Gardens at Cuyahoga Falls The

Based on observation, interview and facility record review, the facility failed to ensure safe handling of food to prevent potential cross contamination and food borne illness. This had the potential to affect all 124 residents who resided in the facility. The facility census was 124.

Findings include:

Observation on 05/06/24 at 7:04 A.M. during the tour of the kitchen with Dietary Manager #13 revealed inside the walk-in refrigerator there was an open 60 pound box of chicken breasts thawing on the second shelf with a pool of chicken juice below it on the floor; two-gallon size Ziploc bags of open, undated thawed Tator Tots, and an undated two-inch-deep pan full of cooked balsamic chicken. In the walk-in freezer thee was a one-gallon Ziploc bag of ground hamburger meat that appeared to have diced green peppers in it which was unlabeled and undated as well as a one-gallon bag of unlabeled, undated frozen fish. In the reach in refrigerator there was a five-pound open, undated bag of shredded cheddar cheese and an open, undated five-pound bag of mozzarella cheese. Review of the temperature monitoring logs for May 2024 revealed no recorded temperatures for 05/03/24, 05/04/24, and 05/05/24.

Observation of the kitchen temperature logs for tray line revealed no temperatures for breakfast and lunch on 05/03/24 and no recorded temperatures for breakfast, lunch, or dinner on 05/04/24. Observation of the dish machine revealed no evidence of temperatures being taken to ensure proper sanitation.

Interview at the time of the above observations with Dietary Manager #13 confirmed the refrigerator and freezer temperature logs were not complete and there were no dish machine logs to review for April or May 2024.

Observation on 05/06/24 at 7:40 A.M. of the breakfast tray line temperatures with Cook #14 revealed scrambled eggs were 174 degrees Fahrenheit (F), oatmeal was 187 degrees F, pancakes were 179 degrees F and toast was 90 degrees F. Interview at the time of the observation with Cook #14 revealed one of the steam wells was not working on the steam table and she had placed the deep pan full of sliced, buttered toast on top of it but did not have a heat source to keep the toast warm during tray line. Cook #14 confirmed the side of the pan of toast did not feel warm.

Observation on 05/06/24 at 7:46 A.M. with Dietary Manager #13 of the self-serve area in the lobby revealed a self-serve juice machine and coffee machine. Both machines had evident build up on the dispenser tubes. Dietary Manager #13 confirmed the buildup on the dispenser tubes and stated dietary staff were to clean it nightly but was unable to provide cleaning logs or confirm the last time the machine was wiped down or the dispenser tubes were removed to be cleaned.

A test tray was completed on 05/06/24 with Dietary Manager #13 at 8:15 A.M. following the last breakfast meal being served. The temperature of the scrambled eggs was 161 F, oatmeal was 175 degrees F, pancakes were 106 degrees F, and the toast was 78 degrees F. Interview with Dietary Manager #13 confirmed the temperature of the pancake and toast were not warm enough for her preference and stated the toast should have been kept on a heat source during the tray line to prevent it from getting cold.

Observation on 05/06/24 at 3:20 P.M. with the Executive Director (ED) of the self-serve juice machine and coffee machine located in the facility lobby revealed she was not sure of the cleaning procedures for the juice machine as it was just purchased a week ago. The ED confirmed the coffee machine was working and the water filtration filter below the sink was dated 11/30/20 and stated it should have been replaced since then.

Review of the 2010 facility policy called; Food Storage revealed all refrigerator units would be kept clean. Thermometers should be checked at least twice daily. Cooked foods must be stored above raw foods and in drip proof containers. All foods should be labeled, covered, and dated.

Review of the 2010 facility policy called; Food Temperatures revealed the temperatures of the food items would be taken and properly recorded for each meal.

Review of the undated facility policy called; General Food Preparation and Handling revealed the kitchen was to be kept neat and orderly and the equipment was to be kept clean. Meats were to be defrosted using safe thawing practices; in the refrigerator in a drop proof container and in a manner that prevented cross contamination. Leftovers were to be dated, labeled in a refrigerator. All food service equipment was to be cleaned, sanitized, dried, and reassembled after each use.

This violation represents non-compliance investigated under Complaint Number OH00153604.

Based on observation and interview the facility failed to ensure kitchen garbage which stored outside was in a non-absorbent container with a close-fitting cover. This had the potential to affect all 124 residents residing in the facility.

Findings include:

Observation on 05/06/24 at 7:16 A.M. with Dietary Manger #13 of the outside dumpster revealed four bags of garbage and three boxes on the ground outside of the closed dumpster. Dietary Manager #13 confirmed the observation.

This violation represents non-compliance investigated under Complaint Number OH00153604.

Based on observation and interview facility failed to ensure a clean and sanitary environment by safely removing mold and preventing fire hazards in the laundry area. This had the potential to affect all residents living at the facility. The facility census was 124.

Findings include:

Observation on 05/02/24 at 2:30 P.M. with Maintenance #17 of the back hallway leading to the rear loading dock revealed several sheets of peeling wallpaper that had visible mold that was black in color starting at the floor level and rising up about three feet. Maintenance #17 stated he was unaware how long it had been or how it occurred.

Observation on 05/02/24 at 4:17 P.M. with the Executive Director (ED) of the loading dock revealed peeling wallpaper and visible mold that was black in color behind it that was approximately one third the wall up the wall from the floor baseboard. The ED stated she had been aware of it for about three months but was unable to provide documentation of any scheduled repairs.

Observation on 05/06/24 at 5:52 A.M. with Caregiver #9 of the 100-hall laundry room revealed two socks and a sweatshirt under the dryer vent. Caregiver #9 confirmed the observation.

Observation on 05/06/24 at 6:03 A.M. with Licensed Practical Nurse (LPN) #11 of the 300-hall laundry room revealed six clothing items behind the two washers and two dryers. One of the washers and one dryer had a sign on them that the machines were out of service. The exact items were unable to be determined due to tight space configuration. LPN #11 stated there were frequent issues with washers or dryers being out of service and she was aware of the mold in the loading dock hallway, employee breakroom and employee bathrooms and chooses not to use them.

Observation on 05/07/24 at 12:03 P.M. with Concierge #20 of the employee breakroom revealed three sheets of peeling wallpaper on one wall with visible mold which was black in color behind it. Observation of the employee restroom revealed it was painted and no mold was visible at the time of the observation. Concierge #20 confirmed the observation of the employee breakroom.

Interview on 05/07/24 at 11:14 A.M. with the ED revealed she was not aware of any concerns related to items of clothing behind dryers.

Review of the undated facility policy The Physical Environment revealed proper care of the physical environment involved preventative activities, daily maintenance activities and repair and replacement activities.

This violation represents non-compliance investigated under Complaint Number OH00153604 and OH00153467.

Based on observation, medical record review, review of a facility investigation and police report, AccuWeather website data review, review of the facility Elopement policy and procedure, and interview, the facility failed to provide adequate supervision to prevent Resident #206 from eloping through an unlocked gate within a fenced outdoor courtyard located off the secured memory care unit. This resulted in Real and Present Danger and the likelihood of serious harm, injury, or death on 04/18/24 at approximately 12:15 P.M. when Caregiver #3 noticed Resident #206, who resided on the facility memory care unit, was severely cognitively impaired, and assessed at high risk for elopement and falls was missing from the facility. On 04/18/24 at an unknown time, Resident #206 entered a gas station, located a mile from the facility, Resident #206 was confused, and asked the attendant to call the police because she was being held against her will. The police arrived at the gas station at 12:39 P.M. and contacted the facility to see if they were missing a resident and subsequently returned Resident #206 to the facility at 12:51 P.M. This affected one resident (#206) of three residents reviewed for elopement. The facility identified 36 residents (Resident #188, #189, #190, #191, #192, #193, #194, #195, #196, #197, #198, #199, #200, #201, #202, #203, #204, #205, #206, #207, #208, #209, #210, #211, #212, #213, #214, #215, #216, #217, #218, #219, #220, #221, #222, and #223) who resided on the memory care unit as being an elopement risk. The facility census was 124.

On 05/06/24 at 10:12 A.M. the Executive Director (ED) was notified Real and Present Danger began on 04/18/24 at 12:15 P.M. when it was identified Resident #206, who was severely cognitively impaired and at risk for elopement and falls, was missing from the facility and not located on the premises. The resident had entered a gas station located one mile from the facility and asked the attendant to call the police. The gas station attendant contacted the local police. Local police arrived at the gas station on 04/18/24 at 12:39 P.M., contacted the facility to see if they were missing a resident and then brought Resident #206 back to the facility at 12:51 P.M.

