Every finding on record at Vista Center, The

Based on review of the medical records, review of facility policy, and interview with staff, the facility failed to provide timely baseline care plans. This affected four residents (#2, #3, #27, and #53) of four residents reviewed for baseline care plans. The facility census was 45. Findings include: 1.Review of the medical record for Resident #2 revealed an admission date of 07/07/26. Diagnoses included unspecified dementia with agitation, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, adult failure to thrive, other seizures, unspecified fracture of upper end of right humerus, intermittent explosive disorder, impulse disorder, and need for assistance with personal care. Review of an admission Minimum Data Set (MDS) 3.0 dated 07/11/26 revealed the resident could not complete a Brief interview for Mental status (BIMS) score because he could not be understood. He required a wheelchair for ambulation and was dependent on staff for all activities of daily living. Review of the medical record failed to reveal a baseline care plan for Resident #2. Interview with the director of nursing (DON) on 08/03/26 at 10:00 A.M. confirmed Resident #2 did not have a baseline care plan. She had discovered about a month ago this had been an issue and the nurses who were doing admissions should have done them, but had not. 2.Review of the medical record for Resident #3 revealed admission to facility on 04/30/26 with diagnoses including lung disease, edema (swelling from fluid), anemia (low blood count), spinal stenosis (narrowing of the back bones), urinary tract infection, and C-diff (a contagious explosive diarrhea). Review of the medical record for Resident #3 revealed no evidence of a baseline care plan being completed from 04/30/26 through 05/02/26. 3.Review of medical record for Resident #27 revealed admission to the facility on [DATE] for diagnoses including metabolic encephalopathy (water on the brain), Alzheimer's Disease (progressive brain disease leading to severe memory impairment and confusion), malnutrition, irregular heartbeat, high blood pressure, major depression, and lung disease. Review of the medical record for Resident #27 revealed no evidence of a baseline care plan being completed from 01/14/26 through 01/16/26. 4.Review of the medical record for Resident #53 revealed admission to facility on 07/24/26 for diagnoses including iron deficiency anemia (low blood count), diabetes, heart failure, adjustment disorder with mixed anxiety and depression, kidney disease, and Parkinson's disease. Review of the medical record for Resident #53 revealed no evidence of a baseline care plan being completed from 07/24/26 through 07/26/26. Interview on 07/30/26 at 3:10 P.M. with the DON revealed the baseline care plans for Residents #3, #27, and #53 were not completed. The DON further revealed that at the end of June, 2026 she had noticed a concern with the baseline care plans not being completed for new admissions by the nursing staff. The DON reported that she did staff education about the completion of the baseline care plans at the staff meeting in June. The DON denied addressing the concern with the Quality Assurance and Performance Improvement (QAPI) team or starting a performance improvement project (PIP) for the area of concern. The DON denied performing any audits for baseline care plan completion after the education was provided to the staff. Review of the staff meeting agenda and item discussed with staff by the DON, dated 06/30/26, revealed that baseline care plan assessment needed printed and signed by the resident and could be located in the assessment tab of the electronic medical record, Point Click Care software, titled, Baseline Care Plan – V2. Review of the facility policy titled, Care Plan and Advanced Care Plan Process, undated, revealed the facility would initiate an interim plan of care within 48 hours of resident admission. The interim plan of care should include at minimum the necessary healthcare information necessary to properly care for the residents and the interim plan of care facilitates care until the comprehensive interdisciplinary plan of care was developed with 7 days after completion of the comprehensive assessment.

Based on review of medical records, facility policy review, and interview with staff, the facility failed to obtain consent for the use of psychotropic medication (class of medications used to treat mental and behavioral illnesses) for a resident. This affected one resident (#27) of five residents reviewed for unnecessary medication use. The facility census was 45. Findings include:Review of medical record for Resident #27 revealed admission to the facility on [DATE] with diagnoses including metabolic encephalopathy, Alzheimer's Disease, malnutrition, irregular heartbeat, high blood pressure, major depression, lung disease, brief psychotic disorder, and intermittent explosive disorder. Review of the most recent minimum data set (MDS) 3.0 quarterly assessment completed on 05/02/26 revealed Resident #27 had a brief interview for mental status score of 7/15 indicating severe cognitive deficits. The quarterly assessment also revealed Resident #27 had behaviors present including refusals of care and being verbally or physically combative with staff at times. Further review revealed Resident #27 required supervision and set up assistance for dressing, personal care, and walking throughout the facility. Resident #27 also required a wander guard device due to increased risk of elopement from the facility. Review of a care plan dated 02/17/26 for Resident #27 revealed she received anti-depression medications and interventions to include administering medications as ordered, monitoring for signs and symptoms of increased depression, and monitoring for adverse effects including agitation, shaky, anxious, diarrhea, dizziness, headaches, loss of appetite, dry mouth, insomnia and fatigue and notify MD if present. Review Resident #27 medication orders revealed an order prescribed on 01/26/26 by medical doctor (MD) #600 for divalproex sodium (Depakote) oral tablet delayed release 250 mg give three times a day related to brief psychotic disorder and intermittent explosive disorder. According to reference.medscape.com Depakote was classified as an anti-convulsant medication but could be used for manic behaviors with bipolar disorder. Review of Resident #27's informed consent for use of psychotropic medications, dated 02/17/26 and signed by Resident #27 revealed consent for the medications Exelon, Namenda, and Remeron for Alzheimer's Disease and depression. Depakote was not listed on the form. Review of Resident #27's informed consent for use of psychotropic medications, dated 07/08/26 and signed by Resident #27 legal guardian revealed consent for the medications Exelon, Namenda, Remeron, and Cymbalta for Alzheimer's Disease and depression. Depakote was not listed on the form. Interview on 08/03/26 at 12:31 P.M. with the Director of Nursing (DON) verified that there was no consent obtained prior to the use of Depakote on 0/126/26 for Resident #27 in the medical record.

Based on review of the medical record, facility policy review, and interview with staff, the facility failed to ensure review and revision of the preadmission screening and annual resident review (PASARR) assessment when there were changes to the resident's condition. This affected one resident (#1) of one resident reviewed for PASARR assessments. The facility census was 45. Findings Include: Review of the medical record for Resident #1 revealed admission to facility on 03/20/25 for diagnoses including liver cancer, malnutrition, lung disease, viral hepatitis C (contagious virus infecting the liver), bipolar disorder (mood fluctuations), tobacco use, and history of alcohol abuse. Resident #1 began in facility hospices services on 09/15/25 for terminal diagnosis of liver cancer. Review of the preadmission screening PASARR completed on 03/18/25 by [NAME] Regional Medical Center for Resident #1 revealed mental health diagnoses to include bipolar disorder. Further review of the PASARR revealed no evidence for diagnosis of alcohol abuse under the section of substance abuse diagnoses. Review of the hospital referral for Resident #1 sent to the facility prior to admission by [NAME] Regional Medical Center revealed a progress note dated 03/17/25 and authored by the hospital medical provider indicating that Resident #1 had a diagnosis of acute alcohol use and history of chronic alcohol abuse since 07/10/23. Further review revealed Resident #1 generally consumed 6-12 beers per day and last used alcohol on 03/14/25 and used marijuana 1-2 times per month with last use 5 days prior to admission to hospital. Further review of the medical record for Resident #1 revealed no evidence of an updated PASARR form being revised by the facility after admission to add the diagnosis of alcohol abuse. Interview on 07/29/26 at 10:44 A.M. with the facility social services designee (SSD) #145 revealed she typically reviewed the PASARR form on all new admissions for accuracy. SSD #145 verified that Resident #1 did not have alcohol abuse on the PASARR form under the section of substance abuse history that was completed by the hospital on [DATE]. SSD #145 verified that the history and physical provided by [NAME] Regional Medical center did in fact have diagnoses of acute alcohol use and chronic alcohol abuse as diagnoses. SSD #145 further reported that she personally knew Resident #1 prior to her admission to the facility and she had quit drinking, so SSD #145 did not think it was necessary to update the PASARR with the corrected diagnosis. SSD #145 further reported that the diagnosis of substance abuse would not have changed the outcome of review and deferred to the PASARR reviewer at the Ohio Agency on Aging that reviews the document. Interview on 07/29/26 at 11:14 A.M. with the PASARR reviewer (PR) #602 from the Ohio Agency on Aging revealed the hospitals often do not fill the PASARR form out correctly nor include all applicable diagnoses. PR #602 also confirmed the outcome of Resident #1 would not have changed but that the expectation was for long term care facilities to review and update the PASARR form upon admitting residents.

Based on review of the medical record, review of facility policy, observations of oxygen use, and interviews with staff, the facility failed to administer oxygen as prescribed. This affected one resident (#14) of one resident reviewed for respiratory care. The facility census was 45. Findings include:Review of the medical record for Resident #14 revealed admission to facility on 02/10/23 with diagnoses including Chronic Obstructive Pulmonary Disease (lung disease), malnutrition, depression, high blood pressure, gastric reflux and insomnia (inability to sleep). Further review of the most recent minimum data set (MDS) 3.0 comprehensive assessment completed on 07/04/26 revealed Resident #14 was hard of hearing and had a brief interview for mental status (BIMS) score of 10/15 indicating moderate cognitive deficit. The MDS assessment also revealed Resident #14 utilized continuous oxygen and was receiving hospice care and was dependent on staff for personal care including dressing, bathing, transfers, and mobility with a wheelchair. Review of the medical record for Resident #14 revealed a physician order prescribed by medical doctor (MD) #600 and revised on 04/01/26 stating oxygen at 2 liters (L)/per minute (PM) via nasal canula (tubing that enters in the nose) continuous to maintain oxygen saturation above 92%. Review of the oxygen use care plan revised 03/16/23 for Resident #14 revealed interventions including administer oxygen as ordered, monitor lung sounds as ordered, monitor oxygen saturation levels as ordered and observe for signs and symptoms of shortness of breath such as labored breathing, low oxygen levels, use of accessory muscles to breathe, bluish color of lips and nails, changes in mental status, and high breathing rate. Observation on 07/27/26 at 1:20 P.M revealed Resident #14 resting in bed with oxygen on via nasal cannula. The oxygen cannister was observed at 4 LPM. Interview and observation on 07/27/26 at 4:01 P.M. with the Director of Nursing (DON) revealed verification that Resident #14 was currently receiving oxygen at 4 LPM. The DON also confirmed that Resident #14's physician order revised on 04/01/26 was for oxygen at 2 LPM. The DON adjusted the oxygen flow rate at that time for Resident #14 to 2 LPM and assessed Resident #14 oxygen saturation to be at 96%. Review of the facility medication administration policy dated 01/25 and confirmed by the DON revealed, Medications are administered in accordance with written orders by the prescriber. Review of the facility policy titled, Oxygen Therapy Policy #: EQM 2, undated revealed hazards of oxygen therapy/adverse reactions in resident with COPD have a greater risk of hypoventilation (slowed breathing) with excessive oxygenation use that can lead to severe slowed breathing and even death.

