Every finding on record at Vista Center at the Ridge

Based on record review, interview and facility policy review, the facility failed to ensure Resident #143's Advance Directive (legal document outlining your future medical care in the event you cannot communicate them yourself) code status was accurate. This affected one resident (#143) of three residents reviewed for code status and had the potential to affect 52 residents (#4, #5, #8, #11, #12, #15, #16, #27, #29, #30, #32, #34, #36, #37, #46, #47, #54, #57, #63, #65, #68, #70, #73, #76, #77, #87, #89, #90, #91, #92, #96, #99, #100, #101, #103, #104, #105, #109, #110, #111, #112, #113, #114, #118, #119, #121, #122, #128, #133, #134, #138 and #163) with an Advance Directive. The facility census was 143. Findings include: Review of the medical record for Resident #143 revealed an admission date of [DATE] and a discharge date of [DATE]. Diagnoses included diabetes, dementia, muscle weakness, depression, and breast cancer.Review of the Brief Interview for Mental Status (BIMS) evaluation dated [DATE] revealed Resident #143 was severely cognitively impaired. The Minimum Data Set (MDS) assessment was not yet due to be completed.Review of the history and physical progress note dated [DATE] and authored by Certified Nurse Practitioner (CNP) #207 revealed Resident #143 was a Full Code (all possible measures are attempted to save a patient's life during a medical emergency).Review of the multidisciplinary care conference dated [DATE] revealed Resident #143 had a code status of Do not Resuscitate; Comfort Care (a type of Do-Not-Resuscitate order indicating CPR should not be administered; DNRCC).Review of the nursing progress note dated [DATE] at 6:47 A.M. authored by Licensed Practical Nurse (LPN) #203 revealed she was called to the room around 5:25 A.M. by the Certified Nurse Aide (CNA) #210 because Resident #143 was unresponsive. Cardiopulmonary Resuscitation (CPR; an emergency procedure for someone whose breathing or heartbeat has stopped, involving chest compressions and rescue breaths to keep blood and oxygen flowing to vital organs until medical help arrives) was initiated and an emergency code, as well as 911 was called, and the residents' son/Power of Attorney (POA) were notified. When emergency services arrived, Resident's #143's heart had stopped beating.Interview on [DATE] at 10:55 A.M. with LPN #203 revealed CNA #210 told her Resident #143 was unresponsive, so she checked the resident's code status in the computer and found nothing regarding Advanced Directives. She then checked the physical chart where she saw a yellow sheet of paper in the front of the chart which was used to indicate the resident was a Full Code, at which time she began CPR and contacted emergency services. She said she did not find out until a few days after Resident #143 expired that she was a DNRCC.Interview on [DATE] at 11:26 A.M. with Resident #143 son/POA revealed Resident #143 was a DNRCC when she was admitted to the facility according to her own wishes. He confirmed the facility had called him to notify him she had an emergency code and he arrived within approximately half an hour, during which time the resident had already expired. He could not confirm if the facility told him they had initiated CPR and whether or not they honored the resident's wishes for her DNRCC.Interview on [DATE] at 1:28 P.M. with Social Service Designee (SSD) #206 revealed she held a care conference with Resident #143's son on [DATE], at which time he chose to make the residents' code status a DNRCC. She revealed at that time, the form was faxed to CNP #207 which was signed and placed in the residents' physical chart. She revealed she notified Registered Nurse (RN) #208 of the change in Resident #143's code status and asked her to update the order. SSD #206 confirmed there was no order in Resident #143's chart regarding any code status.A call was made on [DATE] at 1:35 P.M. to RN #208 and a message left to return the call. No return call was received.Interview on [DATE] at 2:18 P.M. with the Administrator confirmed Resident #143 was a DNRCC at the time she expired, and CPR should not have been initiated. She also confirmed there was no physician's order for the DNRCC.Review of the undated facility policy titled Advanced Directives revealed the facility would ensure residents' Advanced Directive wishes were honored including revising and reviewing directives as necessary. Facility staff would document the presence of an Advanced Directive, and the physician would write an appropriate order for residents choosing Advanced Directives.This deficiency represents noncompliance investigated under Complaint Numbers 2627715 and 2618634.

Based on record review, observations, review of the housekeeping cleaning schedule, interviews and facility policy review, the facility failed to maintain a clean and sanity environment for residents. This affected six (Residents #1, #2, #3, #4, #5, and #11) of 21 residents residing on the 400 unit and had the potential to affect all residents residing in the facility. The facility census was 144. Findings include:1. Review of the medical record for Resident #1 revealed an admission date of 12/18/18. Diagnoses included schizophrenia and unspecified intellectual disabilities. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had impaired cognition. 2. Review of the medical record for Resident #2 revealed an admission date of 10/07/21. Diagnoses included schizophrenia and catatonic disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #2 had impaired cognition. 3. Review of the medical record for Resident #3 revealed an admission date of 04/03/14. Diagnoses included schizophrenia and Alzheimer's disease. Review of the quarterly MDS assessment dated [DATE] revealed Resident #3 had impaired cognition. 4. Review of the medical record for Resident #4 revealed an admission date of 07/23/18. Diagnoses included schizophrenia and bipolar disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #4 had impaired cognition. 5. Review of the medical record for Resident #5 revealed an admission date of 08/12/20. Diagnoses included dementia and anxiety disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #5 had impaired cognition. 6. Review of the medical record for Resident #11 revealed an admission date of 08/09/24. Diagnoses included schizophrenia and unspecified psychosis. Review of the quarterly MDS assessment dated [DATE] revealed Resident #11 had intact cognition. Observations on 09/06/25 from 8:14 A.M. to 9:00 A.M. of the west 400 unit noted the following: Dried coffee stains and miscellaneous food and paper debris on the floor throughout the unit. Resident #11's room noted the trash can was heaped over with garbage, and there was food on the floor and ground in dry brownish/blackish marks on the floor. Resident #1's room noted five serving bowls with food stored in the dresser drawers and several butter knives stored in the nightstand. Resident #1's linens were stained with brownish debris. Resident #2, who also resides with Resident #1, had a pillow that was without a cover that was heavily stained with orange/brown substances. Resident #3 and Resident #4 noted several (plus ten) gnats sitting and flying around the sink and countertop. Resident #5's room noted a strong smell of urine; the bathroom floor was wet and rusted where Resident #5 would urinate. The toilet seat was covered with dried feces. Interview on 09/06/25 from 8:39 A.M. to 8:50 A.M. Certified Nursing Assistant (CNA) #200 was the only staff working on the unit at the time of observations. CNA #200 stated housekeeping services do not clean this unit daily. CNA #200 stated that the mess was a daily thing, and she had brought her own cleaning supplies in to clean the unit. CNA#200 stated the unit needed to be cleaned daily due to the acuity and behaviors of the residents. Interview and observations with Housekeeping Director #201 verified the findings. She would get staff to clean the unit; no other comments were provided regarding the condition of the unit. Interview on 09/06/25 at 10:00 A.M., Housekeeper #208 stated she was able to complete her cleaning tasks daily. Housekeeper #208 did not work on the west 400 unit and was pulled from another unit to clean the west 400 unit. Review of housekeeping cleaning schedule signoff sheet for the month of September 2025 noted cleaning services were not signoff for 09/01/25, 09/03/25, and 09/04/25. Review of the facility policy titled Housekeeping Policy/Procedure, dated 2019, noted the facility will be maintained and cleaned to meet a home like environment for our residents. This deficiency represents noncompliance investigated under Complaint Number 1290111 (OH00167443).

Based on record review and interview, the facility failed to ensure Resident #128 was provided a 30-day notice at discharge and appropriate discharge planning to secure safe discharge placement. This finding affected one (Resident #128) of three residents reviewed for discharge planning. Findings include: Review of submitted concerns to the state agency on 04/08/25 revealed the facility attempted to send Resident #128 to a group home, but the resident did not want to live in the area due to distance from friends and local stores. The facility did not offer any other places for the resident to be discharge to. Resident #128 was approached about being discharged on 04/03/25 and he reported to the facility he did not have anywhere to go. Resident #128 was discharged from the facility on 04/04/25 with no place to go other than a hotel. Resident #128 was discharged to a hotel and was not provided a 30-day notice. Review of Resident #128's medical record revealed the resident was admitted on [DATE] and discharged on 04/04/25 with diagnoses including morbid obesity, difficulty in walking and epilepsy. Review of Resident #128's Social History Evaluation dated 12/13/24 revealed the resident lived in a hotel and was not able to return due to trashing the place. Review of Resident #128's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #128's Multidisciplinary Care Conference form dated 03/20/25 at 8:33 A.M. revealed the resident was present for the meeting and did not have family involvement. The resident's medications were reviewed and the resident stated he cannot go back to his prior living arrangements due to being evicted from his hotel room. The resident was homeless. Review of Resident #128's Notice of Adverse Decision form dated 04/02/25 revealed that the request for continued stay at the nursing facility cannot be approved. The dates of service from 04/02/25 to 04/03/25 had been approved but starting on 04/04/25 the stay was denied. The resident was [AGE] years old and had been in the facility since 12/13/24. The resident did not need skilled nursing daily and no longer needed therapy five days a week. The therapy notes showed the resident was able to do all his own daily needs like taking a bath, moving in bed, walking, using the restroom, eating and getting dressed. The resident did not need 24-hour care for memory impairment and the resident's needs can be managed at a lower level. Review of Resident #128's social service progress note dated 04/03/25 at 2:30 P.M. authored by Social Service Designee (SSD) #814 revealed the resident's last covered day was 04/03/25 and the resident stated he had been looking for housing due to being evicted from the motel he lived in for the last year. He had not been able to locate anything. SSD #814 called the Budget Inn hotel, and they had rooms available at a weekly rate of $270.00. SSD #814 made the resident an appointment to establish a primary care provider (PCP) and the resident had an appointment on 04/24/25 at 3:00 P.M. A referral was sent to home health services, and the therapy department had provided the resident with home exercises. Review of Resident #128's medical record revealed no evidence Resident #128 was issued a 30-day discharge notice, evidence the facility coordinated discharge services with the Ombudsman, or assisted the resident in seeking resources to secure safe housing and alternative discharge placement other than a hotel. The medical record did not contain evidence Resident #128 was in agreement to be discharged to a hotel. Review of Resident #128's Resident Fund Management Service (RFMS) statement dated 04/03/25 revealed the resident withdrew $1,190.00 (one thousand one hundred and ninety dollars) from the account prior to discharge. Review of Resident #128's Discharge Review dated 04/03/24 at 3:48 P.M. revealed the resident was discharged home with prescriptions. Review of Resident #128's progress note dated 04/04/25 at 1:15 P.M. authored by Registered Nurse (RN) #817 revealed the discharge instructions were explained and provided to the resident. Medication cards and an inhaler with instructions were provided and the resident verbalized and signed understanding. The resident was transported via a wheelchair in the facility transport van. Review of Resident #128's progress note authored by the Director of Nursing (DON) dated 04/05/25 at 4:41 P.M. revealed a courtesy call was made to the resident and he stated he was adjusting well and had enough food/medication to be comfortable to the next week. The resident wanted information on the group home and was inquiring if that was still an option for him. The DON documented she would inquire and follow-up with the resident on 04/06/25. Interview on 05/27/25 at 7:20 A.M. with Assistant DON #808 revealed Resident #128 came from a hotel and was admitted with a fungal rash. Assistant DON #808 stated the resident was cut from therapy, appealed and lost the appeal. She confirmed the resident did not want to turn over his check and pay for an additional stay at this facility and was discharged to a hotel. She stated the facility transported the resident using the facility transport bus. Interview on 05/27/25 at 7:37 A.M. with RN #810 revealed Resident #128 came from a hotel and she discharged the resident to a hotel per the resident's request. Interview on 05/27/25 at 9:10 A.M. with the Administrator revealed Resident #128 chose to be discharged from the facility to a hotel. The Administrator revealed the resident did not want to pay patient liability to stay in the facility and the facility closed the resident's RFMS account and gave the resident the $1,190.00 that was in the account. The Administrator also confirmed the Ombudsman's office was not involved in the resident's discharge from the facility. A telephone call was placed to the hotel on 05/27/25 at 10:15 A.M. and Resident #128 was no longer living at the hotel. A second interview on 05/27/25 at 10:08 A.M. with the Administrator indicated Resident #128 did not want to pay the liability for the facility and chose to discharge. She stated the resident was having a hard time finding a place to go and the facility assisted the resident to find a hotel in which the resident could afford. The Administrator denied the facility had kicked the resident out at any point and that was why a 30-day discharge notice was not initiated. Telephone interview on 05/27/25 at 10:14 A.M. with the Ombudsman revealed their department had a history with Resident #128 and the facility did not inform them of the resident's discharge on [DATE] to a hotel. An interview on 05/27/25 at 12:23 P.M. with the DON indicated she attempted to call Resident #128 on 04/07/25 and the phone just rang. She stated the Administrator called the group home and gave them the resident's phone number. She was unsure of the date and time. The DON confirmed she did not document the follow up in the resident's medical record. A second interview on 05/27/25 at 12:27 P.M. with the Administrator confirmed she called the group home on [DATE] at 3:05 P.M. and gave them Resident #128's phone number for them to call the resident for admission. Review of the undated Discharge Planning and Managing Length of Stay policy revealed it was recommended that the facility's Administrator and/or Admission's Coordinator communicate to the hospital representatives the information that would be needed upon admission. This would allow the facility to provide an optimal plan of care throughout the resident's stay. A final discharge summary would be completed upon discharge that can be provided to the resident or an authorized person including a reconciliation of medications with post discharge medication orders and post discharge plan of care. The post discharge plan of care would include where the individual plans to reside, any arrangements that have been made for the residents' follow up care, and any post discharge medical and/or non-medical services. The Ombudsman must be notified in writing of all transfers and discharges. This deficiency represents non-compliance investigated under Complaint Number OH00164484.

Based on observation, staff interview and facility policy review, the facility failed to ensure food was labeled and dated appropriately. This had the potential to affect 143 of 144 residents who received meals from the facility kitchen. The facility identified one resident (#50) who received no food by mouth. The facility census was 144. Findings include: Observations during of the main initial kitchen tour conducted on 02/03/25 between 8:27 A.M. and 9:10 A.M. with [NAME] #1238 revealed the following concerns: The main walk-in refrigerator contained one pork loin in a metal container that was undated and unlabeled. The reach in refrigerator revealed one undated metal container of 12 quartered hard-boiled eggs which was undated and unlabeled, one metal container of ham which was undated and unlabeled, one Chef salad that was undated, and one metal container of a gelatinous brown-green substance which [NAME] #1238 could not identify, which was unlabeled and undated. Interview on 02/03/25 at 8:50 A.M. with [NAME] #1238 verified all the above items were unlabeled and undated and that she did not know when they were placed in the refrigerators. Review of the undated facility policy titled, Policy and Procedure Manual: Food Storage stated under Refrigerated food storage: All foods shall be covered, labeled, and routinely monitored, to assure that food (including leftovers) will be consumed by their use dates, or frozen (where applicable) or discarded.

Based on review of personnel records and interview the facility failed to maintain documentation the COVID-19 vaccine was offered to the staff, and the staff were provided education regarding the benefits and risks associated with COVID-19 vaccine annually. This had the potential to affect all 144 residents in the facility. Findings include: A review of Certified Nursing Assistant (CNA) #1234's, CNA #1274's, CNA #1226's, CNA #1315's and Licensed Practical Nurse (LPN) #1231's personnel records revealed there was no documentation the facility had provided education and/or offered the information/consent regarding the COVID-19 vaccine. An interview with Infection Control Preventionist (ICP) #1240 on 02/06/25 at 10:50 A.M. stated she did not file the employee's consent and/or education regarding the COVID-19 vaccine in the employees' personnel files. ICP #1240 stated the Human Resources Manager (HRM) filed the consents and education in the employees' personnel files. An interview with the HRM #1267 on 02/06/25 at 11:00 A.M. verified the facility failed to maintain documentation the COVID-19 vaccine was offered to the staff, and the staff were provided education regarding the benefits and risks associated with COVID-19 vaccine for staff. Only the newly employed staff with a hire date from 02/06/24 to 02/06/25 had the required documentation in their personnel record. The facility policy titled COVID 19 Vaccination, revised 12/2021, indicated: Prior to offering the COVID-19 immunization to the staff, the nursing facility will provide education regarding the benefits and potential side effects of the immunization. The nursing facility will offer the vaccine for COVID-19 series or booster per the manufacturer guidelines via the authorized provider, unless the immunization is medically contraindicated, the staff refuses the immunization, or if the staff have already been immunized during the time period. The staff would be observed for 15 minutes post vaccination by the authorized administering provider and/or facility licensed nursing staff to monitor for anaphylactic reaction and deliver emergency response care, as needed. The staff had the right to refuse the COVID-19 immunization. The refusal and the reason for the refusal should be documented within the staff member's personnel file. If a staff member refuses to receive the vaccine, they must present evidence from their physician as to why the vaccine would be contraindicated for them. If they cannot do so, they would be removed from the schedule until they provide evidence of vaccination to the facility. Failure to do so may result in disciplinary action to include termination. The human resource coordinator/designee will document in the staff member's personnel file:That the staff member was provided education regarding the benefits and potential side effects of the COVID-19 immunization. That the staff member either received the COVID-19 Immunization or did not receive the COVID-19 immunization due to medical contraindications or refusal. The facility would record the COVID-19 vaccine receipt, refusal, or contraindications within the staff member's personnel file.

