Resident #144. LPN #13 verified STNA #10 did not wait for the oncoming shift to arrive before she left the facility. LPN #13 also said many residents have independent leave of absences (LOA) privileges and bring in cigarette lighters when they return to the facility. LPN #13 said it was "very easy" for a resident to get a lighter. Review of Resident #144's medical record revealed no evidence or documentation to indicate "one on one" monitoring was provided for Resident #144. On 04/28/11 at 1:32 P.M., an interview with the DON verified staff failed to document in Resident #144's medical record any "one on one" observations from 03/12/11 at 11:39 P.M. through the time of the fire on 03/13/11 at 7:25 A.M. The DON also verified Resident #144 attempted to assault Resident #113 on 03/12/11 with scissors three times, and verified Resident #144 set Resident #113's bed on fire on 03/13/11 when "one on one" observation by staff was ordered for Resident #144. Additional interview with LPN #11 on 05/24/11 at 8:45 A.M. revealed she assessed Resident #113 after the fire and no injuries were found. LPN #11 said Resident #144 went out of the facility to the wound clinic approximately three times a week and returned with dressing kits that included bandage scissors. LPN #11 said residents on the behavioral unit were not permitted to have scissors, and the scissors should have been removed from Resident #144's room when he returned from the wound clinic. Interview with the DON on 05/24/11 at 9:52 A.M. revealed both Resident #144 and Resident #113 were offered a room change after the physical altercation that occurred on 03/13/11 at 2:15 A.M., and both residents refused; however the facility failed to provide further interventions including increased supervision, or "one on one" monitoring as directed. Interview with LPN #17 on 05/24/11 at 11:41 A.M., revealed she was assigned the care for both Resident #144 and Resident #113 on the midnight shift of 03/13/11. LPN #17 stated she was getting report at 11:39 P.M. when she heard Resident #144 threaten to run over Resident #113 with his wheelchair. LPN #17 said STNA #10 was assigned to provide "one on one" continuous observation of Resident #144 during the night shift and that was her only assignment. LPN #17 indicated she did see STNA #10 follow Resident #144 around in his wheelchair at times during the shift. However, LPN #17 also said STNA #10 was not providing "one on one" observation at the time Resident #113 hit Resident #144 in the head with a radio and she was not providing "one on one" observation of Resident #144 at the time of the fire. LPN #17 stated she instructed STNA #10 not to leave the facility until she gave a verbal report to the oncoming day shift STNAs and until a day shift STNA relieved her from her "one on one" observation duties. LPN #17 said STNA #10 left the facility without giving a report to the day shift STNAs which left the day shift STNAs unaware of Resident #144's "one on one" observation order. LPN #17 said she was giving report to the oncoming day shift nurse, LPN #11, when the fire alarm sounded and she began taking residents to safety in a different smoke compartment. On 05/24/11 at 1:38 P.M., interview with the DON and review of facility personnel records dated 05/23/11 revealed STNA #10 was no longer employed at the facility through voluntary resignation. Review of a "Disciplinary Action Form" with a violation date of 03/13/11 at 7:28 A.M. revealed STNA #10 was given a verbal warning for "leaving one on one patient without replacement. Failure to monitor one on one resident." The form also revealed the "STNA will be written up or terminated if STNA continues to ignore policy." STNA #10 signed the verbal warning form on 03/16/11. Review of the facility's policy titled "Resident Abuse," dated May 2008, identified that abuse can include resident to resident abuse. The policy also listed under "Methods of Prevention," assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address those issues by involving qualified psychiatrists and other mental health professionals to help the staff manage difficult or aggressive behaviors. Review of the "One on One Observation" policy dated October 2010 revealed the administrator or charge nurse would assign a staff member to observe the resident, and the assigned staff member "will remain with the resident in view at all times." Should the assigned staff member need to leave the area they were responsible to assure the resident was watched during their absence by another staff member. During an interview on 05/02/11 at 9:22 A.M., the administrator stated the staff member assigned to complete the "one on one" observations was not expected to provide any documentation during their "one on one" assignment, and would report anything unusual to the nurse in charge. The administrator reported the "one on one" staff member was to "keep an eye on them" and make sure the resident being observed did not have an altercation and did not harm themselves. The administration said the assigned staff member did not provide the supervision necessary to address Resident #144's behaviors. Interview with the administrator and the DON on 