Every finding on record at Westpark Healthcare Campus

Based on record review, review of the facility investigation, staff and family interviews, review of the 2025 American Heart Association and review of facility policy, the facility failed to ensure advance directives were honored for residents. This affected one resident (#63) of three residents reviewed for Cardio-pulmonary Resuscitation (CPR). The facility census was 79. Findings include:Review of the closed medical record for Resident #63 revealed an admission date 01/18/15 and discharged to hospital on [DATE]. Diagnoses included heart failure, atherosclerotic heart disease, chronic obstructive pulmonary disease, atrioventricular block complete and myocardial infarction.Review of the resident's record revealed an Advance Directive for Do Not Resuscitate Comfort Care (DNRCC) form dated 03/25/25 that was signed by the physician.Review of Resident #63's care plan dated 04/06/26 revealed Resident #63 had an Advance Directive order in place for emergencies. Interventions included advocating for the patient's wishes in the event of a medical emergency, follow facility policies and during an emergency the staff will ensure the attending physician, emergency medical technician and hospital person all have my information relating to my documented advance directives and end-of-life wishes.Review of the physician order dated 11/30/25 for Resident #63 revealed the resident had a Do Not Resuscitate Comfort Care Arrest (DNRCCA) order which indicates lifesaving treatments would be utilized up to the point of cardiac arrest.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #63 was cognitively impaired. Resident #63 required partial/moderate assist for all activities of daily living (ADL).Review of the statement dated 07/29/26 for LPN #457 revealed at approximately 8:00A.M. on 07/29/26 she was informed by a housekeeper that Resident #63 was about to fall out of her chair in the dining room so, I immediately went to the dining room and observed Resident #63 had a tray in front of her with food opened. LPN #457 looked at Resident #63 face and it appeared that she was choking on her breakfast. LPN #457 initiated the Heimlich maneuver and yelled to grab the unit manager. LPN #215 upon entering the dining room, LPN #215 took over doing the Heimlich. LPN #457 explained that she entered the dining room and believed the Resident #63 was choking on breakfast in the process of doing the Heimlich Resident #63 began to change colors and go limp. Resident #63 was then placed on the floor and a mouth sweep was completed; no food was in Resident #63's mouth and the unit manager then proceeded to say that she was going to have to crack her chest. LPN #457 informed unit manager LPN #215 that Resident #63 was a DNR. LPN #215 stated that she is a full code and she knows the residents code status by exceptions then began to start chest compressions on Resident #63. LPN #457 yelled out to the aide to grab the crash cart and called a blue code. LPN #457 asked the housekeeper for her phone to call 911. A moment later, while report was being given to 911 operator, Resident #63 made gasping sounds, as the crash cart was being brought into the dining room. The second-floor unit manager LPN #204 walked into the dining room asking if any help was needed. LPN #204 went to print out paperwork as oxygen was being applied to Resident #63. LPN #204 then returned with printed out paperwork for Resident #63. LPN #204 went and got Resident #63's hard chart and it was showing that she has a copy of a DNR CCA paper in her chart. At this time, EMS arrived at facility for the resident. LPN #215 stated she will write a progress note along with updating the family and hospital.Review of the statement in an electronic mail (email) dated 07/30/26 at 10:10 A.M. from Licensed Practical Nurse (LPN) #215 revealed LPN #215 heard someone yelling resident #63's name and for her. She ran into the dining room and LPN #457 had picked Resident #63 up out of her chair from behind and was preforming the Heimlich Maneuver on her. She was standing straight up behind Resident #63's chair and had Resident #63 upright trying to clear her pathway. LPN #215 took resident out of nurse's hands because she was gray and Resident #63 was fading. I immediately asked if she was a full code and LPN #457 said yes I told her to call 911 and laid Resident #63 on the floor and began abdominal thrusts to try to clear the resident's airway as we thought she was choking. I told the aid to go get the crash cart and continued with the abdominal thrusts a few times. I also performed a mouth sweep. Resident #63 began to turn gray and her pulse was thready and then went into respiratory arrest. As I checked for her pulse it was thready and agonal pulse (clinical sign closely tied to respiratory and cardiac arrest, abnormal, involuntary pattern of breathing). LPN #215 gave her 30 seconds of chest compressions to obtain a solid heartbeat still thinking that the resident was a full code. It is correct I bagged a resident for a few minutes, and Resident #63 started talking. I sent LPN #204-unit manager to print papers and at that point. LPN #457 said wait I think she might be DNR CCA. I said I don't think she is but I sent LPN #204 to check. It took a while for her to come back with the papers because she was unable to print them in the nurses station or my office as she forgot the code. So, it took her a minute as she went to both offices and then ran upstairs to print the papers during this time Resident #63 was talking and laughing and said, I feel horrible. When LPN #204 finally got back, LPN #457 said she thought Resident #63 may be a full code so, we started going over it and I stated I tried to remember by exceptions and I asked LPN #204 instead of the papers go grab the chart. LPN #204 returned and stated Resident #63 was the DNR CCA, this means everything up until chest compressions or agonal pulse or heart rate to keep tissues perfused until paramedics arrive which they did and took over care. I called report to the hospital and told them she had a signed DNRCCA and that the Heimlich maneuver had been done multiple times and that we also did sternal rubs on her heart and gave her 30 seconds of compressions because of her agonal pulse LPN #204. LPN #457 and herself we're discussing who was DNR CC's and I asked was she a full code before I gave compressions. Going forward I will not initiate CPR until I have someone grab the chart to confirm they are in fact a DNR or a full code right after calling 911.Review of the written statement from LPN #204 dated 07/31/26 revealed on 7/29/26 she was alerted by the aide that Resident #63 had coded on the 1st floor, she immediately went to the first floor to observe resident lying on the dining room floor alert and laughing with staff. Seeing that resident was alert she went to print paperwork for the resident to transfer to the hospital. When she returned LPN #215 asked her to go check the resident's chart for code status. She grabbed the resident's chart and saw that Resident #63 had DNR CCA paperwork in front of her chart. She took the chart to the dining room to show LPN #215 and LPN #457 the resident's code status. That is when EMS arrived to transfer the resident to the hospital.Interview on 08/03/26 at 1:48 P.M. with sister of Resident #63 revealed she had seen the video of them doing CPR to Resident #63 after doing Heimlich maneuver. Chest compressions were done for 30 seconds. She was told Resident #63 had a pulse and they did compressions. She felt they did CPR and this was not Resident #63's wishes. Resident #63's sister stated Resident #63's underlying conditions and the fracture ribs and punctured lungs were not helping and Resident #63 was still in the hospital due to her injuries. Interview on 08/03/26 at 2:26 P.M. with LPN #215 and Director of Nursing (DON) revealed on 07/29/26 LPN #215 was notified that there was an emergency in the dining room related to Resident #63. When she arrived, LPN #457 was giving Resident #63 the Heimlich maneuver. The nurse thought that the resident was choking. Resident #63 was eating breakfast and started to change color and slumped over. LPN #457 had Resident #63 up and out of the chair doing the Heimlich. When LPN #215 came into the dining room, she took over and Resident #63 was gray in color and unresponsive. She laid the resident on the floor and gave two more abdominal thrusts and did a mouth sweep for foreign body. LPN #215 told staff to call 911 and to get the crash cart. LPN #215 stated she did a sternal rub and checked Resident #63's pulse it was thready about 30-35 beats per minute (bpm). So, LPN #215 started CPR, did a few compressions and checked the resident's pulse again and it was thready and pulse was 20 bpm. She then continued compression for about 15-30 seconds until Resident #63 came to. LPN #215 stated she had asked LPN #457 if the resident was a full code and she stated yes. LPN #215 started chest compressions and then she bagged the resident for about five minutes before ambulance got there. LPN #215 stated when Resident #63 came back to she stated she was in horrible pain. LPN #204 came into the dining room and stated to wait as she thought the resident was a DNRCCA. LPN #215 stated she told her to go get Resident #63's chart. When Resident #63 came to, a non-rebreather mask with oxygen was put on her. When LPN #204 came back with the hard chart, the staff identified that Resident #63 had a DNRCCA in the front of the chart.Interview on 08/03/26 at 3:06 P.M. with LPN #204 (unit manager) stated at the time of the occurrence with Resident #63, she was upstairs on her unit and was told Resident #63 had coded. When she walked in the dining room Resident #63 was alert and talking. LPN #215 asked her to go get paperwork to send to the hospital. When LPN #204 got back to the dining room LPN #215 asked if she could go and get Resident #63's chart for her code status and when LPN #204 opened the chart she saw the DNRCCA form. LPN #204 stated she did not know they had started chest compressions.Interview on 08/03/26 at 3:10 P.M. with the DON and RN #334 revealed they had started an investigation when they found out Resident #63 received chest compressions and was a DNRCCA. They notified the medical director and Nurse Practitioner (NP) #502. The family had been notified by someone else of the incident prior to the DON knowing anything about the incident. The facility did a code status audit on all residents. Education with ODH PowerPoint with all nurses at the facility at the time and then all nurses prior to their next working shift. They met with Resident #63's sister. They also got statements of all staff involved.Interview on 08/03/26 at 4:00 P.M. with LPN #457 stated she was Resident #63's nurse on 07/29/26 and was doing med pass when Housekeeper (HK) #257 came up to her and stated something was wrong with Resident #63 in the dining room as she was about to get ready to fall out of her chair and not acting right. When LPN #457 entered the dining room Resident #63 was sitting in front of her breakfast and her first thought was that she was choking. LPN #457 stated she started to do the Heimlich maneuver and yelled to get LPN #215, the unit manager. When LPN #215 came in she took over, she stated the resident stopped breathing and placed her on the floor and did a mouth sweep. She started to do compressions, and LPN #457 told her that the resident was a DNR. Before she started compressions again, she stated she knew the code status, and the resident was a full code and began CPR again. LPN #457 stated she called 911 and got the crash cart and pulled out the Ambu bag. LPN #215 put the Ambu Bag on Resident #63 until Resident #63 responded and stated she did not want it on, so LPN #215 put the non-rebreather mask and oxygen on Resident #63 until the ambulance got there. Resident #63 stated her chest hurt and LPN #215 told her we almost lost you. LPN #204 came in asked if we needed anything and she went to print off paperwork, her electronic chart did not say if she was a DNRCCA. She had to go get the physical chart and it had the DNRCCA on the front page. LPN #215 said she was going to update Resident #63's sister, hospital and put in the progress note. Interview on 08/04/26 at 7:49 A.M. with Housekeeping (HK) #257 stated she was working on 07/29/26. She walked through the dining room and spoke to Resident #63 but she was slumped over her plate and her chin was in her eggs. She tapped her and tried to get her to respond but she did not respond and started to lean over. She immediately told Certified Nurse Assistant (CNA) #261. CNA #261 told her to go tell the nurse. HK #257 stated CNA #261 went to assist the resident, and the nurse went to the dining room also.Interview on 08/05/26 at 8:08 A.M. with Nurse Practitioner (NP) #502 stated she was notified that Resident #63 coded on 07/29/26. NP #502 stated it could be a possibility that Resident #63's ribs were fractured while doing the Heimlich maneuver but most likely her ribs were broken during CPR. Review of the video footage dated 07/29/26 at 7:58 A.M. revealed Resident #63 was sitting at a table in the dining room in front of her breakfast and Housekeeper #257 noticed Resident #63 was slumped over and unresponsive so the housekeeper left the dining room. LPN #457 came in and immediately did a mouth sweep and started the Heimlich maneuver, Resident #63 was still unresponsive. At 8:05 A.M. LPN #215 came into the dining room. Resident #63 was placed on the floor, LPN #215 did a mouth sweep, sternal rub and two abdominal thrusts. She checked her pulse and started compressions, she stopped compressions and checked pulse again and started compressions again for about 30 seconds. LPN #457 was in the dining room observing. Then LPN #204 came in at 8:07 A.M. LPN #204 the left area and returned at 8:08 A.M. with papers, left again 8:09 A.M. and returned with the dynamite (blood pressure machine) at 8:11 A.M. At this time the non-rebreather mask was placed on Resident #63. Again LPN #204 left the dining room and returned at 8:14 A.M. with Resident #63's chart and opened it up and showed LPN #215.Review of education Responding to a Medical Emergency and Ohio Department of Health (ODH) PowerPoint on DNR revealed the education was started on 07/29/26. Any staff member can activate an emergency response system to get help. Send someone to call the nurse STAT and call 911 and have the chart brought to the scene. Verify the code status in the chart. If the resident is a DNR CC or DNR CCA continue to assess for underlying causes of medical emergency, check vitals, blood sugar and ensure clear airway.Review of the 2025 American Heart Association on CPR for DNRCC Arrest with thready Agonal pulse revealed the patient's known DNR status if the patient has a valid, documented DNR order, and the provider is within their scope to honor it, CPR should not be initiated. If the patient has a valid DNR but is unresponsive with agonal breathing or a thready pulse, CPR should still be withheld if the provider is within scope to honor the DNR.Review of the facility policy Advance Directives, not dated revealed it is the policy of this facility that the facility shall comply with all valid advance medical directives. The facility shall inquire as to the existence of an advanced medical directive at the time of residency. It will be documented in the resident's medical record whether or not the resident has executed an advance medical directive. A copy of such advanced directive shall be placed in the permanent medical record.This deficiency represents non-compliance investigated under Master Complaint Number 3124479 and Complaint Number 3124333.

Based on staff interview, record review and facility policy review the facility failed to ensure all wound care treatments were provided to residents. This affected one resident (#100) of three residents reviewed for wound care treatments. The facility census was 79.Findings include:Review of the closed medical record for Resident #100 revealed an admission date of 06/15/26 with a readmission date of 07/07/26 and a discharged date of 07/19/26. Diagnoses included cutaneous abscess of lower left limb, chronic obstructive pulmonary disease, and viral hepatitis C. Review of the admission nursing assessment dated [DATE] identified Resident #100 was admitted with a left antecubital wound. Resident #100 had a nonremovable dressing to lower left extremity covered by ace wrap. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 07/14/26, revealed the resident had intact cognition. The assessment indicated Resident #100 had a surgical wound. Review of the physicians' orders for June 2026 identified orders dated 06/23/26 and a discontinued date of 07/02/26 to cleanse lower left extremity with normal saline, pat dry, apply ag (silver) alginate strip and cover with foam dressing daily and as needed (PRN) every evening shift for treatment, orders started 06/15/26 and a discontinued date of 06/22/26 to pack open incisions at surgical site on left lower extremity between Penrose drain (drainage tube) with 0.5-inch packing tape, cover with ABD (absorbent dressing), wrap kerlix then ace wrap every day and night shift. Review of the Treatment Administration Record (TAR) for June 2026 identified orders to pack open incisions at surgical site on left lower extremity between penroses with 0.5-inch packing tape, cover with ABD, wrap kerlix then ace wrap every day and night shift was not signed off as completed on first shift on 06/17/26 and 06/22/26 and was not completed either day shift or night shift on 06/18/26. Review of the Treatment Administration Record (TAR) for June 2026 revealed identified orders to cleanse lower left extremity with normal saline, pat dry, apply ag alginate strip and cover with foam dressing daily PRN every evening shift for treatment were not signed off as completed on 06/25/26 and 06/28/26. Review of physician orders for July 2026 identified orders dated 07/17/26 to cleanse left leg site with soap and water, pat dry, apply ag alginate and cover with ABD kerlix daily and PRN, one time for wound care, orders started 07/08/26 and a discontinued date of 07/16/26 for cleanse left leg abscess site with soap and water, 2 millimeter (mm) thick coat of Santyl to wound bed, and cover with saline moistened gauze and secure with dry protective dressing one time a day for wound care, orders started 06/23/26 and a discontinued date of 07/02/26 for to cleanse lower left extremity with normal saline, pat dry, apply ag alginate strip and cover with foam dressing daily PRN every evening shift for treatment, orders dated 07/17/26 to cleanse left leg site with soap and water, pat dry, apply ag alginate and cover with ABD kerlix daily as needed (PRN). Review of the Treatment Administration Record (TAR) for July 2026 revealed identified orders to cleanse left leg abscess site with soap and water, two millimeters (mm) thick coat of Santyl to wound bed, and cover with saline moistened gauze and secure with dry protective dressing one time a day for wound care were not signed off as completed on 07/09/26. Interview on 08/04/26 at 1:30 P.M. with Licensed Practical Nurse (LPN) #292 verified the above treatments were not completed as ordered. LPN #292 verified that if it was not documented it was not completed. LPN #292 verified treatments for Resident #100 were not signed off and there was no progress note indicating why the treatment was not completed. Interview on 08/04/26 at 3:14 P.M. with LPN #293 revealed Resident #100's dressing was to be changed daily. There were multiple areas on the back on the right leg from the abscess. One wound area appeared to be the size of ankle scabbed yellow underneath. In addition, a couple inches up the leg, there was another wound area that looked the same and did not appear to be infected. Review of the facility policy Dressing, Dry/clean, dated 09/2013 revealed the following information should be recorded in the resident's medical record, treatment sheet or designated wound form, the date and time the dressing was changed, the name and title(or initials) of the individual changing the dressing and notify the supervisor if the resident refused the dressing change. This deficiency represents non-compliance investigated under Master Complaint Number 3124479, Complaint Number 3124333, and Complaint Number 3123682.