39973 Based on observation, interview, record review and facility policy review, the facility failed to adequately clean and maintain Resident #63's room, Resident #23's wheelchair, the laundry room and the resident common areas for [NAME] unit and 200-hall. This affected two residents (#23 and #63) and had the potential to affect all 144 residents residing in the facility. Findings include: 1. Observation on 02/03/25 at 9:38 A.M. of the 200-hall common area revealed a two-person fabric couch located to the right of the television across from room [ROOM NUMBER]. The couch armrests and seats were heavily soiled with the seat fabric torn open from the far-right of the cushion across toward the far-left of the cushion. The large tear was moderately wide which exposed the yellow-colored foam-like material underneath the fabric. Nearby, to the right of the couch was one non-reclining fabric chair with an ottoman placed in front of it which was located across from room [ROOM NUMBER]. Both the chair and the ottoman were heavily soiled with multiple scattered dark colored stains. The fabric of both armrests and the upper rear portion of the chair was worn away which revealed multiple open holes exposing the wood and metal framing beneath. The right armrest had torn fabric which exposed seven large metal nail heads from the wood frame underneath, and the left armrest also had exposed the wood framing from fabric torn away. There were six dining chairs located within the vicinity of the non-reclining chair. Each chair was heavily soiled with dark colored stains on both the seats and upper backs of the chairs. Each wooden chair leg had excessive damage including multiple deep marks, dents and gashes which were unsightly. To the left of the television was a door frame leading from the 200-hall resident care area towards the facility front entrance. There was a large crack in the wall from the right mid to the upper portion of the wall surrounding the door frame. This was adjacent to room [ROOM NUMBER]. There were small areas of missing plaster alongside the cracks and the word crack was written in black onto the lower portion of the cracked wall. The metal framing underneath the damaged wall was visible through the cracked areas on the lower portion of the damage. An interview at the time of the observation with the Director of Nursing (DON) verified the findings. 2. Record review for Resident #63 revealed an admitted [DATE] and diagnoses included dementia, altered mental status, aphasia, anxiety disorder, and hypertension. Review of care plan last revised 05/21/24 revealed Resident #63 was at risk for impaired skin integrity related to fragile skin, incontinence and that he preferred to urinate in various inappropriate places. Interventions included inspecting skin during routine daily care, medications as ordered, and incontinent care after each incontinence episode. There were no interventions regarding the prevention of urinating in inappropriate places. Observation and interview on 02/04/25 at 8:18 A.M. revealed Resident #63's room had a large puddle in the upper left corner of his room with brown stained tiles. The closet by the door also had a large puddle, and the inside of the closet had brown, black staining where it appeared the tiles were lifting, and the liquid was seeping underneath the tiles. There were two puddles on the floor by the closet near the window that also contained brown tiles. The baseboards in each of the closets were black covering the length of each closet. There was a strong pervasive urine smell coming from the room that could be smelled from the hallway. Resident #63 was unable to provide any details of the condition of his room. Interview on 02/04/25 at 8:18 A.M. with Registered Nurse (RN) #1273 verified the above findings. She verified all the puddles were urine, and the staining on the baseboards and tiles were also caused by Resident #63 urinating on the floor continuously. She revealed, he just urinates all over his room. She also verified that the tiles were lifting, and the urine was seeping underneath the tiles, and the floor was sticky. She revealed the room had been like that for some time, but housekeeping cleans the room daily and tried to clean the best that they could. She stated all the puddles observed were most likely from the last time housekeeping had cleaned his room yesterday, 02/03/25. She verified that housekeeping or staff do not clean more than once a day because it was an ongoing issue with him continuously urinating on the floor. She stated, yes, it is pretty bad but not sure what else to do for him except his whole room needed to be redone but then he would just continue to urinate on the floor. She was not aware of any toileting program that Resident #63 was on. Observation and interview on 02/04/25 at 8:21 A.M. with the DON #1238 and Maintenance Director #1256 of Resident #63 room verified the above findings. They both stated that they had no knowledge of the condition of his room. DON #1238 stated, oh my yes this is unacceptable and not good. They both also verified the multiple puddles of urine throughout the room and strong urine smell that was smelled in the room as well as from the hallway. DON #1238 verified staff should be cleaning after each episode, not waiting for an accumulation of puddles. Maintenance Director #1256 verified the tiles, and the baseboards needed to be replaced. DON #1238 verified there was no urinal present in his room as well as she was not aware if he was on a toileting program and/or what interventions were in place. Observation on 02/04/25 at 11:23 A.M. revealed there was a wet floor sign on the outside of Resident #63's room, but a strong urine smell continued coming from the room into the hallway. The floor was sticky; when this surveyor walked on it, shoes could be heard sticking to the floor, and the stains to the floor and baseboards continued. The puddles of liquid were no longer present. Resident #63 was sitting in the lounge in a recliner. Observation on 02/04/25 at 12:11 P.M. revealed Resident #63 got up from the recliner in the lounge and ambulated down the hallway past RN #1273 and CNA #1403 into his room where he urinated in the closet by the window leaving a puddle of urine. Interview on 02/04/25 at 2:54 P.M. with Housekeeping/Laundry Supervisor #1253 revealed Housekeeper #1244 was the housekeeping staff on the unit Resident #63 resided. She verified Housekeeper #1244 should be cleaning Resident #63's room at least twice a day. She revealed, often when she comes in, there were multiple puddles of urine throughout his room. She had been working at the facility for over three years and that the urine was embedded into the floor tiles and baseboards causing the tiles to heave up and pull away from the floor. She revealed she knew Maintenance Director #1256 was aware of the condition of his room for quite a while because she had communicated it to him. She verified no matter how much they cleaned the room; the strong urine smell was still present as the urine had seeped under the stained tiles and baseboards. 3. Observation on 02/03/25 at 9:04 A.M. on [NAME] unit revealed a couch in the lounge area with multiple brown stains covering the seat cushions and arm rests. The couch seat cushions also contained brownish circular stains appearing to be from urine. Interview on 02/03/25 at 9:04 A.M. with Certified Nursing Assistant (CNA) #1200 verified the couch in the lounge area contained stains. She revealed several of the residents were incontinent on the unit and frequently urinated on the couch causing the brown circular stains, and the couch had been in that condition for quite a while. Observation on 02/04/25 at 7:38 A.M. revealed the couch on [NAME] unit continued to be in the same condition. Interview on 02/04/25 at 7:38 A.M. with the DON verified the couch had multiple brown stains covering the seat cushions and arm rests. She stated, yes it looks like dried urine stains on the seat cushions. 4. Observation on 02/03/25 at 8:27 A.M. revealed Resident #23 was up in her wheelchair and dried food and a white substance was on the side of the chair as well as on her wheelchair seat. There was an accumulation of brown/black substance on her wheelchair seat and brakes. Interview on 02/03/25 at 10:57 A.M. with Licensed Practical Nurse (LPN) #1303 verified the above condition of Resident #23's wheelchair. She revealed that Resident #23's wheelchair needed cleaned as it looks like it had not been cleaned recently. She was not aware of the schedule of how often wheelchairs were cleaned, and who was assigned to clean them. Interview on 02/05/25 at 4:41 P.M. with Administrator revealed the facility did not have a policy in regards to cleaning of wheelchair or a schedule of who or when they were cleaned. She revealed there was nothing formal in place regarding who was assigned to clean the wheelchairs. 5. An observation of the laundry room on 02/04/25 at 8:06 A.M. revealed a thick coating of dust and debris behind the two washing machines. There was a small cardboard box covered in dust and a metal container covered with dust behind the washing machines. An interview with Laundry Aide (LA) #1216 on 02/04/25 between 8:00 A.M. and 8:15 A.M. verified there was an excessive amount of dust and debris behind the washing machines. LA #1216 stated the maintenance department was responsible for cleaning behind the washing machines. An interview with Maintenance Director (MD) #1256 on 02/04/254 at 9:30 A.M. revealed he was responsible for dusting the top of the washing machines, dryers and high areas in the laundry room. MD #1256 stated he was not responsible for cleaning behind the washing machines. 41526

Based on observation, record review, interview, review of the centers for Disease Control and Prevention (CDC) guidelines and facility policy review, the facility failed to ensure staff donned the appropriate personal protective equipment (PPE) when providing direct care to Resident #13, Resident #16, Resident #36, Resident #50 and Resident #119. This affected five residents (#13, #16, #36, #50, and #119) out of five residents reviewed for enhanced barrier precautions (EBP) and/or transmission based precautions (TBP) and had the potential to affect and additional 19 residents (#4, #7, #15, #23, #31, #33, #60, #81, #91, #93, #96, #106, #111, #114, #125, #127, #135, #196, and #444) identified by the facility with orders for EBP. The facility census was 144. Findings include: 1. Resident #50 was admitted on [DATE] with diagnoses including respiratory failure, senile degeneration of the brain, gastronomy and colostomy status, diabetes mellitus, depression, bone density disorder, anxiety, gastroesophageal reflux disease, hemiplegia and hemiparesis, kidney failure, plasma-protein disorder, hyperosmolality, polyneuropathy, vitamin D deficiency, anemia, high blood pressure, and high cholesterol. Resident #50's physician order revised 11/22/24 indicated to implement EBP related to tube feedings. Resident #50's care plan revised on 05/29/24 indicated Resident #50 was at risk for infection related to an ostomy. Interventions on the care plan indicated to maintain EBP with care as indicated and provide education on EBP to family as needed. An observation on 02/05/24 at 7:19 A.M. of Certified Nursing Assistant (CNA) #1261 and CNA #1421 provide incontinence care for Resident #50 revealed a failure to wear the appropriate PPE. A sign outside of Resident #50's doorway indicated implementing EBP when providing care for Resident #50 as needed during direct care tasks. CNA #1261 and CNA #1421 entered Resident #50's room and proceeded to provide incontinence care. Both staff donned a pair of gloves but did not wear a gown while providing the incontinence care for Resident #50. The staff assisted Resident #50 with changing the soiled incontinence brief and linens, cleaned Resident #50's perineal area and repositioned Resident #50 for comfort during the incontinence care. An interview with CNA #1261 and CNA #1421 on 02/05/25 at 7:27 A.M. verified they did not wear the appropriate PPE during Resident #50's incontinence care. Both of the staff stated they thought they were only supposed to wear gloves during the task and stated they didn't know where to find the disposable gowns because there was no supply cart located outside of Resident #50's room with PPE supplies. An interview with Director of Nursing (DON) #1241 on 02/05/25 at 7:27 A.M. verified the staff were supposed to wear the appropriate PPE for EBP during Resident #50's incontinence care and proceeded to provide education to CNA #1261 and CNA #1421 on the policy and procedure for EBP implementation. 2. Resident #16 was readmitted on [DATE] with diagnoses including muscular dystrophy, below the right knee amputation, diabetes mellitus, neuromuscular bladder, polyneuropathy, anemia, high blood pressure, malnutrition, optic atrophy, heart failure, atherosclerotic heart disease and atherosclerotic lower extremity arteries, high cholesterol, encephalopathy, and chronic pain. Resident #16's physician order dated 09/16/24 indicated to implement EBP related to the presence of an indwelling urinary catheter. Resident #16's plan of care initiated on 06/15/20 indicated Resident #16 was at risk for infection related to the presence of an indwelling urinary catheter (Foley), diabetes mellitus, malnutrition, multiple co-morbidities, and communal living. Intervention on the care plan initiated on 12/20/24 indicated to maintain EBP related to Foley catheter. An observation of CNA #1234 on 02/04/25 at 9:35 A.M. assist Resident #16 with bathing and dressing and personal hygiene revealed a failure to wear appropriate PPE during the task. A sign located outside of Resident #16's room revealed EBP during direct care tasks. The sign indicated the staff should don a gown and gloves when providing direct care tasks including bathing, dressing, and personal hygiene. CNA #1234 entered Resident #16's room and donned a pair of gloves but did not wear a gown during the task. On 02/04/25 between 9:30 A.M. and 10:00 A.M. an interview with CNA #1234 stated she forgot to wear the appropriate PPE while assisting Resident #16 with dressing, bathing, and personal hygiene. CNA #1234 stated the PPE was located on the linen cart located in the hallway and she should have worn a gown in addition to the disposable gloves while assisting Resident #16. Review of the undated facility policy and procedure titled Enhanced Barrier Precautions indicated the purpose of the policy was to reduce the transmission of multidrug resistant organism (MDROs) when high contact resident care activities for residents with known to be colonized or infected with MDRO as well as those at increased risk to acquire MDRO. Residents with the following triggers will receive Enhanced Barrier Precautions (EBP) and indicate they should be followed for any resident in the facility with: Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Indwelling medical devices may include central lines, urinary catheters, feeding tubes, and tracheostomies. Chronic wounds include pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous status ulcers. EBP is to be used in conjunction with standard precautions and requires use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Use of eye protection may be necessary when splash or spray may occur but is not necessary in other situations. Examples of high-contact resident care activities requiring gown and glove use among residents that trigger EBP use include: Dressing Bathing/Showering Transferring Providing hygiene Changing linens Changing briefs or assisting with toileting Device care or use; central line, urinary catheter, feeding tube, tracheostomy/ventilator 39973 3. Review of the medical record for Resident #13 revealed an admitted [DATE] with diagnoses including acute cystitis (inflammation of the bladder) with hematuria, diabetes, and altered mental status. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 had impaired cognition and was on antibiotic therapy. Review of the care plan dated 01/20/25 revealed Resident #13 received intravenous therapy through a peripherally inserted central catheter (PICC) (a thin flexible tube inserted into a vein in the upper arm and threaded into larger vein near the heart). Interventions included administering medications per physician orders, assessing intravenous site daily for signs of infection, assessing intravenous site daily for signs of infection and change dressing to insertion site per facility policy. Review of February 2025 physician orders revealed Resident #13 had a physician order dated 01/10/25 for EBP every shift due to intravenous therapy and wound care and an order dated 01/11/25 for vancomycin (antibiotic) hydrochloride intravenous solution 1000 milligram (mg) intravenously two times a day for 28 days. Review of the care plan dated 02/04/25 revealed Resident #13 was at risk for infection or worsening of related to PICC line. Interventions included administering medications as ordered, encourage frequent hand washing, and maintain EBP with care as indicated. Observation on 02/04/25 at 3:57 P.M. revealed Registered Nurse (RN) #1206 walked into Resident #13's room that had signage on the outside of her door indicating she was on EBP. There was no bin outside of Resident #13's room that contained PPE, including a gown. RN #1206 who already had a mask donned proceeded to wash her hands and donned gloves. RN #1206 then lifted Resident #13's left arm and leaned up against her bed as she administered her intravenous vancomycin. She was not wearing a gown as ordered. RN #1206 then doffed her gloves and washed her hands, exiting the room. Interview on 02/04/25 at 4:09 P.M. with RN #1206 verified she did not don a gown during the administration of Resident #13's intravenous antibiotic. She revealed she had forgotten as there was no PPE sitting on the outside of the door in a bin as she was used to instead of just a sign. She revealed when barriers out of sight then out of mind. She verified Resident #13 had an order for EBP and that she should have had a gown on during the administration. Interview on 02/05/25 at 9:09 A.M. with the DON verified Resident #13 was on EBP, and RN #1206 was to wear a gown during the administration of her intravenous antibiotic. Review of the facility policy labeled, Enhanced Barrier Precautions, last revised March 2024, revealed residents with the following triggers would receive EBP including residents with indwelling medical devices. The policy revealed medical devices may include central lines. EBP was to be used in conjunction with standard precautions and required use of gown and gloves during high- contact resident care activities that provided opportunities for the transfer of MDRO. 41526 4. Observation on 02/04/25 at 8:36 A.M. revealed Resident #119's room had an EBP sign posted at the entrance. There was no PPE including gowns and gloves located nearby. RN #1310 then entered Resident #36's room to administer medications wearing only gloves and no gown. Resident #119 had an enteral tube which RN #1310 used to administer the medications without wearing a gown. Interview at the time of the observation with RN #1310 verified not using the appropriate PPE for EBP which included wearing both gloves and a gown. Review of the medical record for Resident #119 revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebrovascular disease affecting the right dominant side, and gastrostomy status. The physician orders effective February 2025 indicated Resident #119 received medications via an enteral tube. Interview on 02/04/25 at 09:17 A.M. with Infection Preventionist (IP) #1240 confirmed staff were to use both gloves and a gown with EBP. The gloves were located inside resident rooms and gowns were located on clean linen carts. Review of facility policy, Enhanced Barrier Precautions, revised March 2024, revealed residents with an indwelling medical device including feeding tubes will receive EBP which required use of a gown and gloves during device care or use. 5. Observation on 02/04/25 at 8:07 A.M. revealed Resident #36's room had a TBP sign posted at the entrance. The sign was a CDC droplet precautions sign which indicated everyone must fully cover their eyes, nose and mouth before room entry and remove face protection before room exit. The sign included a picture which showed the use of a mask and either goggles or a face shield. There was no PPE including masks and goggles or face shields located nearby. CNA #1225 then entered Resident #36's room to deliver a breakfast meal tray wearing only a surgical mask. Afterwards, CNA #1225 exited the room without removing or changing the surgical mask. Interview at the time of the observation with CNA #1225 verified not wearing goggles or a face shield for droplet precautions and not changing or removing the mask upon the room exit. Observation on 02/04/25 at 8:09 A.M. revealed RN #1310 entered Resident #36's room to administer medications wearing only a surgical mask. Afterwards, RN #1310 exited the room without removing or changing the surgical mask and returned to the medication storage cart to prepare additional medications. RN #1310 then re-entered Resident #36's room to administer the additional medications wearing the same surgical mask and no eye protection. After that, RN #1310 exited the room without removing or changing the surgical mask. Interview at the time of the observation with RN #1310 verified not wearing goggles or a face shield for droplet precautions and not changing or removing the mask upon the room exit. Review of the medical record for Resident #36 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, diabetes mellitus type two and heart failure. The laboratory test dated 01/28/25 indicated Resident #36 was positive for influenza A. Interview on 02/04/25 at 09:17 A.M. with IP #1240 confirmed with droplet precautions the staff were to use masks and eyewear either goggles or a face shield which would be washed or disposed of after use. The masks would be disposed of or changed when staff exited the room, and PPE placed outside the door for staff use. Review of Infection Prevention and Control Strategies for Seasonal Influenza in Healthcare Settings, dated 05/13/21, from the CDC's Influenza (Flu), located at https://www.cdc.gov/flu/hcp/infection-control/healthcare-settings.html revealed droplet precautions were to be used for any residents with suspected or confirmed influenza for seven days after illness onset or 24 hours after the resolution of fever and respiratory symptoms whichever is longer. Review of the facility policy, Transmission-Based Precautions, dated September 2024, revealed droplet precautions included use of a well fitted mask and eyewear in resident care areas at the discretion of the facility. Review of the undated facility policy, Policy Isolation Precautions revealed isolation procedures remained in effect until being discontinued by the physician and the Infection Control Nurse or Designee. Precaution signs were posted on residents' doors to alert staff or visitors.

Based on observation, medical record review, interview and review of the NSO (Nurses Services Organization) guidelines, the facility failed to ensure Resident #13's bowel and bladder assessment was accurately documented in Resident #13's medical record. This affected one resident (#13) out of three residents reviewed for incontinence care. The facility census was 144. Findings include: Resident #13 was admitted on [DATE] with diagnoses including acute cystitis (urinary bladder infection), encephalopathy, morbid obesity, diabetes mellitus, obstructive sleep apnea, anxiety, cognitive decline, arthritis, scoliosis, diverticulitis, vitamin D deficiency, Raynaud's Syndrome, depression, insomnia, thyrotoxicosis (excessive thyroid hormone) with goiter, fibromyalgia (wide-spread pain), hypothyroidism (underactive thyroid), and meninges (membranes covering the brain) tumor. A review of Resident #13's clinical record revealed a Minimum Data Set (MDS) admission assessment dated [DATE] which indicated Resident #13 had an indwelling urinary catheter. Review of Resident #13's certified nursing assistant (CNA) documentation dated 01/10/25 to 01/30/25 indicated Resident #13 had frequent urinary incontinence with occasional urinary continence. There was no plan of care or interventions implemented to provide care for an indwelling urinary catheter. Further review of Resident #13's clinical record revealed no physician orders to discontinue an indwelling urinary catheter. Resident #13's nursing progress notes dated 01/10/25 to 02/06/25 indicated no documentation of the presence of an indwelling urinary catheter or that the indwelling urinary catheter was discontinued. Resident #13's progress note dated 01/10/25 indicated she had a Brief Interview Mental Status (BIMS) score of 10 which indicated she had moderate cognitive impairment. Resident #13 was alert, oriented, and pleasant. An observation of Resident #13 on 02/03/25 at 9:45 A.M. revealed there was no indwelling urinary catheter tubing or urine drainage bag observed hanging from Resident #13's bed frame. An interview with Resident #13 on 02/05/25 at 12:05 P.M. revealed she had never had an indwelling urinary catheter on admission to the facility. An interview with Director of Nursing (DON) #1241 on 02/05/25 at 10:29 A.M. verified the above findings and agreed there was inconsistent documentation of the presence and/or absence of an indwelling urinary catheter for Resident #13. Interviews with CNA #1294 and CNA #1420 on 02/06/25 between 11:30 A.M. and 12:00 P.M. they had provided care for Resident #13 upon admission to the facility. Both staff indicated Resident #13 did not have an indwelling urinary catheter upon admission to the facility. A review of the NSO (Nurses Services Organization) guidelines dated 2024 for nursing documentation indicated a complete and accurate clinical record presents the strongest defense against any malpractice or licensing board action. While some specialized settings, practice [NAME], regulations and other areas may require additional types or components of documentation, the following principles may lessen nurses' liability exposures: Chart in the correct record. Ensure that key patient identifiers are accurate, including the spelling of the patient's name and their date of birth, to ensure effective linking of patient healthcare information records within and across systems. Chart promptly. As soon as possible after you make an observation or provide care, document your actions for more detailed notes. If you wait until the end of your shift, you could forget to include important information. Be accurate, objective, and complete. Document what you see, hear, and do. Include data relating to all aspects of patient care and the nursing process.

