Every finding on record at Wellspring Health Center

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents were free from significant medication errors. This affected one (Resident #10) of three residents reviewed for pain medication. The facility census was 43 residents.Findings include: Review of the medical record for Resident #10 revealed an admission date of 03/09/26 with diagnoses including left lower leg fracture, depression, adjustment disorder, and anxiety disorder. Resident #10 was discharged home with family on 03/30/26. Review of the care plan for Resident #10 dated 03/20/26 revealed the resident had the potential for pain related to status post fracture repair and multiple contributing factors. Review of the physician order audit revealed an order for hydrocodone-acetaminophen 5-325 milligrams (mg) (opioid pain medication) give one tablet by mouth every four hours as needed for pain for 30 days was created on 03/20/26 and backdated to 03/17/26. Review of the Medication Administration Record (MAR) for Resident #10 dated for 03/2026 revealed hydrocodone-acetaminophen 5-326mg was given to the resident one time on 03/17/26, three times on 03/18/26, and three times on 03/19/26 when there was no active order for the medication to be given. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 03/30/26 revealed the resident was cognitively intact and required substantial to moderate assistance with activities of daily living (ADLs.) Interview on 06/01/26 at 10:00 A.M. with the Director of Nursing (DON) verified the physician order for hydrocodone-acetaminophen 5-325mg was created three days after medication had be given to Resident #10, and the facility staff had administered the pain medication without a valid physician's order. Review of the facility policy titled Medication Administration dated 09/09/25 revealed medications were to be administered as ordered by the physician and in accordance with professional standards of practice. This deficiency represents noncompliance investigated under Complaint Number 2962542.

Based on record review, staff interview, review of the facility's investigation and policy review, the facility failed to provide adequate physical assistance for a resident who was dependent on staff for toileting, personal hygiene, and bed mobility. Actual Harm occurred on 01/19/26 at approximately 6:00 P.M. when one staff member was providing incontinent care to Resident #39 while in bed. Certified Nursing Assistant (CNA) #250 rolled Resident #39 to his left side and the resident fell from the bed onto the floor. Resident #39 had fractures to his right humerus (upper arm bone), right coronoid (elbow), left femur (upper leg bone), and left patella (kneecap). This affected one (Resident #39) of three residents reviewed for falls. The census was 48.Findings Include:Resident #39 was admitted to the facility on [DATE]. Diagnoses included osteoarthritis, hypokalemia, congestive heart failure, hypertensive heart and chronic kidney disease, low tension glaucoma, dementia, vitamin D deficiency, atherosclerotic heart disease, chronic kidney disease, thrombocytopenia, polyneuropathy, hyperlipidemia, cardiomyopathy, anxiety disorder, irritable bowel syndrome, major depressive disorder, hypertensive heart disease, and atrial fibrillation.Review of Resident #39's care plan, dated 02/21/25, revealed a care plan for activities of daily living (ADL) self-care performance. Interventions included Resident #39 was totally dependent on two staff with use of draw sheet to scoot up toward the head of his bed. Also, Resident #39 was dependent on staff for toileting hygiene.Review of Resident #39's Minimum Data Set (MDS) assessment, dated 01/31/26, revealed he was cognitively intact, had an impairment to both sides of his upper and lower extremities. He was dependent on staff assistance for toilet hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, and bed mobility. Review of Resident #39's fall risk assessment, dated 07/24/25, revealed he scored a 12. A score above ten meant Resident #39 was at risk for falls.Review of Resident #39's ADL Task documentation, dated 01/14/26 to 01/19/26 documented Resident #39 required the assistance of two people for bed mobility and hygiene.Review of Resident #39's Incident Report, dated 01/19/26, revealed CNA #250 was completing peri-care for Resident #39 in his bed. She assisted him with rolling to his left side, away from her, while she cleaned him. Resident #39's hand lost strength and he fell from the bed. The incident report documented that Licensed Practical Nurse (LPN) #200 was contacted to assess Resident #39. LPN #200 took his vital signs, which were within normal limits, and then received assistance from a second person to use the mechanical lift and place him back in bed. Resident #39 had a hard lump to the right humerus near his elbow where Resident #39 complained of pain, rating it a nine on a one to ten scale. A stat X-ray was ordered and education was provided to the staff related to positioning during care. The incident report documented Resident #39's care plan instructed Resident #39 was to have the assistance of two staff during care at all times. Review of Resident #39's progress note, dated 01/19/26, revealed Resident #39 refused to go to the emergency room after the fall, so the X-ray was ordered by the physician to be completed in the facility. Resident #39 and his power of attorney were notified.Review of Resident #39 progress note, dated 01/20/26, revealed a delay in X-ray service at the facility. There was swelling and continued pain to Resident #39's right arm. Resident #39's power of attorney was notified and all parties agreed to send the resident to the emergency room for further evaluation.Review of Resident #39's hospital documentation, dated 01/20/26, revealed X-rays were performed and Resident #39 had a right distal humerus supracondylar traverse closed fracture, right coronoid non-displaced fracture, left distal femur supracondylar closed fracture, and left patella fracture. The documentation confirmed the injuries occurred when he slipped off the bed while changing brief.During an interview on 02/13/26 at 1:45 P.M., the Director of Nursing (DON) confirmed Resident #39's Kardex/ADL assistance tracking documented Resident #39 needed the assistance of two people for toilet hygiene and bed mobility tasks. The DON also confirmed since 02/21/24, he needed the assistance of two people for bed mobility, which is in his care plan. She stated it was the nurse aide's judgement at the time of peri-care, to determine if the resident needed a second person for safety. She confirmed he had impairments on both sides of his upper and lower extremities and that he needed two-person assistance when he was being transferred via mechanical lift.During an interview on 02/13/26 at 1:55 P.M., Resident #39 stated it's about 50/50 if the facility had two staff with him or not when providing incontinent care or cleaning him in his bed. He confirmed the day of his fall, he was turned in bed by one staff, she was cleaning him, his hand gave out, and then he fell to the ground. He felt he fell from a long distance, but in reality, the bed was in a normal height position. He stated he was in a lot of pain. He confirmed he didn't want to go to the hospital at first, but after X-ray didn't come, he was fine with going to the hospital.During an interview on 02/13/26 at 2:30 P.M., LPN #200 stated she was the nurse on duty when Resident #39 fell and got injured. She stated she was called to the room to assess Resident #39 prior to being moved; his vital signs were fine, and the only pain he was expressing was in his right arm. She stated she was not sure what his care levels were for staffing at the time of the fall, but confirmed there was only one aide (CNA #250) assisting with his care when he fell. She called for a stat X-ray order because Resident #39 did not want to go to the emergency room; this was agreed upon by Resident #39's POA as well. By 01/20/26, the X-ray still had not been done so she called the physician and POA again; they agreed to send him to hospital, because some swelling and pain were still present.An attempt was made to interview CNA #250 on 02/13/26 at 2:39 P.M. She was not available for an interview; a voicemail message was left and no call was returned during the survey.Review of the policy titled Fall Prevention Program, dated 09/10/25, revealed a fall was defined as an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force. The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere. Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. When a resident experiences a fall, the facility will: assess the resident, complete a post fall assessment, complete an incident report, notify the physician and family, review the resident care plan and update as indicated, document all assessments and actions, and obtain witness statements in the case of injury. This deficiency represents non-compliance investigated under Complaint Number 2724402.

