Every finding on record at Wayside Farm Inc

Based on review of the facility's nursing schedules and interview, the facility failed to ensure a Registered Nurse (RN) for at least eight consecutive hours on 07/25/26. This had the potential to affect all 89 residents in the facility. Findings include:Review of daily staffing schedules, daily posted staffing, and master schedule revealed there was no documented evidence of RN coverage for at least eight consecutive hours on 07/25/26. On 07/29/26 at 3:57 P.M., an interview with the Director of Nursing (DON) verified the master schedule indicated there was no RN scheduled on 07/25/26. On 07/29/26 at 4:39 P.M., an interview with the DON verified the facility did not have an RN on-site in the facility on 07/25/26. The DON said there was a RN unit manager on call, but she was not physically on-site.

Based on medical record review, observation, interview, review of manufacturer guidelines, and review of the facility policy, the facility did not ensure insulin was dated when opened. This affected four (Residents #1, #56, #67, #69) out of five residents reviewed for properly stored insulin. This had the potential to affect eight additional (Residents #15, #39, #49, #57, #60, #65, #71, and #85) identified by the facility as also receiving insulin. The facility census was 89.Findings include: 1. Review of the medical record for Resident #69 revealed an admission date of 04/18/23 with diagnoses including diabetes and chronic obstructive pulmonary disease (COPD). Review of the care plan dated 04/19/23 revealed Resident #69 had diabetes. Interventions included diabetes medications as ordered, fasting blood sugar as ordered by the physician, and monitoring for signs of hypo and/or hyper glycemia. There was nothing in the care plan regarding ensuring insulin was dated after it was opened. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #69 was cognitively intact and received insulin. Review of July 2026 physician's orders revealed Resident #69 had the following orders: lispro (fast acting) insulin 100 units per milliliter (ml) inject subcutaneously (sq) as per sliding scale including two units for a blood sugar between 101 and 150 and glargine (Lantus) (long acting) insulin 100-unit pen inject 26 units sq at bedtime. Observation on 07/28/26 at 7:57 A.M. revealed Licensed Practical Nurse (LPN) LPN #529 administered two units of lispro insulin to Resident #69's left arm according to the sliding scale as his blood glucose was 138. The lispro insulin pen was not dated as to when it was opened.An interview on 07/28/26 at 8:02 A.M. with LPN #529 verified the lispro insulin was not dated as to when it was opened, and that she did not check for a date of when the pen was opened prior to the administration of the insulin. Observation on 07/28/26 at 8:06 A.M. revealed Resident #69 also had a glargine (lantus) insulin pen that was opened but not dated in the Lower-Level medication cart. An interview on 07/28/26 at 8:06 A.M. with LPN #529 verified Resident #69's Lantus insulin pen was opened and not dated as to when it was opened. 2. Review of the medical record for Resident #67 revealed an admission date of 12/27/16 with diagnoses including diabetes and asthma. Review of the care plan dated 03/29/23 revealed Resident #67 had diabetes. Interventions included diabetes medications as ordered, fasting blood sugar as ordered by the physician, and monitoring for signs of hypo and/or hyper glycemia. There was nothing in the care plan regarding ensuring insulin was dated after it was opened. Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #67 was cognitively intact and received insulin. Review of July 2026 physician's orders revealed Resident #67 had the following orders: Lantus Solostar 100 unit per ml insulin pen inject 30 units sq at bedtime and 46 units sq in the morning. She also had an order for lispro 100 unit per ml insulin pen inject eight units sq before breakfast and ten units sq before lunch and dinner. Observation on 07/28/26 at 8:06 A.M. revealed Resident #67's lispro insulin pen and Lantus insulin pens were opened but not dated in the Lower-Level medication cart. An interview on 07/28/26 at 8:06 A.M. with LPN #529 verified Resident #67's Lispro and Lantus insulin pens were opened and not dated. 3. Review of the medical record for Resident #56 revealed an admission date of 11/12/19 with diagnoses including diabetes and hypertension. Review of the care plan revised last 10/31/23 revealed Resident #56 had diabetes. Interventions included administering medications as ordered, encouraging compliance with diet, and monitoring blood glucose as ordered. There was nothing in the care plan regarding ensuring insulin was dated after it was opened. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #56 had impaired cognition and received insulin. Review of the July 2025 physician's orders revealed Resident #56 had the following order: Lantus Solostar 100 unit per ml insulin pen inject 36 units sq at bedtime.Observation on 07/28/26 at 8:06 A.M. revealed Resident #56's Lantus insulin pen was opened but not dated in the Lower-Level medication cart. An interview on 07/28/26 at 8:06 A.M. with LPN #529 verified Resident #56's Lantus insulin pen was opened but not dated. 4. Review of the medical record for Resident #1 revealed an admission date of 07/16/19 with diagnoses including diabetes and acute respiratory failure. Review of the care plan last revised 03/29/23 revealed Resident #1 had diabetes. Interventions included diabetes medication as ordered and fasting serum blood sugar as ordered. There was nothing in the care plan regarding ensuring insulin was dated after it was opened. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #1 had intact cognition and received insulin. Review of the July 2026 physician's orders revealed Resident #1 had the following order: lispro 100 unit per ml pen inject 18 units sq one time a day and inject 32 units sq two times a day. Observation on 07/28/26 at 8:06 A.M. revealed Resident #1's Lispro insulin pen was opened but not dated in the Lower-Level medication cart. An interview on 07/28/26 at 8:06 A.M. with LPN #529 verified Resident #1's lispro insulin pen was opened but not dated. Review of the facility policy labeled Labeling of Medication Containers, dated as last revised April 2019, revealed all medications maintained in the facility were to be properly labeled in accordance with state and federal regulations. Labels for individual resident medications include necessary information such as resident name, prescribing physician name, name, address, telephone number of the issuing pharmacy, name, strength and quantity of the medication, prescription number, date medication was dispensed, expiration date when applicable, and directions for use. There was nothing in the policy regarding ensuring the medication was dated after it was opened including insulin.Review of the lispro insulin manufacture guidelines, last revised 10/20/23, revealed to only use the lispro pen up to 28 days after its first use. Review of the facility policy labeled Insulin Administration Purpose, last revised March 2025, revealed the nurse was to check the expiration date if drawing from an opened multi-dose vial. If opening a new vial, record expiration date and time on the vial. The nurse was to follow manufacturer recommendations for expiration after opening. Review of the Lantus Glargine insulin Injection manufacturer guidelines, last revised May 2025, revealed to only use the Lantus pen up to 28 days after its first use. The guideline revealed to throw away the Lantus pen after 28 days even if still had insulin in it.

Based on record review, interview, and facility policy review, the facility failed to offer the pneumococcal vaccine to four (Residents #8, #10, #19, and 76) out of five residents reviewed for immunizations. The facility census was 89.Findings include:Record review for Resident #8 revealed no evidence the resident was offered the pneumonia vaccine or a signed declination for the pneumonia vaccine at the time of admission, 03/09/17, or anytime thereafter. Record review for Resident #10 revealed no evidence Resident was offered the pneumonia vaccine or a signed declination for the pneumonia vaccine at the time of admission, 01/20/25, or anytime thereafter. record review for Resident #19 revealed no evidence Resident was offered the pneumonia vaccine or a signed declination for the pneumonia vaccine at the time of admission, 04/08/21, or anytime thereafter. Record review for Resident #76 revealed no evidence Resident was offered the pneumonia vaccine or a signed declination for the pneumonia vaccine at the time of admission, 09/23/25, or anytime thereafter. Review of the facility Pneumococcal Vaccine policy last revised October 2023, revealed prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or the resident has completed the current recommended vaccine series. The policy also states the assessments of pneumococcal vaccination status are conducted within five working days of the resident's admission if not conducted prior to admission. Resident medical record will be documented accordingly and is declined or when administered. On 07/30/26 at 11:50 A.M. interview with Infection Preventionist #582 confirmed the facility is not following the facility Pneumococcal Vaccine policy. The IP #852 stated the facility is not offering the pneumococcal vaccine to any of the residents at the time of admission. A follow up interview with IP #852 on 07/30/26 at 12:17 P.M. revealed IP #852 provided a second facility Pneumococcal Vaccine policy last updated August 2025 and stated the wrong policy was provided earlier and stated the facility is assessing residents at the time of admission; however, the facility is not documenting this process. Review of the second policy provided revealed the facility will follow the same process as in the first policy provided. IP #852 confirmed there was no evidence the residents were assessed prior to or at the time of admission for the pneumonia vaccine, no evidence of residents declining, accepting vaccine and when the vaccine was administered. IP #852 stated the facility will do better in documenting the assessment and if vaccine is not indicated, declined or administered.

Based on observation, interview, and review of facility policy, the facility failed to ensure a safe, clean, sanitary, functional, and comfortable environment for residents, staff, and the public. This deficient practice had the potential to affect 66 residents: 29 residents residing on the Lower-Level Unit (#1, #11, #16, #19, #21, #23, #27, #28, #29, #32, #33, #36, #38, #40, #46, #47, #48, #50, #56, #61, #67, #69, #70, #72, #78, #79, #82, #84, #88) and 37 residents residing on the [NAME] and North Units (#2, #3, #5, #7, #8, #9, #10, #13, #15, #17, #20, #22, #24, #26, #30, #34, #35, #37, #42, #43, #49, #51, #53, #58, #59, #60, #62, #63, #64, #66, #68, #74, #75, #76, #80, #86, #93). The facility census was 89.Findings include: Observations conducted on 07/27/26 at 9:14 A.M. of Lower-Level Tub room [ROOM NUMBER] revealed multiple ceiling tiles with small black dots, rusted wall brackets on the grab bar above the tub faucets, blackened grout around the ceiling, and a rusted valve mounted between the tub and shower.Observation on 07/27/26 at 9:24 A.M. of the Lower-Level resident community bathroom beside Tub room [ROOM NUMBER] revealed a rusted drop-ceiling metal frame above three toilets, three ceiling tiles with brown, dirty markings, and a sink running continuously that could not be turned off.Observation on 07/26/26 at 9:34 A.M. of a third unnumbered Lower-Level Tub Room revealed a rusty ceiling vent, peeling paint in the back right corner of the shower, an upside down metal shelf resting on loose brackets, a rusted grab bar above the tub faucets, chipped and cracked tiles near the tub faucet, and a dirty plastic rolling cart and cabinet.Observation on 07/26/26 at 9:47 A.M. of a fourth unnumbered Lower-Level Tub Room across from the housekeeping closet revealed a rusted ceiling vent, broken bedside table, dirty grout near the tub faucet, a gap in grout where the tub and wall met, blackened ceiling above the shower, brown or black grout throughout, and a rusted ceiling access panel with black markings.Observation on 07/26/26 at 10:40 A.M. revealed Residents #42 and #80 shared one closet in their room and the closet door was missing.An interview on 07/27/26 at 9:27 A.M. with Licensed Practical Nurse (LPN) #567 confirmed the tub rooms were in need of repair and cleaning. An interview on 07/29/26 at 9:39 A.M. with Residents #67 and #84, during Resident Council, revealed Resident #84 stated he does not like the way the tub rooms look, they feel dirty with all the dark spots on the ceiling and rusty fixtures. Resident #67 states they have looked that way for as long as she can remember.An interview on 07/27/26 at 9:56 A.M. with Certified Nursing Assistant (CNA) #503 confirmed all four tub rooms were very dirty and have been for a long time.Observation on 07/27/26 at 3:02 P.M. revealed over 100 dead insects inside the hallway light covers on both the [NAME] and North Units.Observation on 07/27/26 at 3:04 P.M. of the North Unit resident community bathroom revealed an approximately five foot by five foot area of missing tiles with exposed plumbing pipes near the second and third sink, missing tiles exposing pipes behind the second toilet, and a two inch thick black substance around the circumference of all three toilets accompanied by brown discoloration of the flooring.Environmental tour and interview on 07/28/26 at 11:01 A.M. with Maintenance Director #521, who had worked at the facility for one month, verified the Lower-Level tub rooms required significant repair and deep cleaning. He stated he was unaware of outstanding maintenance requests for these areas and was waiting on pricing for moisture-sensing exhaust fans before addressing other repairs. He reported he needed shut off valves repaired to address leaking faucets and stated he was playing a lot of catch up.He also verified over 100 dead insects were present in the hallway light covers on the [NAME] and North Units and acknowledged there was no preventive maintenance program outlining cleaning expectations for light fixtures. He confirmed the missing closet door for Residents #42 and #80 and stated it had not been reported. He verified the exposed plumbing behind the sinks and toilet in the North bathroom had been present before his employment and agreed the thick black substance around all toilets was really bad and really dirty.Environmental tour and interview on 07/28/26 at 12:31 P.M. with Housekeeping Supervisor #552, who had worked at the facility for approximately one month, verified the two inch thick black substance around the toilets in the North Unit bathroom. She stated housekeeping cleaned daily, but the substance did not come off and had been present since her start. She did not know the cause but believed it was likely dirt buildup over time and stated she would have the floor technician attempt to scrape it.An interview on 07/29/26 at 10:00 A.M. with LPN # 529 confirmed the bathrooms on the Lower-Level were not as clean as the other tub rooms in the facility. LPN #529 also stated she was aware maintenance had staff turnovers recently. Review of the facility policy, Homelike Environment, last revised February 2021, revealed residents were to be provided a safe, clean, comfortable, homelike environment, including maintaining clean, sanitary, and orderly surroundings with appropriate room furnishings and arrangements.This deficiency represents non compliance investigated under Complaint Number 3107734.

Based on record review, observation, interview, and review of facility policy, the facility failed to ensure Resident #8 was provided with timely toileting/ incontinence care and that two incontinence briefs were not applied at one time. This affected one Resident (#8) out of three residents reviewed for bowel and bladder incontinence. This had the potential to affect 42 Residents (#2, #3, #4, #5, #6, #7, #8, #12, #14, #18, #22, #24, #25, #26, #30, #31, #34, #35, #39, #42, #44, #45, #52, #54, #57, #58, #60, #62, #64, #65, #66, #68, #71,#74, #75, #77, #80, #81, #85, #86, #88 and #93) identified by the facility with bowel and/or bladder incontinence. The facility census was 89.Findings include: Review of the medical record for Resident #8 revealed an admission date of 03/09/17 with diagnoses including paranoid schizophrenia, borderline personality disorder, morbid obesity, and osteoporosis. Review of the care plan dated 03/10/20 revealed Resident #8 had bladder incontinence related to confusion, impaired mobility, physical limitations, poor toileting habits and refusal of care. Interventions included encouraging fluids during the day to promote prompted voiding responses, establishing voiding patterns, encouraging the resident to participate with therapy as ordered and ensuring the resident had an unobstructed path to the bathroom. There was nothing in the care plan regarding frequency of assistance with toileting/ incontinence care and/or use of two incontinence briefs. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #8 was cognitively intact and was independent with transfers. She required supervision or touching assist with toileting hygiene, partial to moderate assistance with showers and was dependent on staff for personal hygiene. She was frequently incontinent of bowel and bladder. Review of nursing notes from 06/01/26 to 07/27/26 revealed no documented evidence Resident #8 refused incontinence care, including on 07/27/26. Observation on 07/27/26 at 10:31 A.M. revealed Resident #8 was sitting in the hallway in front of her room with an eight-inch circular diameter wet section on the front of her blue shorts. Certified Nursing Assistant (CNA) #536 walked by and stated Resident #8 was waiting for her to clean her up. An interview on 07/27/26 at 10:31 A.M. with Resident #8 revealed her shorts were wet as she had an accident and could not remember when the last time she went to the restroom and/or when she was changed last. Observation on 07/27/26 at 10:36 A.M. revealed CNA #536 assisted Resident #8 to the shower room. CNA #536 encouraged Resident #8 to stand up as she pulled down her shorts which were wet from urine. She then proceeded to remove two heavily saturated incontinent briefs. She provided Resident #8 with a shower including perineal care. An interview on 07/27/26 at 10:39 A.M. with CNA #536 verified Resident #8 was wearing two incontinent briefs that were heavily saturated with urine, and urine had leaked through the two briefs and then through her shorts. She revealed she had arrived at the facility on 07/27/26 at 9:00 A.M. and was unsure when the last time Resident #8 was last changed. When asked if Resident #8 was to have two incontinent briefs in place and with how saturated the briefs and her shorts were if she had gone with being changed for prolonged time, CNA #536 did not respond. An interview conducted on 07/29/26 at 8:21 A.M. with the Director of Nursing (DON) confirmed that residents, including Resident #8, were not to be wearing two incontinent briefs at the same time. When asked about Resident #8 reportedly leaking through two briefs and her shorts, the DON stated, No, that is unacceptable. She explained that the facility had been experiencing issues on the night shift, which was staffed with agency personnel who were placing two briefs on residents and not providing timely incontinence care. She noted she had been coming in during night shift to complete rounds and believed the issue had been resolved. The DON also verified that there was no documentation in the medical record indicating Resident #8 had refused incontinence care on 07/27/26.Review of the facility policy labeled, Urinary Incontinence- Clinical Protocol, last revised April 2018, revealed as appropriate based on assessment and causes of the incontinence the staff would provide scheduled toileting, prompted voiding, or other interventions to try to improve the resident's continent status. There was nothing in the policy regarding ensuring two incontinence briefs were not applied and frequency of toileting/ incontinence care. This deficiency represents non-compliance investigated under Complaint Number 3107734.

Based on record review, interview, and review of the facility policy, the facility did not ensure the Optum (insurance healthcare service with clinical team including a Nurse Practitioner (NP) or Physician Assistant (PA) providing proactive on-site medical care) was notified when blood sugar for Resident #3 was above 200 as ordered. This affected one Resident (#3) out of one resident reviewed for notification. The facility census was 89.Findings include:Review of the medical record for Resident #3 revealed an admission date of 04/12/22 with diagnoses including diabetes, chronic obstructive pulmonary disease, and paranoid schizophrenia. Review of the care plan dated 04/19/22 revealed Resident #3 had hyperglycemia related to diabetes. Interventions included diabetic medications as ordered, and blood sugars as ordered. There was nothing in the care plan regarding ensuring Optum was notified if the resident's blood sugar was above 200 according to the physician order. Review of Optum NP #900 progress note dated 05/16/26 revealed she evaluated Resident #3 due to a urinary tract infection. She also noted Resident #3 used insulin and was currently stable. There were no other progress notes from Optum from 05/16/26 to 07/30/26. Review of June 2026 Medication Administration Record (MAR) revealed the following blood sugars were above 200:-06/16/26 at 11:00 A.M. his blood sugar was 208-06/17/26 at 4:00 P.M. his blood sugar was 202 -06/19/26 at 7:00 P.M. his blood sugar was 204 -06/21/26 at 7:00 P.M. his blood sugar was 213 -06/27/26 at 7:00 P.M. his blood sugar was 203 Review of nursing notes from 06/01/26 to 07/29/26 revealed there was no documented evidence that Optum was notified regarding Resident #3's blood sugar was above 200 as ordered. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 had intact cognition and received insulin. Review of July 2025 Physician Orders revealed Resident #3 had an order dated 04/15/25 to check his blood glucose level before meals and at bedtime due to diabetes. The order revealed to call Optum for a blood sugar above 200. Review of July 2026 MAR revealed the following blood sugars were above 200: -07/01/26 at 4:00 P.M. his blood sugar was 206-07/01/26 at 7:00 P.M. his blood sugar was 215-07/04/26 at 7:00 P.M. his blood sugar was 202-07/07/26 at 7:00 P.M. his blood sugar was 209 -07/16/26 at 4:00 P.M. his blood sugar was 224-07/16/26 at 7:00 P.M. his blood sugar was 224 -07/17/26 at 4:00 P.M. his blood sugar was 211-07/17/26 at 7:00 P.M. his blood sugar was 244-07/19/26 at 7:00 P.M. his blood sugar was 225 -07/20/26 at 7:00 P.M. his blood sugar was 354-07/22/26 at 4:00 P.M. his blood sugar was 210-07/24/26 at 7:00 P.M. his blood sugar was 207-07/25/26 at 7:00 P.M. his blood sugar was 230 -07/27/26 at 7:00 P.M. his blood sugar was 207 An interview on 07/27/26 at 9:50 A.M. with Resident #3 revealed he was concerned about his blood sugars as at times his blood sugar dropped, and he had symptoms including dizziness. An interview on 07/29/26 at 3:17 P.M. with the Director of Nursing (DON) verified per the June 2026 and July 2026 MARs, the above times where Resident #3's blood sugar was above 200. She verified Resident #3 had an order to notify Optum if his blood sugar was above 200, and there was no documented evidence Optum was notified as ordered. She verified the last time Optum NP #900 had seen Resident #3 was on 05/16/26. Review of the facility policy labeled, Guidelines for Notifying Physicians of Clinical Problems, last revised February 2014, and revealed the guidelines were to help ensure that medical care problems were communicated to the medical staff timely, and all significant changes were assessed and documented in the medical record. There was nothing in the policy regarding ensuring the physician, NP, and/or PA was notified as ordered.

Based on record review, interview, observation, review of Centers for Medicare and Medicaid services (CMS) memorandum, QSO-24-08-NH, and review of facility policy, the facility failed to ensure enhanced barrier precautions (EBP) were utilized for Resident #2 during the administration of his medications through his feeding tube (a soft, flexible tube placed through a small incision in the abdominal wall directly into the stomach to administer nutrition and/ or medication). This affected one resident (Resident #2) out of two residents observed for EBP. This had the potential to affect seven additional residents (#5, #39, #57, #58, #61, #81, and #93) identified by the facility on EBP. The facility census was 89.Findings include: Review of the medical record for Resident #2 revealed an admission date of 09/17/18 with diagnoses including cerebral palsy, hemiplegia and hemiparesis following cerebrovascular disease affecting right non-dominant side, and dysphagia (difficulty swallowing). Review of the care plan dated 11/11/25 revealed Resident #2 was on EBP due to feeding tube. Intervention included direct care staff to utilize gowns and gloves for all personal care. There was nothing in the care plan regarding the nurse implementing EBP during device care and the administration of his medications through his feeding tube. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 had impaired cognition and had a feeding tube. Review of the July 2025 physician's orders revealed Resident #2 had the following orders: check feeding tube placement twice a day, enteral tube feeding of Jevity1.5 9nutritional supplement) at 50 milliliter (ml) per hour continuous, and medications were ordered to be administered through feeding peg tube. There was no order for EBP. Observation on 07/28/26 at 8:45 A.M. revealed Licensed Practical Nurse (LPN) #519 walked into Resident #2's room to administer his medications through his feeding tube. On the outside of the door to his room there was no signage that he was on EBP. On the back of the door of his room was a yellow bag that contained personal protective equipment (PPE) including gowns and gloves. LPN #519 proceeded to apply gloves but no gown and then removed Resident #2's abdominal binder, checked for placement and residual of his feeding tube, and administered his medications through his feeding tube per orders. During the administration of his medications LPN #519's shirt and pants came into direct contact with Resident #2 who was seated in a wheelchair. An interview on 07/28/26 at 9:15 A.M. with LPN #519 verified she did not wear a gown during the administration of Resident #2's device care and administration of his medications through his feeding tube. LPN #519 checked Resident #2's physician orders and verified he did not have an order for EBP. She revealed she did not wear a gown during device care and the administration of medication through a resident with a feeding tube as she only wore EBP including a gown for residents with wounds. She revealed she was not aware she needed to wear EBP for residents with a device such as a feeding tube. An interview on 07/28/26 at 9:22 A.M. with the Director of Nursing (DON) verified Resident #2 was to be on EBP as he had a feeding tube. She verified LPN #519 should have worn a gown while providing device care including administering his medications through his feeding tube. She stated she had signage up on all the residents' doors that were to be on EBP but a resident at the facility continued to take down all the signs and verified he should have had a physician's order for EBP.Review of the facility policy labeled, Enhanced Barrier Precautions, dated August 2022, revealed it was the policy of the facility to implement EBP for the prevention of transmission of multidrug-resistant organisms (MDRO). Clear signage would be posted on the door or wall outside the resident's room indicating the type of precaution required, and for what high contact resident care activities. The policy revealed a physician order for EBP would be obtained for residents with any of the following: wounds, and/or indwelling medical devices including a feeding tube. High contact resident care activities included device care or use: central lines, urinary catheters, and feeding tubes. Review of the memorandum, QSO-24-08-NH, entitled Enhanced Barrier Precautions in Nursing Homes, dated 03/20/24, by CMS Department of Health & Human Services revealed EBP were indicated for residents with indwelling medical devices including feeding tubes even if the resident is not known to be infected or colonized with a MDRO. EBP was an infection control measure designed to reduce transmission of MDRO and employs targeted gown and glove use during high contact care activities. The effective date for implementation of EBP under the guidelines was 04/01/24.

