Every finding on record at Willow Woods Rehabilitation and Nursing

Based on observation, record review and interview, the facility failed to ensure a clean and sanitary environment in good repair. This finding affected 16 residents (#1, #7, #9, #16, #20, #24, #33, #35, #38, #40, #45, #56, #57, #65, #75 and #76) of 34 residents who reside on the Buckeye secured unit and had the potential to affect all the residents in the facility. The facility census was 76.Findings include:1. Tour of the Buckeye secured unit on 05/18/26 at 8:07 A.M. with Maintenance Director (MD) #721 of the resident rooms revealed: - Scrape damage and missing paint on the wall surfaces of Resident #75's room.- Scrape damage and missing paint on the wall surfaces of Resident #1's room and missing molding.- Scrape damage and missing paint on the wall surfaces of Resident #20's room.- Scrape damage and missing paint on the wall surfaces of Residents #40 and #45's room.- Scrape damage and missing paint on the wall surfaces of Residents #7 and #38's room.- Scrape damage and missing paint on the wall surfaces of Resident #33's room.- Scrape damage and missing paint on the wall surfaces of Residents #9 and #16's room.- Scrape damage and missing paint on the wall surfaces of Resident #76's room.- Scrape damage and missing paint on the wall surfaces of Residents #35, #65 and #57's room.- Scrape damage and missing paint on the wall surfaces of Resident #56's room.- Scrape damage and missing paint on the wall surfaces of Resident #24's room, as well as a broken closet door. Interview on 05/18/26 at 8:20 A.M. with MD #721 revealed he was only one person, and the facility took away his assistant. MD #721 confirmed the resident rooms on the Buckeye unit required maintenance. 2. A tour of the facility on 05/18/26 from 8:30 A.M. to 9:00 A.M. revealed the floors throughout the facility common areas, including the hallways, dining areas and gathering areas in the facility revealed the floors were sticky, scuffed, with dried liquid spills, ground in dirt and debris present throughout the facility and resident care areas. An interview with Housekeeper #769 on 05/19/26 at 7:06 A.M. verified the floors in the facility had been neglected and were sticky with dried spills and debris. Housekeeper #769 stated he was responsible for ensuring the floors were cleaned. Housekeeper #769 stated he had been off work due to illness and there was nobody assigned to take over his job duties while he was sick. Housekeeper #769 stated the facility did not have a machine to buff the floors and the floors appeared dull and scratched throughout the facility in need of deep cleaning. Review of the Homelike Environment policy revised 02/2021 revealed residents were provided with a safe, clean, comfortable homelike environment and encouraged to use their personal belongings to the extent possible. This deficiency represents non-compliance investigated under Complaint Number 2998651.

Based on observation, record review, policy review, and interview the facility failed to ensure Resident #29 and Resident #59's medications were administered as ordered by the physician resulting in a six percent error rate. This affected two out of five residents observed during medication administration. The facility census was 76.Findings include:An observation of four nurses (Registered Nurse (RN) #733, RN #744 and Licensed Practical Nurse (LPN) #746, LPN #747) administer 30 medications to five residents (Resident #12, Resident #29, Resident #57, Resident #59, Resident #76) with 31 opportunities for error revealed two medication errors were observed resulting in a six percent error rate. 1. A review of Resident #59's clinical record revealed an admission date of 12/30/24 with diagnoses including malnutrition, pleural effusion, cognitive communication deficit, cerebral infarction (stroke), transient ischemic attack (temporary blockage of blood flow to the brain), spastic hemiplegia affecting the right side (muscle weakness or stiffness affecting one side of the body), dysphagia (difficulty swallowing), hyperlipidemia (high cholesterol), constipation, aortic valve stenosis, mental disorder, and aphasia (difficulty speaking, understanding, reading and writing). A review of Resident #59's physician orders dated 05/01/26 to 05/31/26 indicated to administer the following medications scheduled to administer in the morning: -Aspirin 81 milligrams (mg) (blood thinner) delayed release by mouth. -Clopidogrel bisulfate 75 mg (antiplatelet) by mouth. -MiraLAX (polyethylene glycol 3350) oral packet 17 grams (gr) (laxative) mixed in 4 to 8 ounces of water by mouth. -Tamsulosin hydrochloride capsule 0.4 mg (treats enlarged prostate) by mouth. -Gabapentin 100 mg (controls seizures and manages nerve pain) by mouth. And a physician order indicated oxycodone 5 mg/325 mg (opioid pain medication) to administer one tablet orally as needed for pain. An observation on 05/18/26 at 9:53 A.M. of RN #733 administer the above listed medications to Resident #59 revealed a failure to measure the ethylene glycol 3350 powder correctly. RN #733 obtained a plastic bottle of ethylene glycol 3350 from the medication cart. RN #733 then poured the ethylene glycol powder into the cap of the plastic bottle up to the first line on the white inner liner of the cap. RN #733 then attempted to mix the measured powder in a cup of water when she was stopped and asked to read the directions on the ethylene glycol 3350 plastic bottle. The directions indicated to fill the ethylene glycol powder to the top of the inner white line of the cap for 17 gr dosage of the ethylene glycol powder. When the inner white liner of the cap of the ethylene glycol 3350 powder was inspected there was an arrow pointing to the top line of the inner white liner indicating to fill the powder to the top of the inner liner of the cap. An interview with RN #733 on 05/18/26 at 10:00 A.M. revealed RN #733 agreed she had not measured the ethylene glycol 3350 powder correctly. 2. A review of Resident #29's clinical record revealed an admission date of 01/31/24 with diagnoses including chronic respiratory failure, malnutrition, chronic obstructive pulmonary disease, gastroesophageal reflux disease, diabetes mellitus type II, hyperlipidemia, hypertension (high blood pressure), obstructive sleep apnea, dysphagia, cognitive communication deficit, and chronic venous hypertension. A review of Resident #29's physician orders dated 05/01/26 to 05/31/26 indicted to administer the following medications scheduled to administer in the morning: -Ascorbic acid 500 mg (Vitamin C supplement) by mouth. -Atorvastatin calcium 10 mg (lowers cholesterol) by mouth. -Docusate sodium 100 mg (stool softener) by mouth. -Ferrous sulfate 325 mg (iron supplement) by mouth. -Folic acid 1 mg (supplement) by mouth. -Multivitamin 1 tablet (supplement) by mouth. -Pantoprazole sodium (Protonix) 40 mg (decreases stomach acid) by mouth. -Thiamine hydrochloride 100 mg (Vitamin B1 supplement) by mouth. -Vitamin B6 50 mg (supplement) by mouth. -Zinc 50 mg (supplement) by mouth. An observation on 05/19/26 at 7:38 A.M. of RN #744 administer medications to Resident #29 revealed RN #744 failed to administer zinc 50 mg supplement by mouth as ordered by the physician. RN #744 administered the other above listed medications but had not administered the zinc medication. An interview with RN #744 on 05/19/26 at 8:02 A.M. agreed she had not administered 50 mg zinc by mouth as ordered by the physician. A review of the facility policy titled Administering Medications revised April 2019 indicated medications were administered in a safe and timely manner, and as prescribed. Under the Policy Interpretation and Implementation section item number 4 indicated medications were administered in accordance with the prescriber orders. Including any required time frame. This deficiency represents non-compliance investigated under Complaint Number 2993659.

Based on observation, record review, policy review, and interview, the facility failed to ensure Resident #20 was provided adequate incontinence care. This finding affected one (Resident #20) of three residents reviewed for incontinence care. The facility census was 76.Findings include:Review of Resident #20's medical record revealed the resident was admitted on [DATE] with diagnoses including schizoaffective disorder, muscle wasting and hypothyroidism. Resident #20 resided on the Buckeye secured unit.Review of Resident #20's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment and was always incontinent of bowel and bladder.Observation on 05/18/26 at 6:56 A.M. with Certified Nursing Assistant (CNA) #732 and CNA #769 of Resident #20's morning activities of daily living including the resident's incontinence care revealed the staff used disposable wipes to cleanse the resident's peri area and coccyx. The staff stated they could not dry the resident because they did not have towels or washcloths available for use.Observations on 05/18/26 at 6:59 A.M. with CNA #769 of the first and second linen closet on the Buckeye secured unit revealed several sheets and blankets but no towels and no washcloths.Attempted interview on 05/18/26 at 7:00 A.M. with Resident #20 and the resident was not interviewable.Interview on 05/18/26 at 7:00 A.M. with CNA #732 revealed there were no linens for staff use on a regular basis. CNA #732 confirmed they had to make do with what they had and confirmed the facility did not have towels to dry Resident #20 following incontinence care.Interview on 05/19/26 at 9:46 A.M. with the Administrator revealed she was aware the facility was running low on linens, and new linens were ordered.Review of the Incontinence Care policy revised 09/2010 revealed the staff and practitioners will appropriately screen for, and manage, individuals with urinary incontinence. The physician and staff will provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible.This deficiency represents non-compliance investigated under Complaint Number 2998651.

Based on record review, interview, and policy review, the facility failed to ensure Resident #78's care plan was revised with individualized interventions to address his behaviors. This affected one (Resident #78) out of three residents reviewed for behaviors. The facility census was 76.Findings include:A review of Resident #78's clinical record revealed an admission date of 01/29/26 with diagnoses including congestive heart failure, mood disorder, schizophrenia, pulmonary disease, diabetes mellitus, sleep apnea, and morbid obesity. Resident #78 was discharged from the facility to the hospital on [DATE] and did not return to the current facility upon his discharge from the hospital. A review of Resident #78's clinical record revealed multiple nursing progress notes dated 02/14/26 to 05/01/26 that indicated Resident #78 had behaviors including agitation, yelling/screaming at staff, accusations of being poisoned by the staff, staff threatening bodily harm, voicing distrust of staff accurately administering his medications, in medications, accusations of cleaning staff moving his belongings and was verbally abusive to the staff accusing staff of messing with his food, refusing care. A review of Resident #78's care plan indicated Resident #78 exhibited behavioral symptoms such as accusatory statements, verbal aggression, noncompliance with care and medication administration recommendations related to his diagnoses of schizophrenia and mood disorder. The goal of the plan of care was Resident #78 would not harm himself or others through the review date 07/28/26, and Resident #78's safety would be maintained through the review date 07/28/26. Interventions included: -Contract with the resident as needed. -Document all behaviors. Attempt to identify patterns to target interventions. -Notify supervising nurses of noted negative behaviors, accusatory statements, verbal aggression, non-compliance with care. -Offer foods of choice (within dietary orders) to reduce episodes of negative behavior and risk for all or injury. An interview with Registered Nurse (RN) #733 on 05/18/26 at 3:43 P.M. stated Resident #78 had behavior and complained to the staff accusing them of changing his medications and was distrustful of medications administered. RN #733 stated Resident #78 needed to watch the nurses dispense the medications from the original packaging into a medication cup or he would refuse to consume the medications. RN #733 verified there was no intervention in his plan of care for all the nurses to provide the same intervention during medication administration to prevent Resident #78's refusal to consume his medications. An interview with RN #748 on 05/19/26 at 6:20 A.M. agreed Resident #78 was particular about his medication administration and needed to watch the nurses dispense his medications in a medication cup or he would refuse to take the medications. RN #748 stated two housekeeping staff members needed to be present while cleaning Resident #78's room due to accusations of stealing and/or looking through his personal belongings. RN #478 verified the interventions in his care plan were not individualized to include strategies some of the staff were using to address Resident #78's behaviors. An interview with Certified Nursing Assistant (CNA) #749 on 05/19/26 at 6:53 A.M. revealed two staff members needed to be present when staff provided direct care for Resident #78 due to his accusations of staff abusing him and other accusations. An interview with Administrator on 05/19/26 at 10:27 A.M. verified the above findings and agreed Resident #78's care plan needed to revised to include individualized interventions to address his behaviors. A review of the facility policy titled Care Plan, Comprehensive Person-Centered dated 2001 indicated the policy was a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the residents' physical, psychosocial and functional needs was developed and implemented for each resident. The interdisciplinary team, in conjunction with the resident and his/her representative, develops and implements a comprehensive, person-centered care plan for each resident. The comprehensive, person-centered care plan included measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: -services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; -any specialized services to be provided because of PASARR recommendations; and -which professional services are responsible for each element of care; includes the resident's stated goals upon admission and desired outcomes; builds on the resident's strengths; and reflects currently recognized standards of practice for problem areas and conditions. This deficiency is an incidental finding discovered during the course of the complaint investigation.

Based on record review, interview and policy review, the facility failed to honor Resident #1's preferences to heat up leftover food items. This finding affected one (Residents #1) of nine residents reviewed for preferences. The facility census was 76.Findings include:Review of Resident #1's medical record revealed the resident was admitted on [DATE] with diagnoses including fibromyalgia, depression and anxiety disorder. Resident #1 resided on the Buckeye secured unit.Review of Resident #1's physician orders revealed an order dated 03/03/26 for a regular diet, regular texture with thin liquids consistency and a house shake (supplement) with breakfast.Review of Resident #1's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Interview on 05/18/26 at 8:35 A.M. with Resident #1 revealed staff refused to heat up leftovers and she has had to throw food out. She indicated the Director of Nursing (DON) stated it was the facility policy. When questioned, she also stated the Administrator stated the same thing and it had something to do with cross-contamination. Resident #1 stated she had asked the kitchen to heat things up for her and was told they could not heat them up. Resident #1 stated she asked staff not to bring in meals because she cannot eat them, and she orders her food from outside vendors.Interview on 05/19/26 at 7:22 A.M. with Social Service Designee (SSD) #734 revealed Resident #1 had visited the Administration office and reported to the DON that staff were not heating up the leftover food. SSD #734 confirmed the DON told the resident that staff were not allowed to heat up the leftover food per the Administrator and that the resident was to talk to the Administrator. SSD #734 was unsure of the time of the occurrence but stated it was within the last 14 days.Interview on 05/19/26 at 7:26 A.M. with Registered Nurse (RN) #744 revealed the facility had a microwave in the Pines nursing office, the therapy room and the maintenance office.Interview on 05/19/26 at 7:35 A.M. with Maintenance Director (MD) #721 confirmed the microwave in his office was his own personal microwave along with the refrigerator. MD #721 confirmed the microwaves in the therapy room and the nursing office belonged to the facility (along with the one in the kitchen).Interview on 05/19/26 at 8:25 A.M. with Resident #1 revealed the last time she talked to the Administration staff was on 05/05/26 when she went in and asked the DON about heating up the leftover food items. Resident #1 revealed the DON told her the facility staff were not able to heat up the food per the Administrator.Interview on 05/18/26 at 8:47 A.M. with the DON revealed she did not talk to any resident about heating up outside food items.Interview on 05/19/26 at 9:46 A.M. with the Administrator revealed she had told staff that food needed to be heated up in the kitchen with a temperature obtained. Review of the Foods Brought by Family/Visitors policy revised 02/2014 revealed liberalized diets will be permitted as much as possible. Staff must be aware of, and approve, foods brought to a resident by family/visitors.This deficiency represents non-compliance investigated under Master Complaint Number 3011311.

Based on observation, review of dietary schedules, review of posted mealtimes, and interview, the facility failed to ensure sufficient dietary staff to ensure meals were delivered in the scheduled time frame. This had the potential to affect all 73 residents residing in the facility. Findings include:1. Observations on 03/30/26 at 7:05 A.M., Dietary Aide #365 verified breakfast was scheduled to arrive on the Maple unit at 7:30 A.M., at the Pines rooms at 7:55 A.M. and in the Pines dining room at 8:10 A.M. This was consistent with posted tentative times for meals to arrive on the units.On 03/30/26, breakfast arrived on the Maple unit at 8:07 A.M.On 04/02/26 at 9:28 A.M., the cart containing the Pines dining room and Pines room meals arrived.On 04/02/26 at 9:05 A.M., [NAME] #370 and [NAME] #371 verified it was difficult to get meals out to the units at the scheduled times when there were two dietary staff working. Sometimes, like that day, there was a third person sent to the dietary department to provide assistance. The assistant that day, Certified Nursing Assistant (CNA) #332, arrived at 8:00 A.M. (1/2 hour after the first cart was scheduled to be delivered). Cooks #370 and #371 revealed when there were three regularly scheduled dietary staff working on Fridays and Saturdays they could deliver meals on time. Review of dietary schedules revealed on Mondays and Wednesdays, there were two dietary aides and/or cooks scheduled to work the 6:00 A.M. to 2:00 P.M. shift.2. Review of the tentative mealtimes for lunch revealed the Maple unit was scheduled for delivery at 11:30 A.M., Buckeye dining room was scheduled for delivery around 11:25 A.M., Pines rooms at 11:55 A.M. and Pines dining room at 12:10 P.M. Observations on 04/02/26 at 12:17 P.M. revealed dietary staff were still preparing the cart for Maple unit. On 04/02/26 at 12:30 P.M., Residents #3, #32, and #84 were observed sitting in the Buckeye dining room complaining about how hungry they were with one of them stating she was starving.On 04/02/26 at 12:53 P.M., the cart containing the trays for Pines rooms and dining room left the kitchen. The cart arrived to the Pines dining room at 12:55 P.M. The cart arrived on the Pines unit for those who ate in their rooms at 12:58 P.M. The last tray was served at 1:10 P.M. [NAME] #370 stated dietary appreciated when they were provided extra assistance from other departments, but it took extra time to get meals out because the staff from the other departments needed more direction of what to do verses having somebody who was already trained in the kitchen.

Based on observation, policy review, and interview, the facility failed to ensure food was prepared and stored in a manner to prevent contamination. This affected/had the potential to affect 53 residents (Residents #1, #2, #3, #5, #7, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #23, #24, #25, #26, #27, #29, #30, #31, #33, #37, #39, #42, #43, #44, #46, #48, #51, #52, #55, #56, #58, #59, #60, #61, #63, #65, #66, #68, #71, #72, #73, #74, #75, #77, #79, #84, #86, and #87) of 73 residents who had orders for diets with regular texture. The facility census was 73.Findings include:1. During meal preparation and service observations on 03/31/26 between 4:18 P.M. and 5:23 P.M., [NAME] #369 was observed monitoring the temperature of foods. While taking food temperatures, the cord of the thermometer came into direct contact with potato wedges for approximately 30 seconds. The thermometer had been observed on multiple surfaces in the kitchen with only the probe part cleaned.During the dinner tray line on 03/31/26, when a plate with double portions was prepared, there was not sufficient room on the plate for all the food, so [NAME] #369 used her gloved hand she had been using to pick up hoagie buns and potato wedges to open a cupboard and obtain bowls. The inner part of the top bowl and the outside of the bottom bowl came into contact with the gloves used to open the door. [NAME] #369 returned to steam table and started handling buns and potatoes with the same gloved hand.On 03/31/26 at 5:23 P.M., Dietary Manager #400 verified the thermometer cord should not have been permitted to come into contact with food and verified [NAME] #369 should have washed her hands and changed gloves after she came into contact with cupboard instead of using the same gloves to continue to handle buns and the potato wedges.Review of the Food Safety and Sanitation policy (implementation date not listed) revealed employees were to wash their hands just before they started to work in the kitchen and after smoking, sneezing, using the restroom, handling poisonous compounds or dirty dishes and touching face, hair, other people or surfaces or items with potential for contamination. 2. On 04/02/26 at 9:50 A.M., the refrigerator on Buckeye unit was observed to contain two large Styrofoam food carry out containers and a Styrofoam bowel with Resident #25's name on them. Two of the three containers had a date of 03/01 on them. The other had a number three, but the remaining numbers were illegible. On 04/02/26 at 9:50 A.M., Licensed Practical Nurse (LPN) #311 verified two of the containers had a date of 03/01 written on them while the third container only had a three which was legible. LPN #311 stated food was only supposed to be kept for three days. Review of the facility's policy, Food Brought by Family/Visitors (no implementation date), addressed notification of staff if someone wished to provide food from an outside source. Perishable foods must be stored in resealable containers with tightly fitting lids in the refrigerator and labeled with the resident's name, the item and the use by date. The nursing staff was responsible for discarding perishable foods on or before the use by date. The facility identified Residents #1, #2, #3, #5, #7, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #23, #24, #25, #26, #27, #29, #30, #31, #33, #37, #39, #42, #43, #44, #46, #48, #51, #52, #55, #56, #58, #59, #60, #61, #63, #65, #66, #68, #71, #72, #73, #74, #75, #77, #79, #84, #86, and #87 with orders for diets with regular texture.

Based on observations, interviews and facility policy review, the facility failed to secure one of three medication storage rooms (Pines Unit) to prevent potential unauthorized resident entry. This had the potential to affect 25 residents (#1, #6, #7, #10, #15, #20, #23, #24, #25, #27, #31, #37, #39, #40, #43, #45, #49, #50, #52, #61, #63, #69, #72, #79, and #87) residing on the Pines Unit. The facility census was 73.Findings include:During observations conducted on 03/30/26 at 5:50 A.M., Licensed Practical Nurse (LPN) #382 left the facility before the arrival of scheduled oncoming staff for the Pines Unit. The medication storage room on that unit was left unsecured and accessible (it was unknown what time she left or how long the medications were left unsecured). Follow up observations at 6:00 A.M. confirmed that medications were not secured inside the room, and several medications were left on the countertop, making them accessible to any resident entering the room. There were no residents observed around the medication storage room or the countertop at the time of the observation. At 6:01 A.M., LPN #341 was interviewed and stated that all medication storage rooms were required to remain locked at all times. LPN #341 acknowledged that the Pines Unit medication room had not been secured as required.An interview conducted on 03/30/26 at 11:20 A.M. with the Director of Nursing (DON) revealed that the DON was informed of the unsecured medication room and the unsecured medications. The DON confirmed that, according to facility policy, all medication storage rooms must remain locked and secured at all times. The DON also reported that LPN #382 was no longer employed by the facility.A review of the facility's Medication Labeling and Storage policy, dated 2001, indicated that all medications and biologicals must be stored in a locked cabinet, cart, or medication room that is inaccessible to residents and visitors. Access to medication keys is limited to authorized personnel only.

Based on observation, review of menus/spreadsheets, and interview, the facility failed to ensure staff were adequately trained regarding scoop/portion sizes and failed to have sufficient tools available to accurately measure portion sizes. This had the potential to affect ten residents (Residents #6, #8, #19, #22, #28, #35, #36, #45, #62, and #69) who had orders for mechanical soft diets and 53 residents (Residents #1, #2, #3, #5, #7, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #23, #24, #25, #26, #27, #29, #30, #31, #33, #37, #39, #42, #43, #44, #46, #48, #51, #52, #55, #56, #58, #59, #60, #61, #63, #65, #66, #68, #71, #72, #73, #74, #75, #77, #79, #84, #86, and #87) as residents who received regular texture food. The facility census was 73.Findings include:Observations on 03/31/26 between 4:18 P.M. and 5:23 P.M. revealed the following as [NAME] #368 was placing scoops and utensils in the food for serving, she placed a size 16 scoop (equivalent to two ounces) in the mechanical soft meat. While doing so, [NAME] #368 referred to the scoop as three ounces. Dietary Manager #400 overheard and verified with a chart posted on the wall that a size 16 scoop was only two ounces. [NAME] #368 continued to refer to the #16 scoop as three ounces. At first, Dietary Manager #400 stated it would be okay because it would be served on a hoagie bun. After discussing the nutritional difference between the meat and bread and the fact a roll was already on the menu to be served for residents receiving mechanical soft diet, Dietary Manager #400 stated residents on mechanical soft diets should not receive the hoagie anyway and provided rolls to be provided for residents on mechanical soft diets. After reviewing the menu, Dietary Manager #400 stated residents on mechanical soft diets were supposed to receive three ounces of meat and verified the size 16 scoop [NAME] #368 still planned to use was indeed two ounces and did not follow the menu. [NAME] #369 and Dietary Manager #400 searched for a three-ounce scoop and were unable to locate one. [NAME] #369 stated she was upset because she had worked at the facility for 4.5 years and always thought the size 16 scoop was equivalent to three ounces because that was what she was taught. A one and 5/8 scoop was located with [NAME] #369 indicating she would serve one full scoop and part of another scoop to equal three ounces. Further review of the menu revealed residents on regular diets were ordered four ounces of red skin potatoes while residents with orders for mechanical soft and low concentrated sweet diets were supposed to receive four ounces of potato wedges. Observations revealed for the first tray [NAME] #369 used a utensil shaped like a spaghetti scoop to serve potato wedges. All other residents, except those with orders for pureed diets, received potato wedges with the wedges picked up with a gloved hand with no measuring completed.Dietary Manager #400 stated she looked for tongs to serve the potato wedges but could not find any.The facility identified Residents #6, #8, #19, #22, #28, #35, #36, #45, #62, and #69 as residents who received mechanical soft diets. The facility identified Residents #1, #2, #3, #5, #7, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #23, #24, #25, #26, #27, #29, #30, #31, #32, #33, #37, #39, #42, #43, #44, #46, #48, #50, #51, #52, #55, #56, #58, #59, #60, #61, #63, #65, #66, #68, #71, #72, #73, #74, #75, #77, #79, #84, #86, and #87 as residents who received regular texture food.

