Cherry Blossom Senior Living

Based on fire drill record review and staff interview, the facility failed to evacuate residents in at least two fire drills a year on each shift. This had the potential to affect all of the residents residing in the facility. The facility census was 88 residents.

Findings include:

Review of the fire drill records dated June 2023 to June 2024 revealed there were two fire drills conducted which included resident evacuation for the residents who were capable of self-evacuation: a drill on night shift on 08/29/23 at 5:30 A.M., a drill on day shift on 04/29/24 at 3:00 P.M.

Interview on 07/03/24 at 2:26 P.M with Maintenance Director (MD) #191confirmed the facility had a day shift which ran from 7:00 A.M. to 7:00 P.M. and a night shift from 7:00 P.M. to 7:00 A.M. MD #191 confirmed the facility did not conduct fire drills which included evacuation of residents for two fire drill per year on each shift as required.

Interview on 07/03/24 at 2:50 P.M. with the Administrator confirmed the facility had not conducted fire drills which included evacuation of residents for two fire drills per year on each shift as required.

Based on observation, record review, review of video camera footage, review of National Weather Service information, review of the facility Neglect policy, review of a police report and interviews with family, staff, and the county coroner, the facility failed to provide a safe environment and adequate assessment and supervision to prevent Resident #1, who had a diagnosis of Alzheimer's dementia and significant mental health history, from exiting the facility without staff knowledge. This resulted in Real and Present Danger, actual harm and death beginning on 01/20/24 at 1:22 A.M. when Resident #1 left the facility without staff knowledge and was subsequently found on 01/20/24 at 8:55 A.M. outside, on the side of the building by another resident's window at 8:55 A.M. Licensed Practical Nurse (LPN) #149 found Resident #1 deceased with his face down in the snow and his forehead on cement with blood surrounding the area. On the morning of 01/20/24, the outside temperatures were between six and 10 degrees Fahrenheit (F) with wind chills up to seven below zero and snow accumulation of two inches. Preliminary autopsy results revealed Resident #1 died from hypothermia and blunt force injuries with small hemorrhages and contusions on the scalp. This affected one (#1) resident of seven residents reviewed for elopement. The facility identified six residents (Resident #5, #6, #32, #39, #49, and #51) in the assisted living who were assessed at being at a safety risk for elopement. The facility census was 76. On 01/23/24 at 2:26 P.M., the Executive Director (ED), Director of Operations #140, and Registered Nurse (RN) Consultant #200 were notified Real and Present Danger began on 01/20/24 at 1:22 A.M. when Resident #1 left the facility without staff awareness and was subsequently discovered approximately seven hours and thirty minutes later by facility staff, frozen and deceased. On 01/20/24 from 12:22 A.M. to 1:22 A.M., Resident #1 was seen walking on facility video camera in the assisted living (AL) AL hallway and sitting in one of the lounge areas for an hour. There were no staff observed in the facility's video surveillance cameras during this time. On 01/20/24 at 1:22 A.M., Resident #1 was seen on video camera exiting an egress door outside the lounge area wearing a hooded sweatshirt. The egress door did not have any type of sensor alarm to alert staff the resident had left the facility, and the door locked after it closed. The egress door did not have any signage alerting residents the door locked and that they would not be able to re-enter without the use of a key fab. Resident #1 did not have a key fob or nursing call pendant on his person at the time he exited the facility. Resident #1 was not checked on by staff on 01/20/24 from 12:22 A.M. until 8:45 A.M. The resident was found by LPN #149 at 8:55 A.M. outside, on the side of the building by another resident's window deceased with his face down in the snow and his forehead on the cement with blood surrounding the area. The Real and Present Danger was abated on 01/26/24, when the facility implemented the following corrective actions: On 01/20/24, the ED and Wellness Director (WD) #90 began all staff education in the AL facility regarding inclement weather and resident safety, frequent checks on residents including initiating one-hour checks and 15-minute door checks from 7:00 P.M. to 7:00 A.M. All staff were educated by 01/25/24. Any staff not educated by 01/25/24 were unable to work until the education was completed. From 01/20/24 to 01/24/24, one-hour safety checks were completed on all 54 AL residents. On 01/20/24 at 6:00 P.M., all doors were inspected by the ED, Maintenance Director #100, and Corporate Maintenance #205. A standard of practice (SOP) was created that all egress doors were checked for proper functioning each shift with documentation of the check. The ED would monitor compliance with the new standard of practice. On 01/20/24 at 7:30 P.M., all doors in the AL were monitored from 7:00 P.M. to 7:00 A.M every 15 minutes. The ED and/or Director of Operations #140 reviewed door check documentation the next business day. This was completed by the end of the day on 01/24/24 because all (resident) risk assessments were completed. On 01/20/24, the ED and Director of Operations #140 interviewed staff related to an investigation of Resident #1's death. All staff on duty the evening of 01/19/24 and the morning of 01/20/24 were interviewed. The interviews revealed Resident #1 did not exhibit any wandering or exit-seeking behavior and had not been identified by staff to be at a safety risk. On 01/23/24, WD #90 was suspended related to unsatisfactory work performance. On 01/24/24, WD #90 resigned from employment at the facility. On 01/23/24, the ED and Director of Operations #140 revised the safety check SOP and began educating employees on 01/24/24. All staff were educated by 01/25/24. Any staff not educated by 01/25/24 would not be able to work until the education was completed. On 01/24/24, Interim Wellness