Based on record review, observation, interview, and review of facility policies, the facility failed to administer Resident #2's enteral tube feeding as ordered. This affected one (Resident #2) out of two residents identified by the facility as receiving enteral feeding. The facility census was 89. Findings include:Review of the medical record for Resident #2 revealed a re-admission date of 08/30/23 with diagnoses including cerebral palsy, aphasia, autistic disorder, Asperger's syndrome, and dysphagia. Review of the physician's orders for Resident #2 identified orders for enteral feed of Jevity 1.5 (nutritional supplement) at 50 milliliters (ml) per hour for 24 hours with 200 ml water flush every six hours effective 05/04/26. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/20/26, indicated Resident #2 had severe cognitive impairment for daily decision making, was dependent on staff for eating, and the tube feeding provided 51% or more of his daily calorie intake and 501 ml or more of his daily fluid intake. Review of the treatment administration record (TAR) for July 2026 indicated residuals were being marked as completed with a check mark; however, there were no parameters for actions to take based on the amount of residuals, and there was no indication as to what the residuals were. On 07/27/26 at 10:30 A.M., an observation of Resident #2 revealed his tube feeding was not hooked up. On 07/27/26 at 10:41 A.M., an interview with Licensed Practical Nurse (LPN) #505 verified Resident #2's tube feeding was turned off because he had 90 ml of residuals. On 07/27/26 at 12:05 P.M., an interview with the Director of Nursing (DON) said they don't hold tube feedings for residuals anymore, they just perform placement checks. The DON further stated 90 ml of residuals would not be an indicator to hold a tube feeding. The DON verified there was no documentation regarding Resident #2's tube feeding being held or what the residuals were, stating the residual checks were just indicated by a check mark on the TAR. On 07/27/26 at 1:13 P.M., an observation of Resident #2 revealed his tube feeding pump was displaying the message hold error, and the tube was wrapped around the pump, not infusing. On 07/28/26 at 8:19 A.M., an observation of Resident #2's room revealed the tube feeding pump was in his room with the bag of formula hanging and Resident #2 was not in his room. On 07/28/26 at 8:25 A.M., an observation revealed Resident #2 was in the activity room and was not receiving his tube feeding at that time. On 07/28/26 at 8:45 A.M., an observation revealed Resident #2's tube feeding was not running. An interview at the time of observation with LPN #519 verified the tube feeding was not running. LPN #519 stated Resident #2's tube feeding was not running because he went to breakfast in the dining room for his pleasure feeding. LPN #519 stated she was going to let Resident #2 sit up for a while before reconnecting his tube feeding to let his food and medications digest. On 07/28/26 at 9:21 A.M., an interview with the DON confirmed they took Resident 2 off the tube feeding for meals and for activities. The DON confirmed Resident #2's tube feeding orders indicated to run the tube feeding for 24 hours. On 07/28/26 at 10:00 A.M., an observation of Resident #2 revealed his tube feeding was not hooked up. On 07/28/26 at 10:00 A.M., LPN #519 confirmed the tube feeding was not hooked up, stating she was letting him sit up a bit after medication pass and she had not hooked him back up yet. On 07/28/26 at 10:18 A.M., an interview with Dietary Technician #582 stated she was not aware the facility was turning Resident #2's tube feeding off for meals or activities, further stating his meals were for pleasure foods only and he did not eat enough at meals to justify turning the tube feeding off. Dietary Technician #582 said Resident #2's current orders did not have orders to turn the tube feeding off for meals and the tube feeding was supposed to run for 24 hours. Dietary Technician #582 said with his current oral intakes, Resident #2 really needed the TF to run for 24 hours daily to meet his nutritional needs. On 07/28/26 at 11:10 A.M., the DON confirmed there was no order to pause or hold the tube feeding, and they just got the order today from the physician that it was ok to pause Resident #2's tube feeding for meals and activities. Review of the facility's policy titled Enteral Tube Feeding via Continuous Pump, dated November 2018, revealed the purpose of the procedure was to provide a guideline for the use of a pump for enteral feedings, staff needed to verify the physician's order and the enteral formula provided must match the physician's order. Facility staff should document the date and time the tube feeding was initiated, verification of tube placement, amount and type of enteral feeding, fluid intake, all assessment data obtained during the initiation of the tube feeding, and all complications or negative consequences must be promptly reported to the supervisor and attending physician. Review of the facility's policy titled Checking Gastric Residual Volume (GRV), dated November 2018, revealed if the GRV was between 250 to 500 ml then measures should be taken to reduce the risk of aspiration and if the GRV was above 500 ml then the physician must be notified and the resident assessed for feeding intolerance. Facility staff should document the date and time the residuals were checked, the amount of residuals, all assessment data obtained, and how the resident tolerated checking the residuals. The policy did not indicate the tube feeding should be stopped or held for a residual of 90 ml.On 07/27/26 at 1:13 P.M., an observation of Resident #2 revealed his tube feeding pump was displaying the message hold error, the tube was wrapped around the pump and it was not infusing. On 07/28/26 at 8:19 A.M., an observation of Resident #2's room revealed the tube feeding pump was in his room with the bag of formula hanging and Resident #2 was not in his room. On 07/28/26 at 8:25 A.M., an observation revealed Resident #2 was in the activity room and was not receiving his tube feeding at that time. On 07/28/26 at 8:45 A.M., an observation revealed Resident #2's tube feeding was not running. An interview at the time of observation with LPN #519 verified the tube feeding was not running. LPN #519 stated Resident #2;s tube feeding was not running because he went to breakfast in the dining room for his pleasure feeding. LPN #519 stated she was going to let Resident #2 sit up for a while before reconnecting his tube feeding to let his food and medications digest. On 07/28/26 at 9:21 A.M., an interview with the DON confirmed they take Resident #2 off the tube feeding for meals and for activities. The DON confirmed Resident #2's tube feeding orders indicated to run the tube feeding for 24 hours. On 07/28/26 at 10:00 A.M., an observation of Resident #2 revealed his tube feeding was not hooked up. On 07/28/26 at 10:00 A.M., LPN #519 confirmed the tube feeding was not hooked up, stating she was letting him sit up a bit after medication pass and she had not hooked him back up yet. On 07/28/26 at 10:18 A.M., an interview with Dietary Technician #582 stated she was not aware the facility was turning Resident #2's tube feeding off for meals or activities, further stating his meals were for pleasure foods only and he did not eat enough at meals to justify turning the tube feeding off. Dietary Technician #582 said Resident #2's current orders did not have orders to turn the tube feeding off for meals and the tube feeding was supposed to run for 24 hours. Dietary Technician #582 said with his current oral intakes, Resident #2 really needed the TF to run for 24 hours daily to meet his nutritional needs. On 07/28/26 at 11:10 A.M., the DON confirmed there was no order to pause or hold the tube feeding and they just got the order today from the physician that it was ok to pause Resident #2's tube feeding for meals and activities. Review of the facility's policy titled Enteral Tube Feeding via Continuous Pump, dated November 2018, revealed the purpose of the procedure was to provide a guideline for the use of a pump for enteral feedings, staff needed to verify the physician's order and the enteral formula provided must match the physician's order. Facility staff should document the date and time the tube feeding was initiated, verification of tube placement, amount and type of enteral feeding, fluid intake, all assessment data obtained during the initiation of the tube feeding, and all complications or negative consequences must be promptly reported to the supervisor and attending physician. Review of the facility's policy titled Checking Gastric Residual Volume (GRV), dated November 2018, revealed if the GRV was between 250 to 500 ml then measures should be taken to reduce the risk of aspiration and if the GRV was above 500 ml then the physician must be notified and the resident assessed for feeding intolerance. Facility staff should document the date and time the residuals were checked, the amount of residuals, all assessment data obtained, and how the resident tolerated checking the residuals. The policy did not indicate the tube feeding should be stopped or held for a residual of 90 ml.

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure nutritional orders were monitored and completed. This affected one (Resident #29) of three residents reviewed for nutritional status. The census was 88. Findings Include: Resident #29 was admitted to the facility on [DATE]. His diagnoses were schizoaffective disorder, dementia, hyperlipidemia, hypertension, tachycardia, osteoarthritis, seborrheic dermatitis, muscle weakness, dysphagia, and unsteadiness on feet. Review of his minimum data set (MDS) assessment, dated 06/26/25, revealed he was cognitively intact. Review of Resident #29's physician orders, starting date of 06/11/25, revealed the facility was to complete weekly weight checks. There was no end date listed. Review of Resident #29's weight documentation, dated 06/11/25 to 09/12/25, revealed the following weights were not taken on a weekly basis: 07/08/25 and 07/21/25. Also, there were no weights taken between 08/06/25 and 09/04/25. Review of Resident #29's nutritional notes, dated 06/11/25 to 09/12/25, revealed no documentation to support an end date to the weekly weights, or a recommendation/order from the dietitian/physician to end to weekly weights. Interview with Director of Nursing (DON) on 09/12/25 at 12:53 P.M. and 1:40 P.M. confirmed there was a current order for Resident #29 to have weekly weights, which had been in place since 06/11/25. She stated there was no documentation to support the dietitian or any other clinician had ordered the weekly weights to be stopped. She also confirmed the above missing weights were not documented as being completed. Review of facility Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, undated, revealed the nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparison over time. The physician will review for medical causes of weight gain, anorexia, and weight loss before ordering interventions. For individuals with recent or rapid weight gain or loss (for example, more than a pound a day), the staff will review for possible fluid and electrolyte imbalance as a cause. The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes. The physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions. The physician and staff will document the medical and ethical rationale for recommending, not recommending, or discontinuing tube feedings, consistent with the clinical situation, and applicable to laws and regulations about the withholding or withdrawing of artificial nutrition and hydration. This deficiency represents non-compliance found during the investigation of complaint number 1320053.

Based on observation, record review, facility policy review and interview, the facility failed to ensure Resident #36's risk of elopement was properly and timely re-assessed, and failed to ensure comprehensive care planned interventions were updated and implemented to prevent Resident #36 from eloping from the facility. This affected one resident (#36) of three residents reviewed for wandering and elopement. The facility census was 92. Findings include: Review of Resident #36's medical record revealed an admitted [DATE] with diagnoses including schizoaffective disorder, bipolar type, type two diabetes mellitus with unspecified complications, paranoid personality disorder and anxiety. Review of Resident #36's care plan dated 04/26/24 included Resident #36 was at risk of elopement due to new admission, history of wandering and elopement, exit seeking and disease process. Resident #36's risk of leaving the facility unattended would be decreased through the next review on 11/08/24. Interventions included to identify patterns of wandering and was wandering purposeful, aimless or escapist; distract from wandering by offering diversions, structured activities, conversation and television. Further review of the care plan did not reveal interventions were added after 04/26/24. Review of Resident #36's Elopement and Wandering Risk assessment dated [DATE] revealed Resident #36 was at medium risk for elopement. Review of Resident #36's care plan dated 10/17/24 included declarations in guardianship would honored unless revoked by court and, or responsible party. Engage in ongoing advanced care planning with Resident #36 and guardian to discuss options. Interventions included to notify guardian of all medical changes. Review of Resident #36's medical record including assessments dated 08/11/24 through 03/19/25 did not reveal evidence Resident #36 had an Elopement and Wandering Risk assessment completed. Review of Resident #36's progress notes revealed a late entry progress note dated 10/14/24 at 8:25 P.M. which revealed on 10/14/24 at 5:04 P.M. Licensed Practical Nurse (LPN) #200 was administering medications to the residents in the lower level common area and the fire alarm sounded and next she heard the lower-level exit door alarm sounding. LPN #200 saw Resident #36 running out of the door, he pulled the fire alarm and exited the building. LPN #200 used the walkie-talkie to alert staff that Resident #36 exited the building and was headed into the woods. Resident #36 was found, a head-to-toe assessment was completed, and Resident #36's physician and guardian were notified. Review of Resident #36's progress notes dated 10/15/25 at 11:28 A.M. revealed the guardian and Resident #36 agreed to a room move. Review of Resident #36's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was cognitively intact. The assessment revealed Resident #36 was independent for toileting, hygiene and dressing and required (staff) set-up or clean-up assistance with personal hygiene. Resident #36 was independent in his ability to walk at least 150 feet in a corridor or similar space. Review of the facility incident log dated 03/14/25 at 3:40 A.M. revealed Resident #36 had an elopement from the facility. Observation of facility camera footage dated 03/14/25 at 2:51 A.M. with the Administrator revealed Resident #36 resided on the north hall nursing unit on the main level of the facility. The Administrator stated Resident #36 knew the code for the stairwell and was allowed to use the stairwell or the elevator to go down to the lower level. Review of the camera footage at 2:51 A.M. of the lower level nursing unit revealed Resident #36 walked out of the northwest stairwell into the lower level hall and took a few steps toward the nurse's station. At 2:52 A.M. Resident #36 paused, looked around, dropped down to his hands and knees and crawled past the nurses station until he was about half way up the opposite hall. At the end of the hall was a door leading to the outside area and a fire alarm pull station on the wall by the door. When Resident #36 crawled by the nurse's station the nurse (RN #203) was in the nurse's station with her back to the desk and hall, she was tending to the medication cart and was not aware Resident #36 crawled by. The aide (Certified Nursing Assistant (CNA) #202) was not seen in the camera footage and the Administrator stated he did not know where she was. At 2:53 A.M. Resident #36 stood up, walked to the end of the hall by the door to the outside and the fire alarm pull area, stepped into a resident room doorway and stood there. At 3:19 A.M. CNA #202 was seen walking around by the nurses station. Review of the camera footage at 3:37 A.M. revealed Resident #36 stepped out of the resident room, laid on the ground because it appeared he saw the nurse and did not want to be detected. Resident #36 stood up and walked to the fire alarm pull area, tugged at the cover for a bit, then pulled the alarm cover up and off the alarm. At 3:39 A.M. RN #203 saw Resident #36 standing by the fire alarm area, tugging at the cover, she stood up, might have said something, and Resident #36 activated the fire alarm at 3:40 A.M. The door to the outside unlocked and Resident #36 opened the door and ran out of the facility. RN #203 ran and followed him outside and ran back in the building at 3:40 A.M. then ran to the double doors and went through them. The Administrator stated he asked Resident #36 what route he took to the gas station and Resident #36 stated he went through the woods and then by the schools. The Administrator asked Resident #36 why he left the facility and Resident #36 said he wanted to talk to cops. Review of a Witness Statement dated 03/14/25 at 3:40 A.M. written by Licensed Practical Nurse (LPN) #205 revealed Resident #36 was agitated because he got caught trying to steal an aides back pack out of the nurse's station and was in his room listening to music. LPN #205 was in the nurse's station charting and Resident #36 left his room and went downstairs. The lower level aide (CNA #202) came up to the break room and right after that the fire alarm went off. Review of a Witness Statement dated 03/14/25 at 3:40 A.M. revealed Registered Nurse (RN) #203 was in a resident's room administering a pain medication and when she returned to the medication cart she noticed Resident #36 was at the end of the hall but she did not know what he was doing because an oxygen tank was on the counter and obstructed her view. RN #203 stated she stood up to tell Resident #36 he needed to return to his room and as she stood up Resident #36 pulled the fire alarm and escaped out of the now unlocked door. RN #203 stated she ran after him, shouting for him to come back, and she could not see where he ran. RN #203 returned to the building, ran up the stairs to alert the rest of the staff that Resident #36 ran off. RN #203 stated she ran outside along with the rest of the staff, but they could not find Resident #36. Review of a Witness Statement dated 03/14/25 at 3:40 A.M. written by Certified Nursing Assistant (CNA) #204 revealed Resident #36 was last seen in his room and was sitting on his bed. When CNA #204 heard the fire alarm he rushed directly to Resident #36's room since I knew he could do that and unfortunately he was not in his room. CNA #204 alerted his coworkers about Resident #36's absence in his room and they rushed outside to look for him. Review of a Witness Statement dated 03/14/25 at 3:45 A.M. written by Certified Nursing Assistant (CNA) #202 revealed she was on her break and did not witness Resident #36 leaving the facility. CNA #202 stated she became aware Resident #36 left the facility when the fire alarm sounded. Review of Resident #36's progress notes dated 03/14/25 at 9:06 A.M. revealed an interdisciplinary team (IDT) note stating on 03/14/25 at 3:40 A.M. the nurse observed Resident #36 pull the fire alarm and go through the now unlocked door. The nurse immediately went after him but could not see where he ran. The nurse ran back to inform the other staff members that Resident #36 was outdoors. All staff responded, the elopement protocol was immediately implemented and a search began. The Administrator, police and Resident #36's guardian were notified. At 8:35 A.M. the local police notified the Administrator that Resident #36 was located and was in their custody. Resident #36's physician and guardian were notified. Review of a facility Self-Reported Incident tracking number 258228 dated 03/14/25 at 11:46 A.M. included the Administrator was notified by nursing staff at 3:45 A.M. that Resident #36 was observed pulling the fire alarm and exiting the now unlocked door on the 300 hall (lower level). Staff followed Resident #36 outside but lost sight of him. Staff returned to the building and started the facility elopement protocol by notifying the Administrator, Resident #36's guardian and the local police. The facility staff continued ground searches until Resident #36 was located by the local Police at 8:35 A.M. The police returned Resident #36 to the facility and he was sent to the local hospital per physician orders for evaluation. Review of Resident #36's progress note dated 03/14/25 at 12:37 P.M. revealed Resident #36 returned to the facility at 9:30 A.M. Vital signs were blood pressure 160/88, pulse 109, respirations 20, oxygen saturation was 96 percent on room air, and temperature was 98.1 Fahrenheit. Resident #36 was escorted to his room, one-to-one supervision was started, his medications were administered, and a skin assessment was completed with multiple scratches noted. Medical Director #201 gave orders to send Resident #36 to the local hospital for evaluation. Resident #36's guardian was aware. Resident #36's blood pressure was rechecked and was 132/80. Interview on 03/19/25 at 9:36 A.M. with the Director of Nursing (DON) revealed Resident #36 tried to elope from the facility in the past and had a guardian. Resident #36 hid by the door leading to the outside, waited for no staff to be around, pulled the fire alarm and ran out of the facility. The nurse (RN #203) saw Resident #36 pull the fire alarm and run out of the facility and ran after him, but lost track of him and came back into the building and started the elopement protocol. The DON stated the fire alarm releases egress and the doors open. The DON indicated the fire alarm signal was loud, staff responded and went to the doors to monitor them and make sure no other residents left the facility. The DON stated the police were involved and brought dogs to help find Resident #36, and a ground search was conducted until Resident #36 was found. Resident #36 was found at a gas station a couple miles away near busy roads at 8:35 A.M. The DON stated the temperature was about 40 degrees Fahrenheit and Resident #36 was wearing gloves, boots and long pants. The DON indicated on 03/14/25 at the time Resident #36 eloped from the facility there was one nurse and one aide working on the lower level. The DON stated the medication cart was located behind the nurse's station desk, Resident #36 crawled by the nurse's station and the nurse saw him towards the end of the hall. After Resident #36 eloped all the windows and doors were checked and staff was re-educated on the elopement policy. Observation on 03/19/25 at 10:00 A.M. revealed Resident #36 resided in the north nursing unit of the facility and it was on the main first floor level. There were stairwells and an elevator which were used to access the lower level nursing unit. The stairwells had a keypad located next to the door and required a code to be entered to be able to use the stairs to descend to the lower level. On the lower level a door was located at one end of the hall which led to the outside and near the door was a fire alarm pull station. Outside of the door was a small hill which led toward a barn and a fenced in area for horses and to the left of the door was a sidewalk leading towards an open field and a wooded area. Interview on 03/19/25 at 11:05 A.M. of CNA #202 revealed she was working on the lower level nursing unit on 03/14/25 when Resident #36 eloped from the facility. CNA #202 stated she did not know Resident #36 was in the lower level nursing unit and she told RN #203 she was taking a break and went to the main floor break room to make coffee. CNA #202 indicated during her break she heard the alarm, looked out into the hall and saw RN #203 running and RN #203 told her Resident #36 eloped from the facility. CNA #202 stated Resident #36 often came to the lower level but when he did come they directed him back upstairs because if they did not have eyes on him he would try to take other resident belongings or he tried to leave the facility. CNA #202 indicated Resident #36 used to live on the lower level and he was moved upstairs because he tried to leave the facility. CNA #202 revealed a prior incident when Resident #36 was found by the bushes and brought back right away. Interview on 03/19/25 at 1:11 P.M. with LPN #206 revealed she worked on the unit Resident #36 resided on and stated the resident was still in the hospital and had not returned since his elopement on 03/14/25. LPN #206 stated Resident #36 played his music loudly, especially at night, was disruptive to the other residents, and took their belongings. LPN #206 stated Resident #36 was not supposed to go to the lower level without a staff member escorting him. LPN #206 indicated Resident #36 was very quick on his feet and very smart. LPN #206 stated the Administrator immediately changed the stairwell code if a resident on the main level had the code because none of them were supposed to have it, but they could ride the elevator to the lower level and it was easier to monitor who was going up and down. LPN #206 indicated Resident #36 was definitely an elopement risk, had been on every 15 minute checks in the past, saw a psychiatrist, has had medication changes and should not have the code to the stairwell. LPN #206 stated Resident #36 waited for his opportunity. Interview on 03/19/25 at 3:07 P.M. with the Administrator, the Director of Nursing (DON) and Interim DON (IDON) #207 revealed staff should monitor and redirect Resident #36 if they saw him go by doors to the outside. The DON stated when the facility had fire drills the staff would immediately make sure Resident #36 was in his room and everyone knew this. The DON stated she did not know if it was written as an intervention anywhere in Resident #36's medical record. The Administrator stated the main level was more secure because residents had to try harder to leave than if they resided on the lower level, and staff were always checking with Resident #36 to see how things were going. The Administrator stated changing the stairwell code and not allowing Resident #36 to use the stairwell would be difficult to enforce because Resident #36 would linger by the stairwell and see what the code was when others used it or another resident would give him the code. The DON stated hourly rounds were made to check on Resident #36 and other residents and if he was on the lower level he would be redirected back to his nursing unit. The Administrator stated they tried to make life here as enjoyable as possible without being overly restrictive. Interview on 03/19/25 at 4:33 P.M. with CNA #204 revealed he was working on 03/14/25 when Resident #36 eloped from the facility. CNA #204 stated most of the time Resident #36 was okay to take care of but sometimes he got agitated and shouted. On those occasions CNA #204 was able to calm him down. CNA #204 stated Resident #36 had tried to get out of the facility in the past and when there was a fire drill he checked on him right away. On 03/14/25 he checked on Resident #36 as soon as he heard the fire alarm, but Resident #36 was not in his room. Interview on 03/19/25 at 5:36 P.M. with the Administrator, DON, and IDON #207 revealed the stairwell code was not changed if a resident was at risk, but the resident was not provided the stairwell code. The DON and Administrator confirmed Resident #36 did not have an elopement assessment completed since 08/10/24 and his care plan was not updated with new interventions as noted above. Review of the facility undated policy titled Missing Resident and Elopement revealed it was the policy of the facility to provide a safe and secure environment for all residents. In the event of resident elopement, it was the policy of the facility to implement its policies and procedures immediately to locate the resident in a timely manner. This deficiency represents non-compliance investigated under Control Number OH00163709.

