Every finding on record at Adams Lane Healthcare and Rehabilitation Center

Based on observations, staff interview, and review of menus and recipes, the facility failed to ensure food was prepared by methods that conserve nutritive value. This affected four of four residents who received a pureed diet (Residents #9, #31, #33, and #80). The facility census was 107. Findings include:Review of the menu for the lunch meal on 06/03/26 revealed residents were to receive a beef taco salad with corn chips and cake. Observation of the pureeing of food for the lunch meal on 06/03/26 at 10:00 A.M. revealed [NAME] #183 to place five 3 ounce servings of taco meat into the food processor. She added water to the meat to blend it and get it to the correct consistency. She removed the meat from the food processor. She then placed eight bags of corn chips into the food processor. She added water to get it to the correct consistency. Review of the recipe for beef taco salad revealed staff were to process in food processor until smooth pudding like consistency is achieved. Add juice, milk, or broth, whichever is most appropriate for the item being pureed, a little at a time as needed to achieve desired consistency. Review of the recipe for corn chips revealed staff were to process in food processor until smooth pudding like consistency is achieved. Add juice, milk, or broth, whichever is most appropriate for the item being pureed, a little at a time as needed to achieve desired consistency. Interview with [NAME] #183 on 06/03/26 at 10:18 A.M. revealed she typically used water to get the pureed food items to the correct consistency. She confirmed the recipes for the pureed taco meat and corn chips called for using juice, milk, or broth but she used water.

Based on observations, staff interview, and policy review, the facility failed to ensure that resident personal food items were stored appropriately in nursing unit refrigerators. This affected Resident #79 but had the potential to affect the residents residing on four (Unit 300, 400, 600 and 700) of five nursing units. The facility census was 107. Observations on 06/03/26 at 8:30 A.M. of the nursing unit refrigerator on the 300/400 unit revealed two takeout food containers containing Chinese food and a burrito. The takeout containers were not labeled with a resident name and were not dated to indicate when they were placed in the refrigerator or when they were to be discarded. Observations on 06/03/26 at 8:35 A.M. of the nursing unit refrigerator on the 600 unit revealed a bag containing food from Taco Bell dated 05/28/26. The food was not labeled with a resident name and did not have a date of when it was to be discarded. Interview with Licensed Practical Nurse Supervisor #261, at that time, confirmed the food was not labeled and should have been thrown away after three days. Observations on 06/03/26 at 8:38 A.M. of the nursing unit refrigerator on the 700 unit revealed a takeout food container for Resident #79 that contained mashed potatoes and carrots. The takeout container was not dated with when the food was placed in the refrigerator or when it should be discarded. There was also two takeout containers of gravy with no name or dates and a takeout container with chicken and mashed potatoes with no name or date. Interview with the Director of Nursing, at the time of the observations, confirmed the resident food items were not labeled and dated appropriately so that staff know when to discard the food items. Interview with Dietary Manager #251 on 06/03/26 at 8:42 A.M. revealed a date marking guide lets staff know when to throw away food based on when it is placed in the refrigerator. She confirmed there were no date marking guides near the refrigerators. Review of the facility policy dated 02/01/18 and updated 09/15/24 titled Food Brought into Facility by Family/Visitors revealed foods brought into the facility by family or visitors shall be stored safely and under sanitary conditions and handled properly to ensure safe consumption. A community food refrigerator/freezer shall be available to store perishable food items brought into the facility by family or visitors. A date marking guide will be placed near the refrigerator, or the dietary department will be referenced for date marking an item. All opened, in use food items will be date marked with the day of preparation or purchase date and an expiration date per the date marking guide. Food items brought in will be dated appropriately and have the residents name on the food item. When food items have expired, the resident will be informed and the food items removed and disposed of.

Based on observation, interview, record review and review of facility policy the facility failed to maintain infection control principles as evidenced by open packages of incontinence products stored on the floor, gloves not being changed when needed while checking a finger stick blood sugar, not covering the end of a tube feeding line after unhooking it from a resident and not maintaining a resident's urinary catheter tubing off of the floor. This affected five resident's (#4, #43, #64, #85 and #92) of eight sampled for infection control. The facility census was 107.Findings include: 1. Review of Resident #64's medical records revealed an admission date of 06/09/25, a re-entry of 08/05/25 and diagnoses including chronic obstructive pulmonary disease, diabetes, cervicalgia, hypertension, depression, unspecified diastolic (congestive) heart failure, peripheral vascular disease and acquired absence of left leg above the knee. Review of Resident #64's quarterly Minimum Data Set (MDS) dated [DATE] revealed a brief interview for mental status score of 15 indicating the resident was cognitively intact. Further review of the MDS revealed Resident #64 used a wheelchair for mobility, was dependent on staff for toileting hygiene and transfers, required substantial/maximal assistance with bed mobility, and was always incontinent of bladder and bowel. An observation on 06/01/2026 at 10:46 A.M. revealed Resident #64 was in the bed. A small three drawer dresser was located near the foot of Resident #64's bed. Several boxes and bags of Resident #64's personal belongings, including an open bag of incontinence briefs, were stored on the floor just past the dresser. An observation on 06/03/2026 at 9:23 A.M. revealed Resident #64's open bag of incontinence briefs was stored on the floor just past the dresser. An observation and interview on 06/03/26 at 1:25 P.M. with the Director of Nursing (DON) verified several boxes and bags of Resident #64's personal belongings including an open bag of incontinence briefs were stored on the floor just past the dresser. 2. Review of Resident #92's medical record revealed an admission date of 08/07/23 and diagnoses including chronic systolic (congestive) heart failure, diabetes, major depressive disorder, atrioventricular block, hypertension, and hyperlipidemia. Review of Resident #92's quarterly Minimum Data Set (MDS) dated [DATE], revealed a brief interview for mental status score of 15 indicating the resident was cognitively intact. Further review of the MDS revealed Resident #92 utilized a wheelchair for mobility, was dependent on staff for toileting hygiene, required substantial/maximal assistance for showering/bathing, bed mobility and transfers, and was always incontinent of bladder and bowel. An observation on 06/01/2026 at 10:21 A.M. of Resident #92's room revealed an open bag of incontinence briefs on the floor by the free standing closet visible from the hallway. An observation on 06/03/2026 at 9:23 A.M. of Resident #92's room revealed an open bag of incontinence briefs on the floor by the free standing closet visible from the hallway. An observation on 06/03/26 at 1:25 P.M. made with the Director of Nursing (DON) revealed an open bag of Resident #92's incontinence briefs were on the floor by the free standing closet and were visible form the hallway. In an interview completed at the same time the DON verified an open bag of incontinence briefs on the floor by the free standing closet, visible from the hallway, in Resident #92's room. 3) Review of Resident #43's medical record revealed admission date 03/19/26 with diagnoses including but not limited type two Diabetes Mellitus, Chronic Obstructive Pulmonary Disease (COPD), and heart failure. Resident #43 had intact cognition and required limited assistance from staff for Activities of Daily Living (ADL) tasks. Review of Resident #43's signed physician orders revealed an order dated 04/29/26 for insulin Novolog Injection Solution (Insulin Aspart) inject 5 units subcutaneously with meals for Diabetes Mellitus, hold for blood sugar less than 150, blood sugar checks three times per day at meals. Observation on 06/03/26 at 11:13 A.M. revealed Registered Nurse (RN) #266 completing lunch meal blood sugar check for Resident #43. RN #266 positioned the medication cart in front of Resident #43's room doorway, sanitized hands and donned a pair of gloves. RN #266 proceeded to gather the supplies required to obtain Resident #43's blood sugar reading, including the glucometer, lancet, alcohol pad, and test strip. RN #266 placed all supplies in a plastic cup, knocked on the door and entered Resident #43's room. RN #266 obtained Resident #43's blood sugar, returned to the medication cart. RN #266 disposed of used supplies and cleaned the glucometer per manufacturer guidelines. RN #266 removed the gloves and sanitized hands. RN #266 did not change gloves prior to obtaining Resident #43's blood sugar reading. Interview on 06/03/26 at 11:28 A.M. with RN #266 verified there was not a glove change from when RN #266 sanitized hands to when the glucometer was cleaned. RN #266 stated gloves should have been changed prior to obtaining the blood sugar reading for Resident #43. Review of the facility's policy titled, Glucose Monitoring and Disinfecting dated 01/03/25 revealed proper use of personal protection devices (PPE) and hand hygiene prior to performing any invasive procedure, including point -of-care testing, will be observed. 4. Review of Resident #4's medical record revealed he was admitted to the facility 04/07/2026. Diagnoses included dementia, depression, obstructive uropathy, diabetes, fracture of the seventh cervical vertebrae, fracture of the right mandible, and fracture of the neck of the left humerus. Review of the 5-day minimum data set (MDS) assessment dated [DATE] revealed his cognition was not intact, He required set up or clean up assistance for eating, dependent for oral hygiene, toileting, substantial/maximal assistance for shower/bathing dressing and turning and repositioning. He has an indwelling urinary catheter and is frequently incontinent of his bowel. On 06/01/2026 at 4:35 P.M. Resident #4's 4:35 PM Urinary catheter tubing was observed on the floor. This was verified during interview with Registered Nurse (RN) #243 on 06/01/2026 at 4:37 P.M. 06/08/2026 at 10:20 A.M. the urinary catheter drainage bag was observed laying flat on the floor with no barrier.At 10:21 A.M. interview with RN #266 verified the urinary drainage bag was lying flat on the floor with no barrier. 5. Review of Resident #85's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included cerebral palsy, severe intellectual disability, seizures, encephalopathy, and gastrostomy. Review of the quarterly minimum data set assessment dated [DATE] revealed his cognition was severely impaired. He was dependent for oral hygiene, toileting, shower/bathing, dressing, personal hygiene and turning and repositioning. He is always incontinent of his bowel and bladder. On 06/03/2026 at 11:00 A.M. observation of Registered Nurse (RN) #172 without wearing gloves unhooked the tube feeding from the gastrostomy tube and did not provide covering to the end of the tubing for the tube feeding solution and moved the pump to the resident's room. RN #172 then checked for residual (obtained 20 cc) and checked tube placement by auscultation with a stethoscope (the nurse was observed not to disinfect her stethoscope before or after use with Resident #85), flushed with 10 cubic centimeters (cc) of water, gave medication per gravity flow, then flushed with 10 cc of water per gravity flow. She then reconnected Resident #85's tube feeding, removed her gloves and washed her hands and moved Resident #85 back out in the lounge area. Interview with RN #172 revealed she had not donned gloves before disconnecting the resident's tube feeding solution or covered the end of the tubing for the tube feeding solution after disconnecting the tubing from the resident's g-tube. The nurse also verified she had not disinfected her stethoscope before or after use. Review of the policy titled Infection Control Prevention Policy, dated 04/2019 and updated 01/11/2025, revealed residents have a right to reside in a safe environment that promotes health and reduces the risk of acquiring infections.

Based on observations, staff interview, family interview, and policy review, the facility failed to ensure the residents right to privacy of personal and clinical information. This affected four residents (#17, #29, #33, and #35) of 38 residents reviewed for personal privacy. The facility census was 107. Findings include:1.Review of the record for Resident #35 revealed an admission date of 12/03/24 with diagnoses including memory deficit following cerebral infarction, post traumatic stress disorder (PTSD), hypertension, and chronic kidney disease. There was a physician's order of 10/24/25 for the resident to reside on the secured Blue Sky Living Community to meet the physical, mental, spiritual, and emotional well-being and safety needs of the resident. Review of a Minimum Data Set (MDS) assessment completed 04/25/26 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Observations on 06/01/26 at 12:07 P.M. revealed a sign posted on the wall above the resident's bed that included the resident's name and stated that she was incontinent, alert x 1, was on a regular diet, and required assistance of one with showers. (Resident #35 shared the room with another resident). Interview with the Director of Nursing on 06/03/26 at 1:02 P.M. confirmed the personal and clinical information was posted in the resident's room in view of visitors/contractors that have no need to see the information. Review of a consent to reside in Blue Sky Living revealed the consent included a statement that to assist team members with communication, resident information may be placed in a binder and/or posted in each resident room as a visual aid for staff members. Consent to reside in this community includes consent for resident information to be posted for purposes of consistent care and staff communication. The consent for Resident #35 stated that verbal consent was obtained from the resident's daughter by the Director of Nursing. Interview with Resident #35's daughter on 06/04/26 at 9:45 A.M. revealed she consented for the resident to reside on the Blue Sky unit but was not aware that she was consenting to personal information being posted in the room. She stated she did not want the personal information posted and stated that her mother would not want the information posted, especially about her being incontinent. Interview with the Director of Nursing on 06/04/26 at 1:39 P.M. revealed she spoke to Resident #35's daughter on the phone about the Blue Sky unit consent but did not get a written consent signed after she received verbal consent. 2. Review of the record for Resident #33 revealed an admission date of 06/02/25 and diagnoses including dementia, adult failure to thrive, chronic kidney disease, metabolic encephalopathy, and hypertension. There was a physician's order dated 07/21/25 for the resident to reside on the secured Blue Sky Living Community to meet the physical, mental, spiritual, and emotional well-being and safety needs of the resident. Review of a MDS assessment completed 03/26/26 revealed the resident had a BIMS score of 3, indicating severe cognitive impairment. Observations on 06/01/26 at 12:12 P.M. revealed a sign posted on the wall above the resident's bed that stated the resident is on a regular diet and uses a wheelchair. The posted sign also included the resident's date of birth . (Resident #33 shared the room with another resident). Interview with the Director of Nursing on 06/03/26 at 1:02 P.M. confirmed the personal and clinical information was posted in the resident's room in view of visitors/contractors that have no need to see the information. 3. Review of the medical record for Resident #17 revealed an admission date of 05/31/24 and diagnoses including dementia, Alzheimer's disease, diabetes, heart failure, malignant neoplasm of the prostate, and hypertension. Review of a MDS assessment completed 04/20/26 revealed the resident had long and short term memory impairment. The resident resided on the secured Blue Sky living unit. Observations on 06/01/26 at 11:03 A.M. revealed a sign posted on the wall above the resident's bed that included the resident's name and stated he was on a pureed diet, was incontinent, was alert x 1, and required two assist with showers. (Resident #17 shared the room with another resident). Interview with the Director of Nursing on 06/03/26 at 1:02 P.M. confirmed the personal and clinical information was posted in the resident's room in view of visitors/contractors that have no need to see the information. 4. Review of Resident #29's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included Alzheimer's dementia with behaviors, major depressive disorder, anxiety, insomnia and high blood pressure. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed her cognition was severely impaired. She required set up or clean up assistance with eating, substantial/maximal assistance with oral hygiene, toileting, shower/bathing, dressing and personal hygiene. She was always incontinent of bowel and bladder. On 06/01/26 at 2:35 P.M. observation revealed Resident #29 had a paper above the bed telling information about the resident, it revealed resident's name, diet, she was incontinent, and required the assistance of two staff members for showers. (Resident #29 shared the room with another resident). The paper was in view and able to be seen by staff and visitors. On 06/02/26 at 4:02 P.M. observation revealed the paper remained above the resident's bed telling information about the resident. The paper was in view and able to be seen by staff and visitors. On 06/03/26 at 10:00 A.M. observation revealed the paper remained above the resident's bed telling information about the resident. It was in view and able to be seen by staff and visitors. Again at 1:02 P.M. observation revealed that the paper remained above the resident's bed telling information about the resident. It was in view and able to be seen by staff and visitors. The privacy violation was verified during interview with the Director of Nursing on 06/03/26 at 1:02 P.M. Review of the facility policy dated 10/2024 and titled Privacy Policy revealed in accordance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996, our company and centers must ensure the confidentiality, integrity, and availability of all the protected health information (PHI) it creates, receives, maintains, or transmits. The privacy of PHI is important to us. Our company and centers understand that PHI is personal and we are committed to protecting it. Protected Health Information is about an individual, including demographic information that may identify an individual's past, present, or future physical or mental health or condition related to health care services.

Based on medical record review, observation, staff interview, and facility policy and procedure review, the facility failed to maintain a clean and homelike environment. This was observed in four units (100, 200, 300 and 700) of seven units in the facility and affected five residents (#26, #33, #85, #97, and #107) of 107 residents reviewed for their environment. The census was 107. Findings include: 1. Observation on 06/03/26 at 12:50 P.M. revealed in room [ROOM NUMBER] the baseboard by the closet was coming loose, and area on the ceiling by the closet patched and stained a light colored brown. This was verified during interview with Maintenance Director #228 on 06/03/26 at 12:55 P.M. 2. Observation on 06/03/26 at 12:56 P.M. revealed in room [ROOM NUMBER] paint scuffed off the wall in multiple places. This was verified during interview with Maintenance Director #228 on 06/03/26 at 12:56 P.M. 3. Observation on 06/03/26 at 12:57 P.M. revealed in room [ROOM NUMBER] paint was scuffed off the walls in multiple places. This was verified during interview with Maintenance Director #228 on 06/03/26 at 12:57 P.M. 4, Observation on 06/01/26 at 10:13 A.M. revealed at the end of the 700 hallway a lounge area with a television mounted on the wall, table and chairs, a couple recliner chairs and a small couch. On the other side of the room were two bed frames, an electric wheelchair and several manual wheelchairs. There were no residents in the lounge area. Interview on 06/01/26 at 11:03 A.M. with housekeeping staff (HSK) #246 verified the two bed frames, the electric wheelchair and several manual wheelchairs. HSK #246 stated the equipment had been in the lounge area for several weeks, residents used to use the lounge area, but don't come to the lounge area anymore and activities does not use the lounge area either. The equipment used to be stored in the storage room, which was now being used as an office. Interview on 06/02/26 at 10:10 A.M. with the Administrator stated the facility did not have a policy for equipment storage for review. 5. Review of Resident #85's medical record revealed an admission date of 10/23/23 and diagnoses including cerebral palsy, severe intellectual disabilities, dysphagia, gastrostomy status, unspecified convulsions, and other muscle spasm. Review of Resident #85's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was unable to complete the brief interview for mental status due to rarely/never understood and had severe cognitive impairment. Further review of the MDS revealed Resident #85 was dependent on staff for all activities of daily living, was always incontinent of bladder and bowel and received nutrition via enteral feeding. An observation on 06/03/26 at 11:00 A.M. revealed Resident #85's floor to have an unknown black substance ground into the tile in front of the free standing closet in a random scattered pattern and a chipped/broken area of tile in front of the right side of the free standing closet. An observation on 06/03/26 at 1:26 P.M. with the Maintenance Director revealed Resident #85's floor to have an unknown black substance ground into the tile in front of the free standing closet in a random scattered pattern and a chipped/broken area of tile in front of the right side of the free standing closet. In an interview at the same time the Maintenance Director verified Resident #85's floor to have an unknown black substance ground into the tile in front of the free standing closet in a random scattered pattern and a chipped/broken area of tile in front of the right side of the free standing closet. Review of the policy titled Housekeeping Policy revised 06/2023 revealed resident's room floors are to be clear of spills, stains and derbies. 6. Observations on 06/01/26 at 2:08 P.M. revealed Resident #33 was up a customized chair. The foot rest of the chair was completely covered with strips of black tape with the resident's feet resting on the tape. Observations on 06/03/26 at 1:00 P.M. revealed the black strips of tape remained on the foot of the customized chair. This was confirmed during interview of the Director of Nursing at the time of the observation. 7. Observations on 06/02/26 at 9:02 A.M. revealed the floor in Resident #97's room was dirty with a heavy build up of dirt around the parameter of the room, especially near the bathroom door and around the edges of the dressers in the room. There was a white material splattered on the bottom of a black dresser in the room. Resident #97 stated, at that time, that the facility does not do any deep cleaning of the room including moving furniture to clean under it. Observation on 06/03/26 at 1:30 P.M. revealed the dirty floor and dirty dresser was confirmed by the Director of Nursing. 8. Observations on 06/02/26 at 10:53 A.M. revealed the floor in Resident #26's room was dirty with a heavy build up of dirt around the parameter of the room, especially near the bathroom. Observations on 06/03/26 at 1:32 P.M. revealed the dirty floor was confirmed by the Director of Nursing. 9. Observations on 06/02/26 at 7:49 A.M. revealed the bathroom sink (used by Resident #107) in the bathroom connected to room [ROOM NUMBER] was cracked in the basin making it an uncleanable surface. The sink faucet was corroded where the water came out. The mirror in the bathroom had a film over it making it difficult to see in. These observations were confirmed by the Director of Nursing on 06/03/26 at 1:33 P.M. This deficiency represents non-compliance investigated under Complaint Number 2982079.

Based on medical record review and staff interview the facility failed have timely care conferences and invite family to care conferences. This affected two residents (#3, #35) of five residents reviewed for care plan timing and revision. The census was 107. Findings include:1.Review of Resident #3's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included diabetes, gastroparesis, congestive heart failure, Chronic kidney disease, PTSD, ASHD, and chronic pain syndrome. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed his cognition was intact. He required set up or clean up assistance for eating, oral hygiene, supervision or touching assistance for toileting, turning and repositioning and personal hygiene, substantial/maximal assistance for shower/bathing, Occasionally incontinent of urine and always continent of bowel. Review of the record revealed a care conference was held on 10/16/25 and not again until 03/18/26 identifying five months in between. On 06/03/26 at 9:33 A.M. interview with Social Service Designee (SSD) #186 verified care conferences were not held timely. 2. Review of the medical record for Resident #35 revealed an admission date of 12/03/24 and diagnoses including memory deficit following cerebral infarction, Post Traumatic Stress Disorder (PTSD), chronic kidney disease, and hypertension. Review of a MDS assessment completed 04/25/26 revealed a brief interview for mental status score of 3, indicating severe cognitive impairment. The resident resided on the secure memory care unit. Interview with Resident #35's daughter (listed in medical record as her #1 emergency contact) on 06/02/26 at 11:23 A.M. revealed she had never been invited to participate in a care conference to review the plan of care. She stated she would participate if invited. Review of an Interdisciplinary Care Conference Summary form for 07/14/25 revealed the resident attended and it was documented that staff called and spoke with daughter (#1 emergency contact). Review of Interdisciplinary Care Conference Summaries for 10/06/25, 01/05/26, and 04/02/26 revealed Resident #35 attended but there was no evidence that the resident's daughter or any other family member participated in the care conference. There was no documentation to indicate that any family member had been invited to the meetings. Interview with Social Service Designee #186 on 06/04/26 at 9:20 A.M. revealed letters are sent out quarterly to invite family members to participate in care conferences. She stated they also call family if they don't hear back from them after the letters are mailed. She stated that she normally calls Resident #35's son (not the #1 emergency contact) but he does not answer and does not attend care conferences. She stated she did not invite the daughter (#1 emergency contact) because she lives out of town. She stated that she had talked to Resident #35's daughter last July 2025 to discuss adult protective services and that was why her name was on the care conference summary 07/14/25. She stated a care conference was not held with the daughter at that time. She confirmed there was no documentation for Resident #35 to say who was invited to care conference or that they did not respond.