Director (IWD) #215 started at the facility and was trained in properly assessing resident safety issues. The facility implemented a plan so that when a new WD was hired, the new WD would be trained in assessing resident safety issues. On 01/24/24, all residents in the AL had a new risk assessment completed and safety needs addressed for those identified on the risk assessments. Six residents, Residents #5, #6, #32, #39, #49, and #51 were identified to be at safety risk for potential elopement and appropriate safety checks were added to the resident's care plans. Risk assessments would continue with the initial, 30-days after initial, six months thereafter and as needed for change of condition. On 01/24/24, Maintenance Director #100 installed door sensors on all six egress doors. Staff pagers would now be alerted when the egress door was opened. All staff were trained in the functionality of the door sensors and alerting to the pagers and their responsibility to respond. A plan for Maintenance Director #100 to audit door sensors monthly and document completion in TELS program (a program to create safer environments and increase Life Safety compliance) was implemented. Director of Operations #140 revised the SOP for the system and training was added to the orientation program. The ED/designee would monitor staff compliance once daily for two weeks, then two times a week for two weeks, and then spot check thereafter. On 01/24/24, Maintenance Director #100 posted temporary signage on each egress door in the AL that the door locked once exited. On 01/24/24, the ED in-serviced all AL residents on the new sensor system and alerting staff when egress doors were opened, proper usage of doors/entering front-main door, locking of the six egress doors and the ability to use a key fob or key to re-enter if exiting a locking door. Any resident who was unable to attend the meetings on 01/24/24 would be trained one-on-one by the ED. Beginning on 01/24/24, Director of Operations #140 created an education tool for new residents on usage/securing of the doors and re-entry. This education tool would become part of the move-in paperwork for each resident. On 01/26/24, observations of the six egress doors revealed each door had a sensor that alerted nursing staff when opened. There was signage posted inside and outside the six egress doors that stated This door will lock behind you with a stop sign. On 01/26/24, review of the medical records for Residents #39 and #49 revealed they were assessed on 01/24/24 and identified to be at safety risks and safety checks were addressed on the resident's care plan. On 01/26/24, interviews with the staff including Nurse Aide #106, Nurse Aide #113, and Licensed Practical Nurse (LPN) #221 verified awareness of the six egress door sensors and documentation. The staff verified they were aware of the six residents at safety risk who required at least every two-hour checks. On 01/26/24, observations and interviews with four assisted living residents (#31, #39, #49 and #51) verified they were aware a key fob was required to enter the facility when exiting one of the six egress doors. Although the Real and Present Danger was abated on 01/26/24, the violation continues as the facility is in the process of implementing their corrective action plan and monitoring for on-going compliance. Findings include: Closed record review revealed Resident #1 was admitted to the facility on 11/30/23 with diagnoses included Alzheimer's dementia, schizophrenia, and anxiety. Prior to admission, the resident lived alone on a farm, was found underneath his deck, and thought someone was out to shoot him. The resident was admitted to a psychiatric facility on 11/07/23 and diagnosed with schizophrenia spectrum, mood disorder, and probable major neurocognitive disorder due to Alzheimer's disease with behavioral disturbance. The resident's most recent medications included the psychoactive medications Haldol two milligrams (mg) three times per day and Seroquel 50 mg at bedtime, the anti-depressant Trazadone at 100 mg daily, and medications for dementia including Galantamine at 12 mg and Memantine HCL 10 mg both twice daily. Review of the psychiatric facility's continuity of care form, dated 11/30/23 revealed the recommendation was for Resident #1 to discharge to AL with no mention of the resident needing a secured facility or medical equipment. In the history and physical, it was noted Resident #1 was not able to understand the risk/benefits of accepting and/or refusing treatment and was not able to utilize a rational thought process to appropriately compare available options. Review of the Personal Service EvaluationBased on observation, record review, review of video camera footage, review of National Weather Service information, review of the facility Neglect policy, review of a police report and interviews with family, staff, and the county coroner, the facility failed to provide a safe environment and adequate assessment and supervision to prevent Resident #1, who had a diagnosis of Alzheimer's dementia and significant mental health history, from exiting the facility without staff knowledge. This resulted in Real and Present Danger, actual harm and death beginning on 01/20/24 at 1:22 A.M. when Resident #1 left the facility without staff knowledge and was subsequently found on 01/20/24 at 8:55 A.M. outside, on the side of the building by another resident's window at 8:55 A.M. Licensed Practical Nurse (LPN) #149 found Resident #1 deceased with his face down in the snow and his forehead on cement with blood surrounding the area. On the morning of 01/20/24, the outside temperatures were between six and 10 degrees Fahrenheit (F) with wind chills up to seven below zero and snow accumulation of two inches. Preliminary autopsy results revealed Resident #1 died from hypothermia and blunt force injuries with small hemorrhages and contusions on the scalp. This affected one (#1) resident of seven residents reviewed for elopement. The facility identified six residents (Resident #5, #6, #32, #39, #49, and #51) in the assisted living who were assessed at being at a safety risk for elopement. The facility census was 76.