Based on observation, interview, facility policy and document review, and the Food and Drug Administration 2022 Food Code, the facility failed to ensure meals were prepared and food was stored in accordance with professional standards for food safety. This had the potential to affect 38 residents who received meals from the kitchen. The facility census was 40. 1. A facility policy titled, Sanitation - Dish and Utensil Procedure Guideline, dated 03/19/2019, specified, The following guidelines provides an overview of routine cleaning services and the general frequency of various cleaning tasks. The policy specified, 6. Dishes and utensils shall be air dried before storage. Do not towel dry, and 10. Cutting boards need to be washed and sanitized between each use. Replace cutting boards once they have deep knife marks and are unsanitizeable. Color-coated cutting boards are useful for designating boards for raw products verses cook products. A. During the initial tour on 12/01/2025 at 9:11 AM, it was discovered the facility had a main kitchen and also a serving kitchen that was used to serve the residents of the skilled nursing facility (SNF). An observation in the main kitchen on 12/01/2025 at 9:34 AM revealed a shelving unit next to the dish machine with clean items in stacks. The observation revealed each stack had approximately eight items that included a stack of full metal pans for the steam table, a stack of half pans for the steam table, metal quarter pans for the steam table, and approximately four metal soup buckets for the steam table. The observation revealed all items were stacked upside down, with significant moisture in between each pan. An observation on 12/01/2025 at 10:06 AM in the SNF serving kitchen revealed insulated food serving bases and domes used to keep food warm were stacked and wet in between each dome and each base. The observation also revealed trays used to deliver food were stacked, face down, near the dish machine, and wet in between each tray. A return visit to the kitchen and observation on 12/03/2025 at 10:20 AM revealed a shelving unit next to the dish machine with clean items in stacks. The observation revealed upside down stacks of full metal pans, half pans, and quarter pans with significant moisture in between each pan. On 12/03/2025 at 11:38 AM the Dietary Services Manager (DSM) stated the soup bowls and domes were being used while they were still wet. On 12/03/2025 at 5:28 PM the Administrator (ADM) stated kitchen items were supposed to be air dried, and items could not dry properly if they were stacked. On 12/04/2025 at 8:57 AM the Director of Dining Services (DDS) stated it was her expectation that kitchen items were left to air dry. On 12/04/2025 at 9:33 AM the Director of Nursing (DON) stated kitchen items should be fully air dried before they were put away, and items should not be stacked when wet. B. An observation of the facility's kitchen on 12/01/2025 at 9:50 AM revealed three red cutting boards, two blue cutting boards, two yellow cutting boards, and three white cutting boards. The observation revealed the cutting boards had large gouges, primarily in the center area of each board; there was minimal color left in the center of each board due to wearing; and except for the white cutting boards color only remained around the edges of the cutting boards, indicating excessive wearing from deep knife marks and concern that the boards could no longer be properly sanitized. On 12/03/2025 at 10:10 AM the Executive Chef stated the cutting boards appeared to be worn and needed to be replaced. On 12/03/2025 at 5:28 PM the Administrator (ADM) stated staff should be checking the cutting boards weekly for wear and tear, and if there was no color left in the center of the cutting board that was an indicator the cutting boards were worn out. 2. A facility policy titled, Food Preparation - Food Storage Policy, reviewed 08/20/2018, specified, Policy: Food items should be stored following good sanitary practices and local codes and manufacturers specifications. The policy also indicated, 6. Opened products should be completely wrapped or placed into a sealable plastic bag, or container with a tight-fitting lids and labeled and dated. During the initial tour of the main kitchen on 12/01/2025 at 9:46 AM, an observation of large bins containing rice, flour, sugar, and panko were observed to be labeled but not dated with no way to know how long that product had been in the bins. A concurrent observation of the serving kitchen and interview on 12/01/2025 at 9:57 AM revealed a hot dog bun in an opened bag without a label or date and a bagel in an opened bag without a label or date. The observation revealed the Dining Services Manager (DSM) removed both items from the bags and placed them in the trash. The DSM stated it was his expectation for the main kitchen to label all bread products prior to sending them to the serving kitchen, and it was the responsibility of the serving kitchen staff to make sure the bags were sealed. An observation of the walk-in freezer on 12/01/2025 at 10:09 AM revealed an unsealed, opened, and exposed box of beef burgers hamburgers on a shelf. An observation of the serving kitchen on 12/03/2025 at 11:22 AM revealed a half of loaf of white bread and a half of loaf of wheat bread not securely closed. On 12/03/2025 at 11:37 AM, the Dining Services Supervisor (DSS) confirmed the bread was not securely tied closed and should have been. On 12/03/2025 at 5:28 PM, the Administrator (ADM) stated it was her expectation that any food item opened in the kitchen should be labeled and dated. The ADM stated bread should be tightly sealed if it was not being used. The ADM stated if the box of hamburgers in the freezer was stored open it could potentially be contaminated. On 12/04/2025 at 8:57 AM, the DDS stated the facility had a procedure for labeling and dating food. The DDS stated food should be closed and sealed, and everything should have a received and opened date on it. The DDS stated bread was audited often, and that was not the first time bread had been found left open. The DDS stated everything in the freezer should be closed and sealed. On 12/04/2025 at 9:33 AM, the Director of Nursing (DON) was interviewed. The DON stated there was a normal expectation that food needed to be closed and stored under ServSafe (a food and beverage safety training and certificate program) regulations and state regulations. 3. Chapter Two of the FDA [Food and Drug Administration] 2022 Food Code titled Hygienic Practices specified, 2-402 Hair Restraints - 2-402.11 Effectiveness. (A) Except as provided in paragraph (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. (B) This section does not apply to food employees such as counter staff who only serve beverages and wrapped or packaged foods, hostess, and wait staff if they present a minimal risk of contaminating exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. A facility policy titled, Personal Hygiene - Personal Hygiene Policy, reviewed 08/20/2018 specified, Policy: Guidelines for personal hygiene to promote a sanitary and safe department. The policy continued, Procedure - 1. Head Covering Worn a. Wear a clean hat or other hair restraint in all kitchen production/food service areas. Hair must be appropriately restrained per state regulations. b. Head covering must be clean. C. Beards or any body hair that may be exposed must be covered. The policy also indicated, 3. Clean hands and Fingernails a. Hands must always be washed prior to beginning work. b. Hands must always be washed after smoking, using the restroom, or handling and any unsanitary items. A. An observation during the initial tour of the skilled nursing facility's (SNF) serving kitchen on 12/01/2025 at 9:11 AM revealed the Dining Services Manager (DSM) had facial hair without any covering in the food preparation area. An observation during the initial tour of the main kitchen on 12/01/2025 at 9:25 AM revealed the Executive Chef was observed to have facial hair without any covering in the food preparation area. On 12/03/2025 at 10:12 AM, during a concurrent interview with the Executive Chef and the DSM, the Executive Chef stated he had never been asked to wear a beard guard. The DSM stated he guessed anything longer than half inch would need a beard guard. On 12/03/2025 at 10:14 PM, the Director of Dining Services (DSS) stated she was not aware of a formal policy regarding beard guards, but one did not have to be worn if a beard was well-trimmed. A concurrent observation and interview on 12/03/2025 at 10:50 AM revealed Dietary Aide (DA #1) had long braided hair that reached below his shoulders, the hairnet he was wearing covered the top of his head, but the braids were hanging loose. DA #1 stated all of his hair was supposed to be in the hairnet. A concurrent observation and interview on 12/03/2025 at 10:55 AM revealed DA #2 had long braided hair that reached just below his shoulders as well as facial hair, and a hairnet covered the top of his head but did not include his braids. DA #2 indicated he knew all his hair was to be in the hairnet, but he was never asked to wear a beard guard. On 12/03/2025 at 5:28 PM, the Administrator (ADM) was interviewed. The ADM revealed the local health department did not enforce a beard guard if the hair was trimmed close to the face, but she acknowledged the facility's policy was to wear a beard guard with any facial hair, and it was her expectation the dietary staff would follow the facility policy. On 12/04/2025 at 8:57 AM, the Director of Dining Services (DSS) was interviewed. The DSS stated it was her expectation for all hair to be restrained within the hairnet. On 12/04/2025 at 9:33 AM, the Director of Nursing (DON) was interviewed. The DON stated it was her expectation that hairnets were to be worn at all times when in the kitchen. The DON stated she did not know the policy on beard guards and hair length, but believed they should be worn if someone had facial hair. B. An observation on 12/03/2025 at 10:50 AM of Dietary Aide (DA) #1 washing his hands in the skilled nursing facility's (SNF) serving kitchen revealed he turned on the water, placed soap in his hands, and washed his hands for approximately seven seconds. The observation revealed DA #1 then turned off the water with his clean hands, reached for the paper towel, and dried his hands. The observation revealed above the sink was a handwashing guide that stated to wet hands, wash with soap for at least 20 seconds, use paper towels to dry hands, use paper towel to turn off the water, and to not touch a dirty surface with clean hands. An observation on 12/03/2025 at 11:04 AM revealed the Dining Services Manager (DSM) washed his hands in the SNF's serving kitchen. The observation revealed the DSM turned off the water with his wet hands and then reached for paper towel. The observation revealed the DSM did not wash his hands for 20 seconds, and the DSM stated, Oops, I guess I didn't. On 12/03/2025 at 5:28 PM, the Administrator (ADM) was interviewed. The ADM stated her expectation of hand washing was that an employee should wash their hands for at least 20 seconds, use disposable towels to dry their hands, and use paper towels to turn off the water so that they did not touch a dirty surface. On 12/04/2025 at 8:57 AM, the Director of Dining Services (DDS) was interviewed. The DDS stated Dietary Aide (DA) #1 was still going through orientation, but she would have expected the DSM to wash his hands correctly by turning off the faucet with a paper towel.

Based on observation, interview, record review, and facility document and policy review, the facility failed to ensure effective coordination between facility staff, the provider, and the pharmacy regarding a refill for a narcotic medication for one (Resident #19) of five residents reviewed for pharmacy services. As a result, the pharmacy was unable to fill Resident #19's prescription for as-needed oxycodone (a narcotic pain reliever), and the resident did not have access to the medication for seven days. The facility census was 40. A facility policy titled, Unavailable Medications - Skilled, revised 04/02/2024, revealed, Policy: When medications or treatments are unavailable, the community should make every effort to obtain the medication or treatment for the resident prior to the scheduled dose. The policy also revealed, 2) Upon notification that a medication or treatment is unable to be supplied by the Preferred Pharmacy, the back up Pharmacy, or the resident/legally responsible party, the Director of Nursing, Administrator or designee should: a) Contact the pharmacy or resident/legally responsible party as appropriate and explore available options to get the medication or treatment delivered as soon as possible, and document all conversations/calls. b) Notify the physician to explore alternative options and document the follow-up instructions in the resident's Progress Notes in the EHR [Electronic Health Record]. An admission Record revealed the facility admitted Resident #19 on 09/17/2020. According to the admission Record, the resident had a medical history that included diagnoses of contracture of the right lower leg muscle, osteoarthritis, unspecified pain, and dorsalgia (back pain). An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/30/2025, revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident took an opioid (narcotic, pain medication) medication. Resident #19's Care Plan Report included a focus area, revised 09/08/2025, that indicated the resident had chronic pain related to generalized pain, neuropathy (nerve damage), hypertension (high blood pressure), congestive heart failure, arthritis, and lumbar stenosis (narrowing of the spinal canal. Interventions directed staff to administer pain medication as ordered and to give before treatments or care as indicated (initiated 03/24/2021). Resident #19's Order Summary Report, with active orders as of 12/04/2025, contained a verbal order, dated 11/16/2025 for oxycodone HCL (oxycodone hydrochloride), 5 milligrams (mg) by mouth every eight hours as needed for pain. The Order Summary Report also contained an order, dated 05/10/2024, for acetaminophen (Tylenol) 325 mg two tablets by mouth every six hours as needed for general pain, do not exceed 3000 mg in 24 hours. Resident #19's Medication Administration Record (MAR), dated 11/2025, revealed oxycodone 5 mg was administered to the resident on 11/01/2025, 11/03/2025, 11/04/2025, 11/05/2025, 11/08/2025, 11/09/2025, 11/10/2025, 11/11/2025, 11/13/2025, 11/16/2025, and 11/17/2025. The MAR revealed oxycodone was not administered from 11/18/2025 through 11/23/2025, oxycodone was administered on 11/24/2025, 11/26/2025, 11/27/2025, 11/28/2025, and 11/30/2025. Resident #19's Plan of Care (POC) Response History for the last 30 days revealed: the resident complained of pain on 11/18/2025 at 4:40 AM and 3:26 PM, and the resident had no pain at 7:36 PM; the resident complained of pain on 11/20/2025 at 4:13 PM and the pain was resolved on 8:14 PM; and the resident had no pain on 11/21/2025. A nursing Progress Note[s], dated 11/17/2025 at 5:32 AM, revealed a request for a new prescription for oxycodone was sent to the Medical Director (MD) on 11/16/2025. A nursing Progress Note[s], dated 11/19/2025 at 7:23 PM, revealed a call was placed to the on call medical doctor because a prescription was needed for oxycodone, and the nurse was waiting a callback. A nursing Progress Note[s], dated 11/21/2025 at 5:31 AM, revealed a prescription for oxycodone had not been received, and the nurse faxed a prescription request to the MD. A facility fax transmission record, dated 11/23/2025 at 2:23 PM, revealed a prescription, dated 11/20/2025, for Resident #19 for 75 tablets of 5 mg oxycodone HCL. Two Emergency Kit Authorization Forms, both dated 11/24/2025 and untimed, indicated oxycodone was removed from the facility's emergency medication kit twice on 11/24/2025. A pharmacy delivery Manifest, dated 11/25/2025 at 3:51 AM revealed the delivery of 30 oxycodone tablets for Resident #19 to the facility. During an interview on 12/01/2025 at 9:57 AM, Resident #19 stated the facility had run out of their medication for about 10 days. Resident #19 stated they had told the nurses that the resident needed the oxycodone, but the resident did not remember the nurses' names. During an interview on 12/04/2025 at 8:23 AM, Resident #19 stated they had pain on the right side of their body due to having a bad hip. Resident #19 stated they took oxycodone one to two times a day and sometimes took Tylenol. Resident #19 stated the Tylenol was effective for mild pain. Resident #19 stated they were uncomfortable when the facility did not have the resident's opiate pain medication, but the pain was bearable. Resident #19 stated the staff did offer Tylenol, and the resident took that medication. Resident #19 stated they did not feel that they needed to go to the hospital for pain during that time. During an interview on 12/03/2025 at 6:43 PM, Licensed Practical Nurse (LPN) #8 stated if a resident ran out of oxycodone, she would contact the pharmacy to determine if there was a delivery scheduled or if the pharmacy needed a prescription. LPN #8 stated if the pharmacy had a prescription, the pharmacist would provide a code to pull the medication from the emergency kit, but if the pharmacy did not have a prescription, she would not be able to get the medication out of the emergency kit and would call the on-call provider. LPN #8 stated the on-call provider would not provide a prescription for a narcotic. LPN #8 stated that she worked part-time, and Resident #19 ran out of pain medication for about a week around 11/19/2025. LPN #8 stated she called the pharmacy, and the pharmacy did not have a prescription. LPN #8 stated she then notified the on-call provider, and the on-call provider told her they would send a prescription to the pharmacy. LPN #8 stated she called the pharmacy a few hours later, and they still did not have the prescription. LPN #8 stated she was not able to pull the medication from the emergency kit because the pharmacy had not received the prescription. LPN #8 stated she called the on-call provider back and did not receive a call back, and she told Registered Nurse (RN) #8 in report that morning, 11/19/2025, to follow-up. LPN #8 stated she returned to work that Friday night, 11/21/2025, and Resident #19 still did not have any oxycodone. LPN #8 stated she offered Resident #19 Tylenol, but the resident refused because it was not effective. LPN #8 stated the resident looked like they were in pain, because the resident was grimacing. LPN #8 stated she called the on-call provider and did not receive a call back, so she called the Director of Nursing (DON) and notified her of the situation. LPN #8 stated the DON provided LPN #8 a phone number for the Nurse Practitioner (NP), but the NP texted back that the NP was not on-call, so LPN #8 told the DON that she had not received a call back from the on-call providers. During an interview on 12/04/2025 at 8:43 AM, RN #9 stated that sometimes the on-call providers did not call back if it was not considered an urgent matter. RN #9 stated was told in report (information sharing between shifts) by LPN #8, the night nurse, that Resident #19 was out of pain medication. RN #9 stated she did not follow up because the medication was already ordered. RN #9 stated LPN #8 was using the fax machine at the nurse's station, and the MD was not receiving the fax. RN #9 stated a dayshift nurse had emailed the MD, and the MD received the email request. RN #9 stated on the day shift Resident #19 asked for Tylenol, so she gave it to the resident, and she felt like the Tylenol was effective because the resident was very verbal and would have complained if it was not. RN #9 stated that she was off for three days, and when she returned the medication had been refilled. During an interview on 12/04/2025 at 9:28 AM, LPN #10 stated she did not remember the date when Resident #19 ran out of medication, but it was for about a week. LPN #10 stated she was told in report that the MD was on vacation, and the on-call provider would not refill the medication as the on-call providers would not refill narcotics. LPN #10 stated she was then off for a few days, and the medication was refilled when she returned. LPN #10 stated Resident #19 was good about telling her when they were in pain, and the resident told her that they were not in pain. LPN #10 stated Resident #19 also had Tylenol for pain, and that sometimes the resident requested Tylenol and sometimes the resident requested oxycodone. LPN #10 stated Resident #19 did not appear to be in distress while the oxycodone was unavailable. LPN #10 stated she faxed a prescription request to the MD using Documo (cloud-based online fax service). LPN #10 stated Documo seemed to work better than using the fax machine. During an interview on 12/04/2025 at 9:43 AM, the Assistant Director of Nursing (ADON) stated that if a narcotic needed to be refilled then it could be requested by using the reorder tab on the EMR, by faxing the MD using the fax machine, or by faxing the MD using Documo. The ADON stated some of the staff used Documo, but most of the staff just used the fax machine. The ADON stated if it were after hours or on the weekend, the nurse would be able to pull the medication from the emergency kit, but not until a prescription was sent to the pharmacy. The ADON stated there was always an on-call provider, and the on-call provider for the MD should be able to send a prescription for narcotics. The ADON stated nurses could call the ADON or DON but should just call the MD for refills. The ADON stated she was not aware Resident #19 was out of oxycodone for a week. The ADON stated she could see all faxes that were sent via Documo and opened the program on her computer. The ADON stated there was a refill request sent to the doctor on 11/16/2025. The ADON stated that then the pharmacy faxed the facility a prescription on 11/21/2025 at 10:46 AM and requested for the MD to sign it. On 11/22/2025 at 6:56 PM, the MD sent the prescription back to the facility via Documo. The ADON stated the staff would have to check the Documo program to see that the fax was sent by the MD. The ADON stated the staff should always have Documo open and be checking for incoming faxes. The ADON stated the facility did not fax the prescription to the pharmacy until 11/23/2025 at 2:23 PM. The ADON stated the staff must not have checked the fax, and that is why it took so long to send the prescription to the pharmacy. The ADON stated she did not know why the medication was not refilled on 11/16/2025 when it was initially requested. During an interview on 12/04/2025 at 8:30 AM, the Pharmacist stated Resident #19 had an as-needed (PRN) order for oxycodone. The Pharmacist stated that a new prescription for oxycodone was received on 11/23/2025 after the pharmacy was closed. The Pharmacist stated the order was processed on 11/24/2025 and delivered on the morning of 11/25/2025. During an interview on 12/04/2025 at 10:08 AM, the DON stated Resident #19 had Tylenol that could be given. The DON stated she was not aware that Resident #19 was out of oxycodone, and no one had notified her or requested to send the resident to the hospital due to no pain medication being available. The DON stated that if she had been aware that the resident was out of pain medication, she would have contacted the MD herself and followed up. The DON stated that she and the ADON were responsible for monitoring that medications were refilled. The DON stated that her expectation was that if a medication needed refilled, the floor nurse would notify the ADON or DON, put in a progress note, and contact the on-call provider. The DON stated the on-call providers for the MD would not refill narcotics, and narcotics would not be available if a resident needed them after hours or on the weekend if the MD was not available. During an interview on 12/04/2025 at 10:43 AM, the MD stated if the facility needed narcotics refilled, they would fax the request to him. The MD stated that he checked his faxes every evening, and the pharmacy could call him for an emergency three-day supply. The MD stated his on-call providers would forward any narcotic refill request to him. The MD stated that it did not make sense for Resident #19 to be out of medication for that long, and he only remembered being told that the resident's medication had been refilled. The MD stated that he was in the building twice a week, and no one told him anything. The MD stated Resident #19 did need the medication, and the pharmacy should have contacted him for a three-day supply. The MD stated the pharmacy never contacted him. During an interview on 12/04/2025 at 10:20 AM, the Administrator (ADM) stated that the nurses were responsible for monitoring that narcotics were refilled. The ADM stated that she expected the nurses to check and manage the medications and expected a quicker turnaround time from the doctors.