Based on record review and staff interview, the facility failed to ensure a resident was free from chemical restraints when a psychoactive medication was given without attempting non-pharmacological interventions and without adequate indication for use. This affected one resident (#103) of five residents reviewed for unnecessary medications. The facility census was 107. Findings include:Review of the record for Resident #103 revealed an admission date of 01/14/26 and diagnoses including dementia, epilepsy, chronic pain, anxiety disorder, and depression. Review of a Minimum Data Set (MDS) assessment completed 04/20/26 revealed a Brief Interview for Mental Status score of 10, indicating moderately impaired cognition. It did not indicate any type of behaviors exhibited by the resident. The resident resided on the secure memory care unit. Observations on 06/04/26 at 8:13 A.M. revealed Resident #103 to be seated at a table and talking with three other residents. They had just finished breakfast. Resident #103 was well dressed and groomed. She was pleasant and smiling. Observations on 06/04/26 at 1:50 P.M. revealed Resident #103 to be sitting at a table with three other residents. They all had pens and crossword puzzles to work on. Interview with Nursing Assistant #195 on 06/08/26 at 11:00 A.M. revealed Resident #103 has days when she is emotional because she misses being home and misses her boyfriend. She stated the resident sometimes cries but has never been agitated. She stated she is easily redirected and calms down if you take her for a walk or go to her room and talk. Record review revealed Resident #103 had received an antidepressant medication (Zoloft) 100 milligrams daily for depression since admission. Review of nursing progress notes since admission did not reveal any evidence of any behaviors being exhibited, including anxiety, crying, or pacing until 05/12/26. On 05/12/26 at 8:59 A.M. it was documented that the resident had increased anxiety and crying. There was no evidence that any non-pharmacological interventions were attempted. There was no evidence the resident requested any medication. The physician was notified and the resident was started on an antianxiety medication (Hydroxyzine) 25 milligrams twice daily. Review of a physician progress note dated 05/12/26 revealed the physician was contacted by the Director of Nursing. Director of Nursing reports that resident is requesting medication for increased anxiety. Order given for Hydroxyzine 25 milligrams twice daily for a diagnosis of anxiety. Interview with the Director of Nursing on 06/08/26 at 11:45 A.M. confirmed there were no other behavior incidents documented except on 05/12/26. She stated the non-pharmacological intervention attempted was offering the resident a room change. (However, record review revealed the room change was offered to the resident in February 2026).

Based on medical record review, staff, and resident interview, the facility failed to obtain dental services for one (Resident #10) of nine residents reviewed for dental services. The census was 107. Findings include:Review of Resident #10's medical record revealed he admitted to the facility on [DATE]. Diagnoses included diabetes, encephalopathy, Downs syndrome, obstructive and reflux uropathy, urinary retention, chronic kidney disease, Stage 3. Review of the annual MDS dated [DATE] revealed his cognition is severely impaired. He requires supervision or touching assistance for eating, partial/moderate assistance for oral hygiene, personal hygiene and turning and repositioning, dependent for toileting, substantial/maximal assistance for shower/bathing and dressing. Indwelling urinary catheter and always incontinent of bowel. Review of the plan of care dated 03/31/2025 revealed the resident has oral/dental health problems due to he has his own teeth in poor condition with some broken 06/01/2026 5:07 P.M. interview with Resident #10's guardian revealed he needs his teeth pulled, we have been trying to get him into [NAME] for about two years. On 06/08/2026 at 1:58 P.M. interview with Resident Transportation Scheduler (RTS) #232 revealed he was on a waiting list at [NAME], then he went on hospice last year and the guardian decided she didn't want anything done, then a few weeks ago she decided she wanted something done. So I called [NAME] last week and they said he will have to be seen for an evaluation first and then go back on a waiting list. RTS #232 was unable to provide any documented evidence.

Based on medical record review, observation, staff interview and review of facility policy and procedure, the facility failed to maintain a resident's dignity with use of an indwelling urinary catheter. This affected one resident (#4) four residents observed with indwelling urinary catheters. The census was 107. Findings include: Review of Resident #4's medical record revealed he was admitted to the facility 04/07/26. Diagnoses included dementia, depression, obstructive uropathy, diabetes, fracture of the seventh cervical vertebrae, fracture of the right mandible, and fracture of the neck of the left humerus. Review of the 5-day minimum data set (MDS) assessment dated [DATE] revealed his cognition was not intact. He required set up or clean up assistance for eating, dependent for oral hygiene, toileting, substantial/maximal assistance for shower/bathing dressing and turning and repositioning. He had an indwelling urinary catheter and was frequently incontinent of his bowel. Review of physician orders revealed an order for a #16 FR (french) urinary catheter to straight drain due to urinary retention. On 06/01/2026 at 4:35 P.M. the resident's urinary drainage bag was observed in a wash basin on the floor with yellow urine in the drainage bag, the catheter tubing was observed on the floor and the drainage bag was uncovered facing the doorway. This was verified during interview with Registered Nurse (RN) #243 on 06/01/26 at 4:38 P.M. Review of the facility policy Foley Catheter Care dated 08/2025 revealed the urinary drainage bag will be covered to maintain the resident's dignity and not to expose the urine contents in the drainage bag.

Based on record review, observation, and interview the facility failed to maintain accurate medical records related to pressure relieving interventions. This deficient practice affected one resident (Resident #27) of four residents reviewed for medical equipment. The census was 107.Findings Include:Review of Resident #27's medical record revealed admission date 12/31/23 with diagnoses including but not limited to type two Diabetes Mellites, heart failure, Alzheimer's Disease, and high blood pressure.Review of Resident #27's signed physician orders revealed an order dated 11/06/25 for use of a Low Air Loss (LAL) mattress to bed. Check function/inflation every shift (QS).Review of Resident #27's annual Minimum Data Set (MDS) dated [DATE] revealed Resident #27 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of 3 out of possible 15, had impairment on one side of the body, used a wheelchair for mobility, was at risk for developing skin impairment, and was dependent on staff for Activities of Daily Living (ADL) tasks.Observation on 06/01/26 at 10:20 A.M. revealed Resident #27 was in bed watching television. The LAL mattress was located on the bed frame. The LAL mattress control box, hanging on the footboard, did not indicate it had power and the LAL mattress appeared partially deflated. The power cord for the LAL mattress was observed to be on the floor, approximately halfway between the head and foot of the bed.Observation on 06/02/26 at 9:31 A.M. revealed Resident #27 was sitting up in bed, finishing breakfast meal. The LAL mattress control box was observed with no power, and the power cord was observed to be in the same position as the previous day. The LAL mattress appeared to be partially deflated.Review of Resident #27's Treatment Administration Record (TAR) dated 06/01/26 to 06/30/26 revealed the order for Low Air Loss (LAL) mattress to bed. Check function/inflation every shift (QS) was signed off as being completed on 06/01/26 day shift and night shift and was signed off as being competed for the day shift on 06/02/26.Interview on 06/02/26 at 3:53 P.M. with Licensed Practical Nurse (LPN) #158 verified Resident #27's had an order for Low Air Loss (LAL) mattress to their bed. Check function/inflation every shift (QS) had been signed off as completed for the day shift on 06/02/26. LPN #158 stated the LAL mattress was not checked for proper function prior to signing the order entry as being completed as it was found to not have power and not be inflated.

Based on record review, observation, interview and review of the manufacture user guide, the facility failed to ensure a physician ordered low air loss mattress for pressure ulcer prevention was was powered and inflated. This deficient practice affected one resident (Resident #27) of four residents reviewed for medical equipment. The census was 107. Findings include: Review of Resident #27's medical record revealed an admission date of 12/31/23 with diagnoses including but not limited to type two diabetes mellitus, heart failure, Alzheimer's Disease, and high blood pressure.Review of Resident #27's potential for skin impairment care plan dated 09/02/25 revealed Resident #27 refused to get out of bed at times, was at risk for skin impairment, and has a low air loss mattress (LAL) mattress to bed as an intervention for development of skin impairment.Review of Resident #27's signed physician orders revealed an order dated 11/06/25 for use of a LAL mattress to the bed. Check function/inflation every shift (QS).Review of Resident #27's annual Minimum Data Set (MDS) dated [DATE] revealed Resident #27 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of 3 out of possible 15, had impairment on one side of the body, used a wheelchair for mobility, was at risk for developing skin impairment, and was dependent on staff for Activities of Daily Living (ADL) tasks.Review of Resident #27's Braden Scale assessment (used to identify risk of developing pressure ulcers) dated 05/27/26 revealed a score of 16 placing Resident #27 at risk for developing pressure ulcers.Observation on 06/01/26 at 10:20 A.M. revealed Resident #27 was in bed watching television. The LAL mattress was located on the bed frame. The LAL mattress control box, hanging on the footboard, did not have power and the LAL mattress appeared partially deflated. The power cord for the LAL mattress was observed to be on the floor approximately halfway between the head and foot of the bed.Observation on 06/02/26 at 9:31 A.M. revealed Resident #27 was sitting up in bed finishing the breakfast meal. The LAL mattress control box was observed with no power, and the power cord was observed to be in the same position as the previous day. The LAL mattress appeared to be partially deflated.Interview on 06/02/26 at 3:53 P.M. with Licensed Practical Nurse (LPN) #158 verified Resident #27's LAL mattress was unplugged, with the power cord on the floor. The LAL mattress control box was observed with no power, and the power cord was observed to be in the same position as the previous day. The LAL mattress appeared to be partially deflated.Review of the LAL mattress Prius 3-1 Alternating Anti-decubitus System user manual maintenance and troubleshooting section revealed if the pump is not functioning, check power source connection.

Based on medical record review and staff interview, the facility failed to ensure medications were administered within ordered physician parameters. This affected one (Resident #3) of five residents reviewed for unnecessary medications. The census was 107. Findings include: Review of Resident #3's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included diabetes, congestive heart failure, chronic kidney disease,and chronic pain syndrome. Review of the quarterly minimum data set assessment dated [DATE] revealed his cognition was intact. He required set up or clean up assistance for eating and oral hygiene, Supervision or touching assistance for toileting, turning and repositioning and personal hygiene, substantial/maximal assistance for shower/bathing, Occasionally incontinent of urine and always continent of bowel. Review of the physician orders revealed an order dated 04/14/2026 for Humalog insulin Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject 17 units subcutaneously before meals for diabetes hold if the blood sugar (BS) is less than 130. Notify provider if blood sugar is less than 70 or greater than 400. Review of the Medication Administration Record (MAR) for 02/2026 revealed the Humalog insulin was administered on 02/03/2026 at breakfast for a blood sugar (BS) of 124, on 02/06/2026 at breakfast for a BS of 84, on 02/11/2026 at dinner for a BS of 122 and 02/17/2026 at breakfast for a BS of 85. Review of the MAR for 03/2026, the Humalog Insulin was administered on 03/05/2026 at dinner with a BS of 106, 03/07/2026 at breakfast with a BS of 69, at lunch with a BS of of 121, on 03/09/2026 at lunch with a BS of 121, on 03/12/2026 at lunch with a BS of 124 and 03/31/2026 at dinner with a BS of 92.Review of the MAR for 04/2026, the Humalog insulin was administered on 04/17/2026 at breakfast for a BS of 95 and at dinner for a BS of 75, and on 04/22/2026 at dinner for a BS of 120.Review of the MAR for 05/2026 revealed the Humalog insulin was administered on 05/06/2026 at lunch for a BS of 116 and at dinner for a BS of 117. On 05/12/2026 at breakfast for a BS of 85, on 05/15/2026 at breakfast for a BS of 75 and 05/20/2026 at breakfast for a BS of 112. On 06/04/2026 at 10:34 A.M. interview with the Director of Nursing verified the insulin were documented as given and the blood sugar levels were outside of the ordered parameters for administration. The DON verified the insulin should not have been given.

Based on medical record review, observation, staff interview and facility policy and procedure review, the facility failed to follow physician orders for flushing the gastrostomy tube (tube through the abdominal wall into the stomach for nutrition) during medication administration . This affected one (Resident #85) of one resident observed for medication administration through a gastrostomy tube. The census was 107. Findings include: Review of Resident #85's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included cerebral palsy, severe intellectual disability, seizures, encephalopathy, and gastrostomy. Review of the physicians orders for 10/23/2023 revealed an order for every shift to flush the gastrostomy tube with 30 milliliters (ml) of water pre/post medication administration and 5 to 10 mls of water between each medication. The resident was also ordered to receive dicyclomine hydrochloride (Bentyl used to treat spasms of the intestines) 10 milligrams (mg) per five ml of medication. Administer 10 mg via g-tube. Review of the quarterly minimum data set assessment dated [DATE] revealed his cognition was severely impaired. On 06/03/2026 at 11:00 A.M. observation of Registered Nurse (RN) #172 related to medication administration for Resident #85 revealed the RN checked for residual (using a special syringe to measure the amount of enteral formula or medication that remains in the stomach from a previous medication or feeding) and checked by auscultation (listening to air flow over the gastric region) to verify tube placement. The RN then flushed with 10 mls of water (used to ensure the g-tube remains patent, does not get clogged, medications are moved through the tube and for essential hydration) then administered the ordered medication (dicyclomine hydrochloride) per gravity flow. The RN then flushed the tube with 10 cc of water per gravity flow. She then reconnected Resident #85's tube feeding, removed her gloves and washed her hands and moved him out in the lounge area then signed off his medication. On 06/03/2026 at 11:20 A.M. interview with RN #172 revealed she had flushed the gastrostomy tube with 10 mls of water before and after administering the medication, not the ordered 30 ml pre and post medication administration. Review of Feeding Tubes: Care and Treatment revised 06/2023 revealed feeding tubes will be utilized according to physician orders, which typically include: the kind of feeding and its caloric value, volume, duration, mechanism of administration and frequency of flush.

Based on observations, record review, and staff interview, the facility failed to develop a comprehensive care plan. This affected one resident (#33) of 38 residents reviewed for comprehensive care plans. The facility census was 107. Findings include:Review of the record for Resident #33 revealed an admission date of 06/02/25 and diagnoses including dementia, metabolic encephalopathy, adult failure to thrive, and hypertension. The resident resided on the secure memory care unit. Review of a Minimum Data Set (MDS) assessment completed 03/26/26 revealed a Brief Interview for Mental Status score of 3, indicating severe cognitive impairment. It further stated the resident was dependent upon staff for personal hygiene and bathing. Review of the plan of care for Resident #33 revealed it did not address a behavior of rectal digging or the provision of personal hygiene by staff. Observations on 06/01/26 at 2:10 P.M. and 06/04/26 at 8:00 A.M. revealed Resident #33 to have a dark brown substance under her fingernails. Interview with Licensed Practical Nurse #184 on 06/04/26 8:00 A.M. confirmed the resident frequently has bowel movement under her nails. She stated the resident has a routine behavior of rectal digging and will even remove her disposable brief. Interview with the Director of Nursing on 06/04/26 at 1:47 P.M. confirmed the plan of care for Resident #33 did not address rectal digging or the provision of personal care by staff including nail care.

Based on observation, interview and record review the facility failed to individualize a resident's room to allow the resident to access all areas of the room. This affected one resident (#64) of one resident reviewed for reasonable accommodation of need. The facility census was 107. Findings include:Review of Resident #64's medical records revealed an admission date of 06/09/25, a re-entry of 08/05/25 and diagnoses including chronic obstructive pulmonary disease, diabetes, cervicalgia, hypertension, depression, unspecified diastolic (congestive) heart failure, peripheral vascular disease and acquired absence of left leg above the knee.Review of Resident #64's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for mental status score of 15 indicating the resident was cognitively intact. Further review of the MDS revealed Resident #64 used a wheelchair for mobility, was dependent on staff for toileting hygiene and transfers, required substantial/maximal assistance with bed mobility, and was always incontinent of bladder and bowel. In an interview on 06/01/26 at 10:46 A.M. Resident #64 stated she could not get to the window or her things that were stored against the wall at the foot of the bed. Resident #64 stated the wheelchair that she utilized for mobility will not fit between the foot of the bed and the small dresser that was against the wall to the right of the foot of the bed to allow her to reach her belongings or the window. An observation on 06/01/26 at 10:46 A.M. revealed Resident #64 was in the bed by the window in her room with the head of the bed against the wall parallel to the window. Her roommate's bed was against the wall with the head of the bed against the wall with the door and the foot of the bed toward Resident #64's bed. A freestanding closet was located on the wall opposite of Resident #64's roommate's bed and just past the door to the bathroom. A small three drawer dresser was located against the wall beside the free standing closet and near the foot of Resident #64's bed. Resident #64's oversized, custom fitted power assist wheelchair was stored in front of the freestanding closet and several boxes and bags of Resident #64's personal items were stored on the floor just past the dresser.An observation on 06/03/26 at 9:23 A.M. revealed Resident #64's oversized, custom fitted power assist wheelchair was stored in front of the freestanding closet and several boxes and bags of Resident #64's personal items were stored on the floor just past the dresser.An observation on 06/03/26 at 1:25 P.M. made with the Director of Nursing (DON) revealed several boxes and bags of Resident #64's personal items were stored on the floor just past the dresser. In an interview completed at the same time, the DON verified that Resident #64 would not be able to reach her personal items stored on the floor just past the dresser.

Based on record review and staff interview, the facility failed to conduct a comprehensive assessment for a resident with a diagnosis of post traumatic stress disorder (PTSD). This affected one resident (#67) of 38 residents reviewed for comprehensive assessments. The facility census was 107. Findings include:Review of the medical record for Resident #67 revealed an admission date of 03/01/26 and diagnoses including PTSD, dementia, urinary retention, and malignant neoplasm of the prostate. Review of a Social Service History and Assessment form dated 03/02/26 revealed he had previously lived with his wife and daughter. The question: has the resident experienced a past trauma? had a response of military veteran. The question: does the resident have identified triggers? had a response of unable to identify at this time. The assessment indicated his wife was his contact. It stated his cognition was severely impaired. Review of a Minimum Data Set assessment completed 03/07/26 revealed a Brief Interview for Mental Status score of 5, indicating severe cognitive impairment. It indicated the resident had a diagnosis of PTSD. Resident #67 resided on the secure memory unit. Review of the plan of care dated 03/19/26 for Resident #67 revealed the resident had PTSD and a traumatic event was identified as the resident served in the military. It stated triggers were identified as loud noises. An intervention included to gain as much additional background from family/friends and other healthcare professions as possible. There was no evidence the facility attempted to further assess what specific loud noises were a trigger for the resident or that they had attempted to gain any further additional background related to the PTSD diagnosis. Interview with Licensed Practical Nurse (LPN) #184 on 06/04/26 at 7:53 A.M. revealed Resident #67 does not have any negative behaviors but staff are careful about what the television is on in the dining room as he sometimes thinks the show is real and he is part of it. Interview with Social Service Designee #186 on 06/08/26 at 11:18 A.M. confirmed there was no evidence of a comprehensive assessment of the PTSD diagnosis to determine what prompted the diagnosis and what the specific triggers were. She stated that she talked to the resident and family but did not document the findings and confirmed there was nothing further than what was documented in the plan of care.

Based on medical record review and staff interview, the facility failed to follow physician orders for monitoring urinary output. This affected one resident (#4) of four residents reviewed with indwelling urinary catheters. The census was 107. Findings include: Review of Resident #4's medical record revealed he was admitted to the facility 04/07/26. Diagnoses included dementia, depression, obstructive uropathy, diabetes, fracture of the seventh cervical vertebrae, fracture of the right mandible, and fracture of the neck of the left humerus. Review of physician orders revealed an order dated 04/07/26 for an Indwelling Urinary (Foley) Catheter: measure and record output. Review of the 5-day MDS dated [DATE] revealed his cognition was not intact, He required set up or clean up assistance for eating, dependent for oral hygiene, toileting, substantial/maximal assistance for shower/bathing dressing and turning and repositioning. He had an indwelling urinary catheter and was frequently incontinent of his bowel. Review of the treatment record for April, 2026 revealed there was no evidence of the urinary output for the 7:00 P.M. to 7:00 A.M. shift on 04/08, 04/10, 04/18, 04/23 and 04/26. Review of the treatment record for May, 2026 revealed there was no evidence of the urinary output for the 7:00 A.M. to 7:00 P.M. shift on 05/08, 05/27, and 05/29. Review of the treatment record for May, 2026 revealed there was no evidence of the urinary output for the 7:00 P.M. to 7:00 A.M. shift on 05/17, 05/24 and 05/31. Review of the treatment record for June, 2026 revealed there was no evidence of the urinary output for the 7:00 A.M. to 7:00 P.M. shift on 06/01, 06/04 and 06/06. On 06/08/26 at 1:33 P.M. interview with the Director of Nursing verified the urinary output was not documented every shift for the indwelling catheter as ordered by the physician.