06/09/11 between 11:00 A.M. and 2:30 P.M. revealed all facility staff were in-serviced on the new Resident Observation/Intervention Policy and the associated one to one observation form. The psychologist began weekly in-services with the staff relative to behavioral interventions, which according to facility documentation were conducted on 05/13/11, 05/18/11, 05/27/11, and 06/03/11 with no more than seven (7) staff in attendance at each of these in-services. Further interview with the administrator and DON on 06/29/11 revealed these in-services continued on 06/24/11 and 06/28/11. They also reviewed their implementation of the secured unit which opened on 06/01/11 on the fifth floor, with 39 residents currently residing on that unit. Additional staff hired for this unit included an activity staff person, a unit manager, and an additional security staff for the third shift. Security staff were working on all three shifts, and were in addition to the other security staff available in the facility. They were also anticipating the hire of a licensed social worker for the secured unit. Interview with the psychologist on 06/09/11 between 12:20 P.M. and 12:45 P.M. revealed he was creating care plan books for each resident with behavior care plans for the STNAs to utilize on the units. This was being done as the STNAs did not have access to the plans of care in the residents' medical records, and they only utilized resident care cards, which had no evidence of any behavioral interventions to be aware of when supervising these residents. On 06/30/11 between 9:15 A.M. and 10:00 A.M., the surveyor observed that the nurse aide activity of daily living (ADL) notebooks on the fifth floor secured unit included the resident's care plans relative to their behaviors. However, further review of the nurse aide ADL notebooks on the third floor revealed the behavior care plans of residents with behaviors were not included in the ADL notebooks for their review. Interview with LPN #13 on 06/30/11 at 3:00 P.M. revealed the behavior care plans were included in the nurse aide ADL notebooks on the secured unit only, and the nurse aides working on the remaining facility units would rely on verbal instruction from the nurses regarding resident's behavioral and supervision needs. On 06/30/11 at 4:30 P.M., interview with the psychologist revealed the facility was planning on including resident behavior care plans in the nurse aide ADL notebooks on all units of the facility. On 07/07/11 at 3:15 P.M., the surveyors reviewed the nurse aide ADL notebooks on the second and third floors. The nurse aide ADL notebooks for residents with behaviors included care plans for their behaviors. 2. According to a facility incident report, dated 05/09/11 at 11:30 A.M., Resident #139 was involved in a physical altercation with Resident #95 by the first floor elevator. Resident #139 punched Resident #95 in the jaw, resulting in Resident #95 sustaining a fractured mandible. No staff were present at the time of the altercation, but the assistant director of nursing, who was nearby, overheard the fight and immediately assisted. Resident #139 was transferred to the hospital for psychiatric evaluation, and was discharged from the facility on 05/10/11. Resident #95 was admitted to the hospital on [DATE] and readmitted to the facility on [DATE] with a wired jaw. He received subsequent outpatient surgery on 06/17/11 to have the wires and screws removed and returned to the facility the same day. Resident #139 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admitting summary from the Ohio Department of Mental Health Placement Option dated 01/28/11 indicated he experienced symptoms of disorganized behavior, [MEDICAL CONDITION], hallucinations, physical aggression/combative behaviors, abrasiveness/irritable behaviors, threatening, disruptive and inappropriate behaviors. This summary noted, " The most effective strategy used to manage these symptoms is close, consistent monitoring and supervision and good medication compliance. " Admitting social service notes dated 01/07/11 indicated Resident #139 was severely confused, had severely impaired cognition, had hallucinations and [MEDICAL CONDITION], and " believes he is Bruce Lee. " He had a known history of physical aggression and, according to nursing notes, had exhibited eight aggressive episodes in an eight week period (03/21/11: physical aggression, victim-no injury; 03/31/11: physical aggression, victim-no injury; 04/02/11: verbal aggression; 04/03/11: physical aggression, victim-no injury; 04/19/11: physical aggression, victim-3 centimeter laceration with sutures; 04/20/11: physical aggression, victim-no injury; 04/22/11: physical aggression, victim-minor scratches; and 05/09/11: physical aggression, victim-fractured jaw). The facility implemented one to one observation of Resident #139 for eight hours after the 03/21/11, 04/02/11, 04/03/11, 04/19/11 and the 04/20/11 incidents, and 30 minute observation for 24 hours after the 03/31/11 incident. However, there was no evidence that the facility increased or changed the plan for daily monitoring of Resident #139 after the completion of their post incident observations. The plan