Based on interview, record review, and facility document and policy review, the facility failed to provide proper treatment and care to one (Resident #19) of one resident reviewed for bowel management. Specifically, the facility failed to address Resident #19's lack of a bowel movement for over three days. The facility census was 40. A facility policy titled, Constipation - Skilled, reviewed 07/14/2022, revealed, 1. The staff will be aware that if a resident has not had a bowel movement after three (3) days, further intervention may be necessary. 2. The certified nursing assistance [sic] will be responsible for documenting if the resident had a bowel movement in Point of Care [the electronic medical record, EMR]. This will be addressed at least every shift and PRN [as needed]. 3. Point of Care has triggers that if no BM [bowel movement] documentation has been noted by the certified nursing aide for 3 days, a Clinical Alert will be posted to the nursing dashboard in Point Click care. 4. The licensed staff will be responsible to follow-up with the nursing aide to ensure if no documentation of a BM is accurate. 5. If certified nursing assistant and/or the resident is unable to vocalize if in fact a bowel movement did occur, the nurse will assess the abdomen to determine if abdominal pain or distention is present. An admission Record revealed the facility admitted Resident #19 on 09/17/2020. According to the admission Record, the resident had a medical history that included diagnoses of benign neoplasm (noncancerous tumor) of the colon and unspecified pain. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/30/2025, revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident required substantial/maximal assistance with toileting hygiene and was always incontinent of bowel. Resident #19's Care Plan Report included a focus area, initiated 10/22/2025, that indicated the resident had constipation related to decreased mobility and receiving opioid (narcotics for pain) medications. Interventions directed staff to: monitor medications for side effects of constipation and keep the physician informed of any problems (initiated 10/22/2025); monitor, document, and report as needed signs and symptoms of constipation (initiated 10/22/2025); and record bowel movement patterns each day in the EMR and indicate the amount and consistency (initiated 10/22/2025). Resident #19's Order Summary Report, contained an order, dated 11/21/2025, for senna (a laxative) one tablet by mouth one time a day for constipation. The Order Summary Report also contained an order, dated 11/16/2021, for Bisacodyl suppository (a rectally administered laxative) insert one suppository rectally every 24 hours as needed for constipation. Resident #19's Bowel POC [Plan of Care] Response History, indicated the resident had a continent bowel movement on 11/27/2025 and next had an incontinent bowel movement on 12/03/2025 at 12:09 AM, six days later. Resident #19's 11/2025 and 12/2025 Medication Administration Records (MARs) revealed documentation that indicated the resident's Senna was administered once daily as ordered; however, the MARs contained no documented evidence that staff administered the resident's as-needed Bisacodyl during the timeframe the resident had no bowel movements. During an interview on 12/03/2025 at 9:15 AM, Resident #19 stated they thought it had been a week since they had a bowel movement, and they did not feel like they should have to tell the staff. Resident #19 stated the staff were supposed to chart Resident #19's bowel movements and keep up with the resident's condition. Resident #19 stated that the staff should have known the resident was constipated by looking at the resident's chart, and the resident had not told anyone that the resident's stomach felt bruised. Resident #19 stated they felt like it was constipation that caused their stomach to feel bruised. During an interview on 12/03/2025 at 9:01 AM, Certified Nursing Assistant (CNA) #11 stated if a resident had a bowel movement then it should be documented in the EMR. CNA #11 stated if a resident had not had a bowel movement in two to three days then she would notify the nurse. CNA #11 stated she had been out of the facility for the last five days and was unsure when Resident #19's last bowel movement was. CNA #11 stated the nurse would be able to check for the resident's last bowel movement, and the resident had not complained of any stomach pain. During an interview and concurrent observation on 12/03/2025 at 9:29 AM, Licensed Practical Nurse (LPN) #10 stated bowel movements were documented by the CNAs in the EMR, and the Director of Nursing (DON) was responsible for checking the EMR to see if residents had bowel movements within three days. LPN #10 opened Resident #19's EMR, and an alert was seen on the screen indicating the resident had not had a bowel movement in three days. LPN #10 stated she could not see when the resident's last bowel movement was, and she did not see the alert the day before. LPN #10 stated the DON had not told her about the alert, but the DON usually did. During an interview and concurrent observation on 12/03/2025 at 9:46 AM, the Assistant Director of Nursing (ADON) stated the CNAs documented every bowel movement and would report to the nurse if a bowel movement was abnormal. The ADON stated if a resident had not had a bowel movement in three days then an alert on the EMR would notify staff that the resident had not had a bowel movement. The ADON stated she and the DON received the alerts, checked the alerts daily, and were responsible for monitoring the alerts. The ADON reviewed Resident #19's EMR and stated she was unable to see when the resident's last bowel movement was, but that the nurses should have been able to see it. The ADON stated she could see the alert on Resident #19's EMR that indicated the resident had not had a bowel movement in over three days, and the alert had not been cleared. The ADON stated Resident #19 had an order for senna that was scheduled and administered as ordered. The ADON stated Resident #19 had an order for a suppository that had not been administered. During an interview at 12/03/2025 at 10:42 AM, the DON stated she expected the nurses to ask residents when their last bowel movement was, and if the residents were not able to verbalize then to check the residents' charts. The DON stated the CNAs should document every bowel movement on the EMR. The DON stated if a resident had gone longer than three days without having a bowel movement, the nurse should notify the doctor. The DON stated if a resident went without a bowel movement longer than three days an alert would pop up on the EMR, and the ADON checked the dashboard for alerts every day. The DON stated the nurses were able to see the alerts, but the expectation was for the ADON and DON to check the alerts. The DON stated the nurses were responsible for monitoring that residents had bowel movements, and the ADON was responsible for monitoring the alerts. The DON stated that LPN #10 told her that Resident #19 had a bowel movement on Monday, 12/01/2025, and Tuesday, 12/02/2025. The DON stated she did not ask Resident #19 when their last bowel movement was, and the last bowel movement documented on the EMR was on 11/27/2025. The DON stated there should have been an alert on the EMR three days prior, 11/30/2025. The DON checked her computer and stated there was an alert at that time. The DON stated that when the alert appeared, the ADON should have followed up with the nurse and aides to verify if the documentation was correct, and, if the documentation was correct, the physician should have been notified. During an interview on 12/04/2025 at 10:26 AM, the Administrator (ADM) stated that she expected staff to immediately chart bowel movements and follow-up if a resident had not had a bowel movement in three days. The ADM stated nurses were responsible for monitoring bowel movements, and CNAs were expected to document every shift.