Based on medical record review, review of a fall incident report and related facility investigation, review of hospital documentation, interviews with staff and review of facility policy, the facility failed to provide timely and necessary medical intervention to Resident #41 following a fall with injury and severe pain. Actual harm occurred on 01/24/24 when Resident #41, who had moderate cognitive impairment, muscle weakness, and was known by the facility to be a safety risk for falls with injury, fell to the floor while ambulating in a common area, and was picked up off the floor by Speech Therapist (ST) #899 and walked back to his room prior to completion of a thorough nursing assessment by Licensed Practical Nurse (LPN) #898. Upon assessment by LPN #898 on 01/24/24, Resident #41 was noted to have severe pain (seven out of 10 with 10 being the worst pain), a bruise to his left front thigh yet his physician was not notified. The resident began experiencing increased leg pain with facial grimacing with left leg movement on 01/26/24, faded bruising to the left inner thigh was noted on 01/30/24, and the resident began experiencing left hip pain on 02/03/24. The resident was sent to the hospital on 02/07/24 (14 days after the fall) upon request of his legal guardian where he was diagnosed with a left hip fracture requiring palliative hip fracture surgical repair and remained in the hospital until 02/09/24. This affected one (Resident #41) of two residents reviewed for accidents/hazards. The facility census was 91. Findings include: Review of the medical record for Resident #41 revealed an admitted [DATE] with diagnoses including schizophrenia, sarcoidosis, epilepsy, legal blindness, cachexia, muscle weakness, unspecified abnormalities of gait and balance and alcohol induced persisting dementia. A physician order dated 11/21/23 revealed Resident #41 was admitted to Gentiva Hospice for alcohol induced persistent dementia. Resident #41's primary physician was Medical Director #874. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #41 revealed the resident had severe cognitive impairment, no functional limitation in range of motion (ROM) of the lower extremities (hip, leg, ankle, foot), he used a walker and wheelchair for mobility, required substantial/maximum assist to walk ten feet and walking 50 feet with two turns was not attempted due to medical condition or safety concerns so the resident would require a wheelchair with substantial/maximum assistance of a helper to wheel 50 feet with two turns. Review of Resident #41's care plan (dated 04/20/17) with revisions on 02/07/24 revealed Resident #41 was at risk for falls related to his well-documented poor balance, unsteady gait, post seizure, and noncompliance with staff assistance. Intervention dated 03/30/21 revealed to encourage resident to utilize walker to aid with mobility and safety. Review of a progress note dated 01/23/24 from psychiatric services for Resident #41 revealed Resident #41 was seen via telehealth for medication evaluation. Resident #41 was noted to still be having problems with his vision, pain, and was given Morphine to treat pain. It was also noted he was a safety risk as far as falling and injuring himself. A recommendation was made to decrease his total daily (anti-psychotic medication) Haldol from 18 mg to 15 mg to allow him to be more active. It was noted he could ambulate independently. Review of nursing progress note dated 01/24/24 timed at 2:29 P.M. revealed Resident #41 was ambulating unassisted without a walker and fell in the 100-hall lounge area. There was no head involvement per witness. Resident was assisted to bed. Neurological checks, pain and skin assessments were performed. Resident determined to be at baseline post fall. ROM was within normal limits per baseline. Resident reported no pain at the time of the incident. Parties notified included Hospice, the guardian and the Assistant Director of Nursing (ADON). Immediate action taken was to have the resident use a wheelchair for ambulation. There was no evidence Resident #41's physician was notified of the incident. Review of the document titled #2811 Fall dated 01/24/24, timed 10:25 A.M. and prepared by LPN #898 revealed the resident (#41) was ambulating without walker and assistance of one and he fell in the 100hall/lounge. He did not hit his head, and he was unable to give a description. Immediate action taken was the resident was assisted to bed and would be given a wheelchair for further ambulation. There were no injuries noted. He was not taken to a hospital. A bruise was noted on his left front thigh. His pain level was seven (severe). He was alert and oriented to person. Predisposing factors included recent medication change and ambulating without assistance. Other info included non-compliance with walker and assistance, fixation on cigarettes and seizure history. There were unspecified staff witnesses at the time of the fall. Under the section titled agencies/people notified there were no notifications documented. Review of the facility document titled Pain assessment dated [DATE] at 2:39 P.M. revealed the resident was having severe, almost constant pain. The location of the pain was not specified. Pain management included administer as-needed morphine and acetaminophen and encourage repositioning. In the comment section no new pain indicated by patient post fall was written. Review of the facility investigation dated 01/24/24 revealed a witness statement dated 01/24/24 from Housekeeper #887 revealed she observed Resident #41 walking down the hall without his walker, lost his balance and fell . Housekeeper #887 notified the nurse. ST #899 came and helped Resident #41 up from floor and took him to his room. Review of the witness statement dated 01/24/24 from Dietary Manager (DM) #885 revealed she saw Housekeeper #887 running towards 100 hall and tell an unidentified resident not to pick Resident #41 up. DM #885 yelled for LPN #898 and LPN #898 was giving care and finished providing care before coming to assist Resident #41. Resident #41 told DM #885 he was okay, and DM #885 instructed him not to move. DM #885 went to get Resident #41's walker and ST #899 helped Resident #41 up from the floor. Review of the witness statement dated 01/24/24 from ST #899 revealed she was walking out of the therapy room and DM #885 and Housekeeper #887 notified her Resident #41 had a fall. LPN #898 was providing care and did not come for over one minute and ST #899 assisted Resident #41 up from the floor and walked him back to his room. ST #899 notified the nurse she assisted Resident #41 back to his room. Review of the witness statement dated 01/24/24 from LPN #898 revealed she was providing resident care when she received the radio call that Resident #41 had fallen. Upon completion of care, she found Resident #41 in his bed in his room. The statement included LPN #898 performed skin, neurological, and pain assessment on Resident #41 in his room. Review of the witness statement from State tested Nursing Assistant (STNA) #810 revealed she was in the shower room with another resident and heard ST #899 yell for the nurse. STNA #810 opened the door and witnessed Housekeeper #887 and ST #899 lifting Resident #41 off the floor. Review of nursing progress note dated 01/26/24 timed at 7:30 A.M. revealed 0.5 milliliter (mL) of morphine sulfate (MS) oral solution 20 milligrams (mg) mg/5 mL was given for pain. Resident was noted to have new complaint of leg pain. States started with his fall last week. Resident #41 was unable to tell nurse where the pain was on his legs but grimaced when left leg was moved. Review of nursing progress note for Resident #41 dated 01/28/24 timed at 8:40 P.M. revealed MS oral solution 20 mg/5mL was given for leg pain rated a nine out of ten (on a scale of zero to 10). Review of nursing progress dated 01/29/24 timed at 7:02 P.M. revealed Resident #41 complained to the hospice nurse of pain and pain medication was administered. Review of nursing progress noted dated 01/30/24 timed at 1:32 P.M. revealed Resident #41 was noted to have a purple/red partially faded area on his left inner thigh area. Resident #41 was noted to cry out and complain of pain when repositioned to observe the area. Review of the 01/24 Medication Administration Record (MAR) for Resident #41 revealed as needed MS oral solution 20 mg/5 mL was given on the following dates and times but location of pain was not specified in the correlating MAR nursing progress note: 01/26/24 at 7:30 A.M. with noted pain level of 8 out of 10 01/26/24 10 :14 A.M. with noted pain level of 6 out of 10 01/26/24 at 8:10 P.M. with noted pain level of 7 out of 10 01/28/24 at 8:40 P.M. with noted pain level of 9 out of 10 01/29/24 at 5:55 P.M. with noted pain level of 6 out of 10 01/31/24 at 7:40 A.M. with noted pain level of 7 out of 10 01/31/24 at 9:16 P.M. with noted pain level of 5 out of 10 Review of nursing progress note dated 02/03/24 timed at 1:25 P.M. revealed MS 20 mg/5 mL was given for left hip pain and was noted to require maximal assist of one to transfer. Review of nursing progress note dated 02/04/24 timed at 8:03 A.M. revealed MS 20 mg/5 mL was given for left leg/hip pain. Review of 02/24 MAR for Resident #41 revealed as needed MS oral solution 20 mg/5 mL was given on the following dates and times, but location of pain was not specified in the correlating MAR nursing progress note: 02/02/24 at 3:53 A.M. with noted pain level of 7 out of 10 02/02/24 at 9:49 A.M. with noted pain level of 5 out of 10 02/02/24 at 2:00 P.M. with noted pain level of 4 out of 10 02/03/24 at 1:25 P.M. with noted pain level of 8 out of 10 02/04/24 at 4:31 A.M. with noted pain level of 5 out of 10 02/04/24 at 8:03 A.M. with noted pain level of 8 out of 10 02/05/24 at 5:39 A.M. with noted pain level of 6 out of 10 02/05/24 at 2:50 P.M. with noted pain level of 7 out of 10 02/06/24 at 3:32 A.M. with noted pain level of 8 out of 10 02/06/24 at 6:06 P.M. with noted pain level of 7 out of 10 Review of nursing progress note dated 02/07/24 timed at 9:55 A.M. revealed follow up with hospice related to Resident #41 having continued pain on left hip area. Observation of left hip/groin area swollen with asymmetrical body alignment. Review of nursing progress note dated 02/07/24 timed at 10:30 A.M. revealed Resident #41 continued to complain of pain with facial grimacing and inability to bear weight on left foot and was medicated. Hospice nurse noted swelling and asymmetry with resident hip/groin area. Order given for hip/pelvic x-ray for Resident #41 with two views and ultrasound to left extremity. Review of nursing progress note dated 02/07/24 timed at 10:45 A.M. revealed x-ray performed, hospice aware of results, ordered morphine 20 mg (1 mL) every two hours for severe pain/prevention. Guardian requested Resident #41 be sent to hospital for evaluation and treatment. Review of nursing progress note dated 02/07/24 timed at 11:30 A.M. revealed Resident #41 went to the hospital. Review of nursing progress note dated 02/08/24 timed at 7:37 A.M. Resident #41 scheduled to have palliative hip repair. Record review for Resident #41's hospital discharge record from [NAME] Health dated 02/09/24 at 1:38 P.M. authored by Hospital Physician #903 revealed Resident #41 had an admitted to the hospital of 02/07/24. The discharge diagnosis from the hospital for Resident #41 included closed left hip fracture, initial encounter with an active problem of left displaced femoral neck fracture. Hospital course included Resident #41 was brought to the emergency room with complaints of left hip pain after a fall on 01/24/24. Resident #41 stated he usually walked with a walker but not since his fall. Resident #41 had been having pain in his left hip which is new. Chronically Resident #41 had no pain other than occasional headaches which get better with Tylenol. He was found to have a left hip fracture and underwent left hemiarthroplasty. Pain was well controlled post-operatively. Interview was conducted on 08/07/24 at 8:24 A.M. with State tested Nursing Assistant (STNA) #843 who revealed Resident #41 was on hospice, was able to make his needs known to staff, required staff to push him in his wheelchair, was legally blind and frequently tried to self-transfer. STNA #843 said he gets reminders to call for staff assistance and had been getting better with asking the staff for help. STNA #843 was familiar with the resident but was not present at the time of the fall on 01/24/24. Interview via phone was attempted with former employee STNA #810 on 08/08/24 at 9:41 A.M. and 08/14/24 at 1:10 P.M. and a voice mail message with request for a call back was left. No return contact was made. Telephone interview on 8/08/24 at 9:56 A.M. with LPN #898 revealed she was in a resident room providing care and she was notified by the walkie talkie Resident #41 had fallen. LPN #898 stated she looked out the door and saw three staff assisting him (no specific staff identification provided) and finished providing care to the resident she was assisting. LPN #898 stated when she finished Resident #41 was already in his room. LPN #898 stated she was told by Speech Therapist (ST) #899 she had assisted Resident #41 back to his room with the assistance of Dietary Manager (DM) #885. ST #899 told her Resident #41 did not have any complaints of pain and did not have any signs of injury. LPN #898 confirmed Resident #41 was taken back to his room before he was assessed by the nurse. Telephone interview was attempted on 08/08/24 at 10:15 A.M. and 08/14/24 at 1:26 P.M. with ST #899. A voice mail message with call back phone number was left on the voice mail. No return contact was made. Interview was conducted on 08/08/24 at 10:18 A.M. with Resident #41 who was alert but unable to answer any simple or open-ended questions due to cognitive impairment. Interview on 08/08/24 at 10:20 A.M. with DM #885 stated she observed Resident #41 on the floor by his walker and ST #899 was walking towards him. DM #885 stated she did not assist as she knew she needed to wait for the nurse to assess him. DM #885 stated ST #899 notified LPN #898 of his Resident #41's fall and told DM #885 she was okay to leave. Interview on 08/08/24 at 10:27 A.M. with Housekeeper #887 revealed she was walking by the 100 hall nurses' station and saw Resident #41 fall. Housekeeper #887 stated he was standing using his walker in the common area by the nurse's station and fell . Housekeeper #887 stated there were no staff near him when he fell so she radioed LPN #898. LPN #898 stated she was in the middle of med pass and would be there as soon as possible. Housekeeper #887 stated she did not recall if other staff assisted him back to his room. Housekeeper #887 was not allowed to assist and did not help Resident #41 get up. Interview on 08/08/24 at 2:03 P.M. with the Director of Nursing (DON) confirmed if a resident has a fall, the resident was not to be moved until after the nurse assessed the resident and if there was a change in condition, the nurse was to notify hospice and update the physician of any changes. The DON confirmed according to the review of the fall investigation report dated 01/24/24 for Resident #41, Resident #41 was helped up off the floor and assisted back to his room before the nurse assessed him. The DON confirmed the resident was experiencing worsening pain post-fall and bruising to the left leg had been identified by LPN #898 on 01/24/24. Interview on 08/08/24 at 3:02 P.M. with Registered Nurse (RN) #801 revealed after Resident #41's fall on 01/24/24, he was still trying to attempt to walk but was unable to bear weight due to pain. Review of the March 2018 revised facility policy called; Assessing Falls and Their Causes revealed if a resident had just fallen, evaluate for possible injuries. If an assessment rules out significant injury, help the resident to a comfortable sitting, lying or standing position. Notify the attending physician and family.

Based on observation, interview, and review of the facility policy, the facility failed to ensure stock medications used for residents were not expired. This had the potential to affect 15 residents (Resident #57, #2, #65, #9, #79, #84, #74, #30, #45, #61, #342, #76, #49, #43, and #10) the facility identified as receiving stock medications out of 91 residents residing in the facility. Findings include: Observation on 08/06/24 at 11:54 A.M. with Unit Manager (UM) Licensed Practical Nurse (LPN) #836 of the west hall medication stock room revealed a partially used bottle of ducosate sodium 250 milligrams (mg) with an expiration date of 06/2024. An additional bottle of ducosate sodium 250 mg with an open date of 05/05/23 expired on 06/2024. A bottle of aspirin 81 mg expired 07/2024. A bottle of cranberry tabs 450 mg expired 05/2024. A bottle of vitamin D 25 micrograms expired 02/2024. The expired medications were verified by UM LPN #836. Observation on 08/06/24 at 12:10 P.M. with UM LPN #836 of the north hall medication stock room revealed a bottle of magnesium oxide 400 mg expired 04/2024. The expired medication was verified by UM LPN #836. Interview on 08/07/24 at 2:00 P.M. with DON confirmed expired medications should be disposed of from the stock medications. Record review provided by DON revealed Resident #57, #2, #65, #9, #79, #84, #74, #30, #45, #61, #342, #76, #49, #43, and #10 received facility stock medications from the stock medication rooms and had the potential to receive the expired medications. Review of the facility policy titled, Storage of Medications dated 11/2020 revealed discontinued, outdated, or deteriorated drugs or biological's are returned to the dispensing pharmacy or destroyed.

Based on record review and staff interview the facility failed to ensure residents personal funds accounts with balances greater than 100 dollars were deposited into an interest-bearing account as required. This affected four (Residents #33, #47, #55, and #69) of five residents reviewed for personal funds. The facility census was 91. Findings Include: 1. Review of the statement for Resident #33 revealed month ending account balance of $154.15 for the month of May 2024, $141.15 for the month of June 2024 and $289.99 for the month of July 2024. No interest was noted credited to Resident #33's account during these three months. 2. Review of the statement for Resident #47 revealed month ending account balance of $1,285.30 for the month of May 2024, $1,327.30 for the month of June 2024 and $1,373.30 for the month of July 2024. No interest was noted credited to Resident #47's account during these three months. 3. Review of the statement for Resident #55 revealed month ending account balance of $11,990.95 for the month of May 2024, $10,802.20 for the month of June 2024 and $10,400.59 for the month of July 2024. No interest was noted credited to Resident #55's account during these three months. 4. Review of the statement for Resident #69 revealed month ending account balance of $129.84 for the month of May 2024, no interest was noted credited to Resident #55's account for the month of May 2024. Resident #69's account balances for June and July 2024 were under $100.00. Interview on 08/06/24 at 8:34 A.M. with Business Office Manager (BOM) #837 verified Residents #33, #47, #55 and #69 did not receive interest for the year of 2024. BOM #837 stated he completed an audit in January 2024, and it was discovered that the facility's original bank, which held the resident fund accounts, did not pay interest to the residents. He found out that the interest that was accrued on the resident fund monies was absorbed back to the bank because their fees were higher than the interest accrued. BOM #837 stated that a new bank account was opened, and social security checks started to be deposited on 04/01/24 and continued to be deposited. BOM #837 stated that he will give interest when all the accounts are transferred. Interview on 08/07/24 at 1:26 P.M. with Administrator revealed he was the former Business Office Manager before being promoted and he didn't notice that the residents were not getting interest.

Based on observation, interview, and policy review, the facility failed to serve pureed foods at a smooth consistency for safe swallowing. This had the potential to affect nine residents (#10, #16, #18, #23, #27, #39, #45, #50, #62) the facility identified as receiving pureed diets of 91 residents who consumed meals from the facility's kitchen. No residents were identified as nothing by mouth (NPO). The facility census was 91. Findings include: Observation of puree preparation on 08/06/24 from 3:45 P.M. through 4:00 P.M. revealed [NAME] #881 pureed pepper steak. [NAME] #881 portioned a sample of the puree pepper steak into a souffle cup. A taste test of pureed pepper steak revealed there were intact pieces of the beef that was not smooth in consistency. A taste test on 08/06/24 at 4:00 P.M. with Dietary Manager (DM) #885 verified that the puree pepper steak was not a smooth consistency. DM #885 told [NAME] #881 to puree the pepper steak more. As [NAME] #881 was pureeing the pepper steak, the robot coupe (mechanical chopper) was making a noise. DM #885 stated that the bearings were starting to go on it and the backup robot coupe was just sent out for repair. Review of the undated facility's policy titled, Texture Modified Diets, revealed pureed foods should be of a mashed potato consistency.

Based on observation, interview, record review and review of facility policy, the facility failed to maintain appropriate hand hygiene during the tracheostomy (trach) care. This affected one (Resident #15) of one resident who was identified by the facility as having a trach. The facility census was 91. Findings include: Review of the medical record for Resident #15 revealed an admitted [DATE]. Diagnoses included but were not limited to chronic obstructive pulmonary disease, major depressive disorder, schizophrenia, and dependence on supplemental oxygen. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 05/06/24, revealed the resident had moderately impaired cognition. The resident required supervision for activities of daily living (ADLs). Review of the physician's order for August 2024 revealed Resident #15 revealed an order for trach care every shift. Observation of trach care on 08/06/24 at 2:37 P.M. with Licensed Practical Nurse (LPN) #892 revealed he did don personal protective equipment (PPE) correctly. LPN #892 removed the trach necktie and removed the split gauze and took a fresh gauze to clean the area. The area was red. LPN #892 then removed his gloves and put on a new pair of gloves. LPN #892 did not wash or sanitized his hands before putting on new gloves. LPN #892 verified that he did not wash hands prior to putting on the new pair of gloves and stated that Resident #15 usually does his own trach care. Review of the undated facility policy titled Tracheostomy Care revealed hand hygiene should be performed prior to putting on clean gloves.

Based on medical record review, review of a fall incident report and related facility investigation, interviews with staff and review of facility policy, the facility failed to timely notify Resident #41's primary care physician of a fall. This affected one (Resident #41) of two residents reviewed for accidents/hazards. The facility census was 91. Findings include: Review of the medical record for Resident #41 revealed an admitted [DATE] with diagnoses including schizophrenia, sarcoidosis, epilepsy, legal blindness, cachexia, muscle weakness, unspecified abnormalities of gait and balance and alcohol induced persisting dementia. A physician order dated 11/21/23 revealed Resident #41's primary physician was Medical Director #874. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #41 revealed the resident had severe cognitive impairment, no functional limitation in range of motion (ROM) of the lower extremities (hip, leg, ankle, foot), he used a walker and wheelchair for mobility, required substantial/maximum assist to walk ten feet and walking 50 feet with two turns was not attempted due to medical condition or safety concerns so the resident would require a wheelchair with substantial/maximum assistance of a helper to wheel 50 feet with two turns. Review of Resident #41's care plan (dated 04/20/17) with revisions on 02/07/24 revealed Resident #41 was at risk for falls related to his well-documented poor balance, unsteady gait, post seizure, and noncompliance with staff assistance. Intervention dated 03/30/21 revealed to encourage resident to utilize walker to aid with mobility and safety. Review of nursing progress note dated 01/24/24 timed at 2:29 P.M. revealed Resident #41 was ambulating unassisted without a walker and fell in the 100-hall lounge area. There was no head involvement per witness. Resident was assisted to bed. Neurological checks, pain and skin assessments were performed. Resident determined to be at baseline post fall. ROM was within normal limits per baseline. Resident reported no pain at the time of the incident. Parties notified included Hospice, the guardian and the Assistant Director of Nursing (ADON). Immediate action taken was to have the resident use a wheelchair for ambulation. There was no evidence Resident #41's primary care physician was notified of the incident. Review of the document titled #2811 Fall dated 01/24/24, timed 10:25 A.M. and prepared by LPN #898 revealed the resident (#41) was ambulating without walker and assistance of one and he fell in the 100hall/lounge. He did not hit his head, and he was unable to give a description. Immediate action taken was the resident was assisted to bed and would be given a wheelchair for further ambulation. There were no injuries noted. He was not taken to a hospital. A bruise was noted on his left front thigh. His pain level was seven (severe). He was alert and oriented to person. Predisposing factors included recent medication change and ambulating without assistance. Other info included non-compliance with walker and assistance, fixation on cigarettes and seizure history. There were unspecified staff witnesses at the time of the fall. Under the section titled agencies/people notified there were no notifications documented. Interview on 08/08/24 at 2:03 P.M. with the Director of Nursing (DON) confirmed if a resident had a fall, the resident was not to be moved until after the nurse assessed the resident and if there was a change in condition, the nurse was to notify hospice and update the physician of any changes. The DON confirmed according to the review of the fall investigation report dated 01/24/24 for Resident #41, Resident #41 was helped up off the floor and assisted back to his room before the nurse assessed him. The DON confirmed the resident was experiencing worsening pain post-fall and bruising to the left leg had been identified by LPN #898 on 01/24/24 and the primary care physician was not notified. Review of the March 2018 revised facility policy called; Assessing Falls and Their Causes revealed if a resident had just fallen, notify the attending physician in an appropriate time frame. When a fall results in a significant injury or change of condition, notify the physician immediately by phone. If the fall does not result in a significant injury or change of condition, notify the physician routinely by fax or phone the next office day.

Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure residents were provided a facility phone they could use timely and in a private area. This affected two residents (Resident #31 and #21) out of 20 residents reviewed for right to forms of communication with privacy. The facility census was 91. Findings include: 1. Record review for Resident #31 revealed an admitted [DATE]. Diagnosis included chronic obstructive pulmonary disease. Review of the Admissions Minimum Data Set (MDS) 3.0 assessment for Resident #31 dated 05/08/24 revealed Resident #31 was cognitively intact. Resident #31 had clear speech, was able to make self-understood and was able to understand others. Interview on 08/08/24 at 9:11 A.M. with Social Worker Designee (SWD) #803 and SWD Assistant #841 revealed if a resident wanted to make a phone call, and they did not have a personal cell phone, they would have to be put on a phone call waiting list to make a call which would be done at the nurses station. The residents that get on the list wait until the nurses were not busy, then they can use the phone. Interview on 08/08/24 at 10:56 A.M. with Resident #31 revealed her personal cell phone was broken. Resident #31 revealed if she wanted to make a phone call, she had to fill out a form and then wait for the staff. Resident #31 revealed she made out two papers (forms) at two different times to use the phone. Resident #31 stated, That's what they told me, oh you got to make out a paper, they still have not let me use their phone. Resident #31 revealed she never gets to make a call in private. Interview on 08/08/24 at 10:58 A.M. with Licensed Practical Nurse (LPN) #920 and Unit Manager LPN #836 revealed when a resident wanted to make a call, they needed to fill out a form. Unit Manager LPN #836 revealed once the form is filled out, the nurse will make the call for them at the nurses station and the nurse must stay right there with them while the resident is on the phone. Unit Manager LPN #836 revealed there was a pay phone available for the residents to use if they had money. Unit Manager LPN #836 confirmed the pay phone was not in a private area and the residents would not be able to make a private phone call. Interview and observation on 08/08/24 at 11:05 A.M. with Activity Director #807 of the pay phone made available for resident use confirmed the pay phone was in a public area. Activity Director #807 confirmed the pay phone also did not work. Activity Director #807 confirmed if a resident wanted to make a phone call, and they did not have a personal cell phone, they would need to fill out a phone call request form and turn it into the nurses station. The nurses or State tested Nursing Assistant (STNA) would let the resident know when they had time to allow the resident to make their call. Record review of the Phone Call Request Form revised 03/2024 revealed the form to be completed included Resident name, date, Person you are requesting to call, day you would like to make the call, phone number, circle a time 8:00 A.M. - 12:00 P.M., 1:00 P.M. to 4:00 P.M., and 6:00 P.M. - 9:00 P.M. 2. Record review for Resident #21 revealed an admitted [DATE]. Diagnosis included metabolic encephalopathy. Review of the quarterly MDS 3.0 assessment for Resident #21 dated 06/28/24 revealed Resident #21 had moderate cognitive impairment. Resident #21's speech was clear, made self-understood and was able to understand others. Interview on 08/08/24 at 11:10 A.M. with Resident #21 revealed the staff refused to let her use the phone in the past telling her they need the phones for incoming calls. Resident #21 revealed the staff did not want residents using their phones. Interview on 08/08/24 at 11:15 A.M. with STNA #894 revealed she helped residents in the past to make phone calls. STNA #894 revealed the resident must first fill out a form then they have to wait until the STNA, or nurse had time to help them with the call. STNA #894 revealed the residents phone calls were made from the nurses station and staff had to stay with the resident during the call. STNA #894 revealed there was also a phone located at the end of the hall the resident could use but that phone was also not a private area. Interview on 08/08/24 at 11:18 A.M. with Registered Nurse (RN) #801 revealed when a resident wanted to use a facility phone, someone had to help them. The resident must fill out a paper first. RN #801 revealed the nurse would place the call from the nurses station then they could transfer the call to the phone in the hall. Observation of the phone located at the end of the hall revealed three residents sitting in the hall within hearing distance of the phone RN #801 referred to. RN #801 confirmed the phone in the hall would not allow outgoing calls, only incoming calls and confirmed the phone in the hall would not be a private phone call. Interview on 08/08/24 at 11:36 A.M. with Administrator confirmed the pay phone was currently not accepting coins. To allow opportunity for all residents to make outgoing calls, the facility created the phone call request form. The form was to be used if the payphone was unavailable or the resident did not have money. Once the form was filled out, it would be provided to the nurse, then at the nurses earliest available opportunity, the nurse would provide use of facility phone either at the nurses station or transfer the call to the hall phone. Administrator confirmed the hall phone would not allow outgoing calls. Administrator confirmed the residents have the right to make a call in privacy, and it would be either at the nurses station or in the hall. Interview on 08/08/24 at 1:03 P.M. with DON revealed residents have the right to use a phone in privacy and at the time of request. Review of the facility policy titled, Telephones, Resident Use of undated revealed Residents shall have easy access to telephones. Designated telephones are available to residents to make and receive private phone calls. The telephones at the nurses stations are reserved for staff use, unless no other alternative is available.

Based on record review and staff interview the facility failed to ensure resident funds were conveyed timely upon resident discharge from the facility. This affected one (Resident #242) of five residents reviewed for resident funds. The facility census was 91. Findings Include: Resident #242 was admitted to the facility on [DATE] and expired on [DATE]. Review of the business records for Resident #242 revealed a check for $2,169.85 was dispersed to the Treasurer of Ohio State on [DATE]. Interview on [DATE] at 8:34 A.M. with Business Office Manager (BOM) #837 verified that Resident #242's funds were dispersed on [DATE] and Resident #242 expired on [DATE]. BOM #837 stated that he thought he had up to 90 days after the resident's death. BOM #837 stated that according to the Revised Ohio Code that the 90 days was because of an open application for release filed. BOM #837 could not provide documentation of any open application, and it was explained that the federal regulations are more stringent, and funds must be conveyed within 30 days.

Based on interview, record review and facility policy review, the facility failed to complete a baseline care plan within 48 hours after admission as required. This affected one (Resident #342) of 20 residents reviewed for care plans. The facility census was 91. Findings include: Review of the medical record for Resident #342 revealed an admitted [DATE]. Diagnoses included but were not limited to schizoaffective disorder, generalized anxiety disorder, unspecified dementia, type II diabetes mellitus, chronic respiratory failure, and neuromuscular dysfunction of bladder. No evidence was found of a baseline care plan following admission. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #342 had severe cognitive impairment, required maximum assistance of one for dressing and was dependent upon staff for toileting and transfers. Interview on 08/07/24 at 4:17 P.M. with the Director of Nursing confirmed she was unable to provide evidence of a baseline care plan or comprehensive care plan developed within 48 hours of admission for Resident #342. Review of undated facility policy called; Care Plan-Baseline revealed a comprehensive care plan may be used in place of a baseline care plan providing the comprehensive care plan is developed within 48 hours of the resident's admission and meets the requirements of a comprehensive assessment.