Based on observation, staff interviews, and facility policy, the facility failed to maintain the resident environment and equipment in a safe, sanitary, and homelike manner. This affected resident #17, #29, #52, #11, #28, #46 out of 85 residents residing in the facility. The census was 85.Findings include: 1.Observation of building B on 04/23/26 with Administrator from 10:14 A.M. to 11:00 A.M. confirmed the followingResident #17 had ceiling tiles with large brown stains and brown dried liquid stains that have dripped from the ceilingResident #29 had cracks in multiple areas in the floor and yellow stains throughout the flooring and multiple tiles crackedResident #52's inside bathroom door had severe wood chipping along the entire width of the doorResident #11's bathroom ceiling tiles had water stainsResident #28's bathroom paper towel holder not fully attached to the wall and paper towels were on the toiletResident #46 had three ceiling tiles with brown water stains2nd floor dining room had water stains on the ceiling tilesBuilding B 1st floor the floor boards along hallway were stained and not fully attached. Interview on 04/23/26 at 11:00 A.M. with Administrator confirmed the observations.2.Follow-up observation on 04/27/26 from 8:27 A.M. to 8:52 A.M. of Building B with Corporate Administrator #403 and Maintenance Director #279 confirmed the followingResident #17 had ceiling tiles with large brown stains and brown dried liquid stains that have dripped from the ceiling Resident #29 had cracks in multiple areas in the floor and yellow stains throughout the flooring and multiple tiles crackedResident #52's inside bathroom door, hinges were not painted and rough to touchResident #11's bathroom ceiling tiles had water stainsResident #28's bathroom paper towel holder not fully attached to the wall and very looseResident #46 had three ceiling tiles with brown water stains2nd floor dining room had fourteen ceiling tiles noted with water stainsInterview on 04/27/26 at 8:55 A.M. with Corporate Administrator #403 and Maintenance Director #279 confirmed the observation findings from 8:27 A.M. to 8:52 A.M. Review of facility policy, Homelike Environment, dated February 2021, revealed the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary, and orderly environment.This deficiency is an incidental finding discovered during the complaint investigation.

Based on observation, resident and staff interview, and facility policy review, the facility failed to maintain the resident environment and equipment in a safe, sanitary, and homelike manner. This affected 29 (#2, #3, #6, #7, #8, #10, #14, #18, #20, #22, #24, #26, #28, #29, #30, #31, #51, #53, #57, #58, #59, #63, #71, #76, #77, #81, #85, #94, and #103) of 86 residents residing in the facility. The census was 86.Findings include:1. Observation of Building B during facility tour on 01/29/26 at 10:33 A.M. through 12:35 P.M., conducted with the Director of Nursing (DON), revealed the hallway outside of the dining room on the first floor had multiple unattached hand railings and missing hand railing end caps. A chair in the hallway was heavily stained and dirty. There were multiple cracks in the tiles between the dining room and nurses station estimated to 10.0 feet long by 7.0 feet wide, and the floor boards along hallway were stained and not fully attached to the wall. The second floor dining room had multiple areas of water stains on the ceiling tiles and the mechanical lift in the 100 Hall was dirty and rusted. The DON confirmed the facility had tried to clean the lift but the rust would not come off. Observation in Resident #103 and Resident #24's bathroom were two broken wall tiles, a 1.0 inch (in.) long by 1.0 in. wide hole in the wall above the floor trim, and a 1.5 in. long by 1.0 in. wide dent to the right of the entry door. The siding around the door was cracked and broken on the left side. There were also numerous scuffs and scraps throughout the walls and a 1.0 in. long by 1.0 in. wide hole by Resident #24's bed and the cable outlet was not properly attached to the wall. The wall trim below the furnace vents was unattached from the wall. Observation of Resident #85's room revealed multiple brown water stains on the bathroom ceiling tiles. Observation of Resident #94's floor revealed cracks in multiple areas and yellow stains throughout flooring. There were also two holes in the bathroom door and a large chip in the wall tile by the toilet. Observation of Resident #30's bathroom floor revealed four missing tiles, the furnace vents had large splatter stains, and the floor trim underneath was unattached from the wall. The wall air conditioning unit insulation plate was broken and unattached and the floor in the right corner had rust and cracks. The ceiling had large brown stains on the tile and brown dried liquid stains that had dripped from the ceiling. The light cover was completely unattached from the fixture. Interview with Resident #30 during the observation revealed he thought there was a leak from an upstairs toilet. Resident #8 and Resident #18's bathroom had no door. Resident #8's dresser drawers were broken and the light above the bed was not fully attached to the fixture. The privacy curtains in the room would not move along the tracks. Resident #8's telephone outlet cover was unattached from the wall Interview with Resident #8 during the observation stated the electrical outlet next to the telephone outlet did not work. At that time, the DON tested the outlet and confirmed it was not working properly. There was also a 2.0 in. long by 4.0 in. wide piece of tile missing beside Resident #8's bed and a 1.0 in. long by 1.0 in. wide hole in the wall across from the bed. Resident #18 had eight yellowish ceiling tiles and rust was along the ceiling trim near the window. There was a 1.0 in. long by 1.0 in. wide hole in the ceiling tile. There were dark brown stains around the ceiling light and on the tiles around light. The window had a crack on the outside panel and the wall air conditioner (AC) unit was covered with plastic and duct tape due to cold air seeping in. Continued observation of Building B with the DON revealed Resident #7 had a 1.0 in. long by 3.0 in. wide tile missing by the entry way door. Resident #31's room had a 1.0 in. long by 3.0 in. wide hole in the tiles in the entry way into the bathroom. Also, the wall AC unit trim was missing on the right side. Observation of Resident #22 and Resident #53's bathroom door revealed chipped paint and stains. The inside of the bathroom door had a 0.5 in. long by 0.5 in. wide hole. The drywall had been patched in the bathroom but was not sanded down or repainted. The floor by Resident #53's dresser was chipped and the light fixture about the bed was missing the end cap. Resident #26's room had a 2.0 in. long by 5.0 in. wide chip in the floor by the closet. The wall AC unit cover was being held in place with duct tape, the light was completely unattached from the fixture, broken and cracked, and there was a 12 foot long brown water stain on the ceiling tiles by the window. Resident #81's room had a 0.5 in. long by 0.5 in. wide hole in the wall above the bed. The wall AC unit had a towel taped over it, the window blinds had a towel taped to them, and the window had a bed sheet taped over the window with plastic wrap, a metal piece, and screws along the window seal with cold air was coming in. There was duct tape along the sashes of the two windows. Interview with Resident #81 revealed he would like to be able to look out the window and it had been like that since he moved into the room. Observation by the portable heater attached to the wall was a 1.0 foot long by 1.0 foot wide area and a 4.0 in. long by 6.0 in. wide area where the paint was chipped. Continued observation revealed Resident #20's room wall AC unit was covered with plastic and cold air could be felt. The toilet was not fully attached to the floor and was crooked. The rim around the toilet was brown and stained. There were multiple chips in the paint by the bed and the bathroom door was heavily scuffed. Resident #58's room had five dry wall patches that were not painted over, the light fixture was unattached, three ceiling tiles had brown water stains, the bathroom vanity was missing a door, there was missing floor tile in the bathroom, and trim below the bed was unattached to the wall. Resident #57's room had a 2.0 in. long by 2.0 in. wide crack along the floor and the bathroom door was extremely scuffed on the lower part. Resident #71's bathroom had a 6.0 in. long by 8.0 in wide stain on the ceiling tile and multiple chipped tiles in the floor. Resident #2's room cork board above the bed was splattered with a dry liquid. The wall AC unit did not have a trim panel and the vent cover was severely broken and missing pieces in several areas. The light fixture was not attached above the bed. The ceiling tile above the sprinkler had a 10.0 in. long by 5.0 in. wide water stain. The bathroom was missing a light bulb. The bathroom ceiling tiles had an 18.0 in. long by 12.0 in. wide water stain. The bathroom vanity doors were broken and unaligned, and the shelves inside the vanity had laminate peeling off with large pieces missing. The paper towel holder had been replaced and the wall was not repainted. Resident #29's room had splatter on the ceiling above the bed. There was various water stains on the ceiling tiles estimated to be 2.0 feet long by 2.0 feet wide. The light above the bed was not attached to the fixture and the bathroom floor had two tiles missing and a 4.0 in. long by 4.0 in/ wide wall tile was missing across from the toilet. Continued observation revealed Resident #10's room had various large water stains on the ceiling tiles. The bathroom vanity latch was rusted and the lament on the shelves was peeling off. The seal along the vanity and the sink was cracked. Resident #63's room ceiling tile above the window had a 2.5 feet long by 1.0 feet wide stain and a 6.0 in. long by 4.0 in. wide hole in the bathroom door was repaired with white medical tape. The inside of the bathroom door had severe wood chipping along the entire width of door. Resident #28's room had a 1.0 foot long by 1.0 foot wide water stain on the ceiling tile, the bathroom ceiling tiles had a 12 in. long by 8.0 in. wide water stain, the toilet paper holder was broken and missing pieces, and the toilet paper roll was on the vanity. Resident #76's room grab bar by the toilet was rusted, the bedroom wall had a 1.0 foot long by 1.0 foot wide black adhesive residue and missing floor tile, the paper towel holder in the bathroom was not attached fully to the wall and was not level and the paper towels were placed on top of the toilet, and floor tile was missing in the bathroom. The was also drywall by the soap dispenser that had been fixed but not painted. Resident #3's room had a large ceiling tile stain above bed and the wall AC unit was missing trim on the left side. Resident #14's room had trim missing from the entry door and outside of the bathroom, there was a 10.0 in. long by 5.0 in. wide hole in the tile, the bathroom vanity handle was missing, and the laminate placed over the tile floor was coming up. Resident #77's room had no bathroom door or curtain, the bathroom floor had five tiles missing, and there was a large rusted splatter stain on the ceiling outside of the bathroom and on the privacy curtain track. Resident #6's room window unit was missing trim and had exposing broken dry wall with pieces flaking off. Interview with the DON on 01/29/26 between 10:33 A.M. and 12:35 P.M. confirmed all of the above findings at the time of discovery. 2. Observation on 01/27/26 at 11:25 A.M., of Resident #51's wheelchair noted the vinyl on the right and left arm rest cushion was missing and underlying foam padding was exposed. Interview with Resident #51 at the time of the discovery stated the right and left arm rest cushions had the foam padding exposed for a long time. Interview on 01/28/26 at 4:30 P.M. with Certified Nurse Aide (CNA) #321 confirmed the vinyl on Resident #51's bilateral wheelchair arm rests was gone and the foam padding was exposed. She stated staff document issues like that on the computer to let the correct department know of an issue. She stated the maintenance and physical therapy departments were aware, but could not provide any documentation as she did not let anyone know. Interview on 01/29/26 at 12:24 P.M. with License Practical Nurse (LPN) #324 confirmed the bilateral arm rests on Resident #51's wheelchair had foam padding exposed. Interview on 01/29/26 at 12:33 P.M with Director of Rehabilitation (DOR) #334 revealed she did not know about Resident #51 needing new bilateral wheelchair arm rests. Observation with DOR #334 on 01/29/26 at 12:41 P.M. verified the bilateral arm rests on Resident #51's wheelchair needed replaced as the vinyl was gone and the foam padding was exposed. She stated she did not know Resident #51's bilateral arm rests were so worn and stated wheelchairs were checked monthly to ensure they were in good working condition. 3. Observation on 01/28/26 at 4:30 P.M. revealed Resident #59's right arm rest on the wheelchair was totally gone leaving only a screw left in place. The left arm rest had a large area where the black vinyl was rubbed off/missing and the foam padding was exposed. Interview at the time of the observation with CNA #321 verified the condition of the resident's left arm rest and the missing right arm rest, and stated the maintenance or therapy department was notified via the computer, but could not provide the document to verify the date of notification. Interview on 01/29/26 at 12:41 P.M. with DOR #334 revealed she did not know about Resident #59's bilateral wheelchair arm rests until 01/28/26 in the late afternoon and put a new arm rest on the wheelchair right away. Review of facility policy titled, Homelike Environment, dated February 2021, revealed the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary, and orderly environment.

Based on medical record review, staff interview, and resident family interview, the facility failed to ensure a resident was timely and accurately assessed for trauma-informed care needs. This affected one (#58) of one residents reviewed for post-traumatic stress disorder. The facility census was 84.Findings include:Review of the medical record revealed Resident #58 was admitted to the facility on [DATE]. Diagnoses included post-traumatic stress disorder (PTSD), schizophrenia, and dementia. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 was severely cognitively impaired and required hands-on assistance of two staff persons for completion of activities of daily living.Interview with Resident #58's family member on 01/28/26 at 2:45 P.M. revealed the resident had a history of PTSD related to multiple traumatic events, including a traumatic birth and adverse childhood experiences in her home country. The family member further stated institutional, hospital-like environments are a significant trigger for Resident #58's distress and behavioral symptoms due to past trauma associated with her birth. Resident #58 also grew up in a city that was the site of multiple military battles during World War II, further contributing to her trauma history.Review of Resident #58's inital trauma screen document dated 09/17/25 revealed the facility answered, No, to the resident having a diagnosis of or history of traumatic events, despite the resident's documented PTSD diagnosis and the trauma history discussed during Resident #58's family member interview.Interview with the Administrator on 01/28/26 at 3:00 P.M. confirmed the facility did not accurately assess Resident #58 for trauma history or trauma-informed care needs.

Based on medical record review, resident family interview, and staff interview, the facility failed to develop resident-centered care plans to address all relevant physical and mental conditions. This affected two (#44 and #58) of 24 sampled residents reviewed for care plans. The facility census was 84.Findings include: 1. Review of the medical record revealed Resident #58 was admitted to the facility on [DATE]. Diagnoses included post-traumatic stress disorder (PTSD), schizophrenia, and dementia. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 was severely cognitively impaired and required hands-on assistance of two staff persons for completion of activities of daily living. Interview with Resident #58's family member on 01/28/26 at 2:45 P.M. revealed the resident had a history of PTSD related to multiple traumatic events, including a traumatic birth and adverse childhood experiences in her home country. The family member further stated institutional, hospital-like environments are a significant trigger for Resident #58's distress and behavioral symptoms due to past trauma associated with her birth. Resident #58 also grew up in a city that was the site of multiple military battles during World War II, further contributing to her trauma history. Review of the care plan for Resident #58 revealed no problems, goals, or interventions related to Resident #58's PTSD diagnosis. Interview with the Administrator on 01/28/26 at 3:00 P.M. verified the facility did not address interventions specific to Resident #58's PTSD diagnosis in the resident's comprehensive care plan. 2. Review of Resident #44's medical record revealed the resident was admitted on [DATE]. Diagnoses including osteomyelitis of the right ankle and foot, diabetes, chronic obstructive pulmonary disease, acute kidney failure, hypertension, peripheral vascular disease, and cellulitis. Review of Resident #44's MDS assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #44's medical record revealed a physician order dated 11/13/25 for the facility to provide two female staff, together, at all times for resident interactions due to inappropriate behaviors. Interview on 01/29/26 at 1:22 P.M. with Licensed Practical Nurse (LPN) #334 confirmed there was no care plan developed to address the order for the facility to provide two people at all times for Resident #44's care.