Based on review of personal funds balance, quarterly statements, and interview, the facility did not ensure residents with balances over $1800 received notifications to spend down. This affected two residents (#8 and #45) out of five residents reviewed for personal funds. The facility census was 73.Findings include:Review of the quarterly statement dated 02/18/26 revealed Resident #8 had accumulated a balance of $5496.14 as of 01/02/26, $4892.15 as of 02/02/26 and a balance of $6133.00 as of 02/18/26. Review of the quarterly statement dated 02/18/26 revealed Resident #45 had accumulated a balance of $3289.76 as of 01/02/26 and $4558.80 as of 02/18/26. Interview on 04/06/26 at 9:51 A.M. with Business Office Manager (BOM) #301 revealed she was unable to provide documentation showing the residents and/or residents' representatives were provided written notice to spend down personal funds as required.

Based on observation and interview, the facility failed to post required nurse staffing information. This had the potential to affect all 73 residents residing in the facility.Findings include:On 03/30/26 at 6:05 A.M. revealed the only nurse staffing information posted was dated 03/27/26.On 03/30/26 at 6:05 A.M., Licensed Practical Nurse (LPN) #314 verified the posted staffing information was dated 03/27/26.

Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure residents rooms were clean and homelike. This affected five residents (#49, #52, #60 , #67, and #72) out of 11 residents reviewed for physical environment. The facility census was 73. Findings include:1. Review of the medical record for Resident #49 revealed an admission date of 01/09/26. Diagnoses included unspecified mental disorder due to known physiological condition, difficulty walking not elsewhere classified, anxiety disorder, impulsive disorder, major depression recurrent, and obsessive-compulsive disorder.Further review of Resident #49's medical record revealed the admission Minimum Data Set (MDS) assessment, dated 01/18/26, which indicated the resident was cognitively intact. Observation during an environmental tour on 02/13/26 from 12:23 P.M. to 12:40 P.M. with Maintenance Director (MD) #369 revealed in Resident #49's room, there were two windows side by side on the back wall which looked out onto the facility's parking lot. Each window had a blind and each of the blinds were fully extended yet the blinds were not long enough to fully cover the windows leaving an approximate four-inch gap between the bottom of the blind and the windowsill on both windows. At the time of observation, MD #369 confirmed the blinds did not go completely down to the windowsills, and the windows looked out onto the facility parking lot so anyone could look into the resident's room via the window view. Interview on 02/13/26 at 1:41 P.M. with Resident #49 revealed that since the blinds did not completely cover the whole window in his room, he was unable to achieve a dark room, which he preferred for sleeping. As a result, the resident voiced his ability to sleep had been negatively affected. He also voiced concerns regarding privacy, since he felt others were able to look into his room from the parking lot.Review of facility map revealed Resident #49's room faced the facility parking lot and the resident's windows were within view of anyone who entered the facility.2. Review of the medical record for Resident #72 revealed an admission date of 12/24/25. Diagnoses included noninfective gastroenteritis and colitis, ulcerative colitis, anxiety disorder, abdominal pain, diarrhea, and diverticulitis of intestine without perforation.Further review of Resident #72's medical record revealed a Medicare five day MDS assessment, dated 01/08/26, indicated the resident was cognitively intact. Observation during an environmental tour on 02/13/26 from 12:23 P.M. to 12:40 P.M. with MD #369 revealed in Resident #72's room, there were two windows side by side on the back wall which looked out onto the parking lot. Each window had a blind and each of the blinds were fully extended yet the blinds were not long enough to fully cover the window which left an approximate an eight inch gap between the bottom of the blind and the windowsill for the left window and a twelve inch gap between the bottom of the blind and the windowsill for the right window. There were various dark brown stains on the resident's privacy curtain. At the time of observation, MD #369 confirmed the blind did not go completely down to the windowsill and the windows looked out onto the parking lot, and the privacy curtain needed cleaned.Interview on 02/13/26 at 2:27 P.M. with Resident #72 revealed her blinds were open all the time, and at home, she kept her blinds closed since she liked the room dark. She stated sometimes she worried that others could look into her window and see her using the bedside commode and other times she felt she was being watched through her window. Observation at the time of interview revealed sitting to the right of the window on the back wall of the room was a bedside commode.Review of facility map revealed Resident #72's room faced the facility parking lot, and the resident's windows were within view of anyone who entered the facility.3. Review of the medical record for Resident #60 revealed an admission date of 07/12/21. Diagnoses included Alzheimer's disease, hemiplegia affecting left dominant side, anxiety disorder, major depressive disorder, and chronic kidney disease.Further review of Resident #60's medical record revealed an annual Minimum Data Set (MDS) assessment, dated 01/02/26, which indicated the resident was cognitively intact. Interview with Resident #60 on 02/13/26 at 10:10 A.M. revealed she was not sure how often her room was getting cleaned since she hadn't seen anyone coming in to clean her room. She stated the privacy curtain was a mess and it hadn't been cleaned since she had been there. She stated her room wasn't getting dusted, and the blinds didn't go all the way down. Since the blinds didn't extend the full length of the window, she had to pull the privacy curtain between her bed and the window to block the sunlight from shining into her face. She also stated not having the blinds being able to fully cover the window bothered her because she felt people could look into her room. Observation at the time of the interview revealed the blinds were fully extended but left a gap between the bottom of the blinds and the windowsills and the sunlight coming into the resident's room was shining toward the resident, who was laying in her bed, which was to the right of the window, with the head of the bed on the same back wall as the window. If the privacy curtain hadn't been pulled, the sun would have shined directly into the resident's face.Observation during an environmental tour on 02/13/26 from 12:23 P.M. to 12:40 P.M. with MD #369 revealed in Resident #60's room, there were two windows side by side on the back wall which looked out onto the facility parking lot. Each window had a blind and each of the blinds were fully extended yet the blinds were not long enough to fully cover the room, which left an approximately eight-inch gap between the bottom of the blinds and the windowsills. There were broken slats on the blinds, and the windowsill had a build of up of dirt and debris which included remnants of what appeared to be dried up flower petals. There were various colored stains on the resident's privacy curtain and the dresser, which had a TV sitting on it, had a visible layer of white dust on both the top of the dresser and the black base of the television. At the time of observation, MD #369 confirmed the blinds did not go completely down to the windowsill and were broken, the windows faced the facility parking lot, the privacy curtain needed washed, and the room needed dusted.Review of facility map revealed Resident #60's room faced the facility parking lot, and the resident's windows were within view of anyone who entered the facility.4. Review of he medical record for Resident #52 revealed an admission date of 12/28/25. Diagnoses included acute and chronic respiratory failure, chronic obstructive pulmonary disease, personal history of other mental or behavioral disorders, idiopathic sleep related nonobstructive alveolar hypoventilation, and obstructive sleep apnea.Further review of Resident #52's medical record revealed a quarterly MDS assessment, dated 01/27/26, which indicated the resident was cognitively intact and had trouble falling or staying asleep or sleeping too much seven to eleven days of the past two weeks of the assessment reference period. Interview on 02/13/26 at 10:01 A.M. with Resident #52 revealed his blinds were broken and didn't go all the way down the window, which had affected his ability to sleep. He also indicated he had concerns with his room not being private since the blinds didn't fully cover the windows. Observation at the time of the interview revealed the blinds covering both windows had broken slats, were fully extended but didn't cover the whole window with a gap between the end of the blind and the windowsill, and the parking lot could be seen from the windows.Observation during an environmental tour on 02/13/26 from 12:23 P.M. to 12:40 P.M. with MD #369 revealed in Resident #52's room, there were two windows side by side on the back wall which looked out onto the parking lot. Each window had a blind and each of the blinds were fully extended yet the blinds were not long enough to fully cover the room, which left an approximately eight-inch gap between the bottom of the blind and the windowsill for both windows. There were broken slats on the blinds. At the time of observation, MD #369 confirmed the blinds did not go completely down to the windowsill, the windows faced the facility parking lot, and the blinds were broken. Review of facility map revealed Resident #52's room faced the facility parking lot, and the resident's windows were within view of anyone who entered the facility.5. Review of the medical record for Resident #67 revealed an admission date of 01/16/26. Diagnoses included chronic respiratory failure, depression, and chronic obstructive pulmonary disease.Further review of Resident #67's admission Minimum Data Set (MDS) assessment, dated 01/25/26, revealed the resident was cognitively intact; had trouble falling or staying asleep or sleeping too much 12 to 14 days over the past 2 weeks of the assessment reference period. Observation during an environmental tour on 02/13/26 from 12:23 P.M. to 12:40 P.M. with MD#369 revealed in Resident #67's room there were two windows on the back wall of the room with blinds, which were fully extended and covered the whole length of the windows. The blind on the left side window had one broken slat one third the way up the blind which had been repaired with scotch tape, and there was another slate broken one third the way down from the top. The privacy curtain had three orange stains. At the time of the observation, MD #369 confirmed the blind had broken slats and the privacy curtain needed cleaned.Interview on 02/13/26 at 3:57 P.M. with Resident #67 revealed he had to tape the blinds since they were ugly and he wanted his room to be nice. He went on to state the facility would come in and sweep and mop the floor, empty the garbage, and clean the bathroom, but he had never seen someone come in and dust. As a result, he had been dusting his room himself. He also indicated the stained privacy curtain did bother him, and he felt it needed to be washed.6. Observation upon entry to the facility on [DATE] at 8:05 A.M. revealed as you walked toward the building, there were eight resident rooms to the right of the entrance. The windows had white horizontal blinds and some of those blinds were open and did not extend the full length of the window.Interview on 02/13/26 at 9:43 A.M. with Housekeeper #372 revealed normally there were two to three housekeepers a day who worked dayshift to clean the facility but today she was the only housekeeper on day shift, and as a result, she was would only be able to get the common areas cleaned and would not be able to get any cleaning done in the residents rooms. She indicated she was not sure who was responsible for cleaning the privacy curtains in the residents' rooms.Interview on 02/13/26 at 10:25 A.M. with Registered Nurse (RN) #356 revealed she didn't feel residents' rooms were being dusted as frequently as they should, since she often saw an accumulation of dust on the dressers and windowsills. When it came to cleaning of the privacy curtains, she didn't think they were being frequently cleaned. She also stated the shortness of the window blinds could affect the privacy of those residents and some of the residents were using a privacy curtains to block the sun from shining into their face. Interview on 02/13/26 at 10:26 A.M. with Certified Nursing Assistant (CNA) #302 revealed she has seen the windowsills and dressers in residents' rooms have a buildup of dust on them. She went on to state when she would see a buildup of dust, she would try to wipe those areas down herself. When it came to who was responsible for cleaning the privacy curtains, CNA #302 indicated it was laundry's responsibility to ensure they were getting cleaned and went on to state she was unsure the last time she had seen a privacy curtain being cleaned. She also voiced concern about the length of the blinds in the residents' windows not fully covering the window which would provide a lack of privacy, especially for those resident rooms that faced the parking lot.Interview on 02/13/26 at 11:05 A.M. with Licensed Practical Nurse (LPN) #341 revealed the residents' rooms were not being dusted as often as they should since she has seen a buildup of dirt on the windowsills and dust on the tops of the dressers where the televisions sat. When it came to the cleaning of privacy curtains, she believed maintenance took them down and laundry washed them, but she was unsure of the last time she had seen one cleaned. She voiced concerns that some of the blinds in the residents' rooms do not go all the way down to cover the entire window which could affect the residents' privacy, especially for those residents' rooms which faced the parking lot.Interview on 02/13/26 at 11:20 A.M. with CNA #301 revealed she didn't feel residents' rooms were getting cleaned as thoroughly as they should since she had seen an accumulation of dead bugs and debris on windowsills and an accumulation of dust under the areas where the television sat. When it came to who cleaned privacy curtains, CNA #301 indicated it was housekeeping's responsibility to take them down and for laundry to wash them. CNA #301 indicated overall the privacy curtains were filthy and since she started almost two years ago, she had never seen a privacy curtain taken down to be cleaned. CNA #301 also indicated blinds in some of the residents' rooms were broken or didn't fully cover the window, which could affect the resident's privacy, and some residents needed to pull a privacy curtain between the window and them so it would block the sunlight from shining into their eyes.Interview on 02/13/26 at 11:33 A.M. with CNA #321 revealed sometimes when housekeeping was short, he would see residents' rooms not getting dusted like they should. When it came to the cleaning of privacy curtains, he indicated if he asked housekeeping to take a privacy curtain down to have it cleaned, it would be taken down to be cleaned, but he then went on to state it had been a while since he had seen a privacy curtain cleaned.Interview on 02/13/26 at 12:03 P.M. with Laundry #360 revealed she didn't know how frequently privacy curtains were being washed. She stated that when a privacy curtain was brought down to laundry, she would make sure it was washed. She voiced years ago the facility did have a schedule for when privacy curtains were to be cleaned, but currently there was no cleaning schedule for the privacy curtains.Interview on 2/13/26 at 12:07 P.M. with MD #369 revealed when it came to when privacy curtains were cleaned, there wasn't a cleaning schedule for when privacy curtains would be cleaned, and the curtains were only cleaned as needed. An additional interview on 02/13/26 at 12:40 P.M. after the environmental observation had been completed with Maintenance Director #369 confirmed many of the privacy curtains needed cleaned, residents' rooms were not being dusted as often as they should, and many of the blinds were too short and didn't completely cover the window and/or were broken.Interview on 02/13/26 at 5:00 P.M. with the Administrator confirmed rooms should be dusted, privacy curtains should be cleaned, and window blinds should be able to extend the full length of the window and shouldn't be broken.Review of facility policy titled Homelike Environment, revised February 2021, revealed the facility would provide a safe, clean, comfortable, and homelike environment with comfortable lighting with minimum glare.This deficiency represents noncompliance investigated under Complaint Number 2713771.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, interview, review hospital paperwork, review of the facility investigation and witness statements, review of personnel files, review of the manufacture's guidelines and facility policy review, the facility failed to ensure safe use of a Sara Steady lift for Resident #62. This affected one (Resident #62) of 6 reviewed for accidents. The facility census was 59.Findings include: Review of the medical record revealed Resident # 62 was admitted to the facility on [DATE] with diagnoses including memory deficit following unspecified cerebrovascular disease, Type II Diabetes Mellitus, chronic hepatic failure without complications, chronic obstructive pulmonary disease, hemiplegia, affecting unspecified side, major depressive disorder, recurrent severe with psychotic symptoms, traumatic brain injury, and deficiency of multiple nutrient elements.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of nine out of 15, indicating impaired cognition. The resident required activities of daily living (ADL) assistance, including mobility, personal hygiene, and transfers.Review of the plan of care dated [DATE] revealed Resident #62 required dependent assistance related to self-care deficit related to decreased mobility Interventions included Resident #62 to perform active range of motion to bilateral extremities for 15-minute sessions three to six days a week as tolerated to improve/maintain current level of function. There was no intervention for the use of a Sara Steady lift for transfers.Review of the physician's orders for [DATE] revealed no order for a Sara Steady lift for transfers. Review of the nursing progress note dated [DATE] 11:47 A.M. revealed two certified nursing assistants (CNAs) entered Resident #62's room and observed the resident slumped over and unresponsive at approximately 6:28 P.M. One CNA ran to get the nurse while the other CNA stayed with the resident. The nurse responded and noted Resident #62 to be void of vital signs, no pulse or respirations detected. Resident #62 was a Full Code (all possible life-saving measures). Code Blue was called, and staff immediately initiated cardiopulmonary recusation (CPR) at 6:30 P.M. Two additional nurses immediately responded to the room, one with the crash cart. 911 was called by the CNA at 6:30 P.M. Nurses rotated in maintaining CPR per protocol. The local fire department personnel arrived at facility at 6:38 P.M. and assisted nurses with ongoing CPR. The ambulance arrived at the facility at 6:42 P.M. and initiated compressions with the use of the LUCAS machine (a device that gives automatic chest compressions during CPR). The ambulance crew administered epinephrine (medication that helps improve blood flow) and intubated the resident. A pulse was detected, and the resident was transferred to the local hospital by ambulance at 7:07 P.M. Resident #62's son and Medical Director #578 were updated by the facility nurse.Review of the facility investigation dated [DATE] revealed the root cause analysis was conducted by [NAME] President (VP) of Operations #575, VP of Clinical Services #576, Regional Director of Clinical Services #577, the Administrator, and the Director of Nursing (DON). The root cause was determined to be the staff member not following protocol for the resident lift and lack of supervision. VP of Operations #575 and VP of Clinical Services #576 provided education to the Administrator and DON on the following topics: transfer assistance, supervision of residents, call light availability, mechanical lift usage, change in condition, dignity, and facility abuse and neglect policy.Review of the witness statement dated [DATE] authored by Registered Nurses (RNs) #537 and #539 and CNAs #507, #512, #521, #523, #524, and #566 revealed CNA #567 placed Resident # 62 in a Sara Steady lift and left the resident standing there alone while she went to find help. CNA #567 was gone approximately four to five minutes according to witness statements. Resident #62 was found slumped over the Sara Steady bar, absent of vital signs, with bloody bowel movement noted. Resident #62 was placed in bed, and CPR was initiated. The resident was then transferred to the hospital. CNA #567 was immediately removed from her duties.Review of the hospital paperwork dated [DATE] revealed Resident #62 was transferred to the hospital by the local fire department. Personnel arrived at the facility at 6:38 P.M. and assisted nurses with ongoing CPR. The ambulance arrived at the facility at 6:42 P.M. and initiated compressions with the use of the LUCAS machine. Ambulance crew administered epinephrine and intubated the resident. A pulse was detected, and the resident was transferred to the local hospital by ambulance at 7:07 PM. with diagnoses including cardiac arrest. On [DATE], the resident expired after family withdrew care. Time of death was 10:06 P.M. The cause of death of was bilateral pneumonia versus massive aspiration or combination of these possibilities. Interview with RN #539 on [DATE] at 11:44 A.M. revealed at approximately, 6:15 P.M. on [DATE] report was given between RNs for shift change. They heard someone yelling for help. RNs #539 and #537 grabbed the crash cart and responded to Resident #62's room. Upon entering the room, Resident #62 was in the Sara Steady lift. CNAs were present in the room upon their arrival. Resident #62 was unresponsive, absent of vital signs. Resident #62's code status was checked and verified to be Full Code. Staff placed the resident in bed, called Code Blue, started CPR, called 911. The local fire department assumed CPR upon arrival. The resident regained a pulse and was transported to the local hospital. CNA #567 was immediately suspended and not left unattended; RN # 539 sat with her while she wrote a witness statement, and she was sent home directly after.Interview with CNA #512 [DATE] at 2:49 P.M. CNA # 567 called my phone for help with Resident #62 in the Sara Steady because she wouldn't stand. I told CNA #567 I would be down to help. I walked down to the other hallway and I called CNA 567 three times, and I couldn't find her. I walked into Resident #62's room and found her slumped over the Sara Steady bar with a bloody bowel movement and immediately called for help from the other staff. Resident #62 was moved to the bed, CPR was started.Review of the manufacture's guidelines for the Sara Steady Lift explicitly state that a resident must never be left unattended in the Sara Steady lift. The device is an aid for transfers and supported standing, not a seating device for long periods. A trained caregiver must always be present and maintain control of the device during the entire transfer process and any period the resident is in the Sara Steady. The Sara Steady is designed for safe and active sit-to-stand transfers (e.g., to/from a chair, bed, or toilet) and as a supportive aid for tasks like changing incontinence pads, not for unassisted seating or transportation for long distances/periods. The warning labels on the equipment specifically state: To prevent falls, never leave the patient unattended in the Sara Steady.Review of the undated manufacturer's guidelines revealed constant supervision by a trained caregiver must always be present and maintain control of the device during the entire transfer process and any period the resident is in the Sara Steady.- Intended Use: The Sara Steady is designed for safe and active sit-to-stand transfers (e.g., to/from a chair, bed, or toilet) and as a supportive aid for tasks like changing incontinence pads, not for unassisted seating or transportation for long distances/periods.- Fall Prevention: The warning labels on the equipment specifically state: To prevent falls, never leave the patient unattended in the Sara Steady.- Patient Participation: The device is intended for use by residents who can bear some weight on at least one leg, have some upper body strength, and can actively participate in the standing process by pulling themselves up with the support of the handlebars.- Caregiver Training: Use of the equipment requires a caregiver trained in following the instructions for use and in assessing the resident's condition and capabilities before each use.- Failing to follow these guidelines could result in serious injury or falls for the resident. The deficient practice was corrected on [DATE] when the facility implemented the following corrective actions: - On [DATE] at 7:20 P.M. LPN #524 notified Resident #62's son of the transport to the hospital. He reported that he had just spoken to the hospital.- On [DATE] at 7:30 P.M. LPN #524 notified Medical Director #578 of Resident #62's transfer to the hospital.- On [DATE] at 8:19 P.M. CNA #567 was suspended pending investigation.- On [DATE], all staff were immediately educated by the DON on transfer assistance, supervision of residents. Call light availability, mechanical lift usage, change in condition, dignity, and facility abuse and neglect policy.- On [DATE] at 9:00 am-9:30 A.M. the DON reviewed the clinical documentation for the past 72 hours to ensure all changes in condition were addressed.- On [DATE] from 10:30 A.M. to 10:55 A.M. an Ad-hoc Quality Assurance and Performance Improvement (QAPI) meeting was held with the Administrator, DON, Assistant Director of Nursing (ADON) #576, Medical Director #578, Activities Director #557, Staffing Coordinator #561, Business Office Manager #503, Human Resources (HR) Director #545, Wound RN #528, Social Services Director (SSD) #514. The root cause analysis was reviewed and corrective action taken. The Administrator educated those in attendance on transfer assistance, supervision of residents, call light availability, mechanical lift usage, change in condition, dignity and facility abuse and neglect policy.- On [DATE], Activity Director #557 and Wound RN #528 completed interviews of all residents with a BIMS greater than 12 and assessments of all residents with a BIMS score of 12 or lower to ensure freedom of abuse, neglect, and misappropriation. - On [DATE], the DON and ADON #576 reviewed and updated transfer status orders for all residents, reviewed and updated care plans as necessary for transfer status for all residents, and reviewed and updated Kardex and Point of Care tasks as necessary for transfer status for all residents.- On [DATE] from 10:56 A.M. to 11:45 A.M. SSD #514 completed an observational audit to ensure all residents' call lights were within reach in room and residents were treated with dignity and respect.- On [DATE], the DON completed an audit to ensure all nurses had valid CPR training. - On [DATE], competencies were initiated by Regional Director of Clinical [NAME] #577 and CNA Supervisor #561to ensure all nursing staff is competent utilizing lifts. Competencies will be completed prior to the next scheduled shift. - Beginning [DATE] the Administrator/designee will complete observational audits and interviews with five residents a week for four weeks and randomly thereafter to ensure no abuse/neglect allegations and that call lights are within reach through [DATE].- Beginning [DATE], the DON/designee will complete an audit of documentation for change in condition an new admissions to ensure appropriate care planning, orders, assessments and interventions for resident transfer status five times a week for four weeks and randomly thereafter though [DATE].- Beginning on [DATE], the Administrator/designee will complete observational audits and interviews with five residents a week for four weeks and randomly thereafter to ensure residents are being transferred appropriately through [DATE]. This deficiency represents noncompliance investigated under Master Complaint Number 2667747 and Complaint Number 2667167.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLAINCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, interview, record review and review of facility policy, the facility did not ensure residents were adequately supervised and did not ensure staff responded appropriately to a door alarm on the Buckeye unit to mitigate accident risk for Resident #49. This affected one resident (#49) out of three residents reviewed for accidents/hazards and had the potential to affect an additional 29 residents residing on the Buckeye unit ( Residents #4, #52, #68, #59, #24, #57, #44, #45, #7, #26, #25, #51, #21, #12, #27, #47, #23, #29, #55, #65, #61, #33, #71, #8, #40, #56, #48, #11 and #35). The facility census was 71. Findings include: Review of Resident #49 ' s medical record revealed an admission date of 02/23/2005 with diagnoses including paranoid schizophrenia, bipolar with severe psychotic features, neoplasm of endocrine glands, dementia with psychotic disturbance, muscle wasting, cognitive communication deficit, chronic kidney disease, age related cataract, anxiety disorder, obsessive compulsive disorder, dissociative identity disorder, and brief psychotic disorder. Resident #49 had a court appointed legal guardian. Review of Preadmission Screening/Resident Review (PAS/RR) dated 02/23/2005 revealed Resident #49 was admitted to the facility and was not able to return to community living due to poor safety awareness, mental health fluctuated, and Resident #49 required frequent monitoring, interventions and twenty-four-hour supervision to ensure safety. Review of plan of care date initiated 12/17/17 revealed Resident #49 had behavior problems that consisted of short tempered, and pushed buttons on code pads at doors, and wandered into other ' s rooms on a daily basis. Interventions included administering medications per physician order. Observe for mental status and behavior changes when new medication started or with new changes in dosage. Psych referral as needed. When Resident #49 was pushing buttons on code pads outside of doors it was best to let resident finish, and resident would return to appropriate unit without incident. A revision on 03/20/23 revealed Resident #49 was an elopement risk due to impaired cognition and competence, however, Resident #49 did not exhibit exit seeking behavior. Interventions included distract Resident #49 from wandering by offering pleasant diversions, structured activities, food, conversation, television and a book. Identify patterns of wandering, divert as needed and interview as appropriate. A revision on 08/21/23 revealed Resident #49 could go on a leave of absence without restrictions. Intervention included leave of absence per physician orders.Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #49 ' s cognition was intact with a Brief Interview Mental Score of 15 out of 15. Resident #49 had psychosis delusions present and wandered daily. Resident #49 did not need a mobility device and was independent to walk 150 feet once standing. Review of physician orders start date 08/23/25 and end date of 09/27/25 revealed Resident #49 could go out on a leave of absence with medication per nursing judgment. Review of an Elopement Review dated 08/24/25 revealed Resident #49 was low risk for elopement with an elopement score of eight. Review of a physician order start date of 09/27/25 revealed Resident #49 may go out on a leave of absence with supervision. Review of an Elopement Review dated 09/27/25 revealed Resident #49 was high risk for elopement with an elopement score of 10. Review of an Elopement Review assessment dated [DATE] revealed Resident #49 was ambulatory and had predisposing diagnosis of paranoid schizophrenia and bipolar disorder. Mental status was cognitively intact, and Resident #49 was responsive to redirection and cues. Resident #49 had an elopement episode in the past three months on 09/27/25. There was no medical cause increasing confusion, there was no psychological cause. Resident #49 was moved to secure unit. Review of a Medical Visit assessment , dated 10/01/25 , written by Physician Assistant (PA) #371, revealed Resident #49 had a recent elopement. Resident #49 was seen on 10/01/25 after she had eloped over the weekend. PA #371 assessed Resident #49 as alert , and in no distress. Resident #49 stated to PA #371 she left to inquire about moving to another facility next door. Resident #49 denied current desire to leave the facility. Review of plan of care, revision date 09/27/25, revealed Resident #49 was at risk for elopement due to impaired cognition and competence. Intervention included reside on a secured unit. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television or a book. Identify pattern of wandering, divert as needed and intervene as appropriate. Leave of absence with supervision was updated. Review of the facility document titled Witness Statement Form, dated 09/27/25, written by certified nurse assistant (CNA) #373 revealed she came out of room one on the Buckeye unit and heard the back door alarm go off. CNA #373 walked down the hall to check the door, and did not see anyone outside, therefore CNA #373 turned off the alarm. CNA #373 thought the wind set the alarm off. The last time CNA #373 saw Resident #49 was 4:50 A.M. Review of the facility document titled Witness Statement Form, dated 09/27/25 at 5:30 A.M., written by CNA #311 revealed they did not witness the incident but assisted with the return of Resident #49 to the facility. Review of the facility document titled Witness Statement Form, dated 09/27/25 at 5:30 A.M., written by Licensed Practical Nurse (LPN) #322 revealed the last time Resident #49 was seen was 5:00 A.M. exiting her room and standing in the hallway near the vending machine on the Buckeye Unit. Review of facility document titled , Resident Leave of Absence Log, on 09/27/25, revealed Resident #49 did not sign out at 5:00 A.M. to leave the facility . Resident #49 ' s sister signed Resident out on 09/27/25 at 10:24 A.M. and Resident #49 returned to the facility on [DATE] at 3:22 P.M. An interview on 10/06/25 at 9:55 A.M. with Housekeeper #339 revealed Resident #49 got out of the facility and was gone for 20 minutes without staff realizing Resident #49 was gone. A staff member silenced the alarm and did not report the door alarm went off. An interview on 10/06/25 at 10:00 A.M. with CNA # 359 revealed Resident #49 left the facility early one morning. Resident #49 was known to wander. An interview on 10/06/25 at 10:15 A.M. with Central Supply #362 revealed Resident #49 got out of a locked door at the end of the Buckeye unit. The alarm sounded but the aid did not notify the nurse and a head count was not done. Resident #49 walked to another facility when Resident #49 was found. An interview on 10/06/25 at 10:25 A.M. with Resident #26 revealed Resident #49 got out of the building and ended up at another facility. An interview on 10/06/25 at 10:30 A.M. with Licensed Practical Nurse (LPN) #306 revealed Resident #49 got out of the building through a fire door. An interview on 10/06/25 at 10:45 A.M. with Resident #49 verified she went out the door at the end of the Buckeye unit after she pushed the door open. Resident #49 stated she heard the alarm go off, and no staff were around her when she left the facility out the door while the alarm was sounding. Resident #49 stated they did not like me on the road without a vehicle. An observation on 10/06/25 at 10:50 A.M. of the Buckeye Unit revealed it was a locked unit which required pass code for any staff member or resident to leave or enter the unit from other areas of the facility. At the end of the long hall there was an exit door that led outside to the side of the building. The door was not in view of the nurse station or the dining room on the Buckeye unit. This door which Resident #49 exited out of to the outside of the facility could be opened after pressing on the door for 15 seconds, as it was a fire door exit. The door would emit a loud alarm to alert staff and the alarm would need to be shut off by staff to stop the alarm sound. An interview on 10/06/25 at 12:03 P.M. with Physician Assistant #371 revealed Resident #49 was not safe to be outside the facility unsupervised. An interview on 10/06/25 with Resident #49 ' s Guardian #372 revealed Resident #49 was smart enough to hold the door handle for 15 seconds to exit the facility. Guardian #372 stated she was notified Resident #49 got out of the facility, a staff member heard an alarm but did not see anybody outside so they turned off the alarm. Guardian #372 stated they were told that Resident #49 was last seen on 09/27/25 at 5:00 A.M. and was found at the other facility at 5:20 A.M. An observation on 10/06/25 at 12:15 P.M. with Maintenance Director (MD) #333 revealed the Buckeye Unit long hall exit door alarm sounded when pushed on the handle for 15 seconds and opened to the outside. Once outside there was a crossroad leading to another nursing facility on the property. MD #333 stated Resident #49 walked approximately 75 feet to the other facility traveling up a slight hill that graded upward. There was car traffic observed driving down the street to reach the facility. An interview on 10/06/25 at 12:50 P.M. with the Administrator revealed Resident #49 went from this facility to another facility without staff knowledge until the other facility called to see if the facility was missing a resident. CNA #373 was fired because they did not follow protocol and did not respond properly when the door alarm sounded. The Administrator stated corrective action had been put into place to ensure there would be no further incidents. Review of the facility policy titled Elopements, revised December 2007, revealed staff shall investigate and report all cases of missing residents. Staff shall promptly report any resident who tried to leave the premises to the charge nurse or the director of nursing. When the departing resident returns to the facility the DON would examine for injuries, notify the attending physician, notify legal guardian, complete and file incident report and document the event in the medical record. Review of the facility policy titled Signing Residents Out, dated August 2006, revealed all residents leaving the facility must be signed out. Staff observing a resident leaving the premises and having doubts about the resident being properly signed out, should notify their supervisor at once. Restrictions noted on the residents chart concerning who may not sign the resident out must be honored. As a result of the incident, the facility took the following corrective actions starting 09/27/25: On 09/27/25 the Administrator directed LPN #322 to move resident #49 to fully secured unit, after notifying the physician and responsible party. On 09/27/25 a root cause analysis was conducted by the Administrator, [NAME] President of Operations (VPO) #378, the DON , and Regional Director of Clinical Services (RDCS) #379. VPO #378 educated the Administrator and the DON on elopement and wandering resident policy and best practice, leave of absence policy, abuse policy, supervision of residents policy, and change in condition policy.On 09/27/25, Ad-hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator , the DON, Medical Director #374, Activities Director #356, Transportation Director #370, Dietary Manager #327, Staffing Coordinator #362, and Business Office Manager #301. Reviewed root cause analysis and corrective action. The Administrator educated those in attendance on elopement and wandering resident policy and best practice, leave of absence policy, abuse policy, supervision of residents policy, and change in condition policy.On 09/27/25, the DON and Assistant Director of Nursing (ADON) #314 reviewed and updated elopement assessments for all residents (71 of 71 residents).On 09/27/25 the Activities Director #356 and Business Office Manager #301 updated BIMS assessments for 71 of 71 residents. On 09/27/25, the DON and ADON #314 reviewed and updated, if needed, elopement care plans for 71 of 71 residents. On 09/27/25 the staffing coordinator #362 completed door checks of all facility exit doors.On 09/27/25 the DON reviewed and updated elopement binders. Resident #1, #2, #5, #13, #17, #20, #22, #27, #28, #38, #72, #43, #49, #58, #62, #70 were identified as elopement risk and verified information was in the Elopement binder. On 09/27/25 the Administrator updated door codes on all facility exit doors.On 09/27/25 the Staffing Coordinator #362, Dietary Manager #327, Transportation Director #370, and the Administrator initiated staff education on elopement and wandering resident policy and best practice, leave of absence policy, abuse policy, supervision of residents policy, and change in condition policy. 71/71 staff educated. The Agency Nurse Company was provided with an education on elopement and leave of absence policy and procedure and a quiz for all incoming agency aids to the facility.On 09/27/2 the Administrator conducted elopement drills on afternoon shift and day shift. ADON #314 completed/will complete one elopement drill on each shift weekly for four weeks then one elopement drill on rotating shifts monthly for three months and randomly thereafter beginning 09/27/25 and ending 02/27/26. The DON would complete audits of documentation for change in condition five times a week and randomly thereafter beginning 09/29/25 and ending 10/24/25. The Administrator completed/will complete audits of bed boards for change in leave of absence five times a week for four weeks and randomly thereafter beginning 09/29/25 and ending 10/24/25.At the time of the survey completed on 10/07/25, there were no further incidents of non-compliance identified related to hazards/accident risk. This deficiency represents non-compliance investigated under Complaint Number 2633309.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the facility's Self-reported incident (SRI), review of facility investigation, observations, staff and resident interviews, and review of the facility's Abuse, Neglect, Exploitation, and Misappropriation of Resident policy, the facility failed to ensure a resident was free from staff to resident physical abuse. This affected one (#17) of four residents reviewed for abuse. The facility census was 67. Findings include: Record review revealed Resident #17 was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder bipolar type, borderline personality disorder, and mild intellectual disabilities. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was cognitively intact, and required supervision with showers, dressing, and personal hygiene. Resident #17 did not require any mobility devices. Review of the care plan dated 03/13/25 revealed Resident #17 was prone to behaviors that included verbally abusing staff and others and threatening self-harm. Resident #17 also had the potential for mood problems related to the identified mental health diagnoses of which interventions included anticonvulsant medication therapy, behavioral health services, and monitoring of signs and symptoms of mania, increased irritability, and frequent mood changes. Review of the Police Report (Incident Number 25BV04872) revealed a report time of 04/07/25 at 9:07 P.M. The original narrative indicated the police department responded to an assault at nursing home. The supplemental narrative revealed the officer was dispatched for a fight/assault between a resident and and employee. The officer spoke to Licensed Practical Nurse (LPN) #153 who advised she was the supervisor for the night shift and the resident was identified as Resident #17. Resident #17 was hysterically crying in the hallway. When asked what happened, Resident #17 stated she was trying to get from one area to the other but there was another resident in her way who was in a wheelchair. Resident #17 began to move the other resident out of her way when Certified Nurse Aide (CNA) #177 shouted at her and told her not to touch her residents ever again. Resident #17 then explained that she told CNA #177 to move her own damn patient out of the way, both parties than began shouting at one another. Resident #17 then stated CNA #177 walked over to her and got in her face and belly bumped her causing them to fight. The next thing Resident #17 knew, she was pushed to the ground causing her to hit her head. CNA #177 and the officer spoke outside of the facility (CNA #177 had been suspended prior to the officer's arrival and was not permitted in the facility). CNA #177 said she was coming out of another resident's room and observed Resident #17 pushing another resident. CNA #177 told Resident #17 to stop pushing the resident. CNA #177 explained Resident #17 called her an expletive and told her to catch her outside. CNA #177 then told Resident #17 do something if you want, I'm not scared. CNA #177 then explained she began moving the other resident down the hall when Resident #17 ran up to her and belly bumped her causing them to fight. CNA #177 grabbed Resident #17 by the arms causing her to fall to the floor. CNA #177 then showed the officer scratch marks on her arms and elbow that occurred during the altercation. The officer spoke with LPN #153 and asked if she witnessed the incident which she did and LPN #153 filled out a witness statement. LPN #153 told the offices that everything Resident #17 explained to the officer was accurate and CNA ran up to Resident #17 and started the altercation by belly bumping Resident #17. The report further indicated after discussion with other officers, it was apparent that CNA #177 was the aggressor in the situation. CNA #177 was told she was being placed under arrest for assault. CNA #177 was transported to the police department. Resident #17 was transferred to the local hospital for evaluation. Review of progress noted dated 04/07/25 timed 9:42 P.M. revealed Resident #17 had a change in condition due to a fall and was transported to the hospital for evaluation. Review of the presenting problem in the hospital assessment dated [DATE] revealed Resident #17 presented with complaints of headache and had been assaulted by one of the staff members in her facility and was subsequently punched on the head. A computed tomography (CT) scan of her head and spine was performed and did not show evidence of abnormal findings. Resident #17 did not suffer any loss of consciousness, there was no presence of any external lacerations or bleeding. Resident #17 was discharged back to the facility per the legal guardian's request. Review of the facility SRI dated 04/07/25 revealed Resident #17 reported the altercation began when she attempted to move another resident out of her way when CNA #177 told Resident #17 not to do that, then began to yell at Resident #17 and approached her quickly. CNA #177 then punched Resident #17 in the head at which time Resident #17 fought back. During the melee, Resident #17 suffered a fall and hit her head. Review of CNA #177's witness statement dated 04/07/25 revealed Resident #17 was observed pushing Resident #19 into the wall at which time CNA #177 told Resident #17 not to do that. Resident #17 responded by using expletives to communicate that CNA #177 needed to move that resident out of her way. CNA #177 reiterated to Resident #17 not to push Resident #19. Resident #17 then called CNA #177 a derogatory name and threatened her. CNA #177 responded by warning Resident #17 she was not afraid of her. Resident #17 moved into CNA #177's personal space, bumped into her belly, stepped back, then struck her in the face. CNA #177 grabbed Resident #17's arms to prevent being struck again. CNA #100 then grabbed Resident #17 who was still actively fighting. Resident #17 tripped and fell on the floor. Review of CNA #100's witness statement dated 04/07/25 revealed Resident #17 was observed pushing Resident #19 into the wall. CNA #177 then advised Resident #17 not to push Resident #19. Resident #17 began to use profanity and argue with CNA #177 at which time Resident #17 stated she would beat up CNA #177. CNA #177 continued to move Resident #19 towards the nurse's station in a wheelchair when both CNA #177 and Resident #17 became face-to-face. Resident #17 then struck CNA #177 who then grabbed Resident #17's arms. CNA #100 pulled Resident #17 back who then fell . CNA #100 jumped out of the way to prevent herself from falling with Resident #17. Review of LPN #153's witness statement dated 04/07/25 revealed LPN #153 heard CNA #177 yelling at Resident #17 to not push her resident (Resident #19). Resident #17 stated she did it because she needed to use the bathroom. CNA #177 continued to yell and swear at Resident #17 who responded with derogatory insults. LPN #153 advised both Resident #17 and CNA #177 to stop arguing. Resident #17 was standing in the hallway when CNA #177 approached her and the two were face-to-face. LPN #153 did not see who struck the other first but did report Resident #17 fell to the ground and hit her head when CNA #100 broke up the fight. Observations of Resident #17 on 04/28/25 at 9:07 A.M., 11:54 A.M., and 3:03 P.M. revealed the resident remained in her room. Multiple attempts to interview Resident #17 were unsuccessful. Interview on 04/28/25 at 1:34 P.M. with CNA #177 revealed Resident #17 pushed another wheelchair bound resident into a wall. CNA #177 commanded Resident #17 to stop. Resident #17 began calling CNA #177 derogatory names; however, CNA #177 continued to perform her duties and ignored Resident #17 who was yelling down the hallway at CNA #177. When CNA #177 moved towards Resident #17 in the hallway, CNA #177 was bumped by Resident #17 with her belly. CNA #177 grabbed Resident #17's wrist but CNA #177 was still struck in the face. CNA #177 confirmed LPN #153 witnessed the ordeal and said there were no other witnesses. CNA #177 reported she was arrested by the local police the night of 04/07/25 and was charged with assault on a functional disabled person. Interview on 04/28/25 at 1:46 P.M. with CNA #100 revealed Resident #17 pushed Resident #19 into a wall in her wheelchair and CNA #177 advised her not to push her resident (Resident #19) like that. Resident #17 stormed down the hall and began calling CNA #177 derogatory names. Resident #17 and CNA #177 began to argue, and Resident #17 approached CNA #177, bumped her with her belly, and then immediately struck CNA #177. CNA #100 grabbed Resident #17 and pulled her back at which time she (Resident #17) stumbled and fell . CNA #100 confirmed LPN #153 was in the hallway passing medications at the time of the incident. Multiple attempts to interview LPN #153 were unsuccessful; she was not available and did not return phone messages. Interview on 04/28/25 at 2:15 P.M. with the administrator revealed LPN #153 contacted her the night of the incident. The administrator advised LPN #153 Resident #17 needed to be assessed and CNA #177 suspended pending investigation. LPN #153 was also advised to contact local police and to obtain statements from witnesses. The administrator explained Resident #17 was also referred to counseling. After reviewing the conflicting witness statements, the administrator made attempts to contact CNA #177 however the calls were never returned. Review of the Abuse, Neglect, Exploitation, and Misappropriation of Resident Property revised 10/27/17 revealed the facility was intolerant of abuse which was defined as willful injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse irrespective of any mental or physical condition cause harm, pain, or mental anguish. The deficiency was corrected on 04/17/25 when the facility implemented the following corrective actions: Immediately following the incident on 04/07/25, Resident #17 was assessed for injuries by the nurse and transported to the hospital for further assessment. The hospital assessment revealed no injuries. On 04/07/25 CNA #177 was immediately suspended after the incident pending investigation of abuse and was subsequently terminated on 04/17/25. On 04/08/25 a list was compiled by the administrator of the cognitive level of each resident by reviewing the Brief Interview for Mental Status (BIMS) score of each resident. Residents with a BIMS score of 13 and above which indicated mild to no cognitive impairment, were interviewed by the Assistant Director of Nursing/LPN #17 and abuse questionnaire was completed. Residents with a BIMS score of 12 or below which indicated moderate to severe cognitive impairment, received a skin assessment completed by the wound nurse and Director of Nursing. There were no concerns identified regarding abuse. On 04/08/25 the administrator and regional director of clinical services conducted a root cause analysis with the vice president of clinical services. The root cause was found to be failure to appropriately deescalate and manage behaviors. On 04/08/25 an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held which included the medical director, administrator, director of nursing, assistant director of nursing, social services director, dietary manager, maintenance director, CNA supervisor, activities director, and human resources director. The QAPI meeting was held to review the root cause analysis and facility interventions. On 04/08/25 all facility staff received training on abuse and de-escalation which included tips, tools, and reminders for immediate reporting as well as notifying a manager of any resident with increased agitation. The training was completed by the department managers of nursing, CNAs, dietary, laundry and housekeeping. Training was completed in-person and telephonically. This was confirmed via review of sign in sheets. On 04/09/25 management began conducting random pop in visits during off hours one to two times per week for observations of any concerns or issues. This would continue for four weeks then randomly On 04/14/25 audits of 10 residents per week for four weeks for signs or symptoms of abuse commenced. The audits were completed on 04/14/25 and 04/21/25. No abuse concerns were identified. Interviews on 04/28/25 and 04/29/25 with LPN #114, LPN #117, and CNA #100 revealed they were knowledgeable regarding the facility policies and procedures regarding abuse and de-escalation of residents having catastrophic reactions. On 04/28/25 three additional residents (#11, #19, #27) were sampled and reviewed for abuse. No concerns were identified.

