Woodlands of Shaker Heights The

Based on observations, interviews and review of the manufacture's safety recommendations, the facility failed to ensure portable space heaters are used in accordance with manufacture's safety recommendations. This deficient practice has the potential to affect 33 residents who lived within the smoke compartments of the identified space heaters of 55 residents residing in the facility.

Findings include:

1. On 01/07/25 at 9:15 A.M. observations made during the tour of the facility revealed one space heater being utilized in the Administrators office within three feet of combustibles. The temperature of the heating element on the heater was 266 degrees when tested.

2. On 01/07/25 at 9:39 A.M. observations made during the tour of the facility revealed one white Heat Wave space heater in resident room #101. The temperature of the heating element on the heater was 225 degrees when tested. Additionally, this space heater was found to be left powered on unattended, with the resident out of the room.

3. On 01/07/25 at 9:46 A.M. observations made during the tour of the facility revealed one black Heat Wave space heater in resident room #105. The temperature of the heating element on the heater was 271 degrees when tested. Additionally, this space heater was found plugged into a multiple outlet power strip.

4. On 01/07/25 at 9:48 A.M. observations made during the tour of the facility revealed one space heater in resident room #107. The temperature of the heating element on the heater was 283 degrees when tested.

5. On 01/07/25 at 9:52 A.M. observations made during the tour of the facility revealed one black oil filled radiant space heater in resident room #109. The temperature of the heating element on the heater was 311 degrees when tested.

6. On 01/07/25 at 9:56 A.M. observations made during the tour of the facility revealed one black tower style space heater in resident room #114. The temperature of the heating element on the heater was 212 degrees when tested.

7. On 01/07/25 at 9:58 A.M. observations made during the tour of the facility revealed one white Heat Wave space heater in resident room #201. The temperature of the heating element on the heater was 228 degrees when tested.

8. On 01/07/25 at 10:01 A.M. observations made during the tour of the facility revealed one black Heat Wave space heater in resident room #202. The temperature of the heating element on the heater was 274 degrees when tested.

Additionally, the facility failed to follow the Manufacturers safety recommendations and requirements for safe use of space heaters. Space heaters were found to be unattended while powered on, within three feet of combustible materials, not plugged directly into the 120 v wall outlet, and being utilized on carpeted floors. Furthermore, all tested space heaters heating elements were above the permissible limit of 212 degrees Fahrenheit.

The Director of Maintenance verified the findings at the time of observation.

This violation represents non-compliance investigated under Master Complaint Number OH00161242 and is a recite to the surveys completed 06/06/24 and 09/10/24.

Based on medical record review, facility self-reported incident (SRI) review, employee personnel file review, interview and facility policy review, the facility failed to prevent an incident of staff-to-resident physical and verbal abuse for Resident #29. This affected one resident (#29) of three residents reviewed for abuse. The facility census was 55.

Findings include:

Review of the medical record revealed Resident #29 was admitted to the facility on 12/22/22 with diagnoses including diabetes, dementia, and hypertension.

Review of the service plan dated 12/17/24 revealed Resident #29 was alert and oriented to person and sometimes place. The resident used a wheelchair for mobility, was able to self-propel, and needed assistance to transfer.

Review of the facility SRI tracking number 255405 completed on 12/23/24 by the Executive Director (ED)/Director of Nursing (DON) revealed Certified Nursing Assistant (CNA) #203 and Caregiver #208 told Assistant Director of Nursing (ADON) #205 that they witnessed Licensed Practical Nurse (LPN) #213 slap Resident #29's arm while trying to obtain a blood sugar. Resident #29 was being combative, and LPN #213 slapped her arm and called her an [expletive]. The nurse was removed from the schedule. The facility substantiated the allegation of abuse.

Review of the facility investigation for SRI tracking number 255405 dated 12/23/24 revealed the Nurse Aide Registry (NAR) checks were reviewed for LPN #213, CNA #203 and Caregiver #208. Witness statements from CNA #203 and Caregiver #208 stated Resident #29 was having behavioral issues and would not let LPN #213 check her blood sugar. The aides tried to help when the resident dug her nails into the LPN #213's hand. LPN #213 swiped at her hand per Caregiver #208. Per CNA #203, LPN #213 hit a resident (Resident #29) and called her a [expletive]. LPN #213 did not write a witness statement. An in-service on abuse was completed on 12/24/24. The SRI stated skin checks were completed but copies were not included in the investigation documentation.