On 01/23/24 at 2:26 P.M., the Executive Director (ED), Director of Operations #140, and Registered Nurse (RN) Consultant #200 were notified Real and Present Danger began on 01/20/24 at 1:22 A.M. when Resident #1 left the facility without staff awareness and was subsequently discovered approximately seven hours and thirty minutes later by facility staff, frozen and deceased. On 01/20/24 from 12:22 A.M. to 1:22 A.M., Resident #1 was seen walking on facility video camera in the assisted living (AL) AL hallway and sitting in one of the lounge areas for an hour. There were no staff observed in the facility's video surveillance cameras during this time. On 01/20/24 at 1:22 A.M., Resident #1 was seen on video camera exiting an egress door outside the lounge area wearing a hooded sweatshirt. The egress door did not have any type of sensor alarm to alert staff the resident had left the facility, and the door locked after it closed. The egress door did not have any signage alerting residents the door locked and that they would not be able to re-enter without the use of a key fab. Resident #1 did not have a key fob or nursing call pendant on his person at the time he exited the facility. Resident #1 was not checked on by staff on 01/20/24 from 12:22 A.M. until 8:45 A.M. The resident was found by LPN #149 at 8:55 A.M. outside, on the side of the building by another resident's window deceased with his face down in the snow and his forehead on the cement with blood surrounding the area.

The Real and Present Danger was abated on 01/26/24, when the facility implemented the following corrective actions:

On 01/20/24, the ED and Wellness Director (WD) #90 began all staff education in the AL facility regarding inclement weather and resident safety, frequent checks on residents including initiating one-hour checks and 15-minute door checks from 7:00 P.M. to 7:00 A.M. All staff were educated by 01/25/24. Any staff not educated by 01/25/24 were unable to work until the education was completed.

From 01/20/24 to 01/24/24, one-hour safety checks were completed on all 54 AL residents.

On 01/20/24 at 6:00 P.M., all doors were inspected by the ED, Maintenance Director #100, and Corporate Maintenance #205. A standard of practice (SOP) was created that all egress doors were checked for proper functioning each shift with documentation of the check. The ED would monitor compliance with the new standard of practice.

On 01/20/24 at 7:30 P.M., all doors in the AL were monitored from 7:00 P.M. to 7:00 A.M every 15 minutes. The ED and/or Director of Operations #140 reviewed door check documentation the next business day. This was completed by the end of the day on 01/24/24 because all (resident) risk assessments were completed.

On 01/20/24, the ED and Director of Operations #140 interviewed staff related to an investigation of Resident #1's death. All staff on duty the evening of 01/19/24 and the morning of 01/20/24 were interviewed. The interviews revealed Resident #1 did not exhibit any wandering or exit-seeking behavior and had not been identified by staff to be at a safety risk.

On 01/23/24, WD #90 was suspended related to unsatisfactory work performance. On 01/24/24, WD #90 resigned from employment at the facility.

On 01/23/24, the ED and Director of Operations #140 revised the safety check SOP and began educating employees on 01/24/24. All staff were educated by 01/25/24. Any staff not educated by 01/25/24 would not be able to work until the education was completed.

On 01/24/24, Interim Wellness Director (IWD) #215 started at the facility and was trained in properly assessing resident safety issues. The facility implemented a plan so that when a new WD was hired, the new WD would be trained in assessing resident safety issues.

On 01/24/24, all residents in the AL had a new risk assessment completed and safety needs addressed for those identified on the risk assessments. Six residents, Residents #5, #6, #32, #39, #49, and #51 were identified to be at safety risk for potential elopement and appropriate safety checks were added to the resident's care plans. Risk assessments would continue with the initial, 30-days after initial, six months thereafter and as needed for change of condition.

On 01/24/24, Maintenance Director #100 installed door sensors on all six egress doors. Staff pagers would now be alerted when the egress door was opened. All staff were trained in the functionality of the door sensors and alerting to the pagers and their responsibility to respond. A plan for Maintenance Director #100 to audit door sensors monthly and document completion in TELS program (a program to create safer environments and increase Life Safety compliance) was implemented. Director of Operations #140 revised the SOP for the system and training was added to the orientation program. The ED/designee would monitor staff compliance once daily for two weeks, then two times a week for two weeks, and then spot check thereafter.

On 01/24/24, Maintenance Director #100 posted temporary signage on each egress door in the AL that the door locked once exited.

On 01/24/24, the ED in-serviced all AL residents on the new sensor system and alerting staff when egress doors were opened, proper usage of doors/entering front-main door, locking of the six egress doors and the ability to use a key fob or key to re-enter if exiting a locking door. Any resident who was unable to attend the meetings on 01/24/24 would be trained one-on-one by the ED.

Beginning on 01/24/24, Director of Operations #140 created an education tool for new residents on usage/securing of the doors and re-entry. This education tool would become part of the move-in paperwork for each resident.

On 01/26/24, observations of the six egress doors revealed each door had a sensor that alerted nursing staff when opened. There was signage posted inside and outside the six egress doors that stated This door will lock behind you with a stop sign.

On 01/26/24, review of the medical records for Residents #39 and #49 revealed they were assessed on 01/24/24 and identified to be at safety risks and safety checks were addressed on the resident's care plan.

On 01/26/24, interviews with the staff including Nurse Aide #106, Nurse Aide #113, and Licensed Practical Nurse (LPN) #221 verified awareness of the six egress door sensors and documentation. The staff verified they were aware of the six residents at safety risk who required at least every two-hour checks.

On 01/26/24, observations and interviews with four assisted living residents (#31, #39, #49 and #51) verified they were aware a key fob was required to enter the facility when exiting one of the six egress doors.

Although the Real and Present Danger was abated on 01/26/24, the violation continues as the facility is in the process of implementing their corrective action plan and monitoring for on-going compliance.