The Real and Present Danger was abated on 05/07/24 when the facility implemented the following corrective actions:

On 04/18/24 at approximately 1:00 P.M. Licensed Practical Nurse (LPN) #2 assessed Resident #206 with no apparent injuries, vital signs were stable, and range of motion was within normal range. Resident #206's physician and family were notified.

On 04/18/24 after Resident #206 was returned to the facility and was assessed by LPN #2 she was placed on fifteen minutes checks until she went to bed.

On 04/18/24 at approximately 1:00 P.M. all staff involved (LPN #2, Caregivers #1, #3, #4, #7 and Activities Aide #5) were asked to write statements about the event.

On 04/18/24 following Resident #206's return to the facility, all staff working in the facility were in-serviced on elopement procedures.

Beginning on 05/06/24 elopement risk assessments were being completed on all memory care (MC) residents and would be completed by 05/08/24. The elopement risk assessments would be completed by Resident Wellness Director (RWD), Resident Care Director (RCD), Care Director (CD), and LPNs who worked in the memory care unit. All residents identified as an elopement risk were placed on hourly checks to be documented on resident task sheet by resident assistants, ongoing for all residents identified as an elopement risk.

Beginning 05/06/24, the RWD, RCD and LPNs working in the memory care unit began updating and dating all memory care (MC) service plans to reflect elopement risk. All service plans would be updated by 05/10/24.

The Senior Executive Director revised the Lost or Missing Resident Policy on 05/06/24 to state every resident would be assessed for elopement upon admission and with a significant change of status to develop an appropriate service plan. The previous policy stated upon admission and periodically. Staff would follow the elopement risk policy and procedure in the event of an elopement.

All staff in-servicing on the revised Lost or Missing Resident Policy was started on 05/06/24 and would continue through 05/10/24 to ensure all staff was captured. The in-services would be led by the ED, RWD, and RCD. All staff were notified via text to complete the in-service at start of their next shift.

The RWD began in-servicing the LPNs on notification of change policy beginning 05/06/24 and all LPNs would complete the in-service by 05/10/24.

The ED would audit Resident Assessment and Elopement Assessments monthly ongoing in the electronic medical record to ensure completion. The RWD, RCD and ED would review resident assessments and service plans to ensure they were correct upon completion.

On 05/06/24 the revised Lost or Missing Resident Policy was placed in all new employee orientation on boarding materials.

The facility identified resident standard of care for supervision included two-hour safety checks. Resident Assistants would complete a Resident Assistant Task Sheet each shift which would be reviewed by the RCD and/or RWD and/or designee daily. One-hour checks would be completed by Resident Assistants on all residents identified to be at risk for elopement.

Beginning on 05/06/24 all caregivers and LPNs were being in-serviced by RWD and RCD on two-hour safety checks and task sheets; this in-servicing would be completed by 05/10/24.

Beginning on 05/06/24 the RWD and the RCD began in-servicing all LPNs to check the memory care courtyard gates at the start of every shift after nurse report and document date, time, shift, and signature on gate check log located in Narcotic logbook created by the ED. All LPNs to complete this in-service by 05/10/24.

Beginning 05/07/24 the Maintenance Director or Maintenance Assistant were to check memory care gates to ensure they were closed and locked after any lawn maintenance or fire drills ongoing, and log in the gate log binder created by the ED.

Although the Real and Present Danger was abated on 05/07/24 the violation remained 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 #206 revealed an admission date of 03/18/24. Resident 3206 had diagnoses including cerebral infarction, age related cataract, depression, and diabetes mellitus.

Review of the 03/18/24 admission resident assessment revealed Resident #206 was disoriented to person, place, and time and had an unsteady gait. Resident #206 was noted to require physical assistance for bathing, dressing, incontinence care, was dependent on staff for oral care, used a cane or walker and required supervision for ambulation.

Review of the mini mental state examination (SMMSE) dated 03/18/24 revealed Resident #206 scored a 9.5 out of thirty which indicated severe cognitive impairment.

Review of Resident #206's undated service plan revealed she was not indicated as being at risk for elopement. However, the service plan reflected Resident #206 required two-hour checks, assistance for activities of daily living, and used a cane or walker.

Review of the 03/18/24 elopement risk assessment form revealed Resident #206 was disoriented daily, ambulatory with assist of one, had slightly limited mobility, received psychotropic medications that altered her mental status and had a score of 10 which indicated she was high risk for elopement. There were no interventions or plan initiated after this assessment was completed.

Review of the 03/18/24 fall risk assessment for Resident #206 revealed she was always disoriented to person, place, and time, was ambulatory with assistance of one staff with a walker or cane and scored a 16 which indicated she was high risk for falls.

Review of nursing progress note dated 03/20/24 timed at 8:39 P.M. revealed Resident #206 was refusing medications and following the nurse around the unit attempting to access the medication cart. Redirection was attempted but was not effective for very long. Resident #206 was noted to be expressing paranoid thoughts whenever she was walking by staff when they were having a conversation. Resident #206 thought staff were talking about her. Attempts were made to reassure Resident #206 and she accused staff of lying.

Review of nursing progress note dated 03/22/24 timed at 6:45 P.M. revealed Resident #206 was confused and wandering the unit looking for her mother throughout the day.

Review of nursing progress note dated 03/24/24 timed at 8:43 P.M. revealed Resident #206 was caught with the dining room window open and was making statements about elopement and was able to be redirected after several attempts. Resident #206 followed the nurse around and to take her medications stating, I am leaving. I don't need those. There were no new interventions or plan initiated at this time to address Resident #206's elopement risk other than caregiver to watch resident closely.

Review of the physician progress note dated 04/01/24 revealed Resident #206 remained on the memory care unit and had diagnoses of moderate dementia without behaviors, depression, and type II diabetes mellitus.

Review of nursing progress note dated 04/11/24 timed at 7:36 P.M. revealed Resident #206 was noted to have increased paranoia and hallucinations. Physician order was received for the anti-psychotic medication, Haldol.

Review of physician orders for Resident #206 revealed an 04/11/24 order for Haloperidol (an antipsychotic) 2 milligram/milliliter for paranoia and hallucinations. Give 0.5 milliliter by mouth twice daily. Review of the medication administration record revealed the medication was administered as ordered.

Review of nursing progress note dated 04/13/24 timed at 12:28 P.M. revealed Resident #206 had family visitors and became irate because family members left the facility without saying goodbye. Resident #206 was tearful and started arguing with staff.

Review of a 04/18/24 police report involving Resident #206 revealed a phone call was received at 12:30 P.M. from a local gas station manager who stated an elderly female entered the gas station stating she needed to file a police report because she was being held against her will. The elderly female did not think she had a car and thought she walked to the gas station. It was noted Resident #206 was wearing a white cardigan with pink pants. Police officers arrived at the gas station at 12:39 P.M. Police officers left the gas station at 12:48 P.M. and headed to the facility. Resident #206 arrived back at the facility at 12:51 P.M. and was returned to the facility staff.

Review of nursing progress notes dated 04/18/24 timed at 1:23 P.M. for Resident #206 revealed Resident #206's daughter was notified of resident's departure from the facility unexpectedly. Resident #206 was returned to the facility by local police. Resident #206 was assessed upon return with normal vitals and no noted injuries.

Interview on 05/02/24 at 11:24 A.M. with LPN #2 revealed she received a call around 12:15 P.M. that Resident #206 was missing, and all staff began looking for Resident #206. Resident #206 was brought back to the facility by the police. LPN #2 assessed Resident #206 upon her return and did not find any injuries. LPN #2 stated Resident #206 stated she missed her grandkids and wanted to see them. LPN #2 stated Resident #206 frequently talked about her family and seemed at her baseline prior to her elopement. Staff completed every 15 minutes checks on 04/18/24 after Resident #206's return until she went to bed.

Interview on 05/02/24 at 11:39 A.M. with Caregiver #3 revealed Resident #206's daughter and grandkids had visited a couple days prior to Resident #206's elopement, and she frequently talked about going to see her grandkids. Resident #206 ate lunch between 11:00 A.M. to 11:30 A.M. and around 12:00 P.M. Caregiver #3 could not find Resident #206 and began looking and asking staff if they had seen her. The last time Caregiver #3 had seen Resident #206 was around 11:45 A.M. out in the courtyard. Caregiver #3 stated after Resident #206 was returned to the facility they tried to keep Resident #206 near the nurse's station with staff for close monitoring.

Interview on 05/02/24 at 11:56 A.M. with Caregiver #4 revealed she had seen Resident #206 in the activities room around 11:45 A.M. on 04/18/24 where she stayed for a few minutes and then left. Caregiver #3 came to staff asking if they had seen Resident #206 shortly after 12:00 P.M. and all staff began searching.

Interview on 05/02/24 at 12:07 P.M. with Caregiver #5 revealed she had last seen Resident #206 around 11:30 A.M. On 04/18/24. Around 12:00 P.M. Caregiver #3 told her she could not find Resident #206, so all staff began looking for her.