Based on observation, interview, record review, and facility document and policy review, the facility failed to ensure fingernails were clean and trimmed for one (Resident #26) of one resident reviewed for activities of daily living. The facility census was 40. A facility policy titled, Skilled - Nail Care, dated 09/10/2025, revealed, 3. Routine cleaning and inspection of nails will be provided during Activities of Daily Living (ADL) care on an ongoing basis. The policy continued, 5. The resident's plan of care will identify: a. The frequency of nail care to be provided. b. The type of nail care to be provided. An admission Record revealed the facility admitted Resident #26 on 03/08/2025. According to the admission Record, the resident had a medical history that included diagnoses of contracture of the right hand, adjustment disorder, and mild cognitive impairment. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/28/2025, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident did not have a history of rejecting care, which included ADL assistance. The MDS indicated Resident #26 required substantial or maximal assistance with personal hygiene. Resident #26's Care Plan Report included a focus area, revised 09/18/2025, that indicated the resident had an ADL self-care performance deficit. Interventions directed staff to check nail length, trim nails, and clean nails on bath days and as necessary (initiated 04/03/2025). Resident #26's Plan of Care (POC) Response History, dated 12/03/2025, revealed personal hygiene was provided by staff every day for the last 30 days. An observation on 12/01/2025 at 10:31 AM, revealed Resident #26's fingernails appeared to be about one half inch long. A concurrent observation and interview on 12/03/2025 at 1:35 PM, revealed Resident #26's fingernails appeared to be about one half inch long with a brown substance under the nails. Resident #26 stated they would let someone cut their nails, the nails did not bother the resident, but the nails did need to be trimmed. Resident #26 stated the nails did not bother them when the nails were dirty, but it probably should. Resident #26 stated they would like someone to clean their nails and cut them. During a concurrent observation and interview on 12/03/2025 at 1:40 PM, Certified Nursing Assistant (CNA) #3 stated nail care was provided when showers were provided, and Resident #26 was showered twice a week. CNA #3 went to Resident #26's room, looked at the resident's fingernails, and stated the resident's nails needed to be trimmed and had dirt under them. During a concurrent observation and interview on 12/03/2025 at 1:48 PM, the Director of Nursing (DON) stated CNAs and nurses provided nail care when residents were showered or whenever nail care was needed. The DON went to Resident #26's room, looked at the resident's fingernails, and stated the resident's nails were too long and they were dirty. The DON stated that she expected residents to have their nails trimmed when needed and to be clean. The DON stated the nurses were responsible for monitoring that nail care was provided. During an interview on 12/03/2025 at 4:25 PM, the DON stated the facility did not have shower sheets, and the DON would have to review the schedule to determine who provided showers for Resident #26. The DON stated that she could not tell if or when showers were provided by reviewing the documentation on the Electronic Medical Record (EMR) as all personal care was checked off under one category and was not divided into different categories for nail care and showers. During a concurrent interview on 12/04/2025 at 10:17 AM, the Administrator (ADM) stated that the CNAs were responsible for monitoring residents' fingernails when showers were provided. The ADM stated that she expected the CNAs to keep the residents' fingernails trimmed and clean. The DON stated Lead CNA #4 provided Resident #26's shower on 11/27/2025, CNA #5 provided Resident #26's shower on 11/24/2025, CNA #6 provided Resident #26's shower on 11/20/2025, and CNA #7 provided Resident #26's shower on 12/02/2025. During an interview on 12/04/2025 at 12:03 PM, Lead CNA #4 stated nail care was provided to residents on shower days. Lead CNA #4 stated she did not provide nail care to Resident #26 during their shower on 11/27/2025 and did not remember if the resident's nails were long or dirty.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure care was provided in a dignified manner for one (Resident #43) of one resident reviewed for urinary catheter management. Specifically, the facility failed to ensure Resident #43's urinary catheter drainage bag was covered and urine in the bag was not visually exposed. The facility census was 40. A facility policy titled, Skilled Promoting/Maintaining Resident Dignity, dated 09/10/2025, indicated, It is the practice of this facility to protect and promote resident rights and treat each resident in a manner and in an environment that maintains or enhances the resident's quality of life by recognizing each resident's individuality. A facility policy titled, Urinary Catheter Care, dated 09/08/2013, indicated, Catheter bag should not be visible when in public areas. A catheter bag/cover should be utilized to maintain privacy and dignity. An admission Record revealed the facility admitted Resident #43 on 10/15/2025. According to the admission Record, the resident had medical history that included diagnoses of acute kidney failure and neuromuscular dysfunction of the bladder. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/22/2025, revealed Resident #43 had severe impairment in cognitive skills for daily decision-making and had a short term and long term memory problem per the staff assessment of mental status (SAMS). The MDS indicated the resident was dependent with toileting hygiene and had an indwelling urinary catheter. Resident #43's Care Plan Report, included a problem statement, initiated 10/26/2025, that indicated the resident had an indwelling urinary catheter due to a neurogenic bladder. Interventions directed staff to provide catheter care per the facility's policy, 10/26/2025. An observation on 12/01/2025 at 1:48 PM revealed Resident #43 seated in a wheelchair near the doorway to their room with an indwelling urinary catheter drainage bag attached to the wheelchair. Resident #43's indwelling urinary catheter drainage bag contained urine, was visible from the hallway, and did not have a privacy cover. During a concurrent observation and interview on 12/01/2025 at 2:02 PM, Certified Nursing Assistant (CNA) #13 stated Resident #43 arrived from the hospital without a privacy cover on their urinary catheter drainage bag. CNA #13 stated she could see Resident #43's catheter drainage bag from the hallway and staff were expected to place privacy covers on the urinary catheter drainage bags that were visible from the hallway. CNA #13 stated she would obtain a privacy cover. During a concurrent observation and interview on 12/01/2025 at 2:08 PM, Registered Nurse (RN) #14 stated she could see Resident #43's catheter drainage bag from the hallway. RN #14 stated Resident #43's urinary catheter drainage bag was not expected to be visible from the hallway. RN #14 stated the CNAs were responsible for maintaining privacy covers on the resident's urinary catheter drainage bags. During an interview on 12/01/2025 at 2:12 PM, Family Member #15 stated Resident #43 was admitted to the facility on [DATE] and had not had a privacy cover on the catheter drainage bag since their admission. During an interview on 12/03/2025 at 1:22 PM, the Director of Nursing (DON) stated the catheter drainage bag should have been in a privacy cover at all times. The DON stated Resident #43 returned from the hospital without a privacy cover, and staff should have replaced the privacy bag upon admission. The DON stated she made rounds daily and should have identified any catheter drainage bags without privacy covers. The DON stated Resident #43's uncovered catheter bag could be seen from the hall. During an interview on 12/03/2025 at 2:32 PM, the Administrator (ADM) stated residents who preferred their doors open should be offered a privacy cover for their catheter drainage bag.