Based on record review, observations, interviews, and facility policy review the facility failed to ensure safety of residents was maintained. This deficient practice affected one resident (Resident #12) out of four residents reviewed for safety adaptive equipment for cigarette smoking, affected one resident (Resident #44) out two residents for safety while out on the facility's campus, and affected one resident (Resident #71) out three residents reviewed for bed mattress safety. The facility census was 107. Findings Include: 1. Review of Resident #12's medical record revealed an admission date 09/29/25 with diagnoses including but not limited to Multiple Sclerosis, high blood pressure, depression, anxiety, and paraplegia. Review of Resident #12's smoking assessment dated [DATE] revealed Resident #12 was deemed supervision for smoking with no adaptive equipment or smoking apron required. Review of Resident #12's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #12 had intact cognition with a Brief Interview Mental Status (BIMS) score of 15 out of possible of 15, required moderate to dependent care from staff for Activities of Daily Living (ADL) tasks and was independent with cigarette smoking with staff supervision. Review of Resident #12's at risk for injury related to being a smoker care plan revealed facility goal is to maintain a safe environment during smoking. Observation on 06/02/26 at 8:30 A.M. revealed Resident #12 was in an electric wheelchair, in the smoking area, smoking a cigarette. A small plastic ashtray was observed in Resident #12's, sitting on top of Resident #12's thighs. There was no smoking apron or barrier between the ashtray and Resident #12's clothed legs. Further observation revealed a peer resident extinguished a cigarette in the ashtray, located on Resident #12's lap. Interview on 06/02/26 at 8:50 A.M. with Receptionist #244 verified the ashtray in Resident #12's lap while smoking a cigarette. Receptionist #244 stated the resident has a hard time reaching out to use an ashtray on the table and Resident #12's hands do shake sometimes. Review of the facility's policy titled, Smoking Policy dated 01/03/25 revealed staff will light smoking products and provide other assistance and protective devices as needed. 2. Review of Resident #44's medical record revealed admission date of 12/23/25 with diagnoses including but not limited to major depression, left above the knee amputation, anxiety, and heart failure. Initial review of Resident #44's fall care plan dated 12/23/25 revealed no safety devices or flag to the wheelchair for Resident #44's safety while outside the facility. Review of Resident #44's quarterly MDS dated [DATE] revealed Resident #44 had intact cognition with a BIMS score of 15 out of a possible 15, used a manual wheelchair for mobility, and required limited assistance from staff for ADL tasks. Review of Resident #12's Functional Abilities and Goals assessment dated [DATE] revealed Resident #44 used a manual wheelchair for mobility. Review of Resident #44's facility's sign out sheets dated 01/01/26 to 06/04/26 revealed Resident #44 would sign himself out of the facility to independently move around the facility's campus in his wheelchair. Observation on 06/02/26 at 10:30 A.M. revealed Resident #44 sitting in his wheelchair in the facility's parking lot between the second and third rows of parked cars. There was no flag or safety triangle on Resident #44's wheelchair for easy visual spotting for drivers coming into or leaving the facility's parking lot. Resident #44's fall care plan was revised on 06/03/26 to reveal Resident #44's refusal for having an orange flag on the wheelchair. Observation on 06/03/26 at 4:04 P.M. revealed Resident #44 was sitting at the far end of the facility's parking lot listening to music. There was no flag on the wheelchair for identification by drivers. Interview on 06/04/26 at 8:29 A.M. with Licensed Practical Nurse (LPN) Unit Manager (UM) #261 verified Resident #44 does not have a flag on his wheelchair for when he leaves the facility. On 06/04/26 at 4:00 P.M> interview with Resident #44 revealed the facility did ask him to use a flag on his wheelchair and he told them I don't need one of those but stated he would use one if he needed to. Interview on 06/04/26 at 4:29 P.M. with the DON revealed Resident #44 had admitted to the facility with an electric scooter, which had an orange flag attached to the back of the scooter. The scooter had quit working and had been stored by the facility in the front lounge area. On 06/03/26 Resident #44 was offered by the facility to attach the orange flag from the scooter onto the manual wheelchair that Resident #44 was using currently. Resident #44 refused to place the orange flag on the wheelchair, so the facility gave the flag to another resident who used an electric scooter for mobility. 3. Review of Resident #71's medical record revealed an admission date of 08/16/24 with diagnoses including chronic combined systolic and diastolic (congestive) heart failure, hypertensive heart disease with heart failure, vascular disorder of intestine, diabetes, and Alzheimer's disease. Review of Resident #71's quarterly Minimum Data Set (MDS) dated [DATE] revealed a brief interview for mental status score of three indicating the resident had severe cognitive impairment. Further review of Resident #71's MDS revealed the resident used a wheelchair for mobility, required partial/moderate assistance with toileting hygiene, bed mobility, and transfers and was always continent of bladder and occasionally incontinent of bowel. An observation on 06/02/2026 at 1:11 P.M. revealed Resident #71's mattress did not reach to the foot of the bed, with a large gap visible between the end of the mattress and the footboard of the bed. A bolster used to close gaps between mattresses and bed frames or bed rails was present, but did not correct the gap, leaving part of the wire bed frame exposed at the foot of the bed. An observation on 06/02/2026 at 4:38 P.M. revealed the mattress continued to not reach the foot of the bed. An observation on 06/03/2026 at 9:19 A.M. revealed the mattress continued to not reach the foot of the bed. An observation on 06/03/26 at 1:20 P.M. with the Director of Nursing and the Maintenance Director revealed the gap between the end of the mattress and the metal retainer brackets that held the mattress in place at the foot of the bed, measured nine and 3/4 inches when measured by the Maintenance Director, without the bolster. A bolster was present but did not correct the gap, leaving part of the wire bed frame exposed at the foot of the bed. The Director of Nursing and the Maintenance Director verified the gap and the exposed bed frame. An observation and interview on 06/04/2026 at 2:14 P.M. with Licensed Practical Nurse (LPN) Supervisor #261 revealed Resident #71's mattress did not reach to the foot of the bed, with a large gap visible between the end of the mattress and the footboard of the bed. A bolster was present but did not correct the gap, leaving part of the wire bed frame exposed at the foot of the bed. LPN Supervisor #261 verified the gap and stated she was not sure what the plan was for the mattress but it was not the correct mattress for the bed because the bed was extended and the mattress was the regular kind (to be used with an average length bed).

Based on medical record review, staff, and resident interview, the facility failed to obtain dental services for one (Resident #3) of nine residents reviewed for dental services. The census was 107. Findings include: Review of Resident #3's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included diabetes, gastroparesis, congestive heart failure, chronic kidney disease, and chronic pain syndrome. Review of the quarterly minimum data set assessment dated [DATE] revealed his cognition was intact. He requires set up or clean up assistance for eating, oral hygiene, Supervision or touching assistance for toileting, turning and repositioning and personal hygiene, substantial/maximal assistance for shower/bathing, Occasionally incontinent of urine and always continent of bowel. Interview with on 06/02/2026 at 9:35 A,M. with Resident #3 revealed he has been here a year and has asked to see a dentist and hasn't. There was one here yesterday and I thought they would come and get me. Observation revealed Resident #3 had missing teeth. Review of the revealed no documentation the resident seen the dentist since admission in 07/2025. On 06/03/2026 at 10:03 A.M. interview with Resident Transport Scheduler (RTS) #232 verified he had not seen a dentist and the Veterans administration should have been consulted for a dental appointment.

Based on record review, interview and review of facility policy the facility failed to ensure a resident's physician was notified when a resident was transferred to the hospital. This affected one resident (#112) of three residents reviewed for discharge. The facility census was 107. Findings include:Review of Resident #112's closed medical record revealed an admission date 03/02/26 and a discharge date [DATE] with diagnoses including but not limited to cellulitis of left lower leg, Pancreas cancer, and high blood pressure.Review of Resident #112's Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #112 had intact cognition with a Brief Interview Mental Status (BIMS) score or 15 out of possible 15.Review of Resident #112's progress notes dated 03/06/26 at 2:08 P.M. revealed Social Services spoke with Resident #112 concerning Resident #112's request to transfer to another facility. Social Services provided Resident #112 with a list of potential facilities and will follow-up with Resident #112 with assistance in transferring.Review of Resident #112's progress notes dated 03/06/26 at 3:02 P.M. revealed Emergency Medical Services (EMS) arrived at the facility related to Resident #112 called EMS for transport to the hospital. EMS staff transferred Resident #112 to the gurney and transported Resident #112 to the hospital.There were no further progress notes to review for physician notification of Resident #112's transfer to the hospital.Interview on 06/04/26 at 3:24 P.M. with the Director of Nursing (DON) verified there was no physician notification for Resident #112's self-transfer to the hospital. The DON stated the expectation of the facility nurses was to notify the physician upon transfer of a resident even if the transfer was requested by the resident.Review of the facility's policy titled, Notification of Change in Condition dated 01/2026 revealed upon notification of the resident, physician and if known the resident's legal representation or resident representative documentation will be entered into the resident's record reflecting exchange of information.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, review of a facility self-reporting incident (SRI), review of the facility's related investigation, staff interview, resident interview, family interview, and review of the facility's Abuse Policy, the facility failed to protect Resident #14's right to be free from sexual abuse by Resident #97. This resulted in Immediate Jeopardy and actual harm beginning on 07/08/25 at 7:20 P.M. when Certified Nursing Assistant (CNA) #119 observed Resident #97, who had a history of sexually inappropriate behaviors engaged in non-consensual sexual intercourse with Resident #14, a cognitively impaired and non-interviewable female resident, who lacked the cognitive ability to provide consent to sexual activity. CNA #119 observed Resident #97 lying on top of Resident #14 with his shorts pulled down to his ankles and Resident #14 was noted to be completely naked. Resident #14 was transferred to the emergency room for an evaluation including a SANE exam and a rape kit. Blood work was completed to rule out sexually transmitted diseases (Hepatitis/HIV) and Resident #14 received prophylaxis treatment. Resident #14's immediate reaction at the time of the incident included she was tearful, had scared facial expressions, and reported he hurt me. This affected one resident (#14) of two residents reviewed for sexual abuse. The facility census was 94. On 07/17/25 at 1:12 P.M., the Director of Nursing (DON), Assistant Director of Nursing (ADON), Regional Nurse, Regional Administrator, and Administrator in Training (AIT) were notified Immediate Jeopardy began on 07/08/25 at 7:20 P.M. when the facility failed to protect Resident #14's right to be free from sexual abuse by Resident #97. The Immediate Jeopardy was removed on 07/09/25 and subsequently corrected on 07/10/25 when the facility implemented the following corrective actions:On 07/08/25 at 7:20 P.M. the CNA observed Resident #14 and Resident #97 in Resident #14's bed. Resident #14 was completely naked, and Resident #97 had his shorts pulled down to his ankles lying on top of Resident #14. The CNA immediately intervened and stopped the sexual abuse from occurring separating the two residents. Resident #97 was placed on one-on-one staff supervision to ensure he remained separated from Resident #14, and Resident #14 remained free of further sexual abuse. On 07/08/25 at 7:25 P.M. the Licensed Practical Nurse (LPN) on duty called the facility DON and notified her of the incident between Resident #14 and Resident #97. The DON in turn notified the Executive Director (ED). On 07/08/25 at 7:35 P.M. the DON initiated the facility's investigation of the alleged sexual abuse of Resident #14 and interviewed all on-duty staff at the time of the incident that included four LPNs and four CNAs. On 07/08/25 at 7:45 P.M. the DON and the two LPNs on-duty initiated resident interviews and/or head-to-toe skin assessments on all current residents, excluding the residents residing on the facility's secured dementia unit. All other residents were interviewed and skin assessment completed with no negative findings. On 07/08/25 at 7:49 P.M. the DON completed a head-to-toe assessment on Resident #14. On 07/08/25 at 8:00 P.M., the Executive Director submitted the initial self-reported incident (SRI) of alleged sexual abuse of Resident #14 by Resident #97 to the Ohio Department of Health (ODH) via ODH Application Gateway. On 07/08/25 at 8:04 P.M. the DON called 911 to report the sexual abuse of Resident #14 to local law enforcement and local emergency medical service (EMS). On 07/08/25 at 8:09 P.M. the DON notified Resident #14 and Resident #97's responsible parties and medical providers of the incident that occurred between Resident #14 and Resident #97. On 07/08/25 at 8:20 P.M. the local law enforcement and EMS arrived at the facility. Resident #14 left the facility with EMS to be evaluated in the emergency room of a local hospital. On 07/08/25 at 8:35 P.M. Resident #97 left the facility with law enforcement. Resident #97 remained on one-on-one supervision the entire time from incident to exiting the facility. On 07/08/25 at 9:00 P.M. the DON completed staff interviews with all nursing staff who worked the 500-hall unit that day (4 LPNs and 4 CNAs). On 07/08/25 at 10:15 P.M. the DON completed 72 resident interviews and/or head-to-the-skin assessments to identify any other residents that had potentially been abused. Those residents who could not be interviewed, had a head-to-toe skin assessments completed. On 07/09/25 at 12:20 A.M., Resident #14 returned to the facility. The LPN on duty completed a head-to-toe skin assessment. On 07/09/25 at 12:20 A.M., the LPN on duty updated Resident #14's family on her return and her condition. On 07/09/25 at 8:00 A.M, the DON/ED initiated education with all staff regarding the facility's Abuse Policy with focus on the definition and signs of sexual abuse. On 07/09/25 9:00 A.M., a whole house audit was conducted of all 72 residents residing in the facility to identify any other residents displaying inappropriate sexual behaviors and/or entering other residents' room inappropriately. On 07/09/25 at 10:30 A.M, facility Root Cause Analysis was completed by the [NAME] President (VP) of Clinical and Regional Clinical Support nurse. Facility Root Cause Analysis determined that lack of supervision of Resident #97, who had a history of sexually inappropriate behaviors, lead to the occurrence of an incident. Resident #97 does have a history of sexual behaviors and Tagamet (H2-receptor antagonist) was ordered on 03/05/25. All facility staff were educated on the Abuse Policy with emphasis on sexual abuse. On 07/09/25 at 10:30 A.M., Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the DON, ED, ADON/Infection Preventionist, Medical Director, Regional Clinical Support and VP Clinical Support. The purpose of the meeting was to discuss the incident with the Medical Director to review, develop, and implement corrective actions. On 07/09/25 at 12:10 P.M., the ED notified the State's local Ombudsman of the incident of sexual abuse of Resident #14 by Resident #97. On 07/09/25 at 12:30 P.M., the ED issued an immediate discharge to Resident #97 and his guardian. Resident # 97 remained in custody of local law enforcement at this time. On 07/09/25 at 2:38 P.M the DON and ED completed education with all staff regarding the facility's Abuse Policy with focus on the definition and signs of sexual abuse. Staff educated include ED (1), AIT (1), DON (1), ADON (1), Registered Nurses (RNs) (5), LPNs (29), CNAs (43), Dietary staff (12), Laundry and Housekeeping Staff (15), Activities (3), Therapy (4), Social Services Director (1), Receptionists (2). The facility implemented a plan for the DON or designee to complete ongoing audits by resident interview to ensure there have not been any concerns or allegations of abuse. The audit would be completed with 10 random residents twice weekly for four weeks beginning on 07/08/25, then as determined necessary thereafter. Audit results will be reviewed in QAPI. The facility implemented a plan for the DON or designee to complete ongoing audits by staff interview to ensure they understand the abuse policy and what to do if they have any concerns or allegations of abuse. The audits would be completed with 10 random staff members of any discipline, twice weekly for four weeks beginning 07/08/25, then as determined necessary. Audit results would be reviewed in QAPI. The facility implemented a plan for the DON or designee to complete an observation audit of the residents' environment to ensure no residents were displaying inappropriate sexual behaviors and/or entering other residents' rooms inappropriately. Audits would be completed twice weekly for four weeks beginning 07/08/25, then as determined necessary. Results of audits would be reviewed in QAPI. On 07/10/25 at 3:00 P.M., the facility submitted conclusion of SRI to the ODH via ODH Application Gateway substantiating allegation of sexual abuse of Resident #14 by Resident #97. Findings include: Review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE] with the diagnoses including memory deficit following a cerebral infarction, encephalopathy (group of conditions that cause brain dysfunction that can appear as confusion, memory loss, and personality changes), anxiety disorder, depression, and post-traumatic stress disorder (PTSD). The resident's most current weight listed was 110 pounds. Review of Resident #14's active care plans revealed a plan of care initiated 08/12/24 related to PTSD. The care plan identified the resident as having PTSD and was a known rape survivor. The care plan indicated the resident had been physically and sexually assaulted by a guy. The resident's triggers included yelling, loud noises, and approaching her in a fast manner. The goal was for the resident to have a decreased effect from her triggers daily. The interventions included offering the resident empathy, compassion, and support as needed. Review of Resident #14's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had adequate hearing without the use of a hearing aid and clear speech. She was able to make herself understood and was usually able to understand others (misses some part/ intent of message but comprehends most of the conversation). The resident's vision was adequate with the use of corrective lenses. The assessment revealed the resident's cognition was severely impaired, and she was known to have physical behavioral symptoms directed towards others that occurred one to three days of the seven-day assessment period. The resident was not known to reject care. She did not have any functional limitation in her range of motion and used a wheelchair as a mobility device. The resident was dependent on staff for upper and lower body dressing and required substantial/ maximum assistance for transfers. Review of Resident #14's progress note revealed a nurse's note by the facility DON dated 07/08/25 at 7:20 P.M. that indicated Resident #14 had an observed resident interaction with a male resident. The staff were indicated to have intervened and separated. Resident #14 was assessed without negative effects. The resident's physician and resident representative were notified. A nurse's progress note by the DON on 07/08/25 at 8:20 P.M. revealed the resident was transferred out of the facility via EMS to a local emergency room (ER) for an evaluation. She returned to the facility on [DATE] at 12:20 A.M. in stable condition. Review of the resident's medical record revealed no nursing progress was entered by LPN #215, the nurse on duty at the time of the incident and who was assigned to care for Resident #14. The DON, who authored the progress note above, was not present in the facility at the time of the incident. The DON arrived to the facility 30-45 minutes after she was called and informed of the incident. The DON documented the effective date and time in the note she authored in the resident's medical record. Further review of Resident #14's progress notes revealed a nurse practitioner (NP) note dated 07/09/25 (untimed) that indicated the resident was being seen for a hospital follow up on a sexual assault. The resident was seen in the ER on [DATE]- 07/09/25 after a sexual assault. She was evaluated by the Sexual Assault Nurse Examiner (SANE) nurse. There were no signs of trauma or penetration to the oral cavity, rectum, or vagina. The resident was treated with prophylactic antibiotics, and a referral was placed to infectious disease. A Hepatitis panel and HIV test obtained at the hospital were unremarkable/ negative. The NP indicated she was unable to obtain a full review of systems due to the resident's cognitive impairment. Review of Resident #14's ER notes for her ER visit on 07/08/25- 07/09/25 (3 hours) revealed the resident had been seen for a reported sexual assault. She was diagnosed with a sexual assault of an adult, treated with prophylactics (Metronidazole 2000 milligrams (mg), Azithromycin 500 mg, and Rocephin 500 mg with Lidocaine intramuscularly) and discharged back to the nursing facility. A Hepatitis panel and HIV tests were administered at the hospital and found to be non-reactive at the time. The resident was to follow up with the infectious disease clinic. Review of Resident #97's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including major depressive disorder, severe, recurrent and without psychotic features, adjustment disorder with depressed mood, morbid obesity (severe), and antisocial personality disorder. The resident's most recent weight was 462 pounds.Review of Resident #97's progress notes revealed a nurse's note dated 03/04/25 at 10:07 P.M. by the DON that indicated the on-call physician service was updated on the resident entering another resident's room. Review of a social service note dated 03/05/25 at 8:13 A.M. revealed a referral had been made to a sister facility for Resident #97 to be transferred to their behavioral unit. The social worker indicated she would follow up and assist as needed. Review of a nurse's note dated 03/05/25 at 10:40 P.M. revealed the nurse manager for Resident #97's unit spoke with both the house NP and the psychiatric NP with a new order being given for Tagamet 200 mg po twice daily (BID) on a scheduled basis. The note indicated the resident was to remain on one-on-one supervision until 3:00 P.M. that day and then he was to be on every 15-minute checks for the next 72 hours. Review of Resident #97's active care plans revealed a plan of care initiated 03/05/25 indicating the resident had sexually oriented behaviors. The resident exhibited sexually inappropriate behavioral symptoms due to severe mental illness as evidenced by physical touching and grabbing. The goal was for the resident to comply with staff redirection and behave in a safe and respectful manner. Interventions included conducting an evaluation of the sexually oriented behavioral symptoms to determine what the resident was communicating through the behavior (e.g. need to feel in control, feeling inadequate, feeling angry/ hostile and disrespectful towards himself, and projecting those feelings onto others). The care plan also included the need to intervene and redirect when any inappropriate behavior was observed, communicate assertively the resident must exercise control over his impulses and behaviors, remind the resident to refrain from inappropriate touching, and refer the resident for a psychiatric evaluation and utilize psychoactive medications as warranted. Review of Resident #97's most recent quarterly MDS assessment dated [DATE] revealed the resident did not have any communication issues. The resident was able to make himself understood and was able to understand others. The assessment revealed the resident was cognitively intact and not known to display any behaviors during the seven-day assessment period. The resident did not have any functional limitations to his range of motion and did not require the use of any assistive devices for mobility. The assessment revealed the resident required supervision or touching assistance for transfers and ambulation. Review of a facility self-reported incident, tracking number 262557 dated 07/08/25 revealed the facility reported an allegation of sexual abuse involving Resident #97 and another female resident (Resident #14). Resident #97 was the alleged perpetrator and Resident #14 was the involved resident/ victim. The SRI revealed neither of the residents were able to provide any meaningful information when interviewed. Witnesses to the sexual abuse were identified as CNA #112, CNA #119, and LPN #215. The date/ time/ location of the occurrence was on 07/08/25 at 7:20 P.M. in Resident #14's room. The narrative summary of the incident revealed a CNA entered the room of Resident #14 and saw Resident #97 lying on top of Resident #14 in bed. Neither resident had clothes on. Both residents were immediately separated, and Resident #97 was placed on one-on-one supervision. Local law enforcement was notified. Resident #97 left the facility with the local law enforcement, and he was on one-on-one supervision from the time of the incident until he left with law enforcement. Resident #14 was sent to the ER for an evaluation and returned to the facility later that same night. The SRI included a head-to-toe skin assessment was completed on Resident #14 (after the incident) with no negative findings, signs of trauma, or injuries. The facility substantiated the allegation of sexual abuse based on their investigation. The facility DON was identified as the investigator of the allegation. Review of the facility's related investigation revealed personal witness statements were obtained from the two involved residents, Resident #14's roommate, and the three staff members identified as witnesses to the sexual abuse. Review of Resident #14's personal witness statement revealed a verbal statement was obtained from the resident by the DON regarding the incident that took place on 07/08/25 at 7:20 P.M. The statement was obtained on 07/08/25, without a time indicated. The resident was asked a series of four questions. She was asked if he (Resident #97) touched her and she replied yes. She was asked if he touched her with his hands and she replied yes. She was asked if he touched her with his penis and she said yes. She was then asked if she had any pain and responded no.Review of Resident #97's personal witness statement revealed a verbal statement was obtained from the resident by the DON regarding the incident that took place on 07/08/25 at 7:20 P.M. The statement was obtained on 07/08/25, but no time was indicated for when the statement was obtained. Resident #97 was asked what he was doing? He did not answer at first, but then finally stated I was just in visiting. Review of a personal witness statement obtained from Resident #15 (roommate of Resident #14) by LPN #215 on 07/08/25 at 8:35 P.M. regarding the incident occurring on 07/08/25 (time of incident not specified) revealed she did not see anyone enter the room. She did see him close the curtain. She could hear her roommate (Resident #14) asking for help. She started to yell and stopped. She then heard the aide open the door and tell him to get out. After that, the nurse came in. She thought the other male resident was in the room for about 10 minutes. Review of a personal witness statement from CNA #119 for the incident dated 07/08/25 at 7:20 P.M. revealed she and CNA #112 were looking for a dog toy when they were told Resident #14 was the one who had it last. When she went to Resident #14's room, knocked, and entered she saw Resident #14 and Resident #97 on the bed. Resident #14 was naked with her head on the pillow and her hands clasped together over her chest. Resident #97 had his shirt on and his shorts were down between her (Resident #14's) legs with what looked like his penis in her vagina. She told him (Resident #97) that this wasn't going to be happening. Resident #97 stood up grunting, pulled his shorts up, and then balled his fist while walking towards her. She told him he did not want to do this, and he then walked out the door. She shut the door and went to the bed and noticed Resident #14's depend (incontinent brief) was on her bedside table. Her shoes were beside the wall on the bed. She asked Resident #14 if she was okay and if it was consensual. Resident #14 replied no, he hurt me. CNA #14 then reported she started to put Resident #14's hospital gown on her so she would be covered up. CNA #112 then walked in and the aide told her to go get the nurse and also told the other aide what had happened. LPN #215 came in and she told her what she had seen. LPN #215 contacted the supervisors while she and the other aide stayed outside Resident #97's room until the local law enforcement arrived. She indicated in her statement that she had just seen Resident #14 approximately 20 minutes prior and the resident was in her wheelchair in the lobby playing with a staff member's puppy. Review of a personal witness statement from CNA #112 for the incident occurring on 07/08/25 at 7:20 P.M. given on 07/08/25 (no time indicated) revealed she walked into Resident #14's room and saw that she was naked. The aide that she was training (CNA #119) told her Resident #97 was on her (Resident #14) while she was naked and Resident #97 was naked from the waist down. CNA #119 told her Resident #97's penis was inside of Resident #14 and that he was touching her also. CNA #119 then told Resident #97 to get up. He got up, dressed, and left the room. She confirmed they had just seen Resident #14 20 minutes prior out in the lobby playing with a staff member's puppy while up in her wheelchair. Review of a personal witness statement from LPN #215 for the incident occurring on 07/08/25 at 7:20 P.M. given on 07/08/25 (no time indicated) revealed she was alerted by a CNA that a resident (Resident #97) was found on top of another resident (Resident #14) with his pants around his ankles and he was seen having intercourse. Upon entering the room, both residents were immediately separated. Vital signs were collected, and skin was assessed. She then notified appropriate staff. Both residents were placed on one-on-one supervision until EMS/ local law enforcement arrived. On 07/16/25 at 10:25 A.M., an interview with CNA #119 revealed it was her first day working at the facility when the incident between Resident #14 and Resident #97 occurred on 07/08/25. She stated she had been a CNA for 20 years in the past but had taken a different job outside of healthcare in the past five years. She confirmed she was one of the day shift aides working from 7:00 A.M. to 7:00 P.M. weekend. She further confirmed she was the staff member who found the two residents (#14 and #97) in bed and naked. The incident occurred at 7:20 P.M. She stated she was still there at the time as her relief was running late. She was being trained by CNA #112. She reported she and CNA #112 were looking for a dog toy and had been told Resident #14 was the last one known to have it. She went to Resident #14's room, knocked on the door, and entered finding Resident #14 in bed with her gown off and her incontinence brief lying across the bedside table. Resident #14's shoes were on her bed by the wall. Resident #14 had been in a hospital gown that evening. Resident #97 was lying on top of Resident #14 with his short pulled down. Resident #97 was thrusting his hips into Resident #14 and was making grunting noises. It looked as if his penis was inside of Resident #14. When Resident #97 stood up, he had some kind of liquid on his erect penis. She described the liquid as like fluids but was not sure if they were Resident #97's or Resident #14's. She was also not sure if the fluid was semen or urine. She stated, it just appeared like they were having sex. Resident #14 had her hands clenched in a fist and next to each other over her breast. She denied Resident #14 was making any sounds and did not hear Resident #14 say anything. She stated she saw a tear coming down the side of Resident #14's face and she had a scared look on her face. She had seen Resident #14 minutes prior to that incident in the lobby petting a dog. She was up in her wheelchair at the time and dressed in a gown. She had an incontinence brief on and was wearing shoes, as she was ready for bed. With the way Resident #14 went around in her wheelchair, she did not feel Resident #14 would have been able to transfer herself from the wheelchair to bed. She stated when she walked in and found them, she said oh no, we are not doing this. She then told Resident #97 he needed to get out of Resident #14's room. Resident #97 then started to get up, pulled his pants up, and made a growling noise. She was not sure at the time if Resident #97 was non-verbal or not. He balled his fist at her as he passed her by when leaving the room. After Resident #97 left the room, she went to Resident #14 and asked her if she was okay. Resident #14 replied no, he hurt me. She then put Resident #14's gown on her as she was trying to cover up her breasts. The other aide (CNA #112) peeked in the room at that time, and she told the other aide to go get the nurse as she believed Resident #14 had been raped. The other aide got the nurse (LPN #215) and the nurse came right in. She then informed LPN #215 what she walked in on, and the nurse notified the ADON and the DON. Another aide then came to sit with Resident #14 while she and CNA #112 sat outside the room of Resident #97. They sat outside his room to ensure the two residents remained separated from one another until the local law enforcement and EMS arrived. Resident #97 just sat in his room on his bed moving his hands up and down his leg while tapping his feet on the floor. She was not familiar with Resident #97 at the time to know if he was cognitively intact or not. Resident #97 resided on the same hall as the SR and his room was catty-corner from hers. They remained with Resident #97 until the police arrived. She then went to the shower room twice with the law enforcement officer to give them an account of what had happened. The second time she went to the shower room was so the law enforcement officer could ask her if she had cleaned Resident #14 after the incident. She informed the law enforcement officer that she had not and put the same gown on her that she had on prior to the incident. She remained in the facility until all the interviews were done and all the evidence was bagged. The Law enforcement officer then walked Resident #97 out of the building. She filled out an incident report for the DON before she left the facility around 10:00 P.M. that night. She confirmed what she filled out was the personal witness statement and further confirmed the statement in the facility's investigation was what she had written. She reported she had just come from the county courthouse earlier that morning (prior to her interview) where she had to give testimony to the Grand Jury. She stated the Prosecutor had indicated they were debating on whether the charges against Resident #97 would include any federal charges. If convicted for what they were wanting to charge him with, he could get between 66 and 88 years. On 07/16/25 at 3:05 P.M., an interview with CNA #112 confirmed she was working on 07/08/25 when the incident occurred between Resident #14 and #97. She recalled it was sometime around shift change and thought it was probably 7:25 P.M. to 7:30 P.M. when it happened. She only seen the aftermath of what had happened. She walked into Resident #14's room to check on her coworker (CNA #119) who she was training. Her coworker was the one that had seen what happened and separated the two residents. She suspected she went to check on CNA #119 about five to 10 minutes after CNA #119 went to Resident #14's room. By the time she arrived at Resident #14's room, Resident #14 was still undressed, and CNA #119 was in the process of redressing the resident. She was told what had happened and then she left the room to get the nurse. She confirmed LPN #215 was the nurse working who she went to get. Resident #97 was already in his room when she arrived at Resident #14's room, which was catty-corner from Resident #14's room. She was familiar with the two residents involved prior to the incident, as she would often help the aides on the 500 hall. Resident #14 was normally up in the lobby area by the nurses' station on the North unit. She denied she had any prior interactions with Resident #97 before that incident. She was a little bit familiar with him. She reported that Resident #14 needed help transferring in and out of bed. She described Resident #14 as a two-person assist that needed substantial to maximum assistance for transfers. Resident #14 was non-ambulatory and had the use of a wheelchair. She was only able to stand and pivot when transferred. She reported that Resident #14 was able to undress herself at times but normally needed help doing so. She denied she had ever noted Resident #14 to remove her own clothing herself. She was usually dressed in a T-shirt or long-sleeved shirt and sweatpants. When she went to bed or on shower days, she had a gown on. When she saw Resident 14, the resident had always been dressed in clothes. She reported Resident #14 was normally confused but the level of confusion depended on the day. She was able to talk in short sentences but could not carry a conversation on with you. She had heard Resident #14 say please help or the resident would tell her thank you. Resident #14 could also get agitated, anxious, and restless at times but for the most part was relaxed. She described Resident #97 as being independently ambulatory. He was typically in his room, in the dining room, or outside to smoke. He was known to visit other residents (naming a male resident he visited on the 700 hall) but denied knowledge of Resident #97 visiting any female residents prior to that incident. She then recalled there was one time when Resident #97 did go into one female resident's room a while back. She identified that female resident as Resident #68, who used to reside on the 600 hall. That female resident had since been moved to the facility's memory care unit and was currently out of the facility in the hospital. She reported Resident #97 seemed like he was okay. She was not aware of him having any behaviors. She denied she was aware of him displaying any prior sexually inappropriate behaviors. She then recalled hearing something about Resident #97 cornering an aide in the shower room but wasn't sure of any details. That occurred about a month two ago and she identified CNA #192 as the aide involved. She did not think that Resident #97 touched the aide, he just had her cornered. She reported the nurse (LPN #215) responded to the incident between Resident #14 and #97 immediately. LPN #215 assessed Resident #14 and then had her (CNA #112) call the ADON. The ADON then called the DON. The DON came into the facility. She confirmed she sat with Resident #97 until the DON and the local law enforcement arrived. The DON was on scene before the local law enforcement arrived. She was not interviewed by law enforcement but did give a written statement to the DON. She was not sure how Resident #14 got into bed that night when she was found in bed with Resident #97 on top of her. They normally had to put her in bed, and no one had put her in bed that night. She denied there would be any other aides (other than her and the trainee) that would have put Resident #14 to bed. She believed Resident #97 had put Resident #14 in bed. She felt he would have been capable of lifting Resident #14 from her wheelchair into bed. She confirmed Resident #14 had a roommate who was present when the incident took place. She identified the roommate as Resident #15. She reported Resident #15 was alert and oriented and should be able to answer questions regarding the incident. She believed the roommate was asked to provide information regarding the incident to the facility as part of their investigation. Resident #14 resided in the bed by the door and Resident #15 was in bed by the window. On 07/16/25 at 4:40 P.M., an interview with Resident #15 revealed she recalled the incident that occurred on 07/08/25 and confirmed she was lying in her bed at the time the incident took place. She denied that she had seen anything. The resident stated he (Resident #97) pulled the curtain when he came in. She stated she got a quick look and only saw part of his face. She was not sure at the time if it was an employee or a resident. She just thought someone came in to get her roommate (Resident #14) ready for bed. She could not recall the time of the incident and was not sure if it occurred before or after dinner. She denied that she heard the male say anything. She reported her roommate was just carrying on. She heard her roommate say, get out. She denied she heard any other noises until the staff came in. The staff came in about 15 minutes after Resident #97 was there. They started yelling quite loudly at R[TRUNCATED]