Based on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident #82 received routine showers/bathing to meet his care needs. This affected one (Resident #82) of three residents reviewed for showers/bathing. The facility census was 91. Findings include: Record review for Resident #82 revealed an admitted [DATE]. Diagnoses included encephalopathy and adult failure to thrive. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #82 was severely cognitively impaired. Resident #82 required substantial/maximum assistance for toileting, personal hygiene and dependent for showers. Review of the care plan revealed Resident #82 had a self care performance deficit related to impaired cognition, needs assistance with dressing and grooming. Interventions included to encourage resident to participate in activities of daily living. Review of the shower record for Resident #82 for June and July 2024 revealed Resident #82 was to receive showers on Tuesdays and Thursdays per Hospice. Review of the shower sheet for June 2024 revealed Resident #82 received one shower between the date of 06/13/24 and 06/25/24 (received 06/19/24). Resident #82 received the next shower in July 2024 on 07/03/24. From 07/04/24 through 07/16/24, Resident #82 received one shower (07/10/24). From 07/20/24 through 07/30/24, Resident #82 received one shower (07/24/24). Observation and interview on 08/05/24 at 1:31 P.M. revealed Resident #82 had very oily hair with multiple white particles throughout his hair. Resident #82 had a strong body odor. Resident #82 revealed he would like more showers. Observation and interview on 08/05/24 1:32 P.M. with State tested Nursing Assistant (STNA) #886 confirmed Resident #82 had very oily hair with multiple white partials throughout his hair and confirmed Resident #82 had a strong body odor. STNA #886 revealed hospice gave Resident #82 showers two times a week. If a resident received hospice services, the facility would not schedule routine showers any longer for the resident, that would be the responsibility of hospice. Observation and interview on 08/06/24 at 2:05 P.M. with Licensed Practical Nurse (LPN) #805 confirmed Resident #82 had very oily hair with multiple white partials throughout his hair. Resident #82 had strong body odor, and LPN #805 revealed she could not smell it. Interview 08/06/24 at 4:45 P.M. with DON revealed she would expect staff to give or offer each resident a minimum of two showers a week even if they received hospice services. DON revealed a resident may refuse showers, but the facility should still offer the showers and if they received hospice services, hospice would then also offer two additional showers a week. Interview on 08/07/24 at 9:35 A.M. with Registered Nurse (RN) #930 from Hospice #931 confirmed Resident #82 received Hospice services through her company. RN #930 revealed the hospice aid would visit Resident #82 two times a week and offer a shower or bath. The Hospice Aid would not consistently come the same two days a week. RN #930 revealed hospice provided additional care to the residents in facilities. The expectations would be hospice would provide two showers/baths a week and the facility would continue to provide their two showers/baths a week unless the resident refused. Interview on 08/07/24 at 9:41 A.M. with Unit Manager #836 revealed the STNA's assumed if a resident received hospice services, they dont have to do that residents showers anymore because hospice does them. Unit Manager #836 revealed sometimes hospice doesn't show up on scheduled shower days so they make up the shower when they show up. Interview on 08/07/24 at 1:28 P.M. with DON confirmed there was no further documentation of any showers Resident #82 received, all showers were documented on the shower sheet by hospice aids. DON confirmed there was no documentation of Resident #82 refusing showers. Review of the facility policy titled, Bath, Shower/Tub revised February 2018 revealed the purpose of the procedure was to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin.

Based on observation, record review, review of facility Self-Reported Incidents (SRIs), local police report review, review of the facility's Abuse policy and procedure and interviews, the facility failed to ensure Resident #28 was free from resident-to-resident physical abuse. This resulted in Immediate Jeopardy and actual harm beginning on 08/28/23 at 4:30 P.M., when Resident #37, who was cognitively intact and known to be verbally and physically aggressive, was observed by Licensed Practical Nurse (LPN) #123 entering Resident #28's room, where he squeezed Resident #28's hands in a forceful manner. Resident #28, who was non-verbal, was heard screaming in pain, LPN #123 responded and removed Resident #37 from Resident #28's room. Resident #28 was assessed to have bilateral hand edema, bruising and pain. X-rays of Resident #28's hands revealed Resident #28 had a left (hand) fifth proximal phalanx (finger) fracture and fractures to the right hand second through fifth proximal phalanges (fingers). The resident was subsequently transported to the hospital for evaluation and treatment. Following the incident, the facility failed to develop and implement effective and planned safety measures to protect Resident #28 and other residents from situations of abuse by Resident #37. The lack of adequate and necessary supervision and interventions for Resident #37 placed all residents at risk for actual harm or serious life-threating injuries up to and including death as a result of resident-to-resident abuse. On 09/10/23 State Testing Nursing Assistant (STNA) #114 reported to LPN #174 a verbal confrontation between Resident #37 and Resident #47. Resident #37 attempted to push Resident #47 into his bathroom. Resident #47 was able to grab the door handle to prevent Resident #37 pushing him in the bathroom after Resident #37 entered his room. On 09/10/23 Resident #76 was heard saying stop squeezing my hand and Resident #37 was observed in the day room squeezing Resident #76's hands. On 09/11/23 at a beverage break, Resident #37 had a physical altercation with Resident #85, where Resident #37 was antagonizing Resident #85 by preventing him and blocking him from moving out of the area. Additionally, the facility failed to prevent additional situations of resident-to-resident abuse that did not rise to the level of an Immediate Jeopardy for Residents #45 and #77 who were abused by Resident #91 and for Resident #46 who was abused by Resident #85. This affected seven residents (#28, #45, #46, #47, #76, #77 and #85) reviewed for resident-to-resident abuse and had the potential to affect all residents residing in the facility who Resident #37 could potentially have contact with. The facility census was 91. On 09/14/23 at 1:49 P.M. the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 08/28/23 at approximately 4:30 P.M. when Resident #28 was physically abused by Resident #37 when Resident (#37) forcefully squeezed Resident #28's hands causing swelling, bruising, pain and bone fractures and the safety measures put in place to protect Resident #28 and other residents were not thoroughly and timely implemented or effective. The Immediate jeopardy was removed on 09/14/23 when the facility implemented the following corrective action: On 09/13/23 at 5:34 P.M. Resident #37's physician was notified of Resident #37's behaviors with no new orders. Resident #37's physician deferred to psychiatry. On 09/14/23 at 3:30 P.M. Resident #37 was moved to a private room. On 09/14/23 at 3:30 P.M. one-to-one staff monitoring was implemented for Resident #37. The one-on-one supervision was scheduled to continue for a duration of one week, after which time Resident #37 would be reassessed by the physician, psychiatrist, and the interdisciplinary team. Based on this assessment, a decision would be made regarding Resident #37's supervisory needs. On 09/14/23 at 3:42 P.M. the psychiatrist completed a medication review of Resident #37's medications and adjusted Resident #37's antipsychotic medication due to disruptive behaviors. On 09/14/23 at 4:00 P.M. Resident #37's care plan was updated to include an individualized behavior plan. The behavior plan addressed physical and verbal abuse, staying out of other residents' rooms, and the facility's behavior modification program. The behavior plan was signed by Resident #37, the Administrator, Director of Nursing (DON), Unit Manager Registered Nurse (UM RN) #180 and Social Service Assistant (SSA) #132 and was to be implemented immediately. On 09/14/23 at 5:30 P.M. the unit manager nurses audited all facility residents for similar behaviors and care plans were updated if needed. On 09/14/23 at 5:32 P.M. all staff were in-serviced through a web-based program on abuse, elder abuse and neglect: preventing, recognizing and reporting abuse; de-escalation strategies; and doing and completing in services. On 09/14/23 at 6:30 P.M. the unit manager nurses completed a facility wide audit for pain and injury for all residents. No concerns were identified. Starting on 09/18/23, Human Resources Coordinator (HRC) #135 or designee would audit in-service completion records weekly for the next four weeks. Following the weekly audits, HRC #135 would complete random monthly auditing of in-service completion for three months. Results of the audits would be reviewed monthly in Quality Assurance Performance Improvement (QAPI) meetings and an action plan implemented if not in compliance. Starting on 09/18/23, Director of Nursing (DON) or designee would audit incident reports and investigations weekly for the next four weeks. Following the weekly audits, the DON would complete monthly auditing of incident reports and investigations for three months. The audits were to include assurances that residents were protected from further occurrences and that corrective actions were implemented as necessary. The results of the audits would be reviewed monthly in QAPI meeting, and an action plan implemented if not in compliance. Interviews completed on 09/18/23 between 10:00 A.M. and 11:00 A.M. with Registered Nurse (RN) #182, LPN #106, and State tested Nursing Assistant (STNA) #188 verified staff were knowledgeable on recognizing and reporting abuse and de-escalation strategies. Interviews completed on 09/18/23 between 1:30 P.M. and 3:11 P.M. with RN #101, LPN #167, Housekeeper #103 and STNA #194 verified staff were knowledgeable on recognizing and reporting abuse and de-escalation strategies. Observations on 09/14/23 at 4:00 P.M., 09/18/23 at 7:00 A.M., 11:00 A.M. and 2:38 P.M. revealed a staff member was seated in Resident #37's room or directly outside Resident #37's room for one-to-one supervision. Review of staff schedules from 09/14/23 at 3:30 P.M. through 09/18/23 confirmed a staff member was assigned to always provide one to one supervision for Resident #37. Although the Immediate Jeopardy was removed on 09/14/23, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan and monitoring to ensure continued compliance. Findings include: 1. Review of the medical record for Resident #28 revealed an admitted [DATE] with diagnoses including cerebral palsy, cerebrovascular accident (stroke) with hemiparesis (weakness on one side of the body) and hemiplegia (paralysis on one side of the body) affecting right dominant side, aphasia (loss of ability to understand or express speech) and reduced mobility. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/09/23, revealed Resident #28 was rarely/never understood, with a Brief Interview for Mental Status (BIMS) score of a 00, indicating severely impaired cognition. The assessment revealed Resident #28 required extensive to dependent assistance of one to two staff members for activities of daily living (ADLs). Review of Resident #28's progress note dated 08/28/23 revealed at approximately 4:30 P.M., Resident #28 had his hands forcefully squeezed by another resident and was screaming in his room. LPN #123 assessed Resident #28 for injuries and noted edema and bruising to bilateral hands and updated the physician and facility leadership. Review of Resident #28's mobile radiology report, dated 08/28/23, revealed Resident #28's left hand had an acute appearing fifth proximal phalanx fracture. The report noted the right hand examination was a limited study for which fracture could not be excluded and recommended a repeat study with additional diagnostic views. Review of Resident #28's progress note dated 08/29/23 timed 8:30 A.M. revealed Resident #28's physician was notified of the inconclusive radiology results and Resident #28's status. Resident #28 was observed to have facial grimacing, indicative of pain, with manipulation of the right hand. Resident #28's right hand was observed to be grossly edematous (swollen). The physician ordered a STAT (immediate) repeat x-ray examination of Resident #28's right hand and an order for Tramadol, an oral opioid analgesic, as needed. Review of Resident #28's mobile radiology report, dated 08/29/23, of the right hand revealed acute appearing fractures in the second through fifth proximal phalanges. Review of Resident #28's progress notes dated 08/29/23, revealed Resident #28's physician was updated on the STAT radiology results and ordered Resident #28 to be transferred to the hospital for evaluation. Resident #28 was sent to the hospital on 08/29/23 at 7:35 P.M. and returned to the facility on [DATE] at 2:30 A.M. Review of Resident #28's hospital records, dated 08/29/23, revealed Resident #28 presented to the hospital with injuries after he was the victim of an assault at a nursing facility. The medical record revealed outside x-rays revealed metacarpal fractures to the right hand. Ecchymosis (bruising) and blisters were noted to Resident #28's right hand. Due to the patient being non-verbal, multiple radiological examinations were performed to identify injuries. In addition to the hand injuries identified pre-hospital, Resident #28 was additionally found to have a closed nondisplaced fracture of the phalanx (toe) of right foot, and a closed fracture of one rib on the right side. Hospital records further revealed that the guardian was contacted by the hospital staff who was agreeable for Resident #28 to return to the facility. Review of Resident #28's physician's orders, dated 08/30/23, revealed new orders for two staff members to be present for all care due to acute injuries, and for a mechanical lift with two staff members to be used for all transfers. Resident #28 was referred to an orthopedic physician for consultation. Review of a facility SRI, tracking number 238619 revealed the facility reported an incident of resident-to-resident physical abuse on 08/28/23. The SRI indicated on 08/28/23 LPN #123, who was in a resident room across the hall, heard Resident #28 yell. Upon entering Resident #28's room, the nurse saw Resident #28 lying in bed with Resident #37 seated in his wheelchair next to Resident #28's bed, forcefully squeezing Resident #28's hands. LPN #123 intervened and removed Resident #37 from Resident #28's room. Resident #28 was assessed for injury and found to have bilateral hand swelling and bruising. Resident #28's physician was notified and ordered bilateral hand x-ray examinations. The SRI contained staff statements and identified only one staff member, LPN #123, witnessed the incident. As a result of the investigation, the facility moved Resident #37 to a different hallway, away from Resident #28's room, implemented every 15-minute safety checks for Resident #37 for a period of 72 hours, and all staff were to be in-serviced on abuse and resident rights. Review of the document titled Accident or Incident Report dated 08/28/23 and timed 4:30 P.M. revealed another resident was forcefully squeezing Resident #28's hands. The incident appeared to be non-consensual and caused discomfort or distress to Resident #28. The incident report was completed by LPN #123. Review of local police report, reported on 08/29/23, revealed the DON reported the incident and stated an assault occurred between two residents of the facility on 08/28/23. The victim, Resident #28 suffered multiple fractures. The report noted Resident #28's guardian was unable to be reached but facility staff reported the guardian wished to pursue charges. The report indicated the case was closed on 09/11/23. No disposition or rationale was listed. Observation on 09/13/23 at 1:19 P.M. revealed Resident #28 lying in bed. His bilateral arms were on top of a blanket. Resident #28's right and left hands were observed to be edematous, with the right side more edematous than the left. Resident #28 was awake, but unable to answer questions or meaningfully engage in conversation. Review of Resident #37's medical record revealed an admitted [DATE] with diagnoses including bipolar disorder, psychoactive substance use, opioid abuse, anxiety, depression, and a history of suicidal ideations. Review of Resident #37's hospital medical records prior to admission to the facility, dated 07/19/23, revealed Resident #37 presented to the hospital requesting detox from methamphetamines, cocaine, and fentanyl. He had not taken his prescription medications for the past two weeks since he was kicked out of another nursing home and taken to a park near a homeless shelter. Resident #37 had not been able to secure housing, and had a lifetime ban, for unknown reasons, at homeless shelters in the area. Hospital records indicated Resident #37 had poor impulse control and his insight and judgement were impaired. Review of Resident #37's care plan, dated 08/11/23, revealed a focus on Resident #37's adjustment issues to the facility. Resident #37's care plan also identified he participated in the facility's behavior modification plan. Review of Resident #37's admission MDS 3.0 assessment, dated 08/18/23, revealed he was cognitively intact with a BIMS score of 14. Resident #37 experienced delusions and was identified to have verbal behavior symptoms directed towards others on four to six days, and other behavioral symptoms not directed towards others on one to three days during the seven-day lookback period. Resident #37 was identified to require the use of a wheelchair for mobility. He required extensive assistance of one staff for personal hygiene and required supervision of one staff for all other activity of daily living (ADL) care. Review of progress notes dated 08/15/23 through 09/11/23 revealed instances of Resident #37 being up all night self-propelling through the hallways, verbal and physical aggression towards staff, staffing closing a door to prevent Resident #37 from becoming physically aggressive with the staff, verbal threats of physical aggression, use of profane language, calling staff obscene names, kicking and throwing a trash can down the hallway, ramming his wheelchair into LPN #107's shins and punching LPN #107 in the abdomen, banging on the glass surrounding the north nurses station with a closed fist, going in and out of other resident rooms when they did not consent, verbal confrontations with other residents, pushing another resident (Resident #47) upon entering the resident's room without consent, squeezing Resident #28 and Resident #76 hands forcefully, and preventing and blocking Resident #85 from moving out of an area. Interview on 09/13/23 at 1:26 P.M. with State tested Nursing Assistant (STNA) #144 revealed Resident #28 was almost completely non-verbal. Occasionally he was able to verbalize a one-word phrase, and he frequently used sounds, like a short yell, to communicate discomfort. STNA #144 stated Resident #28 required extensive assistance of one to two staff members for ADL's. STNA #144 revealed she knew Resident #37 to have frequent verbal behaviors directed at staff members and other residents. Interview on 09/13/23 at 1:40 P.M. with LPN #136 revealed Resident #37 to be verbally aggressive. LPN #136 stated there had been instances where he had attempted physical aggression, but staff were able to intervene and de-escalate the situation before situations progressed. LPN #136 recalled an incident that occurred on 09/11/23 where Resident #37 and Resident #85 were both outside at a beverage break. Resident #37 antagonized Resident #85 repeatedly by blocking Resident #85's path which prevented Resident #85 from removing himself from Resident #37. Resident #85 was observed to strike Resident #37 in his head, which knocked his hat off. LPN #136 stated Resident #37 was identified to be the aggressor who initiated the altercation. LPN #136 stated she documented behavior incidents in the medical record and kept nursing leadership informed of behavior patterns. LPN #136 stated both Resident #37 and Resident #85 were known to be verbally aggressive but receptive to redirection. Interview on 09/13/23 at 2:08 P.M. with STNA #105 revealed she cared for Resident #28 on 08/28/23. The nurse on duty had informed her of the incident that occurred around dinner time on 08/28/23 and to be careful when performing care or moving his upper extremities. STNA #105 stated she was cautious when she provided evening care and got Resident #28 ready for bed that evening. STNA #105 stated Resident #28 had edema to both of his hands, including his fingers but she did not recall any bruising or verbal or non-verbal signs of pain. Observation on 09/13/23 at 2:19 PM revealed Resident #37 was seated in a manual wheelchair in the west hall common area. Resident #37 was awake, alert and dressed appropriately. During an interview, Resident #37 stated he had never had a physical incident with another resident at the facility and questioned who said that he did. Resident #37 stated that all the staff at the facility were liars and denied getting physical. Resident #37 stated he had only gone to Resident #28's room to visit as he had tried to be friendly. Resident #37 ended the conversation, raised his hands up in the air and self -propelled his wheelchair down the hallway towards his room. Interview on 09/13/23 at 2:28 P.M. with unit manager (UM) LPN #141 revealed she had seen Resident #37 enter other resident rooms uninvited. Resident #37 was cognitively intact, and staff had attempted to educate and redirect him, but Resident #37 was quick to become verbally aggressive. LPN UM #141 stated she was familiar with the incident between Resident #28 and Resident #37 but had no firsthand knowledge of the event. She stated an additional incident happened on 09/10/23 when Resident #37 was observed to squeeze Resident #76's hands in a common area. LPN UM #141 stated she was concerned about Resident #37's continued stay in the facility and stated he was unpredictable, and it bothered her to see another vulnerable resident who Resident #37 gravitated towards. LPN UM #141 revealed upon returning from the hospital on 08/30/23, Resident #28 returned to a room on the same hall as Resident #37. Resident #37 was moved to another unit midday on 08/30/23. LPN UM #141 stated when incidents occurred, the facility nursing staff completed an incident report that first went to the unit manager, and then was turned into and reviewed by the DON. Interview on 09/13/23 at 2:58 P.M. with the DON verified Resident #37 had a room change to the opposite side of the facility, but not until 08/30/23 at 11:30 P.M., approximately 43 hours after the incident between Resident #28 and Resident #37 occurred. The DON stated Resident #37 primarily had only been aggressive with staff and had a rough adjustment to the facility. Resident #37 was mouthy and rude, but had only been aggressive with one staff member, LPN #107. The DON further stated Resident #37 was relatively new to the facility and needed to continue to learn the rules of the facility. The DON revealed Resident #28 had no falls recorded or reported that could account for the closed nondisplaced fracture of the phalanx (toe) of the right foot, and closed fracture of one rib on the right side (noted in the hospital). The DON stated interventions were put in place following the investigation of the incident between Resident #28 and Resident #37 including 15-minute safety checks for Resident #37, all staff education on abuse and resident rights, and Resident #37 moving to another part of the building. The DON stated the date and time Resident #37 moved to his new room was recorded in his progress notes. The DON indicated the 15-minute checks were to be completed on paper, on a Patient Safety 15 Minute Check Sheet by either the nurse or the aide assigned to care for Resident #37. Upon review of the sheets, interview with the DON verified the 15-minute checks for Resident #37 were implemented on 08/28/23 at 4:15 P.M. and were due to be completed on 08/31/23 at 4:00 P.M. The DON verified that 16 hours of entries were missing from the form dated 08/30/23 and 8 hours of entries were missing from the form dated 08/31/23. Interview on 09/13/23 at 3:37 P.M. with LPN #107 revealed he had been the recipient of Resident #37's physical aggression on one occasion. LPN #107 recalled Resident #37 had rammed his wheelchair into LPN #107's shins and punched him in the stomach after he attempted to discuss with Resident #37 the smoking times and facility routines. LPN #107 stated Resident #37 was an instigator, and repeatedly verbally aggressive with other residents. LPN #107 stated Resident #37 was had not yet adapted to the rules of the behavior modification program and facility rules. Observation on 09/13/23 at 4:50 P.M. revealed Resident #28 was seated in his wheelchair in the small dining room located on the first floor with approximately eight additional residents. An unnamed staff member was seated beside him feeding him supper. Observation on 09/13/22 at 4:52 P.M. of the main dining room located on the first floor revealed approximately 40 residents were seated at the tables eating their meals. In addition, residents were lined up in the hallway leading to the main entrance to await the second meal setting. All residents in the facility ate their meals in either the main or small dining rooms located on the first floor thus placing all residents at risk for interaction/altercation with Resident #37. Interview with on 09/14/23 at 10:10 A.M. with HRC #135 revealed she assigned three training courses to all staff on 08/31/23 after direction from facility leadership. The three training courses assigned were Abuse Investigation and Reporting, Recognizing Signs and Symptoms of Abuse, and Resident Rights. HRC #135 indicated for each of the three in-services there was a completion report which identified each staff member as either having completed or not completed the assigned in-service. HRC #135 stated the information on the completion reports were current as of 09/14/23 at approximately 10:00 A.M. Review of the completion report for the web-based training titled Abuse Investigation and Reporting, revealed the course was assigned to all 106 staff members of the facility on 08/31/23. As of 09/14/23 at 10:00 A.M., only 43 of 106 staff members had completed the training, a completion rate of 40.57 percent. Review of the completion report for the web-based training titled Recognizing Signs and Symptoms of Abuse, revealed the course was assigned to all 106 staff members of the facility on 08/31/23. As of 09/14/23 at 10:00 A.M., only 40 of 106 staff members had completed the training, a completion rate of 37.74%. Review of the completion report for the web-based training titled Resident Rights, revealed the course was assigned to all 106 staff members on 08/31/23. As of 09/14/23 at 10:00 A.M., only 44 of 106 staff members had completed the training, a completion rate of 41.51%. Interview on 09/14/23 at 11:10 A.M. with the DON verified the three training courses assigned on 08/31/23 were not completed by all staff in a timely manner. Interview on 09/14/23 at 12:40 P.M. with the Administrator revealed he evaluated residents in-person prior to admission to the facility. The Administrator indicated Resident #37 had hard life experiences with minimal family involvement and was still in the process of getting acclimated to the facility. The facility put individual plans of care in place for each resident and the behavior plans were in place to promote structure and routine within the facility. The Administrator indicated there were a lot of rules at the facility that took time to learn but the facility strived to give a sense of purpose and a reward system to keep behaviors in check. Interview on 09/14/23 at 3:38 P.M. with Resident #85 revealed occasionally other residents raised their voices at him, and he had raised his voice back at them. Resident #85 recalled an interaction with Resident #37 a few days prior and stated Resident #37 was known to cause problems with residents and staff and recalled Resident #37 had gotten in his face on a few occasions. Resident #85 declined to speak further about the incident or Resident #37. Interview on 09/18/23 at 1:22 P.M. with Resident #47 revealed the resident recalled a recent incident with Resident #37 a few days or a week ago. Resident #37 attempted to push him backwards in his wheelchair into his bathroom. Resident #47 stated he was not injured and had no additional incidents with Resident #37 prior to or since that incident. Resident #47 stated no staff were around at the time of the incident but stated he had reported it to a staff member who checked on him afterwards. Interview on 09/19/23 at 11:00 A.M. with LPN #123 revealed he was across the hallway in another resident's room when he heard Resident #28 yell. LPN #123 stated Resident #28 was not able to talk much, rather he made noises or yelled to communicate. When LPN #123 heard Resident #28 yelling, he looked towards the direction of the yelling into Resident #28's room. LPN #123 observed Resident #37 seated in his wheelchair at Resident #28's bedside, forcefully squeezing Resident #28's hands. LPN #123 stated Resident #28 appeared to be in pain, as he exhibited facial grimacing and negative vocalizations. LPN #123 directed Resident #37 to leave the room, and Resident #37 wheeled himself out into the hallway. LPN #123 assessed Resident #28 for injuries and identified bilateral hand swelling, redness, and the early signs of bruising. LPN #123 contacted Resident #28's physician who ordered x-rays to both hands. LPN #123 stated on the day of occurrence, 08/28/23, the right-hand x-ray came back inconclusive, while the left-hand x-ray identified a fracture to the left pinky finger. LPN #123 revealed Resident #28 appeared to be in pain on 08/28/23 and was medicated with his routine acetaminophen (a mild pain reliever) that was effective. 30809 2. Medical record review revealed Resident #45 was admitted on [DATE] with diagnoses including schizophrenia, major depressive disorder, anxiety, pulmonary disease, high cholesterol, osteoporosis, polyosteoarthritis, extrapyramidal and movement disorder, vitamin D deficiency, and insomnia. Resident #45 was unsteady on feet with difficulty walking, muscle weakness, and had low back pain. Review of a facility Self-Reported Incident (SRI), tracking number 234468 dated 04/28/23, indicated an allegation of physical abuse. The SRI indicated at approximately 11:15 P.M. on 04/27/23 a staff member (unnamed) heard two residents speaking in loud volumes on the west hallway in the facility. The staff member entered Resident #45's room and Resident #45 informed the staff member that Resident #91 had entered her room and struck her on the left side of her face near her eye. Both residents were separated, and a skin assessment was completed for Resident #45. Resident #45 had suffered a 0.1 centimeter (cm) scratch on the inner canthus region of her left eye. The SRI indicated Resident #91 had a diagnosis of paranoid schizophrenia, schizoaffective disorder, severely impaired cognition, dementia with behavioral disturbance and impulse control disorder. Resident #91 was unable to state why she had struck Resident #45. Resident #45 informed the facility that she was sleeping when Resident #91 walked in her room and punched her in the left eye and wanted to file a police report. Resident #45 was moderately cognitively impaired and did not know why Resident #91 had punched her in the eye. A police report was filed, and the local police department investigated the incident. Record review revealed there was no documentation in Resident #45's progress notes of the incident dated 04/27/23. Resident #45's most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated she needed extensive assistance with dressing, toileting and personal hygiene, one-person physical assistance with ambulation, had unsteady balance when walking, turning around and facing the opposite direction, moving on and off the toilet and during surface-to-surface transfers. An interview with State tested Nursing Assistant (STNA) #194 on 09/18/23 at 8:49 A.M. indicated (on 04/27/23) she heard Resident #45 screaming for help and went to investigate the cause of the problem. STNA #194 stated Resident #45 informed her Resident #91 had hit her in the left eye. STNA #194 stated Resident #45's left eye was bleeding and red and she reported the incident to the nurse and wrote a statement of the incident during the facility investigation. STNA #194 stated the police were notified and did talk to both residents regarding the incident. An interview with Resident #45 on 09/18/23 at 10:15 A.M. revealed she had no memory of the incident with Resident #91. Review of Resident #91's MDS 3.0 assessment dated [DATE] indicated Resident #91 exhibited behaviors including hallucinations, delusions, physical symptoms (e.g., hitting, kicking, pushing scratching, grabbing, abusing others sexually), verbal behavioral symptoms (e.g., threatening others, screaming at others, cursing at others). The MDS assessment indicated the behaviors exhibited had an impact on others by putting others at significant risk for physical injury, significant intrusion on the privacy or activity of others, and significantly disrupting the care or living environment. Review of Resident #91's nursing progress note dated 04/28/23 indicated Resident #91 had struck Resident #45 in the left eye causing slight bleeding in the inside corner of her eye. A cold compress was applied, and neurological checks were implemented. A review of Resident #91's plan of care revised on 05/22/23 indicated Resident #91 had potential to demonstrate physical behaviors related to dementia, schizoaffective disorder, impulse control disorder and delusional disorder. Interventions on the plan of care included monitoring and documenting her behavior and report, document and notify physician of danger to self and others. Resident #91 was discharged from the facility and not available to interview. A review of Registered Nurse (RN) #197's written statement regarding the incident where Resident #91 hit Resident #45 in the left eye on 04/27/23 at 11:15 P.M. indicated STNA #194 had reported Resident #91 hit Resident #45 in the left eye causing Resident #45's eye to bleed and the eye was reddened. RN #197 assessed Resident #45 and found the inner corner of her left eye was bleeding and applied a cold compress and notified the Director of Nursing (DON) and physician. 3. Medical record review revealed Resident #46 was admitted on [DATE] with diagnoses including morbid obesity, lymphedema, seizures, mental disorder, intermittent explosive disorder, obsessive compulsive disorder, psychotic disorder, anxiety, moderate intellectual disability, personality disorder, bipolar disorder and major depressive disorder. Resident #46's medical record revealed she had lack of coordination, muscle weakness, and cervical disc disorder with myelopathy. Resident #46's nur [TRUNCATED]