Based on record review, interview and review of facility policy, the facility failed to hold medications which were outside of the ordered parameters. This affected one resident (#44) of five reviewed for unnecessary medications. The facility census was 45. Findings include:Review of the medical record for Resident #44 revealed an admission date of 02/06/25. Diagnoses included need for assistance with personal care, neuromuscular dysfunction of bladder, moderate protein-calorie malnutrition, gastro-esophageal reflux disease without esophagitis, retention of urine, acquired absence of left leg below knee, chronic pain syndrome, long term use of anticoagulants, personal history of covid-19, unspecified atrial fibrillation, hyperlipidemia, and hypotension. Review of a quarterly Minimum Data Set (MDS) version 3.0 dated 07/01/26 revealed a Brief Interview for Mental Status (BIMS) score of 14 on a 0-15 scale. A score of 14 would indicate the resident was cognitively intact. Review of orders for Resident 44 revealed an order for Midodrine (a medication used for the treatment of low blood pressure) dated 01/14/26. The order was for Midodrine 15 (milligrams) mg by mouth three times daily for hypotension. Hold if systolic BP greater than 120. Review of the Medication Administration Record (MAR) for Resident 44 for the month of May 2026 revealed Midodrine was administered on 05/01/26, 05/06/26, 05/21/26, and 05/22/26 when the systolic blood pressure was above 120. Review of the MAR for Resident 44 for the month of June 2026 revealed the Midodrine was administered twice on 06/11/26 and once on 06/17/26, 06/18/26, 06/19/26, 06/24/26, 06/25/26, 06/28/26, 06/29/26, and 06/30/26 when the systolic blood pressure was above 120. This was confirmed on 08/03/26 at 2:40 P.M. by the Administrator. An interview with the Administrator on 08/03/26 at 2:40 P.M. confirmed the Midodrine for Resident 44 was given outside of parameters on 05/01/26, 05/06/26, 05/21/26, 05/22/26, 06/11/26 (twice), 06/17/26, 06/18/26, 06/19/26, 06/24/26, 06/25/26, 06/28/26, 06/29/26, and 06/30/26. Review of a facility policy titled Medication Administration General Guidelines, dated 2007, revealed medications were administered as prescribed in accordance with manufacturer's specifications, good nursing principles and practices and only by persons legally authorized to do so. Prior to administration, the order should be reviewed and confirmed for each resident. Medications were to be administered in accordance with written orders. The staff would obtain and record any vital signs as necessary prior to medication administration. Medications should be given with at least four ounces of water or other acceptable liquid and per manufacturer requirements.

Based on review of the medical record, review of facility policy and manufactures guidelines, observations of medication carts, and staff interviews, the facility failed to label and date the opening of a resident insulin pen. This affected one one resident (#26) of two medication carts reviewed for safe storage and labeling. The facility census was 45. Findings include:Review of the medical record for Resident #26 revealed admission to facility on 03/18/26 with diagnoses including diabetes, dementia, Parkinson's disease, respiratory failure, malnutrition, bipolar disorder, and depression. Review of the most recent minimum data set (MDS) 3.0 quarterly assessment completed on 05/15/26 revealed Resident #26 had a brief interview for mental status (BIMS) score of 13/15 indicating no cognitive deficit. Review of the MDS assessment also revealed Resident #26 was able to walk with supervision and required partial assistance with bathing and toileting. Further review of the quarterly MDS assessment revealed Resident #26 had a diagnosis of diabetes and required insulin injections routinely. Review of the physician orders for Resident #26 revealed an order prescribed by MD #600 and dated 04/08/26 for Basaglar Kwik Pen subcutaneous solution Pen-Injector 100 units/mill-liter (ml), inject 15 unites subcutaneously at bedtime. Basaglar insulin is a long-acting insulin prescribed to manage blood sugar levels over a 12-24-hour period. Observation on 07/29/26 at 11:48 A.M. of the medication cart of the locked memory care unit revealed one Basaglar Kwik Pen labeled for Resident #26's use was stored in the insulin section of the medication cart. The Basaglar Kwik Pen had a sticker on it with the words date opened, and a space to fill in the date. There was no date observed for when the pen was opened. Further observation of the Basaglar Kwik Pen revealed a pharmacy label indicating it was filled by the pharmacy on 07/12/26. Interview on 07/29/26 at 11:49 AM with licensed practical nurse (LPN) #225 revealed verification that the Basaglar Kwik Pen did not have an open date anywhere on the pen itself or on the pharmacy label. LPN #225 also revealed that when insulin was removed from the refrigerator and placed in the medication cart for use it was to be labeled with the date at that time. LPN #225 then removed the Basaglar insulin pen from the cart and discarded it and reported he would notify pharmacy and request a new pen for Resident #26. Interview on 07/29/26 at 2:10 P.M. with the Director of Nursing (DON) revealed that her expectation and the policy was for nursing staff was to label all insulin pens when they are opened for use. Review of the facility policy titled, Medication Storage and dated 01/26 revealed, insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used. Open insulin pens should be stored at room temperature. Review of the manufacturer guidelines and prescribing insert from Lilly Medicine for Basaglar Kwik Pen revised on11/2023 revealed once the Kwik Pen was opened it was to be stored at room temperature up to 86 degrees Fahrenheit and to be thrown away after 28 days of use, even if there was still insulin left in it.

Based on observation, sampled test tray, and interview the facility failed to provide palatable meals at preferred temperatures to residents. This had the potential to affect all 46 residents who received meals from the kitchen. The facility census was 46. Findings include: Interview on 02/17/26 at 9:42 A.M. with Resident #126 revealed food is sometimes cold and believes it is due to being at the very end of the 100 Hall and last to be served. Interview on 02/17/26 at 11:51 A.M. with Resident #32 revealed food is often cold or warm but not hot. Interview on 02/17/26 at 3:17 P.M. with Resident #19 revealed some of the food offered is lousy and that the hamburger provided was very overcooked and tough to bite into and eat. Observation revealed the last tray for the east wing room [ROOM NUMBER] was plated and placed on cart for service at 12:20 P.M. Further observation on 02/17/26 at 12:20 P.M. revealed a test tray was requested containing pizza casserole, green beans, and pumpkin mousse. The test tray was followed to the east wing. Further observation at 12:23 P.M. revealed two certified nursing aides (CNA)'s began to pass trays and drinks to residents who were dining in their rooms. Observation on 02/17/26 at 12:46 P.M. revealed the last tray for room [ROOM NUMBER] being served and then the test tray was sampled for food palatability for taste, texture and preferred food temperature. The green beans were not warm. The temperature was checked and verified by the Dietary Manager #138 at 120 degrees Fahrenheit and confirmed the green beans were not at appropriate temperature for palatability to eat as intended. This deficiency represents non-compliance investigated under Master Complaint Number 2733050.

Based on observation, interview and record review, the facility failed to provide a comfortable and sanitary environment for residents. This had the potential to affect all residents living in the facility. The facility census was 46. Findings include:1. On 02/17/26 at 9:34 A.M., an observation of the west hallway between rooms [ROOM NUMBERS] revealed the hallway was full of equipment on both sides. Between room [ROOM NUMBER] and 215, there was a large covered laundry cart, a blue straight back chair, a dirty linen cart, and a housekeeping cart. These were blocking the handrails. Across the hall, there was a medication cart between room [ROOM NUMBER] and 214. There was also a nurse standing at the medication cart, preparing medications. The hallway was observed to be impassable for a wheelchair, blocked the handrail on both sides, and was impassable for someone with a walker as well. This was confirmed by the Administrator during interview on 02/17/26 at 9:40 A.M. On 02/17/26 at 9:50 A.M., an observation of an emergency exit in the east hall designated Mary's Place revealed the emergency exit door was blocked. There were two large wheelchairs, a bucket of bird food, and a vital sign machine blocking the path of egress out the emergency door. This was confirmed by Registered Nurse (RN) #104. Review of a facility policy titled Means of Egress, dated 10/10/17, revealed the facility would safeguard all residents, visitors and personnel by ensuring all emergency egress paths and exits were clear, unobstructed, completely accessible and illuminated from any residential area within the center to a public way. The policy further indicated all means of egress would be continuously maintained free of all obstructions or impediments to full instant use in case of fires or other emergency. No furnishings, decorations, or other objects shall obstruct exits, access to, egress from or visibility. There would be no couches, chairs tables or other furniture in an exit access corridor. This policy was confirmed by the Administrator during interview on 02/17/26 at 9:40 A.M. An interview with the Administrator on 02/17/26 at 9:40 A.M. confirmed the west hallway had equipment, carts, and people on both sides of the hallway. She confirmed a wheelchair could not get through, nor could a resident with a walker, and the handrails were blocked on both sides of the hallway. This was the hallway leading to the main dining room. She confirmed the facility policy on safe paths of egress. On 02/19/26 at 12:17 P.M., an interview with a source that requested to remain anonymous revealed a resident had difficulty getting through the hallways with their wheelchair. There would always be carts of towels, beds, and all kinds of other stuff in the way and the resident could not get through. 2. On 02/18/26 at 8:20 A.M., observation of the main hallway revealed plaster missing from the corners of the walls. The main hallway, east hallway, and west hallway had a build-up of dirt along the floor and up the baseboards. There were large brown stains on multiple ceiling tiles in the main and west hallways, broken ceiling tiles in all three hallways, and one ceiling tile in the main hallway had a large brown stain with a black, mold-like appearance in the center. A portion of the ceiling in the main hallway, which contained a large light, had a water stain from around the light and across the ceiling. The three vents noted in the ceiling were coated with dirt and debris and two were rusty in appearance. There were balls of lint, dirt and debris hanging from between several of the ceiling tiles. This was confirmed by the Maintenance Director at 8:45 A.M. On 02/18/26 at 8:45 A.M., an interview with the Maintenance Director confirmed the dirty floors, broken and soiled ceiling tiles and air vents. He reported he had plenty of tiles to fix them, and had replaced the one with the moldy appearance several times, but the stain kept returning. This deficiency represents non-compliance investigated under Master Complaint Number 2733050 and Complaint Number 2638657.