Based on record reviews, interviews, review of care conference attendance records and facility policy review, the facility failed to ensure residents and/or their representatives were invited to care conferences as required. This affected four residents (#22, #28, #39, and #54) out of four residents reviewed for care plan meetings. The facility census was 66. Findings include: 1. Review of the medical record for Resident #54 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, dementia, heart failure, cognitive communication deficit, schizophrenia, and disorientation. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed when asked how important it was to have family or a close friend involved in discussion about her care, Resident #54 answered it was very important. Review of the modification of quarterly MDS assessment dated [DATE] revealed Resident #54 was moderately impaired cognitively; altered level of consciousness behavior was present but fluctuated; rejected care four to six days during the assessment reference period; and was independent for walking up to 150 feet. Review of the Letters of Guardianship dated 10/06/15 from the probate of Mahoning County revealed Resident #54 had been deemed incompetent and Guardian #809 had been appointed guardian of person only for an indefinite time period for Resident #54. Interview on 04/07/25 at 11:08 A.M. with Resident #54 revealed the resident stated I don't go to care plan meetings, and my family doesn't either. Interview on 04/07/25 at 2:50 P.M. with Guardian #809, who was also the daughter of Resident #54, revealed she had never been invited or attended a care conference. She went on to state she was in the process of moving the resident into another facility since the facility had not been living up to her expectations. Further review of the progress notes from 03/04/24 to 04/10/25 revealed there was no documented evidence that Resident #54 or Guardian #809 had been invited to the care conferences. Review of facility document titled Care Conference Form V2-V2, dated 02/26/24, 05/23/24, 08/26/24, 10/28/24, and 02/13/25 in Resident #54's medical record revealed there was no documented evidence Resident #54 or Guardian #809 had attended or refused to attend any of those care conferences. 2. Review of the medical record for Resident #22 revealed an admitted [DATE]. Diagnoses included schizoaffective disorder bipolar type, cirrhosis of the liver, type two diabetes mellitus, cognitive communication deficit, altered mental status, vascular dementia, anxiety disorder, and major depressive disorder. Review of the MDS assessment dated [DATE] revealed Resident #22 was cognitively intact; inattention, disorganized thinking, and altered level of consciousness was present but fluctuated; rejection of care occurred daily; and the resident was mainly independent for activities of daily care and mobility. Review of the legal guardian paperwork, dated 07/21/23, from the Probate Court of [NAME] County, revealed Resident #22 was deemed incompetent, and Guardian #810 had been appointed guardian of person only for an indefinite time period for Resident #22. Review of facility document titled Care Conference Form V2-V2 dated 03/11/24, 06/10/24, 09/10/24, 12/12/24, 01/30/25, and 04/02/25 revealed there was no documented evidence Resident #22 had attended or had refused to attend, and the only care conference Guardian #810 was documented to have attended was on 09/10/24. Further review of the progress notes from 04/04/24 to 04/10/25 revealed there was no documented evidence Resident #22 or Guardian #810 had been invited to the care conferences Interview on 04/08/25 at 4:37 P.M. with Social Service Designee (SSD) #516 revealed the care conference meetings were scheduled based off the MDS assessment schedule. He stated he would go down to talk to the residents the day before or the day of the meeting to let them know about the meeting. For the responsible parties and guardians, he would look at the MDS schedule and try and get a hold of someone to let them know when the care conference had been scheduled. He stated he did not document who he had been able to contact and who he was unable to contact in regard to the meetings. He went on to state he would make a mental note of who he had contacted and who still needed to be contacted in regard to the care conference meetings. He confirmed there was no documented evidence of how and when residents and responsible parties/guardians were invited to care conferences. Interview on 04/09/25 at 2:57 P.M. with Guardian #810 stated the facility was not reaching out to him when care conferences were being held. He stated the only way he was getting notification of when care conferences were being held was when he reached out to the facility and asked when the next care conference was being held. Guardian #810 stated he was not aware a care conference for Resident #22 had been held on 04/03/25. He was unsure if Resident #22 had ever been invited to care conference but was not sure if she would agree to attend. 51521 3. Review of the medical record revealed Resident #28 was admitted on [DATE] with a diagnosis of COPD, cognitive communication deficit, unspecified dementia, unspecified severity with other behavioral disturbance, and anxiety disorder. Review of the admission MDS assessment dated [DATE] revealed Resident #28 had moderate cognitive impairment. Review of the care plan dated 03/12/25 revealed Resident #28 had impaired cognitive function and dementia or impaired thought processes. Interventions included communication with the resident's family/caregivers/ regarding resident's capabilities and needs. Monitor, document, report ant changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status. Record review revealed Resident #28 and/or Resident #28's representative have not been invited to care conferences and have not been involved in participating in his care. Resident #28 and/or his resident representative had not been informed of changes in care. The care conference form from 10/07/24 indicated that social services, activities and rehabilitation services attended, and review of the care conference form from 03/25/25 revealed that registered nurse, activities, and nursing administration attended. Interview on 04/09/25 at 8:08 A.M. with Resident #28's Power of Attorney (POA) granddaughter, revealed she had never been invited to care conference meetings and was usually not informed of any changes to the resident's care or changes in appointments. She has never been to a care conference for her grandfather and does not know what is going on with his care. She has had issues with her grandfather missing appointments. She was not happy with the care and was looking to move him. 4. Review of the medical record revealed Resident #30 was admitted on [DATE]. Diagnoses included unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the MDS dated [DATE] indicated Resident #30 had a mild cognitive impairment. Review of the care plan dated 03/24/25 revealed Resident #30 had impaired cognitive function or impaired thought processes secondary to diagnosis of dementia. Interventions included communication, and using the resident's preferred name. Identify yourself at each interaction. Face the resident when speaking, and make eye contact. Reduce any distractions. Monitor, document, report any changes in cognitive function, specifically changes in decision making ability, memory, recall, and general awareness, difficulty expressing self, consciousness and mental status. Record Review of the care conferences from May 2024 to March 2025 revealed the care conference on 05/23/24 revealed the social worker, activities, and nursing administration attended. The care conference on 08/26/24 revealed the social worker, activities, and nursing administration attended. The care conference on 03/03/25 revealed activities attended. There was no documented evidence that Resident #30 and/or her representative had attended care conferences. Interview on 04/08/25 at 03:00 P.M. with Dietary Manager #538 revealed she had attended care conferences in the past but, due to staffing challenges, she hasn't been able to attend the meetings recently. Interview on 04/08/25 at 3:54 P.M. with Dietitian #579 revealed, she will come in as needed. She attended high risk meetings via phone and reviewed the building off site unless she came in when needed. She stated she does not attend care conferences; someone from dietary attends care conferences. Interview on 04/08/25 at 4:37 P.M. with SSD #516 revealed the care conference meetings were scheduled based off the MDS assessment schedule. He stated he would go down to talk to the residents the day before or the day of the meeting to let them know about the meeting. For the responsible parties and guardians, he would look at the MDS schedule and try and get a hold of someone to let them know when the care conference had been scheduled. He stated he did not document who he had been able to contact and who he was unable to contact in regard to the meetings. He went on to state he would make a mental note of who he had contacted and who still needed to be contacted in regard to the care conference meetings. He confirmed there was no documented evidence of how and when residents and responsible parties/guardians were invited to care conferences. Review of the facility policy Resident Participation-Assessment/Care Plans, revised December 2016, revealed a seven-day notice of the care planning conference would be provided to the resident and his or her representative. The social service director or designee would be responsible for notifying the representative/representative and for maintaining records of such notices. Notices included the name of each person contacted; the date he or she was contacted; the method of contact (mail, telephone, or email); input from the residents or representatives if they were not able to attend; and refusal of participation if applicable.