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, review of an emergency medical services (EMS) report, interviews with facility staff and review of facility Code Status policy the facility failed to immediately initiate cardiopulmonary resuscitation (CPR) for Resident #94. This resulted in Immediate Jeopardy and the actual serious life-threatening harm and death on [DATE] beginning at 5:22 A.M. when Resident #94, who had advance directives for cardiopulmonary resuscitation/full code status, was found unresponsive, without a pulse, and was not provided CPR. The facility notified EMS for hospital transport without completing a comprehensive assessment of the resident ' s status. Resident #94 was assessed to be deceased by EMS without evidence of having received life saving measures. This affected one resident (#94) of two residents reviewed for an emergent change in condition and death. The facility identified 51 residents with a full code status. The facility census was 100. On [DATE] at 3:50 P.M., the Administrator, Regional Director of Clinical Operations #300, Regional Registered Nurses (RN) (#206, #207, and #208), and the Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 5:22 A.M. when State tested Nursing Assistant (STNA) #100 found Resident #94 unresponsive. STNA #100 notified Licensed Practical Nurse (LPN) #101 of the resident ' s status, however LPN #101 failed to complete a comprehensive assessment of the resident and failed to immediately initiate CPR despite the resident ' s wishes for a full code status. LPN #101 notified EMS of the need to transport the resident to the hospital however the resident was pronounced deceased upon EMS arrival (exact time unknown but EMS arrived at the facility at 5:38 A.M.). The Immediate Jeopardy was removed, and the deficiency corrected on [DATE] when the facility implemented the following corrective actions. On [DATE], Resident #94 expired in the facility. On [DATE] at 6:25 A.M., the DON immediately educated Licensed Practical Nurse (LPN) #101 on the facility's Code Status Policy. On [DATE] at 10:00 A.M., Human Resources Manager #194 audited employee files for all licensed nurses to ensure they had valid, active CPR certification. On [DATE] at 11:17 A.M., the facility completed an ad hoc Quality Assurance and Performance Improvement (QAPI) plan related to the abatement. The Administrator, Medical Director #301, and the DON were in attendance. The plan was approved by the committee including ongoing compliance. On [DATE] at 12:00 P.M., the DON, RN #160 and LPNs (#115 and #171) audited all hard copies of advanced directives in current resident's medical records to ensure they were present, appropriately signed and had a physician's order in place. On [DATE] from 8:30 A.M. to 4:33 P.M., the DON educated all 31 licensed nursing staff on the facility CPR policy and steps to take when finding a resident without vital signs. Beginning [DATE] the facility implemented a plan for the DON/designee to ensure nursing staff understood the Code Status Policy and when finding a resident without vitals to ensure adherence to Code Status Policy. Audits were completed three times per week for two weeks, then two times per week for two weeks, and then weekly for two weeks, then as determined necessary. Audits were completed ongoing every two weeks since original schedule completion. Between [DATE] and [DATE] no additional resident concerns were identified related to CPR. On [DATE] between 10:45 A.M. and 11:20 A.M. interviews with the Administrator, DON, RN (#160 and #304), LPN (#124, #171, #191, and #192), STNA (#122, #190, and #209) verified they were educated on the facility CPR policy. Findings include: Review of Resident #94's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including anxiety disorder, dementia, fibromyalgia, osteoarthritis, muscle weakness, and repeated falls. Review of a physician order, dated [DATE], revealed Resident #94 was a full code. Review of Resident #94's medical record from [DATE] through [DATE] revealed no documentation of Resident #94 or Resident #94's physician changing Resident #94's code status from a full code. Review of Resident #94 ' s care plan, dated [DATE], revealed Resident #94 desired to be a full code with cardiopulmonary resuscitation (CPR) initiated with the absence of pulse, respirations, and/or blood pressure. Interventions included supporting Resident #94/family with their decision and to honor their preference. Review of Resident #94's quarterly Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed the resident had severe cognitive impairment. The assessment revealed the resident required extensive, one-person physical assistance from staff for bed mobility. The resident required supervision from staff for eating, transfers, toileting, and personal hygiene. Review of Resident #94 ' s nursing progress note, dated [DATE] at 5:22 A.M. and authored by LPN #101, revealed State tested Nursing Assistant (STNA) #100 called LPN #101 into Resident #94 ' s room, the resident was without vital signs by verification of two nurses (identified as LPN #101 and LPN #102) (the progress note did not provide additional details regarding how this was verified). The progress note indicated EMS was notified. EMS arrived and the resident was with vital signs on electrocardiogram (EKG). The deputy was called due to the inability to reach the medical doctor. Resident #94 ' s sister was notified by the deputy. The note also indicated the coroner ' s office would be en route after the notification. Review of an emergency medical services (EMS) report, dated [DATE], revealed EMS were dispatched to the facility on [DATE] at 5:26 A.M., were reroute at 5:31 A.M., and at the scene at 5:38 A.M. Upon arrival, Resident #94 was found lying in bed, unresponsive and apneic (not breathing). The resident was cold to the touch with lividity and the initial stages of rigor. Facility nurse stated the resident was a full code, was found this way just prior to the call to EMS, and CPR was not performed due to the resident ' s obvious death. The resident was last seen approximately two hours prior. The facility was unable to reach their medical director. An EKG was obtained and revealed asystole (cessation of electrical activity of the heart) in three leads. The communication center notified the county sheriff ' s office and a deputy arrived on scene, took over, and contacted the coroner. Review of Resident #94's nursing progress note, dated [DATE] at 7:40 A.M. and authored by the Director of Nursing (DON), revealed there was an order to release the body to the funeral home as requested by the family. Review of LPN #101's witness statement, dated [DATE], revealed her last rounds were at 3:00 A.M. At 5:20 A.M., STNA #100 called her to the memory care unit for a resident without vital signs. EMS was called at 5:22 A.M. A second nurse, (identified as LPN #102), verified there were no vital signs. Review of STNA #100 ' s witness statement, dated [DATE], revealed Resident #94 went to bed at 10:45 P.M. During rounds, STNA #100 checked on the resident at 1:00 A.M. and observed her in bed, lying on her side and sleeping. STNA #100 checked on the resident again at 3:05 A.M. and the resident was still on her side and sleeping. During STNA #100 ' s last round at 5:15 A.M., the resident was lying on her back in bed. STNA #100 attempted to wake the resident with no response and notified the nurse (identified as LPN #101). During interview on [DATE] at 11:24 A.M., LPN #101 stated she was working on Hallway 100 or 200 (on [DATE]) when STNA #100 alerted her that Resident #94 was cold and unresponsive. LPN #101 stated she tapped on the resident ' s shoulder and called her name and there was no response. LPN #101 stated the only vital sign that she obtained was a radial pulse, which was absent, she then left the resident ' s room to get help and called EMS from the nursing station. During this time, LPN #101 stated she asked LPN #102 to check on Resident #94 to verify there was no pulse. LPN #101 stated she did not administer oxygen or start CPR because as soon as she started back into the room, EMS had arrived. LPN #101 stated that she was unsure of how many minutes passed from the time she was notified by STNA #100 of Resident #94 being unresponsive until EMS arrived, but that it felt like a matter of minutes. LPN #101 verified Resident #94 was a full code and CPR should have been administered. An additional interview on [DATE] at 2:23 P.M. with LPN #101 verified her nursing progress note, dated [DATE] at 5:22 A.M., contained a documentation error. LPN #101 indicated Resident #94 did not have any vital signs on EKG as indicated in the progress note. During interview on [DATE] at 11:51 A.M., STNA #100 stated she was doing her morning rounds and getting residents up when she noticed, from the doorway, that Resident #94 was uncovered. STNA #100 stated she walked into the room to check on the resident and noticed the resident was not moving, and her hand was cold. STNA #100 attempted to contact LPN #101 on her handheld, two-way radio, without success, and then went to get her on the 100 Hallway. STNA #100 revealed she did not return to Resident #94 ' s room because she stayed at the door awaiting EMS. During interview on [DATE] at 12:18 P.M., Regional RN #207 revealed the facility knew this incident was an issue and stated they identified it immediately after CPR was not initiated on Resident #94 who was a full code. During interview on [DATE] at 6:08 P.M., LPN #102 stated Resident #94 was not provided CPR and that she did not obtain any vital signs because the resident was unresponsive and cold. This surveyor asked LPN #102 if CPR should have been initiated for Resident #94 after being found unresponsive and without a pulse. LPN #102 stated yes, CPR should have been started and that she knows that now, after receiving the facility in-service education on CPR. During interview on [DATE] at 11:22 A.M., Physician #301 stated that although he was unsure if Resident #94 would have survived CPR efforts, it was unfortunate the staff did not follow the resident's advanced directive order. Review of the facility undated policy titled, Code Status, revealed in accordance with the State of Ohio Do Not Resuscitate (DNR) Comfort Care Protocol the facility would ensure a resident ' s wishes were carried out as they desire. Every effort to maintain a resident ' s wishes and dignity would be carried out as requested by the resident/or resident representative or family. Full Code was when a resident was identified as a full code and the facility staff would provide emergent measures in attempt to resuscitate the patient. This may involve chest compressions, electric shocks, and emergency medications that act to temporarily keep blood moving to essential organs such as the brain. All measures would be attempted to maintain the resident.