Based on personnel record review and staff interview, the facility failed to ensure a performance evaluation was completed for nurse aides at least every 12 months. This deficient practice had the potential to affect all 84 residents residing in the facility. The facility census was 84.Findings include:Review of Certified Nurse Aide (CNA) #371's personnel file on 01/29/26 at 10:30 A.M. revealed a hire date of 08/14/24. There was no evidence of an evaluation performed at least every 12 months for CNA #371. Interview on 01/29/26 at 11:00 A.M. with Human Resources Director (HRD) #701 verified there was no evidence of a performance review at least every 12 months CNA #371 in the personnel file.Review of a document provided by HRD #701 on 01/29/26 at 1:15 P.M. titled, 90-day Employee Evaluation, for CNA #371 revealed a 90-day evaluation dated and signed by CNA #371 on 12/10/25.Interview on 01/29/26 at 1:15 P.M. with HRD #701 verified the date of the evaluation was greater than 12 months from the date of CNA #371's hire.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure Resident #43's allegation of staff-to-resident physical abuse was timely reported to the State Agency. This affected one resident (#43) out of three residents reviewed for abuse. The facility census was 89.Findings include: Review of Resident #43's medical record revealed an admission date of 06/04/24 and diagnoses included cardiac arrest, schizophrenia, and cognitive communication deficit.Review of Resident #43's care plan dated 12/05/24 included Resident #43 had the potential to demonstrate verbally abusive behaviors related to poor impulse control. Resident #43 would verbalize understanding of the need to control verbally abusive behavior. Interventions included to assess Resident #43's coping skills and support system; assess Resident #43's understanding of the situation and allow time for Resident #43 to express self and feelings towards the situation.Review of Resident #43's Minimum Data Set annual assessment dated [DATE] revealed Resident #43 had moderate cognitive impairment. Resident #43 had no impairment of her upper and lower extremities and did not use a cane or walker. Resident #43 required setup or clean-up assistance with toileting hygiene and oral hygiene, and supervision or touching assistance with bathing and dressing. Resident #43 had no physical or verbal behavioral symptoms over the seven day look back period. Resident #43 rejected evaluation or care four to six days over the seven day look back period.Review of Resident #43's medical record including progress notes and assessments dated 08/04/25 at 7:00 P.M. through 08/07/25 at 4:11 P.M. did not reveal evidence of Resident #43's statement that Certified Nursing Assistant (CNA) #203 grabbed her cheek and pinched it during the smoke break on 08/04/25 at 7:00 P.M. There was no evidence Resident #43's cheek was evaluated for pain, injury, bruising and swelling. There was no evidence Resident #43's physician, nurse practitioner, or family member was notified of the allegation. There was no evidence vital signs were checked or that Resident #43 was monitored after the allegation was made. Review of Resident #43's progress notes dated 08/04/25 at 7:00 P.M. through 08/11/25 at 11:20 A.M. did not reveal evidence Resident #43 was evaluated by a physician or nurse practitioner.Review of the facility Self Reported Incident Form dated 08/05/25 at 11:36 A.M. revealed on 08/04/25 at 7:00 P.M., an incident occurred in the smoke room. On 08/05/25, in the morning, Resident #43 stated to Unit Manager (UM) #200 that CNA #203 grabbed and pinched her cheek last night. CNA #203 was not on duty when the allegation was made. UM #200 noted no injury to Resident #43's jaw or cheek. The Administrator was notified of the allegation. The Administrator notified NP #201 immediately and no new orders were given. A message was left on Family Member (FM) #202's phone and CNA #203 was interviewed. Residents #20 and #28 were in the smoke room with Resident #43 and CNA #203 at the time of the incident and were interviewed. Other staff were interviewed. One resident (Resident #20) stated CNA #203 put her hand near Resident #43's face and one resident (Resident #28) did not remember anything happened. Resident #43 was monitored by UM #200 and the nursing staff during the week. FM #202 called the facility on 08/06/25 and stated she was not notified of the allegation. The Administrator called FM #202 and informed her a call was placed the morning of 08/05/25 and UM #200 left a message as well. FM #202 stated she did not receive the messages. FM #202 was informed of Resident #43's allegation, informed CNA #203 was suspended pending an investigation, and that no injury was noted by UM #200 or the charge nurse. The Administrator visited with Resident #43 on 08/07/25, discussed the investigation and CNA #203 was off the schedule during the investigation. Resident #43 stated several times she apologized to CNA #203 for calling her an expletive, and stated CNA #203 pinched her cheek. There was no edema or bruising noted to Resident #43's cheek. Resident #43 stated she was okay with CNA #203 continuing to work her unit and was happy she was suspended for a few days. As a result of the investigation, the facility educated CNA #203 for how to better handle a situation when she was called a name by a resident. Education was previously scheduled for 08/11/25 by the facility psychiatry service and topics included resident behaviors, mental illness, and de-escalation techniques. On 08/08/25, the Administrator requested the in-service also included how to manage reactions when being yelled at by residents or being called names. CNA #203 attended the in-service. CNA #203 was given a break from the behavioral unit and was scheduled to work on other nursing units. Psychiatric NP was notified of the incident and was asked to evaluate Resident #43 on 08/11/25. Due to no evidence that CNA #203 touched Resident #43, no injury was noted, and there was no intention to harm Resident #43, the facility could not determine if abuse occurred. Abuse was not suspected.Review of Resident #43's Allegation of Abuse or Neglect Checklist dated 08/05/25 included on 08/05/25 at 9:30 A.M., the staff member accused was removed from direct resident contact immediately. On 08/05/25 in the morning (time was not identified), UM #200 took Resident #43's statement. On 08/05/25 at 9:30 A.M., Nurse Practitioner (NP) #201 was notified and at approximately 11:00 A.M., Family Member (FM) #202 was notified via message of the allegation. On 08/06/25, the Administrator spoke with FM #202 regarding the allegation. Review of a witness statement dated 08/05/25 (no time identified) included while passing breakfast trays UM #200 walked into Resident #43's room to set up her breakfast tray when Resident #43 stated there was a problem. Resident #43 stated CNA #203 grabbed her left cheek and pinched it the night before. Resident #43 stated she called CNA #203 an expletive and that was why she believed CNA #203 grabbed her cheek. Resident #43 stated she felt safe in the facility, and had no visible marks or bruises noted at the time. Resident #43 stated the pain went away after awhile.Review of a witness phone interview on 08/05/25 (no time identified) included the Administrator immediately interviewed CNA #203 after the Administrator was informed of the situation. CNA #203 stated after dinner she was in the smoke room, she lit Resident #43's cigarette, and when she lit her cigarette Resident #43 said You are a [expletive]. CNA #203 stated she pointed her finger at Resident #43 and asked her why would you call me that. CNA #203 stated Resident #43 did not say anything else but apologized to her for calling her an expletive and they shared a hug. When asked if she touched Resident #43, CNA #203 stated, I never touched her, I did not grab her cheek. Interview on 08/05/25 at 9:00 A.M. of Resident #43 by Social Services Designee (SSD) #204 included Resident #43 was sitting on a chair in UM #200's office and appeared calm and carefree. Resident #43 was swinging her legs and appeared happy. Resident #43 engaged in conversation and made eye contact. Resident #43 stated she call CNA #203 an expletive while in the smoking room. Resident #43 stated after she called CNA #203 an expletive, CNA #203 reached across and grabbed her cheek. Resident #43 stated it was brief, then she exited the smoking room. Resident #43 stated she felt safe in the facility and her cheek was no longer sore.Review of Resident #20's Witness Statement Form dated 08/05/25 included while they were in the smoke room Resident #43 called CNA #203 an expletive, and CNA #203 walked up to Resident #43, put her hand next to her cheek and CNA #203 asked Resident #43 what she called her. Resident #43 hollered out that her cheek hurt. Resident #43 confirmed she called CNA #203 an expletive.Review of Licensed Practical Nurse (LPN) #205's Witness Statement Form dated 08/05/25 (no time identified) included last night (08/04/25) she was administering medications to the residents and Resident #43 asked her for Tylenol. When asked about her pain, Resident #43 stated my mouth and face hurts me. Resident #43 stated CNA #203 grabbed at her mouth after she called her an expletive. Resident #43 stated she squeezed it really hard and asked if her face was swollen. Resident #43 stated give me lots of Tylenol, she was going to tell UM #200 about the incident, and she can't do that to me. On 08/04/25 at 9:30 P.M., Resident #43 repeated what she said multiple times while her medication was administered. LPN #205 wrote a note that Resident #43 had minimal swelling of the left lower cheek and mouth area with a question mark next to it. Review of LPN #205's Teachable Moment via phone dated 08/05/25 in the morning (no time was identified) included LPN #205 did not immediately report a concern reported to her by Resident #43 of a staff member (CNA #203) pinching her cheek. All staff must immediately report any allegation of abuse, neglect, misappropriation or exploitation to the Administrator or Supervisor. LPN #205 voiced understanding.Review of an email sent on 08/07/25 at 4:44 P.M. from the Administrator to the Administrator. There was a handwritten note next to a picture of a phone call to FM #202 stating a call was placed to Resident #43's daughter (FM #202) and a message was left for her to call the facility. The picture had FM #202's phone number showing and the call was placed Tuesday, but there was no date showing Tuesday was 08/05/25.Review of a witness statement dated 08/07/25 (time not identified) written by UM #200 included a message was left for FM #202 to update her on a recent altercation on 08/07/25 as a statement was made FM #202 was not notified. The Administrator placed a call on 08/05/25 to inform FM #202 with no response. Awaiting response for second attempt.Interview on 08/19/25 at 9:26 A.M. of Family Member (FM) #202 revealed she was not notified about Resident #43's allegation that CNA #203 pinched her cheek on 08/04/25. FM #202 stated her Aunt visited Resident #43 on 08/05/25 and Resident #43 told her that CNA #203 hit her in the face. FM #202 indicated Resident #202's face was red, swollen, and pictures were taken. FM #202 stated the Administrator called her after she reported the incident to the Stage Agency and told her they did not observe swelling, bruising, or redness on Resident #43's face. FM #202 indicated CNA #203 was suspended pending the outcome of the investigation, but she was still working at the facility. FM #202 stated she requested that CNA #203 not take care of Resident #43 going forward, and Resident #43 was not comfortable with CNA #203 providing her care. FM #202 stated she told a nurse to call Resident #43's physician or nurse practitioner to make sure they were aware the incident happened.Interview on 08/19/25 at 12:19 P.M. of the Administrator revealed on 08/05/25, UM #200 was passing breakfast trays and Resident #43 told her CNA #203 pinched her cheek. UM #200 reported the allegation to the Administrator at about 9:30 A.M. LPN #205 was in the facility, was interviewed by UM #200, wrote a witness statement then left the facility. The Administrator stated she did not read LPN #205's witness statement until later, and after reading it she called LPN #205 and asked her if she reported the allegation to anyone. LPN #205 stated she told UM #200 about it on 08/05/25. The Administrator stated she told LPN #205 she should have immediately notified the Administrator or a Supervisor when she found out about the incident. The Administrator stated she had a long phone conversation with CNA #203 about the incident, and CNA #203 stated she did not touch Resident #43. CNA #203 was suspended pending the outcome of the investigation. The Administrator stated on 08/05/25, she did not see Resident #43, but UM #200 and SSD #204 interviewed her and did not observe an injury. Resident #43 continued with the story that CNA #203 pinched her cheek. Resident #43 was evaluated on 08/11/25 by a psychiatric nurse practitioner. The Administrator stated she called FM #202 on 08/05/25, left a message, but forgot to call her back on 08/06/25. On 08/06/25, the Receptionist told the Administrator that FM #202 was upset about Resident #43's cheek getting pinched, and FM #202 stated she was not notified this happened. The Administrator stated when she observed Resident #43 on 08/07/25, she did not have an injury. The Administrator stated she could not prove if CNA #203 pinched or did not pinch Resident #43's cheek. The Administrator indicated LPN #205 was off sick from work and when she returned on 08/22/25 she was escalating the Teachable Moment to a Verbal Write Up because she did not report the incident immediately.Interview on 08/19/25 at 12:55 P.M. of Resident #20 revealed she was in the smoking room on 08/04/25 at 7:00 P.M. when the incident between Resident #43 and CNA #203 occurred. Resident #20 stated Resident #43 asked CNA #203 for another cigarette and CNA #203 told her she already gave her one. Resident #43 called CNA #203 an expletive, CNA #203 touched Resident #43's face, it was real quick, then Resident #43 said it hurt and questioned why did you do that? Resident #20 stated it was a touch and Resident #43 cried out and said it hurt. Resident #20 stated from the angle she was sitting she could not see exactly what CNA #203 did to Resident #43 to cause her to yell out. Resident #20 indicated after this happened they were arguing and Resident #43 said she was going to get CNA #203 for hurting her and at that point CNA #203 walked away. Resident #43 did not say anything after CNA #203 walked away.Observation on 08/19/25 at 1:05 P.M. of Resident #43 revealed she was sitting by a table in the common area. Resident #43's left cheek was not swollen, bruised, or reddened. Resident #43 stated she was arguing with CNA #203 and CNA #203 pinched her face and twisted her fingers while pinching it. Resident #43 stated CNA #203 should not have done that, but they had no further issues the rest of the evening. Resident #43 stated she was not afraid, but she did not like CNA #203 and did not want her around her. Resident #43 stated if CNA #203 did it again she was going to punch her and then I will have a problem for protecting myself.Telephone interview on 08/19/25 at 3:07 P.M. of CNA #203 revealed on 08/04/25 at 7:00 P.M. it was smoke time, she shared the cigarettes and Resident #43 was sitting by the door and called her an expletive. CNA #203 stated she did not touch Resident #43's face, but put her hand up and said why would you call me an expletive? CNA #203 indicated Resident #43 apologized for calling her an expletive and she took care of her the rest of the night without issues. CNA #203 stated when she returned to work she was not assigned to the secured third floor where Resident #43 resided and had not cared for her since.Interview on 08/20/25 at 8:47 A.M. of the Administrator revealed when there was an abuse allegation she expected nurses to first protect the resident and make sure the resident was safe. After assuring resident safety the Administrator expected nurses to notify her immediately, assess the resident, and notify the residents nurse practitioner or physician of the allegation of abuse. The Administrator stated statements should be taken from the staff before they left the facility and families and social services should be notified. The Administrator confirmed Resident #43's medical record dated 08/04/25 at 7:00 P.M. through 08/07/25 at 4:11 P.M. did not have documentation regarding the abuse allegation. The Administrator confirmed Resident #43's medical record did not have evidence Resident #43 was assessed for face or cheek pain after the allegation of abuse was made. The Administrator confirmed Resident #43's medical record did not contain evidence FM #202 or Resident #43's physician or nurse practitioner was notified of the allegation that CNA #203 pinched her cheek. The Administrator stated the facility SRI contained all the documentation regarding the allegation of abuse and an assessment of Resident #43 for injury.Interview on 08/20/25 at 9:19 A.M. of UM #200 revealed on 08/05/25 she walked into Resident #43's room with her breakfast tray and Resident #43 stated we have a problem. Resident #43 told her on 08/04/24 during the 7:00 P.M. smoke break she called CNA #203 an expletive and CNA #203 touched her cheek and pinched her. UM #200 confirmed she did not see swelling, bruising on Resident #43's cheek and she denied pain. UM #200 stated she asked LPN #205 if she was aware of Resident #43's allegation that CNA #203 pinched her cheek. LPN #205 stated she knew about the allegation, and Resident #43 told her CNA #203 grabbed her face, but she did not see an injury. After speaking with LPN #205, UM #200 told the Administrator about the allegation and interviewed Resident #43 with SSD #204. Resident #43's story stayed the same, and throughout the day it changed from she pinched my cheek to she tried to kill me. UM #200 stated an investigation was completed and education given to the nurses about reporting abuse allegations immediately. UM #200 confirmed she wrote a witness statement, but did not document it in Resident #43's electronic medical record. UM #200 stated CNA #203 had not worked on the third floor secured unit since the incident occurred on 08/04/25.Review of the facility policy titled Abuse, Neglect, Misappropriation of Resident Property, Exploitation, and Mistreatment Policy dated 11/28/16 included it was the facility policy to investigate all allegations, suspicions, and incidents of abuse, neglect, exploitation, mistreatment, and the misappropriation of resident property, and report the results of any such investigation as required by law. Documentation in the nurses' notes should include the results of the resident's ROM (range of motion), body assessment, vital signs, the notification of the physician (if necessary) and the responsible party and treatment provided. The facility would ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property were reported immediately but not later than two hours after the allegation was made, if the events that cause the allegation involved abuse or resulted in serious bodily injury. This deficiency represents non-compliance investigated under Complaint Number 2585793.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a comprehensive investigation for Resident #43's allegation of staff-to-resident physical abuse was completed. This affected one resident (#43) out of three residents reviewed for abuse. The facility census was 89.Findings include: Review of Resident #43's medical record revealed an admission date of 06/04/24 and diagnoses included cardiac arrest, schizophrenia, and cognitive communication deficit.Review of Resident #43's care plan dated 12/05/24 included Resident #43 had the potential to demonstrate verbally abusive behaviors related to poor impulse control. Resident #43 would verbalize understanding of the need to control verbally abusive behavior. Interventions included to assess Resident #43's coping skills and support system; assess Resident #43's understanding of the situation and allow time for Resident #43 to express self and feelings towards the situation.Review of Resident #43's Minimum Data Set annual assessment dated [DATE] revealed Resident #43 had moderate cognitive impairment. Resident #43 had no impairment of her upper and lower extremities and did not use a cane or walker. Resident #43 required setup or clean-up assistance with toileting hygiene and oral hygiene, and supervision or touching assistance with bathing and dressing. Resident #43 had no physical or verbal behavioral symptoms over the seven day look back period. Resident #43 rejected evaluation or care four to six days over the seven day look back period.Review of Resident #43's medical record including progress notes and assessments dated 08/04/25 at 7:00 P.M. through 08/07/25 at 4:11 P.M. did not reveal evidence of Resident #43's statement that Certified Nursing Assistant (CNA) #203 grabbed her cheek and pinched it during the smoke break on 08/04/25 at 7:00 P.M. There was no evidence Resident #43's cheek was evaluated for pain, injury, bruising and swelling. There was no evidence Resident #43's physician, nurse practitioner, or family member was notified of the allegation. There was no evidence vital signs were checked or that Resident #43 was monitored after the allegation was made. Review of Resident #43's progress notes dated 08/04/25 at 7:00 P.M. through 08/11/25 at 11:20 A.M. did not reveal evidence Resident #43 was evaluated by a physician or nurse practitioner.Review of the facility Self Reported Incident Form dated 08/05/25 at 11:36 A.M. revealed on 08/04/25 at 7:00 P.M., an incident occurred in the smoke room. On 08/05/25, in the morning, Resident #43 stated to Unit Manager (UM) #200 that CNA #203 grabbed and pinched her cheek last night. CNA #203 was not on duty when the allegation was made. UM #200 noted no injury to Resident #43's jaw or cheek. The Administrator was notified of the allegation. The Administrator notified NP #201 immediately and no new orders were given. A message was left on Family Member (FM) #202's phone and CNA #203 was interviewed. Residents #20 and #28 were in the smoke room with Resident #43 and CNA #203 at the time of the incident and were interviewed. Other staff were interviewed. One resident (Resident #20) stated CNA #203 put her hand near Resident #43's face and one resident (Resident #28) did not remember anything happened. Resident #43 was monitored by UM #200 and the nursing staff during the week. FM #202 called the facility on 08/06/25 and stated she was not notified of the allegation. The Administrator called FM #202 and informed her a call was placed the morning of 08/05/25 and UM #200 left a message as well. FM #202 stated she did not receive the messages. FM #202 was informed of Resident #43's allegation, informed CNA #203 was suspended pending an investigation, and that no injury was noted by UM #200 or the charge nurse. The Administrator visited with Resident #43 on 08/07/25, discussed the investigation and CNA #203 was off the schedule during the investigation. Resident #43 stated several times she apologized to CNA #203 for calling her an expletive, and stated CNA #203 pinched her cheek. There was no edema or bruising noted to Resident #43's cheek. Resident #43 stated she was okay with CNA #203 continuing to work her unit and was happy she was suspended for a few days. As a result of the investigation, the facility educated CNA #203 for how to better handle a situation when she was called a name by a resident. Education was previously scheduled for 08/11/25 by the facility psychiatry service and topics included resident behaviors, mental illness, and de-escalation techniques. On 08/08/25, the Administrator requested the in-service also included how to manage reactions when being yelled at by residents or being called names. CNA #203 attended the in-service. CNA #203 was given a break from the behavioral unit and was scheduled to work on other nursing units. Psychiatric NP was notified of the incident and was asked to evaluate Resident #43 on 08/11/25. Due to no evidence that CNA #203 touched Resident #43, no injury was noted, and there was no intention to harm Resident #43, the facility could not determine if abuse occurred. Abuse was not suspected.Review of Resident #43's Allegation of Abuse or Neglect Checklist dated 08/05/25 included on 08/05/25 at 9:30 A.M., the staff member accused was removed from direct resident contact immediately. On 08/05/25 in the morning (time was not identified), UM #200 took Resident #43's statement. On 08/05/25 at 9:30 A.M., Nurse Practitioner (NP) #201 was notified and at approximately 11:00 A.M., Family Member (FM) #202 was notified via message of the allegation. On 08/06/25, the Administrator spoke with FM #202 regarding the allegation. Review of a witness statement dated 08/05/25 (no time identified) included while passing breakfast trays UM #200 walked into Resident #43's room to set up her breakfast tray when Resident #43 stated there was a problem. Resident #43 stated CNA #203 grabbed her left cheek and pinched it the night before. Resident #43 stated she called CNA #203 an expletive and that was why she believed CNA #203 grabbed her cheek. Resident #43 stated she felt safe in the facility, and had no visible marks or bruises noted at the time. Resident #43 stated the pain went away after awhile.Review of a witness phone interview on 08/05/25 (no time identified) included the Administrator immediately interviewed CNA #203 after the Administrator was informed of the situation. CNA #203 stated after dinner she was in the smoke room, she lit Resident #43's cigarette, and when she lit her cigarette Resident #43 said You are a [expletive]. CNA #203 stated she pointed her finger at Resident #43 and asked her why would you call me that. CNA #203 stated Resident #43 did not say anything else but apologized to her for calling her an expletive and they shared a hug. When asked if she touched Resident #43, CNA #203 stated, I never touched her, I did not grab her cheek. Interview on 08/05/25 at 9:00 A.M. of Resident #43 by Social Services Designee (SSD) #204 included Resident #43 was sitting on a chair in UM #200's office and appeared calm and carefree. Resident #43 was swinging her legs and appeared happy. Resident #43 engaged in conversation and made eye contact. Resident #43 stated she call CNA #203 an expletive while in the smoking room. Resident #43 stated after she called CNA #203 an expletive, CNA #203 reached across and grabbed her cheek. Resident #43 stated it was brief, then she exited the smoking room. Resident #43 stated she felt safe in the facility and her cheek was no longer sore.Review of Resident #20's Witness Statement Form dated 08/05/25 included while they were in the smoke room Resident #43 called CNA #203 an expletive, and CNA #203 walked up to Resident #43, put her hand next to her cheek and CNA #203 asked Resident #43 what she called her. Resident #43 hollered out that her cheek hurt. Resident #43 confirmed she called CNA #203 an expletive.Review of Licensed Practical Nurse (LPN) #205's Witness Statement Form dated 08/05/25 (no time identified) included last night (08/04/25) she was administering medications to the residents and Resident #43 asked her for Tylenol. When asked about her pain, Resident #43 stated my mouth and face hurts me. Resident #43 stated CNA #203 grabbed at her mouth after she called her an expletive. Resident #43 stated she squeezed it really hard and asked if her face was swollen. Resident #43 stated give me lots of Tylenol, she was going to tell UM #200 about the incident, and she can't do that to me. On 08/04/25 at 9:30 P.M., Resident #43 repeated what she said multiple times while her medication was administered. LPN #205 wrote a note that Resident #43 had minimal swelling of the left lower cheek and mouth area with a question mark next to it. Review of LPN #205's Teachable Moment via phone dated 08/05/25 in the morning (no time was identified) included LPN #205 did not immediately report a concern reported to her by Resident #43 of a staff member (CNA #203) pinching her cheek. All staff must immediately report any allegation of abuse, neglect, misappropriation or exploitation to the Administrator or Supervisor. LPN #205 voiced understanding.Review of an email sent on 08/07/25 at 4:44 P.M. from the Administrator to the Administrator. There was a handwritten note next to a picture of a phone call to FM #202 stating a call was placed to Resident #43's daughter (FM #202) and a message was left for her to call the facility. The picture had FM #202's phone number showing and the call was placed Tuesday, but there was no date showing Tuesday was 08/05/25.Review of a witness statement dated 08/07/25 (time not identified) written by UM #200 included a message was left for FM #202 to update her on a recent altercation on 08/07/25 as a statement was made FM #202 was not notified. The Administrator placed a call on 08/05/25 to inform FM #202 with no response. Awaiting response for second attempt.Interview on 08/19/25 at 9:26 A.M. of Family Member (FM) #202 revealed she was not notified about Resident #43's allegation that CNA #203 pinched her cheek on 08/04/25. FM #202 stated her Aunt visited Resident #43 on 08/05/25 and Resident #43 told her that CNA #203 hit her in the face. FM #202 indicated Resident #202's face was red, swollen, and pictures were taken. FM #202 stated the Administrator called her after she reported the incident to the Stage Agency and told her they did not observe swelling, bruising, or redness on Resident #43's face. FM #202 indicated CNA #203 was suspended pending the outcome of the investigation, but she was still working at the facility. FM #202 stated she requested that CNA #203 not take care of Resident #43 going forward, and Resident #43 was not comfortable with CNA #203 providing her care. FM #202 stated she told a nurse to call Resident #43's physician or nurse practitioner to make sure they were aware the incident happened.Interview on 08/19/25 at 12:19 P.M. of the Administrator revealed on 08/05/25, UM #200 was passing breakfast trays and Resident #43 told her CNA #203 pinched her cheek. UM #200 reported the allegation to the Administrator at about 9:30 A.M. LPN #205 was in the facility, was interviewed by UM #200, wrote a witness statement then left the facility. The Administrator stated she did not read LPN #205's witness statement until later, and after reading it she called LPN #205 and asked her if she reported the allegation to anyone. LPN #205 stated she told UM #200 about it on 08/05/25. The Administrator stated she told LPN #205 she should have immediately notified the Administrator or a Supervisor when she found out about the incident. The Administrator stated she had a long phone conversation with CNA #203 about the incident, and CNA #203 stated she did not touch Resident #43. CNA #203 was suspended pending the outcome of the investigation. The Administrator stated on 08/05/25, she did not see Resident #43, but UM #200 and SSD #204 interviewed her and did not observe an injury. Resident #43 continued with the story that CNA #203 pinched her cheek. Resident #43 was evaluated on 08/11/25 by a psychiatric nurse practitioner. The Administrator stated she called FM #202 on 08/05/25, left a message, but forgot to call her back on 08/06/25. On 08/06/25, the Receptionist told the Administrator that FM #202 was upset about Resident #43's cheek getting pinched, and FM #202 stated she was not notified this happened. The Administrator stated when she observed Resident #43 on 08/07/25, she did not have an injury. The Administrator stated she could not prove if CNA #203 pinched or did not pinch Resident #43's cheek. The Administrator indicated LPN #205 was off sick from work and when she returned on 08/22/25 she was escalating the Teachable Moment to a Verbal Write Up because she did not report the incident immediately.Interview on 08/19/25 at 12:55 P.M. of Resident #20 revealed she was in the smoking room on 08/04/25 at 7:00 P.M. when the incident between Resident #43 and CNA #203 occurred. Resident #20 stated Resident #43 asked CNA #203 for another cigarette and CNA #203 told her she already gave her one. Resident #43 called CNA #203 an expletive, CNA #203 touched Resident #43's face, it was real quick, then Resident #43 said it hurt and questioned why did you do that? Resident #20 stated it was a touch and Resident #43 cried out and said it hurt. Resident #20 stated from the angle she was sitting she could not see exactly what CNA #203 did to Resident #43 to cause her to yell out. Resident #20 indicated after this happened they were arguing and Resident #43 said she was going to get CNA #203 for hurting her and at that point CNA #203 walked away. Resident #43 did not say anything after CNA #203 walked away.Observation on 08/19/25 at 1:05 P.M. of Resident #43 revealed she was sitting by a table in the common area. Resident #43's left cheek was not swollen, bruised, or reddened. Resident #43 stated she was arguing with CNA #203 and CNA #203 pinched her face and twisted her fingers while pinching it. Resident #43 stated CNA #203 should not have done that, but they had no further issues the rest of the evening. Resident #43 stated she was not afraid, but she did not like CNA #203 and did not want her around her. Resident #43 stated if CNA #203 did it again she was going to punch her and then I will have a problem for protecting myself.Telephone interview on 08/19/25 at 3:07 P.M. of CNA #203 revealed on 08/04/25 at 7:00 P.M. it was smoke time, she shared the cigarettes and Resident #43 was sitting by the door and called her an expletive. CNA #203 stated she did not touch Resident #43's face, but put her hand up and said why would you call me an expletive? CNA #203 indicated Resident #43 apologized for calling her an expletive and she took care of her the rest of the night without issues. CNA #203 stated when she returned to work she was not assigned to the secured third floor where Resident #43 resided and had not cared for her since.Interview on 08/20/25 at 8:47 A.M. of the Administrator revealed when there was an abuse allegation she expected nurses to first protect the resident and make sure the resident was safe. After assuring resident safety the Administrator expected nurses to notify her immediately, assess the resident, and notify the residents nurse practitioner or physician of the allegation of abuse. The Administrator stated statements should be taken from the staff before they left the facility and families and social services should be notified. The Administrator confirmed Resident #43's medical record dated 08/04/25 at 7:00 P.M. through 08/07/25 at 4:11 P.M. did not have documentation regarding the abuse allegation. The Administrator confirmed Resident #43's medical record did not have evidence Resident #43 was assessed for face or cheek pain after the allegation of abuse was made. The Administrator confirmed Resident #43's medical record did not contain evidence FM #202 or Resident #43's physician or nurse practitioner was notified of the allegation that CNA #203 pinched her cheek. The Administrator stated the facility SRI contained all the documentation regarding the allegation of abuse and an assessment of Resident #43 for injury.Interview on 08/20/25 at 9:19 A.M. of UM #200 revealed on 08/05/25 she walked into Resident #43's room with her breakfast tray and Resident #43 stated we have a problem. Resident #43 told her on 08/04/24 during the 7:00 P.M. smoke break she called CNA #203 an expletive and CNA #203 touched her cheek and pinched her. UM #200 confirmed she did not see swelling, bruising on Resident #43's cheek and she denied pain. UM #200 stated she asked LPN #205 if she was aware of Resident #43's allegation that CNA #203 pinched her cheek. LPN #205 stated she knew about the allegation, and Resident #43 told her CNA #203 grabbed her face, but she did not see an injury. After speaking with LPN #205, UM #200 told the Administrator about the allegation and interviewed Resident #43 with SSD #204. Resident #43's story stayed the same, and throughout the day it changed from she pinched my cheek to she tried to kill me. UM #200 stated an investigation was completed and education given to the nurses about reporting abuse allegations immediately. UM #200 confirmed she wrote a witness statement, but did not document it in Resident #43's electronic medical record. UM #200 stated CNA #203 had not worked on the third floor secured unit since the incident occurred on 08/04/25.Review of the facility policy titled Abuse, Neglect, Misappropriation of Resident Property, Exploitation, and Mistreatment Policy dated 11/28/16 included it was the facility policy to investigate all allegations, suspicions, and incidents of abuse, neglect, exploitation, mistreatment, and the misappropriation of resident property, and report the results of any such investigation as required by law. Documentation in the nurses' notes should include the results of the resident's ROM (range of motion), body assessment, vital signs, the notification of the physician (if necessary) and the responsible party and treatment provided. The facility would ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property were reported immediately but not later than two hours after the allegation was made, if the events that cause the allegation involved abuse or resulted in serious bodily injury. This deficiency represents non-compliance investigated under Complaint Number 2585793.