Findings include:

Closed record review revealed Resident #1 was admitted to the facility on 11/30/23 with diagnoses included Alzheimer's dementia, schizophrenia, and anxiety. Prior to admission, the resident lived alone on a farm, was found underneath his deck, and thought someone was out to shoot him. The resident was admitted to a psychiatric facility on 11/07/23 and diagnosed with schizophrenia spectrum, mood disorder, and probable major neurocognitive disorder due to Alzheimer's disease with behavioral disturbance. The resident's most recent medications included the psychoactive medications Haldol two milligrams (mg) three times per day and Seroquel 50 mg at bedtime, the anti-depressant Trazadone at 100 mg daily, and medications for dementia including Galantamine at 12 mg and Memantine HCL 10 mg both twice daily.

Review of the psychiatric facility's continuity of care form, dated 11/30/23 revealed the recommendation was for Resident #1 to discharge to AL with no mention of the resident needing a secured facility or medical equipment. In the history and physical, it was noted Resident #1 was not able to understand the risk/benefits of accepting and/or refusing treatment and was not able to utilize a rational thought process to appropriately compare available options.

Review of the Personal Service Evaluation

Based on observation, record review, and staff interview, the facility failed to ensure Resident #55 was well groomed. The facility also failed to ensure Resident #38, #55, and #91 were bathed once to twice a week. This affected three (Resident #38, #55, and #91) of three residents reviewed for bathing and grooming. Facility census was 89.

Findings include

1. Review of medical record revealed Resident #55 was admitted on 01/03/23 with diagnoses that included dementia and Parkinson's disease. The admission assessment dated 01/03/23 revealed Resident #55 required assistance with showers once to twice a week. The Individual Service Plan dated 01/03/23 revealed Resident #55 required assistance with bathing on Monday and Thursday. The plan also revealed staff were to assist the resident with morning and evening care which included oral care, nail care, and skin care.

Review of the bathing documentation revealed Resident #55 was showered and had hair washed on 01/04/23, 01/09/23, 01/26/23, and 02/03/23. The documentation revealed no evidence of the resident being shaved or nail care done.

Observation on 02/06/23 at 11:35 A.M. revealed Resident #55's face was unshaven. The resident had long, jagged fingernails with a dark substance under the nails. Observation on 02/07/23 at 8:13 A.M. revealed Resident #55 was still unshaven and had long, jagged fingernails with a dark substance under the nails. Interview at this time with Personal Care Assistant (PCA) #103 verified Resident #55 was not shaven and had long, jagged, dirty fingernails.

Interview on 02/07/23 at 10:22 A.M. Executive Director verified the documentation revealed Resident #55 was not bathed, shaved and had nail care provided at least weekly.

2. Review of medical record revealed Resident #38 was admitted on 08/31/22 with diagnoses that included vascular dementia, hypertension, type 2 diabetes, and spinal stenosis. The nursing and services evaluation dated 12/09/22 revealed Resident #38 required standby assistance with bathing once to twice a week.

Review of the bathing documentation revealed Resident #38 was showered and shaved on 12/09/22. Further documentation revealed no evidence of bathing until 01/06/23 and then not again to 01/23/23. There was no documentation of the resident being shaved from 12/09/22 until 02/02/23.

Interview on 02/07/23 at 10:22 A.M. Executive Director verified the documentation revealed Resident #38 was not bathed, shaved, and had nail care provided at least weekly.

3. Review of medical record revealed Resident #91 was admitted on 06/16/22 and discharged on 01/31/23. Resident #91 had diagnoses that included dementia, irritable bowel syndrome, anxiety, and overactive bladder. The nursing and services evaluation dated 12/20/22 revealed Resident #91 required standby assist with bathing once to twice a week.

Review of the bathing documentation revealed Resident #91 received a shower with nail care on 01/06/23. Further documentation revealed Resident #91 was not bathed again until 01/18/23. Nail care was not marked as completed on 01/18/23.

Interview on 02/07/23 at 10:22 A.M. Executive Director verified the documentation revealed Resident #91 was not bathed and had nail care provided at least weekly.

This violation represents non-compliance investigated under Complaint Number OH00139330.

Based on observation, medical record review, interview, and policy review, the facility failed to administer medication as ordered to Resident #35. This affected one (Resident #35) out of three residents observed for medication administration. The facility census was 89.

Findings include:

Review of the medical record revealed Resident #35 was admitted on 01/22/23 with diagnoses that included Parkinson's disease, diabetes mellitus, congestive heart failure, and chronic kidney disease.

Review of a physician order dated 01/23/23 revealed Resident #35 was ordered Midorine (for hypotension) five milligram (mg) one and a half tablet.

Observation of medication administration on 02/06/23 at 8:18 A.M. revealed Licensed Practical Nurse (LPN) #106 administered one five mg tablet to Resident #35. This surveyor interviewed LPN #106 about the physician order reading one and a half tablet. LPN #106 stated the order said five milligrams and that was what one tablet was.

Interview on 02/08/23 at 3:47 P.M. Executive Director/LPN #122 verified LPN #106 had administered the wrong dosage of medication to Resident #35. The resident should have received 7.5 mg of Midorine instead of five mg.

Review of the medication administration policy dated 06/14 revealed any person administering medications was responsible for verifying the medication was the right medication, dose, route, time, and patient.

This violation represents non-compliance investigated under Complaint Number OH00139330.