Review of the progress note dated 12/24/24 revealed it was brought to the ED/DON's attention that Resident #29 was allegedly abused physically and verbally. The resident was unable to state what happened and denied any pain or discomfort. A skin check was performed, and no bruising was noted. There were no other injuries noted. Resident #29's Power of Attorney (POA) and physician were notified of the incident. The Ohio Department of Health (ODH) was notified.

Review of the employee personnel file revealed LPN #213 was hired on 10/02/24. The Bureau of Criminal Investigation (BCI) was checked. The LPN's license look-up and NAR review were not completed until 11/21/24, but when checked had no concerns. LPN #213 had completed training on resident rights and abuse. There were no disciplinary actions. LPN #213 was terminated 12/30/34.

Interview on 01/06/25 at 10:13 A.M. with Caregiver #208 revealed LPN #213 was trying to get Resident #29's blood sugar. The resident hit LPN #213, and LPN #213 hit her back and called her a [expletive].

Interview on 01/06/25 at 10:15 A.M. CNA #203 stated LPN #213 was trying to get Resident #29's blood sugar. Resident #29 dug her nails into LPN #213's hand. LPN #213 hit the resident's hand and called her a name.

Interview on 01/07/24 at 9:45 A.M. with the ED revealed an aide told the ADON that LPN #213 had slapped a resident and called her a name. The nurse was trying to take the resident's blood sugar. Resident #29 was combative, and the nurse smacked the resident's hand and called her a [expletive]. On 12/23/24 the ED called LPN #213 to let her know she was suspended pending investigation. LPN #213 started screaming at the ED about staff working intoxicated or on drugs, having sex at work, not doing their jobs and that I should fire everyone. The ED asked LPN #213 to send her a statement of what happened. She didn't send it. Both nursing aides sent the ED their statements immediately. LPN #213 was removed from the schedule immediately. The abuse was substantiated. On 12/30/24, LPN #213 was terminated. The ED stated she had asked the residents if they were being treated okay. No other aide came forward as witnesses.

Review of the personnel file for LPN #205, hired on 11/04/24, revealed the license lookup was not completed until 11/25/25, and the NAR check was not completed until 11/25/24.

Review of the personnel file for LPN #213, hired 10/02/24, revealed the license look up was not completed until 11/21/24, and the NAR check was not completed until 11/21/24.

Interview on 01/07/25 at 4:50 P.M. the ED stated she called and did reference checks informally.

On 01/08/25 at 12:49 P.M. the ED sent email that revealed the facility screened new hires via Office of Inspector General (OIG), NAR, and Ohio Board of Nursing (OBN).

Review of the Abuse, Neglect and Misappropriation policy, dated 01/02/24, revealed the facility did not tolerate mistreatment, abuse, neglect, and misappropriation. The facility investigated all allegations and reported results as required by law.

This violation represents non-compliance investigated under Master Complaint Number OH00161242 and Self-Reported Incident, Control Number OH00161037.

Based on medical record review and staff interview, the facility failed to complete initial assessments for all residents as required. This affected three residents (#1, #16, and #36) of three sampled residents. The facility census was 55.

Findings Include:

1. Resident #1 was admitted to the facility on 09/01/23 with diagnoses including moderate intellectual disabilities, peripheral neuropathy, Raynaud's syndrome, morbid obesity, hyperlipidemia, polycythemia, hypertension, and chronic kidney disease.

Review of Resident #1's medical record revealed he had a medical and functional assessment completed on 05/15/23, which was more than 90 days prior to he admission to the facility. In addition, review of the medical and functional assessments that were completed on 05/15/23 revealed the following topics were not assessed/addressed: nutrition and dietary requirements, a complete functional assessment including using use of the telephone, acquiring and using public and private transportation, shopping, preparing own meals, performing housework, laundering, and managing financial affairs, type of care or services, and self medication assessment.