Based on observation, interview, and record review, the facility failed to ensure Resident #43 was administered medication per physician order and that medication was accurately documented in the medical record. This affected one resident (#43) out of one resident reviewed for medication administration. The facility census was 89.Findings include: Review of Resident #43's medical record revealed an admission date of 06/04/24 and diagnoses included cardiac arrest, schizophrenia, and cognitive communication deficit.Review of Resident #43's care plan dated 08/21/24 included Resident #43 had the potential for pain related to falls. Resident #43 would voice adequate relief of pain or the ability to cope with incompletely-relieved pain through the review date. Interventions included to administer analgesia medications per orders, give one-half hour before treatments or care, anticipate the need for pain relief, and respond timely to any complaint of pain.Review of Resident #43's Minimum Data Set annual assessment dated [DATE] revealed Resident #43 had moderate cognitive impairment. Resident #43 had no impairment of her upper and lower extremities and did not use a cane or walker. Resident #43 required setup or clean-up assistance with toileting hygiene and oral hygiene, and supervision or touching assistance with bathing and dressing. Resident #43 had no physical or verbal behavioral symptoms over the seven day look back period. Resident #43 rejected evaluation or care four to six days over the seven day look back period.Review of Resident #43's physician orders dated 08/01/25 through 08/20/25 did not reveal orders for Tylenol (an over the counter mild pain reliever and fever reducer).Review of Resident #43's Medication Administration Record (MAR) dated 08/01/25 through 08/20/25 did not reveal Resident #43 was administered Tylenol for pain. Further review did not reveal non-pharmacological interventions were attempted for pain.Review of Resident #43's medical record including progress notes and assessments dated 08/04/25 at 7:00 P.M. through 08/07/25 at 4:11 P.M. did not reveal evidence of Resident #43's statement that CNA #203 grabbed her cheek and pinched it during the smoke break on 08/04/25 at 7:00 P.M. There was no evidence Resident #43's cheek was evaluated for pain, injury, bruising and swelling. There was no evidence Resident #43's physician, nurse practitioner, or family member was notified of the allegation. There was no evidence vital signs were checked or Resident #43 was monitored after the allegation was made. Review of the facility Self Reported Incident Form dated 08/05/25 at 11:36 A.M. revealed on 08/04/25 at 7:00 P.M., an incident occurred in the smoke room. On 08/05/25, in the morning, Resident #43 stated to Unit Manager (UM) #200 that CNA #203 grabbed and pinched her cheek last night. CNA #203 was not on duty when the allegation was made. UM #200 noted no injury to Resident #43's jaw or cheek. The Administrator was notified of the allegation. The Administrator notified NP #201 immediately and no new orders were given. A message was left on Family Member (FM) #202's phone and CNA #203 was interviewed. Residents #20 and #28 were in the smoke room with Resident #43 and CNA #203 at the time of the incident and were interviewed. Other staff were interviewed. One resident (Resident #20) stated CNA #203 put her hand near Resident #43's face and one resident (Resident #28) did not remember anything happened. Resident #43 was monitored by UM #200 and the nursing staff during the week. FM #202 called the facility on 08/06/25 and stated she was not notified of the allegation. The Administrator called FM #202 and informed her a call was placed the morning of 08/05/25 and UM #200 left a message as well. FM #202 stated she did not receive the messages. FM #202 was informed of Resident #43's allegation, informed CNA #203 was suspended pending an investigation, and that no injury was noted by UM #200 or the charge nurse. The Administrator visited with Resident #43 on 08/07/25, discussed the investigation and CNA #203 was off the schedule during the investigation. Resident #43 stated several times she apologized to CNA #203 for calling her an expletive, and stated CNA #203 pinched her cheek. There was no edema or bruising noted to Resident #43's cheek. Resident #43 stated she was okay with CNA #203 continuing to work her unit and was happy she was suspended for a few days. As a result of the investigation, the facility educated CNA #203 for how to better handle a situation when she was called a name by a resident. Education was previously scheduled for 08/11/25 by the facility psychiatry service and topics included resident behaviors, mental illness, and de-escalation techniques. On 08/08/25, the Administrator requested the in-service also included how to manage reactions when being yelled at by residents or being called names. CNA #203 attended the in-service. CNA #203 was given a break from the behavioral unit and was scheduled to work on other nursing units. Psychiatric NP was notified of the incident and was asked to evaluate Resident #43 on 08/11/25. Due to no evidence that CNA #203 touched Resident #43, no injury was noted, and there was no intention to harm Resident #43, the facility could not determine if abuse occurred. Abuse was not suspected.Review of a witness statement dated 08/05/25 (no time identified) included while passing breakfast trays UM #200 walked into Resident #43's room to set up her breakfast tray when Resident #43 stated there was a problem. Resident #43 stated CNA #203 grabbed her left cheek and pinched it the night before. Resident #43 stated she called CNA #203 an expletive and that was why she believed CNA #203 grabbed her cheek. Resident #43 stated she felt safe in the facility, and had no visible marks or bruises noted at the time. Resident #43 stated the pain went away after awhile.Review of a witness phone interview on 08/05/25 (no time identified) included the Administrator immediately interviewed CNA #203 after the Administrator was informed of the situation. CNA #203 stated after dinner she was in the smoke room, she lit Resident #43's cigarette, and when she lit her cigarette Resident #43 said You are a [expletive]. CNA #203 stated she pointed her finger at Resident #43 and asked her why would you call me that. CNA #203 stated Resident #43 did not say anything else but apologized to her for calling her an expletive and they shared a hug. When asked if she touched Resident #43, CNA #203 stated, I never touched her, I did not grab her cheek. Interview on 08/05/25 at 9:00 A.M. of Resident #43 by Social Services Designee (SSD) #204 included Resident #43 was sitting on a chair in UM #200's office and appeared calm and carefree. Resident #43 was swinging her legs and appeared happy. Resident #43 engaged in conversation and made eye contact. Resident #43 stated she call CNA #203 an expletive while in the smoking room. Resident #43 stated after she called CNA #203 an expletive, CNA #203 reached across and grabbed her cheek. Resident #43 stated it was brief, then she exited the smoking room. Resident #43 stated she felt safe in the facility and her cheek was no longer sore.Review of Resident #20's Witness Statement Form dated 08/05/25 included while they were in the smoke room Resident #43 called CNA #203 an expletive, and CNA #203 walked up to Resident #43, put her hand next to her cheek and CNA #203 asked Resident #43 what she called her. Resident #43 hollered out that her cheek hurt. Resident #43 confirmed she called CNA #203 an expletive.Review of Licensed Practical Nurse (LPN) #205's Witness Statement Form dated 08/05/25 (no time identified) included last night (08/04/25) she was administering medications to the residents and Resident #43 asked her for Tylenol. When asked about her pain, Resident #43 stated my mouth and face hurts me. Resident #43 stated CNA #203 grabbed at her mouth after she called her an expletive. Resident #43 stated she squeezed it really hard and asked if her face was swollen. Resident #43 stated give me lots of Tylenol, she was going to tell UM #200 about the incident, and she can't do that to me. On 08/04/25 at 9:30 P.M., Resident #43 repeated what she said multiple times while her medication was administered. LPN #205 wrote a note that Resident #43 had minimal swelling of the left lower cheek and mouth area with a question mark next to it. Interview on 08/19/25 at 11:29 A.M. of the Director of Nursing (DON) confirmed Resident #43's MAR dated 08/04/25 through 08/20/25 did not reveal evidence LPN #205 administered Tylenol for complaints of cheek and face pain. The DON confirmed LPN #205 did not document a pain level for Resident #43's complaints of face and cheek pain from being pinched.Interview on 08/19/25 at 12:55 P.M. of Resident #20 revealed she was in the smoking room on 08/04/25 at 7:00 P.M. when the incident between Resident #43 and CNA #203 occurred. Resident #20 stated Resident #43 asked CNA #203 for another cigarette and CNA #203 told her she already gave her one. Resident #43 called CNA #203 an expletive, CNA #203 touched Resident #43's face, it was real quick, then Resident #43 said it hurt and questioned why did you do that? Resident #20 stated it was a touch and Resident #43 cried out and said it hurt. Resident #20 stated from the angle she was sitting she could not see exactly what CNA #203 did to Resident #43 to cause her to yell out. Resident #20 indicated after this happened they were arguing and Resident #43 said she was going to get CNA #203 for hurting her and at that point CNA #203 walked away. Resident #43 did not say anything after CNA #203 walked away.Observation on 08/19/25 at 1:05 P.M. of Resident #43 revealed she was sitting by a table in the common area. Resident #43's left cheek was not swollen, bruised or reddened. Resident #43 stated she was arguing with CNA #203 and CNA #203 pinched her face and twisted her fingers while pinching it. Resident #43 stated CNA #203 should not have done that, but they had no further issues the rest of the evening. Resident #43 stated she was not afraid, but she did not like CNA #203 and did not want her around her. Resident #43 stated if CNA #203 did it again she was going to punch her and then I will have a problem for protecting myself.Interview on 08/20/25 at 8:47 A.M. of the Administrator revealed when there was an abuse allegation she expected nurses to first protect the resident and make sure the resident was safe. After assuring resident safety the Administrator expected nurses to notify her immediately, assess the resident, and notify the residents Nurse Practitioner or Physician of the allegation of abuse. The Administrator stated statements should be taken from the staff before they left the facility and families and social services should be notified. The Administrator confirmed Resident #43's medical record dated 08/04/25 at 7:00 P.M. through 08/07/25 at 4:11 P.M. did not have documentation regarding the abuse allegation. The Administrator confirmed Resident #43's medical record did not have evidence Resident #43 was assessed for pain, injury or was monitored after the allegation of abuse was made. The Administrator confirmed Resident #43's medical record did not contain evidence FM #202 or Resident #43's Physician or Nurse Practitioner was notified of the allegation that CNA #203 pinched her cheek. The Administrator stated the facility SRI contained all the documentation regarding the allegation of abuse and an assessment of Resident #43 for injury.Interview on 08/20/25 at 11:02 A.M. of the DON revealed Resident #43 did not have a physician order for Tylenol. The DON stated LPN #205 should have contacted Resident #43's physician when she complained of pain on 08/04/25. The DON confirmed there was no reconciliation that Resident #43 received Tylenol as stated in the witness statement.This deficiency represents non-compliance investigated under Complaint Number 2585793.