Based on observation, review of invoices, and interview, the facility failed to provide a comfortable, clean environment for residents when there was a pervasive smell of sewage in the facility shower room which carried into the hallway. This affected five residents (#2, #14, #28, #18, and #24) identified as using the shower room. The facility census was 46.Findings include:On 02/17/26 at 9:42 A.M., an observation of the facility shower room revealed an overwhelming odor of sewage, which caused the surveyor's eyes to water. The hallway nearest to the shower room also smelled of sewage, though not as strong. This was confirmed at the time of the observation by the Maintenance Director (MD).On 02/17/26 at 9:45 A.M., an interview with Certified Nurse Aide (CNA) #164 revealed she knew there were at least three residents who used the shower. She revealed at times, even with the door closed, the odor of Sulphur would come into the hallway. She did not think anyone knew what was wrong with it.On 02/17/26 at 9:48 A.M., an interview with Resident #18 revealed he had been at the facility for three years, and the smell had been there since he got there. He reported one time the facility dumped bleach into the drain and there was some improvement, however, it had just gotten worse lately. He stated, It is f**cking nasty, and I hate to have to get a shower in there, but what option do I have?On 02/17/26 at 9:42 A.M., an interview with the MD revealed the smell in the shower room was about normal. He reported the smell was always there. He indicated plumbers had been to the facility to look at the situation; however, they told him there was nothing wrong. He reported that no residents use the shower during the day, it was only used on night shift, and housekeeping was able to come to the shower room and clean it during the day, which would help mitigate the odor.On 02/17/26 at 3:00 P.M., an interview with the Maintenance Director revealed the plumbing service had returned and checked the shower room on that day. He reported the plumber told him there was nothing wrong with the plumbing.On 02/17/26 at 12:48 P.M., an interview with Plumber #400 revealed his company had been to the facility on at least two occasions, including the day of survey to inspect the sewer smell coming from the shower room. He indicated on the first visit the plumber advised the MD there was a leak in the toilet in the shower room. They advised him the toilet needed pulled, a new seal and new bolts needed to be placed on the toilet. If this was not done, every time a toilet was flushed in the facility, the sewage odor would escape through the leaking toilet in the shower room.Plumber #400 reported his crew returned to the facility on [DATE] and found the issue had not been corrected. The technician advised the MD told them he knew what needed completed on the toilet, and he told them he probably should have completed the work the last time the plumbers advised him of this.On 02/19/26 at 12:17 P.M., an interview with an anonymous family member revealed any time their family member went to the shower room it was dirty. They reported it smelled like plain old sewage, and looked like it was never cleaned. There was always hair and debris in the drains. This had been happening for several months.Review of invoices from the contracted plumbing service revealed services were rendered on 11/25/25 and 02/17/26. The invoice dated 11/25/25 indicated services were for checking for smell in drain. No trapped drain for shower room and its open. The invoice dated 02/17/26 indicated ran floor drain into main line in tub room.This deficiency represents non-compliance investigated under Complaint Number 2733050 and 2638657.

Based on observation, interview and record review, the facility failed to prevent the spread of infection by not following proper hand hygiene during a dressing change. This affected one resident (#20) of three residents reviewed for wound care. In addition, the facility failed to follow proper infection surveillance to prevent the spread of urinary tract infections in January 2026. This had the potential to affect all 46 residents residing in the facility. The facility census was 46.Findings include:1. Review of the medical record for Resident #20 revealed an admission date of 07/05/14. Diagnoses included amyotrophic lateral sclerosis, abnormalities of gait and mobility, muscle weakness, muscle wasting and atrophy, dysphagia, anxiety disorder, need for personal care assistance, moderate protein-calorie malnutrition, and pressure ulcer of sacral region, stage four. A review of a Minimum Data Set (MDS) version 3.0 for Resident #20, dated 01/20/26, revealed a Brief Interview for Mental Status (BIMS) score of 0 on a 0 to 15 scale. A score of 0 indicated the resident had severe problems with thinking and memory. The MDS also revealed the resident required supervision or touch assistance for eating, and was dependent for all other activities of daily living including bathing and personal hygiene. She was dependent for all transfers. Review of physician orders for Resident #20 revealed an order to cleanse peg tube stoma with NSS (normal saline solution), pat dry, apply drain sponge QD (daily) and PRN (as needed). The order was dated 02/18/26. On 02/18/26 at 1:50 P.M., observation of wound care for Resident #20 revealed proper hand hygiene was not followed. Observation revealed Registered Nurse (RN) #122 completed the dressing change for percutaneous endoscopic gastrostomy (PEG) tube. After removing the soiled dressing from the resident, using a gloved hand, RN #122 failed to remove soiled gloved, complete hand hygiene, and apply clean gloves. Instead, RN #122 removed the soiled dressing, cleansed the wound with soiled gloves, then removed gloves and revealed a second pair of gloves underneath. She then applied a clean dressing and performed hand hygiene. This was confirmed by RN #122 at the completion of the dressing change. On 02/18/26 at 2:02 P.M., an interview with RN #122 confirmed she failed to remove gloves, perform hand hygiene, and apply clean gloves after removing soiled dressing from Resident #20's PEG tube. Review of a undated facility policy titled Dressing Change-Clean revealed guidelines for the proper application of a dry, clean dressing. The policy revealed after removing a soiled dressing, the nurse should remove and dispose of gloves, then wash hands thoroughly. This policy was confirmed by Licensed Practical Nurse (LPN) #122 on 02/18/26 at 2:02 P.M Review of a undated facility policy titled Handwashing revealed it was the policy of the facility to maintain a high standard of hygiene in patient care through thorough handwashing procedures. All employees were to wash hands thoroughly with soap and running water before and after contact with resident bodily fluids, indwelling lines, resident equipment, soiled linen, when collecting specimens, or general cleaning. This policy was confirmed by LPN #122 during interview on 02/18/26 at 2:02 P.M. 2. Review of the facility infection control surveillance logs for the months of February 2026, January 2026, and December 2025 revealed the west wing (200 hall) had seven urinary tract infections (UTIs) in the month of January 2026, and the east wing (100 hall) had two UTIs. Further review revealed a facility total of three UTIs in December of 2025, none on the east wing and three on the west wing. Review of the infection surveillance log for January 2026 revealed three of the seven residents with diagnosed UTIs on the west wing did not have an identified organism listed for infection and referenced the diagnoses and orders for antibiotics were obtained from the local emergency rooms. Review of the infection surveillance room mapping for January 2026 revealed residents in rooms within close proximity of each other having UTI's including room [ROOM NUMBER], two residents in room [ROOM NUMBER], two residents in room [ROOM NUMBER], 208, and 210. Interview on 02/18/26 at 11:00 A.M. with Infection Preventionist (IP) #145 revealed she had just started her new position four weeks prior and was still learning the infection program at the facility. IP #145 further revealed she had not investigated or monitored for trends any infections from January or February 2026 yet and the regional nurse was going over it with her this week. IP #145 confirmed that there was an increase in January 2026 of UTI's on the west wing and that three of the residents did not have an organism listed and was entered as unknown from ER. Interview on 02/18/26 at 11:05 A.M. with registered nurse (RN) #401 revealed she was reviewing the infection surveillance logs for January and February 2026 for trends with the new infection preventionist this week and any follow-up needed would be discussed during the monthly quality assurance and performance improvement (QAPI) meeting and a plan would be made at that time. RN #401 also reported that she was new to the company and just started in her position in January of 2026. RN #401confirmed that there was an increase in January 2026 of UTI's on the west wing and that three of the residents did not have an organism listed and was entered as unknown from ER. Interview on 02/18/26 at 12:00 P.M. with the facility Administrator revealed the QAPI team meets quarterly and is due to meet at the end of February and the last meeting occurred for fourth quarter on 12/30/25. The Administrator further revealed that she started working at the facility as the Administrator in August of 2025 and the Director of Nursing (DON) just started at facility three days prior to the survey but had worked as a director of nursing at a sister facility for the past year. Review of the QAPI meeting minutes from 12/30/25 for fourth quarter of calendar year 2025 provided by the Administrator revealed seven nosocomial (facility acquired) infections in October, 12 nosocomial infections in November, and three in December of 2025. There were no problems or trends identified, or action plans taken or reference made as to why no action taken related to facility infections noted. This deficiency represents non-compliance investigated under Master Complaint Number 2733050 and Complaint Number 2638657.

Based on observation and interviews with family, staff, residents, and the Ombudsman, the facility failed to ensure residents and family members were able to contact facility staff members via the telephone. This had the potential to affect all residents in the facility. The facility census was 45. Findings include: Review of the two anonymous complaint intake reports reported to the state agency revealed facility staff did not answer the facility telephones. Attempted phone calls made by the State agency on 04/29/25 at 5:36 P.M., 04/29/25 at 5:40 P.M., 04/29/25 at 5:44 P.M., and 04/30/25 at 7:07 A.M. revealed the facility staff members did not answer the telephone and there was not a way to leave a message. Interview on 04/30/25 at 1:18 P.M., Registered Nurse #60 reported at times she was not able to answer the phone if they were short staffed. She continued that she did try to return the calls if she was able. Interview on 04/30/25 at 2:00 P.M., Ombudsman #47 reported she had received complaints from family members regarding facility staff not answering the telephones. He continued that he had reported the concern to the facility in the past. Phone interview on 04/30/25 at 2:20 P.M., Family Member #48 reported she had attempted to contact the facility on numerous occasions, attempting to check on her family member. She reported several times she was not been able to get ahold of anyone at the facility. She reported one weekend, she had tried for two days to get an update on her family member and was unable to get anyone to answer the phone. She reported she had to call the police department to do a wellness check on her family member. She also reported that she had outside doctors call her asking questions about her family members because they reported they were unable to get in contact with anyone at the facility. Interview on 04/30/25 at 3:00 P.M. Resident #23 reported he had called the facility numerous times, and no one would answer the calls. A couple of weeks ago he waited 90 minutes for someone to answer his call light. He reported that they did not respond so he attempted to call the facility to get someone to help him. He went on to say no one would answer his phone call so he had to call the police to see if he could get someone to help him. He reported he felt fearful when no one answered his calls. Interview on 05/01/25 at 12:20 P.M. with the Administrator reported she was aware of concerns related to contacting the facility via telephone, but thought they had been resolved. She went on to say she was unaware of issues with the phone system on 04/29/25 and 04/30/25. This deficiency represents non-compliance investigated under Master Complaint Number OH00164268 and Complaint Number OH00163222.