Based on record reviews, interviews, review of care conference attendance records and facility policy review, the facility failed to ensure a member of the food and services staff, which was part of the interdisciplinary team, attended care conferences as required. This affected four residents (#22, #28, #39, and #54) out of four residents reviewed for care plan meetings. The facility census was 66. Findings include: 1. Review of the medical record for Resident #54 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, dementia, heart failure, cognitive communication deficit, schizophrenia, and disorientation. Review of the modification of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 was moderately cognitively impaired; altered level of consciousness behavior was present but fluctuated; rejected care four to six days during the assessment reference period; and was independent for walking up to 150 feet. Review of the facility document titled Care Conference Form v2-V2, dated 02/26/24, 05/23/24, 08/26/24, 10/28/24, and 02/13/25 in Resident #54's medical record revealed there was no documented evidence that a representative from food and nutrition services staff attended the meetings. Interview on 04/08/25 at 3:00 P.M. with Dietary Manager #538 revealed she had attended care conferences in the past but due to staffing challenges, she hasn't been able to attend the care conference meetings recently. Interview on 04/08/24 at 3:54 P.M. with Dietitian #808 revealed she did not attend care conferences and stated someone from the facility dietary staff should be attending the care conferences. Interview on 04/08/25 at 4:37 P.M. with Social Service Designee (SSD) #516 confirmed no one from dietary had been attending the care conference meetings, and the Director of Nursing (DON) had been filling out the dietary section of the Care Conference Form V2-V2. 2. Review of the medical record for Resident #22 revealed an admitted [DATE]. Diagnoses included schizoaffective disorder bipolar type, cirrhosis of the liver, type two diabetes mellitus, cognitive communication deficit, altered mental status, vascular dementia, anxiety disorder, and major depressive disorder. Review of the MDS assessment dated [DATE] revealed Resident #22 was cognitively intact; inattention, disorganized thinking, and altered level of consciousness was present but fluctuated; rejection of care occurred daily; was mainly independent for activities of daily care and mobility. Review of the facility document titled Care Conference Form V2-V2 dated 03/11/24, 06/10/24, 09/10/24, 12/12/24, 01/30/25, and 04/02/25 revealed there was no documented evidence that a member from the food and nutrition services staff attended the meetings. Interview on 04/08/25 at 3:00 P.M. with Dietary Manager #538 revealed she had attended care conferences in the past but due to staffing challenges, she hasn't been able to attend the care conference meetings recently. Interview on 04/08/24 at 3:54 P.M. with Dietitian #808 revealed she did not attend care conferences and stated someone from the facility dietary staff should be attending the care conferences. Interview on 04/08/25 at 4:37 P.M. with SSD #516 confirmed no one from dietary had been attending the care conference meetings, and the DON had been filling out the dietary section of the Care Conference Form V2-V2. 51521 3. Review of the medical record for Resident # 28 revealed an admitted [DATE] with diagnoses including COPD, cognitive communication deficit, unspecified dementia, unspecified severity with other behavioral disturbance and anxiety disorder. Review of the admission MDS assessment dated [DATE] revealed Resident # 28 had moderate cognitive impairment. Review of the care plan dated 03/12/25 for Resident # 28 revealed he had impaired cognitive function and dementia or impaired thought processes. Interventions included communication with the resident's family/caregivers/ regarding the resident's capabilities and needs. Monitor, document, report any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status. Record review revealed no documented evidence Resident #28 or Resident #28's representative was invited to care conferences or participated in his care planning. Review of the care conference form dated 10/07/24 indicated that social services, activities and rehabilitation services attended, and review of the care conference form dated 03/25/25 revealed that registered nurse, activities, and nursing administration attended. Interview on 04/08/25 at 3:00 P.M. with Dietary Manager #538 revealed she had attended care conferences in the past but due to staffing challenges, she hasn't been able to attend the care conference meetings recently. Interview on 04/08/24 at 3:54 P.M. with Dietitian #808 revealed she did not attend care conferences and stated someone from the facility dietary staff should be attending the care conferences. Interview on 04/08/25 at 4:37 P.M. with SSD #516 confirmed no one from dietary had been attending the care conference meetings, and the DON had been filling out the dietary section of the Care Conference Form V2-V2. 4. Review of the medical record for Resident # 30 revealed an admitted [DATE]. Diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the MDS assessment dated [DATE] revealed Resident #30 had a mild cognitive impairment. Review of the care conference forms dated 05/23/24 and 08/26/24 revealed the social worker, activities, and nursing administration attended. There was no documented evidence Resident #30 or Resident #30's representative attended the care conference. Review of the care conference form dated 03/03/25 revealed activities attended. There was no documented evidence Resident #30 or Resident #30's representative attended the care conference. Interview on 04/08/25 at 3:00 P.M. with Dietary Manager #538 revealed she had attended care conferences in the past but due to staffing challenges, she hasn't been able to attend the care conference meetings recently. Interview on 04/08/24 at 3:54 P.M. with Dietitian #808 revealed she did not attend care conferences and stated someone from the facility dietary staff should be attending the care conferences. Interview on 04/08/25 at 4:37 P.M. with SSD #516 confirmed no one from dietary had been attending the care conference meetings, and the DON had been filling out the dietary section of the Care Conference Form V2-V2. Review of facility policy Care Plans, Comprehensive Person-Centered, revised December 2016, revealed the interdisciplinary (IDT) team in conjunction with the resident and his/her family or legal representative, would develop and implement a comprehensive, person-centered plan for each resident. The IDT included a member of the food and nutrition services staff.

Based on record review, observations, interviews, facility menu spreadsheets and facility policy review, the facility failed to ensure residents on a reduced concentrated sweets (RCS) diet received the appropriate dessert for lunch on 04/08/25. This affected all 11 residents (#4, #5, #7, #13, #22, #35, #39, #50, #57, #61, and #117) the facility identified as being on a RCS diet. The facility census was 66. Findings include: 1. Review of the medical record for Resident #39 revealed an admitted [DATE]. Diagnoses included schizophrenia and type two diabetes. Review of Resident #39's physician orders revealed an order dated 11/21/24 for a Reduced Calorie Sweets (RCS), Regular texture, Thin/Regular (liquids) consistency. Review of Resident #39's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was mildly impaired cognitively and was receiving a therapeutic diet. Review of Resident #39's care plan dated 04/03/25 revealed the resident had the potential for alteration in nutrition and hydration related type two diabetes diagnosis and or being on a therapeutic diet. Interventions included providing diet as ordered. 2. Review of the medical record for Resident #13 revealed an admitted [DATE]. Diagnoses included schizophrenia, type two diabetes mellitus, and dysphagia (difficulty swallowing). Review of Resident #13's physician's orders revealed an order dated 12/13/24 for a NAS (No Added Salt), RCS (Reduced Calorie Sweets) diet, mechanical soft texture, thin liquids consistency. Review of Resident #13's quarterly MDS assessment dated [DATE] revealed the resident had was moderately impaired cognitively and was receiving a therapeutic and mechanically altered diet. Review of Resident #13's care plan dated 03/17/25 revealed the resident had a potential for alteration in nutrition and hydration related to having a diabetes mellitus diagnosis. Interventions included provide diet per order. 3. Review of medical record for Resident #22 revealed an admitted [DATE]. Diagnoses included schizoaffective disorder and type two diabetes mellitus. Review of Resident #22's physician's orders revealed an order, dated 03/28/23, for a Reduced Concentrated Sweets (RCS) diet, Regular texture, Thin/Regular (liquids) consistency. Review of Resident #22's quarterly MDS assessment dated [DATE] revealed the resident was mildly impaired cognitively and was receiving a therapeutic diet. Review of Resident #22's care plan dated 03/07/25 revealed the resident had a potential for alteration in nutrition and hydration related to diagnosis of diabetes mellitus and being on a therapeutic diet. Interventions included provide diet as ordered. 4. Review of medical record for Resident #7 revealed an admitted [DATE]. Diagnoses included atrioventricular block (delay in the conduction of electrical current as it passes through the conduction system of the heart), systemic lupus (an autoimmune disease where the immune system attacks the connective tissue in the body), and dysphagia (difficulty swallowing). Review of Resident #7's physician orders revealed an order dated 11/01/22 for a Reduced Concentrated Sweets (RCS) diet, Mechanical Soft, Ground texture, Thin/Regular (liquids) consistency. Review of Resident #7's quarterly MDS dated [DATE] assessment revealed the resident had severe cognitive impairment and was receiving a therapeutic and mechanically altered diet. Review of Resident #7's care plan dated 03/25/25 revealed the resident had a potential for alteration in nutrition and hydration related to diagnoses of schizophrenia and lupus and the need for a therapeutic and mechanically altered diet. Interventions included provide diet per physician order. 5. Review of medical record for Resident #61 revealed an admitted [DATE]. Diagnoses included chronic respiratory failure with hypoxia (insufficient oxygen in the body), type two diabetes mellitus, and hyperlipidemia (abnormally high levels of lipids (fats) in the blood). Review of Resident #61's physician orders revealed an order, dated 01/29/25, for a Reduced Concentrated Sweets (RCS) diet, Regular texture, Thin Liquids consistency. Review of Resident #61's annual MDS assessment dated [DATE] revealed the resident had moderate cognitive impairment and was receiving a therapeutic diet. Review of Resident #61's care plan dated 01/27/25 the resident was at nutritional risk related to the diagnoses of diabetes mellitus. Interventions included providing and serving diet as ordered. 6. Review of medical record for Resident #117 revealed an admitted [DATE]. Diagnoses included schizoaffective disorder bipolar type, type two diabetes mellitus, and anxiety disorder. Review of Resident #117's physician orders revealed an order, dated 03/06/25, for Reduced Concentrated Sweets (RCS) diet, Regular texture, and Thin Liquids consistency. Review of Resident #117's admission MDS assessment dated [DATE] revealed the resident was cognitively intact and was receiving a therapeutic diet. Review of Resident #117's care plan dated 03/10/25 revealed the resident had a nutritional problem or potential nutritional problem related to diagnoses including type two diabetes mellitus and schizoaffective disorder and needing a therapeutic diet. Interventions included providing and serving diet as ordered. 7. Review of medical record for Resident #50 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus, muscle weakness, and cognitive communication deficit. Review of Resident #50's physician orders revealed an order dated 12/15/22 for Reduced Concentrated Sweets (RCS) diet, Mechanical Soft texture, Thin Liquid consistency. Review of Resident #50 MDS assessment dated [DATE] revealed the resident was cognitively intact and received a therapeutic and mechanically altered diet. Review of Resident #50's care plan dated 02/09/25 revealed the resident had a potential for alteration in nutrition and hydration related to diagnosis of diabetes mellitus and being on a therapeutic and mechanically altered diet. Interventions included providing diet as ordered. 8. Review of medical record for Resident #35 revealed an admitted [DATE]. Diagnoses included Parkinsonism (an umbrella term which refers to conditions with similar movement related effects), type two diabetes mellitus, and dysphagia (difficulty swallowing). Review of Resident #35's physician orders revealed an order, dated 01/10/24, for Reduced Concentrated Sweets (RCS) diet, Mechanical Soft Texture, Nectar Thickened Fluids consistency. Review of Resident #35's quarterly MDS assessment dated [DATE] revealed the resident had severe cognitive impairment and was receiving a mechanically altered and therapeutic diet. Review of Resident #35's care plan dated 03/03/25 revealed the resident had a potential for alteration in nutrition and hydration related to diagnoses of type two diabetes, Parkinsonism, and being on a mechanically altered and therapeutic diet along with thickened liquids. Interventions included providing diet as ordered. 9. Review of medical record for Resident #57 revealed an admitted [DATE]. Diagnoses included schizoaffective disorder, type two diabetes mellitus, and anemia. Review of Resident #57's physician orders revealed an order dated 11/01/22 for Reduced Concentrated Sweets (RCS) diet, Regular texture, Thin/Regular (liquids) diet. Review of Resident #57's annual MDS assessment dated [DATE] revealed the resident was cognitively intact and was receiving a therapeutic diet. Review of Resident #57's care plan dated 02/24/25 revealed the resident had a potential for alteration in nutrition and hydration related to diabetes and being on a therapeutic diet. Interventions included providing diet per order. 10. Review of medical record for Resident #5 revealed an admitted [DATE]. Diagnoses included schizophrenia, type two diabetes mellitus, and bipolar disorder. Review of physician orders for Resident #5 revealed an order dated for Reduced Concentrated Sweets (RCS) diet, Regular texture, Thin Liquids consistency. Review of Resident #5's quarterly MDS assessment dated [DATE] revealed the resident was mildly impaired cognitively and was receiving a therapeutic diet. Review of Resident #5's care plan dated 03/18/25 revealed the resident had a potential for alteration in nutrition related to diagnoses of type two diabetes mellitus, schizophrenia, and bipolar disorder. Interventions included providing diet as ordered. 11. Review of medical record for Resident #4 revealed an admitted od 07/06/04. Diagnoses included type two diabetes mellitus, chronic pancreatitis, and chronic obstructive pulmonary disease (COPD). Review of Resident #4's physician orders revealed an order dated 11/14/24 for a Reduced Concentrated Sweets (RCS) diet, Mechanical Soft Texture, Thin/Regular (liquids) consistency. Review of Resident #4's quarterly MDS assessment dated [DATE] revealed the resident was moderately impaired cognitively and was receiving a mechanically altered and therapeutic diet. Review of Resident #4's care plan dated 04/01/25 revealed the resident had potential for alteration in nutrition and hydration related to needing an altered consistency/therapeutic diet. Interventions included provide diet per physician order. 12. Review of the facility's spreadsheet titled Garden 2024-2025 F/W(Fall/Winter) Menu revealed for lunch on week (4/08/25) one three-ounce pork steak baked, four ounces of scalloped potatoes, four ounces of green peas, one dinner roll, and one two (inch) by two (inch) brownie would be served. For residents on a Reduced Concentrated Sweets (RCS) diet, four ounces of fresh fruit would be served in place of the brownie. Observations on 04/08/25 from the beginning of tray line at 11:49 A.M. to the end of tray line at 12:33 P.M. revealed residents received a brownie if they were on a regular or mechanical soft consistency diet and received a pureed brownie if they were on a puree consistency diet. There was no observation of fresh fruit on the tray line or any residents receiving fresh fruit as a dessert. Interview on 04/08/25 at 12:21 P.M. with Dietary Aide #563, who was placing the desserts on the meal trays during tray line, confirmed residents received either a brownie or a puree brownie as their dessert for the meal. Interview on 04/08/25 at 12:37 P.M. with Assistant Regional Dietary #807 stated residents on a RCS diet should have received fresh fruit as their dessert instead of the brownie. Review of the facility policy Therapeutic Diets, revised November 2015, revealed the facility would ensure residents received diets as ordered.

Based on record reviews, observations, interviews and facility policy review, the facility failed to ensure Resident #32 was free from a physical restraint. This affected one resident (t #32) out of 16 residents reviewed for restraints. The facility identified no residents as having a physical restraint. The facility census was 66. Findings include: Review of medical record for Resident #32 revealed an admitted [DATE]. Diagnoses included schizoaffective disorder bipolar type, intellectual disabilities, wedge compression fracture of unspecified vertebra, osteoarthritis, mood disorder, disorders of psychological development, and history of falling. Review of care plan dated 09/21/24 revealed Resident #32 was at risk for falls related to fracture of lumbar/thoracic vertebrae, history of repeated falls, impaired safety awareness, and impaired cognition. Interventions included anticipate and meet the resident's needs; be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed; encourage appropriate footwear while in the wheelchair; and ensure the environment was safe which included floors being free from spills, a workable and reachable call light, bed in low position at night, and personal items within reach. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 was severely impaired cognitively; exhibited inattention, disorganized thinking, and altered level of consciousness which was continuously present and did not fluctuate; had no behaviors; was dependent on staff for all activities of daily living except required setup or cleanup assistance for eating; was dependent on staff for all mobility except required staff supervision or touch assistance to wheel 50 feet in manual wheelchair; had no falls since prior assessment; and no physical restraints were being used. Observation on 04/07/25 at 11:24 A.M. revealed Resident #32 was awake and lying in her bed, and the side of the bed was placed against the left side wall with the resident's head facing the back wall. On the side of the bed not against the wall, a blue wedge cushion had been placed between the mattress and the bed frame with the narrow part of the cushion closer to the middle of the mattress and the wider part of the cushion toward the edge of the mattress which resulted in an elevation of the edge of the mattress. Interview at the time of observation with Resident #32 revealed the resident had impaired cognition and was unable to be interviewed. Interview at the time of observation with Registered Nurse (RN) #549 confirmed the wedge cushion had been placed between the mattress and the bed frame, and the wedge cushion was being used to prevent Resident #32 from falling out of bed. Further review of Resident #32's medical record revealed there was no order for the wedge cushion, and nothing was noted in the resident's care plan indicating the reason for the wedge cushion. Observation on 04/08/25 at 9:14 A.M. revealed the blue wedge cushion remained between Resident #32's bedframe and the mattress. Interview on 04/08/25 at 1:03 P.M. with Certified Nursing Assistant (CNA) #573 revealed the wedge cushion was placed between the mattress and the bed frame to help keep Resident #32 on her side and to prevent her from falling out of the bed. He stated if the wedge cushion was placed between the resident and the mattress, the resident would remove it. Interview on 04/08/25 at 3:12 P.M. with CNA #515 and CNA #500 revealed Resident #32 would try and climb out of her bed, and to prevent Resident #32 from hurting herself, the wedge was placed between the mattress and the bed frame. Interview on 04/09/25 at 11:02 A.M. with the Director of Nursing (DON) revealed Resident #32 would get uncomfortable and needed more support in her back from her wedge compression fracture of the thoracic vertebra, which was why the facility was using the wedge cushion for comfort. She stated the wedge cushion was not supposed to be placed between the mattress and the bed frame. The DON stated a restraint prevented a resident from moving and went on to confirm having the wedge cushion placed between the bedframe and mattress on one side of the bed and the bed against the wall on the other side of the bed could restrict Resident #32's movement. Review of the facility policy Resident Rights, revised December 2016, revealed residents had a right to be free from physical restraints not required to treat a resident's symptoms.

Based on record review, interview and review of the facility policies, the facility failed to ensure an accurate care plan for Resident #1. This affected one resident (#1) of two residents reviewed for care plans. The facility census was 66. Findings include: Review of the medical record for Resident #1 revealed an admitted [DATE]. Diagnoses included schizophrenia, type two diabetes mellitus, and cerebral infarction. Review of the physician's order dated 01/19/25 revealed that Resident #1 required the assistance of one staff member for transfers. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #1 had intact cognition. Resident #1 required extensive assistance for all activities of daily living. Resident #1 was frequently incontinent of urine and bowel. Review of the care plan dated 04/08/25 revealed that Resident #1 had no focus area for incontinence care and no interventions for incontinence. Interview on 04/09/25 at 9:07 A.M. with the MDS Registered Nurse (RN) #530 confirmed that Resident #1 was incontinent, and he had no care plan interventions related to incontinence. Review of the facility policy care plans, comprehensive person-centered, revised December 2016, revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on record review, interview and review of facility policy, the facility failed to provide adequate supervision and/or intervention to prevent Resident #64 from sustaining a burn to his abdomen. This affected one resident (#64) of four residents who were reviewed for accidents. The facility census was 71. Actual harm occurred on 11/03/24 when Resident #64, who had severe cognitive impairment, was found in his room with a cigarette lighter (belonging to Resident #85) and his clothing smoldering subsequently sustaining a second-degree burn (an injury that affects both the outer layer of skin or epidermis and part of the underlying layer called the dermis) to his abdomen requiring treatment in the emergency room . Resident #64 returned to the facility from the emergency roiagnom on [DATE] and required follow-up treatment at a wound clinic for the burn. Findings include: Review of the medical record for Resident #64 revealed a date of admission of 04/18/24 with diagnoses including chronic obstructive pulmonary disease, depression, difficulty walking, hypertension, anxiety, and burn of unspecified body region. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 had severely impaired cognition, required (staff) set up or clean up assistance with eating, substantial/maximal (staff) assistance with oral hygiene and dressing and was dependent on staff for toileting, bathing and transfers. Resident #44 had no impairment in range of motion to his upper and lower extremities and did not use a mobility device. There was no skin impairment identified on the MDS assessment. Review of an incident note dated 11/03/24 at 4:45 P.M. authored by the Director of Nursing (DON) revealed a resident hollered for help and fire. A Certified Nursing Assistant (CNA) patted out a smolder on Resident #64's shirt. The nurse removed the shirt, and a blister was noted to the abdomen. Resident #64 was noted to have a blue lighter in his hand. 911 was called and the resident was transported to the hospital. Record review revealed no nursing progress note was entered by the nurse assigned to care for the resident at the time of this incident. Review of facility incident documentation and related investigation revealed an incident report, dated 11/03/24 and authored by the DON, that indicated at 4:45 P.M. a nurse and CNA were alerted by a resident shouting there was a fire. Resident #64 was discovered in his room with a blue lighter in his hand. The resident was not a smoker, and he was unable to give a description of what happened. The resident had a smolder to his shirt and shorts. The CNA patted out the smolder and the nurse removed the shirt to assess his skin. A blister was noted to the abdomen. 911 emergency services were called. Record review revealed no measurements or assessment of the burn/blister contained in the initial incident report or incident note completed. A review of the emergency call log to the local fire department and 911 emergency revealed a call came in at 4:45 P.M. on 11/03/24 regarding a male (Resident #64) who burnt himself with a lighter. At 5:01 P.M. the fire department entered the facility. The fire was noted to be out. Resident #64 was transferred to the hospital. A review of the document titled: SNF/NF to Hospital Transfer Form dated 11/03/24 revealed Resident #64's skin was not intact related to a burn to mid-abdomen. A review of the document titled: SBAR Communication Form and Progress note for Registered Nurses/Licensed Practical Nurses/Licensed Vocational Nurses dated 11/03/24 revealed Resident #64 had a burn. A review of the emergency room note dated 11/03/24 revealed Resident #64 sustained a seven-centimeter by seven-centimeter burn to the right abdomen likely first degree after attempting to light a cigarette and caught his shirt on fire. Follow up with a burn center was advised. There were no discharge medications. A review of the document titled Witness Statement dated 11/03/24 and completed by the DON revealed she interviewed the sister of Resident #85 and discovered the sister had given Resident #85 a lighter which was brought back to the facility after a leave of absence with her. The DON provided education to the sister including any smoking materials were to be given to the unit nurse upon return to the facility. The sister stated she forgot she gave Resident #85 the lighter. The sister verbalized understanding and said she would be vigilant when she returned the resident to the facility. A review of the document titled Witness Statement dated 11/03/24 and completed by Certified Nurse Assistant (CNA) #273 revealed Resident #64 had a smoking shirt and she ran down the hall to Resident #64 and extinguished it with her hands. CNA #273 also stated in the witness statement a lighter was picked up from the floor. A review of the document titled Witness Statement dated 11/03/24 completed by Licensed Practical Nurse (LPN) #241 revealed she heard a resident yelling fire. LPN #241 witnessed Resident #64's shirt on fire. LPN #241 put water on the resident to treat the area. A burn was noted. Review of physician orders for November 2024 for Resident #64 revealed following the burn incident on 11/04/24 the resident had orders for a weekly body audit, abdominal binder to be used to assist with leaving dressing intact, and assess skin integrity under binder every shift, notify wound care center with any increase in pain, temperature greater than 101 degrees, increase of drainage from the wound, drainage with foul odor, bleeding of the wound, increase of swelling, cleanse wound to abdomen with wound cleanser, apply silver alginate to wound bed and cover with silicone border dressing, and multivitamin daily. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #64 had severe cognitive impairment. A review of a progress note dated 11/04/24 at 12:03 A.M. revealed Resident #64 returned to the facility from the emergency room with a burn diagnosis. Bacitracin (an antibiotic ointment) had been applied in the emergency room and a dressing was applied. The burn from a nurse-to-nurse report prior to Resident #64's transfer back to the facility was seven centimeters by seven centimeters with minor blistering. The note included the resident's vital signs were within normal limits and Resident #64 had no complaints of pain. Review of the facility document Wound Weekly Observation Tool V4.0, dated 11/04/24, for Resident #64 revealed he had a first-degree burn acquired 11/03/24. The burn measured 6.0 centimeters (CM) in length by 6.5 cm in width with a depth of 0.1 cm. There was slight clear drainage and no sign of infection. The treatment was cleansing mid-abdomen with normal saline solution, apply Silvadene to wound bed and cover with a dry clean dressing daily and as needed. Review of the facility care plan for Resident #64, revised on 11/04/24, revealed he had impaired skin integrity related to a first degree burn on the abdomen. Interventions included abdominal binder to be in place to assist with leaving dressing in place due to resident removing dressing, assess skin integrity under binder every shift, cleanse wound to abdomen with wound cleanser, apply silver alginate to wound bed and cover with silicone border dressing, observe wound for signs and symptoms of infection every shift, notify the physician of any changes keep skin clean dry and odor free, multivitamin daily to assist with wound healing, observe skin for signs and symptoms of breakdown and notify the physician, resident displays noncompliance of leaving dressing intact regardless of education, one-on-one and redirection provided, resident following with local burn center for continued/ongoing care of the burn to the abdomen, and skin assessment completed weekly and as needed. A review of wound care center notes from the Mercy Health Burn Center dated 11/18/24 through 12/23/24 revealed Resident #64 was being seen for a second degree burn to his abdomen with steady improvement of the wound. An initial wound care note dated 11/18/24 revealed a burn to the abdomen measuring 4.1 centimeters (cm) by 5.4 cm by 0.1 cm. The wound was debrided (a procedure where skin is scraped to promote bleeding which in turn promotes healing). Resident #64 was to return in one week. Subsequent wound care visits revealed: On 11/27/24 Resident #64 had eschar over the abdominal wall wound with some fat layer exposed. The wound was debrided. On 12/02/24 it was noted the wound was improving with some fat layer exposed and the wound was mainly skin. The abdominal wound was debrided. On 12/09/24 it was noted the wound was improving with skin and fat layer noted. The wound was debrided, and Resident #64 was to follow- up in two weeks. On 12/23/24 it was noted the abdominal wound was improving and was mainly skin. The wound measured 0.9 cm by 1.1 cm by 0.1 cm. The wound was classified as 96 percent healed. The wound was again debrided, and Resident #64 was to follow-up with the wound care center in two weeks. On 12/18/24 at 8:30 A.M. an interview with the Administrator verified there was an incident (on 11/03/24) with Resident #64 when he got a hold of a lighter belonging to Resident #85 and lit it causing a burn to his clothes and abdomen. The Administrator was unable to determine how Resident #64 obtained the lighter, other than it was discovered during resident audits and resident and family interviews after the incident that Resident #85 had brought a lighter back to the facility after a leave of absence (LOA). On 12/18/24 at 11:25 A.M. an interview with CNA #273 revealed she was at the facility on 11/03/24, the day of the incident with Resident #64. CNA #273 stated Resident #64's shirt was smoldering like a lit cigarette. CNA #273 stated she patted the fire out while a nurse got the fire extinguisher and water. CNA #273 stated 911 was called by the nurse. CNA #273 stated the fire department responded to the incident and took the resident's shirt with them. Resident #64 was then transported to the hospital. On 12/19/24 at 11:57 P.M. an interview with LPN #241 revealed she was present on 11/03/24, the day of the incident. She stated she was unsure of how Resident #64 got the lighter. LPN #241 stated Resident #64 had a burn to the abdomen as a result of the incident. On 12/31/24 at 12:50 P.M. an interview with the Assistant Director of Nursing/LPN #215 revealed the wound for Resident #64 was blistered and classified as a first degree burn from the emergency room . LPN #215 stated she believed once the blister broke and opened it was then classified as a second-degree burn. A review of the facility policy titled Safety and Supervision of Residents dated 12/2007 revealed resident safety and supervision and assistance to prevent accidents were a facility wide priority. The policy also revealed employees were trained and in-serviced on potential accident hazards and how to identify and report accident hazards and try to prevent avoidable accidents. A review of the facility policy titled Smoking Policy and Procedure revised 11/03/24 revealed Residents who smoke are not permitted to keep smoking supplies in their room or on their person. This includes but is not limited to cigarettes, lighters, matches, pipes, e-cigarettes, machines to roll cigarettes and any other smoking paraphernalia that may be combustible. The deficient practice was corrected on 11/04/24 when the facility implemented the following actions: On 11/03/24 an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator, DON, Assistant DON, the Medical Director, Social Services, the Dietary Manager, Business Office Manager, Activity Director, Maintenance, Central Supply/Scheduler and Admissions. The root cause of the incident was identified as a family member allowed Resident #85 to retain smoking materials when they returned from leave of absence. On 11/03/24 Resident #64 was sent to the emergency room . On 11/03/24 room sweeps on all rooms were completed to check for smoking materials. On 11/03/24 room sweeps of five rooms per week for four weeks was started. On 11/03/24 the smoking policy was reviewed and updated to include that any smoking materials obtained on LOA must be returned to staff upon return to the facility. On 11/03/24 smoking assessments for all residents who smoke (#6, #7, #8, #11, #13, #18, #25, #30, #32, #38, #40, #46, #47, #50, #53, #57, #61, #66, #71, and #85) were updated. On 11/03/24 education was completed by Admissions #220 to all residents who smoke. On 11/03/24 all care plans of residents who smoke were reviewed and updated for all residents who smoke. On 11/03/24 a handout was created for Leave of Absence binders and the front desk reminding family and friends that smoking materials must be returned to staff. On 11/03/24 education was provided to Resident #85's family to turn in smoking materials to staff after leave of absence. On 11/03/24 all staff were in-serviced on resident supervision, smoking policy, leave of absence process and ensuring residents who return from leave of absence do not retain smoking materials. On 11/03/24, five resident and or family interview upon return from leave of absence was started and continued for four weeks. There were no further residents experiencing injury from 11/04/24 through the date of this survey 12/31/24. This deficiency represents noncompliance investigated under Complaint Number OH00160577.