Based on interview, record review and review of the facility policy the facility failed to ensure Resident #102's wound treatment orders were updated after a physician appointment. This affected one resident (Resident #102) out of three resident reviewed for treatment orders. The facility census was 91. Findings include: Review of Resident #102's Referral Information Form for a long term acute care facility stay from 07/16/24 through 08/12/24 included Resident #102 had a Stage IV Pressure ulcer (a full-thickness tissue loss that exposes bone, tendon, or muscle). Review of Resident #102's medical record revealed an admitted [DATE] and diagnoses included other injury of unspecified body region, human immunodeficiency virus, dementia, and neuromuscular dysfunction of the bladder. Resident #102 was transported to the hospital on 09/06/24 and discharged from the facility on 09/18/24. Review of Resident #102's Weekly Wound Data Collection dated 08/13/24 included Resident #102 had a Stage IV left buttock pressure wound and measurements were length was 11.5 cm, width 3.0 cm, depth 1.5 cm., undermining was present. Review of Resident #102's physician orders dated 08/13/24 revealed wet-to-dry dressing twice a day and as needed when the wound vac was malfunctioning, every twelve hours as needed. Review of Resident #102's Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #102 was cognitively intact. Resident #102 was dependent for toileting and personal hygiene, bathing, and chair, bed-to-chair transfer. Resident #102 required substantial to maximal assistance for rolling left and right, sit to lying and lying to sitting on the side of the bed. Resident #102 had an indwelling catheter and her bowel continence was not rated. Review of Resident #102's physician orders dated 08/19/24 revealed Resident #102's FMS (fecal management system) was discontinued. Review of Resident #102's physician orders dated 08/19/24 revealed left upper buttock abrasion, cleanse with normal saline, pat dry, cover with wound vac dressing Monday, Wednesday, Friday and as needed, every day shift. Review of Resident #102's physician orders dated 08/19/24 revealed right gluteal fold, cleanse with normal saline, pat dry, apply alginate, cover with bordered dressing daily and as needed, every day shift. Review of Resident #102's physician orders dated 08/19/24 revealed left buttock wound, apply wound vac at 125 mmHg (millimeters of mercury) Monday, Wednesday, Friday and as needed, every day shift. Review of Resident #102's Trauma Clinic Progress Note Assessment and Plan of Care dated 08/29/24 included wound care and to change order to medial wound. Please replace vacuum on the deepest most medial portion of the wound. As the wound moved out laterally it became superficial and areas of the sponge were covering healthy skin. For the lateral areas please use a wet to dry dressing to keep the new tissue moist. Take daily showers, sponge bath as needed but able to wash wounds in shower with gentle soap and water when the wound vac was off. Allow warm soapy water to wash over the wound, do not scrub at the wound, when out of the shower gently pat the surrounding areas. Do not apply lotions, ointments or creams, avoid soaking in bodies of water until wound was completely healed. Packing the wound, lateral wound, after the shower take Kerlix, moisten with sterile saline and insert it into the opening. Please do not cover healthy skin. The Kerlix should be moist, not soaking wet, please make sure to wring it out, cover the packed area with an abdominal pad and tape. Review of Resident #102's progress notes, physician orders and Treatment Administration Record did not reveal evidence Resident #102's wound treatment orders dated 08/29/24 were followed. Review of Resident #102's care plan dated 09/12/24 (Resident #102 was admitted [DATE]) included Resident #102 had bowel incontinence related to wounds and had a fecal management system. Resident #102 would be continent during daytime through the review date. Interventions included check Resident #102 and assist with toileting as needed. Resident #102 had the potential for skin breakdown, pressure ulcer development related to incontinence, immobility. Resident #102 had a left buttock, hip Stage IV pressure ulcer. Resident #102's pressure ulcer would show signs of healing and remain free from infection through the review date. Interventions included follow facility policies, protocols for the prevention, treatment of skin breakdown; obtain and monitor labs, diagnostic work as ordered. Report results to physician and follow up as indicated. Interview on 10/02/24 at 8:45 A.M. of Licensed Practical Nurse (LPN) #206 revealed when a resident returned from an appointment with new orders the nurse on the floor should review the orders. LPN #206 stated but most of the time the floor nurses were too busy to review the orders, and the orders should be reviewed by the Unit Managers, but that did not always happen. LPN #206 stated she did not know anything about Resident #102's new treatment orders from 08/29/24. Interview on 10/02/24 at 8:57 A.M. of the Director of Nursing (DON) revealed the nurse on the cart was responsible to review orders when a resident returned from an appointment, and if that nurse was too busy then the Unit Manager should review the orders. The DON stated he was ultimately responsible for everything. The DON confirmed Resident #102's new wound treatment orders from 08/29/24 were not updated in Resident #102's medical record. Review of the facility policy titled Wound Care revised 10/2010 included the purpose of the procedure was to provide guidelines for the care of wounds to promote healing. Verify there is a physician's order for the procedure. This deficiency represents non-compliance investigated under Complaint Number OH00157592.