Based on observation, interview, and medical record review, the facility failed to ensure Resident #43 received the correct oxygen dosing and failed to ensure Resident #5's nebulizer equipment and mouthpiece were appropriately stored. This affected two out of three residents reviewed for respiratory care. The facility census was 45. Findings include: 1. Review of the medical record for Resident #43 revealed an admitted [DATE]. Diagnoses included metabolic encephalopathy, dementia, dysphagia, and diabetes mellitus type two. Review of Resident #43's physician orders revealed an order dated 03/15/25 for continuous oxygen at two liters per minute via nasal cannula. Review of Resident #43's care plan dated 04/02/25 revealed the resident had an alteration in respiratory function and required oxygen use with an intervention to administer oxygen as ordered. Review of Resident #43's Treatment Administration Record revealed facility nurses signed off that the resident oxygen was set to two liters on both 04/29/25 and 04/30/25. Observations made on 04/29/25 at 9:25 A.M., 04/29/25 at 11:25 A.M., and 04/30/35 at 2:30 P.M. revealed Resident #43 oxygen was at set at 3.5 liters per minute. Interview on 04/30/25 at 2:38 P.M., Registered Nurse #50 confirmed Resident #43's oxygen was at 3.5 liters per minute and that it should have been placed at two liters per minute. She adjusted the oxygen. 2. Review of the medical record for Resident #5 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), dysphagia, and dependence on supplemental oxygen. Review of Resident #5's physician orders revealed orders dated 07/08/22 for Ipratropium-albuterol solution 0.5-2.5 (3) milligrams (mg) per 3 milliliter (ml) with instructions to inhale 3 ml orally every four house as needed for COPD or shortness of breath. Review of Resident #5's care plan dated 04/11/25 revealed the resident had an alteration in respiratory function and required oxygen use with interventions to administer medications, oxygen and aerosol treatments as ordered. The care plan further revealed the resident had an alteration in respiratory function related to COPD with interventions to provide respiratory treatments per physician orders. Observation on 04/29/25 at 10:55 A.M. revealed Resident #5's nebulizer machine (a medical device used to deliver medication in the form of a mist or aerosol directly into the lungs) was sitting directly on the floor. The top of the machine was covered in an unknown dried substance. The mouthpiece was lying on top of the machine touching the top of the machine and wall. Interview on 04/29/25 at 10:55 A.M., Resident #5 reported the nurses stored the nebulizer on the floor because there was not enough table space in his room. He stated he would prefer it not to be on the floor. Interview on 04/29/25 at 11:10 A.M., Licensed Practical Nurse (LPN) #29 confirmed the findings and moved the machine and mouthpiece from the floor to his bedside table and cleaned the top of the machine. This deficiency represents non-compliance investigated under Master Complaint Number OH00164268 and Complaint Number OH00163713.

Based on observations, interview, review of schedules, and record review, the facility failed to ensure there was sufficient staff to provide residents with timely care. This had the potential to affect all 48 residents. Findings include: 1. During confidential interviews of residents and family, concerns were addressed regarding staffing levels. Interviewees did not wish to be identified but concerns addressed included failure of staff to provide timely assistance with three of the residents interviewed revealing wait times for call light response had extended to an hour or more. It was reported this had affected toileting, ability to transfer, medications not being administered on time and incontinence. On 12/30/25 at 6:00 A.M., Certified Nursing Assistant (CNA) #850 stated there had been times where there was one aide. When there was one aide residents who required transfers with mechanical lifts were not able to be transferred as requested. On 12/30/24 at 6:40 A.M., CNA #840 reported from the hours of 11:00 P.M. to 7:00 A.M., employees in the nursing facility were also required to address any needs that arose for the residential care facility residents. On 01/08/25 at 4:10 P.M., Licensed Practical Nurse (LPN) #844 reported she had worked with one aide on a hall in the past. LPN #844 stated she attempted to assist the aide to provide care but medications could not be administered on time. On those occasions when the facility had one aide she noticed residents might be asked if they wanted a shower but were not encouraged to take one. 2. During the resident council meeting on 01/07/25 between 2:06 P.M. and 2:20 P.M. with three additional residents who were not previously included in the interviews addressed under example #1, residents reported there was insufficient staff to provide the care needed without residents waiting a long time. 3. Interview of a CNA who wished to remain anonymous on 01/07/24 revealed she had worked as the lone full duty nursing assistant even though one time there was a light duty aide who could not provide assistance with lifting. Even if there was one nursing assistant, that person was expected to cover the attached Resident Care Facility residents' needs also if there was no Resident Assistant on duty. The 100 hall had ten residents who required two assists when care was provided. Some of the nurses would try to assist but showers were not consistently able to be provided. Sometimes bathing consisted of wiping armpits and perineal areas. The facility hired staff but they did not consistently stay. 4. On 01/08/25 at 1:50 P.M., CNA #828 revealed she had never worked with less than two aides on the 100 hall but it would not be possible to provide care residents needed. Residents tried to be understanding. Sometimes the ability to provide resident care was dependent on residents' expectations on any given day. 5. On 01/09/25 at 9:39 A.M., the call light in room [ROOM NUMBER] was observed to be activated. No staff were in the room. Resident #2 was observed sitting in the wheelchair and stated she was waiting for assistance to use the bathroom. Resident #2 reported since she started using a mechanical lift it had been a wait time up to one to two hours for sufficient staff to be available to assist with toileting and it had lead to incontinence. On 01/09/25 at 9:49 A.M., Activity Assistant #814 reported to two aides providing assistance to Resident #10 that she was answer the call light in room [ROOM NUMBER]. An unidentified housekeeper had been observed walking past the call light without responding and one other unidentified staff member walked past room [ROOM NUMBER] twice without inquiring if she could provide assistance. On 01/09/25 at 9:50 A.M., Resident #2's call light was turned off then Activity Assistant #814 proceeded to do activity related duties. A call light in room [ROOM NUMBER] was activated at approximately the same time Resident #2's call light was turned off. At 9:53 A.M., Activity Assistant #814 reported to staff in Resident #10's room about Resident #2's request. On 01/09/25 at 9:58 A.M., two certified nursing assistants exited Resident #10's room. An unidentified staff member reported to them that the resident in room [ROOM NUMBER] was requesting assistance from one of the aides. One of the aides (backs turned toward surveyor) requested the staff member informed the resident in room [ROOM NUMBER] they had two other residents to lie down then they would be with him. The unidentified staff member then stated she thought the resident in room [ROOM NUMBER] wanted his machine turned off. CNA #828 referred the staff member to the nurse stating she was the one who would have to turn off the machine. The unidentified staff member responded she did not know but he had requested a nursing assistant and walked down the hall. Meanwhile, Resident #1 who had been in the common lounge area on the 100 hall yelled out (had been periodically doing so throughout the observation). One of the CNAs was overheard asking Resident #1 if she wanted to lie down and she responded affirmatively. The CNA responded they would be with her in a few minutes then entered room [ROOM NUMBER] with the mechanical lift. On 01/09/25 at 10:07 A.M. Resident #2 was overheard calling out when she saw LPN #838 in the hall. LPN #838 asked what Resident #2 needed. Resident reported she had been waiting on the aides. Her call light had been turned off by another staff member and she had been told both aides were busy with another resident. LPN #838 responded she would get the aides to assist her. On 01/09/25 at 10:09 A.M. two CNAs exited room [ROOM NUMBER] with the mechanical lift and assisted Resident #1 to her room with the mechanical lift. While in the hall, Resident #1 reported she would also like to have her teeth brushed. At that time in call light in room [ROOM NUMBER] remained on and call lights in rooms [ROOM NUMBERS] had been activated. Resident #129 was moving around in the bed and cursing. On 01/09/25 at 10:14 A.M., Resident #2 had once again reactivated her call light. On 01/09/15 at 10:15 A.M., LPN #838 responded to Resident #2's call light. Resident #2 was overheard repeating she needed aides. LPN #838 responded the aides were in the next room and she would inform them. At 10:17 A.M. LPN #838 responded to the call light in room [ROOM NUMBER]. At 10:21 A.M., LPN #838 responded to the call light in room [ROOM NUMBER] and turned it off stating she would tell the girls. LPN #838 the proceeded to room [ROOM NUMBER] and told the aides the resident in room [ROOM NUMBER] wanted to get up. On 01/09/25 at 10:22 A.M., one of the aides exited room [ROOM NUMBER] with the left then the second aide exited the room. LPN #838 informed the aides the order she turned off the call lights was room [ROOM NUMBER] (Resident #2's room), room [ROOM NUMBER], and room [ROOM NUMBER]. LPN #838 indicated the resident from room [ROOM NUMBER] was in the bathroom doing his morning routine so he would probably not need assistance for a while. One of the aides proceeded to room [ROOM NUMBER]. It was not observed where the second aide went but at 10:30 A.M. the second aide was observed walking down the residential care facility hall. At 10:31 A.M., one of the aides exited room [ROOM NUMBER]. At 10:35 A.M., one of the aides was in room [ROOM NUMBER]. The other aide obtained the mechanical lift at 10:36 A.M. and stopped by room [ROOM NUMBER] to ask if the other aide could help her with Resident #2. Both aides were in Resident #2's room at 10:37 A.M. to provide assistance. On 01/09/25 at 10:20 A.M., LPN #838 stated it was often busier than it was that morning, acknowledging the wait times for Resident #2 were probably correct. On 01/09/25 at 4:20 P.M., Regional Director of Operations #905 stated she would generally consider toileting should occur within 20 minutes of a request but it varied her resident. Observations would shared regarding Resident #2 having waited a minimum of 58 minutes for toileting assistance and she agreed it was not the number of staff that mattered but the timeliness and quality of the care. Review of the Facility assessment dated [DATE] revealed staffing was based on resident population and acuity. The staffing plan was based on the facility assessment, along with facility-based and community based risk assessments to inform staffing decisions to ensure that there were a sufficient number of staff to care for the residents' needs. 6. During an interview with Ombudsman #950 on 12/30/24 at 9:20 A.M., it was reported during previous visits to the facility he had observed call lights taking over an hour for response, especially on the 100 hall where many residents need two assists. This had been discussed with the Administrator and she was asked to review staff levels. This deficiency represents non-compliance investigated under Master Complaint Number OH00160455 and Complaint Number OH00159892.