Based on observations, resident and staff interview, review of the facility operational and emergency assessment, review of facility policies titled Facility Disaster Preparedness Assessment, Formalized Agreements and Contingencies, and Preparations for Severe Weather, and review of the daily weather conditions and outside temperatures on https://www.wunderground.com, the facility failed to ensure comfortable and safe temperatures were maintained throughout the resident areas of the facility when temperatures fell below 71 degrees Fahrenheit (F) in resident rooms and common areas during an electrical power outage. This resulted in an Immediate Jeopardy when the facility did not implement monitoring of the temperature of resident living areas, did not immediately seek to connect their heating system to the facility generator or implement an alternative emergency heating source in a timely manner. The outside temperature on 02/24/19 fell to a low of 29 degrees F. On 02/25/19 from 1:28 P.M. to 1:50 P.M, facility room temperatures were recorded between 60.2 degrees F and 66.7 degrees F. The outside temperature on 02/25/19 was a high of 30 degrees F and a low of 21 degrees F. This affected the facility census of 95 residents. On 02/25/19 at 2:29 P.M. the Administrator was notified that Immediate Jeopardy began on 02/24/19 at 2:00 P.M. when the facility heating system was no longer functional due to an electrical power outage, and the back-up generator was not supplying power to maintain the operation of the heating system. Additionally, the temperature of resident living areas was not being monitored, and the facility did not have arrangements with offsite locations to temporarily transfer all residents for comfort and safety. On 02/25/19 at 11:15 A.M. the Administrator verified the facility heating system was not working and he had not implemented any alternate source of heat in the facility. The Immediate Jeopardy was removed on 02/27/19 at 2:00 P.M. when the facility implemented the following corrective actions: · On 02/25/19 at 5:00 P.M. the Administrator oversaw the implementation of two diesel fueled heaters and high temperature duct work being installed through the windows of two common areas in the facility to provide an emergency heat source to the resident living areas. · On 02/25/19 at 6:15 P.M., the Administrator began contacting additional staff to come in to work to provide supervision and assistance to the residents during the power outage. · On 02/25/19, the Administrator contacted a generator vendor to evaluate the current generator load and provide a proposal for additional generator power supply. · On 02/26/19 at 12:00 A.M., the facility implemented room temperature checks that were conducted every 30 minutes throughout resident areas of the facility. · On 02/26/19 at 3:00 A.M. Contracted Electrician #905 modified the lines of the generator so that it would supply power to the boiler heating system. · On 02/26/19 at 2:00 P.M., the local electric company fully restored electric power to the facility which made the facility heating system fully operational, including the boiler heating system as well as the individual electric heating units in the resident rooms on the 100 and 300 halls. · On 02/26/19 at 2:00 P.M., the Administrator provided a contingency contract with the supplier of the diesel emergency heat source. · On 02/27/19 at 10:00 A.M. and 2:00 P.M. the Administrator provided two additional nursing home emergency transfer agreements (now totaling four agreements), and said he was waiting for a response from three of 10 additional nursing homes and one hospital that he had contacted regarding additional emergency transfer agreements. · On 02/27/19 at 2:00 P.M., the Administrator provided evidence of a Disaster Preparedness Plan (DPP) team meeting that was conducted to identify additional areas in the facility that needed to be powered by the generator. Although the Immediate Jeopardy was removed on 02/27/19 at 2:00 P.M. the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan which included a scheduled 03/06/19 staff training on the disaster plan and emergency preparedness, and monitoring to ensure on-going compliance. Findings include: Entrance to the facility on [DATE] at 11:05 A.M., revealed the facility felt physically cold. Residents were observed on all units sitting in the common areas or their rooms wearing hats, coats, heavy sweaters with hoods, and gloves as well as being covered with blankets. Hallways that adjoined one unit to the next were very dark with only red exit signs lit by the doors and a few battery operated, dimly lit lanterns placed by the nurses' stations and on medication carts. The faces of the residents sitting in wheelchairs and walking in the darkened hallways were not easily distinguishable due to the lack of light. An interview conducted on 02/25/19 at 11:15 A.M. with the Administrator revealed that since approximately 2:00 P.M. on 02/24/19 there was no heat in the facility and limited lighting due to an electrical power outage affecting the neighboring community. The Administrator said the facility heating source (boiler) was not connected to the back-up generator and he had a limited number of electric outlets connected to the generator so most of the facility lights had no power source. The Administrator indicated he had transfer agreements with two facilities if it got to the point that a transfer was necessary. No action had been taken to restore heat to the building or provide warmth to the residents. An interview on 02/25/19 at 11:20 A.M. with Registered Nurse (RN) #200 revealed she had been working since her shift began on 02/25/19 at 7:00 A.M. on the 100 unit. She stated there was no heat in the facility. RN #200 explained that there was no hot water, the phones were not working, there was no light in most of the hallways, and no light or television in resident rooms except for the natural light coming in from the windows. RN #200 said she had given the residents under her care extra blankets and suggested that they all dress in layers with hats, coats, and gloves to stay warm. RN #200 said she did not know how long it would be until the heat and electric came back on in the facility. RN #200 said that she and the other nurses had walkie talkie devices to communicate with each other. An interview conducted on 02/25/19 at 11:29 A.M. with Social Service Director #300 revealed she was directed by administration to pass out extra blankets and make sure residents were dressing in layers as the heat was not working in the facility. On 02/25/19 at 11:30 A.M., interview with Resident #94 revealed she had no lights and no heat since about 2:00 P.M. on 02/24/19. Resident #94 explained that she and the others had complained of being very cold so staff handed out extra blankets. During the interview the resident was wearing a hooded shirt and a jacket. Interview with Resident #89 on 02/25/19 at 11:40 A.M. revealed that he has felt very cold in his room and in the hallways due to the facility not having any heat. Interview with Laundry Employee #400 on 02/25/19 at 11:50 A.M. revealed there were adequate clean blankets and clothing to pass out to the residents but there was no way to launder any dirty linens due to the washer and dryers having no power. Laundry Employee #400 said that she was not told when the power would come back on. Interview with Resident #24 on 02/25/19 at 11:55 A.M. revealed that since the electric went out on 02/24/19 at approximately 2:00 P.M., there was no laundry service, no heat, no hot water, and no showers. Resident #24 exclaimed that her room was freezing last night, and the staff had to pass out extra blankets to try to keep her warm. During the interview, the resident was dressed in a hat, gloves, hooded sweat shirt, and jacket, as well as being covered with three blankets in her bed. Resident interview on 02/25/19 at 11:59 A.M. with Resident #13 revealed that he had five blankets on his bed last night because it was so cold, due to no heat in the facility. During the interview he was wearing a hat, gloves, coat, and sweatshirt. Resident #13 also said that his room and the hallways around his room had no light and there was no hot water. Interview with Resident #21 on 02/25/19 at 12:10 P.M. revealed she was unable to take a shower due to no hot water, the laundry could not wash her bed linens, and her hands were freezing as she lost her gloves. Resident #21 presented with a worried facial expression as she said she had no idea how long the facility would be without heat, and the halls were so dark at night she was afraid to move. On 02/25/19 at 12:24 P.M. interview with Resident #33, who was in her bed under five blankets, revealed that she was not leaving her bed because it was so cold during the night, and she felt like she was freezing even with the extra blankets. On 02/25/19 at 12:27 P.M. interview with Activity Director (AD) #600 revealed she was offering extra group activities to keep residents busy and get their minds off the cold temperatures and the heating problems. AD #600 said she had been offering extra blankets, coats, gloves, and hats to the residents. An interview on 02/25/19 at 12:52 P.M. with Maintenance Director #700 revealed the facility had been without electrical power several times in the past due to a breaker problem on the pole at the end of the street, and this has been a problem for a while. MD #700 explained that the local energy provider had been out on several calls to fix the breaker prior to the recent power outage. MD #700 revealed that the local energy provider was called about the power going out on 02/24/19 but said they could not come out to service the facility due to there being multiple areas effected by power outages in the area from very high winds. MD #700 explained that there was one main generator and it was not tied into the heating system resulting in no heat in the building. MD#700 said that he had no ambient temperature thermometer to take facility temperatures, so he had done no monitoring of the temperatures since the start of the heating problem, or prior to this heating problem as well. MD#700 stated that he had no emergency heating equipment available to him in the facility and did not know what he was going to do to bring the facility temperatures back to an appropriate level. On 02/25/19 from 1:28 P.M. to 1:50 P.M., the surveyors with the Administrator present, measured room temperatures using the surveyors' digital ambient thermometer. The following temperatures were obtained: room [ROOM NUMBER] - 66.3 degrees F; room [ROOM NUMBER] - 65.8 degrees F: room [ROOM NUMBER] - 64.4 degrees F; room [ROOM NUMBER] - 62.9 degrees F; room [ROOM NUMBER] - 62.4 degrees F; room [ROOM NUMBER] - 60.2 degrees F; room [ROOM NUMBER] - 60.2 degrees F; room [ROOM NUMBER] - 62.7 degrees F; the main dining room - 63.8 degrees F; room [ROOM NUMBER] - 61.7 degrees F; room [ROOM NUMBER] - 64.2 degrees F; room [ROOM NUMBER] - 61.3 degrees F; and the physical therapy room - 66.7 degrees F. During an interview with the Administrator on 02/25/19 at 1:52 P.M., he said he spoke with the local electric energy provider regarding the anticipated duration of the power outage and was told that the facility could be without power until 02/28/19 at 4:00 P.M. The Administrator said he had emergency transfer agreements with two facilities in the area (one nursing home and one group home) with a receiving capacity for total of 15 residents. The Administrator verified that if he needed to evacuate the facility he would not have enough placement for the 95 residents in his facility, nor did he have any other transfer agreements with facilities that could provide service for his population of residents. The Administrator verified he had no emergency heating equipment to use to increase the facility temperature, as he thought the electric would have been restored by now. Interview with the Administrator on 02/25/19 at 3:45 P.M. revealed that two diesel powered heating units were coming to the facility which would be placed outside the windows of the common areas. Heat would be brought into the facility through duct work placed in the common area windows on both levels of the facility. The outside heating units were observed being installed and operational on 02/25/19 from 5:00 P.M. to 5:48 P.M. The heating units pushed a heavy odor of diesel fuel throughout the facility. At 5:48 P.M., the Administrator verified the diesel fumes and indicated he would place two carbon monoxide detectors on each level to monitor for carbon monoxide. The Administrator also said he ordered 15 individual battery-operated heating units and two ambient thermometers, which he expected to arrive at the facility on 02/26/19 or 02/27/19. On 02/25/19 at 6:14 P.M., the Director of Nursing (DON), who had just come out of the common area stated the diesel powered heating unit was bringing warm air into the facility, however, she couldn't stand the fumes present now in the common area of the facility. Interview was conducted on 02/25/19 at 6:23 P.M. with Medical Director #100 who was at the facility. Medical Director #100 said that he would not implement an emergency transfer of the residents unless the facility temperatures dropped to 40 degrees F. The Medical Director indicated the facility had transfer agreements with two facilities, however, those facilities could not house all 95 residents. Medical Director #100 added that he did not know of any other facilities who could take his residents, and there were no additional transfer agreements. Interview with the Administrator on 02/25/19 at 8:11 P.M. revealed that an electrician was at the facility at that time to connect their heating system to the generator for power. The surveyors also observed at this time that the diesel fumes were lessened inside the facility, which the Administrator said resulted from moving the diesel-powered equipment a distance further away from the facility doors and windows. Review of the facility manual titled Disaster and Emergency Response Manual on 02/25/19 revealed it did not contain a policy to address an electrical power outage, as well as the loss of heat or water. Interview with the Administrator on 02/26/19 at 8:58 A.M. revealed that the generator was now powering the boiler heating system for any area of the building with baseboard heat, and the diesel-powered heating units were still being used to provide heat for the 100 hall and 300 hall sections of the building that depended on individual electric heating units in each resident room for heat. The Administrator explained that the electrician was able to restore power to the boiler heating system on 02/26/19 at 3:00 A.M., approximately 37 hours after the power and heat were lost. On 02/26/19 from 8:59 A.M to 9:18 A.M., the surveyors measured the temperatures in resident rooms and common areas with the Administrator and DON. The facility temperatures were as follows: room [ROOM NUMBER] - 76.1 degrees F; room [ROOM NUMBER] - 74.1 degrees F; room [ROOM NUMBER] - 73.5 degrees F; common area on the 100 hall - 84.0 degrees F; room [ROOM NUMBER] - 76.1 degrees F; room [ROOM NUMBER] - 73.9 degrees F; room [ROOM NUMBER] - 73.0 degrees F; North hall common area by the nurses station - 78.4 degrees F; room [ROOM NUMBER] was 74.8 degrees F; room [ROOM NUMBER] - 71.2 degrees F; room [ROOM NUMBER] - 70.7 degrees F; room [ROOM NUMBER] - 73.0 degrees F; room [ROOM NUMBER] - 77.5 degrees F; room [ROOM NUMBER] - 77.4 degrees F; common room on lower level hallway - 84.0 degrees F; room [ROOM NUMBER] - 81.5 degrees F; room [ROOM NUMBER] - 79.3 degrees F; room [ROOM NUMBER] - 75.5 degrees F; and room [ROOM NUMBER] was 71.2 degrees F. The heat blowing out of the base board heater from the boiler heating system was 95.3 degrees F. In addition, there were 40 residents in rooms that had individual electric wall heating units in their rooms, which were not tied into the generator for power. These heating units remained non-functional at the time of this observation. On 02/26/19 at 12:53 P.M., observations with the Administrator revealed the facility lights were partially back on in the facility, and the electric company was still working on restoring full power to the facility. At approximately 2:00 P.M., the Administrator verified power had been restored to the facility and the individual electric heating units in residents' rooms were now functioning. On 02/27/19 at 10:39 A.M. the Administrator \provided an additional manual titled Disaster and Emergency Preparedness and Response Plan. The Administrator explained that he had been working on updating the plan with his Disaster Preparedness Plan (DPP) team over the last two weeks and was not able to provide this information until present day. The Administrator indicated that he would have all staff trained on disaster planning and emergency preparedness on 03/06/19. Review was conducted on 02/27/19 of the facility policies titled Facility Disaster Preparedness Assessment, dated (MONTH) 2011; Formalized Agreements and Contingencies, dated (MONTH) 2011; and Preparations for Severe Weather, dated (MONTH) 2011. The Facility Disaster Preparedness Assessment stated the facility would conduct a thorough assessment annually to determine the readiness of the physical plant and associated supplies to be utilized to manage a disaster or crisis. The Formalized Agreements and Contingencies policy stated the facility had formalized agreements and emergency contingencies with alternate facilities and service providers during the management of a crisis or disaster situation. The Preparations for Severe Weather policy stated that emergency heating equipment would be kept on hand or readily obtained to secure the safety of residents and ensure operability of the facility. The policies were not implemented in their entirety as evidenced by a lack of generator power to run the boiler heat, a lack of emergency heating equipment, and a lack of transfer agreements on file that could accommodate the 95 residents residing in the facility. Interview was conducted on 02/27/19 at 4:23 P.M. with the Administrator who revealed the source of the electrical failure was a tripped breaker out on the pole by the street and the energy provider simply had to reset the breaker to restore electrical power. The Administrator added that after speaking to the supervisor at the energy provider office, the energy provider informed the Administrator that the facility was not listed on their high priority list. The Administrator explained he asked that the facility be added to the high priority list. This deficiency substantiates Complaint Number OH 826.

Based on observations, resident and staff interview, review of the facility operational and emergency assessment, review of facility policies titled Facility Disaster Preparedness Assessment, Formalized Agreements and Contingencies, and Preparations for Severe Weather, and review of the daily weather conditions and outside temperatures on https://www.wunderground.com, the facility failed to ensure the implementation of an effective and prompt emergency response plan for the safety of the residents during an unplanned power outage, resulting in the entire facility being without electricity and heat for approximately 48 hours. This resulted in Immediate Jeopardy when the facility lost power on 02/24/19. On 02/25/19 from 1:28 P.M. to 1:50 P.M, facility room temperatures were recorded between 60.2 degrees F and 66.7 degrees F. The outside temperature on 02/25/19 was a high of 30 degrees F and a low of 21 degrees F. The likelihood of actual harm occurred when the residents were observed wearing coats, hats, multiple layers of clothing, blankets and voicing the concern of being cold with no means to get warm. This affected the facility census of 95 residents. On 02/25/19 at 2:29 P.M. the Administrator was notified that Immediate Jeopardy began on 02/24/19 at 2:00 P.M. when the facility heating system was no longer functional due to an electrical power outage, and the back-up generator was not supplying power to maintain the operation of the heating system. Additionally, the temperature of resident living areas was not being monitored, and the facility did not have arrangements with offsite locations to temporarily transfer all residents for comfort and safety. On 02/25/19 at 11:15 A.M. the Administrator verified the facility heating system was not working and he had not implemented any alternate source of heat in the facility. The Immediate Jeopardy was removed on 02/27/19 at 2:00 P.M. when the facility implemented the following corrective actions: · On 02/25/19 at 5:00 P.M. the Administrator oversaw the implementation of two diesel fueled heaters and high temperature duct work being installed through the windows of two common areas in the facility to provide an emergency heat source to the resident living areas. · On 02/25/19 at 6:15 P.M., the Administrator began contacting additional staff to come in to work to provide supervision and assistance to the residents during the power outage. · On 02/25/19, the Administrator contacted a generator vendor to evaluate the current generator load and provide a proposal for additional generator power supply. · On 02/26/19 at 12:00 A.M., the facility implemented room temperature checks that were conducted every 30 minutes throughout resident areas of the facility. · On 02/26/19 at 3:00 A.M. Contracted Electrician #905 modified the lines of the generator so that it would supply power to the boiler heating system. · On 02/26/19 at 2:00 P.M., the local electric company fully restored electric power to the facility which made the facility heating system fully operational, including the boiler heating system as well as the individual electric heating units in the resident rooms on the 100 and 300 halls. · On 02/26/19 at 2:00 P.M., the Administrator provided a contingency contract with the supplier of the diesel emergency heat source. · On 02/27/19 at 10:00 A.M. and 2:00 P.M. the Administrator provided two additional nursing home emergency transfer agreements (now totaling four agreements), and said he was waiting for a response from three of 10 additional nursing homes and one hospital that he had contacted regarding additional emergency transfer agreements. · On 02/27/19 at 2:00 P.M., the Administrator provided evidence of a Disaster Preparedness Plan (DPP) team meeting that was conducted to identify additional areas in the facility that needed to be powered by the generator. Although the Immediate Jeopardy was removed on 02/27/19 at 2:00 P.M. the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan which included a scheduled 03/06/19 staff training on the disaster plan and emergency preparedness and monitoring to ensure on-going compliance. Findings include: Entrance to the facility on [DATE] at 11:05 A.M., revealed the facility felt physically cold. Residents were observed on all units sitting in the common areas or their rooms wearing hats, coats, heavy sweaters with hoods, and gloves as well as being covered with blankets. Hallways that adjoined one unit to the next were very dark with only red exit signs lit by the doors and a few battery operated, dimly lit lanterns placed by the nurses' stations and on medication carts. The faces of the residents sitting in wheelchairs and walking in the darkened hallways were not easily distinguishable due to the lack of light. Interview with the administrator on 02/25/19 at 11:15 A.M. revealed since 02/24/19 at approximately 2:00 P.M., there was no heat in the facility and limited lighting due to an electrical power outage affecting the neighboring community. The Administrator said the facility heating source (boiler) was not connected to the back-up generator and he had a limited number of electric outlets connected to the generator so most of the facility lights had no power source. Interview with Registered Nurse (RN) #200 on 02/25/19 at 11:20 A.M. revealed due to an electrical power outage, there was no heat, no lighting that could be turned on in hallways or resident rooms, no hot water, and no telephone capability since she began working her shift on 02/25/19 at 7:00 A.M. Interview with RN #200, Social Service Director #300, and Activity Director #600 on 02/25/19 between 11:20 A.M. and 12:27 P.M. revealed they were passing out additional blankets and clothing to the individuals so they were dressed in layers to stay warm. On 02/25/19 between 11:30 A.M. and 12:24 P.M., interview with Residents #94, #89, #24, #13, #21, and #33 revealed they were very cold even though they were wearing additional clothing, coats, hats, gloves, and blankets. They also had concerns relative to not having hot water for cleansing and the lack of lighting in the facility. An interview on 02/25/19 at 12:52 P.M. with Maintenance Director #700 revealed the facility had been without electrical power several times in the past due to a breaker problem on the pole at the end of the street, and this has been a problem for a while. MD #700 explained that the local energy provider had been out on several calls to fix the breaker prior to the recent power outage. MD #700 revealed that the local energy provider was called about the power going out on 02/24/19 but said they could not come out to service the facility due to there being multiple areas effected by power outages in the area from very high winds. MD #700 explained that there was one main generator and it was not tied into the heating system resulting in no heat in the building. MD #700 said that he had no ambient temperature thermometer to take facility temperatures, so he had done no monitoring of the temperatures since the start of the heating problem, or prior to this heating problem as well. MD #700 stated that he had no emergency heating equipment available to him in the facility and did not know what he was going to do to bring the facility temperatures back to an appropriate level. On 02/25/19 from 1:28 P.M. to 1:50 P.M., the surveyors with the Administrator present, measured room temperatures in 13 resident living areas on both floors throughout the facility, using the surveyors' digital ambient thermometer. The room temperatures ranged between 60.2 degrees F and 66.7 degrees F. After completion of resident room temperature measurements, the administrator asked the surveyor to see the digital thermometer used, took a photo of the thermometer, and said he was going to order one online to be delivered to the facility the next day. Interview with the Administrator on 02/25/19 at 1:52 P.M., revealed the local electric energy provider said the anticipated duration of the power outage at the facility could be until 02/28/19 at 4:00 P.M. The Administrator said he had emergency transfer agreements with two facilities in the area (one nursing home and one group home) with a receiving capacity for total of 15 residents. The Administrator verified that if he needed to evacuate the facility, he would not have transfer agreements with enough facilities to accept the transfer of the 95 facility residents in an emergency. The Administrator verified he had no emergency heating equipment to use to increase the facility temperature, as he thought the electric would have been restored by now. On 02/25/19 at 3:45 P.M., interview with the Administrator revealed two diesel powered heating units were coming to the facility which would be placed outside the windows of the common areas. Heat would be brought into the facility through duct work placed in the common area windows on both levels of the facility. These outside heating units were observed being installed and operational on 02/25/19 from 5:00 P.M. to 5:48 P.M. The heating units pushed a heavy odor of diesel fuel throughout the facility. At 5:48 P.M., the Administrator verified the diesel fumes and indicated he would place two carbon monoxide detectors on each level to monitor for carbon monoxide. The Administrator also said he ordered 15 individual battery-operated heating units and two ambient thermometers, which he expected to arrive at the facility on 02/26/19 or 02/27/19. Observation of these heating units on 02/26/19 at 4:15 P.M. revealed there was no capability for battery operation and they required the use of an electric power cord for use in the facility. Interview with Ombudsman #1 on 02/25/19 at 5:27 P.M. revealed she talked to the facility administrator and told him that the facility needed to increase staffing during the power outage to monitor resident care needs, and to get an electrician out to the facility to connect the boiler heating system to the generator. Interview was conducted on 02/25/19 at 6:23 P.M. with the Medical Director #100 who was at the facility. The Medical Director said that he would not implement an emergency transfer of the residents unless the facility temperatures dropped to 40 degrees F. The Medical Director indicated the facility had transfer agreements with two facilities, however, verified that those facilities could not house all 95 residents. The Medical Director added that he did not know of any other facilities who could take his residents, and there were no additional transfer agreements. Interview with the Administrator on 02/25/19 at 8:11 P.M. revealed that an electrician was at the facility at that time to connect their heating system to the generator for power. Review was conducted on 02/25/19 of the facility manual titled Disaster and Emergency Response Manual, as provided by the Administrator. The manual did not contain any policy to address an electrical power outage, as well as the loss of heat. Interview with the Administrator on 02/26/19 at 8:58 A.M. revealed that the generator was now powering the boiler heating system for any area of the building with baseboard heat, and the diesel-powered heating units were still being used to provide heat for the 100 hall and 300 hall sections of the building that depended on individual electric heating units in each resident room for heat. The Administrator explained that the electrician was able to restore power to the boiler heating system on 02/26/19 at 3:00 A.M. On 02/26/19 at 12:53 P.M., observations with the Administrator revealed electric power was partially restored in the facility, with full electric power being restored at approximately 2:00 P.M Interview was conducted on 02/27/19 at 10:39 A.M. with the Administrator who provided an additional manual titled Disaster and Emergency Preparedness and Response Plan. The Administrator explained that he had been working on updating the plan over the last two weeks and was not able to provide this information until present day. This manual was not initially provided to the surveyors on 02/25/19, as he was updating it with his Disaster Preparedness Plan (DPP) team. The Administrator indicated that he would have all staff trained on disaster planning and emergency preparedness on 03/06/19. Review was conducted on 02/27/19 of the facility policies titled Facility Disaster Preparedness Assessment, dated (MONTH) 2011; Formalized Agreements and Contingencies, dated (MONTH) 2011; and Preparations for Severe Weather, dated (MONTH) 2011. The Facility Disaster Preparedness Assessment stated the facility would conduct a thorough assessment annually to determine the readiness of the physical plant and associated supplies to be utilized to manage a disaster or crisis. The Formalized Agreements and Contingencies policy stated the facility had formalized agreements and emergency contingencies with alternate facilities and service providers during the management of a crisis or disaster situation. The Preparations for Severe Weather policy stated that emergency heating equipment would be kept on hand or readily obtained to secure the safety of residents and ensure operability of the facility. The policies were not implemented in their entirety as evidenced by a lack of generator power to run the boiler heat, a lack of emergency heating equipment, and a lack of transfer agreements on file that could accommodate the 95 residents residing in the facility. Interview was conducted on 02/27/19 at 4:23 P.M. with the Administrator who revealed the source of the electrical failure was a tripped breaker out on the pole by the street and the energy provider simply had to reset the breaker to restore electrical power. The Administrator added that after speaking to the supervisor at the energy provider office, the energy provider informed the Administrator that the facility was not listed on their high priority list. The Administrator explained he asked that the facility be added to the high priority list. During interviews with the Administrator and Medical Director throughout the survey, it was determined that the facility administration did not develop and implement an effective emergency response plan for an electrical power outage. There was no evidence the facility administration addressed the following in their emergency plans prior to discussions with the ombudsman or surveyor: · Ensuring generator back-up power would be able to heat the resident use areas of the facility; · Providing generator back-up power or an alternate plan for refrigeration of essential perishable items in the kitchen; · Addressing the increased staffing needs for providing assistance to the residents and monitoring their care needs during the power outage; · Determining when the medical director would be notified of the cold temperatures, status of the residents, and possible need to transfer the residents; · Ensuring sufficient transfer agreements during emergencies were established for the facility census of 95 residents; · Ensuring the availability of a thermometer to measure and monitor resident room temperatures during the power outage; and · Ensuring the facility was on a priority response list with the local utility providers. This deficiency substantiates Complaint Number OH 826.