Based on record review, review of a local law enforcement investigation into an incident of suspected sexual abuse related to facility self-reporting incident (SRI) tracking number 231321, staff interview, and review of the facility Abuse policy and procedure, the facility failed to ensure actual, suspected, or potential incidents of verbal, mental, physical and sexual abuse were timely identified, reported, and investigated when they occurred to Resident #76, a cognitively impaired resident who resided on the facility secured memory care unit. Between 01/02/23 and 01/21/23, facility staff identified and/or observed incidents of interactions reflective of abuse towards Resident #76 by her husband, while he was visiting in the facility. This resulted in Immediate Jeopardy on 01/07/23, after Resident #76's husband was observed to be verbally/ mentally abusive to the resident while he was assisting her with personal care with no immediate protection of the resident, investigation of the incident or report of the incident to the State agency. Additional incidents reflective of actual/suspected/potential abuse occurred (after the initial incident of abuse by the husband) that were either not reported and/or not investigated by the facility. As a result, the facility failed to timely implement effective interventions to prevent those incidents of abuse from occurring and allowed Resident #76's husband to continue to visit the resident unsupervised until 01/21/23 at which time an alleged incident of sexual abuse occurred and the police were called. The lack of timely identification, reporting and investigation of incidents of abuse placed Resident #76 and all 103 facility residents at risk for actual/potential physical, emotional, psychosocial harm. The facility's census was 103. On 01/26/23 at 10:36 A.M. the Administrator was notified Immediate Jeopardy began on 01/07/23 when Resident #76 was observed to be verbally and mentally abused by her husband while he was visiting in the facility and initial reporting of the abuse was not made to the Administrator resulting in no investigation being completed. Resident #76 endured additional incidents of actual/suspected/potential abuse at the hands of her husband with no protection, effective intervention, reporting or investigation from the facility to prevent further abuse from occurring until 01/21/23 following an alleged incident of suspected sexual abuse when the police were contacted and Resident #76's husband was restricted from visiting at the direction of local law enforcement pending a criminal investigation. The Immediate Jeopardy was removed on 01/26/23 when the facility implemented the following corrective actions: On 01/21/23 at 3:00 P.M. State tested Nursing Assistant (STNA) #120 witnessed an incident between Resident #76 and her husband. STNA #120 told the resident's husband to leave and Licensed Practical Nurse (LPN) #88 called the local sheriff's department. At 3:30 P.M. the Muskingum County Sheriff Department arrived at the facility and interviewed the LPN #88, two STNAs, Resident #76, and Resident #76's husband and removed him from the facility. On 01/21/23 at 4:00 P.M. the Director of Nursing and Administrator were notified by LPN #79 of the incident by phone. On 01/21/23 at 4:15 P.M. the LPN #88 completed the skin assessment on Resident #76 and relayed the findings to the Nurse Practitioner (NP) #400, who gave the order to be sent to the emergency room (ER) for evaluation. The resident returned to the facility on [DATE] at 1:09 A.M. in stable condition. On 01/23/23 at 10:30 A.M. the Administrator met with a detective from the Muskingum County Sheriff's Department and went over the incident with him. The detective took pictures of the room and spoke with Resident #76. Also, at this time a dog leash was retrieved from Resident #76 dresser drawer and given to the detective. The detective stated he would keep in contact with the Administrator as to what the next steps for the case would be. On 01/24/23, at 9:30 A.M. the Administrator spoke with the detective from the Muskingum County Sheriff's department. The detective stated Resident #76's husband had been instructed that if he arrived on the premises of the facility he would be arrested. On 01/24/23 at 10:00 A.M. one on one education for staff present and via phone call for staff not present was provided related to the facility abuse policy, which included what abuse was and reporting requirements was initiated by the DON/Designee and the Human Resource Director for all 117 staff members which included eight RNs, 22 LPNs, three Medical Assistants, 23, STNAs, one Activity Director, three Activity Aides, one Physical Therapist, one Occupational Therapist, three Speech Therapists, two COTAs, three PTAs, one Dietary Supervisor, one Dietary Manager, four Dietary Aides, 14 Cooks, one Human Resource Manager, one Medical Records Manager, one Central Supply/EVS Supervisor, two Receptionists, two Resident Assessment Coordinators, one Social Service Designee, one Admissions Director, one Transportation Coordinator, seven Housekeepers, five Laundry Staff, and three Maintenance staff. A plan for any staff member not educated to not work until education was completed was implemented. On 01/25/23 at 11:03 A.M. Social Service Designee #200 spoke with Resident #76's husband and informed him Resident #76 would not be discharging from the facility (the resident had initially been admitted for short term rehabilitation). On 01/25/23 at 1:30 P.M. the Administrator received a statement from the Medical Assistant #95 regarding an incident (alleged sexual abuse) that occurred on 01/20/23 with Resident #76 and her husband. The Administrator initiated an investigation on 01/25/23 at 1:30 P.M. and an initial SRI was submitted to the State agency on 01/26/23. On 01/25/23 at 3:15 P.M. it was discovered that other alleged incidents of abuse occurred on 01/07/23, 01/12/23, unknown date, and 01/20/23. This information was given to the Administrator by the surveyor as discovered during the onsite complaint investigation. The Administrator started an investigation on 01/26/23 at 11:06 A.M. and submitted an initial SRI on 01/26/23. On 01/25/23 at 3:38 P.M. Social Service Designee #200 spoke with the Ombudsman regarding emergency guardianship for Resident #76. The Ombudsman gave Social Service Designee #200 information. SSD #200 made a call to the county Social Worker (SW) who does guardianships and message left. On 01/25/23 at 4:00 P.M. the facility Medical Director completed an expert evaluation for Resident #76 and deemed that she was incompetent. This information will assist in establishing guardianship for the resident. On 01/25/23 at 4:28 P.M. SRI with tracking number 231321 for the incident related to the 01/21/23 incident involving Resident #76 was completed and submitted to the State agency by the Administrator. On 01/26/23 at 10:15 A.M. the Administrator interviewed STNA #120 by phone regarding an incident involving a collar and leash that happened a week or so ago. This alleged incident was never reported and there was no documentation to support the incident in Resident #76 medical record. On 01/26/23 at 10:40 A.M. interviews were started by Management staff comprised of the Activity Director, Central Supply Manager, Medical Records Director, Social Service Designee, Admissions Director, and Activity Assistant for 46 residents with a Brief Interview for Mental Status (BIMS) score greater than 13 using the facility Resident Abuse Questionnaire with questions consisting of: Has anyone made you feel afraid or humiliated degraded, said mean things to you, hurt you, made you feel uncomfortable? Have you seen or heard of any residents being treated in any of these ways? If so, did you tell anyone about what happened? No new concerns were identified by the facility following these interviews. On 01/26/23 at 10:40 A.M. education was started by the Human Resource Manager to all staff regarding the fact Resident #76's husband was not permitted at the facility and facility visitation policy, which included restricting visitation if a visitor was intoxicated and/or belligerent. As of 01/26/23 at 117 staff members had completed the education. The facility implemented a plan that any staff member who had not been educated would be educated prior to their next worked shift. On 01/26/23 at 10:50 A.M. a Facility Quality Assessment and Assurance Committee ADHOC meeting was held by phone with the Facility Medical Director, Administrator, and RN, and Certus Clinical Support Nurse #415 regarding incidents of abuse involving Resident #76 which occurred on 01/07/23, 01/12/23, an unknown date, 01/20/23, and 01/21/23 and what corrective action measures were being taken. On 01/26/23 at 11:00 A.M. RN, Certus Clinical Support Nurse #420 completed re-education regarding the facility abuse policy, including reporting and that even spouses could be abusers. Education was also provided related to the facility visitation policy that included restricting visitation to anyone who was intoxicated and/or belligerent with the Administrator, Director of Nursing via phone, LPN Unit Manager for halls 500, 600, and 700 and LPN Unit Manager for halls 100, 200, and secured unit. On 01/26/23 at 11:06 A.M. the Administrator received a statement from STNA #120 on the secured unit regarding an incident on an unknown date when Resident #76's husband had a collar around his neck with Resident #76. On 01/26/23 from 11:15 A.M. to 12:24 P.M. skin inspections were performed by LPN #250 Unit Manager for 500, 600, 700 halls and LPN Unit Manager 100, 200, and secured unit for 45 residents with a BIMS score less than 13. No abnormalities were found by the staff completing the inspections. On 01/26/23 at 12:30 P.M. Administrator, spoke with Social Worker regarding emergency guardianship of Resident #76. Social Worker emailed a Supplement for Emergency Guardian of Person to Administrator for Medical Director to complete. Medical Director completed at 1:15 P.M. On 01/26/23 at 1:00 P.M. RN Clinical Support Nurse #415 and Transportation Coordinator initiated employee interviews related to staff witnessing abuse or potential abuse for all staff. A plan for any staff not interviewed during this time to be interviewed prior to their next scheduled shift was implemented following the interviews. On 01/26/23 at 2:37 P.M. the Administrator emailed the Social Worker a signed service agreement and the completed supplement for emergency guardian of person forms for Resident #76. On 01/26/23 at 2:46 P.M. Administrator submitted an initial SRI for incidents that were found to have occurred on 01/07/23, 01/12/23, unknown date, and 01/20/23 involving Resident #76. On 01/26/23 at 3:10 P.M. RN, Certus Clinical Support Nurse completed an audit of 37 residents with frequent visitors. Of the list, none were identified as potential resident abusers or ones who could cause harm. On 01/27/23 at 2:16 P.M. emergency guardianship was granted by the Probate Court of Muskingum County for Resident #76. Beginning 01/27/23, during the morning interdisciplinary team (IDT) meeting the facility would discuss if any new allegations or concerns of abuse had been brought to anyone staff members attention as well as reviewing 24-hour report. The facility indicated any/all allegations would be thoroughly investigated, and actions would be taken to ensure the facility was following the abuse policy. The facility identified the deficient practice occurred related to a failure to address and report suspicious behavior of Resident #76's husband per facility abuse policy. Beginning 01/30/23 the Director of Nursing or her designee would conduct an audit of 10 employees using the Staff Abuse questionnaire. The audit would be completed twice a week for four weeks and then as determined necessary. Findings will be referred to the Quality Assurance and Performance Committee for ongoing compliance. Beginning 01/30/23 the Director of Nursing or her designee would conduct an audit of 10 residents using the Resident Abuse Interview Tool and the skin assessment. The audit would be completed twice a week for four weeks and then as determined necessary. Findings will be referred to the Quality assurance and Performance Committee for ongoing compliance. On 01/30/23 from 9:01 A.M. to 9:28 A.M. interviews were conducted by the surveyor with one housekeeper, three STNAs, and two LPNs to confirm they received training on the facility's abuse and visitation policy. All staff interviewed confirmed receiving the training and exhibited an understanding of the training received. Although the Immediate Jeopardy was removed on 01/26/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings Include: A review of Resident #76's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia and major depressive disorder. the resident was admitted to the facility secured dementia unit at the time of her admission. A review of Resident #76's profile in the electronic health record (EHR) identified her spouse as her emergency contact #1. No other family members were identified as an emergency contact. A review of Resident #76's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had adequate hearing without the use of a hearing aid. Her vision was adequate without the use of any corrective lenses. Her speech was clear, and she was able to make herself understood and was able to understand others. The assessment noted the resident had severely impaired cognition. She was not known to display any behaviors, nor was she known to reject care during the seven days of her assessment period. The assessment revealed the resident required extensive assist from two staff for transfers, extensive assist from one staff for locomotion on and off the unit, dressing and toilet use and limited assistance from one staff for ambulation in her room. The assessment revealed the resident required staff supervision with set up help only for eating and was always continent of her bladder and bowel. A review of Resident #76's active care plans revealed the resident was admitted for a short term stay with the desire to return to the community and/or determination for long term stay not approved. Her care plans indicated she had impaired cognitive function/ dementia or impaired thought processes related to dementia and impaired decision making. Interventions indicated the resident needed assistance with all decision making. A review of Resident #76's progress notes revealed a nurse's note dated 01/07/23 at 11:14 A.M. by Licensed Practical Nurse (LPN) #47 that indicated the resident's husband was noted to be in her room, by an unidentified employee of the activity department, and smelled like alcohol. The nurse informed the activity employee the husband was not allowed in the resident's room. The nurse and a trainer (LPN #190) went to the resident's room and saw the husband toileting the resident. The nurse informed the husband staff were to toilet and change the resident. The resident's husband became belligerent and told the nurse the only problem he had with the staff was her. The unit manager (LPN #79) informed the nurse to let the husband do care if he wanted to; he was permitted to be in the resident's room, but the door needed to be open. On 01/25/23 at 10:06 A.M., an interview with LPN #47 revealed there was conversations over the weekend following Resident #76's admission about resident's husband being allowed in the room and providing care to the resident. A housekeeping supervisor was there providing her with the instructions that he was not to be in her room nor was he to provide care to her. The housekeeping supervisor was the weekend supervisor working that weekend and she had talked with someone in authority that was medically trained. She was not sure who that person may have been. She was also present when they received report from the hospital, and it was made known to them to watch Resident #76's husband. The hospital reported they had problems with him while the resident was in the hospital and the husband had been arrested. She reported the hospital had cameras in the room that showed the husband give Resident #76 medications and was also observed to be verbally/ physically abusive towards the resident while there. LPN #47 confirmed it was decided the husband was permitted in Resident #76's room if the door was open and could provide her with care. LPN #47 claimed her trainer was scolded by the facility's Admissions Director and was told since Resident #76 was married her husband had rights and could do whatever he wanted. Further review of Resident #76's progress notes revealed additional documented incidents in which verbal/mental/physical/sexual abuse was indicated to have occurred or was suspected as having occurred. The incidents are as follows: a. A review of a nurse's progress note for Resident #76 dated 01/07/23 at 7:00 P.M. by LPN #55 revealed the nurse and the aides (nursing assistants) were standing in the dining area when they heard Resident #76 scream. The door to her room was open and the husband had the resident on the toilet changing her clothes. The nurse and aides were in the hallway when the husband yelled at her to keep her hands on her F****** head and not to touch anything. The nurse began to enter the room when the husband saw her reflection in the mirror. He then changed how he was talking to the resident and apologized. The documentation did not indicate that the situation of verbal/ mental abuse was reported to anyone in management. On 01/25/23 at 1:25 P.M., an interview with LPN #55 revealed she did consider what she heard on 01/07/23 at 7:00 P.M. to be verbal/ mental abuse. She stated she reported the incident to the unit manager who was on call at the time. The unit manager told her in response that was Resident #76's husband and he could talk to how he wanted to. She was not sure if the unit manager reported it to the Director of Nursing (DON) or the facility Administrator. She did not feel it was passed on to the upper management based on what the unit manager's response was to her. On 01/25/23 at 2:13 P.M., an interview with the Administrator revealed she had worked at the facility for two months as the Administrator. She was asked about the incident that was documented in Resident #76's progress notes for 01/07/23 at 7:00 P.M. The Administrator stated that behavior from the husband was inappropriate, but she would not say it was verbal abuse. The Administrator was asked what she would consider to be verbal abuse and indicated screaming and yelling. The nurse's progress note was reviewed with Administrator again and she confirmed the incident should have been considered verbal abuse. She denied that incident was reported to her but did confirm they had a unit manager by the first name (LPN #250) who was identified by LPN #55 as having reported the incident to. She reported alleged perpetrators in abuse allegations can be a resident's family member. Being married to someone did not exclude them from being able to abuse that person verbally or physically. She confirmed the unit manager should have made her and the DON aware of the incident so it could have been reported and investigated. b. A review of Resident #76's progress notes revealed a nurse's note by LPN #61 on 01/12/23 at 7:58 A.M. that indicated the nurse, and the aides were in the dining room area during breakfast and the morning medication pass. An aide came to the nurse and reported Resident #76's husband told the resident to straighten the F*** up and grabbed her hand throwing it down on the table. The aide also heard him asking her to keep eating even though the resident said she was done. He then told her to put the F****** food in her mouth and started spooning the food into her mouth. The nurse indicated she heard the husband tell the resident that she needed to stop being a F****** B**** and use her God D*** walker. The husband said all those things in a hushed tone and acted totally different and nice to the resident when he noticed staff were watching him. A late entry note, by LPN #61 dated 01/12/23 at 7:30 A.M. revealed the nurse assessed Resident #76 for injuries after the previous incident. No injuries were noted, and the resident did not show signs of distress at that time. The nurse redirected the husband and told him that he could not touch residents like that, regardless of whether they were their spouse or not. On 01/25/23 at 10:30 A.M., an interview with LPN #61 revealed she was not sure if what she witnessed on 01/12/23 was abuse or not. She stated it was not okay to do to someone that was not of sound mind. She indicated she did report the incident to the DON and the DON came back to talk to her about her documentation. She alleged the secured unit manager was there at the time she talked to the DON. The DON reviewed the nurse's note and told them to intervene and redirect. Then and only then were they able to escort the husband off the property or to call the local law enforcement if he did not change his behavior. She then said the DON told her they do not use the word abuse. She felt it met the definition of verbal and physical abuse. She felt the husband was willful in his intent and changed his tone when the staff were present. On 01/25/23 at 12:02 P.M., an interview with LPN #79 revealed he was the unit manager for both the secured unit and the rehabilitation unit. He stated he was aware of the incident that occurred on 01/12/23 between Resident #76 and her husband. LPN #61 told him about it, and he told the DON. He confirmed the DON kept telling staff to redirect and if they felt the husband was a threat then they could call the local law enforcement. He reported he would consider the incident that occurred on 01/12/23 between Resident #76 and her husband to be abuse. He was not sure why that incident on 01/12/23 was not reported to the State agency or investigated. He denied that he heard the DON tell LPN #61 that they did not use the word abuse there. On 01/25/23 at 2:13 P.M., an interview with the Administrator revealed she was not made aware of the incident that occurred with Resident #76 and her husband on 01/12/23 at 7:58 A.M. She had reviewed the note and indicated the staff intervened during that incident between the husband and the resident. She indicated the resident did not show any signs of being in distress nor did she have any signs or symptoms of any injuries. She revealed she did not consider the incident a situation in which an SRI was warranted. c. A review of the local law enforcement's report for a suspicion of sexual abuse on 01/21/23 involving Resident #76, as perpetrated by her husband, revealed the sheriff's deputy had interviewed LPN #88 about the incident that occurred that afternoon at 3:00 P.M. During LPN #88's interview, it was determined there had been other issues that had come up of a sexual nature between the resident and her husband. The report noted an incident that had happened last night (01/20/23) and involved Resident #76's husband being caught lying in the resident's bed while naked. The statement provided by the nurse identified Medical Assistant #95 as the employee who witnessed that incident along with State tested Nursing Assistant #100. None of the prior incidents discussed had been reported to local law enforcement and staff had only documented them in the husband's visitors notes. A review of Resident #76's progress notes revealed it was absent for any documentation of an incident occurring the night of 01/20/23. The last progress note written on 01/20/23 was a social service note at 4:42 P.M. The next note what the nurse's note that documented the incident on 01/21/23 at 3:00 P.M. when sexual abuse was suspected. On 01/25/23 at 12:27 P.M., an interview with LPN #88 confirmed she indicated in her statement to the local law enforcement when interviewed about the sexual abuse suspicion that occurred on 01/21/23 that there had been a prior incident the night before. She had been told earlier that day by a night shift aide (before the sexual abuse incident occurred on 01/21/23 at 3:00 P.M.) that Resident #76's husband had been in bed with the resident the previous night naked. After that, the husband was asked to leave. She stated that incident had been reported and what was told to staff was that was her (Resident #76's) husband and she was allowed to have sex with him. She was not sure who said that but the person that did was management staff. Medical Assistant #95 was the one who relayed the information to her and STNA #100 was also a witness to that incident. She would not consider Resident #76 to be one who could consent to sex, and anything done would not be consensual. On 01/25/23 at 2:13 P.M., an interview with the Administrator revealed she did see in the local law enforcement's report that an incident was alleged to have occurred the night of 01/20/23. She confirmed it was reported Resident #76's husband was found in bed naked with her. She also confirmed there was no documentation in the progress notes to reflect an incident had occurred the night of 01/20/23. She denied they had a visitor's log for the resident's husband that would have recorded any notes. She stated she saw the same when reviewing the report and asked staff if there was such a thing and was told there was not. She denied being made aware of any inappropriate incidents that had occurred between Resident #76 and her husband on 01/20/23. On 01/25/23 at 2:58 P.M., an interview with Medical Assistant #95 confirmed he had witnessed an incident between Resident #76 and her husband the evening of 01/20/23. He stated he was on the unit to pass medications when STNA #100 asked him to stop by and tell Resident #76 what time it was and that visiting hours were going to be over. He observed Resident #76's husband to be lying in bed with her without a shirt on and snuggling with the resident. He could not see at that time if the husband was clothed from the waist down as he had a blanket over him. His first thought was to provide them privacy, so he moved his cart across the hall to another resident's room. He was still able to see into Resident #76's room and then observed the husband to get out of bed. He exited the side of the bed closest to the window and furthest from the door. He was able to see at that time the husband was completely naked. He did not look close enough to see if the husband had an erection or not when he got out of the bed. He reported the resident was dressed in a gown, but he could not tell if she had a pull up incontinent brief on or not. He was not concerned at that moment of abuse occurring. It was not until the resident began to cough that he felt abuse occurred. The husband began to scream at the resident when she started coughing. He told her to shut the F*** up, you're being too loud. She continued to cough, and the husband said, Oh my God, you are being so loud, why are you being so F****** loud. He recalled there had been many incidents with the husband. He had seen the husband in his car with the window down as he was reporting to work and coming into the building. He said the smoke reeked of marijuana and he saw the husband drinking beer. He was not sure why the facility was allowing him to come and go as he pleased. The husband even had the code to the secured unit to be able to enter and exit at will. He felt what he witnessed of the husband screaming at the resident was abuse. He indicated he informed the nurse (RN #550) that was on duty at the time but was not sure if she passed it along. He stated that nurse was good about reporting things when needed. He stated he told the nurse word for word what he had heard and saw. d. A review of Resident #76's progress notes revealed a late entry nurse's note dated 01/22/23 at 11:55 A.M. by LPN #88. The late entry was for 01/21/23. The nurse indicated, upon entering Resident #76's room to complete a skin assessment following the incident that involved suspected sexual abuse on 01/21/23, a metal chained leash with a collar attached was seen on the resident's bedside table. The nurse indicated in her note, to the knowledge of the staff that were on duty, no dog had been brought to the facility by the resident's husband. It was removed from the room and secured at the nurse's station. On 01/25/23 at 8:59 A.M., an interview with STNA #120 revealed Resident #76's husband was known to make gross sexual comments to the resident when he visited. She reported having knowledge of him having a dog chain with a collar on at one time. He placed the collar around his neck and had the resident hold the metal chained leash part and acted like she was walking him around. He did that in the dining room on the secured unit in front of staff and other residents. She recalled him making a comment for everyone to look at him saying I'm her B****. She felt his behavior was inappropriate but did not report it as potential abuse. On 01/25/23 at 12:02 P.M., an interview with LPN #79 revealed he was the unit manager for the secured unit. He denied he had been made aware of any incident occurring with Resident #76's husband that involved a dog collar. He saw the progress note that mentioned the dog collar but was not aware of it being used in a sexual manner. He stated, if the leash and dog collar was used in the manner that STNA #120 described it to be, that would not be appropriate. He stated if he had been made aware he would have shut that down and would have asked him to leave. He felt it would be humiliating and upsetting to the resident if that occurred. He was aware there were times the resident's husband would be in the building smelling of alcohol. He stated the husband admitted to drinking one or two beers before coming into the facility and smoking marijuana. If the husband was doing those things and was belligerent, he would ask him to leave or call local law enforcement. He would consider the resident's husband to be disruptive when there. On 01/25/23 at 12:27 P.M., an interview with LPN #88 confirmed she wrote the late entry nurse's note on 01/22/23 at 11:55 A.M. about the leash and dog collar. When she asked the aides about that, STNA #120 had told her the husband put it on himself and had Resident #76 hold the leash part. The husband would then say see she's not my B****, I'm her B****. She felt the incident with the dog collar was inappropriate. She stated that behavior would be upsetting and humiliating using the reasonable person concept. On 01/25/23 at 2:13 P.M., an interview with the Administrator revealed she had not been notified of there being any incident involving a leash and a dog collar. She stated if she would have been made of that incident, she would have made Resident #76's husband leave. She reported that type of behavior would be inappropriate in front of anyone. She then stated what people do at home was their own business but in a living community it was inappropriate. She indicated she could not say if the resident would have been humiliated or upset by that. She was then asked, if her husband had done that to her in front of others, would it be humiliating and upsetting to her. She replied that it would be. A review of the facility policy on Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property dated October 2022 revealed residents had the right to be free from abuse. It was the facility policy to investigate all alleged violations involving abuse. Facility staff should immediately report all such allegations to the Administrator [TRUNCATED]