Based on employee personnel file review, policy review and staff interview, the facility failed to ensure employees had performance evaluations completed at 90 days and annually. This occurred with four certified nursing assistants (CNA) personnel files reviewed (#807, #816, #850, #873) and had the potential to affect all 49 residents residing in the facility. Findings include: Review of staff personnel files with Human Resources (HR) #877 on 01/14/25 at 9:40 A.M. revealed the following concerns: CNA #807 was hired on 09/24/00 and did not have an annual performance evaluation completed for 2024. CNA #816 was hired on 05/31/18 and did not have an annual performance evaluation completed for 2024; CNA #850 was hired on 04/04/24 and did not have a 90 day performance evaluation completed; CNA #873 was hired on 05/03/24 and did not have a 90 day performance evaluation completed. On 01/14/25 at 9:45 A.M. interview with HR #877 verified CNA #807, CNA #816, CNA #850 and CNA #873 did not have the required performance evaluations completed as required. Review of the facility policy titled Performance Evaluations, dated 01/10 indicated employee must receive a 90-day evaluation and an annual evaluation on or before their anniversary date.

Based on observation, interview, test tray, packaging label review, portion chart review and policy review the facility failed to ensure the menu and menu spreadsheet were followed to ensure accurate portions and food items were served. This had the potential to affect all residents. The facility census was 49. Findings include: Review of the menu for 01/08/25 revealed sauce with meatballs, rigatoni pasta, and Italian blend mixed vegetables. Review of the menu diet spreadsheet revealed: Regular diet: three each meatballs, four ounce (oz) spoodle of rigatoni and Italian vegetables Mechanical soft diet: #8 scoop of ground meatballs, 1/2 cup of carrots Pureed diet: three #30 scoop (black handle provide one ounce each) for pureed meatballs and #8 scoop (gray handle provide four ounces) for the pureed pasta Observation of tray line on 01/08/25 at 11:48 A.M. revealed Dietary [NAME] (DC) #801 observed to plate three meatballs for the regular diet using a black slotted spoon. DC #801 used the same black slotted spoon to serve the mechanical soft meatballs and serve the Italian blend mixed vegetables for the mechanical soft diet. No carrots were observed on the tray line. Observation on 01/08/24 at 12:34 P.M. of the test tray with Dietary Manager (DM) #806 of the regular diet meatballs and rigatoni revealed two meatballs. DM #806 verified there were only two meatballs and stated the recipe called for two but verified the menu diet spread sheet called for three meatballs. Observation on 01/08/25 at 12:40 P.M. revealed last meal cart (dining room) being pushed out of kitchen. Observation of tray line at the end of service with DC #801 revealed the black slotted spoon did not indicate a serving size and was used to serve the meatballs and mechanical soft meatballs. DC #801 verified and stated she did not know what the serving size was for the black slotted spoon. At this time DM #806 came verified she was unable to say what serving size the black slotted spoon provided. Further observation of tray line revealed a blue handled scoop in the pureed pasta and a red handled scoop in the pureed meatballs. DM #806 stated the blue handled scoop was a #16 and the red handled scoop was a #24. DM #806 verified the serving utensils for the mechanical soft meatballs, pureed meatballs, and pureed pasta were not the correct servings. Interview on 01/08/24 at 12:48 P.M. with DC #801 and DM #806 revealed DC #801 only provided one serving each for the pureed pasta and pureed vegetables. DM #806 stated the recipe for the regular meatballs were for homemade meatballs and it called for two meatballs for the serving size. DM #806 stated the meatballs used for the meal were frozen. DM #806 verified the packaging label for the frozen meatballs called for three meatballs for a serving and the menu diet spreadsheets also indicated three meatballs. DC #801 and DM #806 both stated they had carrots available and verified carrots were not prepared or served for the mechanical soft diet. Review of the portion control chart revealed the #30 scoop (black handle) provided one oz serving. The #24 scoop (blue handle) provided one 1/3 oz serving. The #8 scoop (gray handle) provided four oz serving. Review of the packaging label for the cooked, frozen meatballs revealed a serving was three meatballs. Review of the facility policy titled Portion Control, undated revealed individuals will receive the appropriate portions of food as outlined on the menu. Control at the point of service is necessary to assure that accurate portion sizes are served. Review of the facility policy titled Accuracy and Quality of Tray Line Service, undated revealed the director of food and nutrition services or designee will be responsible for assuring that all foods needed for meal assembly are present at the appropriate time. The meal will be checked against the therapeutic diet spread sheet to assure that foods are served as listed on the menu.

Based on observation, review of a dietary department snack list, and interview, the facility failed to ensure snacks were provided at bedtime. This affected Residents #6, #9, #10, #14, #18, #25, and #37 but had the potential to affect all 48 residents residing in the facility. Findings include: During a resident council meeting on 01/07/25 between 2:06 P.M. and 2:20 P.M. Residents #10, #14, #18, and #25 indicated bedtime snacks were not offered. If snacks were requested, staff would tell them none were available. On 01/08/25 at 12:48 P.M., Dietary Manager (DM) #806 stated upon admission she interviewed residents to determine if they wanted a snack then a label was made for them. If a resident changed their mind about wanting snacks it was the responsibility of the residents or nursing staff to ensure the dietary department was aware. Review of the snack labels revealed Resident #10 was to receive milk for bedtime snack. Residents #14 and #18 did not have a label for a snack. Resident #25 was to receive a plain peanut butter sandwich. On 01/08/25 at 4:27 P.M., Dietary Aide #815 stated in addition to snacks that were sent for specific residents each unit received an extra eight to 10 snacks at night. Dietary Aide #815 stated he assumed aides were passing the snacks. Sometimes snacks were returned to the kitchen the following morning. On 01/09/25 at 12:05 P.M., a tray sitting on the 100 hall nursing stated revealed three snacks with labels dated 01/08/24 at bedtime. The snacks were unopened. There was no documentation of refusal of the snacks. Among the snacks was a peanut butter sandwich for Resident #9, a peanut butter and jelly sandwich for Resident #6 and a pack of peanut butter and cheese crackers for Resident #37. On 01/09/25 at 12:37 P.M., Licensed Practical Nurse (LPN) #838 stated she was unaware if or where intake of bedtime snacks was recorded. Residents did not receive snacks on day shift. On 01/09/25 at approximately 2:35 P.M., Dietary Manager #806 stated staff did not always inform her if a resident refused a snack. Sometimes the snacks were returned to the kitchen with no documentation as to why they were not consumed. Interview on 01/09/25 at 1:52 P.M., Resident #37 stated that he has never been offered snacks and would like to be offered one in the evening. On 01/09/25 at 3:55 P.M., Activity Director #816 (had been covering as a dietary manager until DM #806 was recently hired) stated there was no documentation of whether residents had snacks offered and if they accepted or refused them. Activity Director #816, Dietary Manager #806 and the Administrator were all present. No explanation was provided regarding discrepancies in what residents reported and the information provided by staff. Activity Director #816 stated in addition to the residents who received snacks labeled specifically per their request, additional snacks were provided in the event another resident wanted a snack. None of the three staff members were working when the snacks were delivered to the units and could not state with certainty that they were offered/provided.

Based on observation, interview, and review of the facility policy and procedure the facility failed to maintain the ice machine in a clean and sanitary manner. This had to potential to affect all residents except one resident (#36) who had a physician order for no fluids. The facility census was 49. Findings include: Observation during the tour of the kitchen on 01/06/25 from 9:17 A.M. to 9:30 A.M. with Dietary Manager (DM) #806 revealed the ice machine located outside of kitchen, on the outside of each side of the ice machine was a moderate amount of a white substance running down each side. Interview on 01/06/24 between 9:17 A.M. and 9:30 A.M., with DM #806 verified the white substance and stated when they place the water softener it will help eliminate that substance. DM #806 stated she believed the ice machine was cleaned monthly. Review of the facility policy titled Food Safety: Ice, undated revealed ice machines and containers will be cleaned and sanitized on a regular basis.

Based on review of staffing schedules and time sheets and interview, the facility failed to submit accurate data related to direct care staff to the Centers for Medicare and Medicaid Services (CMS) from July 2024 through September 2024. This had the potential to affect all 48 residents. Findings include: On 12/30/24 at 6:40 A.M., Certified Nursing Assistant (CNA) #840 reported the Residential Care Facility (RCF) hall had no separate staff between the hours of 11:00 P.M. to 7:00 A.M. On 12/30/24 at 6:45 A.M., Registered Nurse (RN) #819 stated there was no separate staff for the RCF form 11:00 P.M. to 7:00 A.M. Nursing facility staff cover the RCF during those hours with two nurses splitting the hall. Nursing assistants attended to personal needs of the residents of the RCF. Review of schedules for the RCF from July 2024 through September 2024 revealed there were no RCF staff scheduled from 11:00 P.M. to 7:00 A.M. There were 34 other shifts in which the RCF schedule did not reflect separate staff on the RCF. On 12/31/24 at 9:30 A.M., staffing and scheduling was discussed with Human Resources (HR) manager #906 and the Administrator revealed throughout every day the nurses from the nursing facility were also assigned 1/2 of the RCF residents. During the times when there was no resident aide to care for residents in the RCF, the nursing facility residents were assigned to cover. Payroll records were used to submit staffing information to CMS. All hours direct care staff worked were submitted to CMS for evaluation of the staffing. There was no subtraction of hours worked in the RCF.