Interview with Executive Director (ED) #136 on 07/12/24 at 1:15 P.M. confirmed the assessments were not completed in the required timeframe and also confirmed the facility did not have documentation to support the missing medical and functional assessments were completed for Resident #1.

2. Resident #16 was admitted to the facility on 05/09/22 with a diagnosis including hypertension.

Review of Resident #16's medical records revealed she had no initial medical or functional assessment completed until 06/26/24.

Interview with Executive Director (ED) #136 on 07/12/24 at 1:15 P.M. confirmed medical and functional assessment completed for Resident #16 was not completed timely.

3. Resident #36 was admitted to the facility on 08/05/23 with diagnoses including heart murmur, mild aorta valve stenosis, dementia, and paranoia with behavioral disturbances.

Review of Resident #36 medical records reviewed he had a medical assessment completed on 08/01/23. However, the facility had not completed a functional assessment as required.

Interview with Executive Director (ED) #136 on 07/12/24 at 1:15 P.M. confirmed the facility did not have documentation to support a functional assessment had been completed for Resident #36.

This violation is an incidental finding to Complaint Number OH00155092.

Based on observation, medical record review, facility activity calendar review and interview, the facility failed to provide activities that met the needs and preferences of all residents. This affected five residents (#1, #2, #13, #16 and #36) and had the potential to affect all 55 residents residing in the facility.

Findings Include:

Review of facility activity calendars, dated April 2024, May 2024, and July 2024, revealed no activities on the weekends except for the second and fourth Sundays of each month, which was a pet therapy activity at 10:00 A.M.. Also, during the week, there were no activities past 3:30 P.M., with five to seven days in each month not having an activity past 2:00 P.M. The facility was unable to provide an activity calendar for June 2024.

Review of Resident #1, #16, and #36's medical records and assessments revealed no evidence the facility had assessed or evaluated these resident's preferences for activities or social interactions.

Observations on 07/12/24 at 11:00 A.M. revealed no resident activities occurring. According to the facility activity calendar, the facility was to be playing Jeopardy at this time.

Interview with Caregiver #115 and Executive Director #136 on 07/12/24 at 11:15 A.M. and 11:22 A.M. confirmed jeopardy was not occurring. They stated the residents were not interested in doing that, so they were relaxing in the common room, watching television or in their room.

Interview with Residents #2 and #13 on 07/12/24 at 12:15 P.M. and 12:30 P.M. respectively revealed both residents indicated they would like more activities they enjoyed doing. Both residents indicated they would like to go out in the community more often. When asked if they were able to give their preferences on activities they like, they stated they had never been asked. During the interview, both residents confirmed there were very few activities provided on the weekends as well.

Observation on 07/12/24 at 1:30 P.M. revealed no resident activities occurring. According to the facility activity calendar, the facility was to have a bus trip

Based on record review and staff interview, the facility failed to develop and update service plans in a timely manner. This affected eight residents (#4, #5, #40, #44, #49, #51, #52, and #53) of eight residents reviewed for service plans. The facility census was 56.

Findings include:

Review of the medical records for Residents #4, #5, #40, #44, #49, #51, #52, and #53 revealed there were no service plans available for review.

On 06/03/24 at 3:00 P.M., an interview with the Executive Director stated service plans were supposed to be developed for all residents on admission and updated on a routine and as needed basis. She stated she was not sure if any service plans had been developed or updated for any residents since she took over the building, which she clarified was sometime in January 2024 or February 2024.

On 06/03/24 at 3:49 P.M., subsequent interview with the Executive Director confirmed there were no current service plans available for Residents #4, #5, #40, #44, #49, #51, #52, and #53.

This violation represents an incidental finding identified during the complaint investigation.

Based on medical record review, review of incident log, and staff interview, the facility failed to ensure a resident's elopement was documented in the facility's incident log. This affected one (#53) of three residents reviewed for elopement. The facility census was 56 residents.

Findings include:

Review of the medical record for Resident #53 revealed an admission date of 05/06/24 with diagnoses including moderate Alzheimer's dementia.