Based on observation, record review, interview and facility policy review, the facility failed to ensure Resident #56 and Resident #63 were assisted with toileting and/or incontinence care and failed to provide a toileting program for Resident #63. This affected two residents (#56 and #63) out of three residents reviewed for incontinence care. The facility census was 144. Findings include: 1. Resident #56 was admitted on [DATE] with diagnoses including high blood pressure, atherosclerotic heart disease, hyperlipidemia (high cholesterol), [NAME] Syndrome (A syndrome in which the liver of affected individuals processes bilirubin more slowly than the majority.), senile degeneration of the brain, adjustment disorder, diabetes mellitus, and malnutrition. Resident #56's care plan initiated on 04/02/24 indicated Resident #56 had bladder incontinence. The goal of the care plan was Resident #56 would remain clean and odor free through review date. Interventions on the care plan included providing perineal care as needed, assisting with toileting and incontinence care as needed and encouraging Resident #56 to ask for assistance with incontinent care. Resident #56's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #56 had moderate cognitive impairment, bowel and bladder incontinence and he needed partial/moderate assistance with toileting/perineal hygiene, adjusting clothes before and after voiding or having a bowel movement. An observation and interview with Resident #56 on 02/03/25 at 9:25 A.M. revealed Resident #56 was lying in bed in his room. There was a strong, foul odor of urine present in the room. An observation of Resident #56's restroom revealed a pair of blue jeans hanging on the towel bar which had a large wet area located on the seat of the pants. The foul odor of urine was stronger in the restroom. Resident #56 stated he was incontinent during the nighttime hours and had removed his blue jeans and hung them on the towel rack. Resident #56 was unable to remember what time it was when he woke up from sleeping and was incontinent, but stated it was still dark outside. Resident #56 stated he was not provided with an incontinence brief and had donned a pair of pajama pants after he removed his blue jeans. Resident #56 stated the staff had not been in his room to check him yet this morning. An interview with Certified Nursing Assistant (CNA) #1234 on 02/03/25 at 9:25 A.M. verified the above findings and stated the CNA assigned to care for Resident #56 was currently on her break. CNA #1234 stated the CNA staff arrived in the morning for the start of their shift at 6:30 A.M. and should have made rounds on all the residents to ensure their care needs were met. CNA #1234 stated she had not seen Resident #56 since she arrived at the facility at 6:30 A.M. Review of the undated facility policy titled Incontinence Care indicated the purpose of the policy was to maintain skin integrity, prevent skin breakdown, control odor and provide comfort and self-esteem for the residents. This protocol is to be utilized on residents who are incontinent of bowel and/or bladder. After each episode of incontinence, greet the residents and explain procedure, provide incontinence care, change linens and clothing as needed, and provide an absorbent under pad and/or incontinence brief. 39973 2. Record review for Resident #63 revealed an admitted [DATE] with diagnoses including dementia, altered mental status, aphasia, anxiety disorder, and hypertension. Review of the care plan last revised 05/21/24 revealed Resident #63 was at risk for impaired skin integrity related to fragile skin, incontinence, and he preferred to urinate in various inappropriate places. Interventions included inspecting skin during routine daily care, medications as ordered, and incontinent care after each episode. There were no interventions regarding the prevention of urinating in inappropriate places. Review of the care plan last revised 08/24/24 revealed Resident #63 was on diuretic therapy related to hypertension. Intervention included obtaining and monitoring vital signs as needed. There was nothing in the care plan regarding interventions due to increased urination, especially after administration of medication. Review of the care plan last revised 08/28/24 revealed Resident #63 was at risk for alteration in elimination related to incontinence, decreased mobility and need for staff assist with toileting needs. Interventions including checking and changing the resident every two hours and providing incontinence care as needed. Review of the Continence assessment dated [DATE] revealed Resident #63 was continent as well as incontinent, utilized a toilet, had confusion and memory loss. He was on diuretic therapy which affected his continence. He was frequently incontinent of bowel, and there was not a bowel toileting program in place. He also was frequently incontinent of urine and per the assessment, a trial of a toileting program such as scheduled toileting, prompted toileting, or bladder training had not been attempted since admission. He also was not identified as on a current toileting program and/or trial. There was no documentation explaining why Resident #63 would not be appropriate for a program. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #63 had impaired cognition. He had no behaviors identified and required partial to moderate assistance with toileting. He was able to transfer and ambulate independently. He was frequently incontinent of urine and always incontinent of bowel. Observation and interview on 02/04/25 at 8:18 A.M. revealed Resident #63's room had a large puddle in the upper left corner of his room with brown stained tiles. The closet by the door also had a large puddle, and the inside of the closet had brown, black staining where it appeared the tiles were lifting, and the liquid was seeping underneath the tiles. There were two puddles on the floor by the closet near the window that also contained brown tiles. The baseboards in each of the closets were black covering the length of each closet. There was a strong pervasive urine smell coming from the room that could be smelled from the hallway. Resident #63 was unable to provide any details of the condition of his room. Interview on 02/04/25 at 8:18 A.M. with Registered Nurse (RN) #1273 verified the above findings. She verified all the puddles were urine, and the staining on the baseboards and tiles were also caused by Resident #63 urinating on the floor continuously. She revealed, he just urinates all over his room. She also verified that the tiles were lifting, and the urine was seeping underneath the tiles, and the floor was sticky. She revealed the room had been like that for some time, but housekeeping cleans the room daily and tried to clean the best that they could. She stated all the puddles observed were most likely from the last time housekeeping had cleaned his room yesterday, 02/03/25. She verified that housekeeping or staff do not clean more than once a day because it was an ongoing issue with him continuously urinating on the floor. She stated, yes, it is pretty bad but not sure what else to do for him except his whole room needed to be redone but then he would just continue to urinate on the floor. She was not aware of any toileting program that Resident #63 was on. Observation and interview on 02/04/25 at 8:21 A.M. with Director of Nursing (DON) #1238 and Maintenance Director #1256 of Resident #63 room verified the above findings. They both stated that they had no knowledge of the condition of his room. DON #1238 stated, oh my yes this is unacceptable and not good. They both also verified the multiple puddles of urine throughout the room and strong urine smell that was smelled in the room as well as from the hallway. DON #1238 verified staff should be cleaning after each episode, not waiting for an accumulation of puddles. Maintenance Director #1256 verified the tiles, and the baseboards needed to be replaced. DON #1238 verified there was no urinal present in his room as well as she was not aware if he was on a toileting program and/or what interventions were in place. Observation on 02/04/25 at 11:23 A.M. revealed there was a wet floor sign on the outside of Resident #63's room, but a strong urine smell continued coming from the room into the hallway. The floor was sticky; when this surveyor walked on it, shoes could be heard sticking to the floor, and the stains to the floor and baseboards continued. The puddles of liquid were no longer present. Resident #63 was sitting in the lounge in a recliner. Observation on 02/04/25 at 12:11 P.M. revealed Resident #63 got up from the recliner in the lounge and ambulated down the hallway past RN #1273 and CNA #1403 into his room where he urinated in the closet by the window leaving a puddle of urine. Interview on 02/04/25 at 12:14 P.M. with CNA #1403 revealed she observed Resident #63 get up from the recliner but thought he went into the dining room. She revealed they try to catch him before he urinates in his room, but they get busy with things and do not see when he goes. She verified there was a puddle of urine in the closet by the window and that the floor had not been thoroughly cleaned as it continued to be sticky. She also verified the strong urine smell, and stated, I know, his room is bad; it always was. Interview on 02/04/25 at 2:40 P.M. with Housekeeping #1244 revealed he usually was assigned to Resident #63's unit and stated when he gets to his room there were multiple puddles of urine everyday as well as the stained black substance on the baseboard and brown stained tiles. He revealed no matter how well he tried to clean; the stains do not come off, and the urine had seeped under the tiles causing most all the tiles to lift. He verified the condition of his room had been like that for a long time. He revealed he usually waited to the end of his shift to clean his room because if he did it at the beginning Resident #63 just messed it up by urinating on the floor so that was why he waited till the end of the shift. He verified he usually only cleaned his room once a shift. Interview on 02/04/25 at 2:54 P.M. with Housekeeping/Laundry Supervisor #1253 revealed Housekeeper #1244 was the housekeeping staff on the unit Resident #63 resided. She verified Housekeeper #1244 should be cleaning Resident #63's room at least twice a day. She revealed, often when she comes in, there were multiple puddles of urine throughout his room. She had been working at the facility for over three years and that the urine was embedded into the floor tiles and baseboards causing the tiles to heave up and pull away from the floor. She revealed she knew Maintenance Director #1256 was aware of the condition of his room for quite a while because she had communicated it to him. She verified no matter how much they cleaned the room; the strong urine smell was still present as the urine had seeped under the stained tiles and baseboards. Interview on 02/05/25 at 7:59 A.M. with CNA #1203 revealed Resident #63 had urinated for years on the floor. She revealed they attempted to take him to the bathroom as often as they could, but Resident #63 was not on a specific toileting schedule and did not have any other interventions that she was aware of. Interview on 02/05/25 at 8:56 A.M. with the DON verified she did not have any documentation regarding where a toileting program had been attempted in the past for Resident #63. She was going to investigate what interventions could be attempted. She verified staff (nursing and housekeeping) should be intervening after each time Resident #63 urinated inappropriately in his room not just leaving the puddles of urine. She also verified she had observed his room and that it needed addressed because the tiles and baseboards were stained, tiles were lifting because urine had accumulated underneath, and there was a strong continuous smell of urine in his room as well as in the hallway. Review of the facility policy labeled, Incontinence Care revealed the purpose of the policy was to maintain skin integrity, prevent skin breakdown, control, odor, and provide comfort and self-esteem for the resident. The policy revealed the facility would assess and document the following regarding the resident: elevation status, pattern tracking when indicated, and urine and bowel elimination. The policy revealed after each episode incontinence care would be provided. There was nothing in the policy regarding toileting programs.

Based on record review, interview and facility policy review, the facility failed to ensure Resident #36 was reweighed according to facility policy and failed to have documented evidence the physician was notified of after an 8.7% weight loss in 30 days and failed to ensure Resident #37's weekly weights were obtained as ordered. This affected two residents (#36 and #37) of three residents reviewed for nutrition and had the potential to affect all 144 residents in the facility. Findings include: 1. Review of the medical record for Resident #36 revealed an admitted [DATE]. Diagnoses included malnutrition, muscle weakness, prostate disorder, depression and diabetes. Review of Resident #36's weight record revealed on 12/04/24 Resident #36 weighed 322 pounds and on 01/03/2025 Resident #36 weighed 294 pounds which was a 8.70% weight loss in 30 days. There was no documented evidence the physician was notified of the weight loss and no documented evidence a reweight was obtained. Review of the care plan dated 12/30/24 revealed Resident #36 was at risk for alteration in nutritional status. Interventions included assisting with meals as needed, encouraging healthy choices, providing diets as ordered and monitoring weights as ordered. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #36 was cognitively intact. He required set-up help for eating, supervision for oral hygiene, substantial or maximum assistance for personal hygiene and was dependent for toileting and showering. He had weight loss and was not in a prescribed weight loss regimen. Review of the dietary assessment note dated 01/09/25 revealed Resident #36 had a significant weight loss of 8.70% in 30 days. The note indicated a reweight would be requested to verify accuracy. Interview on 02/05/25 at 3:18 P.M. with Registered Dietitian (RD) #1239 confirmed there was no reweigh for Resident #36, based on the progress note dated 01/09/25. 2. Review of the medical record for Resident #37 revealed an admitted [DATE]. Diagnoses included congestive heart failure, diabetes, morbid obesity, kidney disease, dysphagia, anemia and vitamin D deficiency. Review of the care plan dated 12/16/24 revealed Resident #37 was at risk for alterations in nutrition and hydration. Interventions included communicating with the dialysis dietitian, maintaining weight without a significant unplanned weight change, assisting with meals as needed, monitoring intake and output as needed and obtaining weights as ordered. Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #37 was moderately cognitively impaired. She required supervision for eating and was dependent for toileting, showering, dressing and hygiene. She had weight loss and was not on a prescribed weight loss regimen. Review of the physician's orders for January 2025 revealed an order for weekly weights, which began on 12/13/24. Review of Resident #37's weight record revealed she weighed 181 pounds on 12/14/24 and 174 pounds on 01/08/25, a 3.86% weight loss. No other weights were available to review. Interview on 02/05/25 at 3:18 P.M. with RD #1239 confirmed weekly weights for Resident #37 were not obtained as ordered. Review of the undated facility policy titled Weight Policy and Procedure revealed all new admissions would be weighed weekly for the first four weeks after admission and any weight variance of three pounds in one week or three pounds in one month would be reweighed within 24 hours.

Based on record review, interview and facility policy review, the facility failed to administer the pneumonia and Coronavirus-19 (Covid-19) vaccine to Resident #125. This affected one resident (#125) out of five residents reviewed for immunizations. The facility census was 144. Findings include: Resident #125 was admitted on [DATE] with diagnoses of malignant neoplasm of stomach, bipolar disorder, and feeding difficulties with gastrostomy, dysphagia, protein calorie malnutrition, and urinary incontinence. A review of Resident #125's medical record revealed Resident #125's signed request dated 11/11/24 revealed Resident #125 wanted to receive the pneumococcal and Covid-19 vaccinations. Review Resident #125's electronic medical record dated 11/08/24 through 02/04/25 revealed no provider orders for the pneumococcal or Covid-19 vaccination. Review of Minimal Data Set (MDS) 3.0 assessment for Resident #125 completed on 12/19/24 showed the pneumococcal vaccine was not offered, and Resident #125 was not up to date with the vaccine. Additionally, there was no documentation of the status of the Covid-19 vaccination in the MDS assessment. Interview with Resident #125 on 02/04/25 at 11:05 A.M. stated she had not received the Covid-19 vaccine, and she requested the pneumonia vaccine upon admission in the facility. Review of the undated facility policy titled Influenza, Pneumococcal, Shingles, and Covid 19 Immunizations indicated resident will be offered the influenza and pneumococcal vaccine upon admission and the influenza and pneumococcal consent/declination form will be completed at that time. The facility will obtain a physician order for the vaccine at time of consent. Additionally, the policy indicated The nursing facility will offer the vaccine for Covid-19 per the manufacturer guidelines via the authorized provider.

Based on observation, record review, interview and facility policy review, the facility failed to ensure Resident #128's oxygen was administered as ordered by the physician and failed to ensure Resident #128's oxygen tubing was changed as ordered. This affected one resident (#128) of three residents reviewed for oxygen administration and had the potential to affect four additional residents (#36, #60, #95, #128 and #443) identified by the facility as receiving oxygen therapy. The facility census was 144. Findings include: Review of the medical record for Resident #128 revealed an admitted [DATE]. Diagnoses included left rib fracture, chronic obstructive pulmonary disease (COPD), kidney disease, and history of stroke. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #128 was cognitively intact. She required supervision for eating and oral hygiene, partial to moderate assistance for personal hygiene and was dependent on staff for showering and toileting hygiene. Review of the care plan dated 12/20/24 revealed Resident #128 had an alteration in breathing patterns due to COPD. Interventions included assessing lung sounds and providing oxygen per the physician's orders. Review of the physician's orders for January 2025 revealed an order for three liters per minute of oxygen via nasal cannula continuously which began on 09/27/24 and an order to change oxygen tubing, cannula and/or mask every week on Thursday which began on 10/24/24. Observation on 2/04/25 at 9:30 A.M. revealed Resident #128's oxygen tubing was dated 01/23/25 and the oxygen administration was set at four liters per minute. Interview at the time of the observation with Licensed Practical Nurse (LPN) #1231 confirmed oxygen tubing was dated 01/23/25 and should be changed weekly, and Resident #128's oxygen was set at four liters per minute. Review of the undated facility policy titled Oxygen Therapy revealed oxygen would be administered in accordance with the physician's orders and tubing, nasal cannulas and humidifiers would be changed according to the physician's orders.

Based on record review, interview and facility policy review, the facility failed to ensure pre and post dialysis assessments were accurate and complete. This affected two residents (#37 and #83) of three residents reviewed for dialysis. The facility census was 144. Findings include: 1. Review of the medical record for Resident #37 revealed an admitted [DATE]. Diagnoses included congestive heart failure, diabetes, morbid obesity, kidney disease, dysphagia, anemia, and vitamin D deficiency. Review of the care plan dated 12/16/24 revealed Resident #37 received dialysis three days per week. Interventions included assisting with transfers to dialysis, checking for new orders upon return from dialysis, maintaining communication with dialysis staff and physicians, and monitoring the shunt for signs and symptoms of infection. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 was moderately cognitively impaired. She required supervision for eating and was dependent upon staff for toileting, showering, dressing and hygiene. She was receiving dialysis. Review of the physician's orders for February 2024 revealed an order for hemodialysis Tuesday, Thursday and Saturday. The order began 12/19/24. Review of the pre and post dialysis assessment history revealed no pre post assessments were completed on 12/14/24, 12/17/24, 12/21/24, 12/24/24, 12/31/24, 01/04/25, 01/18/25 or 01/28/25. Completed pre and post assessments revealed not all assessments contained all of the necessary relevant information. 2. Review of the medical record for Resident #83 revealed an admitted [DATE]. Diagnoses included diabetes, depression, end stage renal disease, anemia, arthritis, and heart failure. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #83 cognitively intact. She required supervision for eating, set up help for oral hygiene, substantial assistance for personal hygiene and was dependent upon staff for toileting and showering. She was on dialysis. Review of the care plan dated 11/29/24 revealed Resident #38 received dialysis Three days per week. Interventions included receiving treatments as scheduled with monitoring of the disease process, assistance with transfers when going to dialysis, checking for new orders upon return from dialysis and maintaining communication with the dialysis staff and physician. Review of the physician's orders for February 2025 revealed an order for dialysis every Tuesday, Thursday and Saturday. The order began 11/14/24. Review of the pre and post dialysis assessment history revealed no pre or post assessments were completed on 11/21/24, 12/03/24, 12/07/24, 12/12/24, 12/14/24, 12/21/24, 12/24/24, 12/31/24, 01/11/25, 01/14/25, 01/21/25, 01/23/25, 01/25/25, 01/29/25 and 01/30/25. Completed pre and post assessments revealed not all assessments contained all of the necessary relevant information. Interview on 02/05/25 at 10:40 A.M. with Licensed Practical Nurse (LPN) #1240 revealed she was aware of inconsistencies and incomplete pre and post dialysis assessments and was not surprised. Review of the undated facility policy titled Dialysis revealed that for residents receiving hemodialysis, the nurse would obtain vital signs and weight prior to receiving dialysis treatment and upon the resident's return. The nurse would also assess the hemodialysis site for signs and symptoms of infection, monitor for a thrill or bruit.