Based on observations, record review, review of census sheets, policy review and interview, the facility failed to implement isolation protocol for a resident with clostridium difficile and failed to position catheters in a manner to decrease the possibility of urinary tract infections. This had the potential to affect all 48 residents. Finding include: 1. On 12/30/24 at 10:19 A.M., Resident #37 gave permission for a surveyor to enter his room. After entering the room, Resident #37 reported to the surveyor he had tested positive for clostridium difficile. No signs were posted regarding Resident #37 being on isolation. On 12/30/24 at 10:25 A.M., Activity Assistant #842 carried mail into Resident #37's room without donning personal protective equipment (PPE). Upon exiting Resident #37's room, Activity Assistant #842 stated she was aware Resident #37 had c diff and verified there was no signs for isolation posted. Activity Assistant #842 stated she did not need to wear PPE for residents with c diff when she was delivering mail. On 12/30/24 at 11:38 A.M., two signs were posted on Resident #37's door. One indicated providers and staff were required to don gloves and gown before entering the room and remove them before exiting the room. The second sign for special contact precautions indicated hand sanitizer was not to be used to cleanse hands. Hands were required to be washed with soap and water. On 12/31/24 at 8:40 A.M., Certified Nursing Assistant (CNA) #846 verified she had entered Resident #37's room to remove his meal tray but had not donned gloves and a gown. The tray was carried to the meal cart and placed on it. No hand hygiene was performed. CNA #846 was interviewed at that time and stated she did not wear PPE when just entering the room unless providing direct care and she had only obtained his tray. After addressing hand hygiene, CNA 846 used alcohol based hand sanitizer to clean her hands. Review of Resident #37's medical record revealed diagnoses of enterocolitis due to clostridium difficile (diagnosis list indicated a date of 08/27/24), need for assistance with personal care, bipolar disorder, quadriplegia, and obsessive-compulsive disorder. A nursing note dated 12/19/24 at 1:49 P.M. indicated Resident #37 complained of severe diarrhea which had an odor to it. The physician was contacted and an order was received to obtain a stool specimen to rule out clostridium difficile. A laboratory report indicated a stool sample was collected on 12/27/24. On 12/28/24, the laboratory specimen was determined to be positive for c diff and reported. A nursing note dated 12/29/24 at 10:50 A.M. indicated Resident #37 tested positive for c diff. New orders were received for vancomycin (antibiotic) 125 milligrams (mg) four times a day for ten days. Resident #37 was notified. On 12/30/24, an order was written for contact isolation precautions with all services being provided in his room for c diff infection. The care plan did not address current isolation/antibiotic use. On 01/08/24 at 11:08 A.M., Certified Nursing Assistant (CNA) #836 and CNA #828 were observed providing perineal care to Resident #37 and transferring Resident #37 into a chair with a mechanical lift they had taken into the room prior to providing care. On 01/08/25 at 1:50 P.M., CNA #828 stated the mechanical lift used to transfer Resident #37 was shared among other residents. CNA #828 stated bleach wipes were used to disinfect the lift after it was used to transfer Resident #37. On 01/08/25 at 2:05 P.M., while looking through Resident #37's isolation cart no wipes were found. Maintenance director #804 verified there were no wipes in the cart then went to another isolation cart and stated staff use the sanicloth wipes. While reviewing the information regarding what the sanicloth wipes were effective against, Maintenance Director #804 stated clostridium difficile was not listed. Maintenance Director #804 left and returned with a spray bottle of bleach cleaner which indicated it was effective against c diff stating it was what housekeeping used to clean rooms of residents with c-diff but could not state definitively what aides or nurses were supposed to use for shared equipment before removing it from Resident #37's room. CNA #828 was passing through the area and stated there were no bleach wipes in the cart when they finished transferring Resident #37 so she used the sanicloth wipes. Maintenance Director #804 provided a canister of bleach wipes which indicated it was effective against c diff. On 01/08/24 at 6:00 P.M., due to their being no order for isolation for Resident #37 prior to 12/30/24, the Director of Nursing searched through what the Administrator referred to as a communication board from 12/19/24 through 12/30/24 in the surveyor's presence and verified she was unable to locate any evidence of when Resident #37 was placed in isolation after symptoms of c diff were exhibited on 12/19/24. Review of the facility's C diff policy (not dated) indicated a physician's order would be obtained to initiate isolation precautions if a resident was identified to have active c diff or the resident had three or more loose stools, unrelated to laxative or other known source, in a 24 hour period. Signage should be placed on the resident door, directing staff and visitors to speak with a nurse before entering. Designated equipment items were to be maintained in the resident's room throughout the duration of the isolation precautions. Bleach wipes or 1/10% bleach solution were to be kept in a dirty utility closest to the resident's room to clean any other equipment that could not be designated such as a hoyer lift. Hands should be washed with soap and water as opposed to utilizing hand sanitizers in caring for residents with known C diff as standard sanitizers did not kill the spores. If disposable trays and utensils were not utilized trays were to be bagged and sanitized. 2. Review of Resident #97's medical record revealed diagnoses included osteomyelitis, type two diabetes mellitus with a foot ulcer, obstructive and reflux uropathy, and UTI. An admission assessment dated [DATE] revealed Resident #97 had a urinary catheter with cloudy urine. On 01/06/25 at 12:30 P.M., Resident #97 was sitting in the 100 hall dining/ common area. The urinary catheter tubing was on the floor. Staff were present in the room. At 12:33 P.M. staff approached Resident #97 to wipe ketchup off his face. Catheter tubing remained on the floor. At 2:40 P.M., Resident #97 was propelling himself in the wheelchair with the catheter bag cover and catheter tubing dragging on the floor. On 01/06/25 at 2:48 P.M. the observation was shared with Licensed Practical Nurse (LPN) #838 who acknowledged she would have to fix it. Review of the facility's Foley Catheter Care policy (not dated) instructed staff to position the foley catheter bag below the level of the bladder and to keep the bag and tubing off of the floor at all times. 28701 3. Review of Resident #10's medical record an admitted [DATE] with diagnoses that included chronic osteomyelitis, paraplegia, pressure ulcer to the sacrum and diabetes mellitus. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment with a reference date of 12/02/24 revealed Resident #10 had an independent and intact cognition level and utilized an indwelling urinary catheter. Observation on 01/13/25 at 9:31 A.M. revealed Resident #10 asleep in bed with a urinary catheter drainage bag and tubing lying on the floor next to the bed. Review of the undated facility policy titled Foley Catheter Care revealed staff are to keep the urinary drainage bag and tubing off of the floor at all times. On 01/13/25 at 10:15 A.M. Certified Nurse Aide (CNA) #853 verified Resident #10's urinary drainage bag and tubing were lying on the floor.