Review of the nursing note dated 05/24/24 at 6:02 P.M., revealed the facility received a call from Resident #53's former neighbor stating Resident #53 was observed in Shaker Heights and accompanied to the neighbor's home. A note dated 05/24/24 at 6:50 P.M. revealed LPN #103 left the facility to pick up Resident #53, who was safely transported back to the facility.

Review of the facility's incident report, dated 05/29/24 for the incident that occurred on 05/24/24, revealed Resident #53 exited the facility at 1:33 P.M. out the side door by room 114. The nurse on duty got a call from a community member at 6:01 P.M. stating that she had the resident. Resident #53 was escorted back into the building by a nurse and a caregiver at 6:55 P.M.

Review of the facility's incident log for January 2024 through May 2024 revealed no incidents were documented between 02/25/24 and 05/11/24, and the elopement of Resident #53 on 05/24/24 was not included on the incident log.

On 06/05/24 at 11:12 A.M., an email message from the Executive Director confirmed there were no incidents documented between 02/25/24 and 05/11/24, and the elopement of Resident #53 was not included on the incident log.

This violation represents non-compliance investigated under Complaint Number OH00154256.

Based on observation, medical record review, family and staff interview, review of the facility's incident report and log, review of location information at https://onthegomap.com/s/ugfsvvo7, and review of the facility policy, the facility failed to ensure Resident #53 was provided a safe environment and adequate supervision to prevent elopement. This resulted in Real and Present Danger and the potential for serious life-threatening harm, injuries and/or death, when Resident #53, who had cognitive impairment and a history of exit seeking behaviors, eloped from the facility on 05/24/24 at 1:33 P.M. Resident #53 was located by a community member on 05/24/24 at 6:01 P.M. and escorted back to the facility by facility staff on 05/24/24 at 6:55 P.M. The facility did not know Resident #53 was missing until they received a call from the community member who found Resident #53, nearly four and a half hours later approximately 3.8 miles from the facility. This affected one resident (#53) of three residents reviewed who were identified by the facility as residing on a secured unit. The facility identified seven residents (#47, #48, #49, #50, #51, #52, and #54) who resided on the second floor secured unit and 24 residents (#3, #4, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, and #53) who resided on the third floor secured unit. The facility census was 56.

On 05/30/24 at 5:24 P.M., the Executive Director was notified Real and Present Danger began on 05/24/24 when Resident #53, who was cognitively impaired and had a history of exit seeking behaviors, exited the facility through a stairwell entrance. On 05/24/24, the facility's door alarm system was malfunctioning, causing the door alarms to sound randomly throughout the day. On the morning of 05/24/24, Licensed Practical Nurse (LPN) #100 escorted Resident #53 off the second-floor secured unit for the lunch meal. After lunch, around 1:20 P.M. LPN #100 left Resident #53 unattended in the television lounge on the first floor. The facility's exterior video surveillance footage captured Resident #53 exiting through the stairwell entrance at 1:33 P.M. Upon hearing the door alarm on the interior stairwell door, LPN #100 disabled the alarm, did not see any residents in the hallway by the door or in the stairwell on the other side of the door, and LPN #100 returned to her duties without further searching to ensure no residents went through the exterior door in the stairwell. On 05/24/24 at 6:01 P.M., the facility received a phone call from a community member stating Resident #53 had been found walking in her former neighborhood approximately 3.8 miles away from the facility.

The Real and Present Danger was abated on 06/04/24 when the facility implemented the following corrective actions:

On 05/24/24 at 6:55 P.M. following Resident #53's return, the resident was relocated to the secured memory care unit on the third floor. The third-floor memory care unit had its own dining room and residents on the third floor did not need to be taken to a different floor for meals, which the facility identified was one contributing factor to Resident #53's elopement.

On 05/24/24, an outside contracted company checked all doors and alarms. The maglocks required an adjustment on all doors. After adjustments were made and the facility determined the doors were secure and working properly.

On 05/30/24, the outside contracted company rechecked all doors and alarms. The front door latch plate needed adjustment. After adjustments were made, the doors were secure and working properly.