Based on review of the medical record, review of the Emergency Medical Services (EMS) report, staff interviews, review of witness statements, review of door repair invoices, review of maintenance work orders, review of facility Self-Reported Incident (SRI), review of hospital records and review of the facility policy, the facility failed to provide adequate supervision to prevent an elopement from the Memory Care Unit (MCU) of one resident (#45) who ambulated through a door on the MCU with a malfunctioning alarm and into the East side stairwell where Resident #45 fell down 11 cement stairs. This resulted in Immediate Jeopardy and the potential for serious-life threatening injuries, negative health outcomes and/or death for one resident when Resident #45 exited the third-floor MCU on 03/27/25 through a door with a malfunctioning alarm and into the East side stairwell and fell down the stairs without staff's knowledge. Resident #45 was missing for approximately one hour before the staff determined the resident was missing, and the resident was found lying on the landing between the second and third floors. Nine-one-one (911) was called, and Resident #45 was sent to the hospital for evaluation and treatment of multiple fractures. This affected one (#45) of three residents reviewed for accidents. The facility identified four residents (#28, #32, #37, and #39) at risk for elopement. The facility census was 44. On 04/15/25 at 12:47 P.M., the Administrator, the Director of Nursing (DON), and Operations Specialist (OS) #70 were notified that Immediate Jeopardy began on 03/27/25 at approximately 6:20 P.M., when Resident #45 who was cognitively impaired due to diagnosis of dementia, assessed as being at high risk for elopement and was observed in the lobby by the DON wandering and displaying exit seeking behaviors, exited the third-floor MCU through a door with a malfunctioning alarm and into the East side stairwell. Resident #45 was assessed as being at high risk for elopement; however, no care plan was implemented for the resident being cognitively impaired or at risk for elopement. On 03/27/25 at 7:20 P.M., Certified Nursing Assistant (CNA) #10 found Resident #45 in the East side stairwell at the bottom of the landing between the second and third floors where the resident fell down 11 cement stairs and suffered multiple fractures including fracture to the left scapula, right fifth rib, left second, fifth and sixth ribs, had left parietal abrasion, lacerations to the left frontal scalp and contusions to the left lateral abdomen and pelvis. The Immediate Jeopardy was removed on 04/16/25 when the facility implemented the following corrective actions: • On 03/27/25, after the elopement and fall, Resident #45 was transferred to the hospital and was admitted and did not return to the facility. • On 03/27/25, a loud temporary door alarm was placed on the East stairwell. The door was fixed on 03/31/25. During the time between the discovery of the resident's incident and the new door alarm being placed, the staff members took turns sitting at the door to ensure the door was protected from any further incident. If any alarms were to go off, the staff members were instructed to immediately investigate the alarm. • Starting on 03/27/25 and completed on 04/16/25, each resident was assessed upon admission for elopement concerns and thereafter quarterly. Anyone who triggered for an elopement was moved to the third floor and had a Wanderguard (device to help memory care residents against elopement) placed on their person. When a new behavior was encountered, a new assessment was completed, and the care plan was updated as well. All 44 residents have been assessed for elopements/falls and care plans were updated as needed. No new concerns were identified. • On 03/29/25, the electrician contractor discovered the wires controlling the door alarm and door control panel had been eaten through by rodents. • Starting on 3/31/25, daily checks of the door were implemented by the Administrator. Checks were completed by the DON and OS #70. On 04/09/25, during routine testing, an intermittent lock-out occurred, and maintenance staff came to evaluate and fix any issue found to be occurring. The issue noted was the door did not reset completely from being pushed open to test. The staff entered the code, closed the door and the issue did not occur again. The issue was resolved with the door being reset. • On 04/04/25, the DON was educated on the elopement and fall policy by the OS #70. • On 04/04/25, the DON conducted in-services on elopement and fall polices (only 20 of 74 staff were educated). On 04/15/25, the facility restarted the in-services and completed education with another 41 staff members. All staff have been messaged and have been told they will not be allowed to work a shift until they have read the policy and sign off or send an email confirming they have received and read the policy. • On 04/15/25, an elopement drill was completed by Assistant Maintenance Director (AMD) #41. There were no concerns noted during this drill. • On 04/15/25, an Ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held with Medical Director (MD) #100 in attendance. Also in attendance was the DON, OS #70, Administrator, Dining Director #110, Social Services Director (SSD) #50, Therapy Director #120, and Business Office Director (BOM) #130 to discuss the incident and plan of action to mitigate any further issues. • On 4/15/25, the elopement policy was reviewed with Divisional Director of Health and Wellness #80 and Regional Director #90 and found to be up to date with no changes made. • Starting on 04/16/25, all four doors located at the East and [NAME] ends of the second and third floors will be checked by Administrator/designee five times a week for four weeks, then three times a week for eight weeks. Once this 12-week cycle is completed, the compliance will be turned over to the maintenance staff to be completed once a week through the TELS system (an electronic work order and preventative maintenance program that allows tracking of maintenance tasks). All these checks will be reviewed in the morning meetings and QAPI by the Administrator/designee. Although the Immediate Jeopardy was removed on 04/16/25, 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 is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #45 revealed an admission date of 03/27/25 with a discharge date of 03/27/25. Diagnoses included vascular dementia, atrial fibrillation, and heart failure. The resident was severely cognitively impaired. Review of the maintenance work orders from 02/01/25 through 04/14/25, revealed no documented maintenance work orders indicating the door alarms were not working. Review of a progress note dated 03/27/25 at 1:00 P.M., revealed Resident #45 was admitted to the facility for a seven-day hospice respite (temporary care for relief of a primary caregiver). Resident #45 was oriented to room with no concerns. Review of a progress note dated 03/27/25 at 6:04 P.M., revealed Resident #45 was moved onto the third floor (secured MCU) and a Wanderguard was applied by the DON. Review of a progress note dated 03/27/25 at 6:28 P.M., revealed Resident #45 was welcomed to his room. Resident #45 was ambulating with a walker around the MCU with poor safety awareness. Review of the EMS report dated 03/27/25, revealed the paramedics arrived on scene at 7:42 P.M. Resident #45 was assessed to be oriented to self and had fallen down approximately 15 steps with laceration to forehead. Resident #45 did not recall falling. Resident #45 was transported to a local hospital for evaluation and treatment. Review of a progress note dated 03/27/25 at 9:56 P.M., authored by the DON, revealed Resident #45 was observed lying on his left side with his walker on the third-floor landing of the stairs alert and responsive. Resident #45 had been exit-seeking and difficult to redirect. A Wanderguard was present on the resident's right ankle. The resident had been given snacks, drinks, was toileted, and placed in common area prior to the fall. When paramedics arrived, Resident #45 had approximately a two-inch laceration to his forehead. Resident #45 was transported to the hospital. Review of a witness statement dated 03/27/25 at 7:00 P.M., authored by Director of Hospitality #500, revealed he was made aware of Resident #45's disappearance at approximately 7:25 P.M. Resident #45 was then found shortly afterwards by the DON and CNA #10 on the third-floor East side stairwell. Resident #45 had obviously fallen down several steps due to the laceration on his forehead. EMS came and he was transported to the hospital. EMS notified the resident's daughter of the fall. The facility discovered that the wires to the alarm system were chewed through by a pack of rats causing the door to not alert staff once it was opened. The witness statement indicated that Resident #45 was injured and required medical attention by EMS. Review of the hospital records dated 03/27/25 at 10:40 P.M., revealed Resident #45 presented to the emergency room via EMS after falling down 15 stairs, unwitnessed, and found at the bottom of the stairs. Resident #45 did not remember the events and could not recall if he lost consciousness. Resident #45 was diagnosed with a fracture to the left scapula, right fifth rib, left second, fifth and sixth ribs, had left parietal abrasion, and contusions on the left lateral abdomen and pelvis. Review of the Elopement Risk assessment dated [DATE], revealed Resident #45 had an incomplete elopement risk assessment upon admission to the facility. Resident #45 had a history of wandering and verbalized the desire to leave the facility. Review of the care plans for Resident #45 dated 03/27/25, revealed there was no care plan implemented for Resident #45 with impaired cognition and being at risk for elopement. Review of a facility document titled Incident Audit Report dated 03/28/25 at 7:15 P.M., revealed Resident #45 had an unwitnessed fall in the hallway. Resident #45 was a newly admitted resident today, was exit seeking and had poor adjustment to new facility. The resident was educated not to open the stairway doors because the doors were alarmed. A Wanderguard was in place on the resident's right ankle when the resident eloped from MCU via a stairway. The staff were unable to hear the alarm. The nurses assessed the resident without moving him with the assistance of two nurses and two CNAs. The resident's vital signs were assessed and kept the resident in place until EMS arrived. The resident was alert and able to talk with no change in speech and was able to answer questions. The resident denied any pain, but stated his left arm was uncomfortable. The resident was lying on his left side on the concrete. The resident was able to stand with assistance of two firefighters, but legs were shaky. There was an approximately four-centimeter (cm) laceration to left frontal scalp area with small amount of blood. The resident was secured to a stretcher chair then transferred to the ER via EMS. The incident details indicated that a nurse informed the DON that Resident #45 was missing. The DON instructed all staff to look for the resident in every room and down the stairs. The DON joined the search after completing a wound dressing change and securing the resident in a safe position. A search of the second and third floors was completed, and the resident was found in the stairwell on the landing lying on the floor with his walker. The resident was alert and responsive, not in distress but unable to explain what happened. The resident was originally admitted to the second floor. The hospice nurse assessed the resident soon after his admission. Approximately 30 minutes after the hospice nurse left, therapy informed the nurse that Resident #45 was in the lobby. The resident was returned to the second floor. The resident was oriented to the floor and staff. The resident roamed the halls looking around. The resident soon started exit-seeking and stated he wanted to go home. The resident was oriented to the reason for his stay and reassured and given dinner and snacks. The resident continued to exit seek. The decision to move the resident to the third floor and put a Wanderguard on the resident was made. The staff were updated. The staff repeated the orientation to the resident and the resident continued to roam and exit seek. The resident was in the common area of the MCU for staff to monitor and approximately 40 minutes later, the floor nurse informed the DON Resident #45 was missing. The family and the physician were notified. The section titled Injuries Report Post Incident, revealed the resident had fractured left shoulder (front), left rib and clavicle. The predisposing factors to the elopement indicated the resident was confused with impaired memory and was admitted within the last four hours. Review of an invoice dated 03/29/25, revealed an emergency service call to restore (splice) rodent damaged cabling on the third-floor east stairwell door (delayed egress). The service provider repaired the second-floor east door (door latch not contacting sensor, pulled strike plate and modified opening to accept latch) then tested and manually reset the remaining doors. The Legacy East door was unresponsive, and continued troubleshooting was required. A temporary door contractor with an alarm was installed at non-functional doors pending further troubleshooting and repairs. Review of the SRI created on 03/31/25 at 12:17 P.M., revealed Resident #45 was admitted from a home setting as a seven-day hospice respite. Shortly after admission, Resident #45 presented with wandering and was moved from the second floor to the third floor with a Wanderguard in place. Resident #45 was placed in the common area near the nurse's station and was given a snack. The Administrator was informed of the elopement on 03/27/25 at 7:19 P.M. The Administrator was informed that Resident #45 was found at 7:26 P.M. in the third-floor stairwell on the East Hall. Resident #45 had fallen down the stairs but was alert and responsive. EMS was called, and the resident was transported to the hospital. Resident #45's family and other necessary parties were notified. AMD #41 came onsite during the evening of 03/27/25 after the incident occurred with Resident #45. After inspection, AMD #41 determined the door alarm to be non-functional due to the wires that appeared to be chewed through by rodents. When the door was opened, no alarm in the immediate area was sounding; however, it triggered an alarm at the nurse's station. AMD #41 placed a loud temporary door alarm on the door as an immediate intervention. AMD #41 contacted a contractor to come onsite to fix the existing door alarm and contacted an exterminator to handle the rodent issue. The Administrator followed up on 03/28/25 with the DON and AMD #41 to ensure door alarms were operational including temporary door alarm on the third-floor East stairwell. AMD #41 provided photos showing the chewed wires that prevented the door alarm from sounding. A call light system report was pulled to verify Resident #45 did not utilize a call light. The Administrator directed the DON to conduct in-services on elopement and fall policies. On 03/31/25, the door on the third-floor east stairwell had been fixed and was functionally operating. Review of an invoice dated 03/31/25, revealed the continued troubleshooting of Legacy East delayed egress door. The service provider installed a local controller reset circuit and attempted to isolate the open circuit to the magnetic lock. A temporary door contractor with an alarm was installed at non-functional doors pending further troubleshooting and repairs. Reset the surface raceway, surface junction box, a cover plate, and momentary normally open push button reset switch. Interview on 04/14/25 at 11:48 A.M. with AMD #41 revealed the wires were chewed through by rodents. AMD #41 revealed the red and black wires were chewed through which was why the door alarm did not sound. The gray wires were chewed through, which was the main power source for the door alarm and caused it to malfunction. AMD #41 revealed he was called to the facility on [DATE] at approximately 7:00 P.M. related to Resident #45 falling down the stairs due to the door alarm not functioning. AMD #41 stated he placed a temporary door alarm on the door until the contractor could come out to the facility. AMD #41 noted the secondary alarm that triggered at the nurse's station on the night of the elopement, was a very faint audible alarm and only could be heard if someone was sitting at the nurse's station, and likely no one would even know what it was alarming for. Interview on 04/14/25 at 12:13 P.M. with CNA #10, revealed she came on shift on 03/27/25 at 6:00 P.M. CNA #10 was informed by the DON that Resident #45 was moved from second floor to the third floor related to wandering and exit-seeking behaviors. CNA #10 gave Resident #45 snacks and sat him in front of the nurse's station around 6:10 P.M. At approximately 6:15 P.M., CNA #10 and the DON went into another resident's room to provide care. CNA #10 reported Resident #45 was walking down the hall with his walker, and she told CNA #11 to keep an eye on him. CNA #10 explained around 7:00 P.M. LPN #20 informed the DON and herself that Resident #45 was missing. CNA #10 checked all the rooms on the third floor, and then she went to the [NAME] side stairwell to the outside of the building and then up to the second floor with no sign of Resident #45. CNA #10 came back up to the third floor and checked the East side stairwell where she found Resident #45 on the landing of the second and third floor stairs at approximately 7:20 P.M. CNA #10 stated he was on his left side, and she asked if he was okay and told the resident not to move. The DON was next on scene and EMS was called. Interview on 04/15/25 at 12:47 P.M. with AMD #41, revealed the door alarms including the Wanderguard system were last checked on 02/13/25 and 02/14/25. AMD #41 explained the wires had been chewed through by rodents to the sound system and the main power box. Interview on 04/15/25 at 1:48 P.M. with the DON, revealed Resident #45 was admitted to the facility on [DATE] for a seven-day hospice respite. The DON stated the resident was initially admitted to the unsecured second floor. Shortly after admission, the DON was informed Resident #45 was down in the lobby. The DON stated she moved Resident #45 to the third floor (MCU) and placed a Wanderguard on his right ankle after testing the functionality of the Wanderguard. The DON explained Resident #45 was displaying exit-seeking behaviors and stated he wanted to go home. The DON stated she redirected Resident #45 several times and informed the staff to keep a close watch on him. Between 6:00 P.M. and 6:10 P.M., Resident #45 was last seen by the nurse's station eating a snack. The DON reported her, and CNA #10 went into a resident's room to complete a wound vacuum (vac) dressing change. Approximately 40 minutes later, LPN #20 informed them that Resident #45 was missing. The DON stated she instructed all staff to start looking for Resident #45 and have one staff remain on the third floor. The DON reported she finished the dressing change before going to look for Resident #45, which took about 15 minutes. The DON heard voices and talking coming from the East side stairwell, so she opened the door and saw CNA #10 and Resident #45 on the landing between the second and third floors. The DON completed a non-invasive assessment with a blood pressure (BP) check because she did not want to move Resident #45. The DON called EMS at 7:25 P.M. EMS arrived and transported Resident #45 to the hospital. There was no additional witness statements collected from CNA #10, CNA#11, LPN #20 or the DON, who were directly involved in the incident concerning Resident #45. Review of an undated facility form titled Security Personnel to Complete Only and authored by AMD #41, revealed security was notified of the event and asked to pull the footage of the incident. The footage was not in good condition once obtained. AMD #41 indicated he came into the facility to secure the door to the stairwell where the incident took place. AMD #41 indicated he placed a temporary alarm to the door and the cause of the malfunctioning door was faulty wiring and steps have been taken to resolve this issue. Review of the facility policy titled, Elopement Response Procedure Policy, reviewed on 08/19/24, revealed Senior Lifestyle was committed to the safety and well-being of the residents. Communities will follow a procedure if/when a resident goes missing. A plan would be implemented for conducting a community search. Once the community has identified a missing resident, inform the front desk. Identify a search coordinator who would be tasked with coordinating the search, gathering, and disseminating information. The front desk will notify the Administrator and manager on duty. If an alarm was activated, silence the alarm after the Administrator had been notified. Two people would be assigned to conduct an immediate search of the community perimeter and one team member to search the missing resident's room. Once the resident is found, conduct a thorough examination. Contact the family/responsible party and emergency services if needed. Document the incident in resident progress notes and update the service plan to reflect the incident and risk of further elopement. This deficiency represents non-compliance investigated under Complaint Number OH00164468.