Based on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #29 and #102's specimens were collected and sent to the lab timely to timely treat infections. This affected two residents (Resident's #29 and #102) out of three residents reviewed for specimen collection. The facility census was 91. Findings include: 1. Review of Resident #102's Referral Information Form for a long term acute care facility stay from [DATE] through [DATE] included Resident #102 had a Stage IV Pressure ulcer. Review of Resident #102's medical record revealed an admitted [DATE] and diagnoses included other injury of unspecified body region, human immunodeficiency virus, dementia, and neuromuscular dysfunction of the bladder. Resident #102 was transported to the hospital on [DATE] and discharged from the facility on [DATE]. Review of Resident #102's Weekly Wound Data Collection dated [DATE] included Resident #102 had a Stage IV left buttock pressure wound and measurements were length was 11.5 cm, width 3.0 cm, depth 1.5 cm., undermining was present. Review of Resident #102's Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #102 was cognitively intact. Resident #102 was dependent for toileting and personal hygiene, bathing, and chair, bed-to-chair transfer. Resident #102 required substantial to maximal assistance for rolling left and right, sit to lying and lying to sitting on the side of the bed. Resident #102 had an indwelling catheter and her bowel continence was not rated. Review of Resident #102's physician orders dated [DATE] revealed Resident #102's FMS (fecal management system) was discontinued. Review of Resident #102's physician orders dated [DATE] through [DATE] did not reveal orders for a sacrum wound culture. Review of Resident #102's physician orders dated [DATE] revealed send stool for culture, per CNP (Certified Nurse Practitioner) #200, rule out C-Diff (clostridium difficile), one time only for culture for one day. Review of Resident #102's lab orders dated [DATE] at 1:25 P.M. included Licensed Practical Nurse (LPN) #202 created the lab order and the specimen was for stool culture, comprehensive. There was no documentation the specimen was rule out C-Diff. Further review of Resident #102's lab orders dated [DATE] at 2:09 A.M. created by LPN #201 revealed sacrum wound culture. Review of Resident #102's physician progress dated [DATE] note written by Certified Nurse Practitioner (CNP) #200 included Resident #102 seen as follow up with large sacral wound, now developing fevers, will send for wound culture. Obtain x-ray to rule out osteomyelitis and start Vancomycin and Zosyn. Review of Resident #102's physician telephone orders dated [DATE] revealed CNP #200 gave a telephone order to re-obtain wound culture. Review of Resident #102's lab report for wound culture of the sacrum (there was no initial physician order in Resident #102's electronic record for a wound culture of the sacrum) stated the specimen was collected on [DATE], the time was unknown and the wound culture was reported on [DATE] at 12:03 P.M. the report included Resident #102's stool culture was not collected, an unidentified nurse was notified and to see requisition. Review of Resident #102's lab requisition dated [DATE] at 4:18 A.M. revealed Licensed Practical Nurse (LPN) #201's name was printed on the lab report in the lab use only area, but there were no details regarding Resident #102's stool specimen. Further review of the lab requisition revealed the specimens were a sacrum wound culture, and a comprehensive stool culture (there was no evidence the specimen was rule out C-Diff). The stool culture had CBM ([NAME] media) written next to it. Review of Resident #102's lab report for stool culture included the specimen was collected on [DATE], time unknown and reported on [DATE]. The specimen was in the wrong container for a stool culture, and to send the stool culture in a CBM container. Stool cultures required a CBM container. The report stated to see requisition for notified nurse's name. Resident #102 was in the hospital. Review of the lab requirement for a comprehensive stool culture included the specimen needed to be placed in a CBM container. Review of Resident #102's care plan dated [DATE] (Resident #102 was admitted [DATE]) included Resident #102 had bowel incontinence related to wounds and had a fecal management system. Resident #102 would be continent during daytime through the review date. Interventions included check Resident #102 and assist with toileting as needed. Resident #102 had the potential for skin breakdown, pressure ulcer development related to incontinence, immobility. Resident #102 had a left buttock, hip Stage IV pressure ulcer. Resident #102's pressure ulcer would show signs of healing and remain free from infection through the review date. Interventions included follow facility policies, protocols for the prevention, treatment of skin breakdown; obtain and monitor labs, diagnostic work as ordered. Report results to physician and follow up as indicated. Interview on [DATE] at 12:09 P.M. of Quality Administrator (QA) #203 revealed the lab was able to input results directly into the residents electronic record, and also faxed results to the facility. QA #203 stated she was not sure who was responsible to make sure all results were returned to the facility, but it was probably the Director of Nursing (DON) and the Unit Managers. Interview on [DATE] at 12:24 P.M. of Registered Nurse/Unit Manager (RN/UM) #204 revealed the lab faxed notifications regarding each resident and the specimen they had ordered, and the floor nurses or Unit Managers check for faxes several times a day. RN/UM #204 stated the Nurse Practitioners could also check the results and they mark it as reviewed and that was another way to check to make sure lab results were returned and reviewed by the physician. RN/UM #204 stated the facility had issues with the current lab company and were soon switching to another lab company. Interview on [DATE] at 2:37 P.M. of State tested Nursing Assistant (STNA) #205 revealed Resident #102 had a lot of diarrhea at times, her wound got worse and she did not look good the last time she took care of her. Interview on [DATE] at 3:25 P.M. of CNP #200 revealed Resident #102 had an indwelling catheter and a rectal tube which a family member dislodged when they were transporting her outside. CNP #200 stated she discontinued the rectal tube because Resident #102 did not have the rectal tone to have keep the rectal tube in place. CNP #200 stated Resident #102 had diarrhea and a stool culture for C-Diff was ordered, and a sacrum wound culture was also ordered. CNP #200 stated a wound swab was sent out but it was expired and the facility had to find an unexpired swab and a second specimen was sent out. CNP #200 Resident #102 was started on [DATE] on broad spectrum antibiotics because it had already been a couple days, and the results from the second swab were not back yet and Resident #102 became very sick. CNP #200 stated Resident #102 was sent to the hospital on [DATE] because she had a critically low hemoglobin. CNP #200 stated she was upset about the culture taking so long because she wanted to know what I was treating. CNP #200 indicated the facility tried to get swabs from a second facility and their swabs were expired too, but a specimen was finally sent. CNP #200 stated she did not know when Resident #102's stool culture went out or what the results were. Interview on [DATE] at 3:51 P.M. of the Administrator, the Director of Nursing (DON) and QA #203 revealed the facility had ongoing issues with the current lab, culture swabs were outdated, and culture swabs from a second facility were outdated, the liason from the lab could not find unexpired culture swabs. The Administrator stated QA #203 drove to a sister facility and found unexpired swabs and the specimens were then able to be sent out to the lab via the DON who drove the culture swabs to the lab. The DON stated Resident #29 also had orders for a wound culture and an expired culture swab was used for the culture and sent to the lab, and the lab notified the facility the swab was expired and the culture could not be processed. The DON stated the culture swab should have been checked before it was used, but the lab was responsible to send out culture swabs which were not expired. Interview on [DATE] at 4:32 P.M. of RN/UM #204 revealed the lab did not call about having the wrong container for the stool specimen. Interview on [DATE] at 10:08 A.M. of RN/UM #204 and QA #203 revealed she wanted to clarify Resident #102's wound culture order. RN/UM #204 stated she reviewed her text messages from CNP #200 and found she took a verbal order on [DATE] at 1:00 P.M. to obtain a sacrum wound culture for Resident #102, and this was what prompted CNP #200 to order Vancomycin and Zosyn intravenous. RN/UM #204 stated she forgot to put the verbal order for a sacrum wound culture in the electronic physician orders. RN/UM #204 stated she did not know why there was an order on [DATE] to re-obtain Resident #102's wound culture because it had already been collected and went out on [DATE]. RN/UM #204 confirmed the lab had [DATE] as the date it was collected, but no time was noted. RN/UM #204 and QA #203 stated Resident #102's stool specimen was not placed in the lab system as a stool culture to rule out C-Diff, it was entered in the lab system as a comprehensive stool culture which needed a CBM container. QA #203 stated a specimen for C-Diff did not need a CBM container, but Resident #102's stool specimen was not correctly entered in the lab system by the nurse and the lab did not accept the specimen. 2. Review of Resident #29's medical record revealed an admitted [DATE] and diagnoses included subacute osteomyelitis, left ankle and foot, infection following a procedure, type two diabetes mellitus with hyperglycemia and diabetic peripheral angiopathy without gangrene. Review of Resident #29's Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #29 was cognitively intact. Resident #29 required supervision or touching assistance for toileting, bathing and personal hygiene. Resident #29 required partial to moderate assistance for mobility. Review of Resident #29's physician orders dated [DATE] at 9:01 P.M. revealed obtain wound culture related to odor, one time only for monitoring for three days. Review of Resident #29's lab report dated [DATE] revealed an unknown collection time and Resident #29's specimen was received on [DATE] at 9:28 A.M. Resident #29's wound transport swab was expired on [DATE] and the sample was not viable. Review of Resident #29's lab report dated [DATE] revealed an unknown collection time and was received on [DATE] at 7:29 A.M. The report stated Resident #29's wound transport swab was expired on [DATE]. The lab was unable to accept the specimen due to sample integrity. Review of Resident #29's progress notes dated [DATE] at 2:21 P.M. included wound culture obtained and expiration date was ,d+[DATE]. Resident #29 was sleeping and when nurse explained and attempted to remove the dressing to expose area to be cultured Resident #29 stated her dressing was just completed by the floor nurse and I really don't want it touched until 4:00 P.M. when I can have my oxy again. Resident #29 indicated she understood the culture would be delayed. The DON and CNP #200 aware. Review of Resident #29's lab report dated [DATE] revealed the collection time was 2:30 P.M., it was received on [DATE] at 3:21 P.M. The report stated the specimen was missing the DOB (date of birth) on the wound transport swab, given [DATE] on label. The specimen was received without two patient identifiers on the specimen container Received affidavit from the DON verifying Resident #29's birth date was [DATE]. Review of Resident #29's care plan dated [DATE] included Resident #29 had actual impairment to skin integrity related to surgical wound right stump amputation. Resident #29 would have no complications with skin through the review date. Interventions included to obtain bloodwork, blood cultures and C&S (culture and sensitivity) of open wounds as ordered by the physician. Observation on [DATE] at 8:55 A.M. revealed Resident #29 sitting in a wheelchair in the common area. Resident #29 expressed no concerns. Interview on [DATE] at 3:25 P.M. of CNP #200 stated a wound swab was sent out but it was expired and the facility had to find an unexpired swab and a second specimen was sent out. CNP #200 stated she was upset about the culture taking so long because she wanted to know what I was treating. CNP #200 indicated the facility tried to get swabs from a second facility and their swabs were expired too, but a specimen was finally sent. Interview on [DATE] at 1:27 P.M. of QA #203 and the DON revealed Resident #29's culture swab was expired, and CNP #200 brought a culture swab from another facility and it was expired. QA #203 stated she called the lab, but the lab could not find unexpired culture swabs. QA #203 stated she drove to a sister facility, picked up an unexpired swab, brought it back to the facility, and Resident #29's wound was cultured. The DON stated after the wound culture was completed he drove the specimen to the lab and dropped it off, but the specimen did not have Resident #29's birthday on it, he sent an affidavit to the lab and the lab was then able to process the specimen. The DON stated CNP #200 ordered antibiotics on [DATE] for Resident #29 because she said she wanted to get some broad spectrum antibiotics going. Review of the facility policy titled Lab and Diagnostic Test Results Clinical Protocol dated ,d+[DATE] included physicians or nurses who had concerns about how test results have been handled or reported should communicate such concerns to the DON and, or the Medical Director. Such concerns or disagreements should not prevent timely, clinically appropriate management of a current result or clinical situation. This deficiency represents non-compliance investigated under Complaint Number OH00157592.

Based on observations and interviews the facility failed to ensure the smoking area was maintained in a clean and safe manner. This had the potential to affect all residents. The facility census was 84. Findings include: Observation during the tour of the smoking area located outside of Building B with Staff Aide (SA) #880 on 03/21/23 between 2:40 P.M. and 2:50 P.M. revealed a smoking area was not maintained properly. There were numerous cigarette butts located on the ground and grass-covered area, and not in the designated cans. Interview with SA #880 on 03/21/23 at 2:48 P.M. verified the condition of the smoking area. Observation during tour of the facility with the Maintenance Staff (MS) #861 and #867 on 03/22/23 between 1:00 P.M. and 1:30 P.M. revealed two trash bins with numerous cigarette butts and different types of paper products. Interview with MS #861 and #867 on 03/22/23 verified the condition of the trash bins at the time of the facility tour. Review of the facility document titled Westpark Environmental Services- General Policy undated, revealed the facility had a policy in place to maintain a clean and safe environment to ensure the daily upkeep of the facility to promote a pleasant, clean, odor free and safe environment. Review of the facility document revealed the facility did not implement the policy.

Based on observation and staff interview, the facility failed to ensure food was stored properly. This had the potential to affect 80 residents who the facility identified ate food from the kitchen. Residents #2, #59, #61, and #67 were identified as receiving tube feed with Nothing-By-Mouth (NPO) and received no food prepared from the kitchen. The facility census was 84. Findings include: An initial kitchen tour was conducted on 03/20/23 between 8:47 A.M. and 9:22 A.M. with Dietary Manager (DM) #886. The following was observed and verified at the time of observation. Observation of both the the walk-in cooler and walk-in freezer, revealed a box of sausage patties, a box of sliced bacon, a bag of chicken breast filets, and a bag of fried eggs observed open to air and undated. Review of the facility document titled Refrigerated/Frozen Storage revised 10/06/13, revealed the facility had a policy in place that food stored under refrigeration/freezer storage would be maintained in a safe and sanitary manner to prevent damage, spoilage, and contamination of products. Review of the document revealed the facility did not implement the policy.

Based on interview and record review the facility failed to notify the guardian of transfer to the emergency room . This affected one Resident (Resident #16) of one reviewed for change of condition. The facility census was 84. Findings include: Review of the medical record for the Resident #16 revealed an admitted [DATE]. Diagnoses include paranoid schizophrenia, major depressive disorder, anxiety, and chronic obstructive pulmonary disease (COPD). Review of the care plan dated 08/17/22 revealed a plan for alternation in mood and behavior related to diagnoses of paranoid schizophrenia, major depressive disorder, and anxiety. The Resident exhibits behavior of noncompliance with medication, care needs, verbal and physical aggression, explosive outburst over smoking, impulsive and accusatory behaviors, delusional beliefs, and distorted thought pattern. Interventions included to provide activities for increased socialization and participation. Allow resident to make choices and speak in a calm manor. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed the Resident #16 had impaired cognition and wandering behaviors. Review of the progress notes dated 03/12/23 at 7:21 P.M. Resident #16 was refusing to leave the smoking room. Resident #16 struck the nurse causing her to fall and then struck her with a close fist in the back of the head. The resident remained in the room and all smoking materials were removed. The Certified Nurse Practitioner (CNP) was notified and gave an order to send to the emergency room for a psychological evaluation. There was no evidence of notification to Resident #16's Guardian. Interview on 03/22/23 at 1:59 P.M. with the Assistant Director of Nursing (ADON) #872 stated the was no evidence of Resident #16's guardian was notified of the behavior or transfer to the emergency room . Interview 03/23/23 2:04 P.M. with Licensed Practical Nurse #809, the nurse on duty at the time of the incident, stated she was not sure if Resident #16's Guardian was contacted for the behavior or transfer to the emergency room . Review of the facility's policy titled Change in Condition, revised December 2016 stated the nurse will notify the resident's representative when: a. The resident is involved in any accident or incident that results in an injury or unknown source. b. There is a significant change in the resident's physical, mental, or psychosocial status. c. There is a need to change the resident's room assignment. d. A decision has been made to discharge the resident from the facility. e. It is necessary to transfer the resident to a hospital/treatment center. This deficiency was an incidental finding to OH 00141314.

Based on medical record review and staff interview, the facility failed to notify the state mental health agency after Resident #79's significant mental health change and admission to a psychiatric hospital. This affected one of one resident reviewed for Pre-Admission Screening and Resident Review (PAS-RR.) The census was 84. Findings include: Resident #79 was admitted to the facility on [DATE]. Her diagnoses included major depressive disorder, bipolar disorder, and cognitive communication deficit. Her Brief Interview for Mental Status (BIMS) score was 13, which indicated she was cognitively intact. This assessment was completed on 03/02/23. Review of Resident #79's medical records revealed on 03/03/23 at 12:01 P.M. staff reported the resident was presenting with suicidal ideation. The Certified Nurse Practitioner (CNP) was notified, and Resident #79 was placed on 15 minute checks and an immediate appointment was made with facility psychiatric services via Telehealth. At 4:00 P.M., after three attempts to start the Telehealth appointment, Resident #79 stated I just want to cut my throat and watch myself bleed out. The CNP was made aware, and she ordered the 15 minute checks to continue and for Resident #79 be transported to the local psychiatric hospital. At 5:16 P.M. Resident #79 was transported via ambulance to the local psychiatric hospital. At 9:38 P.M. the hospital intake worker called with a few questions regarding Resident #79's baseline behavior. Review of Resident #79's medical record revealed on 03/04/23 at 2:18 P.M. the resident returned to the facility by ambulance. Resident #79 had new orders and a follow up appointment to be scheduled. Further review of Resident #79's medical records revealed no new PAS-RR was initiated after the residents readmission from the psychiatric hospital. Interview with Licensed Social Worker (LSW) #875 on 03/22/23 at 2:32 P.M. confirmed she had not initiated a new PAS-RR for Resident #79.

Based on interview and record review the facility failed to monitor and conduct on going assessments for dialysis Resident #55. This affected one Resident (Resident #55) of one reviewed for dialysis. The facility census was 84. Findings include: Review of the medical record for the Resident #55 revealed an admitted [DATE]. Diagnoses include end stage renal disease, chronic kidney disease, heart failure and colon cancer. Review of the care plan dated 10/21/22 revealed a plan for dialysis related to end stage renal disease. Intervention included to check and change dressing daily at the access site, to observe signs and symptoms of renal insufficiency, obtain vital signs and weight per protocol and report any significant changes. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #55 had intact cognition, receives a therapeutic diet, and attends dialysis. Review of the March 2023 physicians' orders revealed an order for dialysis on Monday, Wednesday, and Friday. There were no additional dialysis orders. Review of the medical record revealed no evidence of pre or post dialysis assessments or communication forms that accompanied the resident. There was no evidence of monitoring of the arteriovenous (AV) fistula a port and ensuring the dressing site was intact. Interview on 03/22/23 at 1:59 P.M. with Assistant Director of Nursing (ADON) #872 at 1:59 P.M. verified there was no pre and post dialysis assessments conducted. She verified there were no orders monitoring the AV fistula site and dressing. Interview on 03/23/23 at 1:10 P.M. with Licensed Practical Nurse #903, the Unit Manager, revealed she was new to the position and had no knowledge that there was no formal process for assessments, communication and monitoring for dialysis. LPN #903 stated new orders were added to monitor the AV fistula and dressing site and the facility has started a new process for communication with the off-site dialysis facility. Review of the facility's policy titled Hemodialysis Access Care, revised October 2010 stated the nurse should document in the resident's medical record every shift. Documentation includes: 1. The location of the catheter. 2. Condition of the dressing. 3. If dialysis was done during the shift. 4. Any part of report from dialysis nurse post- assessment. 5. Observations of post-dialysis.