On 05/31/24, the Executive Director placed signs on each unit to make sure visitors and staff were not letting residents out of the units without prior approval.

On 06/03/24, the policy for locked doors was revised by the Executive Director to include if the door alarms were malfunctioning, staff were to follow the fire alarm protocols for all doors being unlocked and unsecured. In addition, if a door was disengaged, the staff should always answer it as an elopement and if they don't see anyone after looking, a head count would take place to make sure everyone was within the building. If an elopement was identified, the elopement policy would be followed. The elopement policy included: facility staff would verify the resident had not signed out or discharged, immediately notify the supervisor, call code green over the walkies or verbally, the resident's profile would be copied and provided to all search members, pre-assigned staff members would take assigned positions, staff would convene in the lobby to convey findings, local authorities would be contacted if needed, facility staff would continue to search until the resident was found, documentation would be completed in a timely manner and sent to the appropriate authorities, and the appropriate authorities would be notified when the resident was found.

By 06/04/24, LPN #106, Caregiver #102, Caregiver #108, and Caregiver #107, who were present at the time of the elopement incident 05/24/24 involving Resident #53, were individually educated by the Executive Director and put on a performance improvement plan. The performance improvement plan would continue for three months.

An all-staff meeting was held on 06/04/24 at 8:00 A.M. and 4:00 P.M., led by the Executive Director. This meeting included training on elopement protocols and the secured doors, including if the door alarm malfunctions or breaks. The Executive Director would conduct a phone call with staff who were unable to attend regarding this education before their next scheduled shift.

Beginning on 06/04/24, the residents who resided on the secured two unit would have a physician order for a secured unit and/or wandering behaviors and would eat meals on the third-floor secured unit and would be escorted in and out of that unit with staff present always. The nurses would sign off that the residents were escorted to the third floor for meals. Facility staff were educated on this procedure at the all-staff meeting on 06/04/24, led by the Executive Director.

Beginning on 06/04/24, elopement risks assessments would be completed for all new residents prior to admission by the admissions team, and then upon a change in condition or behaviors and annually thereafter by the Charge Nurse.

Beginning on 06/04/24, the Executive Director would conduct audits daily, Monday through Friday, for a period of three months to ensure continued compliance.

The facility indicated by 07/06/24, all current residents would have a new service plan which would include an elopement risk assessment. All future service plans would include elopement risk as part of the plan and the service plans would be reviewed quarterly and with a change in condition. The new service plans and elopement risk assessments for current residents would be completed by the Charge Nurse and Executive Director.

Although the Real and Present Danger was abated on 06/04/24, the violation continues as the facility is still in the process of monitoring their corrective actions to ensure on-going compliance.

Findings include:

Review of the medical record for Resident #53 revealed an admission date of 05/06/24 with diagnoses including moderate Alzheimer's dementia, hypertension, hyperlipidemia, and diabetes mellitus.

Review of the history and physical document, completed by the nurse practitioner, prior to admission on 05/03/24, revealed the form had a check mark beside the statement secured memory care unit. There was no additional information as to why the unit was necessary for the resident.

Review of a nursing note dated 05/06/24 at 3:26 P.M. revealed Resident #53 was placed in the memory care unit on the second floor and attempted to leave the facility at 1:20 P.M. A note dated 05/06/24 at 3:56 P.M. revealed Licensed Practical Nurse (LPN) #100 notified the Executive Director that Resident #53's room location was not appropriate due to Resident #53 reading the warning on the door that holding the handle for 15 seconds would cause the door to open, Resident #53 was a high elopement risk, and Resident #53 went downstairs for meals. The note further stated LPN #100 notified management Resident #53 needed a true memory care unit.

A note dated 05/07/24 at 4:00 P.M. revealed Resident #53 wandered around the memory care unit and was exit seeking.

A note dated 05/08/24 at 3:23 P.M. revealed Resident #53 was exit seeking throughout the shift and kept packing up her clothes. A note dated 05/08/24 at 10:00 P.M. revealed Resident #53 was exit seeking throughout the shift.

A note dated 05/09/24 at 2:30 P.M. revealed Resident #53 continued to exit seek. A note dated 05/09/24 with no time documented revealed Resident #53 continued to exit seek during the shift.