Based on record review, observations, staff interviews, and policy review, the facility failed to ensure infection control measures were followed when providing catheter care. This affected one (#20) of three residents reviewed for urinary tract infections. The facility census was 44. Findings include: Review of the medical record for Resident #20 revealed an admission date of 11/15/24. Diagnoses included dementia, benign prostatic hyperplasia with lower urinary tract symptoms, and obstructive and reflux uropathy. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12. This resident was assessed to require setup with eating, dependent with toileting, bathing, and dressing, and substantial assistance with transfers. Review of Section H for Bowel and Bladder of the Significant Change MDS assessment dated [DATE] revealed Resident #20 had an indwelling catheter and was frequently incontinent of bowel. Observation on 04/15/25 at 1:15 P.M. revealed catheter care and peri care was completed to Resident #20 by Certified Nursing Assistant (CNA) #12. While providing peri care, CNA #12 used wash cloths that she had cleaned Resident #20's frontal peri area with to clean his backside where he had had a bowel movement. CNA #12 did not change her gloves during care and touched items with soiled gloves including resident's sheets, bed control, resident's head, and pillow. Interview on 04/15/25 at 1:30 P.M. with CNA #12 verified she used the same wash cloths to clean Resident #20's front and back side. CNA #12 also verified she did not change her gloves until after care was provided and touched items (bed control, sheets, resident's head, and pillow) with soiled gloves. Review of the facility policy titled, Hand Hygiene vs Alcohol-based Hand Rub, dated 10/23/24 revealed staff should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to residents including before resident contact, after contact with blood, body fluids, or contaminated surfaces (even if gloves were worn); before invasive procedures; and after removing gloves (wearing gloves did not replace hand hygiene). This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on observation, staff interview, and policy review, the facility failed to ensure medications for administration was not pre-poured prior to administration. This affected eight residents (#2, #3, #4, #5, #6, #18, #19, and #20) of thirteen residents who resided on the 200 hall reviewed for medication administration. The census was 43. Findings includes: Observation on 02/18/25 at 7:43 A.M. revealed the inside of the medication cart Licensed Practical Nurse (LPN) #200 was using revealed medication cups pre-filled with Resident's #2, #3, #4, #5, #6, #18, #19, and #20 medications for the morning doses. Interview with the LPN #200 on 02/18/25 at 7:45 A.M. revealed she was an agency nurse and confirmed she pre-poured the medications for above mentioned residents. She said she wasn't sure if she could do this at this facility, but has done it at other facilities. Review of policy entitled, Medication Administration, dated 02/23/24 revealed medications may not be prepared in advance.

Based on medical record review, staff interview, and policy review, the facility failed to follow physician orders for weekly weights and medication administration. This affected three residents (#36, #16, and #2) of eight residents reviewed for following physician orders. The census was 43. Findings included: 1. Medical record review for Resident #36 revealed an admitted [DATE]. Medical diagnoses included cerebrovascular attack (CVA), dementia, and aphasic. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #36 was moderately cognitively impaired. Review of the physician orders dated 06/07/24 revealed to obtain weekly weights for Resident #36. Review of the care plan dated 06/07/24 revealed Resident #36 was at risk for weight loss and an intervention was for weekly weights. Review of the weights since 11/27/24 for Resident #36 revealed there were missing weights for 11/27/24, 12/11/24, 12/18/24, 12/28/24, 01/04/25, 01/18/25, and 01/28/25. Interview with the Registered Dietician (RD) #205 on 02/18/25 at 2:19 P.M. confirmed Resident #36 missed some weights. She stated at one point the weight order dropped off due to hospitalization and she had to enter the order again into the system. 2. Medical record review for Resident #16 revealed an admitted [DATE]. Medical diagnoses included diabetes, renal insufficiency, and dementia. Review of the quarterly MDS dated [DATE] revealed Resident #16 was cognitively intact. Review of the physician orders dated 12/08/24 for Resident #16 revealed to weigh the resident weekly. Review of weights since 12/08/24 for Resident #16 revealed weights for 12/18/24, 01/28/25, and 02/11/25 were missing. Review of the care plan for Resident #16 dated 01/31/25 revealed she was at risk for weight loss. Interview with the RD #205 on 02/18/25 at 2:19 P.M. confirmed there were missing weights for Resident #16. 3. Medical record review for Resident #23 revealed an admitted [DATE]. His diagnoses included heart failure, renal insufficiency and diabetes. Review of physician orders dated 10/21/24 revealed Resident #23 was to be weighed weekly. Review of the quarterly MDS dated [DATE] revealed Resident #23 was cognitively intact. Review of care plan dated 02/18/25 revealed Resident #23 was at risk for weight loss related to dialysis. Review of the weekly weights since 12/28/24 revealed the weights were not taken on 12/28/24, 01/04/25, 01/28/25 and 02/04/25. Interview with the RD #205 confirmed the weights have not been done weekly. There are times of refusal for him, but they were not documented. This deficiency represents non-compliance investigated under Complaint Number OH00160894.

Based on observation, medical record review, and staff interview, the facility failed to administer medications as ordered. This affected one (Resident #32) of three residents observed for medication administration. The facility census was 43. Findings include: Medical record review for Resident #32 revealed an admitted [DATE]. Medical diagnosis included Alzheimer's disease. Review of the admission MDS dated [DATE] revealed Resident #32 was moderately cognitively impaired. Review of physician orders dated 12/05/24 revealed Folic Acid Oral Tablet one milligram (mg) to give one mg by mouth one time a day for dietary supplement During medication observation with agency Licensed Practical Nurse (LPN) #210 on 02/18/25 at 8:50 A.M. revealed she took a Folic Acid 880 micrograms (mcg) medication out of the bottle and placed in the medication cup. Interview with the LPN #210 on 02/18/25 at 8:52 A.M. revealed she didn't work at the facility. She said the closet medication to the one mg of Folic Acid was the 880 mcg's and the only other option was to not give it to the resident. She stated she didn't know why the pharmacy didn't send the right medication. She confirmed she was going to give the 880 mcg's and not do anything else about the medication. Review of the policy entitled, Medication Administration dated 02/23/24 revealed medications shall be administered in accordance with the physician/ authorized practitioner orders. This deficiency represents non-compliance investigated under Complaint Number OH00160894.

Based on medical record review, staff interview, and policy review, the facility failed to ensure residents representatives were notified of a change in condition. This affected two (#25 and #42) of three residents reviewed for a change in condition. The facility census was 41. Findings include: 1. Review of the medical record of Resident #42 revealed an admitted [DATE]. The resident was discharged from the facility on 01/11/24 to another nursing home. Diagnoses included Coronavirus (COVID-19), hyperlipidemia, essential hypertension, shortness of breath, chronic obstructive pulmonary disease (COPD), depression, atrial fibrillation, and urinary retention. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had intact cognition. The resident required partial/moderate assistance with toileting, personal hygiene, and all mobility. Review of a progress note dated 01/11/24 at 5:04 A.M. revealed Resident #42 had a witnessed fall at approximately 4:50 A.M. when transferring to her wheelchair. Resident #42 was noted to hit her head on the bed site tray table and the State tested Nursing Assistant (STNA) assisted her the rest of the way to the floor. Resident #42 stated she lost her balance and leaned forward. The resident was assessed, assisted back to bed, and ice was placed to the resident's forehead. The physician was notified via an urgent fax. The progress note revealed no documented evidence that the resident's representative was notified. Review of the Change in Condition Evaluation dated 01/11/24 at 5:11 A.M. revealed the resident experienced a change in condition related to a fall. The name of family/healthcare agent notified was documented as self on 01/11/24 at 5:00 A.M. Review of the post-fall interdisciplinary team (IDT) progress note dated 01/11/24 at 11:26 A.M. revealed, on 01/11/24 at 4:50 A.M., staff was assisting Resident #42 with a transfer from her bed to the wheelchair when Resident #42 lost her balance and went forward, hitting her head on the bed side tray table. The STNA then assisted the resident to the floor. The nurse assessed the resident and noted redness to the forehead, which turned into a bump. Prior interventions were to have the call light in reach and to anticipate the residents' needs. A new intervention was to use a gait belt for all transfers with the assistance of two staff. The IDT note revealed no documented evidence that the resident's representative was notified. Interview on 02/20/24 at 4:08 P.M., the DON confirmed there was no documented evidence of the resident's representative being notified of the Resident #42's fall. The DON reported, despite Resident #42 having intact cognition, her representative should have been notified of the fall. 2. Review of the medical record of Resident #25 revealed an admitted [DATE]. Diagnoses included cerebral infarction, humeral fracture, Alzheimer's disease, dementia, repeated falls, morbid obesity, major depressive disorder, and gastro-esophageal reflux disease (GERD). Review of the comprehensive MDS assessment dated [DATE] revealed the resident had severely impaired cognition. The resident required substantial/maximal assistance with toileting, personal hygiene, and was dependent on staff for all mobility. Review of a progress note dated 01/25/24 at 5:52 A.M. revealed Resident #25 was observed lying on the floor at the right side of the bed as the aide entered the resident's room. The on-call physician was notified. The progress note revealed no documented evidence that the resident's representative was notified. Review of the Change in Condition Evaluation dated 01/25/24 at 6:17 A.M. revealed the on-call physician's name was listed in the area for the name of family/healthcare agent notified on 01/25/24 at 6:30 A.M. The evaluation revealed no documented evidence that the resident's representative was notified. Interview on 02/20/24 at 3:55 P.M., the DON verified there was no documented evidence of the representative for Resident #25's being notified when the resident had a fall on the morning of 01/25/24. The DON verified the representative should have been notified of the fall and the notification should have been documented in the medical record. Review of the facility policy titled, Determining Change in Condition, dated 06/27/22 revealed the facility will promptly notify the resident, attending physician, and the representative (sponsor) of changes in the resident's medical condition or status. This deficiency represents non-compliance investigated under Complaint Number OH00150436.

Based on medical record review, staff interview, and policy review, the facility failed to ensure staff utilized appropriate practices to ensure residents were free from falls. This affected one (#42) of three residents reviewed for falls. Additionally, the facility also failed to ensure all falls were investigated. This affected one (#25) of three residents reviewed for falls. The facility census was 41. Findings include: 1. Review of the medical record of Resident #42 revealed an admitted [DATE]. The resident was discharged to another nursing home facility on 01/11/24. Diagnoses included (Coronavirus) COVID-19, hyperlipidemia, essential hypertension, shortness of breath, chronic obstructive pulmonary disease (COPD), depression, atrial fibrillation, and urinary retention. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had intact cognition. The resident required partial/moderate assistance with toileting, personal hygiene, and all mobility. Review of the plan of care dated 01/04/24 revealed the resident had an activities of daily living (ADL) self-care performance deficit related to activity intolerance, disease process, and shortness of breath (SOB). Interventions included utilizing a gait belt and one to two persons assist, depending on her physical functioning abilities and SOB. Review of a progress note dated 01/11/24 at 5:04 A.M. revealed Resident #42 had a witnessed fall at approximately 4:50 A.M. when transferring to her wheelchair. Resident #42 was noted to hit her head on the bed site tray table and the State tested Nursing Assistant (STNA) assisted her the rest of the way to the floor. Resident #42 stated she lost her balance and leaned forward. The resident was assessed, assisted back to bed, and ice was placed to the resident's forehead. The physician was notified via an urgent fax. Review of the post-fall interdisciplinary team (IDT) progress note dated 01/11/24 at 11:26 A.M. revealed, on 01/11/24 at 4:50 A.M., staff was assisting Resident #42 with a transfer from her bed to the wheelchair when Resident #42 lost her balance and went forward, hitting her head on the bed side tray table. The STNA then assisted the resident to the floor. The nurse assessed the resident and noted redness to the forehead, which turned into a bump. Prior interventions were to have the call light in reach and to anticipate the residents' needs. A new intervention was to use a gait belt for all transfers with the assistance of two staff. Interview on 02/21/24 at 9:12 A.M., STNA #340 stated, on the morning of 01/11/24, Resident #42 requested help with getting up and going to the bathroom. STNA #340 stated, as she was attempting to transfer Resident #42, the resident shifted faster than she anticipated, lost her balance, and fell forward. STNA #340 stated she was not utilizing a gait belt for the transfer because she did not have time to put it on the resident. Interview on 02/20/24 at 4:08 P.M., the DON confirmed STNA #340 was transferring Resident #42 without a gait belt when the fall occurred. The DON verified a gait belt should have been used when transferring Resident #42 from her bed to the wheelchair. Review of the facility policy titled, One Person Transfer, dated 07/08/21, revealed residents who have been evaluated/assessed as requiring one-person manual assistance will utilize a transfer belt to promote safety of the resident. 2. Review of the medical record of Resident #25 revealed an admitted [DATE]. Diagnoses included cerebral infarction, humeral fracture, Alzheimer's disease, dementia, repeated falls, morbid obesity, major depressive disorder, and gastro-esophageal reflux disease (GERD). Review of the comprehensive MDS assessment dated [DATE] revealed the resident had severely impaired cognition. The resident required substantial/maximal assistance with toileting, personal hygiene, and was dependent on staff for all mobility. Review of a nurse's progress note dated 01/25/24 at 5:52 A.M. revealed Resident #25 was observed lying on the floor at the right side of the bed as the aide entered the resident's room. The on-call physician was notified. Further review of the medical record revealed no documented evidence of a fall investigation being completed for Resident #25's fall on the morning of 01/25/24. Interview on 02/20/24 at 3:55 P.M., the DON verified there was no investigation completed for the fall which occurred on the morning of 01/25/24. The DON stated she was not aware of the fall and therefore an investigation was not completed. Review of the facility policy titled, Fall Management Program Guideline, dated 12/15/23, revealed all falls must be investigated to the causative reasons/contributing factors. This deficiency represents non-compliance investigated under Complaint Number OH00150436.