Based on observations, resident and staff interview, review of the facility operational and emergency assessment, review of facility policies titled Facility Disaster Preparedness Assessment, Formalized Agreements and Contingencies, and Preparations for Severe Weather, and review of the daily weather conditions and outside temperatures on https://www.wunderground.com, the facility failed to ensure the implementation of a comprehensive and complete emergency preparedness plan for the safety of the residents during an unplanned electrical power outage that occurred during severe high wind weather conditions. This resulted in Immediate Jeopardy when the entire facility lost electrical power and heat for 48 hours beginning on 02/24/19. On 02/25/19 from 1:28 P.M. to 1:50 P.M, facility room temperatures were recorded between 60.2 degrees F and 66.7 degrees F. The outside temperature on 02/25/19 was a high of 30 degrees F and a low of 21 degrees F. The likelihood of actual harm occurred when the residents were observed wearing coats, hats, multiple layers of clothing, blankets and voicing the concern of being cold with no means to get warm. This affected the facility census of 95 residents. On 02/25/19 at 2:29 P.M. the Administrator was notified that Immediate Jeopardy began on 02/24/19 at 2:00 P.M. when the facility heating system was no longer functional due to an electrical power outage, and the back-up generator was not supplying power to maintain the operation of the heating system. Additionally, the temperature of resident living areas was not being monitored, and the facility did not have arrangements with offsite locations to temporarily transfer all residents for comfort and safety. On 02/25/19 at 11:15 A.M. the Administrator verified the facility heating system was not working and he had not implemented any alternate source of heat in the facility. The Immediate Jeopardy was removed on 02/27/19 at 2:00 P.M. when the facility implemented the following corrective actions: · On 02/25/19 at 5:00 P.M. the Administrator oversaw the implementation of two diesel fueled heaters and high temperature duct work being installed through the windows of two common areas in the facility to provide an emergency heat source to the resident living areas. · On 02/25/19 at 6:15 P.M., the Administrator began contacting additional staff to come in to work to provide supervision and assistance to the residents during the power outage. · On 02/25/19, the Administrator contacted a generator vendor to evaluate the current generator load and provide a proposal for additional generator power supply. · On 02/26/19 at 12:00 A.M., the facility implemented room temperature checks that were conducted every 30 minutes throughout resident areas of the facility. · On 02/26/19 at 3:00 A.M., Contracted Electrician #905 modified the lines of the generator so that it would supply power to the boiler heating system. · On 02/26/19 at 2:00 P.M., the local electric company fully restored electric power to the facility which made the facility heating system fully operational, including the boiler heating system as well as the individual electric heating units in the resident rooms on the 100 and 300 halls. · On 02/26/19 at 2:00 P.M., the Administrator provided a contingency contract with the supplier of the diesel emergency heat source. · On 02/27/19 at 10:00 A.M. and 2:00 P.M. the Administrator provided two additional nursing home emergency transfer agreements (now totaling four agreements), and said he was waiting for a response from three of 10 additional nursing homes and one hospital that he had contacted regarding additional emergency transfer agreements. · On 02/27/19 at 2:00 P.M., the Administrator provided evidence of a Disaster Preparedness Plan (DPP) team meeting that was conducted to identify additional areas in the facility that needed to be powered by the generator. Although the Immediate Jeopardy was removed on 02/27/19 at 2:00 P.M. the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan which included a scheduled 03/06/19 staff training on the disaster plan and emergency preparedness and monitoring to ensure on-going compliance. Findings include: Entrance to the facility on [DATE] at 11:05 A.M. revealed the facility felt physically cold. Residents were observed on all units wearing hats, coats, heavy sweaters with hoods, and gloves, as well as being covered with blankets. Hallways that adjoined one unit to the next were very dark with only red exit signs lit by the doors and few battery operated, dimly lit lanterns placed by nurses stations and on medication carts. The faces of the residents sitting in wheelchairs and walking in the darkened hallways were not distinguishable due to the lack of light. An interview conducted on 02/25/19 at 11:15 A.M. with the Administrator revealed that since approximately 2:00 P.M. on 02/24/19 there was no heat in the facility and limited lighting due to an electrical power outage affecting the neighboring community. The Administrator said the facility heating source (boiler) was not connected to the back-up generator and he had a limited number of electric outlets connected to the generator so most of the facility lights had no power source. The Administrator said that he had transfer agreements with two facilities if it got to the point that a transfer was necessary. However, review of the two facility transfer agreements provided by the administrator on 02/25/19 revealed one facility was a group home and the other a nursing home. The administrator said at the time of this power outage, the total number of residents who could be received by these facilities would be 15 residents. Interview with Ombudsman #1 on 02/25/19 at 5:27 P.M. revealed she talked to the facility administrator and told him that the facility needed to increase staffing during the power outage to monitor resident care needs, and to get an electrician out to the facility to connect the boiler heating system to the generator. Review of the Facility Assessment, dated 10/20/18, which was completed by the Administrator, Medical Director and Director of Nursing, revealed the community based and facility based risk assessment could be found in the Emergency Preparedness Plan documentation. A review was conducted on 02/25/19 of the facility manual titled Disaster and Emergency Response Manual, as provided by the Administrator. The manual did not contain any policy to address an electrical power outage, or adequate transfer agreements to support the resident population of 95 residents. The manual contained no contracts or information on provision of an emergency heat source during a power outage. On 02/26/19 at 1:01 P.M., interview with the Administrator who provided an undated Electrical Outage Policy revealed he had no other emergency policies other than what was included in the Disaster and Emergency Response Manual he had already provided on 02/25/19. The Electrical Outage Policy did not address the individual heating units in each resident room in the 100 and 300 hallways, which were dependent on electricity to operate. The remaining rooms in the facility were dependent on boiler heat through baseboards. The policy did not address how to power both heating systems during a power outage. Record review was conducted on 02/27/19 of an additional manual provided by the Administrator, titled Disaster and Emergency Preparedness and Response Plan. The Administrator explained that he did not initially provide that manual to the surveyors on 02/25/19, as he was updating it with his Disaster Preparedness Plan (DPP) team as of 01/31/19. The Administrator said that he would have all staff trained on disaster planning and emergency preparedness by 03/06/19. A review was conducted on 02/27/19 of the facility policies titled Facility Disaster Preparedness Assessment, dated 02/2011; Formalized Agreements and Contingencies, dated 02/2011; and Preparations for Severe Weather, dated 05/2011. The Facility Disaster Preparedness Assessment stated the facility would conduct a thorough assessment annually to determine the readiness of the physical plant and associated supplies to be utilized to manage a disaster or crisis. The Formalized Agreements and Contingencies policy stated the facility had formalized agreements and emergency contingencies with alternate facilities and service providers during the management of a crisis or disaster situation. The Preparations for Severe Weather policy stated that emergency heating equipment would be kept on hand or readily obtained to secure the safety of residents an ensure operability of the facility. The policies were not implemented in their entirety as evidenced by a lack of generator power to run the boiler heat, a lack of emergency heating equipment, and a lack of transfer agreements on file that could accommodate the 95 residents residing in the facility. Interview was conducted on 02/27/19 at 4:23 P.M. with the Administrator who revealed the source of the electrical failure was a tripped breaker out on the pole by the street, and the energy provider simply had to reset the breaker to restore power. The Administrator added that after speaking to the supervisor at the energy provider office, the energy provider informed the Administrator that the facility was not listed on their high priority list. The Administrator said he asked that the facility be added to the high priority list. During interviews with the Administrator and Medical Director throughout the survey, it was determined that the facility administration did not develop and implement an effective emergency response plan for an electrical power outage. There was no evidence the facility administration addressed the following in their emergency plans prior to discussions with the ombudsman or surveyor: · Ensuring generator back-up power would be able to heat the resident use areas of the facility; · Providing generator back-up power or an alternate plan for refrigeration of essential perishable items in the kitchen; · Addressing the increased staffing needs to provide assistance to the residents and monitor their care needs during the power outage; · Determining when the medical director would be notified of the cold temperatures, status of the residents, and possible need to transfer the residents; · Ensuring sufficient transfer agreements during emergencies were established for the facility census of 95 residents; · Ensuring the availability of a thermometer to measure and monitor resident room temperatures during the power outage; and · Ensuring the facility was on a priority response list with the local utility providers. This deficiency substantiates Complaint Number OH 826.

Based on record review and interview, the facility failed to properly assist Resident #51 with ambulation. Harm occurred when Resident #51 ambulated independently with a wheeled walker from the dining room toward the facility 100 hall without the required contact guard assistance, resulting in a fall and fractured scapula. This affected one of three residents reviewed for accidents. Findings include: Resident #51 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #51's annual Minimum Data Set (MDS) assessment dated [DATE] revealed her cognition was moderately impaired and she required extensive one person assistance while walking in the corridor and during locomotion on and off unit. Review of Resident #51's Physical Therapy Evaluation and Plan of Treatment, starting 09/22/17, revealed the resident's functional assessment for gait (walking) was contact guard assistance. Resident #51's Physical Therapy Progress Report noted a goal that Resident #51 would ambulate 150 feet with a four wheeled walker and appropriate stride length at a stand by assistance level in order to safety access meals and activities. On 10/03/17, the resident walked 100 feet with seated rest breaks and the goal was continued. Review of Resident #51's fall history from the last six months, revealed she had a fall on 10/10/17. Resident #51's Nurses Note dated 10/10/17 revealed the activities assistant reported to the nurse that Resident #51 fell in the hallway leading to 100 hall. Resident #51 was observed on the floor lying on her back and stated while she was walking from church service in the main dining room to 100 hall she heard the noise of a meal tray approaching her. Resident #51 turned around to see what it was because it startled her and she lost her balance an fell . Resident #51 stated she hit her head. Resident #51 was taken to the hospital via ambulance. Review of Resident #51's post fall hospital records dated 10/10/17 revealed the resident was diagnosed with [REDACTED]. Review of the facility fall investigation for Resident #51's fall on 10/10/17 revealed a witness statement from State tested Nursing Assistant (STNA) #604. STNA #604 revealed she held the back of Resident #51's chair so the resident could leave church and then STNA #604 assisted other residents to their tables. STNA #604 stated she did not know Resident #51 needed assistance walking. Interview on 01/31/18 at 12:30 P.M. with Assistance Director of Nursing (ADON) #501 revealed Resident #51's assistance with walking varied and at the time of the fall on 10/10/17 the resident could walk independently with her wheeled walker. Interview on 01/31/18 at 1:00 P.M. with STNA #604 confirmed STNA #604 helped Resident #51 out of her chair on 10/10/17, and thought she could walk independently. Interview on 01/31/18 at 1:10 P.M. with Certified Occupational Therapy Assistant (COTA) #605 revealed on 09/22/17 physical therapy assessed Resident #51 and identified that the resident required contact guard assistance with ambulation. COTA #605 explained Resident #51 required a gait belt, with one staff person walking with her with their hand on the resident for assistance. COTA #605 revealed at the time of Resident #51's fall on 10/10/18, the resident still required contact guard assistance. COTA #605 explained the therapy department told nursing how much assistance a resident needed based on their evaluation. Interview on 01/31/18 at 1:28 P.M. with ADON #501 revealed she was unaware the therapy department determined Resident #51 needed contact guard assistance prior to her fall on 10/10/18. ADON #501 revealed the therapy department normally inserviced the staff on the level of assistance a resident needed or wrote an order. ADON #501 revealed there was no order that Resident #51 required contact guard assistance, and was unsure if therapy inserviced nursing staff on the contact guard assistance. ADON #501 confirmed Resident #51 was walking independently on 10/10/17 and fell resulting in a fractured scapula.