Based on record review, interview, review of employee corrective action and facility policy review, the facility failed to complete wound treatments as ordered by the physician for Resident #15. This affected one resident (#15) of three residents reviewed for treatments. The facility census was 144. Findings include: Review of the medical record for Resident #15 revealed an admitted [DATE] with diagnoses including disorders of veins, peripheral vascular disease, congestive heart failure and diabetes mellitus type two. The admission Minimum Data Set (MDS) assessment, dated 11/03/24, revealed the resident had no cognitive impairment. The weekly nurse practitioner (NP) wound assessments from 12/05/24 to 01/23/25 indicated Resident #15 had chronic left lower extremity (LLE) vascular ulcers, one medial and one lateral, which required daily wound dressing changes. Review of Resident #15's treatment administration record (TAR) from December 2024 to January 2025 revealed a daily dressing change ordered to begin 12/06/24 for the LLE medial and lateral wounds. On 12/20/24, 01/09/25, 01/11/25, 01/12/25, 01/13/25, 01/19/25 and 01/23/25, the daily dressing changes were not documented as completed. Interview on 02/06/25 at 10:18 A.M. with Wound Nurse (WN) #1217 verified the daily dressing changes for Resident #15's LLE vascular ulcers were not documented as being completed on 12/20/24, 01/09/25, 01/11/25, 01/12/25, 01/13/25, 01/19/25 and 01/23/25. WN #1217 explained on 01/09/25 and 01/23/25 the NP was in the facility and would have completed the dressing changes, and on 01/13/25 and 01/20/25, she remembered being in the facility so the treatments would have been done but just not signed off. WN #1217 continued to explain if any treatments were found not being done then a corrective action form was completed so it was believed the 01/12/25 and 01/19/25 dressings were probably done. However, WN #1217 confirmed there was no documented evidence Resident #15's dressing changes were completed as ordered on 12/20/24 and 01/11/25, and in addition recalled a corrective action form being completed for an additional two times in December 2024 when a nurse had signed off doing Resident #15's treatment but did not. Review of the employee notice of corrective action form signed by Registered Nurse (RN) #1287 on 12/17/24 revealed a verbal warning for not completing treatments on 12/14/24 and 12/15/24 as ordered, yet documenting it was done. Review of the undated facility policy, Dressing Change - Clean revealed to document the completion of treatments in the TAR.

Based on observation, staff interviews and record review, the facility failed to ensure all medications were secured and stored in locked compartments that would limit access only to authorized personnel. This affected three residents (Residents #13, Resident #16 and Resident #95) out of 31 who residents resided on the 200-nursing unit. The facility census was 144. Findings include: 1. Resident #13 admitted on [DATE] with diagnoses including acute cystitis with hematuria, encephalopathy, morbid obesity with status post gastric sleeve, diabetes mellitus, methicillin susceptible staphylococcus aureus infection, and anxiety. Review of Resident #13's medical record dated 01/01/25 to 02/03/25 showed no physician order for self-medication or an assessment of ability to provide self-medication included in the care plan and Minimum Data Set (MDS) 3.0 assessment. Resident #13's clinical record indicated he had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) assessment score of ten, indicating moderate cognitive impairment. An observation on 02/03/25 at 8:17 A.M. revealed multiple oral medications in a medicine cup on the over-the-bed table and unsecured in Resident #13's room. Medications included: Amitriptyline 10 milligrams (mg) (antidepressant), calcium carbonate 500 mg (supplement), Colace 100 mg (stool softener), Levothyroxine 150 micrograms (mcg) (hormone), Mirtazapine 15 mg (antidepressant), multivitamin 1 tablet (supplement), omeprazole 20 mg (proton pump inhibitor to decrease stomach acid), Venlafaxine 300 mg (antidepressant), vitamin B12 100 mcg (supplement), buprenorphine 1.0 mg (schedule III pain medication), Hydroxychloroquine sulfate 200 mg (antirheumatic and antimalarial), and potassium chloride 20 milliequivalent (mEq) (supplement) dissolved in separate cups of water. Interview with Registered Nurse (RN) #1206 on 02/03/24 at 08:25 A.M. confirmed medications were left unattended in Resident #13's room. 2. Resident #16 admitted on [DATE] with diagnoses including muscular dystrophy, above the left knee amputation, type II diabetes mellitus, neurogenic bladder, anemia, congestive heart failure, and major depressive disorder. Review of Resident #16's medical record dated 05/17/24 through 1/31/25 showed no provider order for self-administration of any medications nor does the MDS 3.0 assessment or care plan indicate the ability to self-administer medications. Resident #16's BIMS score was 13, indicating the resident was cognitively intact. An observation on 02/03/25 at 9:17 A.M. revealed unsecured medications in Resident #16's room on the computer desk. Medications observed included: Fluticasone nasal spray (corticosteroid), Timolol ophthalmic solution (treatment for glaucoma), artificial tears ophthalmic solution (eye lubricant), Systane nighttime ophthalmic ointment (eye lubricant), Brimonidine 0.2% ophthalmic solution (lowers eye pressure), and Latanoprost ophthalmic solution (treatment for glaucoma). Interview on 02/05/25 at 8:32 A.M with Licensed Practical Nurse (LPN) #1204 verified Systane ophthalmic ointment, artificial tears, Fluticasone nasal spray, Timolol ophthalmic solution Latanoprost ophthalmic solution and Brimonidine tartrate ophthalmic solution 0.2 % were present and unsecured on the resident's computer desk. 3. Resident #95 was admitted on [DATE] with diagnoses of acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), type II diabetes mellitus, and schizoaffective disorder. An observation on 02/04/25 at 9:26 A.M. in Resident #95's room revealed two unsecured medications on the bedside table. Medications included: Flonase nasal spray (antihistamine) and Azelastine nasal spray (antihistamine). Record review of Resident's #95's medical record dating 01/18/25 to 02/04/25 found no order for self-administration of medication or the assessment of ability for self-administration in the MDS 3.0 assessment or the care plan. Interview at 02/06/25 at 9:20 A.M. with Medication Technician #1415 confirmed both medications Flonase and Azelastine were present and unsecured on Resident #95's over the bed table.

Based on record review, interview and facility policy review, the facility failed to ensure pharmacist recommendations for Resident #36 were addressed by the physician. This affected one resident (#36) of three residents reviewed for unnecessary medication. The facility census was 144. Findings include: Review of the medical record for Resident #36 revealed an admitted [DATE]. Diagnoses included hypertension, anxiety, malnutrition, muscle weakness, prostate disorder, depression, and diabetes. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was cognitively intact. He required set-up help for eating, supervision for oral hygiene, substantial or maximum assistance for personal hygiene and was dependent for toileting and showering. Review of the physician's orders for February 2025 revealed an order for Lasix 20 milligrams (mg) (diuretic) once per day which began on 09/18/23 and an order for Hydroxyzine 50 mg (antihistamine) three times per day which began on 06/26/22. Review of the medication regime review (MRR) dated 05/28/24 revealed Doctor of Pharmacy #1241 recommended monitoring for signs and symptoms of dehydration, kidney injury, edema, congestion and weight changes due to the use of Lasix. There was no documented evidence the physician addressed this recommendation. Review of the MRR dated 10/15/24 revealed Doctor of Pharmacy #1241 indicated hydroxyzine should be avoided in the elderly and recommended discontinuing the order. The physician responded to the recommendation 11/15/24 and indicated to continue use, but did not provide any rationale for the continued use. Interview on 02/05/25 at 2:29 P.M. with the Director of Nursing (DON) confirmed both MRR's for Resident #36 had not been addressed appropriately by the physician. Review of the facility policy titled Medication Monitoring; Medication Regimen, Review and Reporting, dated January 2024, revealed the consultant pharmacist would review the medication regimen and medical chart of each resident at least monthly to ensure appropriate monitoring of the medication regimen and to ensure medications received were clinically indicated. The findings were communicated to the DON and acted upon by the nursing staff or physician. The physician would act on the report or reject the recommendations, documenting the rationale of why the recommendation was rejected.

Based on interview, record review and review of the facility policy, the facility did not have an individualized care plan with interventions regarding Resident #76's post-traumatic stress disorder (PTSD). This affected one resident (#76) of two residents reviewed for PTSD and had the potential to affect six residents (#15, #21, #38, #76, #194, and #293) that were identified by the facility diagnosed with PTSD. The facility census was 144. Findings include: Review of the medical record for Resident #76 revealed an admitted [DATE] with diagnoses including PTSD, Bipolar disorder, major depression, congestive heart failure, and diabetes. Review of the admission packet dated 12/05/24 and completed by Registered Nurse (RN) #1288 revealed Resident #76 had experienced trauma in his life, but he did not have any triggers identified. Review of the care plan dated 12/10/24 revealed Resident #76 required assistance with activities of daily living (ADL) related to alcoholic cirrhosis of the liver, PTSD, and diabetes. There was nothing in the care plan regarding triggers and/or interventions related to the PTSD. Review of the care plan dated 12/11/24 revealed Resident #76 had an alteration in health maintenance related to alcoholic cirrhosis of the liver, PTSD, and diabetes. There was nothing in the care plan regarding triggers and/or interventions related to the PTSD. There was no other mention of PTSD in the comprehensive care plan. Review of the progress note dated 12/11/24 and completed by Psychiatric Nurse Practitioner (NP) #1240 revealed Resident #76 had a history of abuse as he reported a family friend did some things to young girls and would stare at him inappropriately. He also stated his mother was never happy with anything he did, and she was verbally abusive. The note revealed he had a history of trauma as he stated he had seen people die and he had killed people as he was a veteran of the armed forces. Review of the readmission admission packet dated 12/31/24 and completed by RN #1273 revealed under the area of trauma that Resident #76 had experienced trauma in his life, and he did have triggers that he felt reminded him of his trauma. In the comments section it listed the diagnosis of PTSD but did not list anything regarding specific triggers. Review of Medicare five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #76 had impaired cognition as his Brief Interview for Mental Status (BIMS) score was a ten. Interview on 02/05/25 at 11:29 A.M. with Resident #76 revealed he would start a conversation and lose the train of thought and start another conversation as it was difficult to follow. He was unable to provide any information regarding his PTSD and/or any triggers. Interview on 02/05/25 at 7:59 A.M. with Certified Nursing Assistant (CNA) #1411 revealed she frequently worked on the unit that Resident #76 resided and was not aware of what his past trauma was and/or any triggers that he may have that may re-traumatize in relation to his diagnosis of PTSD. Interview on 02/05/25 at 8:04 A.M. with RN #1273 revealed she frequently worked on the unit Resident #76 resided and was aware that he had a diagnosis of PTSD but was not aware of what his past trauma was as well as any triggers that he may have that may re-traumatize. Interview on 02/05/25 at 8:49 A.M. with MDS/Licensed Practical Nurse (LPN) #1224 verified Resident #76 had a diagnosis of PTSD and that on his re-admission assessment dated [DATE] revealed that he had triggers. She verified there was nothing in his care plan regarding his triggers and interventions to prevent re-traumatization related to his PTSD. Interview on 02/05/25 at 9:09 A.M. with the Director of Nursing (DON) verified Resident #76 had a diagnosis of PTSD and verified on Psychiatric/NP #1240 progress note dated 12/11/24 identified Resident #76 had a history of abuse as well as history of trauma with triggers identified. She also verified on his readmission assessment dated [DATE], under the area of trauma, Resident #76 experienced trauma in his life and that he did have triggers that he felt reminded him of his trauma. She verified Resident #76's care plan did not identify his triggers and/or interventions to prevent re-traumatization related to his PTSD. Review of the facility policy labeled, Trauma Informed Care, dated October 2022, revealed the facility recognizes that residents have had past experiences that have resulted in trauma including veterans, holocaust survivors, crime survivors and victims of sexual, physical and mental abuse. The facility defines trauma: results from an event, series of events, or set of circumstances that was experienced by the individual that had lasting adverse effects. The policy revealed the licensed nurse would assess the resident for potential trauma related to past or current experiences upon admission, quarterly, and with significant changes. Any identified triggers to re-traumatize would be documented and care planned .

Based on observation, interview, record review, and review of the facility policy, the facility failed to maintain fall prevention interventions as ordered by the physician for Resident #112 to prevent further falls. This affected one resident (#112) of three residents reviewed for accidents. The facility census was 125. Findings include: Record review for Resident #112 revealed an admitted [DATE]. Diagnoses included encephalopathy, unspecified dementia with other behavioral disturbances, spinal stenosis, muscle weakness, difficulty in walking, unspecified psychosis, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #112 was rarely or never understood. Resident #112 had no impairment to the upper or lower extremities and used no mobility devices. Resident #112 required setup or cleanup assistance with meals, substantial/max assistance for toileting, and partial/moderate assistance for transfers. Resident #112 had no falls since admission. Record review of the fall history for Resident #112 revealed Resident #112 had falls on 05/20/24, 05/30/24, and 06/13/24. Review of the fall risk evaluation dated 05/17/24 at 1:18 P.M. completed by Registered Nurse (RN) #254 revealed a score of 19 (high risk). Review of the progress notes dated 05/20/24 at 8:09 P.M. for Resident #112 completed by RN #266 revealed at 7:15 P.M. staff found Resident #112 on his right side on the floor of the right side of his bed and reported to this nurse. Cleansed four centimeters (cm) by four cm abrasion on the right elbow and applied a bordered gauze dressing. Resident was to walk with a walker, but the resident's walker was nowhere to be found. Every shift, staff was to ensure Resident #112 had his walker within reach. Review of the progress note dated 05/30/24 at 6:55 A.M. completed by Registered Nurse (RN) #271 revealed Resident #112 was found on the floor in his room by the state tested nursing assistant (STNA). This nurse was notified and went to assess the resident. Resident #112 was on the floor supine next to his bed. There was a very noticeable bump to the right side of his forehead. He was conscious and responded to us accordingly. Pain and discomfort were displayed by moaning and facial grimacing. A new intervention was to keep a light on in his room at night. Review of the progress note dated 06/13/24 at 4:52 P.M. completed by Licensed Practical Nurse (LPN) #237 revealed Resident #112 was found on floor in the dining room lying on his back. Staff reported that Resident #112 was sitting in a stationary chair prior to the fall. The intervention included staff will redirect Resident #112 back to the wheelchair until he builds up his strength. Review of the care plan for Resident #112 dated 03/01/21 and updated on 05/20/24, 05/30/24, and 06/13/24 revealed Resident #112 was at risk for falls and potential injury related to dementia, incontinence, impaired physical mobility, and osteoarthritis in the right hip. Added interventions included: Attempt to keep the resident's walker within reach of the resident, dated 05/20/24. Keep the light on at night, dated 05/30/24. Redirect from the stationary chair to the wheelchair until the resident regains his strength, dated 06/13/24. Review of the physician orders for Resident #112 revealed on 06/12/24 Resident #112 received an order to ensure the resident's walker is within the resident's reach. On 06/13/24 Resident #112 received an order to redirect the resident back to the wheelchair until he builds back up strength, and transfer with two assists with a wheeled walker. Observation on 07/02/24 at 10:41 A.M. revealed Resident #112 was sitting in a stationary chair in the lounge/dining area working on workboard's. Resident #112 rambled incoherently when spoken to. Observation revealed there was no wheelchair or walker present. Medication Aid #255 also observed Resident #112 and confirmed he had recent falls. Medication Aid #255 walked away and did not offer a wheelchair or walker to Resident #112. Interview on 07/02/24 at 11:10 A.M. with RN #266 revealed Resident #112 was confused but did follow directions. Resident #112 had recent falls, interventions were in place, and Resident #112 was supposed to use a walker for ambulation. Observation on 07/02/24 at 11:45 A.M. revealed Resident #112 was now sitting in a stationary chair located in the television (TV) lounge. STNA #297 verified Resident #112 walked independently from the lounge/dining area to the TV lounge. STNA #297 confirmed Resident #112 did not use his walker when he walked to the TV lounge and confirmed she did not know where it was. STNA #297 revealed, [Resident #112] should have his walker and we did not get it for him, but we should have. Interview on 07/02/24 at 12:47 P.M. with the Director of Nursing (DON) confirmed Resident #112 had three recent falls. The DON revealed on 06/13/24, Resident #112 flipped out of his stationary chair onto the floor. The intervention on 06/13/24, after the fall, was to redirect Resident #112 from the stationary chair to a wheelchair until he regained strength. The DON revealed Resident #112 should be sitting in a wheelchair at all times unless he ambulated with staff using his walker. The DON confirmed the walker should be within Resident #112's reach per the physician orders. Observation on 07/02/24 at 1:52 P.M. with the DON, verified Resident #112 was sitting in a stationary chair in the TV lounge. Observation and interview on 07/02/24 between 1:53 P.M. and 1:58 P.M. with DON, STNAs #297 and #331 (Resident #112's assigned STNA's) revealed both STNAs #297 and #331 confirmed Resident #112 ambulated independently. Both STNAs #297 and #331 confirmed they did not know Resident #112 required two assists with ambulation and should sit in a wheelchair rather than a stationary chair. Review of the undated facility policy titled, Fall Management revealed the facility will identify each resident who is at risk for falls and will develop a plan of care and implement interventions to manage falls. This deficiency represents non-compliance investigated under Complaint Number OH00154608.

Based on observation and interview, the facility failed to ensure an effective pest control program. This finding had the potential to affect 122 residents of 125 who eat meals from the kitchen as three residents (Residents #99, #103 and #108) received nothing by mouth. Findings include: Interview on 05/03/24 at 9:18 A.M. with Resident #73 revealed he had concerns with flying ants which were all over the place. Interview on 05/03/24 at 9:33 A.M. with Kitchen Aide #808 revealed the facility used a green liquid in the mop water for gnats in the kitchen but the facility still had a lot of gnats flying around the kitchen. Observation on 05/03/24 at 9:35 A.M. with Kitchen Aide #808 of the food cart located right outside of the kitchen doors revealed five to six black gnats flying around inside the food cart. Observation on 05/03/24 at 9:38 A.M. with Kitchen Aide #808 of the kitchen area revealed multiple gnats flying around the dishwasher and sink area of the kitchen. Interview on 05/03/24 at 9:47 A.M. with Maintenance Director #809 confirmed the facility had a gnat problem and he was aware of the gnats in the kitchen. Review of a list of resident diets revealed Residents #99, #103 and #108 received nothing by mouth. Review of the undated Pest Control policy revealed the purpose of the policy was to attempt to prevent and control the entrance of pests and predators and eradicate infestations in the facility. This deficiency represents non-compliance investigated under Complaint Number OH00152338.