Based on record review, review of facility self-reported incident (SRI) tracking number 231321, review of the facility's investigation related to the SRI, review of law enforcement reports, staff interview, and review of the facility Abuse and Visitation policy and procedures, the facility failed to ensure Resident #76, who was cognitively impaired and resided on the secured memory care unit was free from verbal, mental, physical, and potential sexual abuse following admission to the facility on [DATE]. Between 01/02/23 and 01/21/23, the facility's staff identified and/or observed at least five incidents of interactions reflective of abuse toward Resident #76, by her husband, while he was visiting in the facility. This resulted in Immediate Jeopardy beginning on 01/07/23, after Resident #76's husband was observed to be verbally/mentally abusive to the resident while he was assisting her with personal care. The incident was reported to the unit manager with no interventions initiated. Four additional incidents of actual/suspected abuse occurred (after the initial incident of abuse by the husband) to Resident #76 that were not prevented and either not reported or not investigated by the facility. As a result, the facility failed to ensure Resident #76 was free from situations of abuse, failed to timely implement effective interventions to prevent the incidents from occurring and allowed the resident's husband to continue to visit the resident unsupervised. Resident #76's husband continued to visit Resident #76 until an incident of alleged sexual abuse occurred on 01/21/23, which resulted in the husband being restricted from visiting pending the facility and local law enforcement investigations. Actual/potential physical and psychosocial harm occurred to Resident #76 as a result of the incidents of ongoing abuse including the incident on 01/21/23 when staff heard the resident crying, yelling out no and found the resident to be visibly upset. This affected one resident (#76) of one resident reviewed for abuse. The facility census was 103. On 01/26/23 at 10:36 A.M., the Administrator was notified Immediate Jeopardy began on 01/07/23 when Resident #76 was observed to be verbally/ mentally abused by her husband while he was visiting in the facility and initial reporting of the abuse was not then reported to the facility's Administrator resulting in no investigation being completed. Resident #76 endured four other incidents of actual/ suspected/potential abuse at the hands of her husband with no intervention from the facility to prevent the incidents or further abuse from occurring. It was not until the last incident of suspected sexual abuse (on 01/21/23), that an investigation was completed, and Resident #76's husband was restricted from visiting at the direction of local law enforcement pending their criminal investigation. The Immediate Jeopardy was removed on 01/26/23 when the facility implemented the following corrective actions: On 01/21/23 at 3:00 P.M. State tested Nursing Assistant (STNA) #120 witnessed an incident between Resident #76 and her husband. STNA #120 told the resident's husband to leave and Licensed Practical Nurse (LPN) #88 called the local sheriff's department. At 3:30 P.M. the Muskingum County Sheriff Department arrived at the facility and interviewed the LPN #88, two STNAs, Resident #76, and Resident #76's husband and removed him from the facility. On 01/21/23 at 4:00 P.M. the Director of Nursing and Administrator were notified by LPN #79 of the incident by phone. On 01/21/23 at 4:15 P.M. the LPN #88 completed the skin assessment on Resident #76 and relayed the findings to the Nurse Practitioner (NP) #400, who gave the order to be sent to the emergency room (ER) for evaluation. The resident returned to the facility on [DATE] at 1:09 A.M. in stable condition. On 01/23/23 at 10:30 A.M. the Administrator met with a detective from the Muskingum County Sheriff's Department and went over the incident with him. The detective took pictures of the room and spoke with Resident #76. Also, at this time a dog leash was retrieved from Resident #76 dresser drawer and given to the detective. The detective stated he would keep in contact with the Administrator as to what the next steps for the case would be. On 01/23/23 at 4:47 P.M. Social Service Designee (SSD) #200 contacted the probate court to inquire about getting emergency guardianship for Resident #76. SSD #200 also left a message for the Ombudsman for guidance related to the incident. On 01/24/23, at 9:30 A.M. the Administrator spoke with the detective from the Muskingum County Sheriff's department. The detective stated Resident #76's husband had been instructed that if he arrived on the premises of the facility he would be arrested. On 01/24/23 at 10:00 A.M. one on one education for staff present and via phone call for staff not present was provided related to the facility abuse policy, which included what abuse was and reporting requirements was initiated by the DON/Designee and the Human Resource Director for all 117 staff members which included eight RNs, 22 LPNs, three Medical Assistants, 23, STNAs, one Activity Director, three Activity Aides, one Physical Therapist, one Occupational Therapist, three Speech Therapists, two COTAs, three PTAs, one Dietary Supervisor, one Dietary Manager, four Dietary Aides, 14 Cooks, one Human Resource Manager, one Medical Records Manager, one Central Supply/EVS Supervisor, two Receptionists, two Resident Assessment Coordinators, one Social Service Designee, one Admissions Director, one Transportation Coordinator, seven Housekeepers, five Laundry Staff, and three Maintenance staff. A plan for any staff member not educated to not work until education was completed was implemented. On 01/25/23 at 11:03 A.M. Social Service Designee #200 spoke with Resident #76's husband and informed him Resident #76 would not be discharging from the facility (the resident had initially been admitted for short term rehabilitation). On 01/25/23 at 3:38 P.M. Social Service Designee #200 spoke with the Ombudsman regarding emergency guardianship for Resident #76. The Ombudsman gave Social Service Designee #200 information. SSD #200 made a call to the county Social Worker (SW) who does guardianships and message left. On 01/25/23 at 4:00 P.M. the facility Medical Director completed an expert evaluation for Resident #76 and deemed that she was incompetent. This information will assist in establishing guardianship for the resident. On 01/26/23 at 10:40 A.M. interviews were started by Management staff comprised of the Activity Director, Central Supply Manager, Medical Records Director, Social Service Designee, Admissions Director, and Activity Assistant for 46 residents with a Brief Interview for Mental Status (BIMS) score greater than 13 using the facility Resident Abuse Questionnaire with questions consisting of: Has anyone made you feel afraid or humiliated degraded, said mean things to you, hurt you, made you feel uncomfortable? Have you seen or heard of any residents being treated in any of these ways? If so, did you tell anyone about what happened? No new concerns were identified by the facility following these interviews. On 01/26/23 at 10:40 A.M. education was started by the Human Resource Manager to all staff regarding the fact Resident #76's husband was not permitted at the facility and facility visitation policy, which included restricting visitation if a visitor was intoxicated and/or belligerent. As of 01/26/23 at 117 staff members had completed the education. The facility implemented a plan that any staff member who had not been educated would be educated prior to their next worked shift. On 01/26/23 at 10:50 A.M. a Facility Quality Assessment and Assurance Committee ADHOC meeting was held by phone with the Facility Medical Director, Administrator, and RN, and Certus Clinical Support Nurse #415 regarding incidents of abuse involving Resident #76 which occurred on 01/07/23, 01/12/23, an unknown date, 01/20/23, and 01/21/23 and what corrective action measures were being taken. On 01/26/23 at 11:00 A.M. RN, Certus Clinical Support Nurse #420 completed re-education regarding the facility abuse policy, including reporting and that even spouses could be abusers. Education was also provided related to the facility visitation policy that included restricting visitation to anyone who was intoxicated and/or belligerent with the Administrator, Director of Nursing via phone, LPN Unit Manager for halls 500, 600, and 700 and LPN Unit Manager for halls 100, 200, and secured unit. On 01/26/23 from 11:15 A.M. to 12:24 P.M. skin inspections were performed by LPN #250 Unit Manager for 500, 600, 700 halls and LPN Unit Manager 100, 200, and secured unit for 45 residents with a BIMS score less than 13. No abnormalities were found by the staff completing the inspections. On 01/26/23 at 12:30 P.M. Administrator, spoke with Social Worker regarding emergency guardianship of Resident #76. Social Worker emailed a Supplement for Emergency Guardian of Person to Administrator for Medical Director to complete. Medical Director completed at 1:15 P.M. On 01/26/23 at 1:00 P.M. RN Clinical Support Nurse #415 and Transportation Coordinator initiated employee interviews related to staff witnessing abuse or potential abuse for all staff. A plan for any staff not interviewed during this time to be interviewed prior to their next scheduled shift was implemented following the interviews. On 01/26/23 at 2:37 P.M. the Administrator emailed the Social Worker a signed service agreement and the completed supplement for emergency guardian of person forms for Resident #76. On 01/26/23 at 3:10 P.M. RN, Certus Clinical Support Nurse completed an audit of 37 residents with frequent visitors. Of the list, none were identified as potential resident abusers or ones who could cause harm. On 01/27/23 at 2:16 P.M. emergency guardianship was granted by the Probate Court of Muskingum County for Resident #76. Beginning 01/27/23, during the morning interdisciplinary team (IDT) meeting the facility would discuss if any new allegations or concerns of abuse had been brought to anyone staff members attention as well as reviewing 24-hour report. The facility indicated any/all allegations would be thoroughly investigated, and actions would be taken to ensure the facility was following the abuse policy. The facility identified the deficient practice occurred related to a failure to address and report suspicious behavior of Resident #76's husband per facility abuse policy. Beginning 01/30/23 the Director of Nursing or her designee would conduct an audit of 10 employees using the Staff Abuse questionnaire. The audit would be completed twice a week for four weeks and then as determined necessary. Findings will be referred to the Quality Assurance and Performance Committee for ongoing compliance. Beginning 01/30/23 the Director of Nursing or her designee would conduct an audit of 10 residents using the Resident Abuse Interview Tool and the skin assessment. The audit would be completed twice a week for four weeks and then as determined necessary. Findings will be referred to the Quality assurance and Performance Committee for ongoing compliance. On 01/30/23 from 9:01 A.M. to 9:28 A.M. interviews were conducted by the surveyor with one housekeeper, three STNAs, and two LPNs to confirm they received training on the facility's abuse and visitation policy. All staff interviewed confirmed receiving the training and exhibited an understanding of the training received. Although the Immediate Jeopardy was removed on 01/26/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings Include: A review of Resident #76's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia and major depressive disorder. the resident was admitted to the facility secured dementia unit at the time of her admission. A review of Resident #76's profile in the electronic health record (EHR) identified her spouse as her emergency contact #1. No other family members were identified as an emergency contact. A review of Resident #76's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had adequate hearing without the use of a hearing aid. Her vision was adequate without the use of any corrective lenses. Her speech was clear, and she was able to make herself understood and was able to understand others. The assessment noted the resident had severely impaired cognition. She was not known to display any behaviors, nor was she known to reject care during the seven days of her assessment period. The assessment revealed the resident required extensive assist from two staff for transfers, extensive assist from one staff for locomotion on and off the unit, dressing and toilet use and limited assistance from one staff for ambulation in her room. The assessment revealed the resident required staff supervision with set up help only for eating and was always continent of her bladder and bowel. A review of Resident #76's active care plans revealed the resident was admitted for a short term stay with the desire to return to the community and/or determination for long term stay not approved. Her care plans indicated she had impaired cognitive function/ dementia or impaired thought processes related to dementia and impaired decision making. Interventions indicated the resident needed assistance with all decision making. A review of Resident #76's progress notes revealed a nurse's note dated 01/07/23 at 11:14 A.M. by Licensed Practical Nurse (LPN) #47 that indicated the resident's husband was noted to be in her room, by an unidentified employee of the activity department, and smelled like alcohol. The nurse informed the activity employee the husband was not allowed in the resident's room. The nurse and a trainer (LPN #190) went to the resident's room and saw the husband toileting the resident. The nurse informed the husband staff were to toilet and change the resident. The resident's husband became belligerent and told the nurse the only problem he had with the staff was her. The unit manager (LPN #79) informed the nurse to let the husband do care if he wanted to; he was permitted to be in the resident's room, but the door needed to be open. On 01/25/23 at 10:06 A.M., an interview with LPN #47 revealed there was conversations over the weekend following Resident #76's admission about resident's husband being allowed in the room and providing care to the resident. A housekeeping supervisor was there providing her with the instructions that he was not to be in her room nor was he to provide care to her. The housekeeping supervisor was the weekend supervisor working that weekend and she had talked with someone in authority that was medically trained. She was not sure who that person may have been. She was also present when they received report from the hospital, and it was made known to them to watch Resident #76's husband. The hospital reported they had problems with him while the resident was in the hospital and the husband had been arrested. She reported the hospital had cameras in the room that showed the husband give Resident #76 medications and was also observed to be verbally/ physically abusive towards the resident while there. LPN #47 confirmed it was decided the husband was permitted in Resident #76's room if the door was open and could provide her with care. LPN #47 claimed her trainer was scolded by the facility's Admissions Director and was told since Resident #76 was married her husband had rights and could do whatever he wanted. Further review of Resident #76's progress notes revealed additional documented incidents in which verbal/mental/physical/sexual abuse was indicated to have occurred or was suspected as having occurred. The incidents are as follows: a. A review of a nurse's progress note for Resident #76 dated 01/07/23 at 7:00 P.M. by LPN #55 revealed the nurse and the aides (nursing assistants) were standing in the dining area when they heard Resident #76 scream. The door to her room was open and the resident's husband had the resident on the toilet changing her clothes. The nurse and aides were in the hallway when the husband yelled at Resident #76 to keep her hands on her F****** head and not to touch anything. The nurse began to enter the room when the husband saw her reflection in the mirror. He then changed how he was talking to the resident and apologized. The documentation did not indicate the situation of verbal/mental abuse was reported to anyone in management. On 01/25/23 at 1:25 P.M., an interview with LPN #55 revealed she did consider what she heard on 01/07/23 at 7:00 P.M. to be verbal/ mental abuse. She stated she reported the incident to the unit manager (LPN #250) who was on call at the time. The unit manager told her in response that was Resident #76's husband and he could talk to Resident #76 how he wanted to. LPN #55 was not sure if the unit manager reported the incident to the Director of Nursing (DON) or the facility Administrator. LPN #55 did not feel it was passed on to the upper management based on what the unit manager's response was to her. On 01/25/23 at 2:13 P.M., an interview with the Administrator revealed she had worked at the facility for two months. The Administrator was asked about the incident that was documented in Resident #76's progress notes for 01/07/23 at 7:00 P.M. The Administrator stated that behavior from the husband was inappropriate, but she would not say it was verbal abuse. The Administrator was asked what she would consider to be verbal abuse and indicated screaming and yelling. The nurse's progress note was reviewed with the Administrator again and she confirmed that should have been considered verbal abuse. The Administrator denied the incident was reported to her but did confirm they had a unit manager by the first name (LPN #250) who was identified by LPN #55 as having reported the incident to. The Administrator reported alleged perpetrators in abuse allegations can be a resident's family member. Being married to someone did not exclude them from being able to abuse that person verbally or physically. The Administrator confirmed the unit manager should have made her of and the DON aware of the incident so it could have been reported and investigated. b. A review of Resident #76's progress notes revealed a nurse's note by LPN #61 on 01/12/23 at 7:58 A.M. that indicated the nurse, and the aides were in the dining room area during breakfast and the morning medication pass. An unidentified aide came to the nurse and reported Resident #76's husband told the resident to straighten the F*** up and grabbed her hand throwing it down on the table. The aide also heard him asking Resident #76 to keep eating even though the resident said she was done. He then told Resident #76 to put the F****** food in her mouth and he started spooning the food into her mouth. The nurse indicated she heard the husband tell Resident #76 that she needed to stop being a F****** B**** and use her God D*** walker. The husband said all those things in a hushed tone and acted totally different and nice to Resident #76 when he noticed staff were watching him. A late entry note by LPN #61 dated 01/12/23 at 7:30 A.M. revealed the nurse assessed Resident #76 for injuries after the previous incident. No injuries were noted, and the resident did not show signs of distress at that time. The nurse redirected the husband and told him that he could not touch residents like that, regardless of whether they were their spouse or not. On 01/25/23 at 10:30 A.M., an interview with LPN #61 revealed she was not sure if what she witnessed on 01/12/23 was abuse or not. She stated it was not okay to do to someone that was not of sound mind. LPN #61 indicated she did report the incident to the DON and the DON came back to talk to her about her documentation. LPN #61 alleged the secured unit's unit manager (LPN #79) was there at the time she talked to the DON. The DON reviewed the nurse's note and told staff to intervene and redirect. Then and only then were they able to escort the husband off the property or to call the local law enforcement if he did not change his behavior. LPN #61 then said the DON told her they do not use the word abuse. LPN #61 felt the situation met the definition of verbal and physical abuse. LPN #61 felt the husband was willful in his intent and changed his tone when the staff were present. On 01/25/23 at 12:02 P.M., an interview with LPN #79 revealed he was the unit manager for both the secured unit and the rehabilitation unit. He stated he was aware of the incident that occurred on 01/12/23 between Resident #76 and her husband. LPN #61 told him about it and he told the DON. LPN #79 confirmed the DON kept telling staff to redirect and if they felt the husband was a threat then they could call the local law enforcement. LPN #79 reported he would consider the incident that occurred on 01/12/23 between Resident #76 and her husband to be abuse. LPN #79 was not sure why that incident on 01/12/23 was not reported to the State agency or further investigated. LPN #79 denied he heard the DON tell LPN #61 they did not use the word abuse there. On 01/25/23 at 2:13 P.M., an interview with the Administrator revealed she was not made aware of the incident that occurred with Resident #76 and her husband on 01/12/23 at 7:58 A.M. The Administrator had reviewed the note and indicated the staff intervened during that incident between the husband and Resident #76. The Administrator indicated Resident #76 did not show any signs of being in distress nor did she have any signs or symptoms of any injuries. c. A review of the local law enforcement's report for a suspicion of sexual abuse on 01/21/23 involving Resident #76, as perpetrated by her husband, revealed the Sheriff's Deputy had interviewed LPN #88 about an incident that occurred that afternoon at 3:00 P.M. During LPN #88's interview, it was determined there had been other issues that had come up of a sexual nature between Resident #76 and her husband. The incident mentioned was indicated to have happened last night (01/20/23) and involved Resident #76's husband being caught lying in the resident's bed while naked. The statement provided by the nurse identified Medical Assistant #95 as the employee who witnessed that incident along with STNA 100. None of those prior incidents determined by staff had been reported to local law enforcement and staff had only documented them in the husband's visitors notes. A review of Resident #76's progress notes revealed it was absent for any documentation of an incident occurring the night of 01/20/23. The last progress note written on 01/20/23 was a social service note at 4:42 P.M. The next note was the nurse's note that documented the incident on 01/21/23 at 3:00 P.M. when sexual abuse was suspected. On 01/25/23 at 12:27 P.M., an interview with LPN #88 confirmed she indicated in her statement to the local law enforcement when interviewed about the sexual abuse suspicion that occurred on 01/21/23 that there had been a prior incident the night before. LPN #88 had been told earlier that day by a night shift aide (STNA #100) (before the sexual abuse incident occurred on 01/21/23 at 3:00 P.M.) that Resident #76's husband had been in bed with the resident the previous night naked. After that, the husband was asked to leave. LPN #88 stated that incident had been reported (to unidentified management staff) and what was told to staff was that was her (Resident #76's) husband and she was allowed to have sex with him. LPN #88 was not sure who said that but the person who did was management staff. Medical Assistant #95 was the one who relayed the information to her and STNA #100 was also a witness to that incident. LPN #88 stated she would not consider Resident #76 to be one who could consent to sex, and anything done would not be consensual. On 01/25/23 at 2:13 P.M., an interview with the Administrator revealed she did see in the local law enforcement report an incident was alleged to have occurred the night of 01/20/23. She confirmed it was reported Resident #76's husband was found in bed naked with her. The Administrator also confirmed there was no documentation in the progress notes to reflect an incident had occurred the night of 01/20/23. The Administrator denied they had a visitor's log for the resident's husband that would have recorded any notes. The Administrator stated she saw the same when reviewing the report and asked staff if there was such a thing and was told there was not. The Administrator denied being made aware of any inappropriate incidents that had occurred between Resident #76 and her husband on 01/20/23. On 01/25/23 at 2:58 P.M., an interview with Medical Assistant #95 confirmed he had witnessed an incident between Resident #76 and her husband the evening of 01/20/23. He stated he was on the unit to pass medications when STNA #100 asked him to stop by and tell Resident #76's husband what time it was and that visiting hours were going to be over. Medical Assistant #95 observed Resident #76's husband to be lying in bed with her without a shirt on and snuggling with the resident. Medical Assistant #95 could not see at that time if the husband was clothed from the waist down as he had a blanket over him. Medical Assistant #95's first thought was to provide them privacy, so he moved his cart across the hall to another resident's room. Medical Assistant #95 was still able to see into Resident #76's room and then observed the husband to get out of bed. Resident #76's husband exited the side of the bed closest to the window and furthest from the door. Medical Assistant #95 was able to see at that time the husband was completely naked. Medical Assistant #95 did not look close enough to see if the husband had an erection or not when he got out of the bed. Medical Assistant #95 reported Resident #76 was dressed in a gown, but he could not tell if she had a pull up incontinent brief on or not. Medical Assistant #95 was not concerned at that moment of abuse occurring. It was not until the resident began to cough that he felt abuse occurred. Resident #76's husband began to scream at the resident when she started coughing. He told the resident to shut the F*** up, you're being too loud. Resident #76 continued to cough, and the husband said, Oh my God, you are being so loud, why are you being so F****** loud. Medical Assistant #95 then recalled there had been many incidents with the husband. Medical Assistant #95 had seen the husband in his car with the window down as he was reporting to work and coming into the building. Medical Assistant #95 said the smoke reeked of marijuana and he saw the husband drinking beer. Medical Assistant #95 was not sure why the facility was allowing Resident #76's husband to come and go as he pleased. The husband even had the code to the secured unit to be able to enter and exit at will. Medical Assistant #95 felt what he witnessed of the husband screaming at the resident was abuse. Medical Assistant #95 indicated he informed the nurse (RN #550) who was on duty at the time but was not sure if she passed it along. Medical Assistant #95 stated that nurse was good about reporting things when needed. Medical Assistant #95 stated he told the nurse word for word what he had heard and saw. d. A review of Resident #76's progress notes revealed a late entry nurse's note dated 01/22/23 at 11:55 A.M. by LPN #88. The late entry was for 01/21/23. The nurse indicated, upon entering Resident #76's room to complete a skin assessment following the incident that involved suspected sexual abuse on 01/21/23, a metal chained leash with a collar attached was seen on the resident's bedside table. The nurse indicated in her note, to the knowledge of the staff that were on duty, no dog had been brought to the facility by Resident #76's husband. It was removed from the room and secured at the nurse's station. On 01/25/23 at 8:59 A.M., an interview with STNA #120 revealed Resident #76's husband was known to make gross sexual comments to the resident when he visited. STNA #120 reported having knowledge of Resident #76's husband having a dog chain with a collar on at one time. He placed the collar around his neck and had Resident #76 hold the metal chained leash part and acted like she was walking him around. He did that in the dining room on the secured unit in front of staff and other residents. STNA #120 recalled the husband making a comment for everyone to look at him saying I'm her B****. STNA #120 felt his behavior was inappropriate but did not report it as potential abuse. On 01/25/23 at 12:02 P.M., an interview with LPN #79 revealed he was the unit manager for the secured unit. LPN #79 denied he had been made aware of any incident occurring with Resident #76's husband that involved a dog collar. LPN #79 saw the progress note that mentioned the dog collar but was not aware of it being used in a sexual manner. LPN #79 stated, if the leash and dog collar was used in the manner that STNA #120 described it to be, that would not be appropriate. LPN #79 stated if he had been made aware he would have shut that down and would have asked Resident #76's husband to leave. LPN #79 felt it would be humiliating and upsetting to the resident if that occurred. LPN #79 stated he was aware there were times the resident's husband would be in the building smelling of alcohol. LPN #79 stated Resident #76's husband admitted to drinking one or two beers before coming into the facility and smoking marijuana. If the husband was doing those things and was belligerent, he would ask him to leave or call local law enforcement. LPN #79 revealed he considered Resident #76's husband to be disruptive when there. On 01/25/23 at 12:27 P.M., an interview with LPN #88 confirmed she wrote the late entry nurse's note on 01/22/23 at 11:55 A.M. about the leash and dog collar. When she asked the aides about that, STNA #120 had told her the husband put it on himself and had Resident #76 hold the leash part. The husband would then say see she's not my B****, I'm her B****. LPN #88 felt the incident with the dog collar was inappropriate. LPN #88 stated that behavior would be upsetting and humiliating using the reasonable person concept. On 01/25/23 at 2:13 P.M., an interview with the Administrator revealed she had not been notified of there being any incident involving a leash and a dog collar. The Administrator stated if she would have been made aware of that incident, she would have made Resident #76's husband leave. The Administrator reported that type of behavior would be inappropriate in front of anyone. The Administrator then stated what people do at home was their own business but in a living community it was inappropriate. The Administrator indicated she could not say if the resident would have been humiliated or upset by the incident. The Administrator was then asked, if her husband had done that to her in front of others, would it be humiliating and upsetting to her. The Administrator replied that it would be. e. A review of facility self-reported incident (SRI) tracking number 231321 dated 01/21/23 revealed an allegation of sexual abuse was made with a staff member being the initial source of the allegation/ suspicion. The alleged perpetrator was identified as being a family member/ visitor. The involved resident was indicated to be Resident #76, and the alleged perpetrator was her husband. The date and time of the occurrence was on 01/21/23 at 3:00 P.M. in the resident's room. The resident was noted to have dementia and was not able to provide any meaningful information wh [TRUNCATED]