Record review revealed no nursing progress notes were completed for the resident between 05/10/24 through 05/23/24.

The next note, dated 05/24/24 at 6:02 P.M., documented by LPN #106 revealed the facility received a call from Resident #53's former neighbor stating Resident #53 was observed in Shaker Heights and accompanied to the neighbor's home. A note dated 05/24/24 at 6:50 P.M. revealed LPN #103 left the facility to pick up Resident #53, who was safely transported back to the facility. Resident #53 was assessed with no injuries and Resident #53 denied discomfort. Resident #53 was immediately moved to the memory care unit on the third floor.

Review of the facility's incident report, dated 05/29/24 for the incident that occurred on 05/24/24 (five days prior), revealed Resident #53 exited the facility at 1:33 P.M. out the side door by Room 114. The nurse on duty got a call from a community member at 6:01 P.M. stating that she had the resident. The Executive Director was notified at 6:17 P.M. The other nurse on duty called the Executive Director at 6:44 P.M. stating she had Resident #53 and was taking her back to the facility. Resident #53 was escorted back into the building by a nurse and a caregiver at 6:55 P.M. The Executive Director gave orders to move Resident #53 to the memory care unit on the third floor.

Review of the facility's incident log for January 2024 through May 2024 revealed no incidents were documented between 02/25/24 and 05/11/24, and the elopement of Resident #53 on 05/24/24 was not included on the facility incident log.

On 05/30/24 at 10:20 A.M., an interview with Resident #53's family member revealed the Executive Director had shown her the video surveillance footage of Resident #53 leaving the building on 05/24/24 at 1:33 P.M. She stated she did not understand how Resident #53 was able to exit the facility because she was on a secured memory care unit. She further stated Resident #53 was found at her former address several miles away from the facility.

On 05/30/24 at 10:29 A.M., an interview with the Executive Director confirmed Resident #53 eloped from the facility on 05/24/24.

On 05/30/24 at 11:47 A.M., an interview with the Executive Director revealed the facility door alarms were malfunctioning on 05/24/24 which caused the alarms to sound randomly. She stated she thought staff disregarded the door alarm at the time of Resident #53's elopement because the alarms had been malfunctioning all day. She verified facility staff were unaware Resident #53 had left the building until the facility received a call that evening from a community member. She further stated that facility video surveillance footage outside the building captured Resident #53 leaving the building through the stairwell entrance at 1:33 P.M. The Executive Director stated Resident #53 had been exit seeking the entire time she had been in the facility. She stated there had been discussions about moving Resident #53 to the memory care unit on the third floor prior to the elopement, but it had not been completed. She stated a few days prior to the elopement, Resident #53 had approached a staff member asking about the signs on the doors indicating the doors would open after 15 seconds and if she would be able to leave.

On 05/30/24 at 12:21 P.M., an interview with LPN #100 revealed she was the nurse on duty at the time Resident #53 eloped on 05/24/24. The LPN revealed Resident #53 had been exit seeking consistently since her admission. She stated on 05/24/24, Resident #53 was antsy. She further stated the door alarms had been sounding all day due to a malfunction. LPN #100 said she had heard the door alarm sounding on this date but did not think anything of it because she did not see any residents on either side of the door at the time she disabled the alarm. She stated she last saw Resident #53 around 1:20 P.M. in the television lounge on the first floor, at which time she left Resident #53 unattended so she could attend a meeting with a physician. LPN #100 stated she typically did not complete rounding or resident checks at 3:00 P.M. because she stated the on-coming nurse should do checks when they arrive for their shift. She stated at the time she clocked out at 3:30 P.M., she was unaware Resident #53 was no longer in the facility.

On 05/30/24 at 12:53 P.M., an interview with the Executive Director revealed Resident #53 was on the secured unit on the second floor, which she clarified was a unit for individuals who did not meet the requirements for a secure memory care unit but still needed to be monitored for safety. The Executive Director stated the keypad for the exterior door through which Resident #53 exited the building only had four numbers on it, one through four, and the code to exit through that door was 1-2-3. She stated that the door was not alarming at the time Resident #53 eloped. The Executive Director confirmed Resident #53 would leave her secured unit to attend meals in the first-floor dining room.