Interview on 05/02/24 at 12:17 P.M. with Memory Care Director (MCD) #6 revealed Resident #206 came into the activities room around 11:40 A.M. and was talking with residents and staff and left around 11:50 A.M. to go to the TV room. MCD #6 stated she went to lunch and then about 12:15 P.M. Caregiver #3 asked if she had seen Resident #206, and they all began to look for her.

Observation on 05/02/24 at 2:45 P.M. revealed Resident #206 walking in the hallway near the activities room without a walker or cane in route to her room. Resident #206's gait was unsteady at times.

Interview on 05/02/24 with Activities Aide (AA) #7 confirmed Resident #206's gait was unsteady as she was walking to her room. AA #7 stated Resident #206 was very impulsive and did not always use her walker or cane despite encouragement and became agitated at times when staff reminded her.

Interview on 05/02/24 at 3:10 P.M. with the ED revealed the contracted lawn service had been at the facility earlier in the day on 04/18/24 and closed the gate in the memory care courtyard but it was found not to be fully latched from the outside. The gate led to the facility's back parking lot. The ED was alerted by Caregiver #3 that Resident #206 was missing and all staff began searching the entire facility and grounds for her around 12:15 P.M. While staff were looking for Resident #206, an unidentified staff member realized the gate appeared shut but was unlocked. Maintenance was notified and locked the gate. Police brought Resident #206 back to the facility around 12:50 P.M. and no injuries were observed.

An attempt to interview Resident #206 on 05/06/24 at 3:22 P.M. was unsuccessful. Resident #206 was agitated and kept repeating she wanted to call the police.

Review of AccuWeather website revealed the temperature on 04/18/24 was a low of 55 degrees Fahrenheit (F) and a high of 70 degrees F.

Review of the facility policy Resident Emergency-lost or missing resident

Based on medical record review, resident interview, staff interview and review of the facility policy, the facility failed to ensure residents received showers as scheduled. This affected one (Resident #62) of three residents reviewed for showers. The facility census was 113.

Findings include:

Review of the medical record for Resident #62 revealed an admission date of 10/27/22 with diagnoses including congestive heart failure (CHF), dementia, major depressive disorder, and heart disease. The resident required physical assistance with bathing and had an intact cognition.

Review of the facility shower schedule revealed Resident #62's showers were scheduled on Mondays and Fridays on the second shift.

Interview on 03/13/24 at 11:47 A.M. with Resident #62 confirmed the facility did not consistently provide showers. Resident #62 confirmed she was supposed to have showers twice weekly on Mondays and Fridays but for the week of 03/03/24 she did not receive any showers.

Review of the shower sheets for Resident #62 dated 02/21/24 to 03/11/24 revealed the resident received showers as scheduled until 02/27/24. The next shower was not given until nine days later on 03/08/24.

Interview on 03/15/24 at 11:09 A.M. with Resident Wellness Director (RWD) #445 confirmed Resident #62 was scheduled to have a shower twice weekly and was compliant with her showers. RWD #445 confirmed facility did not provide Resident #62 with a shower between 02/27/24 and 03/08/24.

Review of the facility policy titled Bathing undated revealed residents were bathed in their preferred way at their preferred times.

This violation represents noncompliance investigated under Complaint Number OH00151523.

Based on observation and staff interview, the facility failed to report a fire incident to the state fire marshal and to the Ohio Department of Health (ODH). This had the potential to affect all 113 residents residing in the facility.

Findings include:

Interview on 03/13/24 at 9:10 A.M. with Dietary Services Assistant (DSA) #413 confirmed there was a fire in the kitchen on 01/07/24. DSA#413 confirmed the flames of the fire reached the ceiling and there was still visible evidence of the fire on the ceiling.

Observation on 03/13/24 at 9:10 A.M. revealed there was a section of ceiling tiles between the sink and the stove that had a dark discoloration.

Interview on 03/13/24 at 9:59 A.M. with interview with Resident Wellness Director (RWD) #445 confirmed there was a fire in the facility kitchen on 01/07/24.

Interview on 03/13/24 at 10:27 A.M. with the Executive Director (ED) confirmed there was a grease fire in the kitchen which was not reported to the state fire marshal or to ODH.

Interview on 03/13/24 at 3:37 P.M. with the ED confirmed the facility had a fire in the kitchen fire on 01/07/24 which caused damage to the ceiling tiles above the stove. ED further confirmed she was unaware the fire needed to be reported.

Based on medical record review, observation, interview, and review of resident records, and call system manufacturer's information the facility failed to ensure an effective call system was in place that also allowed deactivation or clearing of the call in the area from which the resident initiated the call. This affected Residents 14, #19, #30, #41, #62, #68, #82, #104, and #106 and had the potential to affect all residents. The facility census was 113.

Findings include:

1.Review of the medical record for Resident #62 revealed an admission date of 10/27/22 including diagnoses including congestive heart failure (CHF), dementia, major depressive disorder, and heart disease. The resident had an intact cognition.

Review of the fall incident report for Resident #62 dated 03/03/24 timed at 11:00 A.M. revealed the resident had an unwitnessed fall from bed and she crawled to the door and called for assistance.

Interview on 03/13/24 at 11:17 A.M. of Resident #62 confirmed when she fell on 03/03/24 she had pressed her call pendant and waited for 15 minutes but no one came to assist her.

Interview on 03/14/24 at 8:11 A.M. with Resident Wellness Director (RWD) #445 confirmed the facility had some issues with the call system not working consistently. RWD #445 confirmed when Resident #62 pressed her call pendant on 03/03/24 and waited 15 minutes with no response so she scooted to the door to find staff.

Interview on 03/14/24 at 12:28 P.M. with CG #468 confirmed she responded to Resident #62 after her fall on 03/03/24. CG #468 confirmed she saw the resident sitting on the floor in her doorway. CG #468 confirmed Resident #62 told the aide she had pressed her call pendant for assistance, and no one came. CG #468 confirmed she pressed Resident #62' s call pendant twice after the fall and it was not working.

2. Review of the medical record for Resident #104 revealed an admission date of 02/17/24 with diagnoses including anxiety, anxiety disorder, muscle weakness, and osteoarthritis.

Review of the fall incident report for Resident #104 dated 03/02/24 timed at 1:30 A.M. revealed the resident had an unwitnessed fall from bed.

Interview on 03/14/24 at 12:56 P.M. with RWD #445 confirmed Resident #104 pressed her call pendant for assistance on 03/02/24 and no one came. Resident #104 confirmed when no one answered she fell out of bed while trying to reach her television remote.

Interview on 03/14/24 at 1:00 P.M. of Resident #104 confirmed that she pressed her call light for assistance on 03/02/24 and no one came. Resident #104 confirmed she fell out of bed while trying to reach her television remote and since the call pendant wasn't working, she had to bang on the wall to alert staff she was on the floor.

Interview on 03/14/24 at 1:11 P.M. with Resident #17 confirmed she heard Resident #104 calling for help on 03/02/24 at approximately 1:00 A.M. Resident #17 confirmed Resident #104 had fallen and told her she had pressed her call pendant, but the alarm was not sounding. Resident #17 confirmed she alerted the staff Resident #104's call pendant was not working.

3. Review of the list provided by RWD #445 on 03/14/24 revealed there were seven residents (#14, #19, #30, #41, #68, #82, and #106) who resided on the memory care unit and were cognitively able to use the call system.

Interview on 03/14/24 at 8:11 A.M. RWD #445 confirmed there was no working call system on the memory care unit.

Interview on 03/14/23 at 8:16 A.M. with Director of Maintenance (DOM) #423 and Maintenance Technician (MT) #446 confirmed the facility call system did not work consistently, and that it did not work well around steel which was present throughout building. DOM #423 confirmed the manufacturer's manual indicated the system did not work properly in building with steel present. Interview further confirmed the facility memory care unit did not have an adequate call system in place on the unit and he been told silence the alarm.

Observation on 03/14/24 at 8:21 A.M. with DOM #423 of memory care unit revealed DOM #423 pulled a call cord in an unoccupied room on the 100 hall but no audible alert. Observation of the call system panel located in the 100-hall dining area revealed it was not working, DOM #423 pressed various buttons on the call system panel, and nothing happened.

Interview on 03/14/24 at 11:26 A.M. with DOM #423 and MT #446 confirmed the call system on the memory care unit had been silenced and been nonfunctional since November 2023.

Review of the manufacturer's information for the call system undated revealed if the product was installed near metals, the range of radio waves could be affected by metal surfaces and other electrical equipment. The system should be installed as far away from these objects as possible and surrounding metal walls or other electrical devices might interfere with or affect the signal.