Based on record review, facility Self Reported Incident review, facility policy and procedure review, and interview, the facility failed to ensure Resident #34 was free resident to resident physical abuse. Actual harm occurred on 12/18/22 when Resident #41, with a known history of aggression and hearing voices to harm others, willfully struck Resident #34 in the face and head multiple times causing facial trauma. This affected one resident (Resident #34) of three residents reviewed for abuse. Findings include: Review of a facility submitted Self Reported Incident (SRI) dated 12/18/22 for physical abuse revealed Resident #41 hit Resident #34 while in the smoke room. Both residents were immediately separated and assessed for injuries. Resident #34 was provided first aid to facial injuries and was sent to the local emergency room for evaluation and treatment. The nurse practitioner and families were notified of the incident. Resident #41 was assessed for physical injuries with none notes. Resident #41 was transported by police to the hospital for a psychiatric evaluation and returned to the facility a couple hours later and was moved to a different unit within the facility. The facility substantiated abuse. Review of facility smokers list revealed Residents #34 and #41 were identified as supervised smokers. a. Review of the medical record for Resident #34 revealed an admitted [DATE]. Resident #34's diagnoses included chronic obstructive pulmonary disease, acute respiratory failure, schizoaffective disorder, and schizophrenia. Review of physician's order dated 11/28/20 for Resident #34, revealed redirect and reposition from any situation as needed for impaired cognition, behaviors. It also stated to use nonpharmacological interventions prior to using medications. Review of physician's order for Resident #34 dated 11/29/20, revealed to monitor behaviors every shift. Behaviors to monitor for included itching and picking at skin, restlessness, hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, and refusing care. Review of nursing care plan dated 07/22/21 revealed Resident #34 had a potential for behaviors as evidenced by verbal aggression towards staff and others. Resident #34 used the n word (racial slur). Interventions included to analyze key times, place, circumstances, triggers and what de-escalated behavior, document and to divert attention, remove from the situation and take to an alternate location. The care plan also identified Resident #34 had a potential for injury when smoking. Interventions included to monitor her during smoking and her smoking utensils would be left at the nurse's station. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 had mild cognitive impairment. Resident #34 required supervision with set-up help only for bed mobility and transfers. Review of nursing progress note dated 12/18/22 revealed Resident #34 was found in the smoking-room bleeding from her nose, and the bridge of her nose was bruised and swollen. Her left eye was bruised and swollen. Resident #34 reported to the nurse that, I told her to cover her mouth when she coughed, and she called me a (explicit) and punched me in the face and head several times. I think my nose is broken. The nurse practitioner and family were notified, and Resident #34 was sent to the emergency room for evaluation. Review of social work progress note dated 12/19/22 revealed she met with Resident #34 and Resident #34 reported she had no ill will to her attacker and agreed to her room change to stay separate from her attacker. Review of physician note dated 12/19/22 for Resident #34 revealed she was sent to the emergency room for evaluation after being hit in the face multiple times. Examination was negative for any fractures but Resident #34 did have bruising to the left side her face. Resident #34 denied any pain and was diagnosed with facial trauma. b. Review of the medical record for Resident #41 revealed an admitted [DATE]. Resident #41's diagnoses included atherosclerotic heart disease, psychotic disorder with hallucinations, chronic obstructive pulmonary disease, hypertension, and schizoaffective disorder. Review of nursing care plan for Resident #41 dated 08/23/22 revealed she had a risk for alteration in mood/behavior/psychosocial well-being having feelings regarding self and social relationships as evidenced by a diagnosis of schizophrenia, psychotic disorder with hallucinations, and risk for grief related to the death of her husband. Resident #41 has exhibited behaviors of hearing voices related to attempt to harm to others. Resident #41 has not acted on hallucinations but becomes upset when being told no and immediate gratification had not been met. Interventions included to encourage her to engage with staff and peers and always approach her to provide care in a calm manor. The care plan also identified Resident #41 had a potential for injury related to smoking. Interventions included to supervise resident while smoking and keep smoking utensils at the nursing station. Review of physician's orders dated 08/24/22 for Resident #41 revealed to redirect resident as needed for impaired cognition, behaviors, and pain. Also, to reposition for calming and comfort as needed for agitation, insomnia, anxiety, and pain. Finally, an order to provide diversional activity as needed for agitation, insomnia, anxiety, and pain. All orders instructed to provide nonpharmacological interventions prior to using medications. Review of quarterly MDS assessment dated [DATE] for Resident #41 revealed she had moderate cognitive impairment. Resident #41 required supervision with set-up help only for bed mobility and transfers; extensive one-person physical assistance for dressing, personal hygiene, and shower; and supervision with set-up help only for eating and toileting. Review of the nursing progress note dated 12/18/22 revealed Resident #41 came to the nurse's station and stated you better go check on that (explicit) in there (pointing to the smoking room) I just beat the (explicit) out of her She told me to cover my mouth because I was coughing. I got mad and beat the (explicit) out of her. Residents were separated and the police arrived to take statements. Resident #41 was sent to the emergency room for a psychiatric evaluation. The physician and family were notified. Review of nursing progress noted dated 12/18/22 revealed Resident #41 returned from the emergency room with no new orders. Review of social worker progress note dated 12/19/22 for Resident #41 revealed she informed the social worker she was sitting next to Resident #34 in the smoking room and Resident #34 called her a name and she went off. Resident #41 would not elaborate on what went off meant. Resident #41 reported she felt safe in the facility. Review of physician's note dated 12/19/22 revealed Resident #41 was seen and evaluated for behaviors. Resident #41 had become agitated and combative over the weekend and physically harmed another resident by punching her in the face multiple times. Resident #41 also became verbally aggressive calling her names. Resident #41 was transferred to another unit and was able to be verbally deescalated. A psychiatric evaluation was ordered. Review of the facility investigation for SRI #230285 revealed a witness statement from State tested Nursing Assistant (STNA) #527 dated 12/18/22 which revealed she was supervising the smokers on 12/18/22 at 5:35 P.M. when she left the smoking room at 5:42 P.M. to wash her hands. At 5:44 P.M. she was standing in the hallway watching the smokers from the window at the door. A resident then approached her for a glass of water. She obtained the water for the resident then at 5:48 P.M. she had severe abdominal cramps. She then went to the restroom in the nurse's station and was in there longer than she anticipated. The incident happened around 5:57 P.M. while she was in the restroom and not supervising the smoke break. Interview on 01/12/23 at 11:36 A.M. with Resident #41 revealed she feels safe in the facility. Resident #41 denied ever having an issue with another resident or hitting them. Interview on 01/12/23 at 11:40 A.M. with Resident #34 revealed she feels safe at the facility. She reported she had no idea why her left eye had a blue mark. She denied having any issues with other residents and reported being happy with her care. Observation during the interview revealed a light blue, yellow bruise beneath her left eye. Interview on 01/12/23 at 2:53 P.M. with Director of Nursing (DON), Administrator, and Licensed Practical Nurse (LPN)/Assistant Director of Nursing (ADON) #500 revealed after investigating it was discovered STNA #527 did leave the smoking break unattended to get another resident some ice water. STNA #527 then had to use the restroom and did leave the doorway to go to the bathroom. They confirmed Residents #34 and #41 were left unsupervised while smoking and both had been identified as supervised smokers. Review of facility policy titled, Abuse, Neglect, Misappropriation of Resident Property, Exploitation, and Mistreatment policy, undated revealed under Federal law abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. If you witness verbal disagreements between residents or suspect that a situation may escalate between residents report it immediately to a charge nurse for immediate intervention so if needed appropriate measures may be taken to resolve the matter and or prevent any further escalation. This deficiency represents non-compliance investigated under Complaint Number OH00138598.

Based on observation, interview, and review of facility policy titled Personal Protective Equipment - Using Gloves, revised September 2012, the facility failed to ensure staff followed appropriate infection control measures while providing care to residents. This had the potential to affect all 48 residents, Residents #1, #3, #4, #5, #6, #7, #10, # 12, #17, #18, #19, #20, #22, #23, #26, #30, #34, #35, #37, #39, #40, #42, #43, #44, #47, #48, #49, #51, #52, #55, #59, #60, #61, #62, #64, #69, #71, #72, #73, #75, #77, #78, #80, #81, #83, #84, #86, and #88, residing on the first floor of the facility. The census was 90 residents. Findings include: On 12/06/22 at 10:05 A.M., during the facility tour, an observation was made of a staff member, later identified as State tested Nurse Aide (STNA) #805, exiting a resident room with soiled linens. STNA #805 was observed appropriately wearing gloves and holding the soiled linens away from her body and clothing. After STNA #805 deposited the soiled linens into a covered plastic bag in the hallway, she immediately walked to the other side of the hallway and grabbed clean linens from a covered cart without removing the dirty gloves and without performing hand hygiene. STNA #805 was then observed re-entering resident room [ROOM NUMBER] and proceeded to change the bed linens on the bed nearest to the window in room [ROOM NUMBER]. STNA #805 was observed exiting the resident room without performing handwashing or any other hand hygiene. On 12/06/22 at 10:07 A.M. interview with STNA #805, it was reported dirty linens are placed in covered bags in the hallways; laundry of residents on Transmission Based Precautions (TBP) went into a blue plastic bag located outside of their room; and garbage from residents on TBP went into a red plastic bag outside of their room. She was asked about her observed practice of removing soiled laundry from a resident room, and then grabbing clean linens with the same gloved hand and continuing to place the clean linens onto a resident bed while the dirty gloves were still being worn. She confirmed she used dirty gloves to get clean linens, and responded she was busy and just did not think about it. She reported she was aware she should have removed the gloves and washed her hands before obtaining clean linen from the linen cart. Review of the facility policy on 12/06/22 titled Personal Protective Equipment, revised September 2010, revealed staff are to wash hands after the removal of gloves.

Based on interviews, medical record review, and review of a facility policy the facility failed to administer resident medications per physician order for Residents #72 and #77. This affected two residents (Residents #72 and #77) of three residents reviewed for medication administration. The facility census was 90. Findings include: 1. Review of the medical record revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including nondisplaced fracture of the right femur, osteomyelitis, type 1 diabetes, hypertension, and hypertrophic cardiomyopathy. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #72 had a Brief Interview for Mental Status (BIMS) score of 15, signifying the resident had no cognitive impairment. The assessment revealed Resident #72 required physical assistance from one staff for bathing and was independent for all other activities of daily living (ADL). Review of the care plan dated 11/21/21 revealed Resident #72 had the potential for hyper- or hypoglycemic reactions due to his diagnosis of diabetes mellitus type 1. Resident #72 was interviewed on 12/06/22 at 10:47 A.M. He reported staff Licensed Practical Nurse (LPN) #908, who he was unsure was regular staff or agency staff, had not on several occasions administered his medications, including insulin. Resident #72 reported none of the missed medications resulted in an abnormal blood glucose reading. He reported the incidents occurred one time in August 2022, one time in late September 2022, and again in late October 2022. He had not informed any staff members at the facility of missed medication administrations. Resident #72 was alert and oriented to person, place, time, and situation. Interviews with LPNs #802 and #804 on 12/06/22 from 11:05 A.M. and 11:23 A.M. revealed there was no knowledge of resident concerns or complaints regarding missed administration of medications. Review of Resident #72's Electronic Medication Administration Record (eMAR) for October 2022 revealed on 10/29/22 for the time of 6:00 P.M., a lack of staff data entry for administration of prescribed Humulin R Solution 100 unit/milliliters (mL) and blood sugar assessment. In an interview on 12/06/22 at 3:25 P.M. with the Assistant Director of Nursing (ADON) #806 an inquiry was made about blank entries on residents' eMAR. She responded stating any blank entry on an eMAR means the medication was not administered. 2. Review of the medical record revealed Resident #77 was admitted to the facility on [DATE], with diagnoses including human immunodeficiency Cirus (HIV), chronic obstructive pulmonary disease, chronic pancreatitis, chronic kidney disease stage 4, hypothyroidism, hypertension, and major depressive disorder. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #77 had no cognitive impairment. This assessment revealed Resident #77 required supervision but independently performed ADL, requiring set-up only for bathing. Review of the care plan revealed Resident #77 would have nursing needs, including medication management, met by the nursing staff. In an interview with Resident #77 on 12/06/22 at 9:57 A.M., it was reported there had been several instances when he did not receive his prescribed medications. Resident #77 was not able to give dates of these incidents. Resident #77 did report he received all his medications on the morning of the survey. Interviews with LPNs #802 and #804 on 12/06/22 from 11:05 A.M. and 11:23 A.M. revealed there was no knowledge of resident concerns or complaints regarding missed administration of medications. Review of Resident #77's eMAR for September 2022 revealed on 09/22/22 for the prescribed medications Descovy Tablet (antiviral) 200-25 milligrams (mg) and Evotaz Tablet (medication to treat HIV) 300-150 mg, both scheduled for administration at 9:00 P.M., the nursing data entry showed a 9, which was defined on the eMAR as Other/ See Nurse Notes. Review of the progress notes was absent of nurse notation describing if medication was held or administered. In an interview with the Director of Nursing (DON) on 12/06/22 at 2:45 P.M. it was confirmed the Electronic Health Record (EHR) of Resident #77 had an entry on the September 2022 eMAR on 09/22/22 for the prescribed medications Descovy Tablet 200-25 mg, and Evotaz Tablet 300-150 mg, both scheduled to be administrated at 9:00 P.M., which showed a code of 9, defined as Other/ See Nurse Notes on the eMAR. The DON was asked to locate the nurse note which correlated with this entry. The DON confirmed he was unable to locate a nurse note to describe if the medications were administered to the resident. The DON reported the nurse who had signed off on this entry had left the facility without any notification, had not responded to the facility attempts to contact her, and had made no attempts to contact the facility. This deficiency represents non-compliance investigated under Complaint Number OH00137768.