Based on closed medical record review, hospital record review, review of facility policy and interview the facility failed to ensure effective and timely ongoing monitoring and assessments were completed for a non-pressure related skin impairment to Resident #132's right forearm. Actual Harm occurred on 01/02/24 at 1:14 P.M. when Registered Nurse (RN) #612 identified a previous open area to Resident #132's right forearm contained thick black necrotic eschar (dead tissue) and was significantly larger in size measuring 12 centimeters (cm) in length by ten cm width. The resident was transferred to the hospital where she required surgical debridement to the fascia (layer of connective tissue that surrounds the cells, nerves, joints, and tendons) and treatment for a venous thrombosis (blood clot) at the lateral ventral aspect of the arm. Prior to 01/02/24 there was no previous documentation Resident #132's right forearm open area was being assessed/monitored and/or measured except on the admission assessment dated [DATE] (almost three weeks) when the area measured 3.0 cm in length by 4.5 cm in width and was described as cyanotic (bluish/ purplish) in color around the open area. This affected one resident (#132) of three residents reviewed for non-pressure skin impairment. The facility identified six current residents (#4, #18, #33, #66, #71, and #79) who had non-pressure skin impairments. The facility census was 125. Findings Include: Review of the closed medical record for Resident #132 revealed an admitted [DATE] with diagnoses including left femur fracture, diabetes, and dementia. Record review revealed the resident was discharged to the hospital on 01/02/24 and did not return to the facility. Review of the Admission Packet-V12 dated 12/13/23 and completed by Registered Nurse (RN) #612 revealed Resident #132 had an open area to her right forearm that measured 3.0 cm in length by 4.5 cm in width. The area was cyanotic around the open area. She also had a laceration to her left elbow and surgical area to her left hip. Review of the physician's order dated 12/13/23 revealed Resident #132 had an order to cleanse her right forearm with normal saline, apply oil emulsion, abdominal (ABD) pad and secure with Kerlix gauze every day and as needed. Review of the care plan dated 12/14/23 revealed Resident #132 had actual impaired skin integrity related to surgical incision to her left hip, open area to right forearm, and laceration to her left elbow. Interventions included complete skin documentation per facility policy, monitor for signs of infection, notify physician of deterioration of wound, provide wound care per orders, refer to wound physician as needed, and skin assessment per policy. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #132 had impaired cognition as her brief interview for mental status (BIMS) score was a one of 15. She was dependent on her activities of daily living (ADL) including toileting, dressing, and showers. Review of the Skin Assessment Weekly/ Return/ ER/ LOA dated 12/26/23 and completed by RN #610 revealed Resident #132's skin was assessed. The assessment revealed she had a surgical wound, and that there were no new areas identified. There was no follow up documentation of the open area to her right forearm including assessment and/ or measurements. Review of the nursing notes dated from 12/13/23 to 01/02/24 revealed there was no documentation regarding any follow up assessment, and/or measurements of Resident #132's open area to the right forearm until it was found to be black and necrotic with significant increase in size as it measured 12 cm in length and 10 cm in width on 01/02/24. Review of the Skin Assessment Weekly/ Return/ ER/ LOA dated 01/02/24 and completed by Wound Licensed Practical Nurse (LPN) #600 revealed Resident #132's right forearm had thick black eschar that was firmly adhered, and the area measured 12 cm in length by 10 cm in width. Review of the nursing note dated 01/02/24 at 1:14 P.M. and completed by RN #612 revealed she noticed the dressing on Resident #132's right forearm became loose. During the assessment she noticed the area was black and necrotic. She was able to obtain a pulse under the resident's armpit but not the wrist area. Resident #132 had no complaints of pain. She notified Primary Care Physician (PCP)/ Medical Director #606 who ordered to send the resident to the hospital. Review of Emergency Physician #622's progress note dated 01/02/24 revealed Resident #132 was evaluated in the emergency room with a right arm wound which she stated started several days ago and progressively worsened. The note revealed she had necrosis on her right forearm and was admitted with diagnoses that included skin necrosis and right arm wound. Review of the Hospital History and Physical dated 01/03/24 and completed by Physician #623 revealed Resident #132 presented to the emergency room with a right black necrotic lesion to her forearm. The note revealed initially the wound was small (at the facility) and now was getting larger. The area was necrotic with surrounding cellulitis displayed. There were no signs of an insect bit and/ or she was not on anticoagulant medications. She started on intravenous antibiotics and a surgical wound care consult was ordered for wound debridement. Review of the general surgery progress note dated 01/04/24 and completed by Surgeon #621 revealed Resident #132 while in the hospital had her right extremity debrided due to necrotizing soft tissue infection. He performed a sharp debridement of the necrotic tissue until viable tissue was seen. The wound was down to fascia (layer of connective tissue that surrounds the cells, nerves, joints, and tendons) and there was a venous thrombosis at the lateral ventral aspect that was tied off. After the procedure the area measured 18 cm in length by 10 cm in width. Interview on 01/24/24 at 9:03 A.M. with Resident #132's daughter revealed she was upset as did not understand how her mother's skin tear/ open area to her right forearm got so bad without anyone noticing. She revealed she had spoken with Assistant Director of Nursing (ADON)/ LPN #608 regarding her concern and was told she would investigate the issue and get back to her. She revealed ADON/ LPN #608 had left her a message that Resident #132's dressing was changed on night shift and the nurses that had worked the few days prior to 01/02/24 when it was found to be black and necrotic were not the nurses who usually worked the 100-unit. She revealed the nurses had not seen Resident #132's right forearm previously; therefore, did not know what her baseline was. She revealed she felt this was an unacceptable response so did not call her back as any nurse should know that the resident's arm did not look good and needed to be addressed. Interview on 01/24/24 at 9:12 A.M. with Wound LPN #600 revealed Resident #132 was admitted to the facility with a skin tear like open area to her right forearm. She revealed she saw the area on admission, 12/13/23, and then not again until the day the resident was sent to the hospital on 01/02/24. She revealed on admission it looked red with granulating healthy tissue, no signs of infection and with no necrosis. She revealed she did not follow skin tears unless there was a concern as they usually healed right up. She revealed as far as she knew the facility did not measure or document weekly on skin tears and/or other open areas that were not pressure related. She verified she did not have any documentation regarding the status of the skin tear (open area) while Resident #132 was at the facility including appearance and measurements except what was on admission, 12/13/23 and on the assessment completed the day the resident was sent out on 01/02/24. Interview on 01/24/24 at 2:46 P.M. with Assistant Director of Nursing (ADON)/ LPN #608 revealed Resident #132 had a skin tear/open area to her right forearm when she was admitted on [DATE] and on 01/02/24 RN #612 changed the dressing and noticed it was significantly larger in size, black, and necrotic. She revealed they sent Resident #132 to the hospital for evaluation. She revealed Resident #132's daughter was upset about the significant change, and she had told the daughter that she would investigate the issue. She revealed the dressing was changed on night shift, and the nurses who were on the previous days before RN #612 discovered it were not usually assigned to the 100 unit. She revealed the nurses had never seen Resident #132's forearm prior to know what her baseline was. She revealed it was possible the nurses would not know that it had declined. She revealed she had left Resident #132's daughter a message regarding her findings but had not received a call back. Interview on 01/25/24 at 9:33 A.M. with RN #610 revealed he worked 7:00 P.M. to 7:30 A.M. on 12/28/23 and had completed Resident #132's dressing change to her right forearm. He revealed he had seen her arm throughout her stay at the facility and on 12/28/23 he did not feel it looked any different. Interview on 01/25/24 at 9:39 A.M. with LPN #611 revealed she was assigned the 100 unit on 12/31/23 from 7:00 P.M. to 7:30 A.M. and completed Resident #132's right forearm treatment. She revealed she could not remember what her arm looked like when she changed her wound dressing. She revealed she could not say if the wound was necrotic or not. She revealed she had never seen her wound before as that was the first time she cared for Resident #132, so she was unable to say if there was any change. Interview on 01/25/24 at 9:45 A.M. with RN #612 revealed she admitted Resident #132 to the facility on [DATE] and stated the resident had an open area to her right forearm. She revealed the area measured 3.0 cm in length by 4.5 cm in width, was red, beefy, with no signs of infection and/or signs of necrosis. She revealed the resident's treatment was scheduled on night shift, so she had not seen the open area to her right forearm until 01/02/24 when she noticed her dressing partially coming off. She revealed she had then noted a significant change as the area was large, necrotic, and completely covered with dry eschar. She stated, How that happened crazy to me as it was a small skin tear/open area on admission that turned to a large black area. She stated that there was no way, in her opinion, that it happened overnight and could not understand if the dressing was being done every night how someone did not notice the significant change. Interview on 01/25/24 at 10:27 A.M. with RN #614 revealed she worked on 01/01/24 from 7:00 P.M. to 7:30 A.M. and was assigned the 100 unit. She revealed she also had two other units (700-unit and [NAME] Court Unit) as there were only two nurses in the facility. She revealed there were medication technicians on these units as well, but they could do treatments and/or assessments. She revealed it was a hectic night trying to get everything done and stated, the whole night was a blur. She revealed if she signed off the treatment then she did the treatment but honestly could not remember anything about what the resident's right forearm looked like, including if it was necrotic. She revealed she had never seen Resident #132's arm previously as she had never taken care of her, so would not know what her arm had looked like before to compare to. Interview on 01/25/24 at 11:54 A.M. and 12:29 P.M. with the Director of Nursing (DON) verified Resident #132 was admitted on [DATE] with an open area to her right forearm that was measured on admission as 3.0 cm in length by 4.5 cm in width. She verified there was no other documentation that the open area was assessed and measured until it was documented on 01/02/24 as 12 cm in length by ten cm in width and was described as black and necrotic. She revealed Wound LPN #600 should have been tracking all open areas not just pressure ulcers and documenting at least weekly on the open area by utilizing a skin grid non-pressure form so that Wound LPN #600 would identify if there was a change as well as a nurse could reference when they were doing a treatment if there was any change in the appearance and/or measurement. Interview on 01/25/24 at 12:38 P.M. with LPN #613 revealed she was assigned the 100 unit on 12/30/23. She revealed she usually worked (Nora's Unit) and only occasionally worked the 100 unit. She revealed Resident #132 she had a large area on her right arm that was dark in color, and it was dry. She revealed she could not remember exactly as she had a lot of treatments that night and that she had never seen Resident #132's arm previously, so could not say if it had declined as she was unsure what her arm had looked like on admission. Interview on 01/25/24 at 1:53 P.M. with Primary Care Physician/ Medical Director #606 revealed he was aware Resident #132 had a fractured leg but was not aware of any open area on her right forearm. He revealed that he was not aware that she had a necrotic area to her arm and stated, I just do not recall. Review of the undated facility policy labeled, Skin Measurement/ Skin Grid revealed the facility would maintain an active record as upon admission or identification of a skin condition the licensed nurse would complete a wound treatment progress record. The policy revealed once the treatment was initiated the licensed nurse would monitor for progress of healing and it was expected that healing should be noticeably visible within two weeks. The policy revealed if there were no visible signs of healing the physician would be contacted and treatment re-evaluated. The policy noted that examples of types of wounds that would receive a skin measurement/ skin grid included pressure ulcers, burn injuries, skin tears, and surgical wounds. The policy revealed every seven days assessments would be completed. This deficiency represents non-compliance investigated under Master Complaint Number OH00150274 and Complaint Number OH00150145.

Based on observation, record review, facility policy review and interview, the facility failed to ensure timely assessments were completed and adequate interventions were implemented to prevent the development of pressure ulcers for Resident #79 and Resident #124. Actual Harm occurred on 11/30/23 (six days after admission) when Resident #79, who was cognitively impaired and required total dependence from staff for activities of daily living (ADL) including bed mobility, toileting, and transfers was found to have a Stage III (full thickness loss of skin where adipose (fat) was visible in the ulcer) pressure ulcer to her right buttock. The pressure ulcer was assessed to deteriorate to an unstageable pressure ulcer on 12/07/23. Actual Harm occurred on 12/14/23 when Resident #124, who was a paraplegic and was dependent on staff assistance with bed mobility and transfers was found to have a Stage III pressure ulcer to his right buttock extending to his sacral area. There was no evidence adequate interventions and monitoring were in place to prevent the development of Resident #79 and Resident #124's pressure ulcers or to ensure the wounds were identified prior to being assessed to be Stage III pressure ulcers. This affected two residents (#79 and #124) of three residents reviewed for pressure ulcers. The facility identified five residents (Resident #10, #71, #77, #79, and #124) who currently had facility acquired pressure ulcers. Findings Include: 1. Review of the medical record for Resident #79 revealed an admitted [DATE] with diagnoses including fracture to her right humerus (arm), chronic obstructive pulmonary disease, and hypertension. Review of the Admission Packet- V12 dated 11/24/23 and completed by Registered Nurse (RN) #612 revealed Resident #79 was confused and disoriented. RN #612 completed a skin assessment and noted skin tears to her right knee, left knee, and left toe. There was no documentation Resident #79 had any pressure ulcer or skin breakdown to her right buttock. The admission packet included a Braden Scale for Predicting Pressure Sore Risk that revealed Resident #79 was at risk for developing pressure ulcers as she was occasionally moist, bedfast, limited with mobility, her nutrition was probably inadequate, and she had a potential problem with friction and shearing. Review of the undated care plan revealed Resident #79 required (staff) assistance with activities of daily living (ADL) related to cognitive impairment and weakness. Interventions included transfer with mechanical lift, weight bearing assistance including holding lifting and supporting of trunk and limbs for dressing, personal hygiene, bed mobility, and she was totally dependent of staff assist with transfers, bathing, and toileting. Review of the undated care plan revealed Resident #79 was at risk for impaired skin integrity and pressure ulcers related to failure to thrive, malignant neoplasm of the skin and dermatitis. Interventions included elevate heels off mattress, inspect skin during routine daily care, lift sheet for positioning, lotion to skin, pillows for positioning, pressure reduction devices, turn and reposition as ordered and skin assessment and treatments as ordered. Review of the nursing note dated 11/30/23 at 10:15 A.M. and completed by RN #619 revealed the treatment nurse was notified Resident #79 had an area to her right buttock. Resident #79 was encouraged to reposition self every two hours to prevent skin breakdown and she verbalized understanding. Review of the Skin Grid Pressure 3.0- V2 dated 12/01/23 and completed by Wound Licensed Practical Nurse (LPN) #600 revealed on 11/30/23 Resident #79 was noted to have a Stage III right buttock pressure ulcer that measured 4.0 centimeter (cm) in length by 2.0 cm in width by 0.2 cm in depth. She described the area: full thickness dark red wound bed with moderate serous (clear to yellow) drainage. Review of the initial Wound Evaluation dated 12/07/23 and completed by Wound Nurse Practitioner (NP) #609 revealed Resident #79 had an unstageable (full thickness tissue loss in which the actual depth of the ulcer was obscured by slough/ dead skin) pressure ulcer to her right buttock that measured a 3.5 cm in length by 1.5 cm in width by the depth was unable to be determined. The wound contained 30 percent granulation tissue and 70 percent slough. (The note incorrectly identified this area was present on admission). Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 has impaired cognition as her Brief Interview for Mental Status (BIMS) revealed she was rarely and/or never able to understand. She was dependent on staff assistance for toileting, dressing, rolling left and right, and transfers. She was always incontinent of bowel and bladder. She was at risk for pressure ulcers and had one unstageable pressure ulcer that was not present on admission. Review of the Wound Evaluation dated 01/18/24 and completed by Wound NP #609 revealed Resident #79's right buttock pressure ulcer was now a Stage III and measured 0.4 cm in length by 0.6 cm in width by 0.2 cm in depth. The wound responded well to debridement and had a smaller wound bed of 100 percent granulation tissue. An attempted interview on 01/24/24 at 9:27 A.M. with Resident #79 revealed she was cognitively impaired and unable to provide any information regarding her pressure ulcer. Interview on 01/25/24 at 8:19 A.M. with Wound LPN #600 revealed Resident #79 was not admitted to the facility with any pressure areas including to her right buttock. She verified on 11/30/23 Resident #79 was found to have a Stage III pressure ulcer to her right buttock measuring 4.0 cm in length by 2.0 cm in width by depth of 0.2 cm. She verified Resident #79 was dependent on staff assistance with bed mobility, transfers, and toileting. She revealed she could not say why the pressure area was found at Stage III just that it was. Observation of wound care on 01/25/24 at 9:51 A.M. for Resident #79 and completed by Wound NP #609 and Wound LPN #600 revealed Resident #79 was completely dependent on staff to roll her to her side during the wound care. She continued to have a pressure ulcer to her right buttock that measured 2.6 in length by 1.8 cm in width by 0.1 cm in depth. The wound bed contained pink- red moist granulated tissue. 2. Review of the medical record for Resident #124 revealed an admitted [DATE] with diagnoses including spina bifida, chronic kidney disease, seizures, and paraplegia. Review of the undated care plan revealed Resident #124 required assistance with his ADL care related to spina bifida, paraplegia, impaired mobility, and muscle weakness. Interventions included a mechanical lift with all transfers, he was totally dependent and does not participate in any aspect of transferring, and he required weight bearing assistance including holding lifting or supporting trunk and limbs with bed mobility, dressing, toileting, personal hygiene, and bathing. Review of the undated care plan revealed Resident #124 had actual impaired skin integrity as he had Stage III pressure areas to his bilateral buttocks. Interventions included custom built cushion to his wheelchair, low air loss mattress to his bed, turn and reposition in routine intervals, wound physician as needed, and notify the physician of deterioration of wounds. Review of the quarterly Braden Scale for Predicting Pressure Sore Risk dated 09/22/23 revealed Resident #124 was at risk for pressure ulcers as he was very limited with his sensory perception, was chair fast, very limited with his mobility, and he had a potential problem with friction and shearing. Review of the quarterly MDS dated [DATE] revealed Resident #124 had intact cognition. He required partial to moderate assistance with toileting. He was dependent on staff to roll left and right, and transfers. He was unable to go from a sitting position to lying or lying to a sitting position and he was unable to ambulate. He was at risk for pressure ulcers but had no pressure ulcers. Review of the Treatment Administration Record (TAR) for December 2023 revealed Resident #124 had an order to clean his bilateral buttocks with normal saline, pat dry, and place calcium alginate on the wound bed and cover every day. Review of the TAR revealed no evidence the treatment was completed as ordered on 12/21/23, 12/22/23, and 12/27/23. Review of the nursing note dated 12/14/23 at 9:54 A.M. and completed by Wound/ LPN #600 revealed a new open area was noted to Resident #124's right buttock during routine dressing change with Wound NP #609 and new orders were received. Review of the Wound Evaluation dated 12/14/23 and completed by Wound NP #609 revealed Resident #124 had a Stage III pressure wound to his right buttock extending to his sacral area. The area was 5.0 cm in length by 2.9 cm in width by 0.2 cm in depth. He was also seen for his pressure ulcer to his left buttock. Review of the Skin Grid Pressure 3.0-V2 dated 12/15/23 and completed by Wound Nurse/ LPN #600 revealed on 12/14/23 a Stage III pressure ulcer was found on Resident #124's right buttock that measured 5.0 cm in length by 2.9 cm in width by 0.2 cm in depth. Review of the Wound Evaluation dated 01/18/24 and completed by Wound NP #609 revealed Resident #124 continued to have a Stage III pressure area to his right buttock as she noted per the progress note larger measurements with two areas measured as one wound. The area was 3.1 cm in length by 4.5 cm in width by 0.2 cm in depth. The wound bed was composed of 60 percent granulation tissue and 40 percent scar tissue. Interview on 01/24/24 at 8:19 A.M. with Wound/ LPN #600 revealed they had been treating a pressure ulcer to Resident #124's left buttock and during wound rounds with Wound NP #609 they had found Resident #124 to have a Stage III pressure ulcer to his right buttock. She revealed she was not sure why the pressure ulcer was not found and/or reported at an earlier stage. She revealed staff responded thought you knew about it especially since we were already treating the area to his left buttock. She verified Resident #124 was dependent on staff assistance on most all his ADL including bed mobility and transfers. Interview on 01/24/24 at 11:13 A.M. with Resident #124 revealed he had a pressure ulcer to his bottom. He revealed since he had the pressure ulcers, he was trying to work hard on healing the area by making sure he turned every two hours as well as have staff assist with placing a wedge under him which had been helping. He revealed his dressing was to be changed once a day and occasionally the nurse did not complete the dressing change daily. Observation of wound care on 01/25/24 at 8:53 A.M. completed by Wound NP #609 and Wound LPN #600 revealed the resident's left buttock pressure ulcer was now considered healed and his right buttock pressure ulcer had improved measuring 0.4 cm in length by 0.9 cm in width by 0.1 cm in depth. Interview on 1/25/24 at 9:04 A.M. with Wound NP #609 revealed on 12/14/23 when she was in evaluating the pressure ulcer to Resident #124's left buttock they had found a Stage III pressure ulcer to his right buttock. She verified on 12/14/23 the pressure ulcer to the right buttock measured 5.0 cm in length by 2.9 cm in width by 0.2 cm in depth when it was found. Review of the undated facility policy labeled, Pressure Ulcer Prevention and Risk Identification revealed the facility would assess each resident for the risk of pressure ulcer development to establish measures to prevent the development of pressure ulcers. The policy revealed interventions would be implemented as indicated by the physician and as determined by the interdisciplinary team. This deficiency represents non-compliance investigated under Complaint Number OH00150145.