Based on observation, record review, review of a facility Self-Reported Incident (SRI) and investigation, review of a police report, facility policy review and interview, the facility failed to protect Resident #2's right to be free from physical abuse by Resident #44. Actual harm occurred on 11/28/24 when Resident #2, who was alert and oriented, was punched in the face by Resident #44, who had known aggressive behaviors towards others, during an unprovoked incident while Resident #2 was laying in his bed, sustaining a hematoma to the right eye area and bruising to his right upper arm. Resident #2 was taken to the hospital emergency department for evaluation, diagnosed with a facial hematoma and returned to the facility. In addition, the incident was identified to be a stressor to Resident #2 and Resident #2 indicated he was shook up as a result of the unprovoked incident. This affected one resident (#2) of three residents reviewed for abuse. The facility census was 71. Findings include: Review of the medical record for Resident #2 revealed an admitted [DATE] with diagnoses including schizophrenia, mild protein calorie malnutrition, muscle wasting, muscle weakness, dysphagia, osteoarthritis, age related cataract, major depression, conduct disorder, and cognitive communication deficit. Review of the comprehensive care plan, with a start date of 09/25/24, revealed Resident #2 had an activities of daily living (ADL) self-care deficit related to diagnosis of schizophrenia. Interventions included a wheelchair as needed for mobility, assist with showers as needed, assist with daily grooming, daily hygiene as needed. Supervision was needed for toileting limited assist, use of one person assist for transfers, and independent for bed mobility. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2's cognition was intact. Resident #2 had no hallucinations or delusions, or verbal or physical behaviors directed towards others. Resident #2 did not refuse care. Resident #2 was independent to walk ten feet. Review of a progress note dated 11/28/24 at 4:22 P.M. written by the Director of Nursing (DON) revealed Licensed Practical Nurse (LPN) #227 was in the hallway when she and a Certified Nursing Assistant (CNA) heard shouting down the hall at 6:30 A.M. LPN #227 entered Resident #2's room while the CNA entered the other resident (Resident #44) room. LPN#227 observed a knot above Resident #2's right eye and bruising to the right upper arm. Resident #2 stated he slugged me. Resident #2 stated Resident #44 hit him. Resident #2 stated he did not know why Resident #44 came in his room for no reason while he was lying in bed. A skin assessment was done on Resident #2 revealing a hematoma above the right eye and bruising to the upper right arm. Both residents denied pain. The local police department was contacted. Both residents were sent to the emergency department (ED), and Physician #279 was notified. Review of the medical record for Resident #44 revealed an admitted from a local hospital of 10/25/24. Medical diagnoses included unspecified psychosis not due to a substance or known physiological condition, unspecified dementia mild without behavioral disturbance, cognitive communication deficit, cannabis use, nicotine dependence, depression and homelessness. Review of hospital documentation dated 10/22/24 to 10/25/24 revealed Resident #44 had been in the hospital after signing himself out of another facility and adult protective services became involved to assist with assigning him a legal guardian due to his poor decision making, dementia and history of homelessness. During this hospital stay Resident #44 was noted to have encephalopathy (a medical condition characterized by a general disturbance in brain function) with signs of physical and verbal aggression. He threatened to punch a nurse, pushed staff and slammed a door to obstruct the view of him from staff. Resident #44 could not be reasoned with during the incidents of aggression and had to be de-escalated with a male presence and hospital police. Resident #44 was assessed as stable for transfer to a secured facility on 10/25/24. Review of the nursing admission assessment dated [DATE] revealed he was admitted to the facility from an acute care hospital related to Parkinson's disease and dementia and was alert and oriented to person and time. No behaviors were noted. Review of the initial physician assessment dated [DATE] for Resident #44 revealed he was hospitalized on [DATE] with encephalopathy and altered mental status related to neurocognitive disorder and Parkinson disease. He did not know why he was at the facility and was having no behaviors at the time of the visit. Review of the care plan for Resident #44, date initiated 10/29/24, revealed he was a smoker and enjoyed activities that did not involve group participation. There was no behavior care plan developed for Resident #44 having a history of cognitive impairment with aggressive behaviors prior to admission. Review of a progress note dated 11/01/24 revealed Resident #44 became belligerent with the social service worker stating he did not want to be at the facility and slammed his door and refused to speak to her. His legal guardian was notified who gave instructions to keep him at the facility. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #44 had severely impaired cognition, and no behaviors present. He was independent for eating and upper body dressing and required supervision and set up assistance for lower body dressing, bathing, toileting and oral hygiene. Review of a progress note dated 11/06/24 revealed Resident #44 was throwing his lunch tray at the wall with food still on it. He was screaming and cursing at the staff and slamming the door repeatedly. The physician was notified and gave orders to send him to the emergency room for psychiatric evaluation. Resident #44 was transferred out of the facility with diagnoses of psychosis and agitation. Review of a progress note dated 11/13/24 revealed he was readmitted to the facility and appeared agitated with the nurse when preforming the re-admission assessment. Review of a progress note dated 11/18/24 revealed Resident #44 became aggressive with a nurse because he was not permitted to stay on another unit after the smoke break. He was threatening to break a door and he hit a staff member. The physician gave an order to send him to the emergency room and police and emergency services picked up the resident for transport. Further review of the care plan for Resident #44 revealed a revision on 11/19/24 to include behavior problems of attempting to break a door, refusing to return to his own unit after a smoke break, aggression, making threats to leave and had physically assaulted staff. The goal was to have Resident #44 with no evidence of behavior problems. Interventions included administer medication as ordered, monitor and document side effects and effectiveness, discuss resident's behavior and explain and reinforce why the behavior was inappropriate or unacceptable, and intervene as necessary to protect the rights and safety of others. Approach and speak in a calm manner, divert attention, remove from situation and take to alternative location as needed. Monitor behaviors episodes and attempt to determine underlying cause. Consider location, time of day, persons involved and situations, document behaviors and potential causes. Review of a progress note dated 11/20/24 revealed the resident was readmitted to the facility in stable condition. No behaviors were noted at the time. Review of the Medication Administration Records (MAR) and Treatment Administration Records (TAR) from 10/25/24 through 11/28/24 revealed Resident #44's behaviors were tracked each shift from 10/26/24 until 10/28/24 when the behavior tracking was discontinued. There was no further behavior tracking after 10/28/24 through the date of this survey. Review of a progress note dated 11/28/24 at 6:30 A.M. written by the Director of Nursing (DON) revealed LPN # 227 was in the hallway when she and a CNA heard shouting from down the hallway. Resident #44 was noted to be angry and hostile but did not explain why. When Resident #44 was questioned and stated, I'm not telling you, I told him I was going to hit him (referring to Resident #2). Resident #44 denied pain and a skin assessment revealed no areas of notation. The police department was contacted and both Resident #2 and #44 were sent to the emergency department (ED). Upon return from the ED both residents were to remain separated, have every fifteen-minute checks for seventy-two hours and Resident #44 was a one-on-one when out of room. Adult Protective Services (APS) was contacted to request consent for psychiatric management of Resident #44 and awaiting response. Review of a facility Self-Reported Incident (SRI) investigation, dated 11/28/24, revealed the nurse and CNA heard raised voices from Resident #2's room. Staff responded and observed Resident #2 in bed and heard the shared bathroom door close. Resident #44 was not present in the room. The nurse noted a hematoma on Resident #2's right forehead. Staff did not witness the altercation. Resident #44 denied the altercation upon interview. Resident #2 was transported to the hospital for evaluation and Resident #44 was transported to the hospital for evaluation. The local police responded and indicated no further investigation warranted. It was noted Resident #2 had a room change to reside on a different unit. Resident #2 had neurological checks implemented with no negative findings. Both Resident #2 and Resident #44 were transported to the hospital and returned with no new orders. Both were referred for counseling follow up, medication review was done on Resident #44, care plans reviewed and updated for involved parties. The facility unsubstantiated that abuse occurred based on Resident #44 having severely impaired cognition. Review of a witness statement dated 11/28/24 at 6:30 A.M. written by CNA #211 revealed she heard Resident #44 yelling from down the hall. CNA #211 entered the room and heard Resident #44 close the bathroom door. Resident #44 was angry and hostile when CNA #211 entered his room. Resident #44 would not state why he was angry and hostile. Upon entering Resident #2's room he was laying in bed and a lump on the right side of the forehead/temple was observed. Resident #2 stated Resident #44 socked him and came in his room for no reason. Review of a witness statement dated 11/28/24 at 6:30 A.M. written by LPN #227 revealed she heard yelling and went into Resident #2's room and observed Resident #2 laying in bed with a knot the size of a gum ball on the side of his right eye. Bruising was observed to right upper arm. Resident #2 stated he slugged me, I don't know, I was just lying there. Review of a witness statement dated 11/28/24 at 6:30 A.M written by LPN #227 revealed she heard yelling and went into Resident #2's room and observed a knot on the side of his right eye. Resident #2 stated Resident #44 hit him. LPN #227 went to check on Resident #44, and Resident #44 stated he was not going to tell LPN #227 what happened and stated, I told him I was going to hit him. Review of a witness statement dated 11/28/24 at 6:30 A.M. written by CNA # 273 revealed she heard residents yelling, and upon entering Resident #44's room she witnessed Resident #44 coming from the other room through the bathroom door. Resident #44 stated to CNA #273 he was not going to tell her anything. CNA #273 then entered Resident #2's room and observed a big knot on the head. Resident #2 stated he slugged me, meaning Resident #44. CNA #273 got the nurse. Review of the local police department (PD) report dated 11/28/24 at 6:20 A.M., revealed the local PD were called to the facility to investigate an assault involving Resident #2 and Resident #44. Upon arrival, nursing staff showed the PD to Resident #2's room and Resident #2 had noticeable swelling on the right side of his face near his eye. Resident #2 pointed to the direction of Resident #44's room when asked who assaulted him. Resident #2 stated Resident #44 hit him, and he did not know why he was struck. Additional bruising was found on the inside of Resident #2's hand that nursing staff stated was not there prior to the assault. Resident #44 was uncooperative and would not speak to staff or the PD about the incident. Local emergency medical services (EMS) were requested to transport Resident #2 to the hospital for evaluation due to swelling on his face and possible concussion. Photos were taken of the injuries. Review of the hospital emergency department (ED) documentation for Resident #2 dated 11/28/24 at 7:49 A.M. revealed Resident #2 presented to the ED for an evaluation of an assault by another resident at the facility and a head injury (hematoma right eyebrow). A Computed Tomography (CT) scan dated 11/28/24 revealed no acute intracranial abnormality, and no intracranial hemorrhage. A CT scan of the spine dated 11/28/24 revealed no acute compression fracture or subluxation of the cervical spine. The final impression was facial hematoma. Resident #2 was discharged back to the nursing home. Review of the hospital ED documentation dated 11/28/24 at 8:01 A.M. revealed Resident #44 presented to the ED due to concerns for altercation. Resident #44 had a history of dementia with psychotic episodes and had an altercation with another resident. Resident #44 stated the other resident was messing with me but no physical harm was done to Resident #44. The attending provider attestation revealed Resident #44 presented to the ED for evaluation of psychiatric evaluation because he had a psychotic episode at a facility and tried to fight another resident. Resident #44 was uncooperative per emergency medicine services. The chief complaint was need for psychiatric evaluation. Resident #44 denied homicidal thoughts. The adult psychiatric social worker spoke with Resident #44 in the ED and Resident #44 was calm but confused. Resident #44 stated another resident was messing with him and they got into it. Resident #44 agreed to return to the facility. It was noted the community Compass program was pending legal guardianship for Resident #44. Resident #44 had a protective order from the court to remain in a secured facility. Resident #44 did state he was aware he became angry and frustrated sometimes and stated things did not make sense to him and he did not know how to not be angry about that. Resident #44 was stable to return to the nursing home. Review of the facility document Open Water Counseling and Recovery Individual Progress Note dated 12/12/24 at 9:20 A.M. revealed Resident #2 presented with a black eye during the counseling session with the Licensed Social Worker (LSW). The LSW explored when the incident occurred and how. Resident #2 reported a peer hit him last week and said he hated the bruise. The LSW reviewed the incident in the medical record and the incident matched what Resident #2 reported. The LSW needed to reassure Resident #2 the bruise would eventually go away. The bruise on Resident #2's eye was indicated as a stressor for him. Interview and observation on 12/18/24 at 5:05 P.M. with Resident #2 revealed he had a bruise on his face because he was hit in the eye. Resident #2 stated he felt shook up afterwards. Resident #2 motioned a jab-like punching movement with his arm and stated, he went like that. Resident #2 stated the incident happened a few weeks ago. Interview on 12/18/24 at 5:05 P.M. with LPN #227 revealed Resident #44 was known to be aggressive and hit Resident #2. Resident #44 hit Resident #2 because he did not like sharing a bathroom with anyone. Resident #44 was aggressive and had physical behaviors with a staff member before this incident occurred. Interview on 12/26/24 with CNA # 265 revealed Resident #44 was known to be physically and verbally aggressive. Interview on 12/26/24 at 11:13 A.M. with LPN #236 revealed Resident #44 was moody, independent with his care and mobility and was known to be aggressive. Interview on 12/26/24 at 11:18 A.M. with CNA #258 revealed Resident #44 had aggressive behaviors at times. Interview on 12/26/24 at 11:23 A.M. with Resident #44 revealed he shared the bathroom with a man next door. Resident #44 stated Resident #2 would move his clothes in the bathroom so Resident #44 hit Resident #2. Resident #44 stated he hit Resident #2 in the face. Resident #44 stated he was continually annoyed with his neighbor because he would take his clothes down. Resident #44 also stated Resident #2 walked in on him sometimes while using the bathroom and this made Resident #44 feel upset. Interview on 12/26/24 at 11:32 A.M. with LPN #232 revealed she did not witness the incident with Resident #44 and Resident #2 but reported to work later in the day on 11/28/24. LPN #232 verified she witnessed a bruise on Resident #2's face and stated Resident #44 was known to be aggressive at times. Resident #44 would often yell at Resident #2 for using the bathroom and staff had to explain to Resident #44 that Resident #2 needed time in the bathroom. Interview on 12/26/24 at 11:37 A.M. with CNA #264 revealed Resident #44 was aggressive towards others. Resident #44 had a tendency to become upset easily and with his roommate in the bathroom. Resident #44 did not like sharing a bathroom. Interview on 12/26/24 at 12:00 P.M. with LPN #232 revealed if a resident had behaviors the nursing staff would document behaviors either in the MAR or TAR or behavior monitoring tab in the electronic medical record. The behavior tab could be used for all residents as needed for documentation and no physician orders were needed. LPN #232 verified no behavior documentation was in Resident #44's MAR/TAR or behavior tab after 10/28/24 and indicated there was no physician order to monitor Resident #44's behaviors. Interview on 12/26/24 at 1:00 P.M. with the DON revealed Resident #44 was known to behave aggressively before the incident involving Resident #2. The DON confirmed there had been no behavior tracking for Resident #44 during the month of November leading up to the incident because behaviors were only documented during a change of condition incident if Resident #44 became aggressive to staff or others. The DON also confirmed without the documentation of the behavior tracking there would be no record of what interventions were tried to de-escalate Resident #44. Interview on 12/26/24 at 2:00 P.M. with LPN #227 revealed on 11/28/24 she was passing medications in the hall and heard yelling from Resident #2's room and noise like a painful whine. LPN #227 witnessed Resident #2 laying in bed and Resident #2 stated he hit me Resident #2's eye was swollen. LPN #227 asked Resident #44 what happened, and Resident #44 stated he hit the resident because he was upset with the bathroom. Interview on 12/26/24 at 3:00 P.M. with the Director of Mental Health Counseling (DMHC) #274 revealed Resident #2 was followed for mental health counseling and was seen on 12/12/24 after the incident. It was noted in the progress note Resident #2 presented to the session with a black eye on 12/12/24 and was under the care of mental health for depression and psychosis. DMHC #274 stated Resident #44 refused mental health counseling. Interview on 12/27/24 at 10:17 A.M. with the DON revealed Resident #44 was placed on one-on-one supervision for seven days that started 11/28/24 after the incident. On 12/07/24 Resident #2 was moved to a different room away from Resident #44. The DON stated Resident #44 did not need one-on-one supervision prior to the incident but was known to be aggressive after hitting a nurse earlier in the month of November. The DON verified Resident #44 was placed on the secured dementia unit for behaviors, but there was no evidence behavior tracking was being completed each shift on the MAR, TAR or under the behavior tracking tab in the medical record for November and December 2024. Interview on 12/27/24 at 10:36 A.M. with the DON, the Administrator and the Regional Director of Operations #271 verified a behavior care plan was not initiated until 11/19/24 after Resident #44 was physically aggressive with staff and did not update the care plan after Resident #44 was physically aggressive with Resident #2 on 11/28/24. Interview on 12/28/24 at 8:00 A.M. with Adult Protective Services Employee (APSE) #280 revealed APS was involved with Resident #44 until a court hearing scheduled for 01/22/24 as a protective gap until a legal guardian could be named. Resident #44 was cognitively impaired, so the facility had authority to make medial decisions for Resident #44's safety while in the facility until guardianship was established. Review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property, dated 10/27/17, revealed abuse was the willful infliction of injury resulting in physical harm or mental anguish. Prevention and identification of abuse included an assessment, care planning, and monitoring of residents with behaviors which might lead to conflict such as residents with history of aggressive behaviors, residents who had behaviors of entering other rooms, and residents with communication disorders. The identification of events such as suspicious bruising of residents may constitute abuse. Upon completion of an investigation the facility would determine if modifications to existing policies and procedures were needed to prevent similar incidents or injuries from occurring in the future. This deficiency represents noncompliance investigated under Complaint Number OH00160577 and OH00160108.