of care dated 02/02/11 identified his history of physical abuse and violence, and included interventions to, " Provide frequent and consistent supervision. Staff to observe, intervene at early signs of escalation. " The only care plan intervention updates prior to the 05/09/11 incident was on 04/19/11 which indicated one to one supervision for 8 hours, and 04/20/11 regarding one to one supervision. The lack of further care plan interventions to address the resident ' s continuing aggressive behaviors was confirmed with the director of nursing on 06/29/11 at 2:45 P.M. 3. Review of the medical record face sheet for Resident #104 revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #104 was moderately impaired in his cognitive skills for daily decision making, had [MEDICAL CONDITION] and had symptoms of being easily annoyed or short-tempered nearly every day. Review of Resident #104 ' s behavioral care plan initiated on 05/27/11 revealed the resident had a history of [REDACTED]. The care plan indicated the resident resided on the secured behavioral unit. Review of a psychiatric evaluation dated 06/17/11 revealed Resident #104 was abusive to staff and peers, confused and had memory problems. Nurse ' s note written by LPN #27 on 06/29/11 at 6:25 A.M. revealed Resident #104 was involved in a physical altercation with Resident #111, and Resident #111 hit Resident #104 in the mouth his with hand. Nurse ' s note written by LPN #28 on 06/29/11 at 8:00 A.M. revealed Resident #104 was placed on " one on one " monitoring after the incident until sent to the hospital. Review of a physician ' s telephone order dated 06/29/11 (no time documented) revealed Resident #104 was ordered to be placed on " one on one " monitoring until he was sent to the hospital for a psychiatric evaluation. Observations made on 06/29/11 at 10:04 A.M. revealed Resident #104 was in his room and in bed. There was no staff member present in the resident ' s room or at the resident ' s door way. At 10:05 A.M. Security Officer (SO) #29 walked to Resident #104 ' s doorway, looked into the resident ' s room and stood outside of the resident ' s door. At 10:07 A.M. observation of Resident #104 ' s room revealed SO #29 was gone and no staff members were in the room or near the doorway. At this time, Laundry Aide #30 was observed down the hall at the nurse ' s station and called to the resident ' s room by the surveyor. Laundry Aide #30 verified no staff was present providing " one on one " monitoring for Resident #104. At 10:12 A.M., SO #29 returned to Resident #104 ' s room. SO #29 verified he left the resident unattended and unsupervised at 10:04 A.M. and at 10:12 A.M. SO #29 revealed he knew Resident #104 was ordered " one on one " monitoring, verified he was assigned to provide the " one on one " observation, and verified he was not to let Resident #104 out of his sight. SO #29 stated he had a key to the elevator on the secured unit, and was assisting staff onto the elevator at the times he was away from Resident #104 ' s room. The SO verified he did not ask another staff member to replace him when he left the resident ' s room. On 06/29/11 at 12:52 P.M. an interview with the director of nursing (DON) verified Resident #104 was involved in " resident to resident " abuse on 06/29/10 resulting in an order for [REDACTED]. The DON revealed Resident #104 was angry at another resident (Resident #111) for wearing his clothes so he ran over the resident ' s foot with his wheelchair. The DON revealed Resident #111 retaliated and hit Resident #104 in the face. The DON said Resident #104 had a history of [REDACTED]. Review of Resident #111 ' s medical record revealed he had a [DIAGNOSES REDACTED]. Another care plan was initiated on 06/28/10 for the problem " history of violence, " and was updated on 06/04/11 and indicated the resident had an altercation with another resident. A third care plan initiated on 05/27/11 for mood and behavior indicated the resident " may become violent at times. " The resident record also contained a consent signed by Resident #111 to move to the secured behavioral unit on 06/01/11. Review of the " Resident Observation/Monitoring Tool " dated 06/29/11 revealed SO #29 initialed every 15 minutes that " one on one " monitoring for Resident #104 was completed from 7:30 A.M. through 10:30 A.M. The monitoring tool revealed " If a resident is on 1:1, the assigned staff member must remain with the resident in view at all times. If staff member needs to leave the area they are responsible to assure the resident is watched during their absence by another staff member. " Review of a " Disciplinary Action Form " dated 06/29/11 at 10:45 A.M. revealed SO #29 was given a written warning for " left resident on 1:1 to open elevator " and for " standing outside of room. " SO #29 signed the written warning on 06/29/11. Review of the facility policy, " Resident Observation/Intervention Policy, " dated 05/04/11, revealed if a resident was on one to one monitoring, an additional staff member would be assigned to remain with the resident in view at all times. If the assigned staff member had to leave the area, they were responsible to assure the resident was watched by another staff member during their absence. This deficiency substantiates Complaint Number OH 565.