Based on staff interview, review of the Centers for Medicare and Medicaid Services (CMS) memo, review of the infection control log, and policy review, the facility failed to implement a program to prevent Legionella (a type of pneumonia caused by bacteria). This had the potential to affect all residents at the facility. The facility census was 46. Findings include Review of the facility policy packet titled, Water Program, dated 12/29/17 included a plan to reduce the risk for growing and spreading Legionella. Maintenance will provide a continuous review of the water management system. The water management program revealed no evidence of a water management team, roles of the team, no evidence of a description of the building water system. The policy revealed to make sure the program was running and the design was effective. Interview on 08/24/22 at 10:45 A.M., and at 2:32 P.M., Maintenance Director #217 revealed he had no documentation of implementing the water management plan/program. Interview on 08/25/22 at 1:36 P.M., the Administrator verified the facility had failed to implement a program to prevent Legionella. Review of the CMS memo dated 06/02/17 revealed facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water. Review of the infection control log for the last 12 months revealed no residents had contracted Legionella.

Based on record review, facility policy review, and interview the facility failed to obtain witnessed authorization forms for residents and/or resident representatives allowing the facility to manage their funds in an interest bearing account. This affected four out of four Residents (#12, #13, #15, #19) reviewed for resident funds. The facility census was 46. Findings include Review of the facility resident accounts files for Resident #12, #13,#15, #19 revealed no witnessed authorization forms permitting the facility to manage their funds. Further review of the resident fund accounts for Resident #12, #13, #15, #19 revealed no interest earned on their accounts. Interview on 08/23/22 at 3:33 P.M. with the Business Office Manager (BOM) # 117 confirmed the facility failed to obtain witnessed authorization fund forms from Resident #12, #13, #15,and #19. BOM #117 confirmed no interest was identified on the resident fund account forms for Resident #12, #13,#15, and #19. Review of the facility policy titled, Resident Personal Funds, dated November 2017, the resident has a right to manage his or her financial affairs to include the right to know, in advance, what charges a facility may impose against a resident's personal funds. Further review of the policy revealed if a resident chooses to deposit personal funds with the facility, upon written authorization of a resident, the facility must act as a fiduciary of the resident's funds and hold, safeguard, manage,and account for the personal funds of the resident deposited with the facility. The facility will deposit any resident's personal funds in excess of $100 in an interest-bearing account(or accounts) separate from any of the facility's operating accounts, and will credit all interest earned on resident funds to that account. (In pooled accounts, there must be separate accounting for each resident's share.

Based on medical record review, observation and staff interview, the facility failed to ensure a cognitively impaired resident was clothed while out in a common area. This affected one resident (#16 ) out of three residents reviewed for dignity. The facility census was 46. Findings Include: Review of Resident #16's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #16's Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of the behavior plan of care dated on 06/05/22 revealed the resident would bite and chew on her clothes. Observations on 08/22/22 at 11:10 A.M. revealed Resident #16 was sitting in the hall by the nurses station. Resident #16 had other residents sitting near by her. Resident #16 was chewing and biting on her top. Resident #16 would pull her top up from the bottom. When Resident #16 pulled her shirt up her breast would show. Staff was noted in the area but did not stop to pull the residents top down. Observations continued until 12:00 P.M. Observations again on 08/23/22 at 11:30 A.M. revealed the resident was again biting and pulling on her clothes, the resident's breast was noted to be exposed. Further observations on 08/24/22 at 12:11 P. M. revealed the resident was pulling her shirt down from the top so her breast did not show but her shoulders and upper chest were exposed. Resident #16 did not have a bra or under shirt on and is cognitively impaired and unable to realize her breast were showing. Interview on 08/22/22 at 12:00 P.M. with State tested Nursing Assistant (STNA) #101 revealed this was daily behavior for the resident. Interview on 08/24/22 at 10:00 A.M. with Licensed Practical Nurse #150 revealed the resident does this all day long. Interview with the Director of Nursing (DON) on 08/24/22 at 4:00 P.M. revealed the resident does pull and bite her clothes and blankets. The DON noted Resident #16 did not have an order or intervention in place to protect the resident from exposing her self.

Based on observation, record review, facility policy review, and interview, the facility failed to provide follow up regarding concerns during Resident Council Meetings. This affected two (Resident #07 and #29) out of three residents reviewed for Resident Council concerns. The facility census was 46. Findings include 1. Record review for Resident #07 was admitted to to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #07 required an electric scooter for mobility. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed he had intact cognition. Further review of MDS assessment revealed he required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. He was independent with eating and required no assistance from staff. Interview with Resident #07 on 08/24/22 at 10:40 A.M. with Resident #07 revealed he was concerned with the front door automatic opener not working. Resident #07 stated he is unable to renter the front door to the facility at times because he utilizes a mobility scooter. He stated he reported this issue multiple times including in resident council and no one has addressed the issued. Interview on 08/24/22 at 11:27 A.M. with the Activity Director (AD) #153 confirmed the issue was brought to the Resident Council Attention in May 2022 and July 2022 meeting. AD #153 stated the process following the resident council meetings are to take the resident concerns to each department manager following the resident council meetings and they will address the issue and provide follow up. AD #153 confirmed the issue was never addressed by the facility management team from May 2022 through July 2022. AD #153 stated the only department that appears to follow up on resident council concerns is the nursing department. Interview and observation on 08/24/22 at 2:32 P.M. with the Maintenance Assistant (MA) #217 confirmed the front door access button was not working. MA #217 confirmed the maintenance department could not provide any type of verification regarding the front door automatic door opener needing repair or that it was report between May 2022 through date of survey. 2. Record review for Resident #29 was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the discharge and return anticipated MDS, dated [DATE], revealed Resident #29 had moderately impaired cognition. Further review of the MDS assessment revealed he required supervision from staff with bed mobility, dressing, eating, and personal hygiene. Resident #29 was independent with transfers, and toilet use. Interview with Resident # 29 on 08/24/22 at 10:40 A.M. revealed he was frustrated with the facility for not addressing the issue in his shower. Resident #29 stated he has mold growing in his shower and no one will address the issue. Interview on 08/24/22 at 11:37 A.M. with AD #153 confirmed Resident #29 has reported a concern with his shower having a black substance along the wall and floor of his shower at resident council in March 2022 and in May 2022 resident council meetings. Interview on 08/25/22 at 01:52 P.M. with Housekeeper (HK) #126 confirmed a black substance along the bottom of the shower wall and along the floor of the shower in Resident #29's room. HK #126 stated this is mold. HK #126 stated she continues to try and remove the mold from the shower, however it returns. HK #126 stated the issue was the shower head in the shower. HK#126 held up the shower head and it was dripping a large amount of water. HK #126 stated the moisture from the leak is allowing mold to continually grow in the shower. HK #126 stated she has reported her concern to the maintenance department. HK #126 stated as soon as she cleans the shower the mold returns. Review of the Resident Council notes revealed the front door automatic door opening button was reported as needing repaired in May 2022 and July 2022. Further review of the Resident Council notes revealed the issue with the black substance (Resident #29 referred the black substance as mold) was reported during the council meeting in March 2022 and May 2022. Interview on 08/24/22 at 4:15 P.M. with AD #153 confirmed the dining room/activity, nurse's station, and hallways are always cold. AD #153 confirmed she had to pass blankets out during the afternoon activity on 08/24/22 because the dining/activity room is so cold. AD #153 stated the residents are constantly saying they are cold on the thrid floor unit. All the activities are in the dining room on third floor and it is always cold like that. Interview on 08/25/22 01:36 PM with the Administrator confirmed the expectation of resident council concerns is to be addressed timely each month. The Administrator confirmed the facility has failed to review and resolve concerns brought up during the Resident Council Meeting. Review of the facility policy titled, Housekeeping and Laundry, Resident Room Cleaning Policy, dated 05/14/20, revealed all resident rooms are cleaned and disinfected on a regular basis. Bathroom cleaning stated, clean and disinfect vanity, countertop, sink/bathtub/shower and toilet. Review of the facility policy titled, Resident Council Association, dated 09/09/21, revealed, Resident organization meetings should discuss and document resident concerns and issues. Further review of the facility stated, Resident Council in a skilled nursing facility will follow regulatory guidelines. This deficiency substantiated complaint OH 607.