Based on observation, medical record review, review of a facility summary of investigation, staff and resident interviews, review of the facility Tray identification policy, review of facility recipes, review of employee disciplinary action and review of in-service records, the facility failed to ensure residents with orders for mechanically altered diets were provided the correct texture food items to prevent choking and to meet their individual needs. This resulted in Immediate Jeopardy when on 07/31/17 during the dinner meal, Resident #39, who was at high risk for choking and was not to receive chicken or turkey, received a breaded chicken sandwich and broccoli raisin salad. Actual harm occurred when the resident choked on food items served during the dinner meal, staff were unable to successfully clear the resident's airway, the resident lost consciousness and subsequently expired. This affected one (#39) resident of three sampled residents and had the potential to affect 22 residents (Residents #2, #7, #11, #14, #16, #24, #25, #26, #40, #41, #47, #48, #49, #50, #51, #52, #53, #54, #55, #57, #58 and #59) identified by the facility to have a physician order [REDACTED].#2, #11, #21, #26, #38, #41, #42, #43, #44, #45 and #46) who were identified by the facility at risk for choking. The facility census was 95. On 08/08/17 at 4:55 P.M., the Director of Nursing (DON) and Assistant Director of Nursing/Licensed Practical Nurse (LPN) #151 were notified Immediate Jeopardy began on 07/31/17 at 4:52 P.M. when Resident #39 was given a meal tray with a breaded chicken sandwich in a mechanical soft form, contrary to the resident's meal ticket indicating the resident was a choking risk and should not have chicken or turkey and broccoli raisin salad which was not included on the menu as an item that could be served to residents on a mechanical soft diet. While consuming the food items, Resident #39 began hitting himself on the back and put his hands to his throat, indicating to staff that he was choking. LPN #159 initially attempted the [MEDICATION NAME] as well as State tested nursing assistant (STNA) #161, who performed the [MEDICATION NAME] maneuver in an attempt to clear the resident's airway and the resident was able to expel some food. However, not all of the food could be expelled. The resident lost consciousness and turned a grey color. Emergency Medical Services (EMS) were notified and arrived at the facility at approximately 5:07 P.M. The resident was assessed to have no pulse. Cardiopulmonary resuscitation was started by EMS staff and the resident was transferred to the hospital. Resident #39 expired at the hospital. The facility implemented the following corrective actions: On 08/01/17 the Administrator provided in-service education to eight (8) of 11 dietary employees related to a review of the incident that had occurred on 07/31/17 involving Resident #39. The education included a review of the facility dietary policies regarding mechanical soft diets, the need to use gravy with these meals and the need to read tray cards out loud during meal tray preparation to ensure meals were prepared and delivered to residents as ordered. On 08/02/17 Dietary Aides (DA) #166 and #167 were given employee warning notices and suspended for three days each for giving Resident #39 a mechanical soft chicken sandwich when his meal ticket indicated he should not have chicken, and for serving the chicken sandwich without gravy. DA #166 remained on the schedule, working 08/01/17 and 08/02/17 and was suspended from 08/03/17 through 08/06/17. DA #167 remained on the schedule, working 08/01/17, 08/02/17, 0803/17 and 08/05/17, and was suspended 08/06/17 through 08/09/17. Informal audits were conducted on 08/02/17 for the dinner meal by DA #167 and on 08/03/17 by the dietary manager. A more formal audit of the tray line procedure, specifically monitoring that meal ticket specifics were read out loud during the tray preparation and the correct diet was plated, as well as the correct consistency of the food, was started on 08/04/17 and had been conducted for 12 of 17 possible meals. Five audits were conducted by the dietary manager, with the other audits conducted by dietary aides. On 08/02/17 LPN #151 in-serviced STNA #157 related to reading tray cards and checking food on the tray prior to giving food to residents. STNA #157 was identified as the STNA who served the resident his meal tray on 07/31/17. On 08/09/17 LPN #151 began in-servicing nursing staff on tray identification. By 08/10/17 at 2:30 P.M., all nursing staff, including 7 of 7 Registered Nurses (RN)s, 18 of 18 LPNs and 26 of 26 STNAs had been in serviced either in person or via phone call on checking food on trays for accuracy according to the ordered diet, consistency, allergies and preferences prior to giving food to residents during meals. On 08/09/17 Speech Pathologist/Therapist (ST) #170 began in servicing all dietary staff on the proper textures of each diet, including mechanical soft and pureed diets and on the need to follow the menu for each diet type for each meal. As of 08/14/17 a copy of in-service including the actual content or list of staff who attended had not been provided. On 08/09/17 the facility administrator and ST #170 began audits of each meal to ensure accuracy of food served according to the menu and spreadsheet and that each food for each diet type was prepared to the proper consistency. The meal audits were to be completed daily for each meal for one month, then weekly for one meal a month then monthly for one meal for a month. The results would be reviewed by the quality assurance team monthly. On 08/09/17 a whole house audit was completed by ST #170 and LPN #151 for each resident to identify residents at high risk for choking. This audit was completed on 08/10/17 and identified 11 residents at risk (Residents #2, #11, #21, #26, #38, #41, #42, #43, #44, #45 and #46). The list was to be reviewed weekly during the facility nutritional at risk meeting and updated weekly. On 08/10/17 LPN #151 began an in-service for all nursing staff to review with them the residents determined at higher risk for choking, behaviors associated with their risks and interventions in place to prevent choking episodes, as well as the expectation that nursing staff would document daily that safety interventions were monitored for each resident. All nursing staff, including 7 of 7 RNs, 18 of 18 LPNs and twenty six of twenty-six STNAs had been in serviced either in person or via phone call, by 08/13/17. On 08/10/17 ST #170 began in-service education for dietary employees on diet types, mechanical soft and pureed demonstration using the high speed blender (Robot-coup), following the menu spreadsheets and given clarification on using gravy with the mechanical texture. As of 08/13/17 10 of 11 currently employed dietary employees had been in-serviced. The remaining dietary aide/cook was to be in-serviced after returning from vacation, prior to returning to work. On 08/11/17 at 12:30 P.M. seven dietary staff members were in-serviced by ST #170 on following recipes and mechanical soft salad preparation, substitution of main courses and preference clarification. The remaining four employees were in-serviced by 08/13/17, with the remaining dietary aide/cook to be in-serviced after returning from vacation, prior to returning to work. On 08/11/17 the 11 residents (Residents #2, #11, #21, #26, #38, #41, #42, #43, #44, #45 and #46) identified at risk for choking were reviewed for interventions and appropriate care plans by the Assessment Nurse RN #172. The Immediate Jeopardy remained on-going until 08/16/17 at 12:30 P.M. when the facility conducted formal in-services with the dietary staff to correct additional concerns observed during the meal observations from 08/11/17 through 08/15/17. The training included education regarding following recipes for preparing foods served for mechanically altered diets. Additionally, systems were noted to be in place to ensure appropriate foods were served to residents on mechanically altered diets. On 08/16/17 at 12:30 P.M., the consultant Dietetic Technician, Registered (DTR #190) conducted training for the dietary department employees. This training included policy review on mechanically altered diets, discussion on general recommendations for residents with swallowing difficulties, swallowing safety awareness, food preferences for the mechanically altered diet including fruit and vegetables and bread, and reviewed guidelines for pureed food. The in-service was attended by the facility administrator, the three dietary managers who provided supervision/coverage in the facility and nine of 11 dietary staff members who were employed by the facility. A plan was in place to ensure the remaining two employees received training prior to returning to work. On 08/16/17, DT #190 observed and inspected meal preparation for the lunch and dinner meals, providing feedback and supervision for staff preparing these meals. On 08/16/17, the facility instituted a menu and recipe inspection prior to tray service for each meal, which will continue for one month. On 08/16/17, the facility instituted a kitchen audit and test tray audit to be completed by the contracted dietetic technician or dietitian weekly during each of their weekly visits with results given to the administrator or his designee. This would begin on 08/18/17. On 08/16/17 at 2:30 P.M. consultant DTR #190 conducted training for two RNs and six LPNs. This training included policy review on mechanically altered diets, discussion on general recommendations for residents with swallowing difficulties, swallowing safety awareness, as well as key information to review on tray tickets to ensure proper meal delivery. On 08/16/17 at 3:15 P.M., the administrator provided evidence that consultant DTR #190 conducted this training. These staff members will be responsible for in-servicing the remaining nursing staff members before their next scheduled shift. Interview with the Administrator on 08/16/17 at 12:15 P.M. revealed the facility has planned to schedule weekly auditing/inspection/training with a consulting dietitian. This will be arranged/scheduled on 08/17/17. The facility has also arranged for training with their food service provider for online menu ordering and menu item clarification from recipes with training dates to be set for the week of 08/21/17. Although the Immediate Jeopardy was removed on 08/16/17 at 12:30 P.M. the deficiency remained at Severity Level II (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility will continue with in-servicing the dietary manager and dietary staff who are on leave and the facility continues to implement their monitoring systems to ensure continued compliance. Findings include: Review of Resident #39's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the information sent with the resident when he transferred from another facility included a form entitled Level of Care-Short Form, dated 07/07/17, which indicated the resident was a choking risk and that staff should monitor water intake for extreme thirst and excessive intake of water (polydipsia). The form also indicated the resident became confused and disoriented under stress. Review of an undated comfort plan for (resident's first name) safety, in the social service section of the resident's medical record revealed the resident responded well to structure and a set schedule and may become stressed when he is denied access to preferred items or activities or when his gratification was delayed. Review of the social service note, dated 07/19/17 revealed the resident required supervision for water intoxication. Review of Resident #39's physician orders [REDACTED]. The diet order was changed to a mechanical soft diet on 07/19/17. The order was communicated to dietary staff, but was not printed in the resident's hard chart medical record or in the resident's electronic medical record. Review of a speech therapy consult, dated 07/19/17 revealed Resident #39 was seen due to his high risk of aspiration and choking and history of dysphagia (difficulty swallowing). The note indicated the speech therapist examined the resident and found him to have a suspected swallowing disorder involving the oral and pharyngeal phase with a good prognosis for dysphagia rehabilitation with therapy ordered daily (5 days a week). The note was signed by the speech therapist and co-signed by the physician on 07/20/17. No specific recommendations, orders or a plan of care was available or developed to review to reflect the swallowing difficulties or interventions to address the resident's dysphagia. Review of an interdisciplinary team (IDT) care plan meeting note, dated 07/24/17 revealed staff including social service, activities, nursing, the physician, case manager and psychologist staff met with the resident. The IDT note revealed the resident's care included behavior modification and physical, occupational and speech therapy. The note addressed concerns for nursing, activities, restorative, social service, psychologist, assessment nurse, behavioral modification and the resident's concerns (I have too much anxiety and stress) but there was no mention of swallowing difficulties, choking risk or interventions to address these concerns. Review of a restorative nursing behavior modification assessment, dated 07/24/17 revealed the resident was extremely anxious daily, and had daily delusions and paranoia. Resident #39 was noted to be very labile, at times presenting with behaviors from smiling to crying within seconds. Review of the behavior modification plan revealed plans to increase socialization, decrease or prevent physical or verbal aggression and assist him to calm down when agitated. Review of Resident #39's admission Minimum Data Set (MDS) 3.0 assessment, dated 07/26/17 revealed the resident was moderately cognitively impaired, had hallucinations and delusions, required limited assistance to supervision of one staff member for his activities of daily living, with supervision after set up of his meals for eating. The assessment indicated the resident did not have swallowing or choking problems. Review of the plan of care related to cognition, implemented 07/26/17 did not indicate any concerns related to eating other than to set up and assist with meals as needed. There were no other care plans related to behaviors. Review of Resident #39's dietary assessment, dated 07/26/17 at 1:15 P.M. stated the resident was on a regular diet and received speech therapy for dysphagia. The note did not accurately reflect the resident's diet change to a mechanical soft diet or address the resident's risk of choking. Record review revealed a plan of care related to nutrition, dated 07/28/17 revealed the resident was at nutritional/dehydration risk. Interventions included to monitor for signs and symptoms of dehydration, obtain laboratory testing, provide diet, substitutions/alternates, labs and therapy and medications as ordered, weigh monthly and review in nutrition at risk (NAR) meeting, a weekly meeting to discuss residents with nutritional risk, per policy. The care plan did not reflect any concerns related to choking or difficulty swallowing. A progress note, entered electronically on 08/01/17 but dated for 07/30/17 at 12:30 P.M. and completed by the assessment nurse (RN #172) revealed Resident #39 had been evaluated by physical, occupational and speech therapy. The note indicated speech therapy was working with the resident on his oral safety needs as he has well documented historical episodes of choking and had a goal of improving his self-feeding abilities. Interview with RN #172 on 08/11/17 at 1:00 P.M. revealed she had seen the notes (prior to admission) about the resident's history of choking. She said the resident was on daily weights for his water intoxication, but verified there were no other interventions in the resident's medical record regarding this concern. She stated when the resident was brought to the facility by staff from his former facility, she asked those staff about any other behaviors they were aware of that the facility should know about. She said the staff told her that he had a history of [REDACTED]. She told them there was not buffet dining and said because that was the staff's main concern, she did not think that information was pertinent. She verified there was no mention in the care plans regarding his choking risk or interventions to prevent choking or monitor the resident's intake. She indicated the interview with the staff from the other facility and the documentation indicating choking risk was what she meant when charting well documented historical episodes of choking. Review of a note dated 07/31/17 at 6:00 P.M. written by the DON revealed staff were called to the main dining room and saw Resident #39 on the floor. The note stated staff in the dining room said he went limp and was holding his throat. The [MEDICATION NAME] maneuver was initiated and the suction machine was brought to the dining room along with oxygen tank and tubing. A mouth check was done and pieces of food were removed. Emergency services were called and when paramedics responded, cardiopulmonary resuscitation was continued by them. The note concluded that the resident was transferred to the hospital by the ambulance. Record review revealed there was no nursing progress note related to the incident, the circumstances surrounding this incident or the care provided to the resident at the time of the incident by the nurse assigned to care for Resident #39 or any other direct nursing staff involved in the actual incident. Review of the local fire department run sheet, dated 07/31/17 revealed EMS arrived at the facility at 5:05 P.M. They were unable to obtain vital signs and Resident #39 was unresponsive. An electrocardiogram (EKG) indicated the resident was in asystole, the absence of ventricular contractions [MEDICATION NAME] longer than the minimum possible to sustain life (about two seconds for a human), a cessation of electrical activity from the heart, asystole is the most serious and irreversible form of [MEDICAL CONDITION], at 5:21 P.M. The resident was receiving cardiopulmonary resuscitation (CPR) and had received two doses of [MEDICATION NAME], with his condition marked as unchanged. Review of the narrative note on the run sheet indicated staff (from the nursing home) had said the resident stood up during dinner and displayed the universal choking sign. Upon arrival, he was found on his left side with (unidentified) staff attempting back blows. The emergency personnel laid him flat and attempted abdominal thrusts, found him pulseless and started CPR with a mechanical CPR machine. The EMS staff were successful in retrieving a small amount of food from his respiratory tract and transferred the resident to the hospital with no change in his condition and CPR continuing. Review of a nursing note dated 08/01/17 at 10:54 A.M. revealed Resident #39 was in an Intensive Care Unit bed and a note dated 08/06/17 at 5:13 A.M. revealed the resident had expired at the hospital. The facility did not have a formal investigation of the above incident but did provide a typed timeline of events that was not signed by the staff member who completed it. The timeline indicated the resident was served his dinner tray on 07/31/17 at 4:52 P.M. and he began eating. At 4:54 P.M., he began hitting himself on the back and the charge nurse (identified as LPN #159) began assisting him with the [MEDICATION NAME] maneuver as he sat at the table. STNA #161 also began to assist the resident and at 4:55 P.M. he began to cough and expelled some food. He was placed on the floor by (unidentified) staff, who did the [MEDICATION NAME] again holding him in an upright position, then laid him down, doing abdominal thrusts and back blows. Emergency services were called as (unidentified) staff continued to assist the resident by performing the [MEDICATION NAME] and attempting to clear his airway, with food expelled several more times. The resident vomited at 5:01 P.M. and suction equipment was utilized and oxygen initiated. Two pieces of food were suctioned from the resident's mouth. At 5:07 P.M. the resident lost control of his bladder as staff continued to perform abdominal thrusts and back blows to dislodge food and clear his airway. The facility timeline indicated emergency staff arrived at 5:07 P.M. An interview with the DON on 08/08/17 at 12:55 P.M. revealed as a result of the incident concerns were identified that Resident #39 was not served his dinner meal prepared at the proper mechanical soft consistency. She indicated some large pieces of meat were noted on the resident's plate after the incident and upon investigation, two dietary employees (DA #166 and DA #167) were suspended. An interview with the dietary director (DD) #168 on 08/08/17 at 2:20 P.M. verified DA #166 and DA #167 were suspended because of the incident with Resident #39 on 07/31/17. DD #168 provided a meal ticket for the resident from the computer, which showed he was receiving a mechanical soft diet, but also indicated he was a choking risk and that he should have no chicken and no turkey. DD #168 stated she had interviewed the resident regarding his food preferences soon after he was admitted and he told her that he had choked in the past on chicken and turkey and did not want to have it again. She said she put the information in the computer to alert staff so that he would not receive those foods. Further interview with DD #168 revealed it was the responsibility of dietary staff to ask all residents their menu choices for the day, each day. She said upon investigation it was determined that DA #167 had asked Resident #39 about his dinner choice on 07/31/17, and DA #167 said Resident #39 said he wanted the entrée, which was a breaded chicken sandwich. She stated Resident #39 was served the breaded chicken sandwich for his dinner meal as he requested even though the resident was not to receive chicken. During the interview DD #168 stated she was unsure if the chicken was processed properly to a ground meat, as required by the recipe. She said facility administrative staff also informed her that ground chicken should be served with gravy, so this was added to the employee warning notice for these two employees. An interview with DA #166 on 08/09/17 at 1:09 P.M. revealed she was working on the tray side of the line on 07/31/17. She said she saw the comment on the tray card that Resident #39 should not have chicken, but said she knew DA #166 knew the residents better than her, so she didn't say anything when he handed her a plate with a chicken sandwich. She said she could not really see the chicken since it was under the bun but she did not think it was in large pieces. An interview with DA #167 on 08/09/17 at 1:19 P.M. revealed he was the cook on 07/31/17. He said he remembered asking Resident #39 earlier in the day what he would like for his dinner, and said he had indicated he would have the main entrée, a chicken patty sandwich. He said he did not question the resident about his choice in regards to the choking risk and warning on the tray ticket that he should not have chicken. DA #167 stated he had prepared the food for the dinner meal and stated he had prepared the chicken patties for the mechanical soft diets by baking the chicken patties and processing them to a ground consistency in the large blender (Robo-coup). He said he added a little bit of water to the blender with the chicken. He said the ground chicken was served on a bun with sides of mayonnaise, ketchup and mustard to be used if desired by the resident. He also said he was unaware of any facility procedure in which all chicken would be served with gravy. A second interview with DA #167 on 08/10/17 at 11:40 A.M. revealed he had served all residents ordered a mechanical soft diet on 07/31/17, a serving of broccoli-raisin salad. He said he combined raw broccoli, bacon bits, raisins and dressing and then put the mixture in the Robo-coup blender, chopped to a finer consistency. Review of the spreadsheet for the dinner meal on 07/31/17 revealed the broccoli salad was served for regular diets and was served in a pureed form for pureed diets, but the mechanical soft option was listed as broccoli. Review of the recipes for the menu items revealed a recipe for the regular and pureed salad, but for that day of the menu cycle, indicated plain broccoli should have been cooked until tender and served to residents with mechanical soft diets instead of the salad. He verified he has always served the salad and did not have broccoli available to serve, as he was unaware it was the menu option for residents with that diet. He said he also served canned pears, which he had chopped to the consistency of a chunky applesauce in the blender for the mechanical soft diets. DA #167 verified the residents receiving mechanical soft diets had been served the wrong food on 07/31/17 when he served the raw broccoli-raisin salad. This was verified with the facility administrator on 08/10/17 at 11:40 P.M., as the dietary director was not present in the facility. Review of a statement from STNA #157 revealed she was in the dining room on 07/31/17 but she was assisting another resident and did not provide direct care to Resident #39. An interview with STNA #157 on 08/09/17 at 2:00 P.M. revealed she had witnessed Resident #39 eating in the dining room prior to 07/31/17 and had told him frequently to slow down. She stated he had been seen eating a sandwich in just a couple bites and would see him shoveling food in his mouth. She said he would be told to slow down, but that did not really make much difference in his behavior. STNA #157 also indicated she was the staff member who gave the resident his meal tray on 07/31/17 during the dinner meal. She remembered that he had a bun with some meat on it, and said she thought the meat was ground up. She said she did not notice the meal ticket said no chicken or turkey. Review of a statement from STNA #161 dated 07/31/17 revealed he observed the resident indicating he was choking while he was eating a chicken sandwich. He verified the nurse started to assist the resident and he also assisted the resident with the [MEDICATION NAME] maneuver. The statement indicated the resident coughed out a lump of food. The statement concluded with a note that the resident had been in the habit of eating too fast even after repeated caution to slow down in most of the meals observed (by STNA #161) An interview with STNA #161 on 08/09/17 at 2:25 P.M. revealed the resident ate his food very quickly. He stated the resident would often have a large mouthful of food that he had not swallowed and get up to leave the dining room, needing direction to return and finish the food in his mouth and the rest of his meal. STNA #161 stated most staff were aware of the need to tell Resident #161 to slow down when he was eating, but said he was also concerned because the resident seemed to hold so much food in his mouth without swallowing. He also verified the events of 07/31/17 as described in his statement, and indicated he also helped with the attempts to dislodge food by abdominal thrusts and [MEDICATION NAME] maneuver. An interview with ST #170 on 08/09/17 at 2:50 P.M. revealed she assessed Resident #39 due to his history of dysphagia and choking and felt he would benefit from speech therapy to improve his swallowing. She said she saw him frequently but did not keep daily notes. She said she would observe his swallowing while he was in the therapy department and while eating a snack, but said she could not say if she had seen him eat a full meal. She said she probably had seen him eat at least a partial meal, but was unaware of the concerns with his eating food quickly. She verified he was at risk for choking due to his history and his impulsivity but was unable to describe any interventions provided to staff to prevent choking for Resident #39. ST #170 stated the resident had been seen for speech therapy eight times from 07/20/17 through 07/31/17. Review of a statement by LPN #159, dated 07/31/17 revealed she saw Resident #39 pointing at his throat and when he indicated he was choking, she started doing the [MEDICATION NAME] and the resident spit out two large pieces of food that looked like bread and chicken. LPN #159 indicated she and other (unidentified) staff continued to do the [MEDICATION NAME] as well as give abdominal thrusts to attempt to expel the food items. An interview with LPN #159 on 08/09/17 at 3:30 P.M. revealed she had seen Resident #39 eat very quickly prior to 07/31/17 and she frequently had to tell him to slow down. She said he also seemed to just put food in his mouth without swallowing consistently and she would see him with chipmunk cheeks (lots of food in his mouth). She said the resident had mentioned to her in the days prior to the incident that he was having trouble swallowing, but she stated she knew he was in speech therapy, which she confirmed with the physician. She said when the resident first started choking on 07/31/17, he coughed out some large chunks of food on his own, but his airway was still blocked. She said more and more food came out, but he began to turn a grey color and eventually passed out. She said she thought the large chunks of food were just from him holding the food in his mouth for so long. A telephone interview with facility dietary technician (DT) #171 on 08/09/17 at 3:45 P.M. revealed she had seen Resident #39 about a week after he was admitted to the facility. She said she reviewed the record and noted the resident was seeing speech therapy for treatment of [REDACTED]. She was unaware of his swallowing concerns or that the resident's diet had been changed to a mechanical soft. An interview with the Administrator on 08/09/17 at 4:15 P.M. verified the above concerns with coordination of care for Resident #39 regarding his choking risk and eating behaviors. The administrator verified the resident's order on admission for a mechanical soft diet was not properly entered as such into the facility computer charting system, which incorrectly indicated the resident was on a regular diet. This would put the resident at risk for any staff who would check the computer to determine the resident's diet order. The Administrator verified the resident was seen by speech therapy beginning at the time of admission for dysphagia due to his risk of choking, however, his care plans did not address a choking risk or provide interventions for staff to prevent choking. Staff had identified behaviors of rapid eating and large amounts of food retained by the resident in his mouth without swallowing prior to the choking incident on 07/31/17. However, the speech therapist and dietician were unaware of these concerns and they were undocumented in the record. As of 08/10/17 the facility has not had a dietary director available. The dietary director's (DD #168's last date worked was 08/09/17. The DD was currently on medical leave with a return to work date planned for 08/21/17. The following concerns were noted during observations of meals: On 08/11/17 at 10:45 A.M. observation in the therapeutic dining room revealed Resident #26 at the table with his mechanical soft meal in front of him. He was observed with a tossed salad with pieces of lettuce, pieces of tomato about 0.5 inches by 1 inch and shreds of red cabbage. LPN #151 was asked about his salad. She looked at his

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on observation, resident and staff interview, medical record review, review of the facility investigation, and review of the facility's Elopement Policy and Maintenance Elopement Risk Audit, the facility failed to provide adequate supervision for one resident (Resident #12) to prevent elopement from the facility. This resulted in Immediate Jeopardy when Resident #12, who was at risk for elopement, had a history of [REDACTED]. Resident #12 was at risk for serious harm, impairment or death as she walked along a heavily trafficked three lane road, crossed the three lanes until seen by an off duty employee who happened to drive by. This affected one of three residents reviewed (Resident #12) for exit seeking behaviors. The facility identified twenty-eight additional residents (Residents #3, #4, #5, #10, #15, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39 and #40) who were ambulatory or independently mobile and assessed as being at risk for wandering and elopement or exhibited exit seeking behaviors. On 08/04/17 at 2:40 P.M., the Director of Nursing (DON) and Assistant Director of Nursing, Licensed Practical Nurse (LPN) #151 were notified Immediate Jeopardy began on 05/20/17 at 6:00 P.M. when Resident #12 was last seen in the building before exiting two locked doors and was found walking along a busy three lane road 0.9 miles from the facility. The Immediate Jeopardy was removed and corrected on 05/31/17 at 2:00 P.M. when the facility implemented the following corrective actions: On 05/20/17 at 6:30 P.M., Resident #12 was returned to the facility by an ambulance and the police. The resident was placed on one to one monitoring and the physician, DON and her guardian were notified of the incident. On 05/22/17, the lock on the West Hall was changed to a keyed lock instead of button style lock by a local lock service. On 05/24/17, the touch pad door opener in the dining room was re-programmed with a different code. On 05/25/17, Licensed Social Worker (LSW) #151 completed a reassessment of all residents for potential exit seeking behaviors and updated the elopement risk list to include the level of risk and behaviors the resident displayed that increased the level of elopement risk. Forty staff members were in-serviced on the new elopement assessment at morning meeting and the assessment was posted in all nursing stations and department areas on 05/25/17. All other staff were in-serviced on the new the start of their next scheduled shift. On 05/31/17 at 2:00 P.M., the Assistant Director of Nursing, LPN #151 completed in-service education with 80 of 80 facility staff members on supervision of residents, elopement policy, securing doors and dining room procedures. This was verified via staff in-service sign in sheets. On 08/04/17 from 1:00 P.M. to 4:00 P.M. and on 08/07/17 from 11:00 A.M. to 6:00 P.M., interviews revealed Housekeeper # 156, Dietary Aide (DA) #155, DA #162, State tested Nurse Aid (STNA) #157, STNA #160, STNA #161, STNA #164, LPN #150, LPN #153, LPN #159, LPN #163, Activity Director #154, Registered Nurse (RN) #158 and Director of Maintenance (DM) #152, had all been in serviced on supervision of residents, the elopement policy, identifying escalating resident behaviors and hourly verification of residents. Findings include: Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission physician note dated 03/09/17 revealed the resident had a history of [REDACTED]. Review of Resident #12's elopement care plan dated 03/10/17 revealed she was at risk of elopement with interventions to identify patterns of wandering, put photograph in elopement book and distract from wandering by offering diversions, structured activities, other activities and keep guardian and family informed of any mood or behavior changes. Review of a nurse practitioner note dated 03/13/17 revealed Resident #12 was sitting with her purse next to her and, when asked if she was going somewhere, stated, sort of. She also stated she wanted to go home to her family's farm and had plenty of money, because every time she says a prayer for someone, he gives her money. Review of her admission Minimum Data Set 3.0 assessment dated [DATE] revealed she was moderately cognitively impaired, frequently felt down or depressed with little interest in doing things, had physical and verbal delusions, and other behavior and frequently refused care. She could ambulate with supervision only. Review of a progress note dated 05/06/17 at 7:12 A.M. revealed Resident #12 was found on the floor and had been incontinent of urine. She had complained of ankle pain but refused to allow the nurse to assess her. Neurological checks were started due to the fall being unwitnessed. Review of a Risk of Elopement/Wandering Review dated 05/17/17 revealed Resident #12 was at risk due to cognitive impairment, verbally expressed desire to leave the facility and was a new admission. Interventions in place included exit and stairwell alarms, a secured unit and frequent monitoring. Review of a progress note dated 05/20/17 at 6:30 P.M. revealed it was discovered that resident was missing. A search was initiated and resident was found walking up the road. Police were called to help get resident back to the facility and she was returned in an ambulance. One on one supervision was initiated. Review of a state reported incident dated 05/21/17 revealed on 05/20/17, Resident #12 had finished eating her dinner and proceeded to her hall after the meal. The kitchen staff finished in the dining room at around 5:30 P.M. and all residents were assisted out of the area and the dining room doors were locked. The investigation indicated Resident #12 was last seen by staff in the facility around 6:00 P.M. The resident's roommate reported the resident was in her room after dinner and left her room before the snack break. The investigation indicated that between 6:00 P.M. and 6:15 P.M., the resident went to the door in her hall and manipulated the door handle until the lock on the opposite side of the handle unlocked. She then entered the main dining room and pushed the number on the key pad lock on the door that led out of the building from the dining room. Resident #12 then walked down the road in front of the facility where she sat on a cement block. The investigation indicated the facility social worker, LSW #150, who was not working at the time, but was driving in the area, saw the resident sitting on the cement block. LSW #150 notified the facility. The social worker stayed with the resident, who refused to return with her, but with the assistance of an ambulance service and the police, the resident was returned to the facility. The investigation indicated the resident had increased delusions and asked that she be taken to a computer hospital. After receiving the phone call from the social worker and checking all doors, the fire door in the dining room was found not completely shut. All other residents were accounted for with no concerns. When interviewed, the resident stated she had squeezed the handle on the unit door until it popped and let me out, then I went to the door with the button and pushed the buttons until the door opened. The resident stated she had been kidnapped and was going to sue everyone because she had not signed any papers to stay at the facility. An interview with LSW #150 on 08/04/17 at 11:50 A.M. revealed she was not working on Saturday, 05/20/17 but lived in a neighborhood near the facility. She was driving toward the facility to her home and noted the resident sitting on a cement block in an area along the road that runs in front of the facility. She said she could not turn into the area where the resident was but drove to the next street, pulled over, and called the facility and the local police. She said by the time she turned back around, the resident had crossed another three-lane street and had walked to a fast food restaurant. LSW #150 pulled her car into the parking lot of the fast food restaurant and approached the resident. She said the resident would not speak to her but kept walking toward a field behind the restaurant. LSW #150 walked with the resident to keep her safe and away from traffic. She said the police came and realized the resident was not going to return easily to the facility, so police backup and an ambulance were called. The ambulance and police personnel helped the resident onto a stretcher and into the ambulance, then returned the resident to the facility. Review of a statement of STNA #161 dated 05/20/17 revealed she had last seen Resident #12 around 5:30-6:00 P.M during dinner time. The statement indicated she did not recall specifically seeing the resident leave, but knew all residents had left the dining room by the time she left after dinner was over. A second statement indicated after the facility received the call from LSW #150, STNA #161 checked all the doors and noted the fire exit in the dining room was ajar. She closed the door and made sure it was locked. On 08/07/17 at 2:45 P.M. The Assistant Director of Nursing, LPN #151 stated STNA #161 had resigned her position at the facility and was no longer employed. Review of a statement dated 05/20/17 by LPN #163 revealed she had seen Resident #12 in the dining room and the dining room was empty after dinner. Her statement indicated dinner was over at 5:30 P.M. An interview with LPN #163 on 08/07/17 at 3:40 P.M. verified she was the nurse in the dining room that night. She stated the dining room would be cleared out once the residents were done eating and all the doors to the dining room were secured. She stated Resident #12 resided on the West Hall, which was adjacent to the dining room, separated by a locked door and confirmed the resident would have gone through the door with other residents when the meal was over, with the door locked behind them. She verified the meal was over and the dining room would have been cleared out by 5:30 P.M. An interview with DA #155 on 08/07/17 at 3:06 P.M. revealed she was working the night Resident #12 left the building from the door in the dining room. She stated the nursing staff assisted the residents out of the dining room after dinner, usually around 5:30 P.M and the kitchen staff cleaned the dining room. The residents usually went to smoke break, then came back to the dining room around 6:10 P.M. or 6:15 P.M. for a snack. DA #155 verified a statement she had written dated 05/24/17 indicated she had not seen Resident #12 in the dining room during the snack time on 05/20/17, and had not noted the door ajar. DA #163, who also wrote a statement on 05/24/17, was interviewed on 08/07/17 at 3:45 P.M. DA #163 verified she was also working on 05/20/17 and verified she had not seen Resident #12 at the snack time that night or observed an opened door. An interview with LPN #159 on 08/07/17 at 5:50 P.M. revealed she was the nurse who was working on the floor on 05/02/17. She stated she had received the phone call from the social worker around 6:30 P.M. saying the resident had been seen walking on the road away from the facility. She said when it was noted an exit door was open she did a head count to ensure no other residents were missing. An interview with DM #152 on 08/08/17 at 10:00 A.M. confirmed Resident #12 had apparently exited the building on 05/20/17 through the West Hall door and the fire door in the dining room. He stated the lock on the West hall door was a handle knob with a key hole on the hall side and a handle knob with a push button lock on the dining room side on 05/20/17. He stated the dining room fire doors were rarely used, but were double doors with a key pad exit code that would alarm if the code was not entered, but would open automatically if the fire alarm went off or if the correct code was entered. DM #152 provided documentation that he checked all windows/grates, roof access, door access and other risk areas as part of a quarterly Maintenance Elopement Risk Audit. The audit forms reviewed were dated October 2016, January 2017 and May 2017, but did not indicate a specific date of the audit. DM #152 stated he did the checks the first couple weeks of the month they were due, so the check would have been done in May prior to Resident #12 leaving the facility on 05/20/17. He stated he was unaware of any concerns with the lock on the West hall door. He said the resident may have been able to either wiggle the door handle to pop the lock or perhaps the lock button had not been pushed to lock the door to the unit from the dining room side. He said the lock was changed on 05/22/17 to a handle lock on both sides, with a key hole on the hall side. He said the door now locked automatically and did not rely on pushing a button lock in to lock the door. The code was changed on the dining room fire door on 05/24/17. Attempts were made to interview Resident #12 on 08/04/17 at 2:00 P.M., on 08/07/17 at 9:00 A.M., 10:30 A.M., 3:25 P.M. and 5:45 P.M. and on 08/08/17 at 8:15 A.M. She was generally in her room in bed, snoring. She would at times respond to the surveyor calling her name but would not open her eyes. She denied concerns by shaking her head, but would not answer questions. She was observed out of her room for meals, but when approached during lunch on 08/08/17 at 11:30 P.M., although she was alert and eating, she would not speak to the surveyor even when asked direct questions. She finished her meal quickly and left the dining room, going back to her room and bed. Observation of Resident #12's hands revealed they were contracted; all fingers were curled inward toward her palms. Further review of Resident #12's record revealed the increased supervision had been completed as ordered after her return to the facility on [DATE], including one to one monitoring for one week, every 15 minute checks for one week, every 30 minute checks for one week, every 45 minute checks for one week, then hourly checks which continue. The resident was seen by the facility psychiatrist on 05/23/17. The note revealed the resident had escaped from the facility this weekend as she does not think she needs to be here, has chronic delusions has been violent and refuses self care. The note indicated she wanted to get home to computer robots who she prayed for and gave training tapes, indicated God talked to her and she was building up her power and could make God do anything as she was the boss and owned everyone's property. The psychiatrist adjusted medications and review of a note dated 07/11/17 indicated the resident had been much more cooperative with care and although delusions had continued, had improved mood symptoms. An interview with the Assistant Director of Nursing, LPN #151 on 08/08/17 at 8:50 A.M. verified Resident #12 was assessed at risk for elopement from the facility on 05/17/17 based on impaired cognition, delusions, ability to ambulate independently, verbally expressed desire to leave the facility and history of elopements as expressed in the physician notes on admission. LPN #151 verified the facility relied on the locked doors, staff observations on an hourly or more frequent basis and observations of resident behaviors to deter residents from leaving the building and the facility property. She verified Resident #12 was seen during the dinner meal on 05/20/17, leaving the dining room by 5:30 P.M. and, according to her roommate, returned to her room. She left her room sometime before 6:00 P.M. and opened the locked door at the end of her hall, either by pushing it open if it had been left unlocked, or manipulating it to pop the lock. She then entered the dining room, which was unattended by staff and entered the code on the double fire door to exit the building, leaving the door ajar. She walked to the road, past a large pond on the property, and approximately 0.6 miles south along a two-lane road with no sidewalks and a slight hill. She was seen by a facility employee (LSW #150) at approximately 6:17 P.M., who was driving in the area, and called the facility, where staff had not noted her absence. LSW #150 then found the resident had crossed a busy three lane road and continued a total of 0.9 miles to a fast food restaurant, where LSW #150 parked and followed her, while waiting for assistance from local authorities to return her to the facility. Review of the facility Elopement Policy (undated) revealed the facility would provide a safe environment for all residents to ensure a multidisciplinary, comprehensive approach was utilized to prevent residents from elopement from the facility. This deficiency is an incidental finding to Complaint Number OH 532.