Based on observations, interview, and record review the facility failed to ensure a clean, sanitary and functional environment. This affected 14 residents (#2, #3, #10, #13, #18, #19, #29, #31, #38, #47, #48, #49, #50, and #144) of 49 residents residing in the facility. The facility census was 49. Findings include: Observation on 12/30/24 at 11:25 A.M. of Residents #29 and #31's bathroom floor revealed a yellow/brown ring around the commode. Observation on 01/06/25 at 11:03 A.M. of Residents #2 and #19's room revealed multiple gouged areas in the bathroom wall, next to the shower, and trash was on the floor. Observation on 01/06/25 at 11:58 A.M. of Residents #47 and #144's room revealed the shower floor had a large, dried dirt stain and dried dirt stains on the bathroom floor and throughout room. Interview at the time of the observation, with Resident #47, revealed the floors were dirty and hadn't been mopped. Interview on 01/06/25 at 2:25 P.M. with Resident #50 revealed the right side bed rail (on their bed) was stuck and doesn't come up. Resident #50 stated it has been that way since she's been at the facility. Observation on 01/6/25 at 3:30 P.M. of Residents #29 and #31's bathroom revealed yellow/brown discoloration remains around floor surrounding commode. Interview on 01/06/25 at 10:51 A.M. with Residents #48 and #49 revealed they had housekeeping concerns. Residents #48 and #49 stated they take trash out and dust but the floors had not been mopped, especially the bathroom floor, in two weeks. Observation at the time of the interview revealed the toilet had bowel movement on the inside back of toilet bowl and the floors in the bathroom and throughout the residents' room were dirty with marks throughout. Observations on 01/07/25 between 11:24 A.M. and 11:38 A.M. of Residents #48 and #49's room and bathroom revealed the floors were still dirty and bowel movement was still in the inside back of the toilet bowl. Observation of Resident #18 and #38 revealed the floors were dirty with dirt stains. Residents #2 and #19 revealed the floors were dirty throughout with dirt stains. Interview at 11:31 A.M. with Resident #19 stated they don't always clean the floor and the last time it was done was couple of days ago, sometime over the weekend. Observation on Residents #10 and #13's room revealed tissues on the floor and a glove near Resident #10's window, by the bed. The floor overall was dirty with dirt stains. The bathroom floor, sink, and walls were dirty and had various stains. Interview on 01/07/25 from 11:46 A.M. to 12:02 P.M. tour with Resident Assistant (RA) #803 stated she helps out in housekeeping in the nursing home. During tour RA #803 verified the identified findings in Resident's #2, #3, #10, #13, #18, #19, #38, #47, #48, #49, and #144. At 11:55 A.M. the Director of Maintenance (DOM) #804 joined the tour and stated he has had some staffing issues in housekeeping. Observation of Resident #50's bed rail, DOM #804 verified the right side bed rail would not come up. DOM #804 stated he was not aware of it but will get it fixed. Follow up tour on 01/07/25 from 1:41 P.M. to 1:47 P.M. with DOM #804 verified the various holes and walls in disrepair in Residents #2, #19, and #3 rooms. DOM #804 stated the painter was let go and as he was able to get housekeeping staff they had to prioritize. DOM #804 verified the yellowing/brown stain around the toilet of Residents #29 and #31's room and stated it may be stains or it may not be. DOM #804 stated the floors of this room were recently stripped and waxed prior to the residents moving in. Review of policy Housekeeping Policy/Procedure, dated 12/28/13 revealed the facility will be maintained and cleaned to meet a home like environment for our residents. Review of policy Housekeeping Cleaning and Disinfection of Environmental Surfaces, revised 01/11/21 revealed housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a daily basis, when spills occur, and when surfaces are visibly soiled. This deficiency demonstrates non-compliance investigated under Master Complaint Number OH00160455.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY: Based on observation, record review, review of a facility investigation, review of the facility Elopement policy and procedure, interviews with staff, a family member and police detective the facility failed to provide adequate supervision and interventions to prevent Resident #4, who was cognitively impaired, utilized a rollator walker for mobility, was frequently exit seeking and identified at risk for elopement, from exiting the facility without staff knowledge. This resulted in Immediate Jeopardy and the potential risk for actual harm, injury or death on [DATE] at 5:28 P.M. when Resident #4 left the facility via an alarmed door, without staff knowledge. Although, the door the resident exited did alarm as designed, Dietary Aide (DA) #103 reset the alarm at 5:35 P.M. without investigating to determine why the door was alarming. On [DATE] at 5:58 P.M. Resident #4 was found by a community member approximately 0XXX,d+[DATE].3 miles from the facility, without his rollator walker, attempting to enter a parked car. The community member contacted the police, and the police and the resident's granddaughter escorted the resident back to the facility. The staff were unaware the resident had eloped from the building at the time he was returned. In addition, a concern that did not rise to the level of Immediate Jeopardy was identified related to the facility's failure to provide appropriate supervision and interventions for Resident #42 which resulted in this resident eloping from the facility on [DATE]. This affected two residents (#4 and #42) of three sampled residents reviewed for elopement. The facility census 41. On [DATE] at 5:09 P.M. the Administrator was notified Immediate Jeopardy began on [DATE] at 5:28 P.M. when Resident #4, who displayed exit seeking behaviors, exited the facility via the front door without staff knowledge. The front door had a keypad and a 15 delayed second push release on it and a keypad to override the alarm. Dietary Aide (DA) #103 heard the alarm once he reached the hall leading to the main entrance restroom and disabled it at 5:35 P.M. DA #103 did not investigate the source of the alarm or report the alarm to any direct care/nursing staff. Resident #4 was subsequently located on a residential street attempting to get into a parked vehicle and was returned to the facility prior to the facility being aware he had exited. The Immediate Jeopardy was removed and the deficiency corrected on [DATE] when the facility implemented the following corrective actions: On [DATE] at 6:07 P.M. Resident #4 was returned to the facility following assistance from Police Detective #109 and the resident's granddaughter. The resident was placed on one on one supervision from staff until he was discharged from the facility on [DATE] at 5:48 P.M. On [DATE] at 6:07 P.M. the facility in-house census was 40 residents. A headcount was performed by Registered Nurse (RN) #108 and RN #235 which confirmed all 40 residents were accounted for once Resident #4 returned to the facility. On [DATE] at 6:10 P.M. RN # 235 obtained vital signs, completed a head to toe assessment, pain assessment, skin assessment, and elopement assessment for Resident #4. No abnormalities were noted. No physical distress was noted. The resident was placed on one on one (1:1) supervision to maintain safety immediately upon return to the facility. A schedule was assembled to provide consistent 1:1 by staff from [DATE] at 6:10 P.M. until discharge [DATE] at 5:48 P.M. Various STNAs provided this continual coverage. On [DATE] 6:30 P.M. Activities Director #218 verified the front door alarm was functioning correctly and was audible from the employee breakroom which was in direct proximity to the employee work areas. On [DATE] at 6:59 P.M. RN #235 notified Resident #4's wife and Physician #300 of the elopement. On [DATE] at 7:00 P.M. the Director of Nursing (DON) initiated education for 15 staff present in the building which included two RNs, two Licensed Practical Nurses (LPNs), eight State tested Nursing Assistants (STNAs), two dietary aides, and one activity aide). Staff working were educated on the facility elopement policy, elopement drill policy, appropriate response when answering alarms, wandering, and resident safety to include making frequent rounds when not delivering resident care, all staff answering call lights, and staff continuing to have a frequent presence in the hallways to ensure responses to alarms including nurses during medication administration. On [DATE] at 8:00 P.M. the DON completed an elopement assessment for all 40 residents in the facility. No new residents were identified to be at risk for elopement. On [DATE] at 8:00 P.M. the DON educated 37 staff (two RNs, eights LPNs, 12 STNAs, one social service member, five dietary staff, one admissions staff, two maintenance staff, one laundry aide, one transport staff, one business office staff and three housekeeping staff) by group text message on the updated elopement policy and procedure. The policy and procedure was updated by RN #301 on [DATE]. The update included completing a head count whenever staff were unable to decipher the cause of a facility alarm and focus areas of response time and monitoring the exit areas routinely. New staff would be educated by Human Resources on the elopement policy and procedure upon hire, annually, and as needed. On [DATE] at 8:35 P.M. all 52 facility staff received education on wandering, elopement, responding to alarms and resident safety in person or via phone by the DON. Any staff on leave were not permitted to work after [DATE] until they received education on their next scheduled workday. In addition, Dietary Aide #103 received a verbal counseling by the Administrator on [DATE]. On [DATE] at 3 P.M. the DON reviewed all resident care plans for elopement risk and appropriate interventions. LPN #200 updated Resident #4's care plan to reflect the resident was placed on 1:1 supervision. On [DATE] at 10:00 A.M. Maintenance Director #233 assessed all door alarms to ensure the alarms were functioning correctly. No issues were identified. On [DATE] Maintenance Director #233 contacted the alarm company regarding the facility alarm system. The system was determined to be at maximum volume. A quote to install additional door monitoring systems at each nurse's station from the alarm company was obtained, approved, and awaiting a tentative date of installation. On [DATE] a statement from Activities Director #218 verified the front door alarm was audible in resident care areas on the [NAME] Hall. Staff interviews reflected the alarm was audible prior to and following incident with Resident #4. STNA #100 and STNA #101 responded to the alarm at 4:30 P.M. as they approached from the [NAME] Wing where the alarm could be heard. On [DATE] a plan for Human Resources Manager #303 to provide new hires and agency staff with education on wandering, elopement, and resident safety in writing and verbally reiterated by HR during general orientation tour, onsite was implemented. On [DATE] at 11:00 A.M., the Director of Nursing and Administrator were educated by Regional Quality Assurance (QA) RN #301 on reviewing all referrals and provided education to deny any referrals for residents who were identified as an elopement risk. Beginning [DATE] a plan for the Administrator/designee to complete elopement drills to ensure all staff responded appropriately on random shifts two times per week for four weeks was implemented. Beginning [DATE] a plan for the Director of Nursing/Designee to review three random residents' nurses notes daily to ensure any documented wandering or elopement behaviors were addressed timely. Beginning [DATE] a plan for the DON/Designee to conduct interviews/audits of three random staff members from various shifts and departments related to elopement/wandering. This would continue five times a week to monitor staff competency of elopement prevention for four weeks. Beginning [DATE] a plan for the Maintenance Director/Designee to conduct audits on three door alarms three times a week for four weeks, then randomly thereafter was implemented. Beginning [DATE] a plan for the Administrator to review the current Facility Assessment to ensure it identified that no residents who were at risk for elopement could reside in the facility. On [DATE] the Quality Assurance Performance Improvement (QAPI) team reviewed and interpreted all investigation and audit findings as well as completed a root cause analysis. A plan for all ongoing audits and findings to be discussed at the monthly QAPI meeting for a minimum of three months or until a pattern of compliance was maintained. Findings include: 1. Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, muscle wasting and atrophy, need for assistance with personal care, muscle weakness, difficulty walking, and hypertension. Review of Resident #4's care plan, dated [DATE] revealed the resident was at risk for falls and potential injury related to impaired gait and mobility and level of assistance required for transfers. Contributing factors included weakness, gait, strength, and muscle endurance. Interventions included sufficient lighting, common items within reach, provide rest periods, room close to nurse's station and transfer with one assist. Review of Resident #4's quarterly Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed the resident had a moderate cognitive impairment, required supervision with one-person physical assistance for walking in the corridor, utilized a walker, and was unsteady but able to stabilize without staff assistance. The MDS did not indicate the resident had wandering behaviors during the assessment period. Review of Resident #4's elopement evaluation, dated [DATE] revealed the resident was at moderate risk for elopement. The assessment revealed the resident attempted to open exit doors, hovered near exit doors, was oriented to self only, and was ambulatory. Review of Resident #4's Fall Risk Evaluation -V2, dated [DATE], revealed the resident was at risk for falls due to impaired cognition, Alzheimer's/dementia, was visually impaired, wandered, was non-compliant, restless, had an unsteady gait, used an assistance device for mobility, had bladder incontinence, and received anti-anxiety medication. Review of Resident #4's care plan, dated [DATE], revealed the resident was at risk for elopement and wandering related to dementia, expressed intent to leave facility, impaired cognition, unawareness of safety needs, and attempting to follow visitors out the door. Interventions included assess risk factors, attempt to involve in decision-making, encourage participation in activities, family conference to discuss resident attempts to leave, follow facility elopement procedures, monitor, and report changes in behavior (restlessness, pacing, etc.), provide diversional activities of interest as needed, and redirect as needed. Review of the resident's progress notes from [DATE] through [DATE] revealed no documentation regarding the resident's exit seeking behavior(s) or the resident leaving the facility without staff knowledge. Review of the local Police Department, Ohio Uniform Incident Report dated [DATE], revealed on [DATE] at 5:58 P.M. Detective #109 was dispatched to a home on a residential street to investigate a gentleman who seemed confused, and who was trying to get into a (parked) car. The detective arrived on scene at 5:59 P.M. Upon arrival, the detective spoke to Resident #4, and he advised he lived at a nursing facility down the road. The resident seemed confused about most things, but the detective started to help him into his car to see if he did live at the facility. A young lady pulled up and advised that he was her grandfather. She gave him the resident's name and her name and advised he does stay at the facility down the lane. Observation of the facility's camera footage of the incident revealed on [DATE] at 5:18 P.M. Resident #4 walked to the main door and attempted to push it open. It did not open, and he walked away. At 5:20 P.M. State tested Nursing Assistant (STNA) #100 and STNA #101 were witnessed turning off the alarm to the main door. At 5:28 P.M. Resident #4 approached the door again, leaned against the door until it opened 15 seconds later. He exited the facility with his rollator walker. At 5:35 P.M. Dietary Aide #103 was observed walking over to the main door, turning off the alarm, pulling the door shut, and then returning to work. He did not walk out the front door to investigate what set the alarm off. At 6:07 P.M. Resident #4 was observed returning to the facility without his rollator walker. The DON confirmed the observations of the footage during an interview on [DATE] at 4:00 P.M. Review of the facility investigation of the incident on [DATE] at 5:28 P.M. revealed Resident #4 left the facility through the main door. The resident exited the building with his rollator and walked down the drive to the main road. As part of the facility investigation, the following staff statements were obtained: A handwritten statement dated [DATE], completed by STNA #104, revealed the last time she saw Resident #4 (on [DATE]) was after dinner when she and another STNA (not identified) caught him trying to go out the back door by the dumpsters. The statement included the other STNA and I got him back in and made sure the door was latched, then he went up the hall towards [NAME] Hall. A handwritten statement dated [DATE], completed by STNA #107, revealed Resident #4 went missing (on [DATE]) but she did not hear an alarm sound. At 6:10 P.M. a family member and the police returned the resident to the facility without his walker. She reported the last time she saw the resident was when she provided him with his dinner tray. The time was not indicated. An undated handwritten statement, completed by STNA #101, revealed the last time she saw Resident #4 (on [DATE]) was when she and STNA #105 went outside with the dinner people. (the facility did not indicate what dinner people meant). STNA #105 was telling the resident to go inside while he was trying to come outside. The STNA's statement also included, shut the alarms off at least 4:30ish and I was with a kitchen girl. Nobody was around-we looked. A handwritten statement dated [DATE], completed by STNA #105, revealed the last time she saw Resident #4 (on [DATE]) was when he was trying to get out of the door where the dumpsters were when someone was going out (of the building); he was trying to push his way out. She and STNA #104 got him in (the building) and he started walking towards the [NAME] Hall (the hall located near the front entrance). Interview on [DATE] at 11:46 A.M. with STNA #104 revealed she was one of the STNAs assigned to care for Resident #4 on [DATE]. She stated the resident had always wandered since his admission to the facility. She went on to say the resident was easily redirected away from the exit doors. She stated on [DATE] the resident attempted to exit one of the back doors by the dumpster as someone else was walking out. She was able to redirect him back inside and he started walking to the [NAME] Hall. She continued that he was able to exit through those doors (the main door, also known as the west door) although no one in the facility had seen him go or knew he was missing until the police brought him back. She confirmed she did not hear the alarm go off. Interview on [DATE] at 1:22 P.M. with Dietary Aide (DA) #103 revealed he worked on [DATE] and had heard Resident #4 went out the back door and he believed STNA #101 brought him back in. Shortly after that he stated he went to use the bathroom and heard the front door alarm sounding and went to the doors. DA #103 stated he peeked out but didn't go outside because he didn't see anything outside. Further interview revealed he was not sure what to do because he had not been briefed on elopement and did not know the facility procedures. He stated he turned off the alarm and went to the bathroom. When he returned to the kitchen, he stated he thought he said something to Dietary Aide #106 about turning off the alarm. DA #103 stated he later heard Resident #4 got out of the facility and the police had to bring him back. Interview on [DATE] at 3:34 P.M. with STNA #107 revealed she was assigned to Resident #4 on [DATE]. She continued that she was not aware Resident #4 left the building until the police returned him after 6:00 P.M. that night. She stated the resident frequently was exit seeking and she did not feel like the facility was equipped to care for residents like him (who were exit seeking). She stated she was not aware of his exit seeking behaviors that day. Interview on [DATE] at 3:48 P.M. with STNA #105 revealed the only interaction she had with Resident #4 was earlier in the day on [DATE] at around 1:00 P.M. to 2:00 P.M. She stated the resident was trying to exit the facility though the door by the dumpsters. The resident was directed back inside the building. She stated later in the day around 6:00 P.M. she answered a call from the police department asking if one of the facility's residents were missing. Further interview revealed, when leaving that night, she found Resident #4's rollator walker about halfway down the drive, beside the mental health facility that was located on the same road as the facility. She also stated she did not hear any alarms going off that day. Interview on [DATE] at 8:53 A.M. with Registered Nurse (RN) #108 revealed she was working on [DATE], was familiar with Resident #4 and knew he was an elopement risk. The RN denied hearing the door alarm or knowledge of him missing until the police called and said they had found a resident. RN #108 denied staff reporting to her Resident #4 was exit seeking on [DATE]. Telephone interview on [DATE] at 10:51 A.M. with Police Detective #109 revealed on [DATE] at 5:58 P.M. he received a call from a woman stating someone was trying to get into her car at the end of the street. He stated he arrived on scene at 5:59 P.M. and observed Resident #4 on the corner of the lane and the main street. The resident was able to point and indicated he lived down the lane. The resident's granddaughter also happened to arrive on scene at this time. The detective confirmed the resident did not have a walker and was confused. The resident's granddaughter put him in her car and drove him back to the facility while the detective followed. The staff at the facility were not aware the resident had left the building. Interview on [DATE] at 4:49 P.M. with Family Member #110 revealed she was driving down the road on [DATE] around 5:30 P.M. when she saw a police car and someone who looked like her family member. She pulled over and the police officer told her the family member was attempting to get into a parked car. Her family member (grandfather) appeared confused and did not have his walker with him. Family Member #110 indicated she took the resident back to the facility and stated she was very upset the facility did not know he was missing. Telephone interview on [DATE] at 12:38 P.M. with Certified Nurse Practitioner (CNP) #111 revealed she oversaw Resident #4's care while he was at the facility. The CNP revealed Resident #4 would not be safe to be outside alone due to poor cognition, unsteady gait, and noncompliance with his walker. Interview on [DATE] at 12:14 P.M. the Director of Nursing (DON) revealed she received a call on [DATE] at 6:20 P.M. from RN #235 stating Resident #4 had eloped from the facility and was brought back to the facility by the resident's granddaughter around 6:10 P.M. A complete assessment was done at the time of his return, and the resident was placed on one-on-one supervision. She stated at the time of the incident, the resident was fully dressed, and it was 73 degrees Fahrenheit outside. The DON stated it was normal behavior for Resident #4 to wander and he was an identified elopement risk. The DON stated an investigation was completed, and by looking at camera footage which determined the resident left the faciity on [DATE] at 5:28 P.M. through the main doors (front entrance). At 5:36 P.M. Dietary Aide #103 responded to the alarm, shut the door, and disabled the alarm without investigating the source of the alarm. She stated Dietary Aide #103 indicated in his statement he notified the [NAME] STNAs (not identified) of the alarm, but camera footage determined this to be untrue. Continued investigation revealed Resident #4 made it to the end of the drive leading to the main road and was found by police and returned around 6:10 P.M. that day. The DON verified the resident's risk for elopement plan of care was not implemented to prevent resident elopement and no additional supervision or interventions were attempted to prevent the resident from eloping. The resident was not safe to be outside of the facility unsupervised. The DON also stated DA #103 should have further investigated the door alarm and reported the door alarm to the appropriate staff. As a result, a verbal warning was issued to DA #103 for failure to report or investigate a door alarm. Review of DA #103's employee file revealed a disciplinary action Reviewed Notice of Corrective Action, dated [DATE]. Dietary Aide #103 received a verbal warning for shutting off door alarm without looking outside or alerting anyone. Prior to the incident, the most recent elopement education provided to DA #103 was on [DATE]. Review of the undated facility Elopement policy revealed residents who had been determined by the team to be as risk for elopement would receive interventions as the team deems necessary. This may include surveillance checks, a wander guard device (a special bracelet worn by at risk residents to alert staff when the resident is near or attempting to exit an exterior door), distraction method, or alternate placement. The policy did not address responding to door alarms. 2. Review of the closed medical record for Resident #42 revealed an admitted [DATE] with diagnoses including dementia, metabolic encephalopathy, muscle wasting and atrophy, need for assistance with personal care, difficulty with walking, and disorientation. The resident utilized a wheelchair for movement on and off the unit. The resident was discharged to another facility on [DATE]. Review of Resident #42's admission MDS 3.0 assessment, dated [DATE], revealed the resident had moderate cognitive impairment and required extensive assistance of two staff for transfers and locomotion off the unit. Review of Resident #42's Elopement Assessment, dated [DATE], revealed the resident was a moderate risk for elopement due to demonstrating exit seeking behaviors such as packing belongings, stating they want or need to leave, searching for exit doors, putting on coat, only being orientated to self, and utilized a wheelchair for mobility. Review of a facility investigation dated [DATE] revealed STNA #253 was passing dinner trays and noticed Resident #42 was missing. The missing resident code (verbal notification to all staff) was called at 5:11 P.M. and the resident was found outside near the dumpster four to five minutes later by RN #108. No injuries were noted, all staff were trained on the Elopement and Missing Person Policy, he was assessed, and placed on a one on one until his discharge. The investigation revealed a locked door had been kept open and the resident had been able to exit through this door. The facility was unable to determine if the door was unlocked or propped open allowing the resident to exit the facility unsupervised. The facility investigation included staff statements. A handwritten statement by STNA #253 revealed (on [DATE]) she started passing dinner trays at 5:00 P.M. In the middle of passing dinner trays, she saw Resident #42 at the main entrance of the building. When the STNA got to the resident's room he was not there. An elopement was called at 5:11 P.M. after the STNA checked the rooms and could not find the resident. The STNA stated she started to look outside and found the resident by the dumpsters at 5:15 P.M. Review of a handwritten statement by RN #108 revealed she was alerted Resident #42 was missing (on [DATE]) at dinner time. A search was started, the resident was found outside by the dumpsters and was only missing for approximately four to five minutes. No injuries were noted. Interview on [DATE] at 12:14 P.M. with the DON revealed on [DATE] Resident #42 was able to exit the facility through a door that had not been locked and was open. The resident was gone for four to five minutes and had no injuries when he was found. Following the incident, signs were placed on all the doors to keep them locked and always shut. The DON stated she verbally trained all staff on keeping the doors shut and locked, on the elopement and missing persons policy and Resident #42 was placed on one-on-one supervision until he was discharged from the facility on [DATE]. Review of the undated facility Elopement policy revealed residents who had been determined by the team to be as risk for elopement would receive interventions as the team deems necessary. This may include surveillance checks, a wander guard device (a special bracelet worn by at risk residents to alert staff when the resident is near or attempting to exit an exterior door), distraction method, or alternate placement. The policy did not address responding to door alarms. This deficiency represents non-compliance investigated under Complaint Number OH00143070.