Based on observation, medical record review, Self-Reported Incident review, camera footage review, interviews, review of the local police report, witness statement review, review of historical local weather, and facility policy review, the facility failed to provide adequate supervision to prevent one resident (Resident #2), who had a court appointed guardian, memory impairment, history of traumatic brain injury (TBI), and diagnosis of vascular dementia from elopement from the facility. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury and/or death when on 02/20/23 at 2:26 P.M. Resident #2 exited the facility without staff knowledge via a first floor secured window. The facility was within proximity to a pond, a heavily wooded area and busy five-lane road. Resident #2 was not identified missing by staff until approximately 6:30 P.M. Resident #2 was found on 02/20/23 at approximately 8:25 P.M. roughly 7.7 miles away from the facility at a friend's house. Resident #2 was returned to the facility on [DATE] at 8:50 P.M. This affected one (Resident #2) of 20 residents (Residents #2, #5, #6, #7, #11, #18, #20, #22, #25, #31, #34, #35, #37, #46, #48, #57, #4, #68, #71 and #73) who were identified as being at high risk for elopement. Facility census 80. On 02/22/23 at 2:12 P.M., the Administrator was notified Immediate Jeopardy began on 02/20/23 when Resident #2, who had a court appointed guardian, memory impairment, history of TBI, and diagnosis of vascular dementia eloped from the facility after verbalizing to staff the desire to leave the facility out a window. Resident #2's bedroom window stopper (controls the height or width a window can be opened) was removed, and Resident #2 exited the facility via the window. Resident #2 was not reported as missing until after 6:30 P.M. The police were called at 7:28 P.M. and Resident #2 was subsequently located roughly 7.7 miles away from the facility at a friend's house at approximately 8:25 P.M. The Immediate Jeopardy was removed on 02/22/23 when the facility implemented the following corrective actions: On 02/20/23 at 7:42 P.M., Resident #2's legal guardian was notified by the Administrator. On 02/20/23 at 7:50 P.M., Resident #2's window was repaired by Maintenance Director (MD) #5. On 02/20/23 at approximately 8:50 P.M. Resident #2 returned to the facility. On 02/20/23 at 9:00 P.M., Resident #2 was assessed for injury by the Director of Nursing (DON). No injuries were observed. On 02/20/23 at 9:30 P.M., Licensed Practical Nurse (LPN) #10 notified Resident #2's physician. On 02/20/23 at 9:20 P.M., Resident #2 was transferred to hospital for evaluation. On 02/21/23 between 7:00 A.M. and 3:30 P.M., MD #5 audited all windows for the presence of window stoppers. On 02/21/23 at 9:30 A.M., Resident #2 returned from hospital. There were no new orders or diagnoses. Resident #2 was placed on every 15-minute checks. On 02/21/23 at 11:00 A.M., Resident #2 was relocated to the secured unit to trial increased supervision. Window alarms were placed on Resident #2's new room window and to the windows in common areas on the secured unit by MD #5. On 02/21/23 at 12:54 P.M., laboratory work was ordered for Resident #2 including Complete Blood Count (CBC), Complete Metabolic Panel (CMP), and urinalysis. On 02/21/23 at 11:13 A.M., Resident #2's elopement assessment was reviewed and updated by the DON. Resident #2 was assessed as being at high risk for elopement. On 02/21/23 at 11:30 A.M., elopement care plans were implemented for residents assessed as being high risk for elopement by Registered Nurse (RN) #11. On 02/21/23 at 12:30 P.M., the Brief Interview for Mental Status (BIMS) assessment was reviewed and updated for Resident #2 by Social Services Designee (SSD) #4. The BIMS score was 13 indicating intact cognition. On 02/21/23 at 4:00 P.M., the psychiatry nurse practitioner reviewed Resident #2's medications and recommended Zoloft (antidepressant) 50 milligrams (mg) once a day and a consult with neurology. Resident #2 refused the Zoloft. On 02/21/23 at 9:30 A.M., an Ad-hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator, DON, Social Service Designee (SSD) #4, Dietary Manager (DM) #13, Business Office Manager (BOM) #1, Director of Rehab (DOR) #14, MD #5, Activities Director (AD) #15, Admissions Director #2, Licensed Practical Nurse (LPN) #16, and Medical Director #17 to review root cause analysis, facility interventions, and facility elopement response. The elopement policy and procedure was reassessed and deemed to be appropriate. No further actions required. On 02/21/23 by 3:30 P.M., elopement assessments for all residents were updated to ensure accuracy by the DON and Assistant Director of Nursing (ADON) #12, and all resident care plans were reviewed and updated as appropriate for risk of elopement by RN #11. On 02/21/23 by 5:30 P.M., elopement risk binders were reviewed and updated as appropriate by the Administrator. Resident #2 was added to the binder as well as two other residents (Residents #71 and #73) who were newly assessed as being at high risk for elopement. On 02/21/23 all staff were educated on the elopement policy and procedure as well as what to do if a resident expressed desire to leave the facility by the Administrator, DON, AD #15, MD #5, DM #13 and ADON #12. Seventy-five staff had been educated as of 02/27/23 and one staff member had yet to be educated. Any staff that had not received the education would be educated prior to their next scheduled shift by the Administrator. On 02/22/23 at 10:22 P.M. and on 02/23/23 at 1:38 P.M., MD #5/designee completed an elopement drill to ensure staff understanding of education. MD #5 reported results to the Administrator. Staff responded appropriately. On 02/22/23 the results of Resident #2's CBC, CMP and urinalysis were obtained. There were no new orders given by the physician. On 02/27/23 the neurology referral for Resident #2 was sent. Beginning the week of 02/27/23, MD #5/designee was to audit all window stoppers weekly for four weeks then monthly for two months then randomly thereafter. MD #5/designee was to report the results to the Administrator. In addition, the Administrator/designee would interview five to seven random staff weekly for four weeks then monthly for two months for knowledge of what to do if a resident verbalized wanting to leave the facility. MD #5/designee was to conduct monthly elopement drills on every shift for three months then monthly thereafter. MD #5/designee would report the results to the Administrator. Interviews on 02/27/23 from 2:40 P.M. to 4:40 P.M. with LPN #21, State tested Nurse Aide (STNA) #22, RN #8, Scheduler #23 and STNA #29 revealed they had received education on the facility elopement policy and procedures and they knowledgeable regarding their roles in the prevention of and response to resident elopements. Although the Immediate Jeopardy was removed on 02/22/23, the deficiency remained at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #2 revealed an admitted [DATE] with diagnoses of dementia, alcohol abuse, vascular dementia, personal history of TBI, atrial fibrillation, and convulsions. Resident #2 was given a court-appointed legal guardian, Guardian #19 on 09/01/22. Review of the Probate Court Statement of Expert Evaluation completed by Physician #20, dated 01/10/22, revealed Resident #2 had dementia, short term memory impairment, orientation impairment, thought process impairment, and judgement impairment. Resident #2 was unable to orient self to date, time, and location and unable to make sound decisions for self regarding medication and activities of daily living. Resident #2 showed difficulty understanding this illness. Resident #2's condition was not reversible. Review of the elopement review assessment dated [DATE] revealed Resident #2 was assessed as being at high risk for elopement. Review of the activities of daily living (ADL) care plan dated 08/03/22 revealed Resident #2 had an ADL self-care performance deficit related to dementia and being forgetful. Review of the fall care plan updated on 11/01/22 revealed Resident #2 was at risk for falls related to unaware of safety needs, history of TBI and diagnosis of dementia. Review of the initial Biopsychosocial assessment for counseling, dated 11/04/22 revealed Resident #2 was referred for counseling with symptoms of depression and anxiety. Resident #2 reported that he was in multiple car accidents and acquired a TBI at some point either during one of those accidents, boxing or falling at home after drinking. Resident #2 had severe deficits in short term memory functioning and had confusion. Review of the social services note, dated 11/09/22 revealed the author of the note spoke to Guardian #19 (Resident #2's legal guardian) about moving Resident #2 to a more appropriate living situation. It was explained to Guardian #19 since Resident #2 had been on the non-secured unit he had not made any attempts to leave the facility. However, Guardian #19 indicated when Resident #2 was at the other facility he had attempted to leave. The possibility of Resident #2 going to an assisted living facility was discussed but Guardian #19 was not sure Resident #2 would do well in an assisted living with the freedom of coming and going as he pleased. Guardian #19 indicated she would talk with her supervisor and call back. Review of the Minimum Data Set 3.0 quarterly assessment dated [DATE] revealed Resident #2 was cognitively intact, was independent with walking in room and corridor and did not use a mobility device. Review of the elopement review assessment dated [DATE] revealed Resident #2 was assessed as being at low risk for elopement. Review of the psychiatry nurse practitioner note dated 01/30/23 revealed Resident #2 was alert and oriented times two spheres and admitted to memory problems. Resident #2 had memory loss/dementia related to a traumatic brain injury. Zoloft 50 mg daily for depression/anxiety was recommended however Resident #2 refused at that time stating he would like to try counseling first. Review of the social services note, dated 02/20/23 timed 1:42 P.M. authored by SSD #4 revealed the nurse on unit came to SSD #4 and informed SSD #4 Resident #2 wanted to leave. Resident #2 stated he did not feel he belonged at the facility. The note further indicated Resident #2 had been talking about leaving and SSD #4 had spoken to Resident #2's legal guardian about the issue. SSD #4 called and left a message for Resident #2's legal guardian on 02/20/23. SSD #4 then called and spoke to Guardian #19's supervisor and explained how Resident #2 had been stating that he wanted to leave on this day (02/20/23). The note indicated Guardian #19 and Guardian #19's supervisor both felt the facility was the best place for Resident #2. They talked about assisted living but did not feel it was appropriate. SSD #4 provided support and reassurance to Resident #2 and told Resident #2 his legal guardian would be contacted. Review of the late entry general progress note authored by LPN #10, documented on 02/21/22 at 10:21 P.M., effective for 02/20/23 at 6:30 P.M. revealed at 6:30 P.M. Resident #2 did not come to nurses' station for smoke break like he typically did. LPN #10 waited a few minutes and when Resident #2 did not come, LPN #10 asked the STNA if she had seen Resident #2 or if he had come up for his smoke break. The STNA stated Resident #2 had not come out of his room and went to look for him. When STNA got to room, she noted Resident #2's dinner had not been touched. Resident #2's room and bathroom were searched, and Resident #2 was not found. LPN #10 asked Resident #2's roommate when he last saw him and he stated he had not seen him since before dinner. LPN #10 and the STNA immediately checked the entire building including bedrooms, closets, bathrooms, laundry, and any possible place. They then walked outside and checked all surrounding areas. LPN #10 then proceeded to contact the DON and notified of the situation. The note further indicated the DON and Administrator were both in building, police were contacted and search for Resident #2 started. The guardian and physician were notified. Review of the late entry general progress note, documented on 02/21/23 at 10:16 P.M., effective for 02/20/23 at 8:50 P.M. authored by LPN #10 revealed Resident #2 was found and returned to facility at this time, all parties were aware. Review of the hospital emergency department physician note dated 02/20/23 timed 9:40 P.M. revealed Resident #2 presented to the emergency department for psychiatric evaluation. Reportedly at facility and crawled out of window and was found wandering. Resident #2 denied any head injury. Resident #2 reported he wanted to walk and wanted to leave the facility. Resident #2 did not want to go back to facility and was pink slipped (paperwork used to detain an individual for the purpose of emergency hospitalization ) by police. The physician spoke to social worker and Resident #2 had no criteria for admission to psychiatric unit, was medically clear and would be discharged back to facility. Review of the general progress note dated 02/21/23, timed 9:26 A.M. revealed Resident #2 returned from hospital on gurney via ambulance. Alert and oriented per usual self. No complaints of pain or discomfort. No new orders noted. Observation on 02/21/23 at 2:30 P.M. revealed the facility was secured and required a code to be entered into a keypad to enter and exit the facility. Interview on 02/21/23 at 4:25 P.M. with the Administrator revealed on 02/20/23 Resident #2 had removed the window stoppers and exited the facility via his bedroom window. Resident #2 was found in a nearby town (where he used to live) at his friend's house. The staff determined he was missing around 7:00 P.M. when Resident #2 did not come for smoke break and his dinner was untouched. The staff searched the premises and could not locate Resident #2. The staff notified the DON and Administrator. The police were notified and involved in the search. MD #5 later identified the window stopper from Resident #2's bedroom window had been removed. Resident #2 had resided on the secured unit when he was originally admitted then was moved off the secured unit. Resident #2 was able to perform all his own care and was ambulatory however he had impaired judgement from a TBI and alcoholism. Observation on 02/21/23 at 4:53 P.M., with the Administrator present, revealed Resident #2 was sitting on the edge of his bed, feeding himself dinner in his room on the secured unit. Resident #2 was nicely groomed and dressed in street clothes. Interview, during the observation, with Resident #2 revealed he had lived at the facility a long time. When asked how he exited the facility, Resident #2 stated, I walked out the door. Resident #2 did not know what time he left the facility and when asked where he went after he exited the facility, Resident #2 replied, nowhere really, I was mad, I just wanted to get away from the facility. When asked if someone gave him a ride in a car, Resident #2 stated he did not know who picked him up. Observation on 02/21/23 at 5:00 P.M. of Resident #2's former room, with the Administrator present, revealed one bedroom window between Resident #2's former bed and his roommate, Resident #36's bed. There was a cracked, plastic window stopper attached by two screws to bottom sliding area of the window to prevent the window from opening more than approximately five inches. Interview on 02/22/23 at 9:05 A.M. with SSD #4 revealed Resident #2 had a legal guardian (Guardian #19). Guardian #19 reported Resident #2 had a house at one time but could not take care of himself then he had an apartment and got evicted. Resident #2 had short-term memory issues. Guardian #19 came to visit Resident #2 on 02/21/23, he went outside to smoke then came back inside and acted like he did not know who Guardian #19 was. Resident #2 said he wanted to leave several times in the past, however this was the first time he eloped. On Monday (02/20/23), the nurse told SSD #4 that Resident #2 wanted to leave and felt he did not need to be at the facility. Resident #2 came into SSD #4 ' s office to talk and SSD #4 told him she would reach out to his guardian. Resident #2 said okay and went back to his room. Interview on 02/22/23 at 9:15 A.M. with MD #5 revealed all the windows had a window stopper on the top or the bottom or both. MD #5 stated the previous maintenance director used short screws to install the window stoppers which made them easy to remove. Resident #2's window stopper was installed on the bottom of the window. MD #5 felt Resident #2 must have used a coin to remove the screws and window stopper. MD #5 revealed a nurse or nurse aide found the removed window stopper in Resident #2's top dresser drawer. MD #5 determined Resident #2 jumped out of his bedroom window because MD #5 observed kicked mulch on the sidewalk where Resident #2's feet landed and observed Resident #2's window screen leaning up against the outside of the building. Observation on 02/22/23 at 9:20 A.M. revealed Resident #2 was sitting in a chair, dressed in street clothes near the nurse's station on the secured unit. Resident #2 had flat affect. Observation of Resident #2's new room on the secured unit, with MD #5 present, revealed a dresser with a television on the top of the dresser was pushed up against and blocking the only bedroom window. The bedroom window curtain was closed. MD #5 had to move the dresser to access the window. There was an audible alarm placed on the top right corner of the window which alarmed when MD #5 opened the window. The window opened into a closed courtyard. Interview on 02/22/23 at 9:46 A.M. with Resident #2's brother revealed on 02/20/23, Resident #2 left the facility and ended up at friend's house next to where Resident #2 used to live. Resident #2's brother picked up Resident #2 at the friend's house between 8:00 P.M. and 9:00 P.M. and brought him back to the facility. Resident #2 could not or would not tell his brother how he got to the friend's house. Resident #2's brother believed Resident #2 walked part way then got a ride to the friend's house. Resident #2's brother gave the address of the friend's house which was located approximately 7.7 miles away from the facility. Resident #2's brother revealed Resident #2 had short term memory loss and had been cognitively impaired for over three years. Resident #2's brother also said Resident #2 attempted to escape from his previous facility. Interview on 02/22/23 at 12:02 P.M. with STNA #7 revealed on 02/20/23, Resident #2 was calm during the day and the last time STNA #7 saw Resident #2 was at the 12:45 P.M. smoke break. Interview on 02/22/23 at 12:04 P.M. with RN #8 revealed Resident #2 had previously discussed his desire to live at an assisted living and RN #8 directed him to call Guardian #19 or SSD #4. On 02/20/23, RN #8 gave Resident #2 his morning medications and had given him his cigarettes for smoke break. That day between 2:00 P.M. to 2:30 P.M., Resident #2 asked RN #8, When am I getting out of this nuthouse? which he had asked before. Resident #2 wanted to speak to Guardian #19 about assisted living so RN #8 directed Resident #2 to speak with SSD #4. Resident #2 spoke to SSD #4 then 10 minutes later, RN #8 observed Resident #2 heading towards his room which was the last time she saw Resident #2. Resident #2 usually stayed in his room. RN #8 was not in the facility when LPN #10 called regarding Resident #2 not attending the 6:30 P.M. smoke break, she had left at the end of her shift. Interview on 02/22/23 at 12:30 P.M. with Guardian #19 revealed she received a call on 02/20/23 from SSD #4 stating Resident #2 was saying he was going to go out a window and was sick of the place. Guardian #19 told SSD #4 if Resident #2 was stating he was going to do it, he would. Guardian #19 encouraged SSD #4 to keep an eye on him. At 7:40 P.M., Guardian #19 received a call from the Administrator notifying her that Resident #2 was missing, and the police were involved. Guardian #19 stated Resident #2 tried to elope from the previous nursing home which did not have a secured unit and that was why he was admitted to this facility. Guardian #19 visited Resident #2 on 02/21/23, they talked then Resident #2 went outside for a smoke break. When Resident #2 came back inside after the smoke break, he acted like Guardian #19 had just arrived and he did not remember they had just spoken 10 minutes prior. Guardian #19 revealed Resident #2 felt he was getting better however Resident #2 did not understand his illness or that was unable to care for himself. A follow-up interview on 02/22/23 at 4:40 P.M. with the Administrator revealed Resident #2 did not have an elopement care plan at the time of the elopement because Resident #2 scored as a low-risk for elopement on the most recent elopement assessment. A follow-up interview on 02/27/23 at 11:10 A.M. with SSD #4 revealed on 02/20/23 before the elopement, Resident #2 did state he wanted to get out and he would try to go through the window. Interview on 02/27/23 at 3:13 P.M. with Resident #2's former roommate (Resident #36) revealed he did not see Resident #2 exit via the window. Resident #36 had his privacy curtain closed and did not see or hear anything. The last time Resident #36 saw Resident #2 he was standing in the front lobby before or after dinner waiting to go smoke. Interview on 02/28/23 at 3:45 P.M. with Police Officer (PO) #3 revealed the police were dispatched on 02/20/23 at 7:28 P.M. for Resident #2 missing from the facility. PO #3 explained Resident #2's brother picked up Resident #2 from a friend's house and drove Resident #2 back to the facility. Another police department called PO #3 at approximately 8:45 P.M. to notify him Resident #2 was enroute back to the facility. PO #3 interviewed Resident #2 once he was returned to the facility however Resident #2 was in and out of it. Resident #2 stated he had walked to his brother ' s house because that was the place he remembered and he was there the whole time. PO #3 stated Resident #2 told him he used a dime to unscrew the screws to remove the window stopper. The friend was interviewed and reported Resident #2 had walked or gotten a ride, knocked on the friend ' s door and was standing outside the door of the friend's house when the friend opened the door. PO #3 reported there were conflicting stories of Resident #2 at his brother's versus at the friend's house. PO #3 voiced his concern that Resident #2 had been missing from the facility for approximately 4 1/2 hours before the staff became of aware he was gone and how easily Resident #2 was able to remove the window stopper. Review of the facility's recorded camera footage dated 02/20/23 with a timestamp of 3:03 P.M., with the Administrator present, revealed an outside eastern view of the front entrance awning, part of the front parking lot, and the front eastside of the building where Resident #2 resided. Resident #2 slid the window open, climbed out of the window then walked East towards an exit door/patio by the facility laundry room. Resident #2 was wearing light colored jeans, a flannel hooded shirt and work boots. Resident #2 looked around then climbed over the sidewalk handrailing. Resident #2 then proceeded to walk East around the back of the facility out of view from the camera. Interview with the Administrator, during observation of the camera footage, revealed the timestamp on the camera footage was incorrect as the camera time was 37 minutes fast so the actual time of the elopement was 2:26 P.M. The Administrator revealed another police department called PO #3 (who was at the facility with the Administrator) around 8:25 P.M. to notify PO #3 Resident #2 had been located. The Administrator verified there were no interventions implemented to prevent Resident #2's elopement after Resident #2 verbalized his desire to leave the facility to the nurse and SSD #4. Review of the facility's recorded outside camera footage dated 02/20/23 with a timestamp of 3:05 P.M. to 3:28 P.M. (actual time of 2:28 P.M. to 2:51 P.M.), with the Administrator present, revealed a northern outside view of the westside of the facility where Buckeye and Maple units located. Resident #2 was not observed on the camera during the 23-minute time frame. Review of the police department incident #23BV03002 for missing person dated 02/20/23 timed 7:28 P.M. authored by PO #3 revealed the facility contacted the department to report a missing person when a male escaped the facility at an unknown time. Police Officer #24 and PO #3 arrived and spoke with Administrator. The Administrator stated a resident (Resident #2) who had dementia, TBI and a history of alcoholism had escaped from the facility. The description was provided as a white male, bald, wearing boot cut jeans, brown work boots, and possibly having a sweatshirt or maroon flannel jacket. The Administrator was reviewing footage to determine where and how Resident #2 escaped the facility. The Administrator indicated all staff were currently trying to locate Resident #2 and received a tip that he may have been at gas station but when gas station footage was reviewed it was determined it was not Resident #2. The Administrator indicated Resident #2 had two brothers in the area and provided their names and addresses. PO #3 contacted dispatch and advised to enter Resident #2 through Law enforcement automated data system/national crime information center (LEADS/NCIC) as missing and endangered, along with putting out a Be on the Lookout ([NAME]) through LEADS and [NAME] (public safety software) to all surround agencies. PO #3 had dispatch advise the nearby town's police department along with nearby township police department to attempt to contact brothers. They advised contact was made but neither brother knew the whereabouts of Resident #2. One of the brothers said he would attempt to locate Resident #2 at other addresses Resident #2 previously frequented. The incident for missing person report further indicated the main custodian of the facility checked the room of Resident #2 and found that he had escaped through the window. It was told that on all windows had a security mechanism to only allow the window to open roughly a few inches. The window in Resident #2's room was missing the safety locked and the screen was not in its correct place, along with mulch being scattered on the ground in front of the window as if someone had climbed out the window. The information was provided to the Administrator who reviewed the camera footage from that specific area and observed around 3:03 P.M., Resident #2 exited the window wearing a maroon flannel, work boots and blue jeans. Resident #2 then replaced the screen on the window and went to the east side of the building. PO #3 contacted Lieutenant #25 who was provided the information, and then began to prepare crisis response team to be activated, thermal imaging [NAME], along with retrieving a K9, and contacting Police Chief #26. The nearby town police department contacted the department advising they received a call from Resident #2's brother stating the other brother had custody of Resident #2 and was enroute. Resident #2 arrived on scene by his brother, along with emergency medical services (EMS) being summoned for a medical admission to hospital. The brother was asked how he had gotten in contact with Resident #2 to which he stated he believed Resident #2 would be at a friend ' s house near Resident #2's old house. When Resident #2 was asked where he was, he stated that he was with his brother the entire time and he left the facility and walked the entire way. EMS arrived and transported Resident #2 to hospital. PO #3 spoke with friend who stated he was sitting inside on his couch when he heard a knock at the door. The friend opened the door and Resident #2 was standing outside and stated that he escaped. The friend asked him to come inside and asked how he had gotten there, and Resident #2 stated some guy that he knew had picked him up and drove him over to the house around 6:30 P.M. The friend sat Resident #2 down, offered him food and put on a movie for him. That was the approximate time Resident #2's brother showed up at the house and took custody of Resident #2. Review of the facility Self-Reported Incident (SRI) dated 02/20/23 revealed an allegation of neglect/mistreatment abuse involving Resident #2. Facility staff reported to the DON that they were unable to locate Resident #2 and that his dinner tray was untouched. Staff were unable to locate Resident #2 in an immediate search of the facility and grounds. The DON reported to Administrator. Administrator notified EMS and police responded to assist in search. Department managers reported to facility to assist with search. Resident had BIMS of 14 but had guardianship established. Resident's guardian notified and provided contact information for family members and background on resident. Administrator provided police with photo and physical description. Resident's brother located him and returned him to the facility. DON evaluated Resident #2 and noted no injuries. Resident #2's mood was at baseline. Resident #2 was placed on a psychiatric hold by the police department and transported to hospital. Review of the nursing and STNA staff schedule from 02/20/23 revealed STNA #7 and RN #8 worked from 6:00 A.M. to 6:00 P.M. on the unit where Resident #2 resided; STNA #28 worked from 2:00 P.M. to 10:00 P.M. on 02/20/23, and STNA #8 and LPN #10 worked from 6:00 P.M. on 02/20/23 to 6:00 A.M. on 02/21/23. Review of the witness statement dated 02/20/23 authored by STNA #7 revealed the last time STNA #7 saw Resident #2 was at the nurse station waiting for smoke break around 12:45 P.M. Review of the witness statement dated 02/20/23 authored by RN #8 revealed Resident #2 approached the nurses station at approximately 2:30 P.M. questioning when he was going to get out of this nuthouse. RN #8 asked Resident #2 if he wanted to discuss further what was bothering him. Resident #2 said he wanted to speak to his guardian and asked for her phone number. RN #8 provided guardian's number. Resident #2 asked again when he was going to be leaving and RN #8 redirected him to SSD #4 for further questions regarding his stay at the facility. Resident #2 then walked away from the nurse ' s desk and walked into SSD #4's office. Review of the witness statement dated 02/20/23 authored by STNA #9 revealed STNA #9 went to pass water and snacks noticed Resident #2 was gone and told the nurse. Resident #2 was not in his room. Review of the witness statement dated 02/20/23 authored by STNA #28 revealed since arriving at work STNA #28 did not see Resident #2. When STNA #28 passed meal trays she noticed he was not in his room but usually when Resident #2 was not in his room he was on another unit. STNA #28 did not suspect anything was wrong because it was not unusual for Resident #2 to visit another unit. Review of the witness statement dated 02/20/23 authored by LPN #10 revealed at 6:30 P.M. Resident #2 did not come up for smoke break like he always did. LPN #10 waited a few minutes and asked the STNA if Resident #2 had come up without LPN #10 noticing. The STNA said she had not seen him and went to check his room. After checking Resident #2's room and finding untouched dinner tray, she notified LPN #10. They asked roommate what time he had last seen Resident #2 and he stated not since before dinner. LPN #10 and the STNA checked entire building including rooms, cleaning closets and other floors. LPN #10 walked around outside of building to locate Resident #2 then proceeded to notify the DON at 7:30 P.M. after completely searchi[TRUNCATED]