Based on record review and staff interview, the facility failed to ensure Resident #91 was ordered an antibiotic in a timely manner. This affected one (Resident #91) that was reviewed for a change in condition. Facility census was 89.

Findings include:

Review of medical record revealed Resident #91 was admitted on 06/16/22 and discharged on 01/31/23. Resident #91 had diagnoses that included dementia, irritable bowel syndrome, anxiety, and overactive bladder.

Review of nurse note dated 12/23/22 at 10:48 P.M. revealed Resident #91 was in quarantine due to COVID-19. The resident had a temperature of 100.1 degrees Fahrenheit (F).

A nurse note dated 12/24/22 at 3:51 P.M. revealed Resident #91 had a temperature of 99.3 degrees F and cough.

A nurse note dated 12/27/22 at 3:44 P.M. revealed Resident #91's oxygen saturation was 75-percent and oxygen at two liters was administered via nasal cannula. A nurse note dated 12/27/22 at 3:48 P.M. revealed an order was received for a STAT chest x-ray.

A nurse note dated 12/28/22 at 3:58 P.M. revealed Resident #91 continued to be in isolation due to COVID-19. The residents oxygen saturation had been 84-percent that morning.

A nurse note dated 12/28/22 at 10:15 P.M. revealed a chest x-ray was done at 10:00 A.M.

Results of the x-ray dated 12/28/22 at 10:33 A.M. revealed Resident #91 had slight right upper lobe infiltrate.

Review of physician order dated 12/30/22 revealed Resident #91 was ordered Levofloxacin (antibiotic) 750 milligram for six days due to pneumonia.

Interview on 02/07/23 at 10:27 A.M. the Wellness Director verified there had been a delay in Resident #91 being ordered an antibiotic after the chest x-ray was received probably due to the holidays.

Interview on 02/07/23 at 1:15 P.M. the Executive Director verified Resident #91 saw a facility certified nurse practitioner that would have been available during the holiday season.

This violation represents non-compliance investigated under Complaint Number OH00139330.

Based on observation, medical record review, staff interview, review of facility video camera footage, review of the weather information at https://www.timeanddate.com/weather/usa/columbus, and review of the facility Elopement policy and procedure, the facility failed to maintain a safe environment and provide adequate supervision to prevent Resident #38, who was cognitively impaired and had exit seeking behaviors, from eloping from a secured memory care unit. This resulted in Real and Present Danger and the potential for serious life-threatening harm, injuries and/or death, when Resident #38 eloped from the secured memory care unit on 12/06/22 at 11:13 P.M. by exiting to the outside of the facility through a locked and alarmed door. Resident #38 was found between 0.1 to 0.2 miles from the facility along a busy main road, attempting to enter another building. The temperature outside on 12/06/22 at 11:25 P.M. was 51 degrees Fahrenheit (F) with light rain and fog. This affected one resident (#38) of three residents reviewed for wandering and elopement. The facility census was 89.

On 02/07/23 at 2:28 P.M. Executive Director (ED) #122 was notified Real and Present Danger began on 12/06/22 at 11:13 P.M. when Resident #38 was observed on video footage exiting the facility. A personal care assistant, (PCA) #100 was observed going to the exit door at 11:14 P.M., pulling the door closed and resetting the alarm. PCA #100 looked through the glass door and then walked away. PCA #100 was observed again on 12/06/22 at 11:16 P.M. looking out the glass door. At no time was PCA #100 observed stepping outside the door to look around. At 11:24 P.M. PCA #100 was seen on video checking resident rooms. At 11:28 P.M. PCA #100 stepped out on the concrete porch where Resident #38 had exited. Video surveillance revealed on 12/06/22 at 11:50 P.M. Licensed Practical Nurse (LPN) #105, LPN #115, and PCA #101 were observed exiting the facility to look outside. Resident #38 was found between 0.1 to 0.2 miles away from the facility along a busy road. Resident #38 was observed returned to the secure memory care unit on 12/07/22 at 12:27 A.M.

The Real and Present Danger was abated on 02/09/23 when the facility implemented the following corrective actions.

On 12/07/22- Upon Resident #38 returning to the facility a full body assessment including vital signs were completed. Resident #38 was then placed on 30-minute checks which he continued to be on with no stop date.

On 12/07/22 Wellness Director #107 and Executive Director#122 provided verbal education to Patient Care Assistants (PCA) staff and nurses to respond to all door alarms immediately.

Beginning 02/08/23 a check off sheet would be provided (for second shift) staff to document the 30-minute checks were being completed for Resident #38. The Wellness Director #107 will check these daily for one week starting 02/10/23 and then weekly on Fridays.

On 02/08/23- The elopement policy was reviewed by the Executive Director #122, Wellness Director #107, and Regional Vice President of Operations. No changes were needed to the elopement policy at that time.

Beginning 02/08/23 Wellness Director #107, Executive Director #122 and Maintenance Director #200 began staff education one-on-one and in small groups. The education included door alarms, and the elopement policy. If staff had not been educated by the morning of 02/13/23 they would be educated by phone. A plan for all staff education to be completed by the end of business day on 02/13/23. Executive Director #122 and Wellness Director #107 also planned to hold Elopement drills every shift starting on 02/09/23 through 02/10/23 at the following times:

02/09/23-10:00 A.M., 3:45 P.M., 11:15 P.M.

02/10/23-2:00 P.M., 7:15 P.M., 11:45 P.M.