On 05/30/24 at 5:35 P.M., an interview with the Executive Director confirmed there was no elopement assessment completed for Resident #53.

On 06/03/24 at 3:41 P.M., an interview with Caregiver #102 revealed she arrived for her shift on 05/24/24 after Resident #53 had eloped. She stated she only became aware of the elopement after the facility received a call that Resident #53 had been found in the community. Caregiver #102 stated she accompanied the nurse to pick up Resident #53 and bring her back to the facility. She stated Resident #53 was a few miles away from the facility.

On 06/04/24 at 10:25 A.M., an interview with LPN #103 revealed she and Caregiver #102 went to pick up Resident #53 on 05/24/24 after the facility was notified Resident #53 was found in the community. She stated she was unaware that Resident #53 was not in the facility prior to the facility receiving the phone call from the community member that evening. LPN #103 stated residents were supposed to be checked on every two hours and she was unable to state why that did not occur for Resident #53 on 05/24/24.

Observations throughout the survey period, 05/30/24 through 06/04/24, revealed Resident #53 was observed seated in the common areas of the third-floor secured unit participating in activities and conversing with other residents. Resident #53 was not observed wandering or exit seeking during the observations made.

Review of the location information at https://onthegomap.com/s/ugfsvvo7 revealed Resident #53 was found approximately 3.8 miles from the facility in the community of Shaker Heights.

Review of the facility's policy titled Policy: Elopement

Based on medical record review and staff interview, the facility failed to ensure accurate documentation in the medical records for Residents #4 and #5. This affected two residents (#4 and #5) of eight residents for medical record reviews. The facility census was 56.

Findings include:

1. Review of the medical record for Resident #4 revealed an admission date of 12/11/23 with diagnoses including dementia and encephalopathy.

Review of the handwritten nurses note, initially dated 05/28/24 and crossed out to read 05/20/24 with no time documented, indicated Resident #4 had a room change due to the presence of bed bugs. A nurses note dated 05/28/24 at 11:30 P.M. revealed Resident #4's responsible party was notified of the room change.

On 06/04/24 at 12:30 P.M., an interview with Licensed Practical Nurse (LPN) #103 stated the date was recorded incorrectly on the handwritten nurse's notes because Resident #4 did not have a room change on 05/20/24. She stated the bed bugs were identified on 05/28/24 and the room change occurred on 05/28/24.

On 06/04/24 at 12:40 P.M., an interview with the Executive Director confirmed bed bugs were identified in Resident #4's room on 05/28/24, not 05/20/24 as indicated in the handwritten nurse's notes.

2. Review of the medical record for Resident #5 revealed an admission date of 06/28/19 with diagnoses including dementia and hyperlipidemia.

Review of the handwritten nurse's note dated 05/20/24 with no time documented indicated Resident #5 had a room change due to the presence of bed bugs. A nurses note dated 05/28/24 at 10:50 P.M. revealed Resident #5's responsible party was notified of the room change.

On 06/04/24 at 12:30 P.M., interview with Licensed Practical Nurse (LPN) #103 stated the date was recorded incorrectly on the handwritten nurse's notes because Resident #5 did not have a room change on 05/20/24. She stated the bed bugs were identified on 05/28/24 and the room change occurred on 05/28/24.

On 06/04/24 at 12:40 P.M., an interview with the Executive Director confirmed bed bugs were identified in Resident #5's room on 05/28/24, not 05/20/24 as indicated in the handwritten nurse's notes.

This violation represents an incidental finding identified during the course of the complaint investigation.

Based on observation and interview, the facility failed to ensure the room of a resident with dementia (Resident #3) was kept at a safe and comfortable temperature. This affected one of 52 facility residents.

Findings include:

Review of the medical record for Resident #3 revealed an admission date of 04/27/22 with a diagnosis of dementia.