Based on record review, facility policy and procedure review and interview the facility failed to provide timely and adequate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Actual harm occurred on 07/02/21 when Resident #75, who was severely cognitively impaired and required staff assistance for bed mobility and transfers, sustained a fall which resulted in bruising and swelling to her hip but was not immediately sent to the hospital for evaluation/treatment. From 07/02/21 to 07/09/21 the resident exhibited increased pain and agitation, yelling out for help and rated her pain up to a nine on a scale of one to 10 (with 10 being the worst pain). The resident was transferred to the hospital on 07/09/21 (seven days after the fall) and diagnosed with an acute closed communicated displaced right femoral interochanteric fracture requiring surgical repair and a severe displaced subacute fracture of left hemipelvis. The resident was hospitalized from 07/09/21 to 07/12/21. This affected one resident (#75) of four residents reviewed for falls. Findings include: Review of the medical record for Resident #75 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 07/19/21 revealed Resident #75 had severely impaired cognition. The assessment revealed the resident required extensive assistance from two staff members for bed mobility and was totally dependent on staff for transfers. Review of a progress note, revealed on 07/02/21 at 1:30 P.M. Resident #75 was found lying on the floor beside her bed. Range of motion was completed for all four extremities and found to be at baseline. The resident reported discomfort in her legs and feet, which the nurse noted was the resident's baseline for transfers and turning. Notifications occurred appropriately. On 07/02/21 at 1:44 P.M. the resident was given [MEDICATION(S)] for generalized discomfort, at 3:00 P.M. Following the administration of pain medication, the resident's pain decreased to a two on a scale of one to 10. On 07/02/21 at 4:41 P.M. the resident was administered [MEDICATION(S)] for increased anxiety and at 4:44 P.M. she was given [MEDICATION(S)] for pain to bilateral legs and feet, the note indicated staff were unable to rate her pain at that time due to her cognitive impairment. On 07/02/21 at 5:53 P.M. the resident was administered [MEDICATION(S)] as the [MEDICATION(S)] ([MEDICATION(S)]) was ineffective and the resident was noted to have more pain than baseline. The resident was assessed to have pink and purple bruising to the top anterior right thigh with slight swelling, however, the note indicated range of motion remained at baseline. The physician was notified of the new findings. The physician indicated to continue with as needed pain meds and stated the resident would be seen on Monday 07/05/21. The physician advised staff to call for increased pain or pain medication being ineffective. Review of Certified Nurse Practitioner #422's notes, with a date of service on 07/02/21 and signed 07/05/21 revealed nothing related to the resident's fall, pain or injury. Further review of the progress notes revealed on 07/05/21 the resident received [MEDICATION(S)] at 8:05 A.M. for generalized pain and pain in buttocks, she received [MEDICATION(S)] at 10:20 A.M. after yelling out about pain all over, and at 3:33 P.M. she received [MEDICATION(S)] for generalized discomfort. Review of the hospice nurse's note, dated 07/07/21 revealed the hospice aide reported the resident had a new bruise on her right thing. When discussed with the nurse it was indicated this was the result a recent fall in the previous week and the nurse reported the resident's pain and anxiety mediations were adequate at the time. In an addendum dated 07/13/21 the hospice nurse documented the hospice aide reported the fall was on 07/05/21 and not the previous week. Review of the hospice nurse's notes dated 07/08/21 revealed the resident was experiencing severe pain intermittently in her right leg, she stated the duration was unable to be determined and the pain was assessed using the Face, Legs, Activity, Cry, Consolability (FLACC) tool. On 07/08/21 at 12:23 P.M. the resident was assessed to have continued purple and yellow bruising to the right hip, thigh, and lower leg into the ankle which was noted from her previous fall. On 07/08/21 at 1:32 P.M. the resident was administered [MEDICATION(S)] for generalized and bilateral leg pain, she was also given [MEDICATION(S)] at that time. In addition, the note revealed the facility called Buckeye Hospice to update them on the resident's bruising. Hospice staff indicated a nurse would be sent to see the resident. On 07/08/21 at 3:40 P.M. the Hospice nurse arrived to see the resident regarding her right lower extremity and increased pain. New orders from hospice were received to increase [MEDICATION(S)] dose and the POA was updated. The resident received [MEDICATION(S)] at 4:33 P.M. for generalized discomfort. On 07/09/21 at 11:44 A.M. the CNP assessed the resident and recommended an x-ray of the right leg. X-ray staff arrived at 4:58 P.M. The progress note on 07/09/21 at 6:00 P.M. indicated the resident was ordered an x-ray to the right hip due to increased bruising to her right lower extremity on that day, and it was discovered she had a right hip fracture. Hospice and Physician #424 were notified and the physician gave an order to send the resident to the emergency room . A note on 07/09/21 at 6:03 P.M. revealed Hospice Registered Nurse #427 notified the facility and the resident's power of attorney (POA) agreed to the resident being sent to the hospital. Review of CNP #423's note, dated 07/09/21 revealed Resident #75 was seen for swelling an ecchymosis to the right leg. The nurse documented the resident fell on [DATE], ecchymosis and worsening [CONDITION(S)] to right hip and leg. CNP #423 documented the resident denied pain upon examination. An x-ray of the right leg was ordered. However, review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. for pain rated a nine out of 10, at 3:10 P.M. for a pain rated a seven out of 10 and at 6:30 P.M. for a pain rated an eight out of 10. Review of the hospice nurse's note, dated 07/09/21 revealed the floor nurse notified hospice the bruise and knot on the resident's right leg from a fall on Monday had progressed to bruising and swelling of the whole right leg. A visit was made to the facility to evaluate and the floor nurse stated the resident was just put into bed and was difficult to get settled due to pain. The hospice physician was consulted and [MEDICATION(S)] was increased. An addendum dated 07/13/21 revealed the hospice nurse had asked the facility nurse if an x-ray had been performed following the fall. The facility nurse revealed one had not been done as the resident was a hospice patient and had originally admitted with a fractured pelvis and comfort care. The hospice nurse's note, dated 07/10/21 revealed the facility called to notify them an x-ray was performed and the resident had a fractured hip. The physician had recommended the resident be sent to the hospital. The resident's power of attorney was notified of the results of the x-ray and asked if he wanted to send her to the hospital, he agreed Review of the hospice aide note, dated 07/09/21 revealed the resident had been complaining of leg and bottom pain, her right leg was very swollen and bruised. The hospice aide said the facility aides reported they had kept the resident in the recliner because they were afraid to put her in bed. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed she received [MEDICATION(S)] Sulfate Solution 20 mg per milliliter (ml) for pain as needed eight times throughout the month (once on 06/08/21, twice on 06/16/21, twice on 06/19/21, once on 06/24/21, once on 06/29/21, and once on 06/30/21). Additionally, Resident #75 received [MEDICATION(S)] 50 mg as needed for pain rated six to ten on seven occasions in June (once on 06/01/21, twice on 06/06/21, once on 06/09/21, once on 06/10/21, once on 06/16/21, and once on 06/22/21). Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . She received [MEDICATION(S)] sulfate 20 mg/ml on 07/02/21 at 1:44 P.M. and 5:53 P.M. for a pain level of four, 07/03/21 at 10:30 A.M. for a pain of eight, 07/04/21 at 2:04 P.M. for a pain of nine and at 6:41 P.M. for a pain of nine, 07/05/21 at 10:20 A.M. for a pain of five and at 3:33 P.M. for a pain of three, 07/06/21 at 10:00 P.M. for a pain of five, 07/07/21 at 10:20 A.M. for a pain of nine and at 2:45 P.M. for a pain of seven, 07/08/21 at 9:32 A.M. for a pain of four, 1:32 P.M., for a pain of five and 4:33 P.M. for a pain of three, and on 07/09/21 at 1:00 P.M. for a pain of nine, 3:10 P.M. for a pain of seven, and 6:30 P.M. for a pain of eight. The resident received [MEDICATION(S)] 50 mg on: 07/02/21 at 4:44 P.M. for a pain of five, on 07/05/21 at 8:05 A.M. for a pain of three, on 07/06/21 at 1:58 P.M. for a pain of six, and on 07/08/21 at 1:32 P.M. for a pain of five. Review of the care of plan, updated 07/22/21 revealed the resident was at risk for alteration in comfort related to fracture of the superior rim pubis and right femur fracture. Interventions included providing medications as ordered to manage pain, monitoring for adverse effects of pain medications, monitoring the effectiveness of interventions, monitoring for increased pain and notifying the physician as needed and repositioning the resident for comfort. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . She was found to have an acute closed communicated displaced right femoral interochanteric fracture, she had an open reduction and internal fixation (ORIF) surgical repair. Additionally, the resident was assessed to have a severe displaced subacute fracture of left hemipelvis with no surgical intervention provided. The physician note documented the resident was found to have a right hip fracture shortly after her fall. The physician documented the resident had little pain initially that increased after several days and she developed ecchymosis. On 09/22/21 at 3:07 P.M. interview with Buckeye Hospice Registered Nurse (RN) #388 revealed she had been unaware of Resident #75's fall until a hospice aide notified her of a bruise. Buckeye Hospice RN #388 said hospice was not made aware of the fall when it occurred, and stated the facility was not great at notifying them of changes. She was under the impression the fall occurred on 07/05/21. Buckeye Hospice RN #388 said she saw the resident once a week but went in to evaluate the resident after learning of the bruise. Upon visiting the facility, she was informed of the fall, she stated on her original visit the facility had not reported a concern with pain. Buckeye Hospice RN #388 said she had asked the facility about an x-ray, but they said they did not get one because she was hospice. Buckeye Hospice RN #388 reported she told them that was not an appropriate reason not to get an x-ray and the facility then stated there were not enough signs to order one. On 09/21/21 at 3:41 P.M. an attempted interview with Resident #75 revealed the resident said she hurt. However, the resident was unable to identify where or how much she hurt and was quickly distracted. Before the end of the conversation the resident again began saying she hurt. On 09/21/21 at 3:43 P.M. interview with Licensed Practical Nurse (LPN) #382 revealed Resident #75 was unable to tell staff where her pain was at or how severe it was. LPN #382 revealed staff use observations to assess when the resident was in pain such as yelling out, and then used a pain scale (FLACC) from the electronic medical record to number her pain based on the signs. LPN #382 reported she had recently given Resident #75 some pain medications because she had been yelling out. On 09/22/21 at 4:10 P.M. interview with the Director of Nursing (DON) verified Resident #75 had sustained a fall on 07/02/21. The DON agreed the resident's as needed pain medications were used more from 07/02/21 to 07/09/21 when comparing her use in June 2021. She stated she knew Resident #75 must have been in pain and that was why she had been advocating for the CNP to see her. In further interviews with the DON on 09/23/21 at 10:43 A.M. and 2:10 P.M. she reported the resident reported pain of eight and nine multiple times in June, so she did not think there was really an increase following her fall. However, she agreed the resident received [MEDICATION(S)] three times a day in June and July and seemingly needed less [MEDICATION(S)] and [MEDICATION(S)] in June to cover this pain. The DON then stated the increase in as needed: pain medications were because they were being used as a preventative measure, as staff figured the resident would be in pain from her fall. The DON confirmed the progress note on 07/02/21 revealed Physician #424 wanted to be notified if the resident experienced increased pain. She additionally confirmed the hospice nurse saw Resident #75 on 07/08/21 for increased pain and there was nothing to indicate the physician was notified. The DON indicated that due to the new [MEDICATION(S)] order, the hospice nurse would have notified the hospice physician. She confirmed there was nothing to indicate the resident's physician, Physician #424, was notified. On 09/22/21 at 4:47 P.M. interview with Physician #424 revealed he had been on vacation when he was initially notified of Resident #75's fall. He stated he originally planned on seeing her the Monday after the fall (07/05/21) but did not realize he would still be on vacation. He would have expected the facility to ask one of the CNP's to see the resident when she started bruising. Physician #424 denied knowing the resident experienced bruising and swelling beginning hours after the fall. He stated if he had been aware of that he would have ordered an x-ray immediately. The physician thought that this case had been an example of poor communication with the involved parties. Physician #424 stated on 07/09/21 the nurses told him the resident began complaining of pain in the middle of the week. He stated Resident #75 had been receiving [MEDICATION(S)], so she probably had not been in too much pain until the fracture displaced. The physician denied ever speaking to the resident's family. On 09/21/21 at 5:21 P.M. interview with Resident #75's POA revealed he was notified of the fall originally and was called a few days later about getting an x-ray. The POA reported when the results came back, he agreed to send the resident to the hospital. Review of the FLACC scoring table revealed resident's behaviors are scored based on the severity to determine a pain score. Behaviors included breathing, negative vocalization, facial expression, body language, and consolability. Review of the policy undated Status Change in Resident Condition- Notification policy revealed the facility nurse was to notify the resident's attending physician when there was a significant change in resident's physical, mental, or psychosocial status, when there was a need to alter the resident's treatment significantly, or when deemed necessary or appropriate in the best interest of the resident.