Based on record review, staff interview and review of facility self reported incident (SRI) investigations, the facility failed to prevent incidents of physical abuse involving Resident #1, Resident #95 and Resident #16. Harm occurred when Resident #16 struck Resident #1 over the head with a chair causing a laceration that required sutures. In addition actual harm occurred when Resident #1 pushed Resident #95 out of the wheelchair and kicked her several times in the head causing redness to the face and a bump to her head. This affected two residents (Resident #1 and #95) of five residents reviewed for abuse. This had the potential to affect 83 residents that resided on the main floor of the facility. The facility census was 95. Findings include: 1. Record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the five day Minimum Data Set (MDS) 3.0 assessment, dated 02/23/16 indicated the resident was severely cognitively impaired and required supervision for walking in the room, corridors and on and off the unit. A progress note dated 03/05/16 at 7:47 A.M. revealed Resident #1 was standing by the court yard door waiting to smoke at 6:45 A.M. Another resident ( Resident #16) was upset and hit the resident in the head with a chair causing him to have a laceration above the left eye and forehead. Both residents were separated. Ice was applied to the area and vitals were taken. The physician and director of nursing (DON) were notified. Orders were obtained to send Resident #1 to the emergency room for evaluation and treatment. Paramedics transported Resident #1 at 7:15 A.M. The local police department arrived and took statements at 7:10 A.M. Resident #1's guardian was notified. On 03/05/16 at 2:32 P.M. Resident #1 returned from the hospital with nine sutures over the left eye which were covered with a bandage. Neurological checks were initiated and Resident #1 was responsive. The physician and DON were notified of the resident's return. Review of Resident #16's medical record revealed a progress note, dated 03/05/16 at 7:56 A.M. that stated Resident #16 was involved in a physical altercation with Resident #1 at 6:45 A.M. Licensed Practical Nurse (LPN) #130 was in the north hall nurse's station when she heard yelling coming from the breezeway area. LPN #130 went to see what was going on and witnessed Resident #16 holding a chair in the air. As LPN #130 got closer to the resident, Resident #16 was aiming a chair at Resident #1. Before the nurse could get to Resident #16 to grab the chair, he had hit Resident #1 in the head with it. Both residents were immediately separated and Resident #1 was assessed by the nurse. An ice pack was placed to the laceration above the left eye. The physician and DON were notified. The guardian was notified. Resident #16 was escorted back to north hall and one on one supervision was provided by staff. Review of facility self reported incident (SRI) investigation, tracking number 8 dated 03/05/16 revealed an incident involving Resident #16 and Resident #1. The SRI indicated Resident #16 as the aggressor. As a result of the facility investigation, willful intent was determined when Resident #16 stated he was angry about not smoking, and Resident #1 kept, running at the mouth. Resident #16 stated he told the resident to get the f--- out of the way picked up a chair and hit him with it. Resident #1 was sent out to the hospital and received nine sutures in his head. Resident #1 stated he didn t know why Resident #16 hit him, but President Obama must have told him to do it. Resident #1 stated he didn't do anything he was just standing there. The residents were separated and Resident #1 was sent out to the hospital. Witness statements were obtained, and reviewed. On 07/13/16 at 11:15 A.M. interview with the Assistant Director of Nursing (ADON) verified the above incident of physical abuse involving Resident #16 and Resident #1. 2. Review of self- reported incident (SRI) tracking number 5 dated 12/03/15 indicated Resident #16 as the aggressor. Review of a progress note for Resident #95 dated 12/03/15 at 10:50 A.M. revealed the nurse heard yelling down the hall while working with another resident. The nurse observed Resident #95's wheel chair had been pushed over by Resident #16 and Resident #16 was kicking Resident #95 in the head. The residents were separated with the assist of four staff members. As staff were attempting to remove Resident #16 he continued attempting to kick at Resident #95. The nurse assessed Resident #95 with a reddened area noted to the left eye, side of right cheek, and small bump to the back of the left side of her head. Neurological checks were initiated. Vital signs were taken. Resident #95 was assisted back into her wheelchair with two staff assist. When Resident #95 was asked what had happened the resident stated I told him he wasn't supposed to be sitting there and he got up and put his middle fingers in my face and called me a [***] and knocked me over and started kicking me. The physician, DON and guardian were notified. Record review revealed there was no further documentation available to review related to this incident at the time of the onsite investigation. Review of Resident #95's medical record revealed the resident exhibited cognitive impairment at times. Although the resident resided in the facility at the time of this onsite investigation, no information could be obtained from the resident via interview due to cognitive deficits. On 07/13/16 at 11:15 A.M. interview with the ADON verified the above incident of physical abuse involving Resident #16 and Resident #95. The ADON also verified the lack of additional information or investigative documentation to ensure Resident #95 was assessed for injury, monitored following the incident and/or that interventions were implemented to prevent additional altercations from occurring. Review of the facility policy on Abuse, Neglect, Misappropriation/ Property dated 2005 revealed residents have the right to be free from verbal, sexual, physical or mental abuse, corporal punishment, neglect, or abusive behavior as defined and is strictly prohibited and thoroughly investigated. The procedure revealed the facility will not permit residents to be subjected to abuse, neglect or misappropriation of property by any one including staff members, other residents, consultants, volunteers, staff of other agencies serving the residents, families legal guardians, sponsors, friends, or other individuals. This deficiency is an incidental finding to Master Complaint Number OH 431.

Based on observation, medical record review, interview with staff, review of facility incident reports, review of police reports, and review of the facility Elopement Policy and Procedures Wayside Farm, the facility failed to provide adequate supervision for Resident #37, who was identified as being a high risk for elopement and had an intervention to monitor whereabouts visually. This resulted in Immediate Jeopardy on 06/03/16 at 3:45 P.M., when Occupational Therapist (OT) #186 observed Resident #37, unattended by staff in the facility courtyard, and reported this to Licensed Practical Nurse (LPN) #115, who did not respond to the lack of visual supervision for Resident #37. The potential for serious harm occurred when Resident #37 was then able to climb an apple tree in the courtyard to access the one-story roof of the facility, lower himself to the ground and elope from the facility by running off the grounds without staff knowledge. This resulted in immediate Jeopardy for one resident (Resident #37) of 36 residents identified by the facility at risk for elopement. The facility census was 94 residents. On 06/09/16 at 11:07 A.M., Director of Nursing (DON)/Administrator #160 and Assistant Director of Nursing (ADON) #183 were notified that Immediate Jeopardy began on 06/03/16 at 3:45 P.M. when Resident #37 was observed by OT #186 unsupervised in the courtyard and reported this to LPN#115 who did not check on Resident #37. Resident #37 was able to climb an apple tree in the courtyard to access the one-story roof of the facility, lower himself to the ground and elope from the facility by running off the grounds without staff knowledge. State tested Nursing Assistant (STNA) # 126 was not able to find Resident #37 in the courtyard at 4:00 P.M. and STNA #126 notified LPN #149 the resident did not go to dinner. The facility staff failed to implement the facility ' s elopement policy until almost 6 hours later when LPN #149 called DON/Administrator #160 at 9:50 P.M., and was instructed by DON/Administrator #160 to implement the facility elopement procedures. On 06/03/16 at 9:48 P.M., Resident #37 was picked up by Police Department #2 at the intersection of a heavily traveled State route which was 4.4 miles from the facility. Resident #37 was then taken to the police department and subsequently transported to Police Department #3 due to an outstanding arrest warrant. The Immediate Jeopardy was removed on 06/09/16 when the facility implemented the following corrective measures: · On 06/03/16, LPN #149 and LPN #115 received disciplinary action for not following the facility elopement policy and procedures. · On 06/06/16, ADON #183 began in-servicing staff regarding keeping the courtyard locked and ensuring all residents were supervised and exited the courtyard after the activity/smoke break was completed. As of 06/09/16, 84 employees and five contracted therapy staff were educated in person including six RNs, 17 LPNs, 25 STNAs, 11 dietary staff, seven housekeeping staff, eight laundry aides, two bookkeepers, one maintenance staff, one assistant administrator, two receptionists, two activity aides, one ward aide, one social worker, and five therapy staff. On 06/09/16, Licensed Social Worker (LSW) #156 educated three RNs and five LPNs by phone regarding keeping the courtyard locked. The remaining two STNAs will be educated on their next scheduled day as they could not be reached by phone. · On 06/06/16, the facility initiated a courtyard key sign out log. The courtyard key will be turned into the receptionist daily Monday through Friday from 8:30 A.M. until 5:00 P.M. After 5:00 P.M. on weekdays and all day during the weekends, the key is to be given to the 100 hall nurse. An audit tool will be completed by ADON #183 two times a week for the first month, then four times a week for one month, and then monthly until staff compliance is assured. · On 06/07/16, the facility initiated trimming the tree in the courtyard that Resident #37 used to access the roof, which was completed on 06/08/16. · On 06/08/16 and 06/09/16, ADON #183 re-educated 39 of 84 employees on the facility Elopement Policy and Procedures, including two RNs, seven LPNs, 17 STNAs, four dietary staff, four housekeepers, three laundry aides, and two receptionists. On 06/09/16, LSW #156 educated by phone eight employees, including three RNs and five LPNs, regarding keeping the courtyard locked and the facility Elopement Policy and Procedures. The last two STNAs will be educated on their next scheduled day as they could not be reached by phone. The remainder of the employees will be in-serviced their next scheduled work day. · On 06/08/16, Activity Director #176 was terminated when she refused to write a witness statement related to this incident. · On 06/09/16, the facility implemented Hourly Visual Check Residents at Risk of Elopement tool for all 36 residents assessed at risk for elopement. Audits of this tool will be completed by ADON #183 two times a week for the first month, then four times a month for one month, and then monthly until the quality assurance team has determined any issue of elopement risk has been resolved. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was implementing an on-going system for monitoring the corrective measures, and continuing the inservice training for remaining staff members who have not yet received training. Findings include: Resident #37's medical record revealed he was initially admitted to the facility on [DATE], and was readmitted to the facility from the hospital on [DATE] after eloping from the facility during an activity on 08/05/15 resulting in a psychiatric hospitalization . The resident had [DIAGNOSES REDACTED]. The resident's plan of care, initiated on 08/12/15 and updated on 03/18/16, revealed he was at an extremely high elopement risk. Staff were to keep behavior logs, monitor the resident's whereabouts visually, and keep all exit doors locked. The resident had a physician's order [REDACTED]. Review of Resident #37's plan of care initiated on 08/12/15, and updated on 03/18/16, revealed he was at an extremely high elopement risk. Staff were to keep behavior logs, monitor the resident's whereabouts visually, and keep all exit doors locked. However, interview with ADON #183 on 06/08/16 at 2:53 P.M. revealed the facility did not document visual monitoring of residents. Review of a witness statement dated 06/04/16 revealed on 06/03/16 at approximately 3:45 P.M., Occupational Therapist (OT) #186 observed Resident #37 in the enclosed courtyard unattended by facility staff. OT #186 notified the 100 Hall nurse, LPN #115, and together they went to LPN #182 and Activities Director #176 who had the courtyard key. They were told the courtyard was left open for residents to enjoy the warm weather. A few minutes before 4:00 P.M., STNA #126 was looking for Resident #37 to get him ready for dinner. OT #186 told her she had just seen him in the courtyard, however, Resident #37 was not found there by STNA #126. There was no documentation in Resident #37's record regarding the elopement until 06/03/16 at 10:00 P.M., when DON/Administrator #160 documented she was called at home at 9:50 P.M. by LPN #149 who stated she could not find Resident #37 to give him his bedtime medications. There was no evidence provided that the resident was being monitored visually. Review of a report from Police Department #1, dated 06/09/16, revealed on 06/03/16 at 10:30 P.M. it was reported by DON/Administrator #160 that Resident #37 was last observed by staff at 12:00 P.M. when he had lunch. He was noticed missing at 5:00 P.M. when he did not show up for dinner. The report indicated it was hard for facility staff to pinpoint the last time they saw him. Nobody on second shift had seen him and second shift started at 3:00 P.M. The first shift workers had already been home. The security cameras were only able to be reviewed for the previous two hours. While in route to have Resident #37 put into the system as a missing adult, Police Officer #200 received a call from his sergeant (Sgt. #201) who had spoken with Police Department #2. Police Department #2 indicated Resident #37 had been arrested on an outstanding warrant at approximately 8:00 P.M. at a heavily traveled State route intersection approximately 4.4 miles away from the facility. Police Officer #200 called to notify the facility Resident #37 was in jail. There was no information related to the condition of the resident when he was found. Review of a report from Police Department #2, dated 06/03/16, revealed at 8:08 P.M. three police officers were dispatched to a local golf course in reference to a suspicious white male. Upon arrival officers were unable to locate the person of concern. Then at 9:48 P.M. while on patrol, Police Officer #202 located Resident #37 walking westbound near a heavily traveled intersection. When asked where he was heading, Resident #37 stated to Richfield, and that he was homeless. A Law Enforcement Automated Data System check revealed he had an active warrant from Police Department #3. Resident #37 was then transported to Police Department #3 and placed in jail on an outstanding arrest warrant. On 06/06/16 at 2:22 P.M. Resident #37 returned to the facility with his brother/guardian. The resident's vital signs were within normal limits and there were no apparent injuries noted. All previous physicians' orders were reinstated per MD #191. The resident was shown his new room on the North Hall and his dining room location was changed to be in the Main Dining room for all meals. On 06/08/16 at 4:50 P.M., Resident #37 was observed independently ambulating out of the common bathroom on the North Hall into his room without difficulty. Interview with ADON #183 at the time of the observation revealed he had no injuries noted and was having no difficulty with his usual activities of daily living. She indicated he likely would not talk with the surveyor as he was very wary of new people. On 06/10/16 at 11:15 A.M., Resident #37 was observed in his room dressed in blue jeans, a dark shirt, gray athletic shoes and wearing glasses. The resident would not make eye contact with the surveyor and chewed on his right thumbnail as he spoke with the surveyor. The resident said he did not have to explain anything to the surveyor. When the surveyor asked Resident #37 if he wanted the surveyor to leave, he replied yes. On 06/06/16, ADON #183 began in-servicing staff regarding keeping the courtyard locked and ensuring all residents were out of the courtyard after the activity/smoke break was completed. The residents were not to be in the courtyard unsupervised. As of 06/09/16, 84 employees were educated in person including, six RNs , 17 LPNs, 25 STNAs, 11 dietary staff, seven housekeeping staff, eight laundry aides, two bookkeepers, one maintenance staff, one assistant administrator, two receptionists, two activities aides, one ward aide, and one social worker. Five contracted therapy staff were educated as well. On 06/09/16, LSW #156 educated eight employees including three RNs, and five LPNs regarding keeping the courtyard locked. The last two STNAs were to be educated on their next scheduled day as they could not be reached by phone. The facility provided evidence of the completed sign in sheets. On 06/06/16, the facility initiated a new courtyard key sign out log. The courtyard key was to be turned into the receptionist daily on Monday through Friday from 8:30 A.M. until 5:00 P.M. At 5:00 P.M. on weekdays, and during the weekends, the key is to be given to the 100 hall nurse. An audit tool is to be completed by ADON #183 two times a week for the first month, then four times a week for one month, and then monthly until staff compliance was assured. On 06/08/16 at 5:00 P.M., Receptionist #166 was observed giving the key to LPN #115 who put it in the medication room. Interview with Receptionist #166 at this time revealed she gave the key and sign in sheet to the 100 hall nurse (LPN #115) as she was leaving for the day. At 5:20 P.M. LPN #115 was observed getting the key to let residents out for a smoke break and at 5:50 P.M. all residents were back into the facility from the courtyard and the door was observed locked. ADON #183 showed the surveyor that the courtyard door key had been placed in the 100 hall medication room. Interview with LPN #115 on 06/08/16 at 6:26 P.M., confirmed she was given the key and the courtyard key log which she locked in the medication room. On 06/09/16, the facility implemented hourly visual checks for all 36 residents assessed at risk for elopement. The Hourly Visual Checks Residents at Risk of Elopement tool included residents at risk for elopement by hall on the 100 hall, West hall, North hall, and Lower level hall. On 06/10/16, the facility provided evidence of the completed logs for all 36 residents. Audits were planned to be completed two times a week for the first month, then four times a month for one month, and then monthly until the quality assurance team has determined the elopement risk visual checks were being completed and updated regularly. On 06/08/16 and 06/09/16, ADON #183 re-educated staff on Elopement Policy and Procedures. Formal in-servicing was completed for 39 of the 86 employees including: two RNs, seven LPNs, 17 STNAs, four dietary staff, four housekeepers, three laundry aides, and two receptionists. On 06/09/16, LSW #156 educated by phone eight employees including three RNs and five LPNs regarding keeping the courtyard locked. The last two STNAs were to be educated on their next scheduled day as they could not be reached by phone. The remainder of the employees will be in-serviced their next scheduled work day. On 06/10/16, the facility provided documentation of the sign in sheets and the phone calls placed. Staff that were educated by phone were required to review the written education and sign the sheets as they entered the facility on their next scheduled day of work. On 06/07/16, the facility began trimming the tree in the courtyard that Resident #37 used to climb to the room and elope, which was completed on 06/08/16. Observation of the tree on 06/08/06 at 5:05 P.M. revealed there were no branches that could be used to climb the tree to access the roof. This deficiency substanatiates the allegations contained in Complaint Number OH 875.

Based on record review and staff interview the facility failed to ensure treatments for a pressure ulcer were completed as ordered for one resident (Resident #99). This resulted in actual harm to Resident #99 who sustained a decline of an abrasion to a pressure ulcer and required antibiotic treatment related infection of the ulcer. This affected one of one residents reviewed for pressure ulcers. The facility census was 95. Findings include: Resident #99 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #99's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was at risk for pressure ulcers. The MDS assessment indicated Resident #99 did not have any unhealed pressure ulcers or any other ulcers, wounds, or skin problems. The MDS assessment also indicated Resident #99 required extensive assistance of two staff members for bed mobility and transfers. Review of Resident #99's physician's orders [REDACTED]. Review of the facility Wound Care Management Documentation Forms revealed the following documentation for Resident #99's coccyx wound. Review of documentation dated 03/27/13 revealed the initial presentation as an abrasion on the lower coccyx which measured 0.8 centimeters (cm) x 0.8 cm x less than 0.1 cm depth with scant light brown exudate. Review of documentation dated 09/18/13 and 09/26/13 revealed the pressure ulcer measured 0.3 centimeters (cm) x 0.6 cm x less than 0.2 cm. No measurements were provided from 09/26/13 through 11/13/13. Review of documentation dated 11/20/13 revealed the area was identified as an abrasion measuring 1.6 cm x 0.8 cm x less than 1.2 cm depth, with 10 percent greenish brown drainage and ninety percent dark brown drainage. Review of documentation dated 12/18/13 revealed the area was identified as an abrasion which measured 1.8 cm x 1.0 cm x less than 0.9 cm. Review of Resident #99's treatment administration record (TAR) revealed Resident #99's lower coccyx pressure ulcer treatment was not completed on day shift on 10 days during the month of November, 2013 and was not completed on day shift on 11 days during the month of December, 2013. On 01/02/13 at 1:46 P.M., interview with Assistant Director of Nursing (ADON) #18 revealed Resident #99 was currently on Keflex (an antibiotic) for an infection to the lower coccyx wound. ADON #18 verified findings that Resident #99's lower coccyx treatment had not been completed as ordered during the months of November, 2013 and December, 2013. ADON #18 verified Resident #99's pressure ulcer was incorrectly identified as an abrasion. Observation of the dressing change was not available to the surveyor. Review of Resident #99's plan of care for impaired skin integrity included interventions to provide treatments as ordered and to notify the physician of all red areas and skin changes. This deficiency substantiates Complaint Number OH 962.

Based on observation, record review and interview, the facility failed to ensure Resident #65 was secured safely in her wheelchair to prevent a fall that resulted in a hip fracture. This affected one of three residents reviewed for falls. The facility census was 93. Findings include: Resident #65 was re-admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not speak and had highly impaired hearing. The resident had a severe cognitive deficit and was dependent on two staff to transfer. The resident was always incontinent of bowel and bladder. The resident was assessed to be at high risk for falls. Review of October, 2011 monthly physician orders [REDACTED]. The resident was also ordered a hoyer lift (mechanical lift) for all transfers. Review of the Hoyer lift policy (not dated) revealed three staff were to be used, one licensed and two nursing assistants to safely transfer the resident. On 10/12/11 at 2:00 P.M. review of the Nurse's Notes revealed the state tested nurse aides (STNA's) reported that the resident's left thigh was swollen from her knee up. At 2:00 P.M., the nurse, Registered Nurse (RN) #1, documented she had noticed a faint bruising on the resident's medial upper thigh earlier at 10:00 A.M. She noted the resident's left leg was bent at the knee with left lateral abduction. The physician was notified and an x-ray of the left femur was obtained. On 10/13/11 at 3:20 A.M., the facility was notified the resident had an acute left intertrochanteric (hip) fracture. The facility initiated an investigation regarding the injury of unknown origin after the swelling and bruising were noted on 10/12/11. Review of the staff statements, dated 10/12/11, revealed neither STNA #2 or STNA #3, had noticed any bruising or swelling on the resident. RN #1 submitted an undated statement in which she noted that she had noticed a faint bruising on or close to the medial upper thigh and what appeared to be a blister up near her hip. The resident was lying on her right side. She noted that when she saw the leg swelling she immediately notified the physician. During an interview with RN #1 on 10/31/11 at 10:15 A.M., she clarified she had initially seen the light-colored bruising at approximately 10:00 A.M., on 10/12/11. She verified she had not reported the bruise because she thought it was old. Review of the hospital physician attending notes revealed on 10/13/11, the physician noted the resident had an unwitnessed fall likely causing a femoral fracture, but (it was) "unknown if she fell , why she fell and how." The physician noted they would complete a syncope work-up as well as head and C-spine CT scans, in addition to the pelvic x-rays and orthopedic consult. Interview with the administrator on 10/31/11 at 1:30 P.M. revealed on 10/14/11, at the end of her shift, STNA #2 notified RN #1 that she knew what had happened to the resident's leg. STNA #2 stated the resident had fallen out of her chair. She stated she heard a loud noise in the hall and observed the resident on the floor. She stated the armrests had been removed, and that STNA #3 had left the resident in the hallway while he went to assist STNA #2. She stated she picked up the resident by her legs and STNA #3 picked up her upper body. She stated STNA #3 kept telling her not to tell, and then STNA #3 took the resident alone into the tub room and gave her a bath by himself. The STNA verified the incident occurred on 10/11/11 at 8:30 A.M. was not reported to the charge nurse, RN #4. The resident had a surgical pinning to her left hip fracture on 10/14/11 and returned to the facility on [DATE]. The initial pain assessment revealed the resident groaned when turned and Tylenol appeared to relieve the pain. The resident was ordered to receive two Tylenol three times per day. Interview with STNA #2 on 10/31/11 at 10:45 A.M. revealed she had only been employed a few weeks when the fall occurred. She stated that STNA #3 was a very long term employee and when he told her not to tell about the fall, she was frightened, and did not report the fall. She stated that on 10/14/11 she decided to tell the truth because she felt "it was the right thing to do". She stated STNA #3 had left the resident unattended in the hallway with both armrests removed. On 10/31/11 at 11:05 A.M., Resident #65 was observed in her low bed, turned on her right side. The resident had a wound dressing to her left hip and leg. STNA #2 was present during the observation. She stated the resident now received therapy and the staff transferred her to the chair in accord with her therapy times. On 10/31/11 at 1:30 P.M. verified with the administrator that STNA #3 was terminated and STNA #3 received verbal counseling regarding incident reporting. The administrator verified STNA #3 also had not followed the Hoyer lift policy. This deficiency is an example of continued noncompliance from the standard survey conducted on 09/22/11, and substantiates Complaint Number OH 904.