Effective 02/08/23 at 9:00 A.M. the facility implemented a plan for Executive Director #122 to conduct monthly elopement drills on varying shifts (dates/shifts provided). The drills were scheduled through December 2023 at which time they would be re-evaluated for continued need. Following each elopement drill, the Executive Director #122 will review with and debrief the staff participating in the elopement drills to ensure the policy was followed and the staff response time is appropriate.

Beginning 02/08/23 at 10:00 A.M. Wellness Director #107 placed a list of resident's at risk for elopement in a binder behind the nurse's station that all staff had access to. Wellness Director #107 will update the list as needed after doing the assessments and identifying residents who were at risk of elopement. Pictures of residents were currently uploaded to ALIS (electronic record) and able to be printed in an emergency. Wellness Director #107 will identify the residents at risk for elopement as identified in the assessment and verbal reports from PCA and nursing staff.

On 02/08/23 at 1:20 P.M. the surveyor was provided a list of residents who were at risk for wandering/elopement. The list included Resident #33, #36, #38, and #46.

On 02/08/23 at 1:40 P.M. interviews with Personal Care Assistant (PCA) #138 and LPN #106 revealed both staff had received facility training about responding to door alarms and what to do if there was an elopement.

On 02/08/23 at 1:42 P.M. interview with Maintenance Director #200 revealed he had the door alarm and elopement policies and was educating staff about the policies and procedures.

On 02/08/23 at 2:17 P.M. interview with Executive Director #122 verified the list of residents who were at risk for wandering/elopement had just been placed at the nurse's station and the staff education began on 02/08/23 at 3:00 P.M. by Wellness Director #107 related to where to locate the list. The Executive Director also stated Maintenance Director #200 was assisting with the training about the door alarms, but Executive Director #122 and Wellness Director #107 would also be doing education about elopement.

Beginning 02/09/23 All residents would have a preadmission assessment completed by the Wellness Director #107 or Executive Director #122. Additional assessments would be completed upon readmission, every six months and as needed (as evidenced by a change in the resident's behavior or change in condition). Wellness Director #107 would maintain information related to who required reassessment by reading nursing notes daily and being present on the unit often to observe resident's behavior. The assessment addresses if there is a history of wandering and a Brief Interview for Mental Status (BIMS) assessment which would assess the resident's cognitive status.

Beginning 02/09/23 a plan for all 27 residents residing on the memory care unit to be reassessed by Wellness Director #107 for wandering and risk of elopement to help ensure no other residents are at risk for wandering or elopement. The facility planned for the reassessments to be completed by 02/15/23.

On 02/09/23 at 9:30 A.M. Wellness Director #107/designee began a Daily Shift Huddles with the nurses and PCA's on the memory care unit to address changes in resident's behaviors with staff.

Beginning on 02/09/23 a plan for new staff to be trained on elopement procedures by Maintenance Director #200 prior to starting on the floor during general orientation was implemented.

Beginning 02/10/23 a plan for Wellness Director #107 to check care tracking for documentation daily for one week starting and then check weekly on Fridays indefinitely.

Although the Real and Present Danger was abated on 02/09 /23, the violation remains as the facility was in the process of monitoring and implementing their corrective action.

Findings include:

Review of the medical record revealed Resident #38 was admitted to the facility on 08/31/22 with diagnoses that included vascular dementia, hypertension, type 2 diabetes, and spinal stenosis.

Review of the admission nursing and services evaluation, dated 09/01/22 revealed Resident #38 had severe orientation deficits with history of poor judgement creating potential for unsafe behaviors to self or others. The resident had difficulty communicating and needed assistance with communication. Resident #38 was independent with mobility and required no assistive devices. The evaluation revealed the resident did not wander. Resident #38 required safety checks 12 times a day. A Brief Interview for Mental Status (BIMS) assessment, dated 09/01/22 (to evaluate aspects of cognition in elderly patients), revealed Resident #38 scored a two which indicated severe cognitive impairment.

A nurse's note dated 10/02/22 at 7:37 P.M. revealed Resident #38 had been wandering into other resident's rooms. When redirected, the resident would refuse to leave and yelled at other residents and staff.

A nurse's note dated 10/04/22 at 1:44 P.M. revealed Resident #38 was found in a female resident's room and attempted to hit the female resident.

Review of the video camera footage, dated 12/06/22 revealed at 11:12 P.M. Resident #38 was at the exit door from the secure memory unit to the outside. At 11:13 P.M. Resident #38 pushed the door open and exited the building. At 11:14 P.M. PCA #100 was observed going to the exit door and pulling the door towards her and turning the alarm off. PCA #100 looked out the door but did not step outside the door. At 11:16 P.M. PCA #100 was observed going back to the exit door and looking out, but they did not open the door or step out onto the porch area.

A nurse's note dated 12/07/22 at 12:56 A.M. revealed Resident #38's wife was notified the resident had gotten out of the secured unit. The resident's wife requested the certified nurse practitioner be notified in the morning to request medication for sleeping since the resident continued not to sleep most nights.

A nurse's note dated 12/07/22 and timed 3:10 A.M. revealed LPN #105 had given Resident #38 a snack before leaving the unit to get report. The nurse later received a page from memory care asking the whereabouts of Resident #38. This nurse requested a room-to-room and patio search. This nurse and off-going staff (LPN #115 and PCA #101) went outside to check for Resident #38. They did not see the resident at this time. Since it was raining, LPN #105 went back outside and continued to search by driving around. A person (identified to be Resident #38) was noticed trying to open the door to a building located off the facility property. LPN #105 called Resident #38's name and he came to the nurse. The resident's hair and hands were wet and cold. The resident had a jacket on top of his pajamas and was wearing shoes. The resident's blood pressure was 143/60 millimeter of mercury (mmHg), pulse was 68 beats per minute, temperature was 97.4 degrees F, and oxygen saturation was 97-percent on room air.