This violation represents non-compliance investigated under Complaint Number OH00151350.

Based on medical record review, observation, resident interview, staff interview and review of the housekeeping schedule the facility failed to ensure resident bathrooms were cleaned in a timely manner. This affected one (Resident #62) of five residents reviewed for clean and sanitary environment. The facility census was 113.

Findings include:

Review of the medical record for Resident #62 revealed an admission date of 10/27/22 with diagnoses including congestive heart failure (CHF), dementia, major depressive disorder, and heart disease.

Observation on 03/31/24 at 11:17 A.M. revealed Resident #62's toilet and the riser on top of the toilet were soiled with dried brown spots and there were also dried brown spots on the floor near the base of the toilet and also on the wall by the toilet paper holder. There was a slight odor of bowel movement.

Interview on 03/13/24 at 11:17 A.M. with Resident #62 confirmed she had housekeeping concerns and that her bathroom had not been cleaned recently. Resident #62 stated she had asked someone to clean her bathroom, but she wasn't sure who was supposed to clean her bathroom. Resident #62 confirmed her room was usually cleaned once weekly on Tuesdays and was last cleaned on Tuesday, 03/05/24.

Interview 03/13/24 at 12:01 P.M. with Caregiver (CG) #426 confirmed Resident #62's bathroom was not clean, and the brown spots on the toilet, the floor, and the wall were dried and appeared to have been in place for a while. CG #426 confirmed the housekeeping department was responsible for cleaning the residents' rooms and bathrooms.

Interview on 03/14/24 at 8:45 P.M. with Maintenance and Laundry Director (MLD) #423 confirmed residents' room were cleaned weekly and Resident #62's room was cleaned on Tuesdays. MLD #423 stated caregivers were responsible for any cleaning outside of the resident's cleaning schedule.

Review of the housekeeping suite weekly assignments schedule undated revealed Resident #62's room was to be cleaned every Tuesday.

This violation represents noncompliance investigated under Complaint Number OH00151523 and OH00151527.

Based on record review, and interview the facility failed to maintain the resident trust fund in an interest bearing account. This affected all 74 residents who had a resident trust account. The facility census was 111.

Findings include:

Review of facility Resident Trust Accounts from 06/15/23 to 09/14/23 revealed the accounts were not accumulating any interest.

Interview on 10/05/23 at 11:45 A.M. with Business Office Manager #500 confirmed the Resident Accounts had never accumulated interest.

Interview on 10/05/23 at 12:00 P.M. with the Administrator and at 12:15 P.M. with Corporate Business Liaison #550 also confirmed the Resident Trust Accounts had never accumulated interest.

Based on interview, closed record review, review of the facility fall investigation, and facility policy review the facility failed to timely report and assess a fall that resulted in a hip fracture for Resident #122. This affected one resident (#122) of three residents reviewed for falls. The facility census was 121.

Findings include:

Closed record review revealed Resident #122 was admitted to the facility on 08/09/22 with diagnoses including dementia, mixed hyperlipidemia, bradycardia, unsteadiness on feet, and localized edema. Resident #122 was discharged on 02/11/23. Review of the Medical Evaluation (ME) dated 08/03/22 revealed Resident #122 was alert to person, required physical assistance with a cane or wheelchair for transferring or ambulating, and increased supervision due to psychological and/or intellectual impairment.

Review of the progress note dated 02/11/23 at 11:09 A.M. revealed Resident #122 received physician orders for x-ray to bilateral hips to rule out fractures due to complaint of extreme pain when moving lower bilateral extremities.

Review of the progress note dated 02/11/23 at 2:21 P.M. revealed Resident #122 was sent to the local emergency room for evaluation and treatment due to a left hip fracture.

Review of the incident report investigation form dated 02/11/23 revealed Resident #122 had an incident with factors that may have contributed to her fall such as fall potential and mental status. Review of the form revealed Resident #122 could have had a bed alarm in place to prevent the incident.

Review of the incident log dated 12/14/22 to 03/08/23 revealed Resident #122 fall was not documented on the log.

Review of the employee disciplinary notice for Staff Nurse (SN) #800 dated 02/17/23 revealed she received education on fall procedures and expectations regarding Resident #122's fall. SN #800 revealed she was not made aware of Resident #122 fall, therefore did not act in a timely manner, in a way she would have had she known.

Review of the employee disciplinary notice for Staff Aide (SA) #801 dated 02/17/23 revealed she alerted SN #800 of Resident #122 fall after assisting her back to bed. SA #801 revealed she heard Resident #122 yelling for help and upon entering her room, she was lying on the floor next to the bed. SA #801 revealed Resident #122 fall occurred between 2:00 A.M. and 3:00 A.M.

Interview on 03/09/23 at 12:23 P.M. with the Executive Director revealed Resident #122 had a fall on 02/11/23 during third shift. The Executive Director revealed Resident #122 complained of pain and had an x-ray that resulted in a fracture. The Executive Director revealed there was a delay in Resident #122 being sent to the hospital due to staff not communicating. The Executive Director revealed SN #800 did not document the fall on the incident log due to the timing of being sent to hospital and not returning to the facility.

Interview on 03/09/23 at 3:19 P.M. with SA #801 revealed Resident #122 was yelling for help while lying on the floor near her bed. SA #801 revealed Resident #122 stated she was in pain and couldn't walk. SA #801 revealed she assisted Resident #122 to bed and informed SN #800 of the fall, but SN #800 stated there wasn't anything she could do unless she went to the hospital. SA #801 revealed she checked on Resident #122 throughout the night but did not see SN #800 assist with her fall.

Review of the physician orders dated 02/11/23 revealed Resident #122 received physician orders for x-ray to bilateral hips to rule out fractures due to complaint of extreme pain when moving lower bilateral extremities and an order to be sent to the local emergency room for evaluation and treatment due to a left hip fracture.

Review of Resident #122 medical revealed she had a fall approximately between 2:00 A.M. and 3:00 A.M. on 02/11/23 but was not assessed and sent to the hospital until approximately 2:11 P.M. on 02/11/23 (approximately 12 hours later).

Interview on 03/09/23 at 12:23 P.M. with the Executive Director confirmed the above findings.

Review of the undated facility document titled Resident Emergency- Falls and Head Injuries Policy revealed the facility had a policy in place that staff would be alert to situations that may cause falls, work to prevent falls, and to treat falls quickly and correctly when they occur. Review of the policy revealed the facility did not implement the policy.

This violation represents noncompliance investigated under Complaint Number OH00140492.

Based on personnel record review, background check log review and interview, the facility failed to maintain a complete criminal background check log. This had the potential to affect all residents residing in the facility. The census was 114.

Findings include:

Review of the personnel record for Caregiver #4 revealed a hire date of 10/05/21. There was a sealed envelope with Caregiver #4's name and a red stamp of confidential on the front of the envelope.

Review of the facility's background check log revealed Caregiver #4 was not listed in the log.

Interview on 10/24/22 at 8:45 A.M. with the Executive Director (ED) revealed there was not a background check log from February 2021 through December 2021 because the facility's computer hard drive had crashed.

This violation represents non-compliance investigated under Complaint Number OH00136577.

Based on observation, court docket review, personnel record review, background check log, policy review, and interview, the facility failed to ensure staff with disqualifying criminal offenses were not hired. This had the potential to affect all residents residing in the facility. The census was 114.

Findings include:

Review of the personnel record for Caregiver #4 revealed a hire date of 10/05/21. There was a sealed envelope with Caregiver #4's name and a red stamp of confidential on the front of the envelope. Review of the facility's background check log revealed Caregiver #4 was not listed in the log.

Interview on 10/24/22 at 8:45 A.M. with the Executive Director (ED) revealed there was not evidence background checks were completed from February 2021 through December 2021 because the facility's computer hard drive had crashed.

Observation on 10/24/22 at 4:50 P.M. revealed Caregiver #4 was standing in the 100-hall dining room on the secured special care unit. Interview, during the observation, with Caregiver #4 revealed she was assigned to work the 100-hall from 3:00 P.M. to 11:00 P.M. that day.

Observation on 10/25/22 at 10:30 A.M. revealed the ED opened Caregiver #4's sealed envelope containing the BCI background check. Interview, during the observation, with the ED revealed Caregiver #4 had a disqualifying offense on her criminal record and should have not been hired at the facility. The Administrator revealed Caregiver #4 would need to be terminated.

Review of the county court of clerk's docket revealed Caregiver #4 was indicted for Receiving Stolen Property and Misuse of Credit Cards in January 2018. The Receiving Stolen Property crime was involving a debit card and knowing or having reasonable cause to believe that the property has been obtained through commission of a theft offense. The Misuse of Credit Cards crime was against an elderly victim. Review of the journal entry, dated 04/11/18, revealed Caregiver #4 pleaded guilty to Receiving Stolen Property and the Misuse of Credit Cards indictment was dismissed. Caregiver #4 had to complete 12 months of probation which started on 04/09/18.