Based on review of the facility fire report dated 02/27/20, the State Fire Marshal's Report, facility investigations, observations of resident rooms on the 100 Wing, interviews with residents and facility staff, and medical record review the facility failed to ensure adequate lighting for one resident (Resident #41) to prevent the use of a cigarette lighter as a light source in his room at night. This resulted in actual harm that was Immediate Jeopardy on 02/27/20 at 2:40 A.M. when Resident #41 used a cigarette lighter for a light source at his bedside while he was using oxygen via nasal cannula, resulting in setting fire to his bedding and sustaining second [MEDICAL CONDITION] his face and left scapular area resulting in an emergent transfer to the local hospital for treatment. This affected one resident (Resident #41) of three residents (Resident #41, #82 and #106) reviewed for adequate lighting and accident hazards. The facility identified a total of ten residents (Residents #41, #82, #106, #135, #15, #63, #18, #97, #138, and #69) currently residing on the 100 Wing, who did not have access to a light source at the bedside. The facility census was 147. On 03/02/20 at 4:18 P.M. the Administrator, the facility Regional Administrator, and Director of Nursing (DON) were notified the Immediate Jeopardy began on 02/27/20 at 2:40 A.M. when Resident #41 who utilized continuous oxygen therapy via nasal cannula, used a cigarette lighter as a light source in his room when he had no other light source available at the bedside while trying to search for an apple in his drawer. This resulted in the oxygen igniting causing a fire at the bedside and Resident #41 suffered second [MEDICAL CONDITION] his face and left scapular region. Resident #41 was transported by Emergency Medical Services (EMS) to the local hospital for treatment. The immediate jeopardy was removed on 02/28/20 when the facility implemented the following corrective actions: · On 02/27/20 at 2:40 A.M. Registered Nurse (RN) #301 and State tested Nurse Aide (STNA) #500 responded to a smoke alarm and extinguished a fire in Resident #41's room. The resident was immediately assessed [MEDICAL CONDITION] his face and EMS was called for fire and ambulance services. STNA #500 stayed with Resident #41. · On 02/27/20 at 2:45 A.M., RN #301 notified Resident #41's physician of the incident. · On 02/27/20 at 2:46 A.M., RN #301 notified Resident #41's family of the incident. · On 02/27/20 at 3:02 A.M, fire services and EMS arrived at the facility and transported Resident #41 to the local hospital. RN #301 notified the Administrator and DON of the incident. · On 02/27/20 at 3:50 A.M., the Administrator, facility Regional Administrator and Licensed Practical Nurse (LPN) #300 arrived at the facility and immediately initiated an investigation of the incident involving Resident #41. · On 02/27/20 at 6:00 A.M., the management team completed whole house rooms sweeps assessing all residents for smoking materials. · On 02/27/20 at 7:00 A.M., RN #301 assessed Residents #18 and #63 who resided in the room adjacent to Resident #41 and determined no negative effects for the residents. · On 02/27/19 beginning at 10:00 A.M. and concluding on 02/27/20 at 6:30 P.M., in-service training was provided to all staff regarding flashlights or night lights being provided to residents on the 100 wing to facilitate having adequate lighting throughout the night. The education included the need to continue to orient residents to the use of flashlights and nightlights and to keep flashlights within reach of the residents during the night. The training was provided by Human Resource Manager (HR) #702, LPN #300, Director of Housekeeping (DHK) #703, and Dietary Manager (DM) #707. All staff (the Administrator, 12 administrative staff, nine registered nurses, 33 LPNs, 53 STNAs, three social workers, five activity staff, 20 dietary staff, and 17 housekeeping and laundry staff) received training either during an in-service at the facility or by telephone call. This was verified by review of sign in sheets. · On 02/27/20 at 10:55 A.M., Resident #41 returned from the hospital and State Fire Marshals (FM) #800, FM #801 and Fire Chief (FC) #802 interviewed Resident #41 and informed the Administrator the fire was deemed accidental. · On 02/27/20 at 11:00 A.M., LPN #303 and RN #304 performed a head to toe assessment of Resident #41 [MEDICAL CONDITION] the resident's face and back. The resident stated a pain level of seven out of ten. Orders were in place for [MEDICATION NAME] (antibiotic ointment) to [MEDICAL CONDITION] a new air mattress. · On 02/27/20 at 11:28 A.M., RN #302 administered pain medication to Resident #41. · On 02/27/20 at 11:45 A.M., Social Services Designee (SSD) #602 completed a psychosocial evaluation of Resident #41 which revealed the resident was alert, able to answer questions and said he was embarrassed by recent events. · On 02/27/20 at 12:00 P.M., Corporate Maintenance (CM) #603 was contacted to discuss placing permanent overbed lighting for the 100 wing resident rooms. Electrical contractors were contacted and arrangements made to give an estimate for installation of the overbed lights. · On 02/27/20 at 12:00 P.M., the Administrator notified the facility Medical Director of the incident. · On 02/27/20 at 12:00 P.M. the DON updated the Daily Ambassador Rounds check sheets to include inquiries to residents about adequate lighting. The DON educated LPN #300, LPN #305, DHK #703, LPN #306, HR #702, the Administrator, Admission Director (AD) #704, LPN #307, LPN #303, Medical Records Clerk (MR) #705, Social Service Designee (SSD) #602, Social Worker (SW) #504, RN #304, SW #503, Maintenance Director (MD) #706, and Dietary Manager (DM) #707 on the updated Daily Ambassador Sheets. Each verbalized understanding of inquiring about adequate lighting including at night for all residents. · On 02/27/20 at 12:40 P.M. the Administrator and LPN #300 interviewed Resident #41 regarding using a cigarette lighter and the fire in his room. Resident #41 told the Administrator he found the cigarette lighter in a bag shortly before the incident and intended to turn the lighter over to the nurse in the morning. He reported on 02/27/20 at 2:40 A.M. he started feeling funny and was looking for an apple in his nightstand. He didn't want to bother staff to turn the light switch on at the doorway and when he found the lighter decided to use it as a light source. Resident #41 stated he was not accustomed to using oxygen at night and, not thinking, ignited the cigarette lighter. Resident #41 stated he saw a quick flash of light and fire and staff responded immediately and put the fire out. · On 02/27/20 at 1:00 P.M., RN #302 provided flashlights and education on the use of the flashlights to all residents residing on the 100 wing (Resident #15, Resident #18, Resident #41, Resident #69, Resident #82, Resident #97, Resident #106, Resident #135 and Resident #138). The flashlights were provided to the residents as an immediate intervention to provide an accessible light source at night while the residents were in bed. All the residents verbalized understanding of the purpose and use of the flashlights except for Resident #63 who was unable to use the flashlight. · On 02/27/20 at 1:00 P.M., the DON provided a night light in Resident #63's room due to the resident's assessed inability to understand the use a flashlight. · On 02/27/20 at 1:30 P.M., LPN #305 assessed Resident #15, Resident #18, Resident #41, Resident #69, Resident #82, Resident #97, Resident #106, Resident #135 and Resident #138 for their ability to use flashlights and the residents' care plans were updated to include the use of flashlights. Resident #63 was assessed and the care plan was updated to include the use of a nightlight in the resident's room. The Administrator notified the Medical Director of the utilization of flashlights and the nightlight for Resident #63. · 02/27/20 at 1:30 P.M. the Administrator, DON, LPN #303, Regional Director of Operations, and Corporate Quality Assurance Nurse reviewed facility incident logs and medical records for nine additional residents (Resident #15, Resident #18, Resident #63, Resident #69, Resident #82, Resident #97, Resident #106, Resident #135 and Resident #138) residing on the 100 wing and verified none of the residents had had any incidents or accidents since 01/30/20. · On 02/27/20 beginning at 7:30 P.M., use of the updated Daily Ambassador Rounds check sheets was initiated by the Administrator and LPN #303. The Ambassador Rounds check sheets were to be completed five days a week, for four weeks and as needed and would be completed by the Administrator or their designee for all residents. · On 03/02/20 at 1:00 P.M. the facility acquired battery-operated adhesive backed touch lights for all resident rooms on the 100 Wing and the DON installed the battery-operated touch lights to the headboards of the beds. · On 03/02/20 at 4:30 P.M., the Administrator and DON reviewed all residents in the facility and identified no additional residents other than the ten residents (Resident #15, Resident #18, Resident #41, Resident #63, Resident #69, Resident #82, Resident #97, Resident #106, Resident #135 and Resident #138) on the 100 wing who did not have a light source accessible from their bed. · On 03/03/20 at 8:30 A.M. C) #603 ordered overbed light fixtures and all necessary equipment for installation. An invoice was provided for confirmation of the order from the local supply company. · On 03/03/20 from 3:15 P.M. to 3:45 P.M. observation of resident rooms on the 100 wing revealed stick on type battery-operated touch lights attached to resident headboards and handheld flashlights in all of the resident rooms except Resident #63 who had the touch light on her headboard and a nightlight plugged into the wall outlet near her bed. · On 03/03/20 from 3:15 P.M. to 3:45 P.M. interviews with Resident #106, Resident #135, Resident #138 and Resident #41, who resided on the 100 Wing, revealed they had handheld flashlights and battery-operated touch lights in their rooms. They were trained on the use of the flashlights, keeping them within reach and use of the touch lights. The residents all said they had sufficient lighting in their rooms at night. · On 03/04/20 at 9:45 A. M. a representative from the local electric service provider came to the facility for the purpose of determining an estimate for the cost of installation of the lighting fixtures on the 100 wing. Facility approval was pending receipt of estimate. · On 03/04/20 from 10:00 A.M. to 10:22 A.M. RN #308, LPN #309, LPN #310, STNA #505 and STNA #506 were interviewed and all indicated they had participated in in-service training regarding the use of flashlights, touch lights and nightlights for residents on the 100 Wing. They verbalized understanding of the need to continue to orient the residents on the use of the flashlights and to keep them within reach at night. · As of 03/04/20 at 4:30 P.M. there have been no new admissions to the 100 Wing. Going forward all new residents admitted to the 100 Wing will be provided a flashlight in their admission package. The admitting charge nurse will be responsible to verify the resident's capability and understanding for the usage of the flashlight. This will be documented in the resident's medical record. This will be monitored by the DON or designee using an audit tool daily and as needed until permanent overbed lighting is installed. · Beginning on 03/04/20 at 5:00 P.M. the DON or designee will be responsible to monitor ongoing use of flashlights for all residents on the 100 Wing including flash lights in place, ability to use, understanding of usage and to address any concerns related to adequate lighting. This will be documented using an audit tool and completed daily times four weeks and as needed, or until the permanent overbed lighting is installed. · Ambassador Rounds will continue on a daily basis to provide ongoing monitoring to ensure all residents in the facility have adequate lighting. Although the Immediate Jeopardy was removed on 02/28/20 the facility remained out of compliance at a 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, including their new policy and procedure and were monitoring to ensure on-going compliance. Findings include: Resident #41 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Review of the admission assessment dated [DATE] at 4:31 P.M. revealed Resident #41 had intact cognition, used a wheelchair for which he required limited assistance for transfers and was a smoker. Review of the facility Resident Tobacco Policy (dated 10/19) signed by Resident #41 on 02/25/20 revealed the resident acknowledged understanding of the facility policy prohibiting residents from keeping cigarette lighters in their rooms. Review of Care Plans dated 02/25/20 revealed Resident #41 was at risk for alterations in oxygen exchange, perfusion and impaired gas exchange related to [MEDICAL CONDITIONS] and acute and chronic [MEDICAL CONDITION] with interventions including assess lung sounds as ordered and provide oxygen as ordered. Resident #41 was at risk for injury related to smoking with interventions including smoking items to be kept at the nurse's station. On 02/27/20 care plans for Resident #41 were modified to include the use of a handheld flashlight for a light source in the resident's room, for staff to keep the flashlight within the resident's reach and encourage the resident to use the flashlight for a light source at night. physician's orders [REDACTED]. On 02/27/20 orders were added for [MEDICATION NAME] (antibiotic) ointment to wounds on face and left scapula (back of shoulder) and a nicotine patch. Review of nursing notes dated 02/27/20 at 4:00 A.M. revealed Resident #41 was found in his room with an active fire to his bed. The nurse (RN #301) and aide (STNA #500) were alerted by the smoke alarm. No smoke could be smelled in the hallway. Upon entering the room, RN #301 noticed the bed was on fire and promptly put out the fire with water from the resident's bedside pitcher. Resident #41 stated he had found a lighter and was using it to look for something in his dresser. RN #301 assessed Resident #41 and [MEDICAL CONDITION] his upper lip and nostrils as well as his upper mid back. The nurse then contacted 911. The hospital, physician, Administrator and resident's family were notified of the incident. Resident #41 was transported to the hospital by EMS. Review of nursing notes dated 02/27/20 at 9:54 A.M. revealed RN #301 spoke with the hospital who reported Resident #41 would be returning to the facility by transport with orders for [MEDICATION NAME] to [MEDICAL CONDITION] a left scapular burn. Review of nursing notes dated 02/27/20 at 10:55 A.M. revealed Resident #41 returned to the facility by ambulance and was readmitted to the facility. FM #800, FM #801 and FC #802 interviewed Resident #41 and informed the Administrator the fire was deemed accidental. Review of nursing notes dated 02/27/20 at 11:00 A.M. revealed LPN #303 and RN #304 performed a head to toe assessment of Resident #41 [MEDICAL CONDITION] the resident's face and back. The resident stated a pain level of seven on a one to ten scale. Orders were in place for [MEDICATION NAME] (antibiotic ointment) to [MEDICAL CONDITION] a new air mattress. Review of nursing notes dated 02/27/20 at 11:28 A.M. revealed RN #302 administered pain medication to Resident #41. Nursing notes dated 02/27/20 at 12:20 P.M. revealed LPN #300 and the Administrator interviewed Resident #41 who reported remorse for his actions. Resident #41 stated he found a cigarette lighter in his bag and flicked the lighter, forgetting he was wearing oxygen and stated it was like a flash. Resident #41 stated he did not wish to smoke anymore and wanted a nicotine patch. The physician was notified. A physician's orders [REDACTED].#41. Review of a facility investigation dated 02/27/20 at 3:15 A.M. revealed, on 02/27/20 at 3:15 A.M. the Administrator, the Regional Director of Operations and Regional Quality Assurance Director arrived at the facility and initiated an investigation into the fire involving Resident #41. The investigation report revealed, on 02/27/20 at 2:20 AM, RN #301 assessed Resident #41 for pain and his call light was in reach. At 2:40 A.M. RN #301 and STNA #500 heard the fire alarm go off in Resident #41's room and responded. RN #301 and STNA #500 entered the resident's room, saw a fire on the resident's bed and extinguished the fire with water from the resident's water pitcher and turned off the oxygen concentrator. Review of the Nursing Home Fire Report dated 02/27/20 revealed on 02/27/20 at 3:15 A.M. a resident (Resident #41) found a lighter and lit the lighter causing a fire in the resident's room with only the resident being injured. The fire department responded, though the fire was extinguished by facility staff. Observation on 03/02/20 at 7:09 A.M. of Resident #41's former room and current room on the 100 Wing revealed the resident had a private room with a twin bed, a window with blinds, a door to a bathroom adjoining the next room and a light fixture on the ceiling with a light switch next to the entry door. There were no overhead or ceiling mounted sources of light accessible from the resident's bed. There was a handheld flashlight on the resident's overbed table. Observations on 03/02/20 from 7:10 A.M. to 11:30 A.M. revealed Resident #41 was alert and oriented and was self-propelling about the facility in a wheelchair. The resident was appropriately dressed, well groomed, was wearing eyeglasses and had scabbing to his nose and face around his mouth. Interview on 03/02/20 at 7:45 A.M. with the Administrator and LPN #300 verified, prior to 02/27/20, Resident #41's room and the other 12 rooms on the 100 Wing only had a ceiling light with a control switch near the entry door of the resident's room. They reported there was no over bed lighting or light switches accessible to the residents when in bed. The Administrator reported, on 02/27/20 at 2:40 A.M., Resident #41 was wearing oxygen via nasal cannula in his room when he ignited a cigarette lighter near his face which caused the oxygen tubing and bedding to catch fire and [MEDICAL CONDITION] the resident's face and his left scapular region. The Administrator reported the fire triggered the smoke detector which initiated an alarm that RN #301 and STNA #500 responded to. RN #301 and STNA #500 extinguished the fire with water from the resident's water pitcher in his room. The Administrator stated RN #301 called 911 and fire and ambulance crews responded. Resident #41 was sent to the hospital for evaluation and treatment of [REDACTED]. The Administrator and LPN #300 revealed, on 02/27/20 at 3:30 A.M. the State Fire Marshals and a local fire chief arrived at the facility to investigate the fire. On 02/27/20 at 10:55 A.M., Resident #41 was readmitted to the facility with orders for an antibiotic cream to his face and back. The Administrator revealed, on 02/27/20 at 11:00 A.M. the Fire Marshals interviewed Resident #41 and determined the fire was accidental and no charges would be filed against the resident. The Administrator stated they modified their Daily Ambassador Rounds check sheets to include a question for all residents at line number #12 concerning sufficient lighting. The Administrator added that flashlights had been provided to Resident #41 and all the other residents on the 100 Wing and one resident who could not use a flashlight was provided a night light next to her bed. They would monitor the effectiveness of these interventions until permanent light fixtures could be installed in all the rooms with access to turn them on at the bedside. Interview on 03/02/20 at 8:01 A.M. with RN #301 revealed on 02/27/20 at 2:40 A.M. she and STNA #500 were documenting care at the nurses' station when the call light system alarmed and indicated there was a fire in Resident #41's room. RN #301 stated she and the STNA responded to the alarm and, when they opened the door of Resident #41's room, they could see his bedding was on fire near the head board and Resident #41 was sitting up on the far side of the bed near the window. RN #301 stated she grabbed the resident's water pitcher and handed it to STNA #500 who threw the water onto the fire to extinguish it. RN #301 stated she saw Resident #41 was using oxygen and disconnected the oxygen tubing from the oxygen source and turned off the oxygen. RN #301 stated she assessed Resident #41 and left to call 911 while STNA #500 stayed with the resident in his room. She stated the fire department and ambulance arrived and Resident #41 was transported by ambulance to the hospital. Telephone interview on 03/02/20 at 10:58 A.M. with STNA #500 revealed, on 02/27/20 while sitting at the nurses' station completing documentation she heard the smoke alarm go off in Resident #41's room. STNA #500 stated she and RN #301 responded to the smoke alarm and, upon entering Resident #41's room, saw the bedding was on fire. STNA #500 stated Resident #41 was sitting at the side of his bed near the window. She stated RN #301 gave her the pitcher of water and she threw it on the fire to extinguish the flames. She stated Resident #41 told her he found a lighter and ignited it which started the fire. STNA #500 took the lighter from the resident. She stated RN #301 turned off Resident #41's oxygen then went to call 911 while she (STNA #500) stayed with Resident #41. Other nurses (LPN #311, LPN #312, LPN #313 and LPN #314) arrived to assist with the resident's care. She stated, after the fire department and ambulance arrived, Resident #41 was transported to the local hospital for evaluation. Interview on 03/02/20 at 11:30 A.M. with Resident #41 revealed on 02/27/20 sometime before 2:40 A.M., he found a cigarette lighter in his duffle bag (which had been packed by his family) and placed it in his nightstand to turn over to the nurse later in the morning. He then stated on 02/27/20 at 2:40 A.M. he was feeling like his blood sugar was low and he began looking in his bedside table for an apple he had saved from earlier that day. He had difficulty finding the apple because the only light was a ceiling light and the switch was located at the doorway. Resident #41 didn't want to bother staff to turn his light on. Resident #41 continued, while searching in the bedside table he found the cigarette lighter and forgetting he was wearing oxygen, ignited the lighter near his face to help him find the apple. He stated he then saw a flash when the oxygen tubing and bedding caught on fire. Resident #41 stated he used his hands to try to extinguish the flames when RN #301 and STNA #500 entered the room and threw water on the flames to extinguish them. Resident #41 stated he felt that his room was too dark that night with his door closed and he had no access to a light source when he was laying in his bed. On 03/03/20 from 3:15 P.M. to 3:45 P.M. observation of resident rooms on the 100 Wing revealed stick on type battery-operated touch lights attached to resident headboards and handheld flashlights in all of the resident rooms except Resident #63 who had the touch light on her headboard and a nightlight plugged into the wall outlet near her bed. On 03/03/20 from 3:15 P.M. to 3:45 P.M. interviews with Resident #106, Resident #135, Resident #138 and Resident #41 who resided on the 100 Wing reported they had handheld flashlights and battery-operated touch lights in their rooms. They were trained on the use of the flashlights, keeping them within reach and use of the touch lights. The residents all said they had sufficient lighting in their rooms at night. On 03/04/20 from 10:00 A.M. to 10:22 A.M. RN #308, LPN #309, LPN #310, STNA #505 and STNA #506 were interviewed and all indicated they had participated in in-service training regarding the use of flashlights, touch lights and nightlights for residents on the 100 Wing. They verbalized understanding of the need to continue to orient the residents on the use of the flashlights and to keep them within reach at night. Review of Daily Ambassador round sheets dated 02/27/20, 02/28/20, 03/02/20 completed by LPN #300 and LPN #305 indicated they were completed and there were no negative outcomes. Review of ongoing monitoring of flashlights for the residents on the 100 Wing completed by LPN #300 on 03/04/20 revealed no concerns with the residents not having flashlights at the bedside or not being able to use them. Review of the new admissions to 100 Wing monitoring sheets for flashlights completed by LPN #300 on 03/04/20 revealed the unit has not had any newly admitted residents since 02/27/20 This deficiency substantiates Complaint Number OH 544.