Based on review of medical records, review of the facility Self- Reported Incident (SRI) and SRI investigation, review of the facility abuse policy and interviews with staff, the facility failed to provide adequate supervision to protect Resident #84 from physical abuse inflicted by cognitively intact Resident #43. Actual harm occurred when Resident #84 was struck in the face by Resident #43 causing a half inch laceration to Resident #84's left eyebrow. This affected one resident (Resident #84) of three residents reviewed for abuse/neglect and it had the potential to affect all 18 residents on the Maple/secured unit. The facility census was 81. Findings included: Review of the medical record revealed Resident #84 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, schizophrenia, bipolar disorder, personality disorder, alcohol abuse and cannabis dependency. She was discharged to another facility on 01/06/23. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #84 had intact cognition. She had no delirium, psychosis, or behaviors. Record review for Resident #43 revealed she was admitted to the facility on [DATE] with diagnoses including restlessness and agitation and schizophrenia. Her plan of care with a date initiated of 08/18/22 indicated she had behaviors including yelling out, pacing and being verbally and physically aggressive towards staff and other residents. Review of the progress note dated 11/14/22 at 12:09 P.M. revealed at approximately 9:50 A.M. Resident #84 was in the restroom and was hit in the face by Resident #43. Resident #84 came out of the restroom and notified the nursing assistant Resident #43 had attacked her in the bathroom. Resident #84 was noted to have a half inch laceration on her left eyebrow and a reddened area below her left eye and the left side of her nose. Review of the SRI dated 11/14/22 provided the following details about the incident involving Resident #84 and Resident #43: On 11/14/22 Resident #84 had reported to the nursing assistant she went into the room of Resident #43. She stated Resident #43 struck her in the face for being in her room and Resident #84 fell against the wall. During the assessment of Resident #84, Resident #84 reported to the nurse on duty Resident #43 had hit her in the face and pushed her against the wall in the bathroom. Resident #43 denied striking Resident #84 when interviewed by the Assistant Director of Nursing and there were no witnesses to the incident. Resident #43 was transported to the local hospital for a psychiatric evaluation. Resident #43 admitted to the hospital staff she pushed Resident #84 because she had made her mad. Resident #43 had not met criteria for inpatient admission so returned to facility with order changes. Resident #43 had a Brief Interview for Mental Status score of 14 indicating she had intact cognition and her diagnoses included schizoaffective disorder bipolar type, schizophrenia, anxiety disorder and personal history of traumatic brain injury (TBI). Resident #43 was in her room at the time of alleged incident and Resident #84 had entered her room without permission, causing Resident #43 to become upset. As a result of the investigation the facility had implemented a room change so Resident #43 was not sharing a bathroom with other residents, a stop sign was placed on her door to discourage entry by other residents, her care plan was reviewed and updated, and she was sent to the hospital for a psychiatric evaluation. Implemented interventions for Resident #84 included a complete head to toe assessment and treatment of her laceration. Both Resident #84 and #43 were referred to psychiatric services for follow up and their physician, psychiatrist and responsible parties were notified of the incident. Review of the signed witness statement dated 11/14/22 at 9:50 A.M. and authored by Nurse #200 indicated upon start of the morning meeting the team was approached by another nurse who stated Resident #43 physically attacked Resident #84. Both nurses responded immediately and upon assessment of Resident #84 it was noted she had a laceration to her left eyebrow which was bleeding. Resident #84 indicated she was just walking, and Resident #43 hit her and slammed her head into the wall. Resident #43 denied hitting Resident #84. Both residents were separated for safety and Resident #43 was sent to the hospital for a psychiatric evaluation. On 01/18/23 at 8:00 A.M. an interview with Licensed Practical Nurse (LPN) #100 revealed Resident #43 could become aggressive at times and would lash out at the other residents who were near her and she would also hit them. On 01/18 /23 at 8:15 A.M. an interview with LPN #101 revealed Resident #43 could become easily agitated and would strike out at other residents. Review of an email dated 01/23/23 at 10:15 A.M. provided by the Administrator revealed the Administrator was aware Resident #43 had behaviors and triggers so the Administrator would put appropriate interventions in place and communicate best practices to the staff. The email revealed Resident #43 had a very complicated and traumatic psychosocial history which resulted in her TBI. Review of an email dated 01/23/23 at 11:35 A.M. provided by the Administrator revealed if Resident #43 was agitated during care, the staff were instructed to stop and re-approach her later. She stated the staff were to distract Resident #43 from any residents from wandering by, offer her pleasant diversions, structured activities, food, conversation, television, and books. They were to intervene as necessary to protect the rights and safety of others, approach/speak to her in a calm manner, divert her attention, remove her from the situation and take her to an alternate location as needed so the staff would provide one on one support to decrease stimulation, monitor behavior episodes, and attempt to determine the underlying cause for her agitation. Review of an email dated 01/23/23 at 12:44 P.M. provided by the Administrator verified the event had occurred however, both residents were on a similar cognitive level with similar diagnoses and there were no witnesses to the altercation other than the involved parties. The Administrator indicated Resident #84 admitted to entering Resident #43's personal space without permission. She indicated when she spoke with Resident #43, Resident #43 was very tearful, which was what prompted the psychiatric evaluation. The Administrator also indicated she reviewed the investigation and findings with the corporate clinical [NAME] President who was no longer with the company and the directive was to substantiate due to the cut on Resident #84's face. Review of the undated facility policy titled, Abuse Prevention Program, revealed the residents had the right to be free from abuse, neglect misappropriation of resident property and exploitation. The administration would protect the resident from abuse by anyone including but not necessarily limited to limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, and any other individual. This deficiency was a result of incidental findings during the investigation of Complaint Number OH00139255.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of the facility's Coronavirus (COVID-19) policy, review of the facility's handwashing policy, review of Centers for Disease Control and Prevention (CDC) guidelines, observations, interviews, and record review the facility failed to implement appropriate infection control practices related to use of personal protective equipment (PPE) for residents on COVID-19 isolation precautions, failed to conduct appropriate screening upon entering the facility and failed to perform hand hygiene. This resulted in Immediate Jeopardy on 04/30/21 at 4:00 A.M. when the facility failed to implement effective practices to prevent the spread of COVID-19 to residents in the facility after a positive COVID-19 test result was received for State tested Nursing Assistant (STNA) #100. The lack of effective infection control practices placed all residents at the facility at risk for serious life-threatening harm, complications and/or death related to the facility's failed practice of infection control. The facility census was 84. On 05/03/21 at 5:04 P.M. the Administrator was notified that Immediate Jeopardy began on 04/30/21 when the facility failed to implement appropriate and recommended infection control practices after STNA #100 tested positive for COVID-19. After the positive test results were received for COVID-19, the facility failed to implement policies to prevent exposure of non-infected (COVID-19 negative) residents from staff who were not donning appropriate Personal Protective Equipment (PPE), performing appropriate hand hygiene, and sanitizing face shields or changing N95 masks upon departure of rooms of residents in quarantine. The Immediate Jeopardy was removed on 05/04/21 at 1:25 P.M. when the facility implemented the following correction actions: · On 05/03/21 at 5:30 P.M. the Administrator ensured appropriate PPE (face masks and eye protection) was readily available at the entrance to the facility. Unit nurses/designee will ensure PPE remains stocked at the front entrance, on PPE carts and at sanitizing stations on their assigned unit every shift. · Dietary manager/designee will continue to ensure hand sanitizer is placed on the tray carts prior to leaving the kitchen. · On 05/03/21 at 5:45 P.M. the Administrator ensured PPE carts and sanitizing stations were stocked and available outside of isolation rooms. · On 05/03/21 at 6:00 P.M. the DON ensured signage was posted outside of isolation areas describing PPE required to enter the room. There was one Resident (Resident #84) who was on quarantine and one resident (Resident #31) who was on isolation related to a positive COVID test. · By 05/03/21 at 10:00 P.M. the DON, Registered Nurse (RN) #145, and RN #150 completed a symptom evaluation on all residents in the facility except one resident who was currently infected with COVID 19 (Resident #31). Facility nurses will complete symptom evaluations per policy ongoing. For those who are asymptomatic, screening will be completed twice a day. Screening and evaluation frequency will be increased based on symptoms. The Physician will be notified of any change in condition. · By 05/03/21 at 10:00 P.M. the DON, RN #150 and RN #155 obtained PCR COVID 19 tests on all residents at risk for COVID 19 infection. The physician will be notified of any abnormal results. Residents will be tested for COVID 19 infection per policy ongoing. All residents were swabbed with the exclusion of active COVID and COVID recovered within the past 90 days (Residents #13, #31, #50, #55, #58, #66, and #69). · By 05/04/21 at 9:12 A.M. the DON and/or designees had educated all 88 employees on proper hand hygiene, proper use of PPE and sanitizing PPE (including eye protection) between residents. All 88 employees were also educated related to properly screening visitors prior to allowing entrance to the facility. Visitors must ring a doorbell to gain entrance to the facility. · The DON/designee will conduct audits related to proper PPE use and availability of PPE (upon entrance to the facility and prior to entering isolation rooms) daily for one week, then 3 times a week for 4 weeks (inclusive of one off-shift), then monthly. · The DON/designee will conduct audits of the screening process and tools daily for one week, then 3 times a week for 2 weeks, then monthly. · The DON/designee will audit hand hygiene during meal pass (including availability of hand sanitizer) daily for one week, then 3 times a week for 4 weeks. Findings will be summarized and reviewed by the Quality Assurance Performance Improvement committee. The committee will determine the need for further audits and/or action plans at least monthly. · On 05/04/21 between 5:03 A.M. and 12:13 P.M. interview with Licensed Practical Nurse (LPN) #105, LPN #160, LPN #180, STNA #115, STNA #170, STNA #175, STNA #185 and STNA #190 revealed they had received the infection control education. All staff were wearing appropriate PPE. · By 05/04/21 at 1:25 P.M. STNA #190 was re-educated after observations of him exiting Resident #31's room after delivering his lunch tray without changing his mask or disinfecting the face shield. Although the Immediate Jeopardy was removed on 05/04/21 the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: During the onsite investigation, beginning on 04/30/21 at 4:00 A.M. the facility revealed they were in outbreak status related to STNA #100 who tested positive for COVID 19. The sample was collected for a PCR test on 04/23/21 and results reported 04/24/21. STNA #100 was asymptomatic and worked her entire shift on 04/23/21. 1. On 04/30/21 at 4:00 A.M. LPN #105 was observed walking toward the doorway. No PPE was applied. After the surveyors introduced themselves, LPN #105 retrieved an N95 mask from a drawer at the entry and stated she needed to apply it. LPN #105 stated staff had been wearing surgical masks. However, earlier in the shift Resident #31 was sent to the hospital due to a psychotic episode and the hospital contacted the facility to inform them Resident #31 tested positive for COVID 19. LPN #105 verified she did not have PPE on when she opened the door. LPN #105 stated staff were not required to use eye protection although the facility was in outbreak status. Simultaneously, STNA #110 was observed standing at the nursing station on the Pine unit self-swabbing for a COVID test. LPN #105 was walking back and forth between the entry door and the nursing station in the vicinity STNA #110 was doing the testing with only the N95 for PPE. LPN #105 directed the survey team to an office behind the nursing station without screening the visitors. LPN #105 was asked if screening was required and she pointed to the thermometer on the wall and screening forms on the table. Recorded temperatures were not verified. On 04/30/21 at 4:24 A.M. LPN #105 verified STNA #120 and STNA #125 were not wearing eye protection. On 04/30/21 at 4:35 A.M. STNA #130 verified she was not wearing eye protection. On 04/30/21 at 4:54 A.M. LPN #105 verified STNA #110 was performing a nasal swab for a COVID test at the nursing station when surveyors entered. There had been no formal training regarding collection of specimens or required PPE during testing. On 04/30/21 at 4:57 A.M. STNA #115 verified she was not wearing eye protection because only staff working on units with residents who were COVID positive were required to wear eye protection. Review of the facility's COVID 19 Preparation Play Book #1 (updated 09/10/20) indicated entrance screening was essential. It was necessary to perform active review of respiratory symptoms, monitor temperatures, ensure hand hygiene was performed, and appropriate PPE was donned. The book indicated staff were to utilize a face shield and N95 mask when caring for residents who were asymptomatic but within 14 days of possible exposure to COVID 19. On 04/30/21 at 9:08 A.M., the Administrator stated because a staff member tested positive for COVID 19 on 04/23/21 all staff were required to wear N95 masks and eye protection. 2. Review of Resident #84's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #84 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/30/21 at 8:37 A.M. STNA #135 was observed delivering a meal tray to Resident #84. No gown was applied prior to entering Resident #84's room. Upon exit, the face shield was not sanitized and the N95 mask continued to be worn. Interview with STNA #135 upon exiting the room revealed she was informed there were no residents on quarantine. Review of the facility's COVID 19 Preparation Play Book #1 revealed if a resident was on quarantine, a face shield and N95 mask should be worn at all times. A gown was to be worn when staff entered the room and doffed when exiting. Face shields were to be cleaned upon exiting the room. On 04/30/21 at 9:08 A.M. the Administrator verified Resident #84 remained in quarantine due to his recent admission and that staff were required to wear gowns when entering the room. 3. On 04/30/21 at 8:08 A.M. STNA #140 was observed delivering breakfast trays with gloves applied. STNA #140 delivered multiples trays with the same gloves while touching objects in the residents' immediate environment such as tray tables. Hand hygiene was not performed and gloves were not changed. On 04/30/21 at 8:08 A.M. STNA #140 verified she had not changed her gloves or performed hand hygiene between residents. Review of the Center's for Disease Control's Hand Hygiene Guidance revealed healthcare personnel should use an alcohol-based hand rub or wash with soap and water after touching a resident or the resident's immediate environment. 4. On 05/04/21 at 12:12 P.M. STNA #190 was observed leaving Resident #31's room who was on isolation due to COVID-19 infection. STNA #190 did not change his face mask or disinfect his face shield. On 05/04/21 at 12:13 P.M. STNA #190 verified he did not change his mask or clean his face shield before or after entering and exiting Resident #31's room. This deficiency substantiates Complaint Number OH 992.

Based on medical record review, interviews with staff and residents, review of the facility's incident investigation and review of the police report, the facility failed to ensure a staff member immediately reported a witnessed incident of staff to resident physical abuse. Actual harm that is Immediate Jeopardy occurred on 10/29/19 when Laundry Aide (LA) #102 witnessed State tested Nurse Aides (STNAs) #100 and #101 hold Resident #1 down on his bed by his arms and slam his head into the overbed table resulting in an abrasion and bruising above the right eye. LA #102 failed to report the incident until 11/03/19 and as a result STNAs #100 and #101 continued to work their scheduled shift from 10/29/19 through 11/03/19. The facility census of 88 residents was at risk for abuse by the staff members. On 11/05/19 at 5:10 P.M. the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) #150 were notified Immediate Jeopardy began on 10/29/19 at 5:30 P.M. when LA #102 witnessed the abuse by STNA #100 and STNA #101 to Resident #1. The abuse was not reported by LA #102 until 11/03/19 when the LA #102 dropped a statement detailing the abuse into the resident concern box, however the administrator did not see the note until 11/04/19. The Immediate Jeopardy was removed on 11/06/19 when the facility implemented the following corrective action: · On 11/04/19 at 1:30 P.M. the Director of Nursing (DON) initiated Self-Reported Incident (SRI) # 29 to report the witnessed physical abuse of Resident #1 by STNA #100 and STNA #101. The Medical Director was notified. The DON suspended STNA #100 pending investigation. STNA #101 had already been suspended from work by the DON on 11/03/19 at 6:00 P.M. due to an unrelated incident. · On 11/05/19 beginning at 4:30 P.M education was provided to employees by facility administrative team ADON #150, Activities Director (ACT) #107, Social Service Designee (SSD) #108 and the DON on the abuse policy to include immediate reporting of witnessed abuse to the supervisor or available administrative person upon observation. This education was completed for all current staff on 11/06/19 at 6:57 P.M. · On 11/05/19 from 5:30 P.M. to 9:15 P.M. 77 current residents who were cognitively intact were interviewed utilizing the Center for Medicaid and Medicare (CMS) # , Critical Element Pathway abuse questions to determine if any abuse has occurred. The interviews were completed by ADON #150, ACT #107, SSD #108 and the DON. The Administrator identified one (Resident #45) who alleged physical abuse by STNA #124 and SRI # 7 was initiated. On 11/06/19 at 4:51 P.M. the investigation was completed, and the allegation was unsubstantiated. · On 11/05/19 from 5:30 P.M. to 8:30 P.M. skin checks were completed by ADON #150, Registered Nurse (RN) #125, RN #126, and LPNs #127, #128 and #129 on all residents. No unexplained bruises or injuries that could be due to abuse were identified. · On 11/05/19 at 3:15 P.M. the Administrator suspended LA #102. LA #102 remains suspended pending further director from the corporate office. · On 11/05/19 at 8:35 P.M. an ad-hoc by Quality Assurance Performance Improvement (QAPI) meeting was held to address staff statements, facility reporting, anonymity of reporters and security measures for center. · On 11/06/19 at 3:30 P.M. staff interviews were conducted to verify receipt and understanding of education including the abuse protocol and reporting with LPNs #103, #105, #118, STNAs #104, #116, #120, and #122, Housekeepers (HSPK) #110, #121, and #131, Cook # 119, and Physical Therapist (PT) #113. All staff confirmed they received the education and were knowledgeable of the abuse protocol. · Beginning on 11/06/19 ten (Resident #5, Resident #17, Resident #30, Resident #31, Resident #38, Resident #20, Resident #65 Resident #69, Resident #70, and Resident #76) non-interviewable residents will have skin checks completed by the DON/designee five times per week per unit for one week and then five residents per unit, weekly for one month. · On 11/07/19 at 9:10 [NAME]M. the Administrator terminated STNA #100 · On 11/07/19 at 9:15 [NAME]M. the Administrator terminated STNA #101. · Beginning on 11/11/19 LPN #129 will complete random interviews of five staff, five times per week per unit for one week and then weekly for one month on the abuse policy to include immediate reporting of any observations of abuse to the supervisor or available administrative person upon observation and that employees need not fear retaliation as all reports would remain anonymous. · Findings will be summarized and reviewed by the QAPI committee. The committee will determine the need for further audits and/or action plans. This plan will be incorporated into monthly QAPI meeting scheduled 11/19/19. Although the Immediate Jeopardy was removed, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure continued compliance. Findings include: Review of the medical record for the Resident #1 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 of 09/17/19 revealed the resident was cognitively intact with no behaviors and independent for Activities of Daily Living (ADL). Review of a nursing note dated 10/30/19 at 9:10 P.M. by Licensed Practical Nurse (LPN) #118 reported Resident #1 had a one centimeter (cm) by two cm scratch above the right eye. It was unknown how it occurred. Neurological checks were initiated and continued through 11/02/19 at 4:45 P.M. with no abnormal findings. Review of the investigative documentation for the SRI revealed a facility Incident Report dated 10/30/19 authored by LPN #118. The incident report indicated initial interview with Resident #1 revealed the resident said he hit his head on the tray table. It was also noted that neurological checks were initiated, and his physician, who was the Medial Director and the resident's responsible party were notified. Staff statements including LA #102 indicated none had any knowledge of how the bruise happened. Review of the facility Self-Reported Incident (SRI) # 9 revealed it was initiated on 11/04/19 at 1:39 P.M. by the DON. The SRI indicated on 11/04/19 a statement was found in the Resident Concern box authored by LA #102 indicating she witnessed abuse of Resident #1 by STNA #100 and #101 on 10/29/19. The allegation of abuse was substantiated on 11/05/19 at 4:58 P.M. Review of the Police Report #1-19- 5 dated 11/05/19 timed 12:16 P.M. revealed Police Corporal (CPL) #111 responded to a report of patient abuse. The report indicated a fourth degree felony was committed. The investigation is ongoing. On 11/05/19 at 9:45 [NAME]M. interview and observation with Resident #1 revealed a dime size reddish-purple bruise above the resident's right eye. The resident reported the bruise was a result of an assault by STNA #101 on 10/29/19. The resident did not recall the time. He stated STNA #101 came into his room and smacked his head against the overbed table. Resident #1 reported the act was deliberate. On 11/05/19 at 10:15 [NAME]M. interview with the DON and ADON #150 revealed the injury to Resident #1's forehead was first noticed on the morning of 10/30/19. Staff were interviewed including LA #102 with no knowledge of how the injury occurred. Resident #1 reported he accidently banged his against the overbed table in his room. On 11/04/19 the Administrator checked the Resident Concern box and found a new statement from LA #102 stating she lied in her earlier statement. LA #102's note indicated on 10/29/19 she witnessed STNA #100 and STNA #101 holding Resident #1's arms down on his bed. When Resident #1 tried to get up, STNA #101 aggressively shoved his table into his face resulting in the scratch and bruise above the resident's eye. As a result of the non-reporting, STNA #100 and STNA #101 continued to work at the facility, with access to all residents from 10/29/19 through 11/03/19. During the interview the DON also said STNA #101 was suspended on 11/03/19 at 6:00 P.M for an unrelated incident. STNA #100 was suspended on 11/04/19 after finding the statement from LA #102. The DON and ADON #150 verified the physical abuse of Resident #1 by STNA #100 and STNA #101 on 10/29/19 should have been reported immediately. On 11/05/19 at 1:00P.M. interview with STNA #106 revealed she was off for a few days and asked LA #102 what happened to Resident #1 when she returned to work on 11/01/19 and saw the bruise above his right eye. LA #102 told STNA #106 that she saw STNA #100 and STNA #101 abuse Resident #1 but did not report it to anyone. STNA #106 also failed to report the abuse after being told by LA #102. On 11/05/19 at 3:10 P.M. interview with LA #102 revealed she witnessed the abuse by STNA #100 and STNA #101 on 10/29/19 at approximately 5:30 P.M. Resident #1 was overheard by LA #102 to say (Expletive) you (expletive)! to STNA #101 and then entered his room and slammed the door. LA #102 reported STNA #101 then called STNA #100 out of another resident's room to come to Resident #1's room. They went into Resident #1's room and left the door open. LA #102 was standing in hall outside of Resident #1's room and saw STNA #100 and STNA #101 each holding one of Resident #1's arms down on the bed. When they released his arms the resident sat up and STNA #101 aggressively pushed the resident's head against the overbed table. Resident #1 then laid down on the bed crying and holding his eye. STNA #100 and STNA #101 then exited Resident #1's room and saw LA #102 in the hallway. STNA #101 told LA #102, If you say anything, I will kick your (expletive). LA #102 admitted to giving an initial statement on 11.01/19 saying she did not know how the injury to Resident #1 occurred. On 11/03/19, STNA #101 was suspended, due to an unrelated matter, so LA #102 wrote a statement and put it in the Resident Concern box indicating she had lied about Resident #1's injury. LA #102 then verified she witnesses STNA #100 and STNA #101 physically abused Resident #1 on 10/29/19 but did not report it until 11/03/19. However ,the administrator did not see the note until 11/04/19. On 11/05/16 at 5:10 P.M. interview with the DON revealed they completed the investigation and substantiated abuse. The DON verified the physical abuse of Resident #1 by STNA #100 and STNA #101 on 10/29/19 should have been reported immediately. Review of the undated abuse policy revealed residents have the right to be free from abuse. Any staff member who has witnessed or believes that a resident has been abused shall immediately report, or cause a report to be made of, the mistreatment or offense. The facility shall immediately investigate all allegations of mistreatment, neglect or abuse including injuries of unknown origin, misappropriation of resident property and suspicion of a crime. This deficiency substantiates Complaint Number OH 161.