Follow-up interviews on 11/01/22 at 8:50 A.M. and 1:00 P.M. with the ED revealed the ED did not have evidence or documentation that Caregiver #4 was hired under Personal Character Standards. Caregiver #4 was not asked about the Receiving Stolen Property conviction upon hire because the ED missed that Caregiver #4 had that offense on her criminal record.

Review of the facility's Verification and Background Checks policy dated 2018 revealed the facility would not employ applicants with unacceptable background checks.

This violation represents non-compliance investigated under Complaint Number OH00136577.

Based on medical record review, incident/accident log review and interview, the facility failed to ensure incidents were notated in the incident/accident log for Resident #1, #2, #3 and former Resident #4. This affected four (Resident #1, #2, #3 and #4) of six residents reviewed for supervision.

Findings include:

Review of the medical record for Resident #1 revealed an admission date of 02/19/16 with diagnoses of abnormalities of gait and mobility, hypertension, and dementia. Review of the physician medical evaluation, dated 04/28/22, revealed Resident #1 used a wheelchair, was oriented only to self, disoriented in some spheres all the time, was aggressive and wandered. Resident #1 was assessed as being an elopement risk and was not able to recognize danger. Resident #1 was identified as needing increased supervision due to safety awareness and psychological/intellectual impairment. Resident #1 resided in the unsecured section of the facility. There was not an elopement risk assessment in Resident #1's medical record.

Review of the nursing progress notes dated 09/16/22 timed 7:11 P.M. revealed the Caregiver from the Memory Care unit stated when she was taking another resident back to the 400-hall from the Memory Care unit she observed Resident #1 outside of the front door heading down the driveway. The Caregiver stated Resident #1 was brought back into the facility and she told the 400-hall Caregiver what had happened. The manager was notified.

Review of the medical record for Resident #2 revealed an admission date of 05/15/20 with diagnoses of dementia with behaviors and generalized anxiety disorder. Review of the physician medical evaluation, dated 06/23/22, revealed Resident #2 was independent with ambulation, was alert to person only, was disoriented in some spheres all the time, was aggressive and wandered. Resident #2 was also assessed as being an elopement risk and unable to recognize danger. Resident #2 was identified as needing increased supervision due to safety awareness and required a special care unit (Memory Care). Resident #2 resided on the secured, Memory Care unit.

Review of the nursing progress notes dated 08/14/22 timed 3:41 P.M. revealed at approximately 2:30 P.M., the Caregiver came to the nurse and stated that she was sitting in the dining area of the 200-hall when she observed Resident #2 was outside in the courtyard. All doors to courtyard were locked. The door was unlocked by the nurse and the Caregiver went outside to redirect Resident #2 back into building. Upon the nurse's investigation on how Resident #2 was outside it was observed Resident #2 had unlocked and opened the window in his room. A cane was observed next to the window and the screen to the window was pushed out.

Review of the medical record for Resident #3 revealed an admission date of 05/20/21 with diagnoses of anxiety and dementia. Review of the medical evaluation, dated 05/10/22, revealed Resident #3 was independent with ambulation, oriented only to person and was disoriented in some spheres some of the time. Resident #3 was also assessed as being an elopement risk and unable to recognize danger. Resident #3 was identified as needing increased supervision due to safety awareness and due to physiological/intellectual impairment and required a special care unit (Memory Care). Resident #3 resided on the secured, Memory Care unit.

Review of the nursing progress notes dated 02/27/22 timed 2:25 P.M. revealed Caregivers stated that as they were approaching the dining area from the TV room area, they observed Resident #3 had opened a window in the dining room and had half of her body out of the window. Caregivers stated Resident #3 was easily redirected back into the building and stated Resident #3 had been asking all staff, residents, and visitors to help her get out of here.

Review of the nursing progress notes dated 03/27/22 timed 5:45 P.M. revealed a Caregiver came to the nurse and stated Resident #3 was observed in the 200-hall walking out of the community shower room chewing on something. The Caregiver stated that when they walked into the shower room, they observed a urine-soaked brief in the trash can with crystallized padding of brief noted on the floor. The Caregiver stated Resident #3 was wiping her mouth and the resident's face and mouth smelled of urine. The nurse placed a call to physician for instruction.

Review of the nursing progress notes dated 07/13/22 timed 5:21 P.M. revealed a Caregiver came to the nurse and stated that when he came back from the kitchen with the meal cart, Resident #3 was observed at one of the windows in the dining room. The Caregiver stated when he approached Resident #3 to have her sit down for dinner, Resident #3 had her right leg out the window and her upper body was on the windowsill. The Caregiver stated the window had no screen prior to Resident #3 opening the window. The Caregiver was unable to understand what Resident #3 was saying to him as he was assisting her back into building.

Review of the nursing progress notes dated 07/29/22 timed 5:04 P.M. revealed Resident #3 was noted by staff ambulating in courtyard and all the courtyard doors were locked. Upon speaking to Resident #3, the resident stated that she climbed through a window. Upon inspection, Room #126's window was open (not Resident #3's room).

Review of the closed medical record for Resident #4 revealed an admission date of 07/09/21 and discharge date of 09/21/22. Resident #4 had diagnoses of Alzheimer's disease, dementia, brief psychotic disorder, acute psychosis, and psychophysiological insomnia. Review of the physician medical evaluation, dated 08/15/22, revealed Resident #4 was independent with ambulation, oriented to person only, was disoriented in all spheres all the time and wandered. Resident #4 was assessed as not being able to recognize danger. Resident #4 was identified as needing increased supervision due to safety awareness and needed a special care unit (Memory Care).

Review of the nursing progress notes dated 05/27/22 timed 10:04 A.M. revealed at approximately 6:50 A.M., the third shift Caregiver came to the nurse and stated Resident #4 consumed almost a full jar of Caregiver's [brand name] body cream. The nurse informed the manger on duty and contacted the poison control center. Per poison control, the type of body cream Resident #4 consumed was not harmful and if anything would act as a laxative. The physician's office and power of attorney were notified. Due to the consumption of body cream, the nurse used nursing judgement and held scheduled laxatives.

Review of the facility's incident/accident log from February 2022 to October 2022 revealed Resident #1 wandering down the driveway on 09/16/22 was not listed on the log, Resident #2's exit from the facility via a window on 08/14/22 was not listed on the log, Resident #3's attempts to exit through windows were not listed on the log for 02/27/22, 03/27/22, 07/13/22 and 07/29/22 and Resident #4's incident of consuming almost a full jar of body cream on 05/27/22 was not listed on the log.

Interview on 11/01/22 at 2:00 P.M. with the Executive Director and Resident Wellness Director verified Resident #1's incident on 09/16/22, Resident #2's incident on 08/14/22, Resident #3's attempts to exit through windows were not listed on the log for 02/27/22, 03/27/22, 07/13/22 and 07/29/22 and Resident #4's incident on 05/27/22 were not in the incident/accident log.

Based on observation, medical record review, staff schedule review, policy review, investigation review and interview, the facility failed to ensure their abuse policy was implemented regarding an allegation of physical abuse involving Resident #1. This affected one (Resident #1) of four residents reviewed for abuse.

Findings include:

Review of the medical record for Resident #1 revealed an admission date of 02/19/16 with diagnoses of h abnormalities of gait and mobility, anemia, and dementia. Review of the physician medical evaluation, dated 04/28/22, revealed Resident #1 used a wheelchair, was orientated only to self, disoriented in some spheres all the time, was aggressive and wandered. Resident #1 was also assessed as unable to recognize danger. Resident #1 was identified as needing increased supervision due to safety awareness and psychological/intellectual impairment.

Review of an undated investigation file revealed four witness statements involving an allegation of Caregiver #4 physically abusing Resident #1. There was no evidence Resident #1 was interviewed or assessed, like-residents were interviewed, or other staff members were interviewed. Review of the witness statement, dated 09/28/22, authored by Caregiver #10 revealed, I seen [Caregiver #4] take the palm of her hand and smack Resident #1 across his face and she tried to play it off as if they were playing but he was clearly scared and kept saying, he was okay and did not want to fight.

Review of the witness statement, authored by Activities Assistant (AA) #2 revealed, on the day of Resident #4's birthday [09/19/22], AA #2 was walking down the 200-hall to put a sign up on her door and saw Caregiver #11, Caregiver #10, and another short new aide talking then stopped once AA #2 approached. AA #2 asked what was going on and they told AA #2 Caregiver #4 slapped Resident #1 in the face in the 400 hall. AA #2 asked if it was reported, and they said no due to Licensed Practical Nurse (LPN) #12 not reporting anything because her relationship with Caregiver #4. Staff was afraid to report issues to LPN #12. AA #2 stated that they needed to speak with the Director of Nursing (DON). Caregiver #10 was hesitant. AA #2 told her that she would say something to the DON so she could pull her aside. The statement further indicated these meeting did not happen.