Review of the weather information at https://www.timeanddate.com/weather/usa/columbus revealed the temperature outside on 12/06/22 at 11:25 P.M. was 51 degrees Fahrenheit (F) with light rain and fog.

Review of a written statement by PCA #100 dated 12/07/22 revealed on 12/06/22 at 11:10 P.M. Resident #38 was given a snack and drink. After the resident ate the snack, he got up and walked to the exit door next to the nurse's station (leads to enclosed patio). The resident tried but did not get the door open. Resident #38 headed down the hallway to his room. PCA #100 went to clean up the kitchen when another resident asked for a snack. PCA #100 gave this resident a snack. During that time, an alarm went off. PCA #100 went to see where the alarm was coming from. PCA #100 discovered the noise was coming from an exit door. The statement noted Resident #38 left the building at 11:18 P.M. When turning off the alarm, a resident came out of their room and asked what time it was, it was 11:40 P.M. Resident #38 could not be located. PCA #100 started checking other resident rooms. PCA #101 and #102 were entering the unit for their shift. PCA #100 informed them Resident #38 was missing. All three PCA's started looking in all the resident rooms on the memory care unit. The three PCA's repeatedly checked every room. PCA #102 called LPN #105, and the nurse came to help search. The nurse, PCA #101, and PCA #102 went outside to look and found Resident #38. The resident was brought back to the unit. PCA #100 took the resident to his room and dried his hair and put him to bed.

Review of a written statement by PCA #102 dated 12/07/22 revealed on 12/06/22 at 11:40 P.M. they entered the secure memory unit. PCA #100 was frantically going room to room near the emergency exit door. PCA #100 stated she had heard the emergency door alarm go off and could not find Resident #38. PCA #100, #101, and #102 checked every room and bathroom at least three times before going outside in the rain to search for Resident #38. PCA #102 checked around the carwash located across the road from the entrance to the facility. PCA #102 notified the nurse they were unable to find Resident #38.

Review of written statement by PCA #101 (no date) revealed PCA #100 told her the door alarm went off and Resident #38 was missing. The PCA's looked in all the resident rooms and courtyard. LPN #105 was notified and began to search outside. PCA #101 and LPN #105 drove around to look for the resident. The resident was located at an office building.

Review of a written statement by LPN #105 (related to the elopement incident) revealed a snack was given to Resident #38 due to his wandering. LPN #105 then left the secure memory care unit to get report from another nurse. LPN #105 then received a page from memory care asking the whereabouts of Resident #38. LPN #105 instructed the PCA to search room-to-room and the patio. LPN #105 and two other nurses went outside to search for Resident #38. Since it was raining, LPN #105 and PCA #101 drove around on Broad Street. A person was observed trying to open the door to an office building. The nurse called Resident #38's name and he came to her. The resident's hair and hands were wet and cold. Resident #38 was wearing a jacket over his pajamas and had shoes on. The resident was assessed, vitals were taken, and the resident was assisted to bed. Safety checks were put in place for Resident #38. The certified nurse practitioner and executive director were notified.

Review of a nursing and services evaluation, dated 12/09/22 revealed Resident #38 had severe orientation deficits with history of poor judgement creating potential for unsafe behaviors to self or others. The resident had difficulty communicating and needed assistance with communication. The resident was independent with mobility and required no assistive devices. The resident did wander with exit-seeking behaviors. Resident #38 required safety checks 12 times a day. Resident #38's BIMS score was a two which indicated severe cognitive impairment.

A nurse's note dated 01/10/23 at 3:17 P.M. revealed Resident #38 was very agitated. The resident kept taking his clothes off and was trying to go outside. The nurse administered medications including Ativan (anti-anxiety), Benadryl, and Haldol (anti-psychotic) Gel (ABH Gel) 0.5/25/0.5 per one milliliter (ml) topically to Resident #38. The note indicated the resident would continue to be monitored.

Interview on 02/07/23 at 10:22 A.M. with Executive Director #122 and Wellness Director #107 verified on 12/06/22 Resident #38 left the facility unattended from the secure memory care unit. They were notified the resident was missing and staff were looking for him. The resident was found and brought back to the facility. Staff were educated on door alarms. A staff member responded to the door alarm but did not see anyone leaving.

Interview on 02/07/23 at 12:06 P.M. with PCA #102 revealed Resident #38 was missing at shift change time. PCA #100 had reported she was unable to find the resident. PCA #102 revealed Resident #38 wandered a lot and jiggled the doors to see if they would open. The nurse stated she had given the resident a cookie before she left the secure memory unit. PCA #102 stated Resident #38 was probably missing for an hour or two. The staff looked three to four times in all the rooms before going outside to look for Resident #38. Resident #38 was found down the road at an office building and was not hurt. PCA #102 could not recall any education or training being provided about elopement or door alarms after the incident occurred.