Based on record review and staff interview, the facility failed to provide supervision to ensure one resident was free from physical abuse. Resident #140 was hit in the face by Resident #141, which resulted in the need for treatment at the hospital for a fractured facial bone, scalp contusion, and the recommendation for administration of a narcotic pain medication as needed and follow-up appointments with a plastic surgeon and ophthalmologist. This affected one of two residents reviewed for abuse (#140). The facility census was 139 residents. Findings include: Review of the record of Resident #140 revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of nursing notes dated 02/07/11 revealed that the resident was observed coming off the elevator at 5:30 P.M. with a bleeding nose. The note stated that the nurse tried to offer assistance and assess the resident, but the resident "refused help, stating she was OK." The note indicated that she proceeded to her room in a rapid pace in her wheelchair, coming out later after "cleaning herself off." The note indicated the writer again asked what had happened, and the resident stated at that time that the Resident #141 had attacked her on the elevator and hit her because she had by mistake run into him with her electric wheelchair. The note indicated that her nose was "busted, her right eye was swollen with some redness." The note indicated that the nurse told the resident that she needed to be evaluated in the hospital, but the resident refused, stating that she wanted to go outside. The note indicated that the nurse attempted several times to assess the resident and encourage her to go to the hospital, but the resident refused until 8:00 P.M., when the resident told the nurse her vision was blurry and she would agree to go to the hospital. The note indicated that the physician was called twice about the occurrence and the resident was sent out to the hospital at 8:40 P.M. The next note dated 02/08/11 at 2:45 A.M., revealed that the resident returned from the hospital with a [DIAGNOSES REDACTED]. The resident was up through that shift in her wheelchair and went outside to smoke. Review of the record of Resident #141 revealed that he was admitted to the facility on [DATE] and readmitted after a psychiatric hospitalization on [DATE]. He had [DIAGNOSES REDACTED]. The resident did refuse medications at times. Review of psychologist notes revealed the resident with a history of altercations with other residents. Review of the resident's care plan dated 08/03/09 and updated through May 2011 revealed a history of violence with interventions to provide anger management counseling through psychology and psychiatry services; approach resident in a calm manner; if the resident did display an outburst, that social service and the psychiatrist were to discuss the incident with the resident; and the resident was to be placed on every 15 minute checks for three days after any outburst. Review of nursing notes for Resident #141 dated 02/08/11 at 12:43 P.M. (late entry for 02/07/11 at 6:30 P.M.), revealed that the resident was involved in a "resident to resident altercation" and stated that Resident #140 hit him with her wheelchair, so he hit her. The note stated that the resident was "non-compliant" with medication, "remained in his room the remainder of the shift, had no behaviors in his room and was only out for meals or to smoke." A nursing note dated 02/08/11 at 12:54 P.M. indicated that Resident #141 had a nursing order written at that time for one to one monitoring. Review of physician orders [REDACTED].M. A note and order dated 02/08/11 at 2:58 PM revealed that Resident #141 was sent to the hospital involuntarily ("pink slipped") at that time. Interview on 04/01/11 at 11:00 A.M. with the psychologist who wrote a note about the resident on 02/08/11, revealed that the resident had began to escalate in his behaviors at that time, so he was sent to the hospital. The resident did not return to the facility. Interview on 03/30/11 at 3:10 P.M. with Licensed Practical Nurse (LPN) #1, who worked on Resident #141's unit on 02/07/11 evening shift, and also on 02/08/11 day shift, revealed that she was notified by the charge nurse, Registered Nurse (RN) #2, who was working on the floor where Resident #140 resided. LPN #1 stated that she was told that Resident #141 had hit another resident. She stated that she went to his room and he was laying in his bed. She stated that he was calm and not agitated. She stated that he stayed in his room most of the shift, coming out only for meals or to go down stairs to smoke. She verified that he was not put on 1:1 monitoring. She further verified that Resident #141 was independently ambulatory. She verified that he had not been agitated prior to hitting Resident #140. She verified that the two residents could have come into contact again with each other as they both could leave the units unsupervised to smoke, and that Resident #141 was easily provoked and would respond physically when this would happen. This deficiency substantiates Complaint Number OH 216.