Based on interview, record review, review of facility self-reported incidents, review of Resident #52's hospital discharge summary, and review of the Criteria for Admission to the Secured Unit policy (12/02/12), the facility failed to prevent Resident #52 from physically abusing Resident #171. Resident #52 returned to the facility from the hospital psychiatric unit on 07/07/17, after being hospitalized since 06/26/17, for hoarding forks and butter knives, and expressing homicidal ideations with the verbalized intent to harm staff and other residents. Immediate Jeopardy, a situation exists that is likely to result in serious injury, harm, impairment or death, began on 08/25/17 when Resident #52's aggressive behaviors escalated with episodes of throwing glass objects shattering in the presence of other residents and delusional ideations of staff killing her unborn child. Immediate Jeopardy continued on 09/03/17 when Resident #52 entered Resident #171's room through an adjoining bathroom, and began choking and slapping her in the face while holding her down in bed. Resident #52 stated Jesus told her to kill Resident #171, and she wanted to kill her. No behavior care plan had been developed or implemented for Resident #52 addressing her actions and ideations upon her hospital readmission. This affected two (Residents #52 and #171) residents reviewed for abuse, with the potential to affect the 24 additional residents (Residents #3, #8, #20, #21, #38, #50, #54, #60, #62, #65, #102, #106, #108, #128, #129, #130, #138, #139, #151, #152, #153, #165, #170, and #175) that resided on the female secured dementia unit. Eight of the 24 residents were receiving Hospice care. On 09/14/17 at 12:35 P.M., Administrator #243, Assistant Director of Nursing (ADON) #240, Corporate Quality Assurance Registered Nurse (QARN) #241, and Corporate Quality Assurance Director (CQAD) #242 were notified Immediate Jeopardy began on 08/25/17 when Resident #52's behaviors escalated into verbal and physical aggression. The facility failed to develop a plan and initiate interventions to protect the 24 residents on the secured dementia unit where Resident #52 resided. On 09/03/17 Resident #52 entered Resident #171's room by means of a connecting bathroom, found the resident in bed, and slapped and choked Resident #171. Staff had to physically lift Resident #52 off of Resident #171. Resident #52 told staff she wanted to kill Resident #171. The Immediate Jeopardy was removed on 09/15/17 at 12:45 P.M. when the facility implemented the following corrective action: · On 09/04/17 at 2:26 A.M. Resident #52 was discharged to the hospital psychiatric unit, and remained hospitalized . · On 09/13/17, local police authorities were contacted by the administrator related to the incident on 09/04/17 when Resident #52 was physically abusing and choking Resident #171. · On 09/14/17 and 09/15/17, all residents on the two secured dementia units and the secured behavior unit were assessed by the interdisciplinary team (IDT) for behaviors, with new interventions planned and implemented where appropriate. Results of these assessments were added on 09/14/17 and 09/15/17 to the residents' care plans, the STNA as needed tasks in the residents' electronic medical records, and the residents' Kardex. · On 09/14/17 and 09/15/17, all facility staff were inserviced by ADON #240 regarding resident behaviors, triggers for behaviors, interventions that are successful to deescalate behaviors and proactive strategies that prevent behaviors from occurring. · On 09/14/17 and 09/15/17, all facility staff were educated by ADON #240 on the facility policies for Addressing Residents with Escalating Behaviors/Violence revised 04/17; Behavior Communication Process, revised 04/17 and Code Orange (an overhead page for help for violent behavior) · The director of nursing (DON)/designee will conduct audits on Monday through Friday for four weeks of the Nursing Behavior Record with changes updated to care plans, tasks and Kardex as needed. · The DON/designee will review the daily nurse's notes on Monday through Friday for four weeks for incidents/behaviors to assure compliance with facility policies addressing residents with escalating behaviors/violence, behavior communication process, and Code Orange (overhead page for staff response to violent behaviors). · On 09/15/17 between 10:08 A.M. and 11:30 A.M., interview with Licensed Practical Nurse (LPNs) #232, #220 and #211; State tested Nurse Aide (STNAs) #342, #312 and#304; Social Service Designee (SSD) #906, and Activity Director #500 revealed they were knowledgeable regarding behavior interventions, triggers for behaviors, and proactive strategies that could prevent behaviors from occurring. They were also knowledgeable regarding the behavior related facility policies, the behavior communication process, and Code Orange. Although the Immediate Jeopardy was removed on 09/15/17, the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in process of implementing their corrective action and monitoring to ensure on-going compliance Findings include: Review of the medical record for Resident #52 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive admission Minimum Data Set 3.0 (MDS) assessment, dated 05/31/17, revealed the resident was cognitively intact (with a Brief Interview for Mental Status score of 15 out of 15) with hallucinations and delusions. She had verbally abusive behaviors which significantly intruded on the privacy and activity of others and significantly disrupted care or the living environment. She also rejected care. She required supervision with bed mobility, transfers, and ambulation. Review of a nursing progress note written by LPN #200, dated 05/30/17 at 12:07 A.M. revealed Resident #52 became upset when staff entered her room to place her roommate in bed. She stated I don't want her in here, get out. When staff explained that her roommate shared a room with her she became agitated slamming closet doors and yelling I don't want her in here. She then went to and sat in front of the nurse's desk with increased delusions, talking with people who were not there. She stated she was leaving and tried to push on the exit door and became more agitated when she could not open the door. She proceeded to pick up a food tray and threw a glass plate on the floor shattering it around other residents who were in the area. She was then sent to the emergency room for a psychiatric evaluation. She returned to the facility at 10:15 A.M. Review of a health status note dated 06/22/17 at 7:36 P.M., written by LPN #200, revealed Resident #52 had stuffed paper towels down the sink and turned on the water flooding rooms. Resident #52 also placed furniture in front of her door to keep staff out. Review of the health status note written by LPN #217 dated 06/26/17 at 10:48 A.M. revealed Resident #52 stated she was very agitated and she was not adjusting well to this facility. She indicated she hates it there, everyone is mean to her and she was going to snap and hurt someone or herself. Review of the behavior narrative written by LPN #217 dated 06/26/17 at 2:49 P.M. revealed Resident#52 was screaming/crying in her room. STNA #352 entered the room to assist Resident #52, and the resident charged towards the STNA. STNA #352 yelled for help, and STNA #319 entered the room to assist. Resident #52 charged towards the STNAs with a handful of metal butter knives and forks. The resident declined to hand staff the knives and forks. Staff removed the knives and forks from the resident when she became combative, hitting, and punching the staff. The physician was notified and gave orders to transfer Resident #52 to the hospital for a psychiatric evaluation. Review of a behavior note written by LPN #217 dated 06/26/17 at 2:54 P.M. revealed the nurse and a STNA attempted to enter Resident #52's room and noted the room door was locked. The nurse and STNA then attempted to enter the resident's room through the bathroom door which was also locked. The nurse was able to unlock the room door and observed a night stand wedged against the room door. The nurse and STNA checked the resident's room and temporarily remove any sharp objects to ensure resident safety needs were met. Review of the social services progress note written by Licensed Social Worker (LSW) #908, dated 06/26/17 at 5:31 P.M., revealed Resident #52 was sent to the emergency room due to threatening harm to herself and to others. Review of the nursing progress note written by LPN #212 dated 06/27/17 at 6:54 A.M. revealed Resident #52 was admitted to the hospital psychiatric unit. Review of the hospital discharge instructions dated 07/07/17 revealed the reason for the hospital admission was risk of harm to others as evidenced by hiding silverware in her room to harm staff and residents. Resident #52 denied homicidal thoughts at the time of discharge. Review of the admission note dated 07/07/17 at 6:39 P.M. revealed the resident returned to the facility. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #52 was cognitively intact with delusions. She was noted to have physically and verbally abusive behaviors directed towards others. She required supervision with bed mobility, transfers, and ambulation. Review of the social service progress note dated 08/21/17 at 11:47 A.M., written by LSW #908, revealed the resident was having outbursts and threatening suicide. Review of the nursing progress note dated 08/21/17 at 12:00 P.M., written by LPN #200, revealed the physician was notified of the resident's threats of suicide, and the physician gave the order to transfer Resident #52 to the emergency room for evaluation. Review of the progress note dated 08/21/17 at 1:15 P.M. revealed the resident was transferred to the emergency room by emergency medical transport. Review of the progress note dated 08/21/17 at 8:13 P.M. written by LPN #224 revealed the resident returned to the facility with orders for every 15 minute checks, keep in a common area, keep bedroom door open for 72 hours and then re-evaluate. Review of the nurse's note dated 08/25/17 at 11:08 A.M., written by LPN #200, revealed there was a team meeting that day and Resident #52 had no signs, nor had she expressed suicidal thoughts or tendency. The interventions of 15 minute checks and keeping her door open were discontinued by the team during this meeting. However, prior to the meeting that day, the resident had the following behaviors: she threw a fan at the nurse's station, breaking the fan; threw items from her breakfast tray around the room; accused the nurse of killing her baby; and stated she was pregnant with Archangel (NAME)'s baby. Review of the nursing progress note dated 08/26/17 at 1:51 A.M., written by LPN #231, revealed Resident #52 kept locking her door and the nurse informed her they needed to get into her room to make rounds and assist with hands on care of her roommate. She was non-compliant, continuing to lock the adjoining bathroom door. Staff explained that the resident in the next room used the bathroom as well, and the door needed to be left unlocked. Resident #52 began yelling out at the nurse, slamming doors, and calling her roommate a derogatory name. She stated she never asked for her to be her roommate, told the nurse to go (explicative) yourself and continued to lock both doors. Review of the nursing progress note dated 08/27/17 at 3:59 A.M., written by LPN #226, revealed Resident #52 observed the day turn nurse and STNA putting her roommate into bed when Resident #52's behavior started. As the nurse and STNA walked out of resident's room she slammed the door shut, pulled the room divider curtains down and was screaming, get this (expletive) out of my room. Resident #52 became louder, aggressive, defiant, and noncompliant. The physician was notified and staff talked to her till she calmed down. Review of the nursing progress note dated 08/30/17 at 6:41 P.M., written by LPN #216, revealed the STNA tried to get into Resident #52's room and the door was locked. When the resident was asked to open the door, she yelled no, go away you (expletive). Staff were able to get the door open, and the resident began throwing forks and knives she had hidden in her pockets at the STNAs. The physician was notified and an order for [REDACTED].>Review of the late entry nursing progress note written on 09/04/17 at 4:38 A.M. by LPN #231 revealed on 09/03/17 at 11:10 P.M., Resident #52 was in her bathroom with the door locked and the call light sounding. The nurse and STNA knocked on the door and asked her if she was alright. She stated, yes, I want to show you something. The nurse instructed her to then open the door. She opened the door and stated I want you to kill me with those, pointing to six forks and one butter knife she had laying on the bathroom vanity. The nurse told the resident that no one would ever do that to her. The resident stated Jesus wants you to. She stated she had been hiding them from her meal trays because she had intended to hurt herself with them. She stated the voices in her head tell her to. The nurse then asked the resident if she could look on her person to see if she had anymore silverware. The resident was agreeable, and no other objects were found. The nursing assistant stayed with Resident #52 while the nurse called over another nurse for assistance to try and calm the resident. The resident appeared to be calm and was sitting on her bed with no further behaviors. There was no evidence the physician was notified. Review of the nursing progress note dated 09/04/17 at 2:26 A.M. written by LPN #231, revealed on 09/03/17 at around 11:30 P.M., the nurse heard Resident #171, yelling get her off me. The nurse entered room immediately to find Resident #52 standing over the top of Resident #171, slapping her with her right hand and choking her with her left hand telling Resident #171 that she wanted to kill her. LPN #200 removed Resident #52 off Resident #171 by wrapping her arms around Resident #52's waist and lowering her to the floor with another staff member present. Resident #52 then began kicking and hitting towards LPN #200 and LPN #231. The physician was notified and gave an order to transfer Resident #52 to the hospital for a psychiatric evaluation. Review of the nurse's note for Resident #171 dated 09/04/17 at 3:43 P.M., written by LPN #231, revealed the resident was examined and noted to have scattered bruising on her right arm, speckling of purple/pink discoloration on her nose, and the left side of her neck was slightly discolored. She stated, some crazy lady tried to kill me last night, but she is in jail now. The resident was anxious and crying Review of the nurse's note for Resident #171 dated 09/07/17 at 11:08 A.M., written by LPN #200, revealed the resident came out of her room and was tearful stating that she was not safe, and people would come into her room. Review of the Criteria for Admission to the Secured Unit, effective 12/01/12, revealed criteria including the primary [DIAGNOSES REDACTED]. Residents who have psychoses or other mental illness [DIAGNOSES REDACTED]. Residents who have physically abusive/combative behaviors must be manageable through a behavior modification program. Interview on 09/13/17 at 10:06 A.M. with LPN #200 stated she was on another unit on 09/03/17 when LPN #231, working on the locked dementia unit, called her over to assist with Resident #52. She stated she was one of the few nurses that Resident #52 would listen to, so she came over to assist. She stated she and LPN #231 were then sitting at the nurse's station attempting to come up with a plan for Resident #52's behaviors related to hoarding silverware when they heard screaming coming from Resident #171's room. She stated they immediately went into Resident #171's room and found Resident #52 standing over Resident #171 choking and slapping the resident stating she was going to kill her. She stated Resident #52 did not exit her room, so she had to have entered Resident #171's room through the bathroom. She stated that Resident #52 was extremely strong and ambulated independently. She was angry at Resident #171 for complaining about her locking the bathroom door. LPN #200 stated Resident #52 was alert and oriented and held grudges. LPN #200 stated the facility had been attempting to get the psychiatrist to see Resident #52, but the earliest that she could be seen was 09/18/17. LPN #200 stated there was no written behavior modification plan. She stated she would verbally pass on information of things that worked for her related to Resident #52's behaviors to other staff. LPN #200 stated Resident #52 was not appropriate for the locked dementia unit, and it terrified her that she may be returning. LPN #200 stated the night of the incident there was only one nurse and one STNA working on that unit. Review of the census from 09/03/17 revealed 24 additional residents (Residents #3, #8, #20, #21, #38, #50, #54, #60, #62, #65, #102, #106, #108, #128, #129, #130, #138, #139, #151, #152, #153, #165, #170 and #175) resided on the female secured dementia unit. Eight of those residents were receiving Hospice care. Interview on 09/13/17 at 10:24 A.M. with Resident #171 revealed she stated that she felt scared for about a week after she was attacked. She felt safe now because Resident #52 was no longer at the facility. Resident #171 stated she would not feel safe if Resident #52 returned. She stated, I don't know why she attacked me, I'm nice to everyone. She said she still had bruises on her arms and pulled up her sleeves. Observation revealed Resident #171 had several faded bruises on both forearms. Interviews on 09/14/17 between 6:05 A.M. and 6:34 A.M. with STNA #300, STNA #301 and RN #202 revealed they were unaware Resident #52 had been hoarding silverware with the attempt to harm staff and other residents before the incident on 09/03/17. All worked on the locked female dementia unit. On 09/14/17 and 09/15/17, all facility staff were inserviced by ADON #240 regarding resident behaviors, how to identify triggers for behaviors, successful interventions to deescalate behaviors, and proactive strategies that prevent behaviors from occurring. All facility staff were also educated by ADON #240 on the facility policies related to behaviors, including Addressing Residents with Escalating Behaviors/Violence (revised 04/17), Behavior Communication Process (revised 04/17), and Code Orange. The facility staff inserviced included six RNs, 34 LPNs, 58 STNAs, two Social Service staff, six therapy staff, 16 dietary staff, 21 housekeeping/laundry staff, three maintenance staff, and three reception staff. One staff member was on leave and will be inserviced upon return to work.