Interview on 02/07/23 at 12:13 P.M. PCA #100 revealed she was the only staff member on the secure memory unit when the door alarm went off. PCA #100 stated she was giving another resident a snack when she heard the door alarm sound. The door that was alarming was near Resident #38's room. PCA #100 went to the door that was alarming and turned the alarm off. She then started checking to see if there were any residents missing. Two other staff members were coming onto the unit when she discovered Resident #38 was not in his room. The staff started looking for the resident and he was found within an hour and a half. PCA #100 stated she had not received any education or training about elopement or door alarms after the incident occurred.

Observation on 02/07/23 at 3:15 P.M. revealed when Resident #38 exited his room, the secure door to the outside was within sight. Observation also revealed the exit door was glass and opened out onto a small, cement porch with a sidewalk that led to the front of the building and parking lot. This surveyor drove from the parking lot of the facility where Resident #38 exited the facility to the building where the resident was eventually located. The driveway was sloped downhill to the road that ran between a carwash and various fast-food restaurants. At the end of the driveway, the surveyor turned right onto the road that was uneven and had various size potholes. The road curved to the left and on the right, there was a large corporate building. The parking lot of the corporate building (where the resident was found) had large potholes.

Review of the facility policy Elopement/Missing Resident OH Region, revised 08/19/22 revealed if a door alarm was activated, the following procedure was to be implemented:

1.Door alarms are to be activated at all times.

2.It is the responsibility of all staff members to respond immediately to any alarm sounds.

3.When an alarm sounds, staff member should determine which door was alarming and announce the status.

4.All assigned staff members must walk outside the door to make certain all residents who might have exited the area are escorted back into the community.

5.During the time the door alarm is being investigated, assigned staff members should initiate a head count of all residents using the census and sign-in and out book.

6.If it is determined a resident was still missing, the staff are to begin the Missing Resident procedure.

7.The door alarm should not be reset until the investigation has been completed and all residents were secured.

8.Door alarms should be tested every shift.

If a resident's whereabouts were not known, the following measures will be immediately implemented:

1. The nurse/aide is informed of the need to locate the resident.

2. A search of the community including offices, apartments, bathrooms, lounges, service hallways, empty rooms, storage areas, etc. is to be conducted.

3.Immediate outside areas surrounding the facility will be searched.

4.If the resident is not located, proceed to the Elopement procedure, and notify the responsible party of the power-of-attorney (POA).

5.Contact Executive Director and Wellness Director.

Procedure Elopement: The search coordinator would be the nurse on duty during the off hours.

1.The Delegated/Assigned Search Coordinator should contact the executive Director and Wellness Director. If the resident is not located after the building and the grounds have been searched, call in other Department Heads, the responsible party and/or POA.

2.The Search Coordinator will print out the resident profile for the police, department heads, and the staff not familiar with the resident.

3.Record all pertinent information in the incident report. Fully describe the sequence of events, including specific timed notations.

This violation is an incidental finding to Complaint Number OH00139330.

Based on medical record review, review of self-reported incident, and interviews, the facility failed to ensure a staff member did not use Resident #64's credit card. This affected one (#64) out of one resident reviewed of misappropriation. Facility census was 89.

Findings include:

Review of the medical record revealed Resident #64 was admitted on 10/18/21 with diagnoses that included hypertension, depression, and hyperlipidemia.

Review of Personal Care Assistant (PCA) #156's personnel record revealed a hire date of 11/04/21. Review of the criminal history record check, bureau of criminal investigation (BCI) convictions on file dated 12/02/21 revealed PCA #156 had a criminal history of passing bad checks on 02/09/99 and forgery on 10/10/12.

Review of self-report incident (SRI) #227976 dated 10/12/22 revealed an allegation of misappropriation by a staff member. On 10/11/22 Resident #64 had heard someone come into her room and was rustling through papers in the middle of the night. Resident #64 reported the incident to family and the family notified the facility. After calling to request a new credit card, two fraud charges were discovered. The fraud charges were found to be to PCA #156's privately owned business. PCA #156 was terminated.

Review of a typed summary provided by the facility dated 10/11/22 revealed Resident #64 heard someone come into her room and started rustling through papers in the middle of the night. The resident's daughter reported the credit card company said there were two fraudulent charges. One occurred on 1:50 A.M. (no date provided) for $1,200 and one at 1:52 A.M. for $325.

Further review of the personnel record revealed PCA #156 was terminated on 10/13/22 due to being tardy multiple times and attempting credit card fraud.

Interview on 02/07/23 at 10:22 A.M. Executive Director (ED) verified PCA #156 was terminated for using Resident #64's credit card.

Interview on 02/07/23 at 10:47 A.M. Resident #64's daughter verified PCA #156 had taken her mother's credit card and attempted to use it. The credit card had declined the charges. The daughter stated even though the resident was not out any money, it was an inconvenience for Resident #64 to get a new card and the resident did not trust people now.

This violation is an incidental finding to Complaint Number OH00139330.

Based on record review, interview and policy review, the facility failed to report positive COVID 19 cases to the local health department. This had the potential to affect all 82 residents.

Findings include:

Review of facility COVID 19 timeline revealed 14 residents tested positive for COVID 19 between the dates of 12/19/22 through 12/31/22.

During interview on 01/11/2023 at 2:00 P.M. Executive Director confirmed the facility did not report the positive COVID 19 cases to the the local health department or COVIDCare portal per facility policy.

Review of policy titled, COVID 19 - Testing Residents, revised 10/07/2022, revealed the facility was to report positive COVID 19 cases to the local health department and COVIDCare portal.

This violation represents noncompliance investigated under Complaint Number OH00138099.