Based on observation, record review, facility policy review, and interview, the facility failed to provide a homelike environment for three residents (#07, #29, and #30) out of three residents reviewed. The facility census was 46. Findings include 1. Record review for Resident #07 was admitted to to the facility on [DATE]. His diagnoses included urinary tract infection, [CONDITION(S)], diabetes mellitus II, asthma, peripheral vascular disease, [CONDITION(S)], [CONDITION(S)], major depressive disorder, spinal stenosis, essential primary hypertension, gastro- [CONDITION(S)] reflux disease, [CONDITION(S)], and tinea pedis. Resident #07 required an electric scooter for mobility. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed he had intact cognition. Further review of MDS assessment revealed he required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. He was independent with eating and required no assistance from staff. Interview with Resident #07 on 08/24/22 at 10:40 A.M. with Resident #07 revealed he was concerned with the front door automatic opener not working. Resident #07 stated he is unable to renter the front door to the facility at times because he utilizes a mobility scooter. He stated he reported this issue multiple times including in resident council and no one has addressed the issued. Interview on 08/24/22 at 11:27 A.M. with the Activity Director (AD) #153 confirmed the issue was brought to the Resident Council Attention in May 2022 and July 2022 meeting. AD #153 stated the process following the resident council meetings are to take the resident concerns to each department manager following the resident council meetings and they will address the issue and provide follow up. AD #153 confirmed the issue was never addressed by the facility management team from May 2022 through July 2022. AD #153 stated the only department that appears to follow up on resident council concerns is the nursing department. Interview and observation on 08/24/22 at 2:32 P.M. with the Maintenance Assistant (MA) #217 confirmed the front door access button was not working. MA #217 confirmed the maintenance department could not provide any type of verification regarding the front door automatic door opener needing repair or that it was report between May 2022 through date of survey. 2. Record review for Resident #29 was admitted to the facility on [DATE]. His diagnoses included [CONDITION(S)], [CONDITION(S)], diabetes mellitus without complications, chronic [CONDITION(S)], [CONDITION(S)], coronavirus 2019 (COVID19), chronic kidney disease, anxiety disorder, alcohol dependence, [CONDITION(S)], [CONDITION(S)], major depressive disorder, pneumonia, [CONDITION(S)], diabetes mellitus, and major depressive disorder. Review of the discharge and return anticipated MDS, dated [DATE], revealed Resident #29 had moderately impaired cognition. Further review of the MDS assessment revealed he required supervision from staff with bed mobility, dressing, eating, and personal hygiene. Resident #29 was independent with transfers, and toilet use. Interview with Resident # 29 on 08/24/22 at 10:40 A.M. revealed he was frustrated with the facility for not addressing the issue in his shower. Resident #29 stated he has mold growing in his shower and no one will address the issue. Interview on 08/24/22 at 11:37 A.M. with AD #153 confirmed Resident #29 has reported a concern with his shower having a black substance along the wall and floor of his shower at resident council in March 2022 an May 2022 resident council meetings. Interview on 08/25/22 at 01:52 P.M. with Housekeeper (HK) #126 confirmed a black substance along the bottom of the shower wall and along the floor of the shower in Resident #29's room. HK #126 stated this is mold. HK#126 stated she continues to try and remove the mold from the shower, however it returns. HK #126 stated the issue was the shower head in the shower. HK #126 held up the shower head and it was dripping a large amount of water. HK # stated the moisture from the leak is allowing mold to continually grow in the shower. HK #126 stated she has reported her concern to the maintenance department. HK #126 stated as soon as she cleans the shower the mold returns. 3. Record review for Resident #30 revealed an admitted [DATE]. Her diagnoses intracerebral hemorrhage, Covid 19, obesity, asthma, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], and essential primary hypertension. Review of the quarterly MDS assessment, dated 06/21/22, had intact cognition. Further review of the MDS assessment revealed she was independent and required no assistance from staff with bed mobility, dressing, and eating. Resident #30 required supervision assistance from staff with bed transfers, and toilet use. Interview on 08/24/22 at 10:40 A.M. revealed Resident # 30 reported the dining room/activity room is always cold. Resident #30 stated the management staff is very aware of the thrid floor dining room/activity room, nurse's station and hallways being very cold. Interview on 08/24/22 at 11:37 A.M. with the AD#153 confirmed the dining room/activity room on the 3rd floor is always cold. AD #153 confirmed management staff is aware of the cold temperature on the floor. Observation on 08/24/22 at 12:15 P.M. reveled Resident # 30 was seated in the dining room with a winter coat on eating her lunch. Interview and observation on 08/24/22 at 2:20 P.M. with MA #217 confirmed the dining room/activity room temperature reading was 68. MA #217 stated he is unable to make everyone happy. MA #217 stated if they will complain its cold and then turn around and state its hot. MA #217 confirmed the residents seated in the dining room/activity room were wrapped in blankets or had coats on because the room was so cold. MA #217 walked into the mechanical room and confirmed the third floor temperature reading was 68. Review of the Resident Council notes revealed the front door automatic door opening button was reported as needing repaired in May 2022 and July 2022. Further review of the Resident Council notes revealed the issue with the black substance (Resident #29 referred the black substance as mold) was reported during the council meeting in March 2022 and May 2022. Interview on 08/24/22 at 4:15 P.M. with AD #153 confirmed the dining room/activity, nurse's station, and hallways are always cold. AD #153 confirmed she had to pass blankets out during the afternoon activity on 08/24/22 because the dining/activity room is so cold. AD #153 stated the residents are constantly saying they are cold on the thrid floor unit. All the activities are in the dining room on third floor and it is always cold like that. Interview on 08/25/22 01:36 PM with the Administrator confirmed the expectation of resident council concerns is to be addressed timely each month. The Administrator confirmed the facility has failed to review and resolve concerns brought up during the Resident Council Meeting. Review of the facility policy titled, Housekeeping and Laundry, Resident Room Cleaning Policy, dated 05/14/2020, revealed all resident rooms are cleaned and disinfected on a regular basis. Bathroom cleaning stated, clean and disinfect vanity, countertop, sink/bathtub/shower and toilet. Review of the facility policy titled, Resident Council Association, dated 09/09/21, revealed, Resident organization meetings should discuss and document resident concerns and issues. Further review of the facility stated, Resident Council in a skilled nursing facility will follow regulatory guidelines.

Based on observation, interview, and record review, the facility failed to ensure that resident medical records provided an accurate depiction of resident medication administration. This affected one resident (Resident #353) of 17 residents reviewed for medications. The facility census was 46. Findings included: Review of the medical record for Resident #353 revealed an admitted [DATE] and a discharge date of [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Minimum Data Set (MDS) dated [DATE] revealed Resident #353 was cognitively intact and was independent for eating, required supervision for personal hygiene, limited assistance of one for bed mobility, walking, and locomotion, and extensive assistance of one for dressing and toileting. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of handwritten paper prescription revealed Lorazapam + po HS/PRN anxiety with 30 tablets ordered. Review of electronic medication administration record (eMAR) for 05/2022 revealed [MEDICATION(S)] was administered once a day on 05/13 to 05/17, 05/21, 05/25, 05/29, and 05/31, for a total of eight doses in 05/2022. Review of eMAR for 06/2022 revealed [MEDICATION(S)] was administered twice a day from 06/01 to 06/12, and once on 06/13/22, for a total of 25 doses in 06/2022, combined number of 33 doses. Review of Controlled Drug Receipt for Resident #353's [MEDICATION(S)] 0.5 mg, revealed order as Give 1 tablet by mouth at bedtime as needed. [MEDICATION(S)] was administered as follow; administrations not noted in eMAR are designated with *: 05/11 at 1:30 A.M.*, 05/13 at 7:16 P.M., 05/14 at 9:00 P.M., 05/15 at 8:00 A.M., 05/15 at 9:00 P.M.*, 05/16 at 8:00 P.M., 05/17 at 8:22 P.M., 05/18 at 8:05 P.M.*, 05/19 at 7:00 P.M.*, 05/21 at 7:00 P.M., 05/22 at 8:00 P.M.*, 05/25 at 7:00 P.M., 05/28 at 8:00 P.M.*, 05/29 at 7:56 P.M., 05/30 at 8:30 P.M.*, and 05/31 at 9:00 P.M. Seven doses of [MEDICATION(S)] were not documented in the 05/2022 eMAR, total of 16 doses administered during 05/2022. Doses of [MEDICATION(S)] administered in 06/2022 were all documented on both eMAR and Controlled Drug Receipt for a total of 42 doses from 05/10/22 to 06/13/22 of 67 possible doses. A medication administration was observed during the annual survey beginning on 08/22/22, 26 medication opportunities were observed without any significant error and a 0% medication error noted overall. Interview on 08/25/22 at 10:15 A.M. Unit Manager (UM) #139 stated that Resident #353's initial [MEDICATION(S)] order was written for 14 days as it was as needed (PRN) and when she reordered it for 06/2022, she made the doses scheduled. UM #139 verified that the eMAR orders and pharmacy orders did not match, nor was the handwritten paper prescription contain a properly written order, + po HS/PRN anxiety. She stated that the physician used the forward slash / to mean and, which led to the interpretation of at bedtime and as needed for anxiety, she verified that that was not an acceptable abbreviation for prescription, just that it was how that physician wrote prescriptions. UM #139 verified that the eMAR and Controlled Drug Receipt sheets did not match, noting specifically that 05/11, 05/15, 05/18, 05/19, 05/22, 05/28, and 05/30/22 doses were not documented in the eMAR. Observations from 08/22/22 to 08/25/22 revealed no resident to appear improperly or overmedicated.

Based on closed medical record review, staff interview, and review of the National Pressure Injury Advisory Panel (NPIAP) guidelines on pressure ulcers, the facility failed to ensure a resident who was assessed at risk had interventions to prevent the development of pressure ulcers. Actual harm occurred to Resident #63 when she developed three (3) Stage III pressure ulcers (full thickness tissue loss; subcutaneous fat may be visible, but bone, tendon or muscle are not exposed; slough may be present but does not obscure the depth of tissue loss.) to the coccyx, and right and left buttocks. This affected one (#63) of three residents reviewed for in-house acquired pressure ulcers. The facility identified eight current residents with pressure ulcers. The facility census was 50. Findings include: Review of the closed medical record for Resident #63 revealed an admission date of [DATE], with a discharge date of [DATE], and readmitted on [DATE], and was discharged home with home health services on 02/16/21. [DIAGNOSES REDACTED]. Review of the form titled, Admission Data Collection and Review, dated 01/08/21, revealed the resident was assessed to have pink scar tissue on the right side of the scalp, on the left upper chest and under bilateral breast. Resident #63 also had the left lower leg in a soft case with ace wrap present. There were no pressure ulcers present upon admission. Review of the pressure ulcer risk assessment dated [DATE], revealed the resident was at risk for skin breakdown. Review of the admission physician orders dated 01/08/21, revealed there was no physician orders to address any interventions to prevent skin breakdown for the resident. Review of the care plan for potential for alteration in skin dated 01/09/21, revealed interventions to complete weekly skin reviews observing for any new skin alterations; staff to implement preventative interventions as indicated by resident's ability to comply with recommendations to prevent skin alteration, i.e. pressure reduction mattress, pressure reduction chair cushion, skin prep bilateral heels, bunny/elevation boots to heels, pillows under calves, barrier cream as ordered, etc.; and complete Braden Scale (pressure sore risk) assessment upon admission, quarterly and as needed. Review of the admission Medicare-Five-day Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had intact cognition. The resident was total dependent with one -person assistance for bed mobility, transfers and required limited assistance for ambulating. The resident was assessed as having no pressure ulcers. The resident was always incontinent of bladder and did not have any refusal of care. Review of skin reposition form revealed the resident was to be turned and repositioned every two hours in bed/chair. The form revealed there was no documentation from 01/08/21 to 01/22/21 of staff turning or repositioning Resident #63. Skin repositioning monitoring sheets were dated 01/23/21. Review of the medical record from 01/08/21 to 01/27/21, revealed no documentation of any open areas or pressure ulcers. Review of Resident #63's wound skin notes documented the wounds were discovered on 01/28/21 at 10:29 A.M. and were assessed as three (3) new Stage III pressures ulcers located on the coccyx, on the right buttock and on the left buttock. The coccyx wound measured 0.5 centimeters (cm.) in length, 0.4 cm. in width, and 0.1 cm in depth and was described to have 100 percent (%) non-viable tissue/slough; natural color, intact. The right buttock wound measured 2.5 cm in length, 2.0 cm in width and 0.1 cm in depth and was described to have 100% non-viable tissue/slough: natural color intact. The left buttock wound measured 1.5 cm in length, 2.3 cm in width and 0.1 cm in depth was described to have 100% non-viable tissue/slough: natural color intact. All wounds were present with small amounts of serous drainage, no odor present, no tunneling and the wound edge shapes were described to be well-defined. Review of a physician order dated 01/28/21, revealed an order for [REDACTED]. Review of the Nutrition/Dietary Note dated 01/29/21 at 12:34 P.M., revealed the resident was seen due to having (3) Stage III pressure areas to the coccyx, as well as the bilateral buttocks. Currently the resident was on a reduced concentrated sweets (RCS) diet with thin liquids. Intakes with meals were fair and ranged from 25-75%. Recommend adding the mighty shake every day and Prostat every day to promote intakes and skin healing. Will continue to monitor resident through clinical course. Interview on 03/29/21 at 2:51 P.M., revealed Physician Assistant (PA) #350, reported she only saw Resident #63 once and it was on 01/28/21, when she diagnosed the three pressure ulcers. PA #350 reported she was told by the facility; Resident #63 was admitted with the wounds. PA #350 reported if she had been informed the pressure ulcers had been acquired in-house, she would have ordered blood work to see if Resident #63 was anemic or could have upgraded the bed or investigated her pain. PA #350 reported, Resident #63's pain could have prevented her from moving around. If she was informed Resident #63 had acquired pressure ulcers in house, it would have led her to a different road of treatment. Interview on 03/29/21 at 7:40 P.M., with the Director of Nursing (DON) verified Resident #63 did not have pressure ulcer upon admission and developed them in-house on 01/28/21. The DON reported he was not the DON during the time Resident #63 was in the facility and can only go off the documentation. Review of information from the National Pressure Injury Advisory Panel (NPIAP) at https://npiap.com/ revealed facilities should develop a plan of care based on the areas of risk, rather than on the total risk assessment score. For example, if the risk stems from immobility, address turning, repositioning, and the support surface. If the risk is from malnutrition, address those problems. Staff should inspect the skin at least daily for signs of pressure injury, especially non-blanchable [DIAGNOSES REDACTED]. Further review revealed a Stage III pressure ulcer is full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. This deficiency substantiates Complaint Numbers OH 931 and OH 785.