Review of the undated witness statement, authored by Caregiver #13, revealed Caregiver #11 told other Caregiver in common area Caregiver #4 was abusive. LPN #12 knew and was not doing anything about it. Other Caregiver and residents heard it.

Review of the witness statement, dated 09/29/22, authored by Caregiver #4 revealed, I, [Caregiver #4], didn't hit Resident #1 at all. I love my residents as they my own family.

Observation on 10/24/22 at 4:15 P.M. revealed Resident #1 was sitting in a wheelchair outside the front entrance of the facility. Interview, during the observation, with Resident #1 revealed he had not been abused.

Observation on 10/24/22 at 4:50 P.M. revealed Caregiver #4 was standing in the 100-hall dining room on the secured special care unit. Interview, during the observation, with Caregiver #4 revealed she had not had any problems with Resident #1.

Interview on 10/25/22 at 10:55 A.M. with Caregiver #10 was attempted however unsuccessful.

Interview on 10/15/22 at 11:15 P.M. with the DON verified Resident #1's family was not notified of the allegation of abuse and verified Resident #1 was not interviewed about the allegation. The DON verified the facility's abuse policy was not implemented.

Interview on 10/25/22 at 11:16 A.M. with Caregiver #11 revealed he witnessed Caregiver #4 slap Resident #1 in the mouth a month ago; Caregiver #11 and Caregiver #10 observed this.

Interview on 10/25/22 at 12:35 P.M. with the Administrator verified there were not any residents interviewed nor was Caregiver #11 interviewed regarding the allegation.

Review of the daily assignment sheet dated 09/19/22 revealed Caregiver #4, Caregiver #10, Caregiver #11 and Caregiver #13 all worked that day.

Review of the facility's Abuse Prohibition policy dated 2018 revealed the Administrator or designee would conduct a through investigation of reports of all alleged resident abuse or neglect to determine if the conduct of the individual was in violation of any standard of care. Obtain witness statements from witnesses. Notify the resident's family and/or responsible party and physician as soon as possible of the incident, and when completed, the results of the investigation. Report the incident to the State Regulatory Agency within three days of the occurrence when: there is a specific written or verbal allegation of resident abuse.

This violation represents non-compliance investigated under Complaint Number OH00136577.

Based on observation, medical record review, staff schedule review, incident log review, activities calendar review, mealtime review, policy review and interview, the facility failed to provide a safe environment and adequate supervision to prevent an elopement. This resulted in Real and Present Danger on 05/30/22 at 2:02 P.M. when Resident #1, who was cognitively impaired and assessed as being at risk for elopement, self-propelled his wheelchair down the facility's inclined driveway, across a two-lane road where he was subsequently found on the ground in a ditch. The risk for serious harm, injury or death occurred due to safety and supervisory needs not being met. This affected one of six residents reviewed for supervision. Facility census was 114.

In addition, concerns that did not rise to level of Real and Present Danger were identified related to the facility's failure to provide a safe environment, adequate supervision, and meaningful activities to prevent distress, agitation and diversion resulting in Resident #2 climbing out a window into an enclosed courtyard without the means for re-entry; Resident #3 being found partially out of a window on two occasions and having ingested a non-food item, and Resident #4's ingestion of non-food items. This affected three (Residents #2, #3 and #4) of six residents reviewed for supervision. The facility census was 114.

On 10/26/22 at 2:50 P.M., the Executive Director (ED) and Resident Wellness Director (RWD) were notified Real and Present Danger began on 05/30/22 when Resident #1 wandered off facility property without staff knowledge and was subsequently found on the ground in a ditch.

The Real and Present Danger was abated on 11/01/22 when the facility implemented the following corrective actions:

On 10/26/22, residents who were at risk for elopement residing on the non-secured section of the facility (Residents #1, #5, #6 and #7) were placed on the secured memory care unit for reverse daycare during the residents' waking hours or until discharged, if needed. Discharge from the reverse daycare would be determined by a Memory Care Assessment completed by a Licensed Practical Nurse (LPN) and the recommendation and assessment sent to RWD/Resident Care Director (RCD) and ED to make determination when reverse daycare no longer necessary.

On 10/26/22, Resident #2 and Resident #3 were placed on 30-minute safety and location checks.

On 10/26/22, staff received education on 30-minute safety and location checks and completion of 30- minute safety check documentation sheets for Resident #2 and Resident #3 by the RWD/RCD. Any staff who did not receive the education would complete in-service/education prior to the start of next scheduled shift. An education station was set up at the nurses' station on the Memory Care unit where the nurse working would provide education to any on-coming staff that had not received the training.

Beginning on 10/26/22, at the end of each shift, staff to provide the 30- minute safety check documentation sheets to the RWD. If the RWD not working, the documentation will be slipped beneath the office door. The RWD to review the safety documentation sheets each day worked and provide disciplinary action if checks not completed as required.

On 10/27/22, non-food items in the memory care unit were secured by a keypad lock device. Only direct care staff would have access to keypad code.

LPNs were trained on Memory Care Assessments during orientation to community by training designee, and on 10/27/22 by the RWD ongoing until all LPNs have been in-serviced.

On 10/27/22 screws were installed on the windows in the rooms of Residents #2 and #3 to prevent the window from opening more than six inches by Maintenance Director #16.

On 11/01/22 screws were installed on all windows in the Memory Care unit to prevent the windows from opening more than six inches by Maintenance Director #16.

On 11/02/22, to keep the memory care unit residents engaged, the activities calendar was updated to increase activities held in the Memory Care Unit. Activities would be run by the Memory Care Coordinator.

Although the Real and Present Danger was abated on 11/01/22, the violation remained as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance.

Findings include:

1. Review of the medical record for Resident #1 revealed an admission date of 02/19/16 with diagnoses of abnormalities of gait and mobility, hypertension, and dementia. Review of the physician medical evaluation, dated 04/28/22, revealed Resident #1 used a wheelchair, was oriented only to self, disoriented in some spheres all the time, was aggressive and wandered. Resident #1 was assessed as being an elopement risk and was not able to recognize danger. Resident #1 was identified as needing increased supervision due to safety awareness and psychological/intellectual impairment. Resident #1 resided in the unsecured section of the facility. There was not an elopement risk assessment in Resident #1 ' s medical record.

Review of the nursing progress notes dated 05/30/22 timed 2:02 P.M. authored by LPN #15 revealed Resident #1 was outside with other residents when he wandered down the driveway in his wheelchair and ended up across the street (two-lane road) from the facility in a ditch. Another resident came to get LPN #15 to let her know Resident #1 was outside, across the street. When LPN #15 ran out to find Resident #1, he was in a ditch directly across from the facility in the grass. LPN #15 helped Resident #1 back into his wheelchair, checked his skin and observed no injuries. Vital signs were stable. Resident #1 ' s son was notified along with Hospice and Manager on Duty.

Review of the nursing progress notes dated 09/16/22 timed 7:11 P.M. revealed the Caregiver from the Memory Unit stated when she was taking another resident back to the 400-hall from the Memory Unit she observed Resident #1 outside of the front door heading down the driveway. The Caregiver stated Resident #1 was brought back into the facility and she told the 400-hall Caregiver what had happened. The manager was notified.

Review of the facility's incident/accident log revealed on 05/30/22 at 1:30 P.M., Resident #1 had a witnessed fall outside the community. Resident #1 was assisted back in chair, brought back into the building, vitals were obtained, and a skin check was completed. The incident of 09/16/22 where Resident #1 was observed heading down the driveway was not included in the incident/accident log.

Observation on 10/24/22 at 4:00 P.M. revealed Resident #1 sitting outside near the front door, on the sidewalk, in his wheelchair. There were no staff members outside with Resident #1. The front door into the vestibule and the door from the vestibule into the facility were unlocked and not alarmed.

Interview on 10/24/22 at 4:10 P.M. with Caregiver #1 and Caregiver #16 confirmed Resident #1 was sitting outside. They each indicated Resident #1 was able to self-propel himself outside in his wheelchair.

Observation on 10/24/22 at 4:15 P.M. revealed Resident #1 continued to sit outside near the front door, on the sidewalk, in his wheelchair. There were not any staff members outside with Resident #1.

Interview on 10/24/22 at 4:25 P.M. with Activities Coordinator #2 revealed Resident #1 sometimes came on the Memory Care unit for daycare. Resident #1 wandered at times, got into other residents' foods and was notorious for wandering outside around the building, out of view.