Based on staff interview, medical record review, and facility policy review, the facility failed to provide adequate supervision to prevent elopement of one resident (Resident #79) who resided on the secured unit and was assessed at risk for elopement. This resulted in Immediate Jeopardy when Resident #79 eloped from the facility. The likelihood for serious harm or injury occurred when Resident #79 eloped from the facility on 06/16/18 at 7:00 P.M. without staff knowledge. She was located by an off-duty employee at 8:10 P.M. approximately 10 miles from the facility. Resident #79 was returned to the facility on [DATE] at 8:49 P.M. This affected one of one resident reviewed for elopement from the facility in (YEAR). The facility identified eleven residents at risk for elopement from the current census of 125 residents. On 07/10/18 at 11:30 A.M., Nursing Home Administrator (NHA) #150 and the Director of Nursing (DON) were notified Immediate Jeopardy began on 06/16/18 at 7:00 P.M., when Resident #79, who was assessed to be at risk for elopement and exhibited exit seeking behaviors, exited the second floor of the facility without knowledge of staff. The Immediate Jeopardy was removed on 06/18/18 when the facility implemented the following corrective actions: · On 06/16/18 at 8:49 P.M. Resident #79 was located and secured at the facility. · On 06/16/18 at 9:00 P.M., Licensed Practical Nurse (LPN) #325 conducted a physical assessment of Resident #79. Vital signs were within normal limits. No concerns or injuries were noted. Certified Nurse Practitioner (CNP) #303 was notified and gave an order to apply a wander guard (a monitoring ankle bracelet that automatically locks exit doors, and triggers an alarm, to notify staff that a resident at risk of eloping is near an exit door, and prevents the resident from exiting the unit or building). An order was also implemented to conduct observations of the resident's whereabouts every fifteen minutes for 24 hours. · On 06/18/18 at 8:00 A.M., Maintenance Staff (MS) #321 changed the security access codes on the first and second floor elevator in B Building, as well as the door codes to the secured Heritage Unit, and the front door codes to enter and exit both Building A and Building B. This was a precautionary measure to ensure that only staff had the current operating codes. · On 06/18/18 at 9:00 A.M. and 2:30 P.M., Registered Nurse (RN) #202, LPN #204 and LPN #322 conducted in service education for all full-time core staff in both buildings to educate staff to not yell out the new codes to the doors and elevators or share them with visitors. Staff were to escort visitors into and out of the secured Heritage Unit. · On 06/18/18 at 3:58 P.M., RN #326 noted Resident #79 had removed and destroyed the wander guard. CNP #314 ordered the wander guard to be discontinued for Resident #79 and continue monitoring the resident's whereabouts every fifteen minutes. · On 06/18/18 State tested Nurse Aide (STNA) #304 and LPN #305 received written disciplinary action from RN #202, for failure to maintain the required supervision for Resident #79. STNA #304 was educated on the care plan for Resident #79 which indicated she was to be assisted on and off the secured unit by staff when being observed for a smoke break. LPN #305 was educated on securing the elevator when entering and exiting between floors to ensure no resident had entered the elevator that required staff supervision. · On 06/18/18 Resident #79 was assessed by CNP #314. The resident presented with increased anxiety and repeatedly expressed her desire to leave the nursing facility. an order for [REDACTED]. · On 06/18/18 between 9:00 A.M. and 10:10 A.M. a new Sign Out Policy for residents who reside on the secured Heritage Unit was drafted by RN #202 and implemented by NHA #150. Any resident leaving the secured Heritage Unit needed to have two individuals sign the resident out and back into the unit. One of the two individuals must be the charge nurse working that unit on the day being signed out. In service training was conducted by nurse managers, RN #202, LPN #204, LPN #323, and RN #312 on their respective shifts. · On 06/18/18 between 10:30 A.M and 11:00 P.M., direct care staff of nurses and STNAs were in serviced on the new Sign Out Policy by RN #202 that included eight RNs, 38 LPNs, and 48 STNAs. Additional staff identified to have been in serviced on the new policy on 06/18/18 by RN #202 included three activity staff, 10 dietary staff, 11 housekeeping staff, two social services department staff, one admission staff, and three therapy staff. As of 07/10/18, the facility identified 32 direct care staff members who had not worked since Resident #79 eloped on 06/16/18. The DON will be responsible to ensure any current staff not trained on the new Sign In/Out Policy for the secured Heritage Unit will be in serviced prior to taking an assignment anywhere in the facility. · On 06/18/18 at 11:30 A.M., a cover was placed over the key pad on the Heritage Hall unit by MS #321 reading please do not let resident see code. Behind the nursing desk on Heritage Hall, a sign was posted by unit manager, LPN #204 please do not yell out code. · On 06/19/18 at 9:30 A.M., the Risk Management team determined the current interventions implemented would support a recommendation to discontinue the fifteen-minute head checks for Resident #79 and an order was obtained from CNP #314 to discontinue the fifteen minute head checks. · On 06/19/18 Psychiatric NP #313 consulted with Resident #79. No additional new orders were implemented. · An Elopement Drill was completed on 07/09/18 at 7:00 P.M. with 20 staff participating, ten STNAs and ten nurses. Code Silver Drills (Missing Resident) will be conducted each shift monthly for three months beginning in (MONTH) (YEAR) then quarterly thereafter, followed by semi-annual drills. Drills will be conducted by designated administration staff. · On 07/05/18 at 11:00 A.M., an interview was conducted with LPN #306; and between 3:15 P.M. and 5:00 P.M., with LPN #204, STNA #307 and LPN #308. Interviews revealed staff members had knowledge on preventing resident elopement and the policy and procedure for signing out residents from the secured unit on the second floor, Heritage Unit. · On 07/05/18 at 3:15 P.M., LPN #204 stated she was the unit manager for the second floor, included the secured Heritage Unit. LPN #204 reported she was monitoring facility staff for compliance with the Sign Out/In Policy for the secured Heritage Unit each week. · On 07/10/18 elopement risk assessments were completed for the current census of 125 Residents. Ten like residents (Resident #29, #37, #39, #59, #66, #73, #120, #124) who resided on the second floor and (Resident #88 and #109) who resided on the first floor unit were identified to be at risk for elopement. Care plans for these residents were reviewed and accurately reflected assessments. · On 07/10/18, within 24 hours of admission, the admitting nurse will complete an elopement risk assessment and report to the Interdisciplinary Team (IDT) any score of three or greater. The IDT will meet and evaluate further to determine if the resident is high risk for elopement and what preventative measures need to be implemented under the direction of the DON. · On 07/10/18 the assistant director of nursing RN #202 verified the elopement books Happy Feet at the front desk and three nursing stations were updated with current photographs and accurate to reflect the 11 residents identified as elopement risks. · On 07/10/18 the Activity Director or designee interviewed existing residents that have been assessed to be high risk for elopement, along with all new admissions, and with the IDT will determine any interventions to keep residents active and engaged in daily routines. · On 07/10/18 between 7:15 A.M. and 7:30 A.M., interviews with STNA #309 and RN #310 verified knowledge and recent in service on signing out residents from the secured unit. At 3:30 P.M., RN #312 verified he conducted an elopement drill on 07/09/18 at 7:00 P.M. and was in serviced on the new Sign Out Policy for residents on the secured Heritage Unit. · On 07/11/18 between 10:30 A.M. and 11:30 A.M., STNA #311, STNA #317, and occupational therapist (OT) #318 were interviewed and verified knowledge of the Code Silver (Missing Resident) Policy; the Happy Feet Books (Photos of residents identified to be at risk for elopement), and the new Sign In/Out Policy for residents on the secured Heritage Unit. At 3:20 P.M., Receptionist #324 who worked in both A Building and B Building was interviewed and confirmed the facility policy required everyone to sign in and out at both buildings. Non-compliant visitors were referred to management. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan that includes policy revisions, conducting in services for staff, and monitoring to ensure on-going compliance. Findings include: Resident #79 was admitted to the facility on [DATE]. Medical history included disorganized [MEDICAL CONDITION], delusional disorders, generalized anxiety disorder, [MEDICAL CONDITION], diabetes, hypertension, [MEDICAL CONDITIONS], and muscle weakness. Review of the resident's hospital medical record information dated 01/31/18 revealed Resident #79 was admitted to the hospital with [REDACTED]. She was admitted to the hospital from a women's shelter and had a guardian provided through the Adult Guardianship Program. The guardian had reported Resident #79 had spent most of (MONTH) in different facilities including a hospital behavioral unit when she was discharged on [DATE]. The resident reportedly took a bus and traveled out of state. She was identified at a bus shelter and was placed in a crisis program in that city. She was inadequately dressed, did not have any shoes and was exhibiting psychiatric problems. She returned to the current city on 01/18/18 and was admitted to a local hospital where she was assessed to require a more secure environment. An elopement risk assessment completed on 02/17/18 on admission to the facility identified Resident #79 as cognitively impaired with poor decision making skills due to a [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. The resident was determined to be at high risk for elopement. Review of the admission Minimum Data Set 3.0 assessment ((MDS) dated [DATE], revealed Resident #79 was assessed to be alert and oriented. The 30 day MDS dated [DATE] and Quarterly MDS dated [DATE] and 04/06/18 assessed Resident #79 as independent with activities of daily living. The resident was verbal, ambulatory, and continent of bowel and bladder. Review of Resident #79's care plan initiated on 02/26/18 revealed she required a secured behavior unit related to impulsiveness, safety unawareness, and disruptive behavior with [DIAGNOSES REDACTED].#79 was at high risk for elopement related to altered thought process, attempts to leave the facility and attempts to exit with visitors. Interventions were for facility staff to monitor and redirect her by engaging her in activities, assess for immediate needs, and maintain routine monitoring of the resident's location. Progress notes from 02/18/18 through 06/16/18 revealed Resident #79 was assessed routinely for anxiety, secure and safe while ambulating within the unit, and no evidence she was attempting to exit the secured unit. Review of the progress noted dated 06/16/18 at 8:15 P.M., revealed Resident #79 was observed in the center of town approximately ten miles away from the facility by an off-duty staff member, STNA #300, who called and reported the location of Resident #79 to facility staff. A shift supervisor and security guard traveled into the center of town and located Resident #79 and returned her to the facility at 8:49 P.M. An assessment was completed and no injuries were noted. Review of the incident investigation report revealed the facility reviewed their newly installed video camera footage. The video revealed Resident #79 was in the smoke room, drinking coffee and walking around the second floor West Dining Room located outside of the secured Heritage Unit where she resided. Several minutes passed when a charge nurse, LPN #305 exited the second floor elevator and proceeded to walk onto the second floor West unit. LPN #305 did not wait for the elevator door to close and Resident #79 entered the elevator behind LPN #305 without her knowledge. The elevator door then opened onto the first floor and Resident #79 exited down the middle hall towards the front door. There were two staff members at the time clock but their backs were turned toward the wall and they did not see Resident #79 exit the facility on 06/16/18 at 7:00 P.M. Resident #79 had previously removed and destroyed two wander guard bracelets and an order was obtained to discontinue the wander guard. Review of the elopement investigation and action plan revealed that both employees received written disciplinary actions. STNA #304 for leaving Resident #79 unsupervised and LPN #305 for not securing the elevator before leaving the area. The key pad codes were changed on the secured Heritage Unit and the key pad was covered. The new Sign In/Out Policy was developed and implemented following staff in-service education. Review of STNA #304's witness statement revealed she usually worked on third shift and was not aware Resident #79 resided on the secured Heritage Unit. Resident #79 was in line with all the other residents who were ready to enter the smoking room on the second floor. She was given two cigarettes to smoke and left the room at 6:45 P.M. STNA #304 was unaware that Resident #79 was the resident who eloped until she was shown a picture of her during the Code Silver process. No one told STNA #304 anything about escorting Resident #79 back over to the Heritage Unit after smoke break. This was her first time supervising smoking for the residents on the second shift. STNA #300 reported in her statement: I was downtown on 06/16/18 at 7:30 P.M. when I saw Resident #79. I called the facility and notified the supervisor and described what she was wearing. LPN #305 reported in her statement: I went to lunch and returned to the floor. I received a call from an off-duty staff person who reported she believed Resident #79 was observed (in the center of town). I went over to the secured Heritage Unit to see if Resident #79 was on the unit and she was not. I notified the supervisor who notified the administrator and security staff who retrieved Resident #79 and returned her to the facility. The incident occurred between 8:00 P.M. and 8:30 P.M. LPN #301 reported in her statement: I was notified by LPN #305 that an off-duty staff member believed to see Resident #79 (in the center of town). I had the nurses and staff complete a head count and initiated a Code Silver. Together, with security personnel, we traveled (into the center of town) and found Resident #79 walking down the street. She got into the car and the manager on call, RN #202, was notified. Resident #79 reported a friend brought her downtown. She was assessed and had no injuries and range of motion was fine. An order was obtained for a wander guard and to monitor the resident every fifteen minutes for 72 hours. On 06/19/18 a psychiatric evaluation was completed for Resident #79. She was assessed to have increased anxiety, was depressed, and stated she would like to leave the nursing home. No medication changes were implemented. On 07/05/18 at 12:00 P.M., an interview was conducted with RN #202. She verified Resident #79 was alert and oriented to person, place, and time most days. The resident usually had some money and could navigate the city using buses and the rapid transit trains. RN #202 confirmed Resident #79 did not sustain any injuries and was appropriate to be placed on the secured Heritage Unit. On 07/09/18 between 7:15 A.M. and 7:45 A.M., an interview was conducted with the DON. He confirmed Resident #79 was assessed to be at risk for elopement when she was admitted to the facility on [DATE]. The DON explained that based on her past history of leaving the state while residing in a group home, she was admitted to the secured Heritage Unit with the approval of her court appointed guardian. The DON confirmed Resident #79 left the faciity on [DATE] without staff knowledge and stated he believed she accessed the door code. The DON confirmed on 06/16/18, Resident #79 again, left the facility without staff knowledge. An employee, who was off-duty, observed Resident #79 (in the center of town) and contacted facility staff. Staff went to pick her up and returned her to the facility at 8:49 P.M. An assessment of the resident revealed no injuries were noted. On 07/10/18 at 1:00 P.M., the DON verified that only Resident #79 had eloped from the facility. No other residents had eloped in (YEAR). On 07/10/18 at 3:10 P.M., an interview was conducted with Psychiatric NP # 313. She reported Resident #79 could be manipulative and did not understand what it meant to have a court appointed guardian to oversee her care. Resident #79 required a secured environment but believed she was too young to live in a nursing home and wanted to leave. She had weekly counseling sessions but they were stopped when she refused to participate. She had been compliant with taking routine medications without incident and had an anti-anxiety medication ([MEDICATION NAME]) to be given as needed for pacing and observed high levels of anxiety. On 07/11/18 at 10:30 A.M., an interview was conducted with Resident #79. She was dressed in appropriate day wear, was clean, and able to ambulate unassisted without any devices and with a steady gait. Resident #79 reported she was independent with her daily routine. Her speech was clear and she appeared to be happy to have a visitor. Resident #79 asked for help to move back into the community and for the telephone number of the Ombudsman. Resident #79 explained she did not want to live in a nursing home and had social security money to use to pay for an apartment. She confirmed she had a guardian, was intact mentally, and did not need to be in a nursing facility. Resident #79 denied leaving the facility except when her guardian took her shopping. This deficiency substantiates Complaint Number OH000OH 852.

Based on interview and medical record review, the facility failed to timely identify and treat a change in skin condition until it had worsened and was first discovered as an unstageable pressure ulcer. Actual Harm occurred when Resident #56 was found to have a new unstageable pressure sore to his left lateral knee on 08/21/13. Resident #56 was one of three residents reviewed for pressure ulcers, of nine residents with pressure ulcers in the facility. Findings include: Resident #56 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #56 was dependent on the extensive assistance of at least two other persons for bed mobility and transfers, and was at high risk for developing pressure ulcers. Resident #56's weekly skin assessments and nursing progress notes from 07/29/13 through 08/26/13 were reviewed with the facility wound nurse, Licensed Practical Nurse (LPN) #34, on 11/19/13 at 3:10 P.M. LPN #34 confirmed there was no documentation that an alteration in skin integrity was noted on Resident #56's left lateral knee. Continued record review with LPN #34 on 11/20/13 at 3:10 P.M. revealed Resident #56 was assessed by the wound nurse practitioner on 08/26/13. The nurse practitioner's Wound Report dated 08/26/13 revealed Resident #56 had a new pressure ulcer to his left lateral knee, with an onset date of 08/21/13. The pressure ulcer measured 6.5 centimeters (cm) long by 5.3 cm wide and was 0.3 cm deep. The wound had pale reddish drainage with signs and symptoms of a local infection. 25% to 50% of the wound bed was covered with necrotic tissue. The nurse practitioner determined that Resident #56's pressure ulcer was unstageable (full thickness tissue loss in which the actual depth of the ulcer is completely hidden by the presence of slough or eschar in the wound bed.) Review of LPN #34's wound grid sheets for Resident #56 revealed the resident was found to have a left knee wound on 08/21/13. The wound measured 6.5 cm long by 5.3 cm wide by 0.3 cm deep. The wound was treated with a silver alginate dressing. There was no evidence that any new pressure relieving interventions were initiated until 08/26/13, when the nurse practitioner ordered elbow protectors over dressings at all times to reduce pressure on Resident #56's left lateral knee. On 11/21/13 at 3:00 P.M., LPN #34 confirmed that Resident #56 did not have a skin alteration to his left lateral knee when he was readmitted to the facility from the hospital on [DATE]. She confirmed that Resident #56's left lateral knee wound was first discovered on 08/21/13, after it had deteriorated to an unstageable pressure ulcer.

Based on observation, record review and interviews, the facility failed to provide intravenous antibiotic therapy according to physician orders [REDACTED].#40. Actual harm occurred to Resident #44 who developed an elevated temperature and continued with a urinary tract infection upon completion of the initial antibiotic. This resulted in an additional 10 days of intravenous antibiotic therapy. Four of the seven residents reviewed for intravenous antibiotic therapy did not receive the complete doses. The facility census was 81. Findings include: On 09/17/11 at 8:15 A.M. the identified charge nurse, Registered Nurse (RN) #1, was working on the second floor of the facility, in an upset manner, and informed the surveyor that he had just arrived and needed to administer all of the 6:00 A.M. intravenous (IV) antibiotics that the residents had not received because there was no RN coverage on the previous shift. He stated that on 09/15/11 he was the RN in charge and had to administer IV medication for the sister facility across the parking lot as well as this facility. He added that due to a report off he also had to work the second floor unit and run back and forth between buildings to monitor the IVs. 1. Resident #44 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. On 08/15/11, the resident was readmitted from a brief hospitalization for a blood and Mediport infection (a port implanted in the chest to infuse IV's) with a replacement of a new Mediport. The 08/04/11 hospital information included the resident had gram negative pseudomonas aeruginosa in her blood and Mediport. The IV antibiotic was completed on 08/24/11. The resident developed elevated temperatures on 09/01/11 and was found to have another urinary tract infection >100,000 CFU/milliliter of Escherichia Coleus. Physician orders [REDACTED]. During interview with Resident #44 on 09/17/11 at 9:30 A.M., she stated that they had missed her IV antibiotic many times and that was why she had another urinary tract infection now. On 09/17/11 at 9:30 A.M., 10:30 A.M. and 11:30 A.M., Resident #44 had not received her 6:00 A.M. IV dose of [MEDICATION NAME]. At 2:30 P.M., during an interview with the assistant director of nursing (ADON), RN #4, she stated that she just hung the resident's 2:00 P.M. dose of [MEDICATION NAME] IV. She verified that Resident #44 did not receive her 6:00 A.M. dose today and stated "I couldn't hang it because I didn't want to double dose her." Review of Resident #44's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. dose, on 08/19/11 the 2:00 P.M. dose, and on 08/21/00 the 6:00 A.M. and the 2:00 P.M. doses. Review of the September 2011, MAR indicated [REDACTED]. No IV doses of the antibiotic were given to the resident until the 2:00 P.M. dosage on 09/17/11. 2. Resident #67 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was followed by an infectious disease physician. The physician progress notes [REDACTED]. During an interview with Resident #67 on 09/17/11 at 10:30 A.M., she stated that she did not receive her 6:00 A.M. antibiotic this morning until 8:30 A.M. She stated "this happens a lot and I've missed many doses of antibiotics because they have no nurse working to hang it." She further stated "I've had my Hickman catheter replaced three times and my length of stay in here extended because of them (facility)." Review of the resident's routine monthly physician orders [REDACTED]. The September MAR indicated [REDACTED].M. and 10:00 P.M. The resident did not receive the ordered dose on 09/08/11 the 10:00 P.M. dose or the 09/11/11 the 10:00 A.M. dose. On 09/12/11 the [MEDICATION NAME] order increased to 1.25 gm IV two times a day. The resident did not receive the 10:00 P.M. dose on that same date. Review of the August MAR for Resident #67 revealed she did not receive the ordered doses of IV [MEDICATION NAME] on 08/06/11, 08/07/11, 08/13/11, 08/15/11, 08/18/11 and 08/21/11 at 10:00 P.M., or the 08/14/11, 08/26/11 and 08/27/11 doses at 10:00 A.M. The July, 2011 MAR indicated [REDACTED]. The IV [MEDICATION NAME] 1 gm was not given on 07/22/11, 07/25/11, 07/26/11, 07/27/11, 07/28/11 or 07/29/11 for the evening doses and the other antibiotic, IV [MEDICATION NAME] 3.375 milligrams (mgs) every eight hours was not given to the resident on 07/22/11 or 07/25/11 10:00 P.M. dose or the 07/24/11 and 07/29/11 2:00 P.M. dose or the 07/27/11 dose as ordered by the physician. 3. Resident #30 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Review of the resident's MAR for September 2011 revealed the resident did not receive any IV antibiotics on 09/15/11 and did not receive IV Tigecycine 50 mgs on 09/16/11 or 09/17/11. 4. Resident #40 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted with a [MEDICAL CONDITION], indwelling Foley catheter for bladder function and a continuous nutritional tube feeding supplement. On 08/26/11 the resident was placed on Hospice services for acute osteo[DIAGNOSES REDACTED]. Following a second brief hospital stay and readmission into the facility on [DATE] the resident was ordered by the physician to receive IV [MEDICATION NAME] 1.5 gm every 12 hours for nine days and IV [MEDICATION NAME] 3.375 mgs every six hours for nine days. Review of the resident's September 2011, MAR indicated [REDACTED].M. On 09/17/11 at 5:30 P.M., the corporate director of nursing verified the lack of RN staffing in order to hang IV antibiotics for the residents. This deficiency substantiates Complaint Master Control Number OH 436.