Based on observation, interview and record review, the facility failed to ensure one resident did not develop an avoidable pressure ulcer, and did not ensure implementation of interventions to promote healing and prevent new ulcers from developing. Harm occurred when Resident #6 was assessed as not at risk for pressure ulcers and pressure reducing interventions were not put in place prior to the resident developing an unstageable pressure ulcer to his right heel. Resident #6 was observed with no new interventions implemented after the development of a pressure ulcer. This affected one (Resident #6) of three residents reviewed for pressure ulcers. The facility identified six residents with pressure ulcers. Findings include: Resident #6 had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 08/30/17, revealed Resident#163 was not at risk for pressure ulcers. The resident required extensive assistance of two or more persons for bed mobility, transfers, dressing, and toileting; and was totally dependent on two or more persons for bathing. The resident was assessed as having no risk of developing pressure ulcers and had no pressure ulcers as of 08/26/17. Review of Resident #6's weekly skin assessment dated [DATE] revealed no skin issues. Review of the resident's skilled nursing note dated 09/11/17 at 3:06 A.M. revealed a surgical area to the back. There was no mention of any issue with the resident's skin in any other area. Review of Resident #6's physician's orders [REDACTED].M. for PRAFO (pressure relief ankle foot orthosis) boots to be worn at all times, may be removed for hygiene. Review of a skin grid non-pressure entry dated 09/11/17 at 10:54 A.M. revealed the wound nurse (Wound Nurse #209) was in to see Resident #6 for a bedside visit. Assessment showed a suspect vascular area to the right heel, measuring 3.2 centimeter (cm) by 1.5 cm by <0.1, 100% black eschar (eschar is described as thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissue that has lost its usual physical properties & biological activity. Eschar may be loose or firmly adhered to the wound.) with superficial layer of skin missing to lateral end of wound, peri wound intact and blanchable, no odor or signs and symptoms of infection noted. Area of eschar was boggy on palpation. Cleanse with normal saline solution (NSS), pat dry, skin prep to peri wound, applied silver alginate to wound bed, covered with foam dressing, to be changed every 3 days and as needed. On 09/12/17 at 5:45 P.M. Resident #6 was observed in bed with both heels resting directly on the bed. State tested Nurse Aide (STNA) #317 and a Licensed Practical Nurse (LPN) #217 entered the room and donned gloves without washing their hands. Interview with LPN #217 confirmed that the resident's heels were on the bed, but indicated Resident #6's heels were floating when they put the pillow under him. When asked about the pressure reducing ankle foot orthotic (PRAFO) that was ordered on [DATE], LPN#217 indicated the PRAFO was to be applied when available as they did not have a PRAFO in the facility for the resident . LPN #217 turned Resident #6 and STNA #317 provided incontinence care as the resident had a bowel movement. As STNA #317 was cleansing the resident, three small open red areas were observed in the resident's sacral and coccyx region. LPN #217 left the room to get Wound Nurse #209 to assess the newly found wounds. At 5:54 P.M., STNA #317 left the room without floating the resident's heels above the bed surface. At 5:56 P.M., LPN #217 returned to Resident #6's room with Wound Nurse #209. At 6:02 P.M., Wound Nurse #209 palpated three areas on and around the coccyx/sacral area and measured the areas. The first area was a red non-blanchable discoloration and measured 0.7 cm by 0.4 cm with 0.1 depth. The second area was a red non-blanchable area measuring 0.7cm by 0.6 cm with no depth. The third area was a purple blanchable discoloration measuring 2.6 cm by 1.0 cm. Interview with Wound Nurse #209 confirmed the areas were new and a scheduled time was made to observe the wound treatment on the resident's right heel at 1:30 P.M. on 09/13/17. Review of the ultrasound arterial study of the resident's lower extremities completed on 09/12/17, and signed by a physician on the same day at 3:04 P.M., revealed no evidence of hemodynamically significant stenosis or occlusion on the images submitted. On 09/13/17 at 10:15 A.M., Assistant Director of Nursing (ADON) #240 said Resident #6's heel wound dressing had been removed for the resident's primary care physician, and for unrelated reasons they would be sending the resident to the hospital. At 10:16 A.M., Resident #6 was observed in his bed with his right foot elevated on pillow with the dressing removed. Resident #6's left heel was directly on the bed surface. The resident was awake and asked the surveyor for a big glass of lemonade. At 10:23 A.M., LPN #219 entered the room indicating she would be dressing the resident's wound. On 09/13/17 at 10:34 A.M., LPN #219 measured the right heel wound at 3.2 cm length by 2.9 cm width (an increase in width of 1.4 cm since measured on 09/11/17). The base was a purple blackened area of eschar. There was a bloody area around the eschar which was confirmed with LPN #219 who said she understood this was a vascular wound. LPN #219 applied the treatment of [REDACTED]. She then applied the PRAFO boot that had been ordered on [DATE]. Review of a nurse's note dated 09/13/17 at 12:05 P.M. revealed Resident #6's physician assessed the area of skin impairment at the sacral/buttocks region and believed moisture [MEDICAL CONDITION] was a precipitating factor. Barrier cream was oredered for treatment. Skin impairment on the heel was at the Achilles area and appeared to be a result of friction obtained while rubbing the foot on the mattress/sheet. (A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissues). Although friction and shear are not primary causes of pressure ulcers, friction & shear are important contributing factors to the development of pressure ulcers.) Interview with ADON #240 on 09/15/17 between 12:13 P.M. and 12:33 P.M. confirmed the content of the ultrasound study for Resident #6 on 09/12/17 with no indication of stenosis or occlusion of the right leg. ADON #240 indicated there had been no order to elevate Resident #6's heels prior to the development of the wound. The facility had not identified the wound as a pressure area. There were no nurse's notes documenting the measurements obtained by LPN #219 on 09/13/17.

Based on record review, interview, review of facility policy, and review of hospital documents, the facility failed to ensure the physician was notified and treatment was provided for a resident with a poor fluid and food intake. This resulted in actual harm when Resident #235 was hospitalized with severe dehydration. This affected one resident (Resident #235) of four residents reviewed for hydration. The facility census was 137. Findings Include: Review of the closed medical record for Resident #235 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The resident was no longer residing in the facility at the time of the survey. Review of a progress note dated 09/04/14 indicated Resident #235 received a chest x-ray indicating the resident had pneumonia. Resident #235 was ordered antibiotics, [MEDICATION NAME] breathing treatments every six hours and a speech therapy evaluation. Review of a progress note dated 09/05/14 revealed Resident #235 was listless, slow to respond to verbal commands, and was spoon fed all meals by staff. Review of a progress note dated 09/09/14 stated Resident #235 remained in bed on this day per the residents request. This progress note also stated the resident was spoon fed all meals by staff consuming less than 50% and responding to verbal commands sluggishly. Review of daily meal intake percentages revealed beginning on 09/06/14 at 5:33 P.M. through 09/10/14, Resident #235 ate 0-25% of all meals documented. Review of fluid intake amounts for Resident #235 revealed the total fluid intake documented in the medical record for 09/04/14 was 1,080 milliliters (ml), on 09/05/14 was 840 ml, on 09/06/14 was 240 ml, on 09/07/14 was 240 ml, on 09/08/14 was 120 ml, on 09/09/14 was 360 ml. Review of a progress note dated 09/10/14 revealed Resident #235 was found unresponsive and was transferred to the hospital. Review of a hospital report dated 09/10/14 revealed Resident #235's Blood Urea Nitrogen (BUN) level was critically high at a level of 122 and the resident was diagnosed with [REDACTED]. There were no progress notes in the medical record for Resident #235 indicating the physician for the resident was informed of the lack of food and fluid intake experienced by Resident #235 from 09/04/14 until the resident was found unresponsive on 09/10/14 and was transferred to the hospital. Interview with the Assistant Director of Nursing #303 on 04/09/2015 at 3:10 P.M. verified the physician of Resident #235 was not notified of the residents lack of food and fluid intake after 09/04/14 until the resident was transferred to the hospital on [DATE]. Review of a facility policy undated entitled Notification of Changes states that the facility will immediately or at least within 24 hours consult with the resident's physician when there is a significant change in the resident's physical status.

Based on medical record review, observation, staff interview, review of the incident report and the Missing Persons policy, the facility failed to provide adequate supervision for Resident #1, who was identified at risk for elopement, when the resident eloped from the secured unit and was located seven tenths of a mile from the facility. This resulted in Immediate Jeopardy for one resident (Resident #1) of 41 residents residing on one of two secured dementia units. The facility identified 66 residents at risk for elopement. The resident census was 146. On 09/03/14 at 11:30 A.M., the Administrator was notified that Immediate Jeopardy began on 08/14/14 at 3:40 P.M. when Resident #1, who had a history of [REDACTED]. The facility failed to assess Resident #1 after the incident to ensure interventions to to prevent further elopements were appropriate after Resident #1 left the secured unit. The Immediate Jeopardy continued on 08/17/14 at 10:30 A.M. when the facility receptionist (Receptionist #12) received a phone call from a local church indicating Resident #1 was found at the church and " was looking to get home. " The facility was located at the top of a long, sloping driveway that led directly to a highly traveled two lane state highway. This area had a high volume of truck traffic. Resident #1 likely walked approximately two-tenths of a mile on the state highway before turning onto a side road and then likely walked approximately five-tenths of a mile and crossed an intersection to get to the church. Resident #1 was returned to the facility by the Receptionist #12 at 11:00 A.M on 08/17/14. The Immediate Jeopardy was removed on 09/10/14, when the facility implemented the following corrective actions: * On 8/17/14 a Wanderguard (an alarming ankle bracelet) was applied to Resident #1. * On 8/17/14 Maintenance Staff #13 changed the entrance/exit security code numbers on the secured units. On this date, the social worker (SW) #21 notified all families by phone of the change and the need to have staff assistance to get in and out of the secured units. * On 8/17/14 signs were posted at the entrance and exit of each secured unit door to notify visitors that staff would be responsible to allow them in and out of the secured units. *On 09/08/14 the administrator accepted a proposal to install delayed egress locks with keypads on all nine doors that exit the facility. *On 09/10/14 the administrator developed a training plan to educate the staff on the secured unit doors and the new codes. The plan to educate the entire staff was not yet completed. *On 09/10/14 interviews with multiple staff on both the day and the night shift, including two licensed practical nurses, one registered nurse, and six state tested nursing assistants revealed these staff were knowledgeable to the secured unit door code changes, not to give out the code to any visitors and to be alert to residents at the doorways. Although the Immediate Jeopardy was removed, 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 the facility had not educated all employees related to Resident #1 ' s elopement, the new code system, the resident ' s new Wanderguard or the elopement drills. Elopement drills were not completed quarterly as indicated in the Missing Person policy. The last elopement drill was completed 09/05/13. The facility had not yet completed re-assessments of all other residents for elopement risk as per their policy. Findings include: Review of a history and physical dated 08/13/14 revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician (Physician #20) noted Resident #1 was awake and confused to time and place, had poor short term memory and could not be left alone. Review of the admission Nursing Progress Note dated 08/11/14 at 5:38 P.M. revealed Resident #1 was ambulatory, alert to self only and a wanderer who packed her things to try to leave. Review of an elopement risk assessment dated [DATE] revealed Resident #1 was at moderate risk for elopement. An interim elopement care plan was developed on 8/11/14 and identified the resident ' s primary [DIAGNOSES REDACTED]. The interim care plan included information regarding her diet and activity of daily living status, but did not identify specific problems or provide any interventions to address Resident #1 ' s exit seeking behaviors. Review of Resident #1 ' s Nursing Note dated 08/12/2014 at 1:24 A.M. revealed the resident sustained [REDACTED]. Licensed Practical Nurse (LPN) #2 noted the resident stated " I ' m going home. " Review of Resident #1 ' s Skin/Wound Note dated 08/14/14 at 2:23 P.M. revealed the resident denied any pain or discomfort, but stated she was depressed and wanted to go home. Review of a Nursing Progress Note dated 08/14/14 at 3:06 P.M. revealed Resident #1 approached the nurse ' s station and politely asked to " check out of this place please. " Registered nurse (RN) #4 noted the resident was re-oriented by the staff and was aware that she would be staying at the facility. Resident #1 asked if her car was in the parking lot. Review of a Nursing Progress Note dated 08/14/14 at 3:40 P.M. revealed LPN #5 was told by housekeeping " you have a resident out". LPN #5 noted a visitor (Visitor #40) let Resident #1 out of the locked unit. LPN #5 indicated Resident #1 was found in less than 45 seconds walking towards Unit 2 behind Visitor #40. LPN #5 indicated she spoke with Visitor #1 and informed him he could not let anyone off the unit. Resident #1 was returned to the unit by LPN #1, the unit manager. Additional information regarding the 8/14/14 incident was documented on 08/18/14 at 12:40 P.M. RN #4 noted the entry was an addendum to the 08/14/14 note. The note revealed Resident #1 followed a visitor (Visitor #40) to the secured unit ' s exit door. Resident #1 continued to walk behind Visitor #40 and walked down the hallway toward the other unit. Resident #1 was in full view at all times (the note did not indicate who observed the incident). Visitor #40 was educated to make sure all locked doors were closed behind him. Review of a Nursing Progress Note dated 08/17/14 at 11:24 A.M., revealed a local church called the facility at 10:30 A.M. and indicated Resident #1 was at the church and was " looking to get home " . Receptionist #12 went to the church alone and brought Resident #1 back to the facility at 11:00 A.M. The resident was assessed to have no injuries. The physician, responsible party, assistant director of nursing (ADON) and the weekend manager were notified. Review of the Nursing Progress Note dated 08/17/14 at 6:57 P.M. revealed Resident #1 was looking for a relative. Resident #1 packed several of her items, put the items on an overbed table and was pushing them around. Resident #1 was pacing and had a key in her hand and was looking for her car. Review of the Nursing Progress Note dated 08/18/2014 at 3:04 P.M. revealed the assistant director of nursing (ADON) called Resident#1 ' s responsible party as a follow up from the 8/17/14 incident. The responsible party was updated on the current interventions and the steps that were taken to reduce the possibility of a repeat situation and if a room change was possible to keep Resident #1 closer to the nurse ' s desk due to her exit seeking behaviors. Review of an undated incident report completed by the director of nursing (DON), revealed Resident #1 was an active exit seeker and wanderer. The investigation revealed the facility obtained staff statements from the dementia unit nurse (LPN #1) and from the three State-tested nurse aides (STNAs #7, #8 and #9) who were scheduled on the dementia unit during the time the resident eloped. Review of LPN#1 ' s statement revealed on 08/17/14 at approximately 10:30 A.M. the local church called to inform the facility Resident #1 was at their church and the resident was " looking to go home. " The last time LPN #1 saw the resident was " early in the shift. " The shift began at 7:00 A.M. LPN #1 stated she was heading to give her morning medications, when she received the phone call. LPN #1 assessed the resident on her return to the facility and notified the physician, responsible party, LPN #6 and the weekend manager. Review of STNA #8 ' s statement dated 08/17/14 revealed she was unaware the incident had occurred. STNA #8 did not indicate when she last visualized Resident #1. Review of the administrator ' s statement dated 08/18/14 revealed she monitored the video from the cameras at the exit doors for the timeframe Resident #1 was missing. The administrator noted there was no evidence on review of the film Resident #1 exited from the front door or the rehab door (the only two doors monitored by video camera). Review of STNA #7 ' s written statement dated 08/19/14 revealed she cleared the table from breakfast and asked Resident #1 if she had enjoyed her meal. STNA #7 indicated the time was " around " 9:00 A.M. Review of STNA #9 ' s written statement dated 08/20/14 revealed the last time she saw Resident #1, the resident was walking in the hallway after eating breakfast. STNA #9 noted the STNAs were completing resident care at that time. Review of the Social Services Note dated 09/02/14 at 2:21 P.M. revealed Resident #1 was scheduled to be transferred to a different secured assisted living facility per family request on 09/04/14. On 09/02/14 at 4:10 P.M. interviews were conducted with the administrator and the ADON to review the elopement investigation and facility policies related to the secured unit and missing persons. Interview with the ADON identified Resident #1 was admitted directly to the secured dementia unit. The ADON stated the resident was assessed at risk for elopement on admission and would have an interim care plan in place prior to the completion of the MDS. The ADON stated all interim care plans were located in the unit medical record; however verified Resident #1 ' s interim care plan was not present on the record. The ADON revealed the unit manager (LPN #1) notified her by phone on 08/17/14 when the elopement occurred. The ADON stated she did not come into the facility, but since she had access to the computer system, she completed an elopement risk assessment for Resident #1 " offsite " by using her home computer to access the facility ' s program on 08/17/14. The assessment indicated Resident #1 was reassessed and the facility applied a Wanderguard to the resident. During this interview, the administrator interjected the facility staff speculated Resident #1 left with a family member. Due to the belief that Resident #1 exited with a family member from the secured unit and out the front door (the only facility door alarmed for the Wanderguard system) the facility placed a Wanderguard on the resident on 08/17/14. The administrator indicated the codes to the secured dementia units were changed and a sign notifying visitors they would have to be let into the unit was posted. The administrator stated the managers were notified on 08/17/14 they were not to give the codes out to the visitors. The administrator was asked if any other staff were interviewed, or if anyone contacted the church for additional information. The administrator indicated the weekend manager, Registered Dietician (RD) #10 had additional information written on the weekend report and the weekend supervisor, and RN #11 submitted a statement. The administrator verified the church was not contacted. On 09/03/14 at 10:14 A.M., the ADON provided a copy of the interim care plan which she stated was located in an assessment folder on the unit. The ADON verified the care plan did not contain any interventions related to the exit seeking behavior of Resident #1. The ADON also provided a copy of the weekend manager report. Review of the report revealed Resident #1 eloped at approximately 9:50 A.M. to 10:00 A.M. RD #10 noted the facility was contacted by the church and the unit manager completed an incident report, obtained staff statements and contacted two family members who visited the secured unit (family members of Resident #16 and Resident #4). On 09/03/14, Resident #1 was observed in the unit dining room for breakfast. The resident had finished her breakfast at 8:40 A.M. and left the room. An interview with the administrator on 09/03/14 at 11:40 A.M. verified Resident #1 ' s current elopement risk care plan was dated 08/22/14. The administrator stated they had a problem with the computer system and there was no way to determine when the care plan was initiated or when updates were made. Interview with the administrator on 09/03/14 at 2:30 P.M., verified the dietary staff and housekeeping staff that were present on the unit the day of the elopement were not interviewed about the incident. The administrator also verified no staff education was provided following the elopement. The administrator verified the facility did not have a separate dementia unit handbook and there were no other policies or guidelines related to the dementia unit. The administrator stated there were no specific policies related to monitoring the number of residents present, but staff would observe the residents related to meal times, medications, or providing personal care. Review of the CODE AMBER policy (Missing Persons Policy) dated 04/24/13 revealed the facility would maintain a safe environment for all residents and implement interventions to keep a resident from harm related to elopement from the facility. Elopement was defined as leaving the facility grounds without knowledge or authorization of facility staff. Review of the CODE AMBER procedure revealed prevention procedures were outlined. The facility staff was to complete an elopement Risk Assessment Tool on admission and quarterly. Current photographs were to be kept in the Medication Administration Record. Secure units were to be protected by a passcode. Secure unit doors were to be equipped with battery backup alarms to operate in the event fire alarms were initiated or other circumstances rendered them non-functional. All disaster plans were to include provisions/assignments for the monitoring of doors. Quarterly elopement drills on varied shifts were to be conducted with residents on secured units and traditional units. On 09/03/14 at 2:00 P.M. the administrator verified the most recent elopement drill was conducted on 09/05/13. The administrator stated she was not sure why the drills were not conducted quarterly. On 09/04/14 at 9:00 A.M. an interview with RD #10 revealed she was notified of the elopement by the unit manager after the church called the facility. RD #10 stated she noted the approximate time of the elopement was 9:50 A.M. to 10:00 A.M. based on the supposition that the resident left with another resident ' s family. RD #10 stated the administrator reviewed the camera films on 08/18/14 and found no evidence to support when Resident #1 left the building, if the resident left with a family or that she left out of the front door. On 09/04/14 at 9:30 A.M. an interview with RN #11 revealed she was the nursing supervisor working the day of the elopement, but was not notified of the incident until Resident #1 returned to the facility. RN #11 verified she was not asked to submit a written statement for the elopement investigation until 09/02/14. Interview with the ADON on 09/10/14 at 5:50 P.M. verified a training plan was in place related to the secured unit and new code locks but all of the facility staff had not yet been educated. *This deficiency substantiated allegations contained in complaint #OH 196. *This is also an example of continued non-compliance from the complaint survey dated 08/14/14.