Interview on 10/24/22 at 4:55 P.M. with Caregiver #5 revealed Resident #1 used to come to the Memory Care unit for daycare.

Interview on 10/25/22 at 11:15 A.M. with the RWD revealed Resident #1 had severe dementia and could not answer questions appropriately.

Interview on 10/25/22 at 3:00 P.M. with RWD and the ED revealed they were not aware of Resident #1 having been found across the street, in a ditch on 05/30/22. RWD and the ED also revealed Resident #1 did not have a Wander Guard (system which alarms when an individual wearing a Wander Guard bracelet nears an armed door) because the Wander Guards only worked on the Memory Care unit. Resident #1 did not reside in the Memory Care unit due to his insurance requirements.

Observation on 10/25/22 at 5:30 P.M. revealed Resident #1 was lying in a fetal position, sleeping, on his bed with his wheelchair next to his bed.

Observation on 10/26/22 at 12:45 P.M. revealed Resident #1 was sitting on the 400-hall unit feeding himself chips. Interview, during the observation, with LPN #8 revealed Resident #1 was able to independently self-propel in his wheelchair out the front door and enjoyed being outside.

Observation on 10/26/22 at 3:00 P.M. revealed Resident #1 was self-propelling in his wheelchair near the front door in the common area.

Review of the facility's elopement risk assessment policy dated 2018 revealed staff were to determine if resident had a cognitive impairment and would be admitted to the safe and secure unit (Memory Care). If the resident was admitted to safe and secure unit, the Memory Care Coordinator or designee would complete an elopement risk assessment form to determine if the resident was a risk to elopement.

2. Review of the medical record for Resident #2 revealed an admission date of 05/15/20 with diagnoses of dementia with behaviors and generalized anxiety disorder. Review of the physician medical evaluation, dated 06/23/22, revealed Resident #2 was independent with ambulation, was alert to person only, was disoriented in some spheres all the time, was aggressive and wandered. Resident #2 was also assessed as being an elopement risk and unable to recognize danger.

Resident #2 was identified as needing increased supervision due to safety awareness and required a special care unit (Memory Care). Resident #2 resided on the secured, Memory Care unit.

Review of the nursing progress notes dated 10/16/21, timed 7:35 A.M. for a late entry for 10/15/21 at 8:55 P.M. revealed Resident #2 had been exit seeking since the nurse came in at 7:15 P.M. Resident #2 was easily redirected but was still attempting to get out of the cottage door. Resident #2 finally sat down on the Gardner's porch while this nurse passed out medication. Resident #2 did take his medicine without any problems or arguments. As soon as the nurse left the Gardner's porch and went down the hall, the Caregiver came up the hall to help Resident #2 to bed and started yelling that she needed help right away! The nurse ran to see what was happening and Resident #2 had the Gardner's porch window all the way up and had his right leg out the window up to his thigh. Resident #2 came back in but said that he was going to find a way of the place one way or another. The nurse explained to Resident #2 that even if he got out of the window he still could not get out because there was a fence all around the cottages so he still would not be able to go anywhere. Resident #2 stated that he would find a way to get over the fence too. The nurse immediately called the Director of Nursing (DON) and informed her of the incident. The nurse told the DON they needed maintenance to come in and put screws in the window frame so the window could not be lifted so high the resident could get out (this was not done).

Review of the nursing progress notes dated 02/21/22 timed 7:13 A.M. revealed Resident #2 was observed standing by common area window near the nurses ' station. After a while, Resident #2 unlocked the window and lifted it all the way open as he was heard saying that he was about to get out of there. The author of the nursing progress note asked Resident #2 to close the window and go to the TV area, which he did. The note indicated nursing would continue to monitor.

Review of the physician psychiatric progress notes dated 03/16/22 revealed Resident #2 was confused and thought he was in New Jersey. Resident #2 was oriented to person only. Resident #2 was disoriented to place and time. The note further indicated Resident #2's memory, concentration and judgement were impaired.

Review of the nursing progress notes dated 04/20/22 timed 10:33 A.M. revealed Resident #2 had been pacing the unit that morning stating he wanted to leave and if he did not get out, he would break out windows to leave. As needed Hydroxyzine (a sedative used to treat anxiety) was administered.

Review of the nursing progress notes dated 08/14/22 timed 3:41 P.M. revealed at approximately 2:30 P.M., the Caregiver came to the nurse and stated that she was sitting in the dining area of the 200-hall when she observed Resident #2 was outside in the courtyard. All doors to courtyard were locked. The door was unlocked by the nurse and the Caregiver went outside to redirect Resident #2 back into building. Upon the nurse's investigation on how Resident #2 was outside it was observed Resident #2 had unlocked and opened the window in his room. A cane was observed next to the window and the screen to the window was pushed out.

Observation on 10/24/22 at 4:50 P.M. revealed residents had just finished eating dinner in the 100-hall. There were no activities occurring. At 4:55 P.M., residents had just finished eating dinner in the 200-hall. There were not activities occurring. At 5:40 P.M., there were no activities occurring on the Memory Care unit and Resident #2 was sitting in a chair in his room.

Observation on 10/25/22 at 7:35 A.M. revealed Resident #2 was seated at a dining room table feeding himself breakfast in the 200-hall dining room. At 10:00 A.M., LPN #3 opened Resident #2's bedroom window, with an opening of approximately two feet. The screen on the right lower side was pulled away from the window.

Interview on 10/25/22 at 10:30 A.M. with the ED verified screws were not placed in Resident #2's window or any other facility windows to prevent the windows from opening all the way because she felt it was too much. The ED verified no other interventions were implemented to prevent Resident #2 from exiting via a window other than the standard one-hour safety checks.

Observation on 10/25/22 at 5:30 P.M. of the Memory Care unit revealed there were not any activities occurring.

Observation on 10/26/22 at 11:20 A.M. with Caregiver #14 revealed a window in the 100-hall dining room could be opened completely. Resident #2 was sitting in a dining room chair in the 200-hall dining room. There were not any activities occurring on the Memory Care unit.

Observation on 11/01/22 at 9:15 A.M. revealed Resident #2 was sitting in a recliner in the television common area on the 200-hall unit near the window. Resident #2 appeared restless; he was fidgeting and attempting to stand from the recliner. At 11:00 A.M., Resident #2 was ambulating and pushing the meal cart into the 200-hall dining room.

Review of the facility ' s incident/accident log revealed Resident #2's exit from the facility via a window on 08/14/22 was not listed on the log.

Review of the Memory Care unit activities calendar for August 2022, September 2022, October 2022, and November 2022 revealed there were no activities scheduled after 2:00 P.M. or 3:00 P.M. all days during the months of August, September, and October 2022.

Review of the daily assignment sheet staff schedule from 09/28/22 through 09/29/22 and 10/24/22 through 10/25/22 revealed there was one Caregiver assigned to the 100-hall and one Caregiver assigned to the 200-hall within the Memory Care unit. Review of the daily assignment sheet staff schedule from 09/28/22 through 09/29/22 and 10/24/22 through 10/25/22 revealed there was one Caregiver assigned to the 100-hall and one Caregiver assigned to the 200-hall (these halls comprise the Memory Care unit).

3. Review of the medical record for Resident #3 revealed an admission date of 05/20/21 with diagnoses of anxiety and dementia. Review of the medical evaluation, dated 05/10/22, revealed Resident #3 was independent with

ambulation, oriented only to person and was disoriented in some spheres some of the time. Resident #3 was also assessed as being an elopement risk and unable to recognize danger. Resident #3 was identified as needing increased supervision due to safety awareness and due to physiological/intellectual impairment and required a special care unit (Memory Care). Resident #3 resided on the secured, memory unit.

Review of the nursing progress notes dated 02/27/22 timed 2:25 P.M. revealed Caregivers stated that as they were approaching the dining area from the TV room area, they observed Resident #3 had opened a window in the dining room and had half of her body out of the window. Caregivers stated Resident #3 was easily redirected back into the building and stated Resident #3 had been asking all staff, residents, and visitors to help her get out of here.

Review of the nursing progress notes dated 02/27/22 timed 8:56 P.M. revealed Resident #3 was observed by Caregiver on 200-hall attempting to open windows in the dining area several times and then attempting to open the door to courtyard stating that she had to get out because her daddy was in a fire.

Review of the nursing progress notes dated 03/09/22 timed 2:20 P.M. revealed Resident #3 was observed by the nurse standing at the Memory Care unit door with a co-resident attempting to punch in numbers to open the door. When the nurse asked Resident #3 and co-resident to step away from the door, Resident #3 stated they had to leave to go talk to the police and the lawyers. When the nurse attempted to redirect Resident #3 away from the door, Resident #3 demanded the nurse open the door. When the nurse told Resident #3 she was not permitted to open the door for the resident, Resident #3 went to the windows and attempted to open and was unsuccessful.