Based on review of the medical record, a facility self-reported incident (SRI), local law enforcement report and interviews with staff and residents, the facility failed to implement their abuse policy and procedure when one resident (Resident #1) was physically abused by two staff members. In addition staff that witnessed the physical abuse failed to report it immediately to administration. This resulted in Immediate Jeopardy that was actual harm on 10/29/19 when Laundry Aide (LA) #102 observed two staff members (State tested Nurse Aides (STNA) #100 and #101) hold down Resident #1 in his bed by his arms and slam his head against the overbed table. This resulted in bruising and an abrasion above the resident's right eye. LA #102 failed to report the observation to administration until 11/03/19 and the two STNAs continued to work their scheduled days in the facility during that time period. This placed all resident in the facility census of 88 at risk for abuse by the staff members. On 11/05/19 at 5:10 P.M. the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) #150 were notified Immediate Jeopardy began on 10/29/19 at 5:30 P.M. when LA #102 witnessed physical abuse by STNA #100 and STNA #101 to Resident #1. The physical abuse was not reported by LA #102 until 11/03/19 when the aide dropped a statement detailing the abuse into the resident concern box The Immediate Jeopardy was removed on 11/06/19 when the facility implemented the following corrective action: · On 11/04/05 at 1:39 P.M. the DON initiated a Self-Reported Incident # 9 and the Medical Director was notified of alleged physical abuse of Resident #1 by two staff. · On 11/05/19 beginning at 4:30 P.M. education was provided to employees by facility administrative team ADON #150, Activities Director (ACT) #107, Social Service Designee (SSD) #108 and the DON on the abuse policy to include immediate reporting of witnessed abuse to the supervisor or available administrative person upon observation. This education was completed for all current staff on 11/06/19 at 6:57 P.M. · On 11/05/19 from 5:30 P.M. to 9:15 P.M. 77 current residents who were cognitively intact were interviewed utilizing the Center for Medicaid and Medicare (CMS) # , Critical Element Pathway abuse questions to determine if any abuse had occurred. The interviews were completed by ADON #150, ACT #107, SSD #108 and the DON. The Administrator identified one (Resident #45) who alleged physical abuse by STNA #124 and SRI # 7 was initiated. On 11/06/19 at 4:51 P.M. the investigation was completed, and the allegation was unsubstantiated. · STNA #101 was suspended on 11/03/19 related to refusal of assignment and STNA #100 was suspended on 11/04/19 when the investigation of alleged abuse was initiated and both remained suspended during the investigation. On 11/05/19 at 3:15 P.M. the Administrator suspended LA #102. LA #102 remains suspended pending further direction from the corporate office. · On 11/05/19 from 5:30 P.M. to 8:30 P.M. skin checks were completed by ADON #150, Registered Nurse (RN) #125, RN #126, and LPNs #127, #128 and #129 on all residents. No unexplained bruises or injuries that could be due to abuse were identified. · On 11/05/19 at 8:35 P.M. an ad-hoc by Quality Assurance Performance Improvement (QAPI) meeting was held to address staff statements, facility reporting, anonymity of reporters and security measures for center. · On 11/06/19 at 3:30 P.M. staff interviews were conducted to verify receipt and understanding of education including the abuse protocol and reporting with LPNs #103, #105, #118, STNAs #104, #116, #120, and #122, Housekeepers (HSPK) #110, #121, and #131, Cook # 119, and Physical Therapist (PT) #113. All staff confirmed they received the education and were knowledgeable of the abuse protocol. · Beginning on 11/06/19 ten (Resident #5, Resident #17, Resident #30, Resident #31, Resident #38, Resident #20, Resident #65 Resident #69, Resident #70, and Resident #76) non-interviewable residents will have skin checks completed by the DON/designee five times per week per unit for one week and then five residents per unit, weekly for one month. · On 11/07/19 at 9:10 [NAME]M. the Administrator terminated STNA #100. · On 11/07/19 at 9:15 [NAME]M. the Administrator terminated STNA #101. · Beginning on 11/07/19 the Administrator/Designee will complete random interviews of five residents, five times per week per unit for one week and then weekly for one month utilizing the resident interview critical element pathway (CMS # ) questions abuse section. · Beginning on 11/11/19 LPN #129 will complete random interviews of five staff, five times per week per unit for one week and then weekly for one month on the abuse policy to include immediate reporting of any observations of abuse to the supervisor or available administrative person upon observation and that employees need not fear retaliation as all reports would remain anonymous. · Findings of all audits will be summarized and reviewed by the Quality Assurance Performance Improvement (QAPI) committee. The committee will determine the need for further audits and/or action plans. This plan will be incorporated into the monthly QAPI meeting scheduled on 11/19/19. Although the Immediate Jeopardy was removed, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure continued compliance. Findings include: Review of Resident #1's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 dated 09/17/19 revealed Resident #1 was cognitively intact with no behaviors and independent for Activities of Daily Living (ADL). Review of a nursing note dated 10/30/19 at 9:10 P.M. by Licensed Practical Nurse (LPN) #118 revealed Resident #1 had a one centimeter ( cm ) by two cm scratch above the right eye. It was unknown how it occurred. Neurological checks were initiated and continued through 11/02/19 at 4:45 P.M. with no abnormal findings. Review of the wound grid dated 10/30/19 by LPN #118 revealed a one cm by two cm scratch with a bruise, slightly red in color above Resident #1's right eye. The wound was cleansed with normal saline solution. Review of the investigative documentation revealed a facility Incident Report dated 10/30/19 authored by LPN #118. The incident report indicated initial interview with Resident #1 revealed the resident hit his head on the overbed table. It was also noted that neurological checks were initiated, and the physician and the resident's responsible party were notified. Staff statements including LA #102 indicated no one had any knowledge of how the bruise occurred. Review of the facility Self-Reported Incident (SRI) # 9 revealed it was initiated on 11/04/19 at 1:39 P.M. by the DON. The SRI indicated on 11/04/19 a statement was found in the Resident Concern box authored by LA #102 indicating she witnessed abuse of Resident #1 by STNA #100 and #101 on 10/29/19. The resident's physician, who was also the Medical Director was notified. The allegation of abuse was substantiated on 11/05/19 at 4:58 P.M. Review of Police Report #1-19- 5 dated 11/05/19 timed 12:16 P.M. revealed Police Corporal (CPL) #111 responded to a report of patient abuse. The report indicated a fourth degree felony was committed. On 11/05/19 at 9:45 [NAME]M. interview and observation with Resident #1 revealed a dime size reddish-purple bruise above the resident's right eye. The resident reported the bruise was a result of an assault by STNA #101 on 10/29/19. The resident did not recall the time. He stated STNA #101 came into his room and smacked his head against the overbed table. Resident #1 reported the act was deliberate. On 11/05/19 at 10:15 [NAME]M. interview with the DON and ADON #150 revealed the injury to Resident #1's forehead was first noticed on the morning of 10/30/19. Staff were interviewed with no knowledge of how the injury occurred. Resident #1 reported he accidentally banged his against the overbed table in his room. On 11/01/19 LA #102 reported she walked by Resident #1's room and saw him rising from sitting on his bed and he hit his head on his table. On 11/04/19 the Administrator checked the resident concern box and found a new statement from LA #102 stating she lied in her earlier statement. LA #102's note indicated on 10/29/19 she witnessed STNA #100 and STNA #101 holding Resident #1's arms down on his bed. When Resident #1 tried to get up, STNA #101 aggressively shoved his table into his face resulting in the scratch and bruise about the resident's eye. STNA #100 and STNA #101 continued to work at the facility, with access to all residents from 10/29/19 through 11/03/19. On 11/03/19 both STNAs were working and objected to being pulled to help on other units. The STNAs caused a disruption in the facility resulting in local law enforcement being called and removing STNA #101 from the facility. The facility then suspended STNA #101. Review of a Police report 19- 2 verified this action. The DON said STNA #101 was suspended on 11/03/19 at 6:00 P.M. STNA #100 was suspended on 11/04/19 after finding the statement from LA #102. The DON and ADON #150 verified LA #102 failed to follow the facility abuse policy by not reporting witnessed abuse of Resident #1 until 11/03/19. On 11/05/19 at 3:10 P.M. interview with LA #102 revealed she witnessed the abuse by STNA #100 and STNA #101 on 10/29/19 at approximately 5:30 P.M. Resident #1 was overheard by LA #102 to say (expletive) you (expletive)! to STNA #101 and then entered his room and slammed the door. LA #102 reported STNA #101 then called STNA #100 out of another resident's room to come to Resident #1's room. They went into Resident #1's room and left the door open. LA #102 was standing in hall outside of Resident #1's room and saw STNA #100 and STNA #101 each holding one of Resident #1's arms down on the bed. When they released his arms, the resident sat up and STNA #101 aggressively pushed the resident's head against the overbed table. Resident #1 then laid down on the bed crying and holding his eye. STNA #100 and STNA #101 then exited Resident #1's room and saw LA #102 in the hallway. STNA #101 told LA #102, If you say anything, I will kick your (expletive). LA #102 stated she told Licensed Practical Nurse (LPN) #118 about the incident. LA #102 admitted to giving an initial statement on 11/01/19 saying she did not know how the injury to Resident #1 occurred. On 11/03/19, LA #102 wrote a statement and put it in the resident concern box indicating she had lied about Resident #1's injury that had occurred on 10/29/19. LA #102 then verified STNA #100 and STNA #101 physically abused Resident #1 on 10/29/19 but she did not report it until 11/03/19. However, the administrator did not see the note until 11/04/19. On 11/05/16 at 5:10 P.M. interview with the DON revealed they completed the investigation and substantiated abuse. The DON verified the abuse policy was not followed when STNAs #100 and #101 physically abused Resident #1 and the physical abuse was witnessed by LA #102 on 10/29/19 but she did not report it until 11/03/19. Review of the punch detail for STNA #100 from 10/29/19 to 11/03/19 revealed STNA #100 worked 11/29/19 from 5:55 [NAME]M. to 6:00 P.M., 10/30/19 from 6:03 [NAME]M. to 2:17 P.M., 11/01/19 from 5:55 [NAME]M. to 6:01 P.M. and 11/03/19 from 5:44 [NAME]M. to 6:44 P.M. Review of the punch detail for STNA #101 from 10/29/19 to 11/03/19 revealed STNA #101 worked 10/29/19 from 5:54 [NAME]M. to 6:00 P.M., 10/30/19 from 6:03 [NAME]M. to 2:16 P.M., and 11/03/19 from 5:44 [NAME]M. to 5:45 P.M. Review of the undated abuse policy revealed residents have the right to be free from abuse. Any staff member who has witnessed or believes that a resident has been abused shall immediately report, or cause a report to be made of, the mistreatment or offense. The facility shall immediately investigate all allegations of mistreatment, neglect or abuse including injuries of unknown origin, misappropriation of resident property and suspicion of a crime. This deficiency substantiates Complaint Number OH 161. This deficiency is an example of continued noncompliance from the survey dated 10/24/19.

Based on review of the medical record, a facility self-reported incident (SRI), local law enforcement report and interviews with staff and residents, the facility failed to prevent staff to resident physical abuse. This involved one intellectually impaired resident (Resident #1) and resulted in actual harm that was Immediate Jeopardy when State tested Nurse Aides (STNA) #100 and #101 were observed by Laundry Aide (LA) #102 holding Resident #1 down and STNA #102 slammed the resident's head against the overbed table. Resident #1 sustained bruising and an abrasion above his right eye. This affected one of three residents reviewed for abuse. The facility census was 88. On 11/05/19 at 5:10 P.M. the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) #150 were notified Immediate Jeopardy began on 10/29/19 at 5:30 P.M. when Laundry Aide (LA) #102 witnessed the abuse by STNA #100 and STNA #101 to Resident #1. The abuse was not reported by LA #102 until 11/03/19 when the she dropped a statement detailing the abuse into the resident concern box The Immediate Jeopardy was removed on 11/06/19 when the facility implemented the following corrective action: · On 11/04/19 at 1:30 P.M. the Director of Nursing (DON) initiated and submitted Self-Reported Incident (SRI) # 9 to the State Agency and began the investigation of the witnessed physical abuse of Resident #1 by STNA #100 and STNA #101. The resident's physician who was the medical director was notified. · On 11/04/19 at 4:30 P.M. STNA #100 was suspended by the ADON pending investigation. STNA #101 had already been suspended on 11/03/19 due to an unrelated issue involving refusing her assignment. · On 11/05/19 at 12:16 P.M. the local police were notified by the DON of the alleged resident abuse and at 12:39 P.M. Police Corporal (CPL) #111 arrived at the facility to investigate the reported abuse. · On 11/05/19 at 3:10 P.M. LA #102 was notified by ADON #150 that she was suspended pending investigation. · On 11/05/19 at 3:50 P.M. the DON reported substantiated physical abuse of a resident by STNA #100 and #101 to Director #200 of the State Nurse Aide Registry. · On 11/05/19 beginning at 4:30 P.M. education was provided to employees by the facility administrative team of ADON #150, Activities Director (ACT) #107, Social Service Designee (SSD) #108 and the DON on the abuse policy to include immediate reporting of any observations of abuse to the supervisor or available administrative person upon observation and all reports would remain anonymous. This education was completed for all current staff on 11/06/19 at 6:57 P.M. · On 11/05/19 from 5:30 P.M. to 9:15 P.M., 77 current residents who were cognitively intact were interviewed utilizing the Center for Medicaid and Medicare (CMS) Critical Element Pathway abuse questions to determine if any abuse has occurred. The interviews were completed by ADON #150, ACT #107, SSD #108 and the DON. The Administrator identified one resident (Resident #45) who alleged physical abuse by STNA #124 and SRI # 7 was initiated. On 11/06/19 at 4:51 P.M. the investigation was completed, and the allegation was unsubstantiated. · On 11/05/19 from 5:30 P.M. to 8:30 P.M. skin checks were completed by ADON #150, Registered Nurse (RN) #125, RN #126, and LPNs #127, #128 and #129 on all residents. No unexplained bruises or injuries were identified. · On 11/05/19 at 8:35 P.M. an ad-hoc by Quality Assurance Performance Improvement (QAPI) meeting was held to address staff statements, facility reporting, anonymity of reporters and security measures for center. · On 11/06/19 at 3:30 P.M. staff interviews were conducted to verify receipt and understanding of education including the abuse protocol and reporting with LPNs #103, #105, #118, STNAs #104, #116, #120, and #122, Housekeepers (HSPK) #110, #121, and #131, Cook # 119, and Physical Therapist (PT) #113. All staff confirmed they received the education and were knowledgeable of the abuse protocol. · On 11/07/19 at 9:10 [NAME]M. the Administrator terminated STNA #100. · On 11/07/19 at 9:15 [NAME]M. the Administrator terminated STNA #101. · Beginning on 11/07/19 the Administrator/Designee will complete random interviews of five residents, five times per week per unit for one week and then weekly for one month utilizing the resident interview critical element pathway questions abuse section. · Beginning on 11/06/19 non-interviewable residents (Resident #5, Resident #17, Resident #30, Resident #31, Resident #38, Resident #20, Resident #65 Resident #69, Resident #70, and Resident #76) will have skin checks completed by the DON/designee five times per week per unit for one week and then five residents per unit, weekly for one month. · Beginning on 11/11/19 LPN #129 will complete random interviews of five staff, five times per week per unit for one week and then weekly for one month on the abuse policy to include immediate reporting of any observations of abuse to the supervisor or available administrative person and that employees need not fear retaliation as all reports would remain anonymous. · Findings of all audits will be summarized and reviewed by the Quality Assurance Performance Improvement (QAPI) committee. The committee will determine the need for further audits and/or action plans. This plan will be incorporated into the monthly QAPI meeting scheduled on 11/19/19. Although the Immediate Jeopardy was removed, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure continued compliance. Findings include: Review of Resident #1's medical record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 dated 09/17/19 revealed the resident was cognitively intact with no behaviors and independent for Activities of Daily Living (ADLs). Review of the progress notes for Resident #1 revealed a nursing note dated 10/30/19 at 9:10 P.M. by Licensed Practical nurse (LPN) #118 which reported the resident had a one centimeter (cm) by 2.0 cm scratch above the right eye. It was unknown how it occurred. Neurological checks were initiated and continued through 11/02/19 at 4:45 P.M. with no abnormal findings. Review of the wound grid dated 10/30/19 by LPN #118 revealed a one cm by two cm scratch with a bruise, slightly red in color above Resident #1's right eye. The wound was cleansed with normal saline solution. Review of the investigative documentation revealed a facility Incident Report dated 10/30/19 authored by LPN #118. The incident report indicated initial interview with Resident #1 revealed the resident stated he hit his head on the tray table. It was also noted that neurological checks were initiated, and the physician and the resident's responsible party were notified. Staff statements including LA #102 indicated none had any knowledge of how the bruise happened. Review of the facility Self-Reported Incident (SRI) # 9 revealed it was initiated on 11/04/19 at 1:39 P.M. by the DON. The SRI indicated on 11/04/19 a statement was found in the Resident Concern box authored by LA #102 indicating she witnessed abuse of Resident #1 by STNA #100 and #101 on 10/29/19. The allegation of abuse was substantiated on 11/05/19 at 4:58 P.M. Review of Police Report #1-19- 5 dated 11/05/19 timed 12:16 P.M. revealed Corporal (CPL) #111 responded to a report of patient abuse. The report indicated a fourth degree felony was committed. On 11/05/19 at 9:45 [NAME]M. interview and observation with Resident #1 revealed a dime size reddish-purple bruise above the resident's right eye. The resident reported the bruise was a result of an assault by STNA #101 on 10/29/19. The resident did not recall the time. He stated STNA #101 came into his room and smacked his head against the overbed table. Resident #1 reported the act was deliberate. On 11/05/19 at 10:15 [NAME]M. interview with the DON and ADON #150 revealed the injury to Resident #1's forehead was first noticed on the morning of 10/31/19. Staff were interviewed with no knowledge of how the injury occurred. Resident #1 reported he accidentally banged his head against the overbed table in his room. On 11/01/19 LA #102 reported she walked by Resident #1's room and saw him rising from sitting on his bed and hit his head on his table. The administrator indicted on 11/04/19 a check of the resident concern box revealed a new statement from LA #102 stating she lied in her earlier statement. LA #102's note indicated on 10/29/19 she witnessed STNA #100 and STNA #101 holding Resident #1's arms down on his bed. When Resident #1 tried to get up, STNA #101 aggressively shoved his table into his face resulting in the scratch and bruise about the resident's eye. STNA #100 and STNA #101 continued to work their scheduled shifts at the facility, with access to all residents from 10/29/19 through 11/03/19. On 11/03/19 the STNAs objected to being pulled to help on other units and caused a disruption with the nursing staff. Local law enforcement were called to remove STNA #101 from the facility. Review of Police Report 19- 2 verified these findings. The DON said STNA #101 was suspended on 11/03/19 at 6:00 P.M. STNA #100 was suspended on 11/04/19 after finding the statement from LA #102. The DON and ADON #150 verified Resident #1 was physically abused by STNA #100 and STNA #101. On 11/05/19 at 12:35 P.M. interview with local law enforcement, CPL #111 revealed there was sufficient evidence patient abuse occurred and he would refer the case to his detective for continued investigation and prosecution. On 11/05/19 at 1:00 P. M. interview with STNA #106 revealed she was off for a few days and when she returned to work on 11/01/19 and asked LA #102 what happened to Resident #1 when she saw the bruise above his right eye. LA #102 told STNA #106 that she saw STNA #100 and STNA #101 abuse Resident #1 but did not report it to anyone. STNA #106 did not repot this to administration as well On 11/05/19 at 3:10 P.M. interview with LA #102 revealed she witnessed the abuse by STNA #100 and STNA #101 on 10/29/19 at approximately 5:30 P.M. Resident #1 was overheard by LA #102 to say (Expletive) you (expletive)! to STNA #101 and then entered his room and slammed the door. LA #102 reported STNA #101 then called STNA #100 out of another resident's room to come to Resident #1's room. They went into Resident #1's room and left the door open. LA #102 was standing in the hall outside of Resident #1's room and saw STNA #100 and STNA #101 each holding one of Resident #1's arms down on the bed. When they released his arms, the resident sat up and STNA #101 aggressively pushed the resident's head against the overbed table. Resident #1 then laid down on the bed crying and holding his eye. STNA #100 and STNA #101 then exited Resident #1's room and saw LA #102 in the hallway. STNA #101 told LA #102, If you say anything, I will kick your (expletive). LA #102 stated she reported she told Licensed Practical Nurse (LPN) #118 about the incident. LA #102 admitted to giving an initial statement on 10/30/19 saying she did not know how the injury to Resident #1 occurred. LA #102 stated on 11/03/19, STNA #101 was suspended, due to an unrelated matter. LA #102 wrote a statement and put it in the resident concern box indicating she had lied about Resident #1's injury. LA #102 indicated she did this on 11/03/19 but did not recall the exact time. LA #102 then verified STNA #100 and STNA #101 physically abused Resident #1 on 10/29/19. However, the administrator did not see the note until 11/04/19. On 11/05/19 at 4:30 P.M. during an interview, LPN #118 denied LA #102 reported Resident #1 was abused by STNA #100 and STNA #101. LPN #118 stated LA #102 reported Resident #1 bumped his head against his table. LPN #118 stated if LA #102 would have reported the abuse of Resident #1, she would have reported to the Administrator and DON. On 11/05/16 at 5:10 P.M. interview with the DON revealed they completed the investigation and substantiated abuse. The DON verified Resident #1 was physically abused by STNA #100 and STNA #101. Review of the punch detail for STNA #100 from 10/29/19 to 11/03/19 revealed STNA #100 worked 11/29/19 from 5:55 [NAME]M. to 6:00 P.M., 10/30/19 from 6:03 [NAME]M. to 2:17 P.M., 11/01/19 from 5:55 [NAME]M. to 6:01 P.M. and 11/03/19 from 5:44 [NAME]M. to 6:44 P.M. Review of the punch detail for STNA #101 from 10/29/19 to 11/03/19 revealed STNA #101 worked 10/29/19 from 5:54 [NAME]M. to 6:00 P.M., 10/30/19 from 6:03 [NAME]M. to 2:16 P.M., and 11/03/19 from 5:44 [NAME]M. to 5:45 P.M. Review of the undated abuse policy revealed residents have the right to be free from abuse. Any staff member who has witnessed or believes that a resident has been abused shall immediately report, or cause a report to be made of, the mistreatment or offense. The facility shall immediately investigate all allegations of mistreatment, neglect or abuse including injuries of unknown origin, misappropriation of resident property and suspicion of a crime. This deficiency substantiates Complaint Number OH 161.

Based on medical record review, hospital records, staff investigation statements and staff interview, the facility failed to ensure weekly skin audits were completed as ordered and new onset pressure ulcers were identified prior to transfer to the hospital. This resulted in actual harm when Resident #88 was found with multiple pressure ulcers upon admission to the hospital. This affected one (Resident #88) of three residents reviewed for hospital admissions. The facility identified one resident currently with a pressure ulcer. The facility census was 85. Findings include: Review of Resident #88's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Upon admission the physician ordered weekly body audits to be completed on Monday evenings. Review of the weekly body audit assessments revealed no evidence the assessment was completed on 02/13/17 as ordered. Pressure ulcer risk assessments completed for Resident #88 on 01/17/17, 01/24/17 and 01/31/17 identified the resident was at low risk for pressure ulcer development. A pressure ulcer risk assessment completed on 02/07/17 identified Resident #88 as high risk for pressure ulcer development. A care plan initiated on 02/01/17 identified Resident #88 as high risk for pressure ulcer development. No evidence of interventions for prevention of pressure ulcer development was found on the care plan. Review of the physician's orders [REDACTED]. Further medical record review revealed on 02/14/17 at 11:55 A.M., Resident #88 was sent to the hospital for further evaluation and treatment of [REDACTED]. Review of the emergency department physician provider note on 02/14/17 at 12:38 P.M. identified Stage 2 pressure ulcers (Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister) on the dorsum of the right foot, heel of the right foot, dorsum of the left foot and medial aspect of the right knee. Stage 1 pressure ulcers (Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes) were also identified on the right medial alveolus and left lateral knee. Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 02/16/17 at 12:15 P.M. revealed the weekly body audit skin assessment was not completed as indicated on 02/13/17 and the facility was unaware of the pressure ulcer wounds until notified by Resident #88's representative on 02/14/17 after admission to the hospital. An investigation was completed by the DON and ADON. An employee statement by State tested Nurse Aide (STNA) #10 revealed she observed a wound to the right heel on 02/13/17 at 11:30 P.M. and she notified Registered Nurse (RN) #11 of the wound. The DON and ADON revealed that RN #11 never returned to work after 02/14/17, will not return calls for interview and has been terminated. An employee statement from RN #12 who relieved RN #11 on 02/14/17 revealed no knowledge or report of any pressure ulcers to Resident #88. Further interview with the DON on 02/16/17 at 3:00 P.M., verified no pressure ulcer interventions were in place other that weekly body audits for Resident #88. This deficiency substantiates Complaint Number OH 911.

Based on medical record review, review of facility policy for Lift Devices-Hoyer, and staff interview, the facility failed to ensure that residents received the appropriate assistance during transfers. Resident #90 sustained an upper arm fracture, spinal fracture and upper leg fracture after a transfer in a mechanical lift by one staff member. This affected one of one sampled resident (Resident #90). Findings include: Resident #90's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the minimum data set (MDS) assessment dated [DATE] revealed she was totally dependent on staff for all activities of daily living. She required assistance of two staff during transfers. Resident #90 had functional limitations in range of motion in her hands, legs, and feet. Review of an Incident/Accident Investigation report dated 08/12/10 at 6:10 A.M., revealed that the nurse was called to Resident #90's room. The resident's right knee was swollen. There was no redness or bruising. Her left shoulder was puffy with a bruise on the elbow. She complained of pain in her left arm. X-rays were ordered for her left shoulder, left arm, and right leg. The results of the x-rays confirmed "left humerus displaced surgical neck, fracture proximal left humerus, spinal fracture distal third junction, femoral shaft fracture extends anterior beneath femoral prosthesis." An order was received to transport the resident to the hospital for an orthopedic evaluation. She was admitted to the hospital. Review of a witness statement dated 08/11/10, revealed that the staff had told the nurse that Resident #90 was lowered to the floor by two staff. The staff said she was not hurt, no injuries were noted. The nurse reminded the staff to check on the resident and notify her if any marks or injuries were noted. Nurses notes contained no assessment by the nurse following the incident. An Investigative Statement obtained by the facility on 08/12/10 revealed that State tested Nurse Aide (STNA) #1 stated she was transferring Resident #90 from the bed to the shower chair using the mechanical lift on 08/11/10. The resident's right foot "got in the way" causing the STNA to have to lower her to the floor. STNA #1 left the room to get another STNA to assist with getting the resident off the floor. They lifted the resident from the floor using the mechanical lift and placed her in the shower chair. She received a shower and then was positioned in the bed. An interview was conducted with the director of nursing (DON) on 11/17/10 at 2:20 P.M. She verified that STNA #1 had attempted to transfer the resident herself. The DON verified at 2:40 P.M., that at least two people were required to operate the mechanical lift at all times. Review of the facility's policy for Lift Devices-Hoyer identified two staff members were needed to use the mechanical lift. This deficiency substantiates Complaint Number OH 472.