A tour of the facility on 11/25/23 from 8:45 A.M. to 10:02 A.M. revealed the temperature of multiple resident rooms on each of the three floors and all the common areas on each of the three floors were within the range of 71.8 degrees Fahrenheit (F) to 79.4 degrees F and felt comfortable. Interviews with some residents revealed it was cold in their rooms.

Observation on 11/27/23 at 8:05 A.M. of Resident #3's room, who resided on the first floor near the front entrance and receptionist desk, revealed the room felt cold. Resident #3 was lying underneath several heavy comforters and a had her hood up, covering her head, from her robe. Interview with Resident #3 at the time of the observation revealed she wanted the thermostat turned on.

Interview on 11/27/23 at 8:10 A.M. with Director of Maintenance (DM) #2 revealed the facility heat was controlled by a boiler however each resident room had their own thermostat, and each resident could control the temperature in their own room. Resident #3 often turned the thermostat in her room to off. DM #2 educated the resident and the resident's family to keep the heat to on and once the heat was turned on at her thermostat, it could takeseveral hours for the room to heat to the desired temperature. DM #2 did not report Resident #3 was turning the heat off to nursing staff or the administrator.

Observation on 11/27/23 at 8:40 A.M. of Resident #3's room revealed the resident was not in the room and her heat was on. The thermostat was set to 90 degrees F but turned off. The room temperature was 60 degrees F according to the thermostat. Interview, during the observation, with DM #2 revealed since the resident's heater was off all night and the boiler was a long distance away plus the return vent was pulling cold air, it would take a while for the resident's room to warm up, usually one degree for every hour.

Observation on 11/27/23 at 10:35 A.M. and 11:00 A.M. revealed Resident #3 was in her room and the room felt cold. There was cool air blowing out of the vent near the ceiling. The Administrator asked Resident #3 to temporarily move to another room until the temperature in her room reached a comfortable temperature. Resident #3 agreed after much encouragement. Interview, during the observation, with the Administrator revealed she was unaware of concerns regarding the temperature in Resident #3's room or that Resident #3 was turning the heat off. The Administrator indicated had she known she would not have allowed the resident to stay in a cold room.

Interview on 11/27/23 at 11:01 A.M. with Business Office Manager (BOM) #6 revealed Resident #3 and the family had complained for the last month about her heat not working and being cold in her room. BOM #3 would check the resident's room and would find the heat was shut to off and/or the window was open. BOM #3 reported this concern to the prior and current Director of Maintenance but did not share the information with nursing staff.

Observation on 11/27/23 at 1:25 P.M. revealed Resident #3 was lying in bed with the door open. The room felt warmer. Interview, during the observation, with Resident #3 revealed she refused to move to another room.

Observations on 11/27/23 of three resident rooms on each of the three floors revealed the temperature was comfortable.

This violation represents non-compliance investigated under Complaint number OH00148628.

Based on record review, staff interview, and review of a resident's account, the facility failed to timely refund a resident's funds upon discharge from the facility. This affected one (Resident #8) of three residents reviewed for funds. The facility census was 30.

Findings include:

Review of Resident #8's medical record revealed an admission date of 01/30/20 and a discharge date of 11/03/22.

Review of Resident #8's ledger revealed on 11/03/22 the resident moved out and was owed a $3,669.30 refund. The refund was not issued until 07/21/23.

Interview on 07/21/23 at 12:54 P.M. with Business Office Manager (BOM) #500, confirmed Resident #8 was discharged from the facility on 11/03/22 and the resident had paid her November 2022 rent in the amount of $4,077.00. BOM #500 stated if a resident moved from the facility, the rent would be prorated for that month. BOM #500 verified Resident #8 was due a refund of $3,669.30. BOM #500 reported a refund request was sent to corporate, who was then responsible for issuing the refund.

Interview on 07/21/23 at 1:56 P.M. with the Administrator, revealed a refund was initiated for Resident #8 on 01/13/23 during a system-change. The Administrator reported the refund got stuck in the system. The Administrator verified Resident #8's refund check in the amount of $3,669.30 was issued on 07/21/23, which was more than eight months after the resident moved out and more than six months since the last attempt was made to issue a refund.

This violation represents non-compliance investigated under Complaint Number OH00139652.