Review of the nursing progress notes dated 03/15/22 timed 3:13 A.M. revealed Resident #3 was exit seeking, opening exit doors and windows on both Memory Care hallways. Resident #3 was redirectable at times.

Review of the nursing progress notes dated 03/27/22 timed 5:45 P.M. revealed a Caregiver came to the nurse and stated Resident #3 was observed in the 200-hall

walking out of the community shower room chewing on something. The Caregiver stated that when they walked into the shower room, they observed a urine-soaked brief in the trash can with crystallized padding of brief noted on the floor. The Caregiver stated Resident #3 was wiping her mouth and the resident's face and mouth smelled of urine. The nurse placed a call to physician for instruction.

Review of the nursing progress notes dated 03/27/22 timed 6:00 P.M. revealed the nurse spoke to the on-call nurse practitioner (NP). The NP stated that she was unsure about the brief eating situation and advised the nurse to call poison control. The nurse called poison control and advised them of the situation. Poison control stated that the material in the incontinence brief was non-toxic and more of an obstruction risk, if the resident showed signs of abnormal bowel habits to contact physician for further instruction.

Review of the nursing progress notes dated 07/13/22 timed 4:07 P.M. revealed the Memory Care Coordinator came to the nurse and stated Resident #3 was observed at the window near the Gazebo exit with the window open and fiddling with the screen in attempt to get it to open. The Memory Care Coordinator stated that when she asked the resident what she was doing the resident stated her husband and his friend were outside hiking and sent her in to get ice cream for them and that she could not get out because they locked her in. The Memory Care Coordinator stated she was able to redirect Resident #3 away from the window and shut and locked the window.

Review of the nursing progress notes dated 07/13/22 timed 5:21 P.M. revealed a Caregiver came to the nurse and stated that when he came back from the kitchen with the meal cart, Resident #3 was observed at one of the windows in the dining room. The Caregiver stated when he approached Resident #3 to have her sit down for dinner, Resident #3 had her right leg out the window and her upper body was on the windowsill. The Caregiver stated the window had no screen prior to Resident #3 opening the window. The Caregiver was unable to understand what Resident #3 was saying to him as he was assisting her back into building.

Review of the nursing progress notes dated 07/13/22 timed 8:22 P.M. revealed a Caregiver came to the nurse and stated that when he went into Resident #3's room to gather clothes for the resident to put on after her shower, he noticed the screen to the window was pulled out of window and lying up against the resident's bed.

Review of the psychiatric nurse practitioner's progress note dated 07/20/22 revealed the psychiatric nurse practitioner spoke with the nursing staff regarding Resident #3 and they had concerns regarding the resident's exit seeking behaviors and verbal aggression towards others. Resident #3 stated she enjoyed walking in the courtyard. Resident #3 was alert and oriented to person and age and disoriented to time and place.

Review of the nursing progress notes dated 07/26/22 timed 5:52 P.M. revealed as the nurse was walking out of nursing office, Resident #3 was observed standing at the window of the porch area of 200 hall. Resident #3 had unlocked and pushed the window up and was attempting to open the screen. The nurse told Resident #3 to get away from the window and Resident stated, do you know how to open the screen so I can get out? The nurse told Resident #3 the screen could not be opened and closed and locked the window. As the nurse was charting, a Caregiver came to the nurse and stated she observed Resident #3 opening the window in dining room on the 200-hall and observed the resident getting ready to go out the window. The Caregiver stated she redirected Resident #3 from window. Again, while the nurse was charting, the nurse heard a co-resident yelling, get out the window, get out the window. The nurse and Caregiver went running down the hall. The co-resident kept stating Resident #3 asked him how she could get out the window.

Review of the nursing progress notes dated 07/29/22 timed 5:04 P.M. revealed Resident #3 was noted by staff ambulating in courtyard and all the courtyard doors were locked. Upon speaking to Resident #3, the resident stated that she climbed through a window. Upon inspection, Room #126's window was open (not Resident #3's room).

Review of the nursing progress notes dated 07/31/22 timed 6:17 P.M. revealed Resident #3 had been extremely exit seeking during the shift. The Caregiver came to the nurse and asked the nurse to follow her. When this nurse and Caregiver went into empty Room #114, the Caregiver stated she observed Resident #3 and a male co-resident in room with the window open. The Caregiver stated that when she walked toward the residents, she observed Resident #3 ripping the screen out of the frame of the window.

Review of the nursing progress notes dated 08/03/22 timed 5:43 P.M. revealed Resident #3 had been observed multiple times through the shift by the nurse and Caregiver on the 100 and 200-halls attempting to open main door to unit and going into other resident rooms, dining room and TV rooms opening windows and attempting to open the screens to get out.

Review of the nursing progress notes dated 09/11/22 timed 2:54 P.M. revealed Resident #3 was administered as needed Vistaril (used as a sedative to treat anxiety). Resident #3 believed she needed to get out because my daddy is dying, and he doesn't have long to live, and I want to see my daddy. Resident #3 had been observed by the Caregiver attempting to open windows in the 200-hall dining area.

Observation on 10/24/22 at 4:50 P.M. revealed residents had just finished eating dinner in the 100-hall. There were not any activities occurring. At 4:55 P.M., residents had just finished eating dinner in the 200-hall. There were not any activities occurring. At 5:40 P.M., there were not any activities occurring on the Memory Care unit.

Interview on 10/25/22 at 10:30 A.M. with the ED verified screws were not placed in the windows to prevent windows from opening all the way because she felt it was too much. The ED verified no interventions had been implemented for Resident #3 to ensure her safety other than the standard one-hour safety checks.

Observation on 10/25/22 at 5:30 P.M. of the Memory Care unit revealed there were not any activities occurring. Resident #3 was sitting in the 100-hall dining room.

Observation on 10/26/22 at 11:20 A.M. with Caregiver #14 revealed a window in the 100-hall dining room could be opened completely. Resident #3 was sitting in the TV room in the common area on the 100-hall. There were not any barriers installed on Resident #3's bedroom windows to prevent the windows from opening completely. There were not any activities occurring on the Memory care unit to keep the residents engaged and prevent exit seeking.

Review of the facility's incident/accident log revealed Resident #3's attempts to exit through windows were not listed on the log for 02/27/22, 03/27/22, 07/13/22 and 07/29/22.

Review of the Memory Care unit activities calendar for August 2022, September 2022, October 2022, and November 2022 revealed there were no activities scheduled after 2:00 P.M. or 3:00 P.M. all days during the months of August, September, and October 2022.

Review of the menu times revealed the Memory Care unit was served breakfast at 7:00 A.M., lunch at 11:00 A.M. and dinner at 4:00 P.M.

Review of the daily assignment sheet staff schedule from 09/28/22 through 09/29/22 and 10/24/22 through 10/25/22 revealed there was one Caregiver assigned to the 100-hall and one Caregiver assigned to the 200-hall (these halls comprised the Memory Care unit).

4. Review of the closed medical record for Resident #4 revealed an admission date of 07/09/21 and discharge date of 09/21/22. Resident #4 had diagnoses of Alzheimer's disease, dementia, brief psychotic disorder, acute psychosis, and psychophysiological insomnia. Review of the physician medical evaluation, dated 08/15/22, revealed Resident #4 was independent with ambulation, oriented to person only, was disoriented in all spheres all the time and wandered. Resident #4 was assessed as not being able to recognize danger. Resident #4 was identified as needing increased supervision due to safety awareness and needed a special care unit (Memory Care).

Review of the nursing progress notes dated 04/07/22 timed 2:55 P.M. revealed Resident #4 was observed eating puzzle pieces from the activity room. The Activity Coordinator came and got the nurse, and the nurse was able to get resident to spit out the puzzle pieces. Resident #4 was redirected.

Review of the nursing progress notes dated 05/27/22 timed 10:04 A.M. revealed at approximately 6:50 A.M., the third shift Caregiver came to the nurse and stated Resident #4 consumed almost a full jar of Caregiver's [brand name] body cream. The nurse informed the manger on duty and contacted the poison control center. Per poison control, the type of body cream Resident #4 consumed was not harmful and if anything would act as a laxative. The physician ' s office and power of attorney were notified. Due to the consumption of body cream, the nurse used nursing judgement and held scheduled laxatives.

Review of the facility's incident/accident log revealed Resident #4's incident of consuming almost a full jar of body cream on 05/27/22 was not listed on the log.

Interview on 10/26/22 at 12:35 P.M. with the ED verified Resident #4 consumed body cream and the intervention was to call poison control. There were no interventions initiated to prevent another occurrence.