Based on observation, record review, facility policy and procedure review and interview the facility failed to implement individualized and comprehensive nutritional interventions to ensure residents maintained acceptable parameters of nutrition, failed to ensure re-weights were obtained to identify actual weight changes and/or failed to ensure nutritional supplements were provided as ordered. Actual harm occurred when Resident #73, who had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected three residents (#73, #63 and #29) of five residents reviewed for weight loss and nutrition. Findings include: 1. Review of the medical record for Resident #73 revealed an admitted [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed the resident was on a regular diet with regular texture and thin liquids. Review of the weight record for Resident #73 revealed on 04/15/21 (admission) the resident weighed 187.6 pounds. On 07/07/21 the resident weighed 173.8 pounds, on 08/10/21 the resident weighed 170.6 pounds, on 08/17/21 the resident weighed 163.8 pounds which demonstrated a continued weight loss following admission. On 08/30/21 the resident weighed 167.8 pounds. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/30/21 revealed Resident #73 was cognitively impaired and required supervision and set up assistance from staff for meals. The assessment revealed the resident had weight loss and no problems with teeth, chewing or swallowing. Review of the progress note, dated 09/01/21 at 2:17 P.M. by Registered Dietitian Nutritionist (RDN) #389 revealed Resident #73's current body weight was 161.8 pounds indicating a continued undesired weight loss of six pounds or three percent in one week related to inadequate oral intake. Resident #73's intake was 0-100% with refused meals noted. The note indicated the resident was accepting current supplement. The dietitian recommended the physician consider adding the medication [MEDICATION(S)] (anti-depressant medication also used for appetite stimulant) for augmentation of appetite. There was no evidence the physician was aware or addressed the recommendation for appetite stimulant at this time. On 09/02/21 the resident weighed 162.4 pounds and on 09/07/21 the resident weighed 157.8 pounds. Resident #73 sustained a 29.8 pound/15.88% severe weight loss from admission through 09/07/21. Review of the progress note, dated 09/06/21 at 2:20 P.M. by RDN #389 revealed Resident #73 had a significant weight change. The current body weight was 162.4 pounds on 09/02/21, 165.6 pounds on 08/04/21 and 181.2 pounds on 06/02/21 indicating a significant unplanned weight loss of 18.8 pounds or 10 percent over three months related to inadequate intakes. At this time the resident was on a house supplement of 237 milliliter (ml) two times daily. Current meal intake was 0-100% but noted the resident was taking 100% of the supplement and adequate fluids. The dietitian recommended an appetite stimulant and noted the physician was aware of the weight loss and recommendations. However, there was no evidence the physician addressed the recommendation for the appetite stimulant. Record review revealed on 09/16/21 supplements for weight loss and nutrition included eight ounces of super coffee every evening with dinner and 237 milliliters (ml) of house supplement three times daily were ordered. Review of the progress note, dated 09/16/21 at 8:00 A.M. revealed the physician was notified of a significant weekly weight change of eight pounds. A note by Registered Dietitian Nutritionist (RDN) #389, dated 09/15/21 at 3:28 P.M. revealed the resident's current body weight on 09/15/21 was 149.8 pounds indicating a continued, significant and unplanned weight loss of eight pounds or five percent in one week related to poor oral intake. The note indicated the resident continued to have agitation at meals and refusals but was taking house supplement decently well. The dietitian recommended an appetite stimulant, super coffee at breakfast, and to increase the house supplement plus 237 ml to three times daily to augment intake. The note revealed to continue to monitor weight weekly. There was no evidence the physician addressed the recommendation for the appetite stimulant. Review of the progress notes from 08/01/21 through 09/22/21 revealed no IDT note addressing Resident #73 significant weight loss, continued weight loss or evidence of the implementation of individualized and comprehensive interventions to prevent additional weight loss and/or to promote weight gain for the resident. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's meal intakes from 08/24/21 through 09/22/21 revealed intakes were recorded by State tested Nursing Assistant (STNA) staff. The intake records revealed the resident's intakes varied from 0-100% with multiple refusals for an average of less than 50% of meals eaten. Observations made from 09/20/21 through 09/24/21 of meal times revealed Resident #73 was not up in the dining room for breakfast on any date and was observed only up for lunch on 09/23/21 and 09/24/21. During the meal observations, the resident was observed to only pick at his food and not eat. There was no evidence of staff supervision being provided for the duration of each meal observed. On 09/22/21 at 8:17 A.M. interview with STNA #331 revealed the resident was not a morning person and rarely ate breakfast. The STNA revealed the resident was usually up out of bed between 10:30 A.M. and 11:00 A.M. but was not offered a breakfast meal at that time as lunch was at 11:00 A.M. On 09/22/21 at 11:22 A.M. interview with RDN #389 revealed nutritional recommendations were written and given to the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) and then the ADON contacted the physician to get orders for the recommendation(s) and documents any changes. RDN #289 confirmed there was no documentation the physician addressed the appetite stimulant recommendation and no evidence of comprehensive and individualized nutritional interventions to prevent additional weight loss for Resident #73 and/or to promote weight gain. In addition, RDN #389 revealed she had not spoken with Resident #73's family in regards to nutritional interventions or alternative methods of feeding to address the resident's continued unplanned severe weight loss. On 09/22/21 at 3:43 P.M. interview with STNA #340 revealed Resident #73 ate depending on his mood. The STNA indicated in her opinion the resident had not been eating well since his wife had not been in the facility to visit. On 09/23/21 at 2:33 P.M. interview with the ADON confirmed the physician did not address the recommendation for an appetite stimulant as recommended by RDN #389 in September 2021. In addition, there was no evidence the physician provided any other individualized interventions to prevent additional weight loss for the resident and/or to promote weight gain. 2. Review of Resident #63's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #63's monthly physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #63's annual MDS 3.0 assessment, dated 01/05/2021 revealed the resident's speech was clear, she made herself understood, understands others, her vision was adequate with corrective lens and her cognition was intact. Resident #63 had minimal depression, no indicators of [CONDITION(S)] or behaviors and did not reject care. Resident #63 was assessed to require supervision with set up assistance from staff for meals. The assessment revealed the resident was 63 inches tall, weighed 220 pounds, had no weight changes and was not on a planned diet for weight change. Review of Resident #63's weight record revealed on 01/05/2021 she weighed 219.6 pounds. On 02/03/2021 she weighed 211.9 pounds. On 03/02/2021 she weighed 208 pounds. On 04/06/2021 the resident's weight was 198 and there was no re-weight obtained, following a 10 pound weight loss in one month. Review of Resident #63's current plan of care for nutrition revealed Resident #63 was at risk for malnutrition and/or dehydration. Resident #63 was obese, received superfoods, was on a therapeutic diet and received insulin. The care plan revealed on 04/08/21 Resident #63 has a significant weight loss in the past three to six months and superfoods were added. Continued review of the resident's weights revealed on 05/03/2021 she weighed 201 pounds. On 06/01/2021 she weighed 203.2 pounds and on 07/02/2021 her weight was 197.3 with no evidence a re-weight was obtained. On 08/02/2021 the resident weighed 187.4 and no re-weight was obtained. On 08/02/21 the resident's plan of care was updated to reflect the resident had again experienced a significant weight loss in the past one and six months. Review of Resident #63's nutritional assessment, dated 08/02/2021 revealed Resident #63 had an unplanned weight loss. The note indicated with the resident's intake and nutritional supplement her weight should stabilize and no recommendations were made at that time. Review of Resident #63's quarterly MDS 3.0 assessment, dated 08/20/2021 revealed the resident had an unplanned weight loss and weighed 187 pounds. On 09/08/2021 Resident #63 weighed 195.4 pounds, which was an eight pound weight gain since August 2021. No re-weight was obtained to verify the accuracy of the weight or identify actual weight changes for the resident. On 09/22/21 at 10:49 A.M. interview with the Director of Nursing (DON) revealed Resident #63 wanted to lose weight and had lost about 30 pounds. However, this was not reflected in the resident's plan of care or dietary notes. The DON revealed Resident #63 would only eat one chicken strip as the resident was very concerned about her blood sugars. On 09/22/21 at 11:39 A.M. interview with RDN #389 revealed she was not notified (dates not provided) that Resident #63 wanted to lose weight and was trying to lose weight. RDN #389 confirmed there was no evidence Resident #63 had re-weights obtained when she gained or lost five pounds or more. In addition, RDN #389 was unable to provide evidence Resident #63 had received education about safe weight loss and balanced diets. Review of the facility undated Weight Policy revealed re-weights would be completed on any weight change of five pounds or more. Re-weights would be done immediately (within 72 hours). 3. Review of Resident #29's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #29's September 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/21/21 at 4:00 P.M. Resident #29 was observed to return from [CONDITION(S)]. The resident did not received the house supplement as ordered at that time. Review of Resident #29's September 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The supplement was not given as ordered on 09/02/21, 09/04/21, 09/07/21, 09/09/21, 09/11/21, 09/14/21, 09/16/21, 09/18/21 or 09/21/21. On 09/22/21 at 9:31 A.M. interview with Licensed Practical Nurse (LPN) #383 revealed Resident #29 does not receive her noon nutritional supplement on Tuesdays, Thursdays or Saturdays when she goes to [CONDITION(S)]. On 09/22/21 at 11:32 A.M. interview with RDN #389 revealed she was not aware Resident #29 was not receiving her noon nutritional supplement on Tuesdays, Thursdays or Saturdays. RDN #389 confirmed the resident should still be receiving the nutritional supplement four times a day even on the days she received [CONDITION(S)]. On 09/22/21 at 11:41 A.M. interview with the Director of Nursing confirmed the facility was not giving Resident #29 the nutritional supplement as it was ordered.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and interview, the facility failed to maintain fall safety interventions for Resident #64 to prevent a fall with injury. Actual Harm occurred on 04/20/21 when Registered Nurse (RN) #213 left the resident's room after providing care and failed to put the resident's bed in the lowest position, place a mat to the floor and a wedge cushion to the left side of the resident's bed resulting in the resident falling out of bed and sustaining a facial laceration requiring stitches, a nose fracture and a closed head injury. This affected one resident (#64) of three residents reviewed for falls. Findings include: Review of Resident #64's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, ataxia (the loss of control of body movements), hypertension and [CONDITION(S)]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/19/21 revealed Resident #64 had severely impaired cognition, required extensive assistance of two staff for bed mobility and was totally dependent on staff for transfers. Review of the fall risk assessment, dated 03/22/21 revealed Resident #64 had a very high potential for falls. A plan of care, dated 03/22/21 revealed Resident #64 was at risk for falls related to dementia, impaired balance, poor safety awareness, being unaware of limitations and a history of falls with fracture. Interventions included a low bed, placing a mat on the floor next to the bed and a wedge cushion to the left side of the bed. Review of a nursing progress note, dated 04/20/21 at 4:58 P.M. revealed Resident #64 had a fall. The resident was observed to have confusion, swelling to her nose, a puncture wound to her forehead and was stating pain to her head. Resident #64's primary care physician provided an order to send the resident to the emergency room . At 11:30 P.M., the resident returned from the hospital with stitches to a facial laceration, a diagnosis of a nose fracture and a closed head injury. Record review revealed Resident #64 sustained a fall on 04/20/21. Review of the facility fall investigation revealed on 04/20/21 at 4:58 P.M., Resident #64 was observed on the floor. The resident had previously been in bed. The resident did not know why she was on the floor. The fall investigation revealed fall interventions were not in place at the time of the fall. On 05/26/21 at 10:06 A.M. interview with the Director of Nursing (DON) revealed Resident #64 had been seen by the wound nurse, Registered Nurse (RN) #213, immediately prior to the fall on 04/20/21. The DON revealed RN #213 had left the resident's room without ensuring fall interventions were in place and when she returned to the room, the resident was observed on the floor. On 05/26/21 at 10:10 A.M. interview with the Administrator verified the fall interventions care planned for Resident #64 were not in place at the time the resident fell from bed and sustained injuries. Review of the facility policy titled Fall Prevention, dated February 2021 revealed appropriate interventions would be initiated to prevent falls. The deficient practice was corrected on 04/22/21 when the facility implemented the following corrective actions: · Resident #64 was sent to the emergency room for evaluation and treatment on 04/20/21. · On 04/20/21 the RN #213 was immediately educated by the Assistant Director of Nursing of the importance of having resident fall interventions in place. · On 04/20/21 a new intervention was initiated by the Assistant Director of Nursing to pad the side of the air conditioner in Resident #64's room. · On 04/20/21 the Assistant Director of Nursing initiated education to staff regarding reading the kardex prior to caring for residents and having fall interventions in place as appropriate. · On 04/20/21 at 11:30 P.M., Resident #64 returned from the emergency room . All fall safety interventions were in place and determined to be appropriate at that time. · On 04/21/21 the Director of Nursing and nursing management team initiated and completed whole house audits to ensure residents' fall interventions were in place and reflected on care plan and kardex as appropriate. · On 04/21/21 the Director of Nursing and nursing management team initiated and completed whole house audits on residents' fall risk assessments and ensured these were current. · From 04/20/21 through 04/21/21 the Director of Nursing and nurse management team completed education with direct care staff regarding having residents' fall interventions in place as appropriate. · On 04/21/21 the Director of Nursing initiated audits to ensure fall interventions were in place. These audits would be completed three times per week for two weeks, then weekly times four weeks and then as determined as necessary. · On 04/22/21 RN #213 was given a notice of corrective action regarding Resident #64's fall due to interventions not being put in place prior to her leaving the room. Education was provided at that time by the Assistant Director of Nursing. This deficiency substantiates Complaint Number OH 305.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, The Department of Health and Human Services, Center for Medicare and Medicaid (CMS) Memo QSO 20-20-ALL dated 03/20/20, Nursing Home Guidance from the Centers for Disease Control (CDC), review of the facility COVID-19 testing log, review of the facility Infection Control/Isolation policy and procedure, observations and staff interviews the facility failed to implement timely, effective and recommended infection control practices following the identification of new COVID-19 positive resident cases to prevent the exposure/transmission of COVID-19 to residents on the secured memory care (300/400 halls). The facility also failed to ensure proper use of personal protective equipment (PPE) and hand hygiene to prevent the spread of COVID-19. This resulted in Immediate Jeopardy on 12/14/20 at approximately 7:00 A.M. when the facility failed to properly isolate residents who tested positive for COVID-19 creating an environment that exposed residents, who had tested negative for COVID-19 to [MEDICAL CONDITION]. The facility identified six residents, Resident #9, #33, #46, #47, #58, and #65 who resided on the secured memory care unit (300/400 halls) who tested positive (on 12/14/20) for COVID-19 via facility point-of-care (POC) testing. At 9:17 A.M. Resident #9, #47, and #65, who had tested positive at 7:00 A.M., were observed in the dining room/common area with 10 residents, Resident #3, #11, #20, #37, #40, #55, #68, #70, #73 and #82 who had tested negative for COVID-19 on 12/14/20. Staff reported Resident #58, who also tested positive for COVID-19 at 7:00 A.M., had eaten his breakfast in the common dining room as well but had been assisted by staff back to his room prior to the 9:17 A.M. observation. Observation of the unit and breakfast meal revealed the residents present in the area were not wearing any type of face mask/face covering and were not socially distanced in the common dining room area. On 12/14/20 a continued observation revealed Temporary Nurse Aide (TNA) #101 was assisting Resident #47, who tested positive (on 12/14/20) for COVID-19, back to her room by leading her by the arm. TNA #101 assisted the resident into bed and then left the room without removing her gown or surgical mask, cleaning her face shield, or performing hand hygiene. TNA #102 was observed pushing Resident #9 backwards in her wheelchair down the hallway into her room. TNA #102 left Resident #9's room without changing her PPE, cleaning her face shield, or performing hand hygiene. There was no evidence of isolation signs on the resident's doors, no PPE carts, or isolation cans/barrels in the resident's rooms or in the hallway near their rooms. TNA #101 reported she was aware some of the resident's had tested positive this morning, however she wasn't aware of which residents until just prior to this observation. TNA #102 reported she was just pulled to the secured memory care unit prior to the surveyor arriving to the unit. She was not aware which residents had tested positive from the testing done earlier that morning. The lack of current effective infection control practices during a COVID-19 outbreak placed 18 of 24 residents, (Residents #3, #10, #11, #20, #24, #25, #37, #40, #43, #52, #55, #68, #70, #73, #76, #82, #86 and #89) who resided on the secured memory care (300/400 unit) and who were identified by the facility as not having COVID-19 at risk for the likelihood of harm, complications and/or death. The census on the secured memory care unit was 24. On 12/14/20 at 2:04 P.M., the Regional Quality Assurance Nurse (RQAN) and Director of Nursing (DON) were notified Immediate Jeopardy began on 12/14/20 when four COVID-19 positive residents, Resident #9, #47, #58 and #65 were in the dining room/common area with 10 residents who had tested COVID-19 negative without evidence of social distancing or mask use. In addition, staff were observed providing direct care to two residents, Resident #47 and #9 who had tested positive for COVID-19 without following proper hand hygiene and PPE use. In addition, the facility failed to timely communicate the positive test results to the TNA staff who were providing direct care to the residents on the secure unit and failed to timely implement infection control measures to prevent exposure/spread of COVID-19 to additional residents on the secured memory care unit. The Immediate Jeopardy was removed on 12/15/20 when the facility implemented the following correction actions: · On 12/14/20 at 9:30 A.M., the Assistant Director of Nursing (ADON) and the DON transferred Resident #9, #65, #58, #47, #33 and #46 to rooms on the facility COVID-19 unit. The residents were placed on droplet isolation precautions per the Medical Director's (MD) order and CDC guidance. · On 12/14/20 at 9:35 A.M. the DON notified the MD of potential exposure to Resident #3, #37, #68, #73, #82 who were identified to be sitting at the table next to Resident #9, #58, and #65 in the dining room. The MD ordered these resident's to be placed in droplet isolation precautions. · On 12/14/20 at 9:45 A.M., the Maintenance Director disinfected all commonly touched surfaces (dining room tables, chairs, handrails, and doorknobs) utilizing the Clorox 360 electrostatic sprayer on the unit. · On 12/14/20 at 2:00 P.M. the remaining 13 residents, Resident #10, #11, #20, #24, #25, #40, #43, #52, #55, #70, #76, #86, and #89 who resided on the secured memory unit were placed in quarantine (droplet) isolation. · On 12/14/20 by 4:30 P.M., the licensed nurse re-assessed all residents on the secured memory unit for signs and symptoms of COVID-19. There were no positive findings at that time. · On 12/14/20 by 5:31 P.M. the DON completed education with the two TNAs, 41 State tested Nursing Assistants (STNA), nine Registered Nurses (RN), 19 Licensed Practical Nurses (LPN), one Dietary Manager, one Respiratory Therapist (RT), eight Dietary Aides (DA), six Housekeeper, three Activity Aides (AA), one Activity Director, two Physical Therapy Assistants (PTA), four Laundry staff, one Human Resource staff, two Certified Occupational Therapy Assistants (COTA), one Occupational Therapist (OT), and three Maintenance staff related to infection control/COVID-19. The facility identified five LPNs, one RN and three STNAs (as needed staff) who did not receive the education with a plan to ensure education was provided prior to returning to work. Education covered the following: Topic of In-Service: Infection control practices inside and outside of the building including but not limited to: o Frequent hand hygiene o Social Distancing o Signage o Barrels and Isolation Setup o Mask/face covering use o Following travel advisories from ODH and CDC o Limit movement throughout facility o Follow facility PPE protocols o Covid-19 methods of transmission o Signs and symptoms of COVID-19 o Stay home and notify facility should s/s of COVID-19 develop o When a resident test positive for COVID-19 staff must immediately place that resident into Droplet Precautions per the CDC guidance. o COVID-19+ residents should not be within 6 feet of other residents who are COVID-19 Negative at any point in time, this includes during mealtimes. o If COVID-19 Negative residents are exposed (Per CDC guidelines within 6 feet for 15+ minutes without appropriate PPE) they must be isolated immediately to prevent further spread of COVID-19. o Donning and Doffing of PPE protocol when caring for COVID-19 + residents o Dignity and Respect policy · On 12/14/20 the facility implemented a plan for the DON/Designee to perform audits for infection control practices including proper isolation practices and proper use of PPE donning/doffing, timely staff notification of positive COVID-19 residents, and to ensure new COVID-19 positive residents were isolated immediately. The audits will be completed three times a week for four weeks, then weekly thereafter to monitor for compliance. · On 12/14/20 the facility implemented a plan for all audit results to be reviewed by the Regional Quality Assurance Nurse weekly with re-education or audit changes made as needed. Any unusual audit findings will be reviewed by the Quality Assurance Program Improvement (QAPI) for prompt resolution. · On 12/15/20 from 10:55 A.M. to 11:07 A.M. interview with four staff, RN #100, LPN #103, Activities #104, and RN #105 revealed the staff interviewed were knowledgeable regarding infection control/COVID-19 and PPE use. Although the Immediate Jeopardy was removed on 12/15/20, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Finding include: Review of the Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memo QSO 20-20-ALL dated 03/20/20 revealed The Centers for Medicare & Medicaid Services (CMS) is committed to taking critical steps to ensure America's health care facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (COVID-19). As part of CMS guidance the Focused Infection Control Survey was made available to every provider in the country to make them aware of Infection Control priorities during this time of crisis, and providers and suppliers may perform a voluntary self-assessment of their ability to meet these priorities. The QSO Memo included additional instructions to Nursing Homes. We are disseminating the Infection Control survey developed by CMS and CDC so facilities can educate themselves on the latest practices and expectations. We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of COVID-19 .We also encourage nursing homes to voluntarily share the results of this assessment with their state or local health department Healthcare-Associated Infections (HAI) Program. Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and whom possible incidents of communicable disease or infections should be reported (42 CFR 483.80(a)(2)(i) and (ii). On 12/14/20 at 8:54 A.M., interview with DON revealed the facility was currently conducting COVID-19 testing in the facility due to an outbreak. Prior to testing on 12/14/20 the facility had 55 residents, 11 new resident admissions and 20 staff who had tested positive for COVID-19. On 12/14/20 the facility identified seven new residents, Resident #9, #14, #33, #46, #47, #58, and #65 who had tested positive for COVID-19 and two members of the staff. Of the seven residents who tested positive, six residents, Resident #9, #33, #46, #47, #58 and #65 resided on the secured memory care unit. Additional information obtained during the onsite survey revealed POC COVID-19 testing was done on the secured memory care (300/400 hall) by the DON at approximately 7:00 A.M. Results of the POC testing are immediate at the time of testing. Review of facility resident COVID-19 testing log dated 12/14/20 confirmed six residents, Resident #9, #33, #46, #47, #58 and #65 who resided on the secured memory care unit tested positive for COVID-19 on this date. On 12/14/20 beginning at 9:17 A.M. a tour of the facility secured memory unit (300/400 hall) with the DON revealed the breakfast meal was occurring in the common dining room area on the unit. Resident #9, #47 and #65 who had tested positive for COVID-19 during the 7:00 A.M. testing were observed in the dining room/common area with 10 residents, Resident #3, #11, #20, #37, #40, #55, #68, #70, #73 and #82 who had tested negative. During the observation, TNA #101 reported Resident #58, who had also tested positive for COVID-19 on this date had eaten his breakfast in the dining room this morning as well. The staff (TNA #101 and TNA #102) revealed they had assisted Resident #58 back to his room just prior to the 9:17 A.M. observation. At the time of the observation, the DON confirmed COVID-19 positive residents were in the dining room with COVID-19 negative residents as noted above. Continued observation with the DON of the common dining area revealed the table where the three positive residents, Resident #9, #58 and #65 had been sitting at for breakfast was less than three feet away from the next table were five negative COVID-19 residents, Resident #3, #37, #68, #73 and #82 were sitting. The residents were not wearing any type of facial covering or properly social distanced. The DON again verified there were six residents, Resident #9, #33, #46, #47, #58 and #65 who resided on the unit who had tested positive for COVID-19 that morning. Resident #33 and #46 were not in the dining room for breakfast because they were in their rooms asleep. On 12/14/20 an ongoing observation with the DON revealed TNA #101 was assisting Resident #47, who had tested positive (on 12/14/2) for COVID-19, back to her room by leading her by the arm. TNA #101 helped the resident into bed and then left the room without removing her gown, surgical mask, or cleaning her face shield. TNA #102 was observed pushing Resident #9 backwards in her wheelchair down the hallway into her room. After assisting Resident #9, TNA #102 left the resident's room without changing her PPE or cleaning her face shield. There was no evidence of isolation signs on the resident's doors, no PPE carts, or isolation cans/barrels in the resident's rooms or in the hallway near their rooms. These findings were confirmed by the DON at the time of the tour/observation. The DON directed both TNAs to the soiled utility area to discard their used PPE at the time of the observation. On 12/14/20 at 10:01 A.M. interview with TNA #101 and TNA #102 revealed TNA #101 reported she was aware some of the resident's in the facility had tested positive this morning, however she wasn't aware which residents until shortly before the surveyor arrived at the unit at 9:17 A.M. TNA #102 revealed she was just pulled to the secured memory care unit prior to the surveyor arriving. TNA #102 revealed she was not aware which residents on the unit had tested positive for COVID-19. The TNAs confirmed the residents were not spaced six feet apart during breakfast at each table or required to remain in their room for the meal. On 12/14/20 the facility was unable to provide any additional information related to why TNA #101 and TNA #102 were not notified timely of Resident #9, #33, #46, #47, #58 and #65 testing positive for COVID-19. In addition, no additional information was provided related to why Resident #9, #47, #58 and #65 were permitted to go to the common dining room area for the breakfast meal on 12/14/20 after testing positive for COVID-19 which resulted in the exposure of 10 additional residents who resided on the unit. Review of the facility policy for Infection Control/Isolation, dated 03/2020 revealed the purpose of the policy was to prevent the spread of infections within the facility using isolation precaution. Signs instructing visitors to report to the nurse's station before entering the room would be placed at the doorway of the resident's room. For droplet precautions the use of a surgical mask when within three feet of the resident and protective eyewear was required. The policy revealed to limit resident movement from the room to essential purposes only. If transport or movement was necessary, the resident must wear a mask. For airborne precaution use a N95 or respirator. The procedures for initiating isolation included to inform the staff members of the need for isolation, gather equipment, obtain table/cart for 24 hour supply of mask, gowns, etc. needed to maintain isolation, obtain appropriate signage and post outside the door, and check the room for hygiene supplies, toiletries, hand washing soap and paper towels. Notify the other departments that resident is in isolation. Review of the CDC Consideration for Memory Care Units in Long-term Care Facilities dated 05/12/20 revealed to try to keep the environment and routines as consistent as possible while still reminding and assisting with frequent hand hygiene, social distancing, and use of cloth face coverings if tolerated. Dedicate personnel to work only on memory care units when possible and try to keep staffing consistent. Limit the number or space resident's at least six feet apart as much as feasible when in a common area, and gently redirect residents who are ambulatory and are near other residents or personnel. Moving a resident with confirmed COVID-19 to a designated COVID-19 care unit can help to decrease the exposure risk of resident and health care personnel. If a resident with COVID-19 was moved from the memory care unit true to move familiar objects into the space before introducing the new space to the resident. Additionally, at the time a resident with COVID-19 had been identified, other resident's and personnel on the unit may have already been exposed or infected, and additional testing may be needed. Review of the CDC's Infection Control for Nursing Homes guidance, dated 11/20/20 revealed: Make necessary PPE available in areas where resident care is provided. o Consider designating staff responsible for stewarding those supplies and monitoring and providing just-in-time feedback promoting appropriate use by staff. o Facilities should have supplies of facemasks, respirators (if available and the facility has a respiratory protection program with trained, medically cleared, and fit-tested HCP), gowns, gloves, and eye protection (i.e., face shield or goggles). Position a trash can near the exit inside the resident room to make it easy for staff to discard PPE prior to exiting the room or before providing care for another resident in the same room. Review of the CDC Interim Infection Prevention and Control Recommendation for Healthcare Personnel During the COVID-19 Pandemic, dated 12/14/20 revealed disposable respirators and facemask should be removed and discarded after exiting the patient's room or care area. If reusable respirators are used, they should be also removed after exiting the patients' room or care area. They must be cleaned and disinfected according the manufacture's reprocessing instructions prior to re-use. Remove eye protection after leaving the patient rooms or care area, unless implementing extended use. Reusable eye protection must be cleaned and disinfected according to manufacturer's reprocessing instruction prior to re-use. Put on clean gloves upon entry into a patient's room or care area. Remove and discard gloves before leaving the patients room or care area, and immediately perform hand hygiene. Put on a clean isolation gown upon entry into the patient room or area. Remove and discard the gown in a dedicated container for waste or linen before leaving the patients room or care area. Disposable gowns should be discarded after each use. Reusable gowns should be laundered after each use. This deficiency is an example of continued non-compliance from the survey dated 12/02/20.

Based on medical record review, resident and staff interviews, observations, and policy review the facility failed to comprehensively assess and implement an effective pain management program for one resident (Resident #61). This affected one of three residents reviewed for pain management. Actual Harm occurred to Resident #61 when the facility failed to assess and implement effective pain management which resulted in the resident having increased pain and decline in functional status as evidenced by a decline in his ability to transfer and ambulate. Findings include: Record review revealed Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 30 day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's brief interview for mental status (BIMS) was 15 (cognitively intact). The pain assessment section revealed the resident had pain almost constantly over the last five days that affected his sleep and day to day activities. He rated the pain seven out of 10. Review of a pain assessment tool dated 01/23/18 revealed the resident had left foot/leg pain that was typically rated a five out of ten (on a 1-10 scale). He described the pain as tender and shooting pain. His pain relief methods were medication. His current orders were Tylenol 500 milligrams (mg) every six hours as needed for pain rated 1-5 and [MEDICATION NAME] 5/325 mg every 4 hours for pain rated 6-10 for two days then discontinue. Review of the inter-disciplinary team (IDT) conference note dated 01/30/18 revealed the resident had frequent pain of the left foot/leg and he used [MEDICATION NAME] with relief. Review of February, (YEAR) orders revealed [MEDICATION NAME] 5/325 mg every four hours as needed for pain and to stop on 02/25/18. On 02/09/18 new orders were received for Biofreeze topical to lower back every morning and night for 30 days. There was no evidence of an order for [REDACTED].>Review of the February, (YEAR) Medication Administration Record [REDACTED]. The resident received Tylenol 500 mg two times on 02/25/18 and one dose on the 02/26/18 and 02/27/18; however, there was no order for the Tylenol. Review of the treatment administration records (TAR) for February, (YEAR) revealed the bio freeze was only given from 02/10/18 to 02/14/18 then it was crossed out. There was no evidence of an order to discontinue the bio freeze. Review of the pain management flowsheet dated February, (YEAR) revealed on 02/21/18 and 02/22/18 the resident received [MEDICATION NAME] for back pain and it was ineffective. On 02/28/18 he received Tylenol for left foot pain that was ineffective. Review of the Certified Nurse Practitioner (CNP) notes dated 02/07/18 revealed the resident reported his pain was not controlled by his current pain medication regimen. The resident currently received [MEDICATION NAME] and he stated that he was not taking that every four hours. He stated if he was not in pain he was not taking the medication. When the [MEDICATION NAME] wore off his pain was excruciating and it was hard to get back under control. The resident was instructed to take his pain medication every four hours for better pain control before making any medication adjustment. Review of CNP notes dated 02/09/18 revealed the resident had low back pain and would use bio freeze ointment. Review of CNP notes dated 02/16/18 revealed low back pain was being relieved with bio freeze. However, according to the TAR, it was marked out in error and the resident had not received the bio freeze since 02/14/18. Review of the pain assessment tool completed 02/28/18 revealed the resident's [DIAGNOSES REDACTED]. The resident reported pain in bilateral legs and left foot. He rated the pain a seven out of 10. The pain was aching and dull. His pain was relieved by [MEDICATION NAME] and elevation. His current medication included [MEDICATION NAME] 100 mg three times a day for the [MEDICAL CONDITION] and therapy was using hot/cold packs. Review of the pain care plan revealed position for comfort, medications per order, observe for pain, bio freeze to lower back morning and night for thirty days. Interview on 02/26/18 at 4:57 P.M., with Resident #61 revealed he was not on any pain medication because they took them all away. He reported he could have Tylenol but it didn't help at all. He had no idea why he couldn't get pain medication and they don't tell him much. Interview on 02/28/18 at 7:10 A.M., with Resident #61 revealed he had voiced concerns with staff regarding his pain was not under control and he was told it was up to the doctor. He told them to give him the doctor's number and he would call the doctor himself. He reported they stopped his pain medication on the 24th and he had not been able to walk since due to the pain and [MEDICAL CONDITION] in his legs and feet. He also conveyed he could not even participate in therapy now. Review of CNP orders dated 02/28/18 revealed clarification orders for Tylenol 500 mg one every 6 hours as needed for pain, discontinue the bio freeze, continue [MEDICATION NAME] 5/325 mg one every 4 hours as needed for pain for 30 days. X-ray the left foot and ankle due to increased pain, and lab work. Interview on 02/28/18 at 7:29 A.M., with Certified Occupation Therapy Assistant (COTA) #127 confirmed on Friday the resident required supervision standby assist with transfer and on Monday he had declined and required contact to stand assistance due to increase pain and [MEDICAL CONDITION]. The resident reported the pain and [MEDICAL CONDITION] to her and she instructed the resident to talk with his nurse or the nurse practitioner the next time they visited. Interview on 02/28/18 at 8:10 A.M., with Registered Nurse (RN) #63 indicated she did notify the doctor Monday afternoon on 02/26/18 of the resident's pain; however, she only documented the [MEDICAL CONDITION]. She confirmed there was no order for the Tylenol and the resident had received Tylenol on 02/25/18, 02/26/18, and 02/27/18 . She also verified the bio freeze was discontinued without an order on 02/15/18 and the resident only received five of the 30 days of the ordered treatment. She confirmed she just assessed the resident's pain and notified the CNP. The CNP was coming around 9 A.M. to see the resident. Interview on 02/28/18 at 9:25 AM with CNP #128 reported she resumed the resident's [MEDICATION NAME] today for increased left foot pain and he also now reported he had right ankle pain. The resident reported to the CNP he thought the pain was related to applying pressure on the right ankle due to trying to baby the left foot. She also reported she ordered lab testing and an x-ray also. She confirmed she spoke to the resident early this month regarding taking his pain medication every 4 hours; however, did not feel comfortable writing an order for [REDACTED]. Interview on 02/28/18 at 9:55 A.M., with the Director of Nursing (DON) revealed the facility had already implemented a plan of correction to re-assess resident pain medication after being discontinued. Observation of Resident #61 on 02/28/18 and 02/29/18 revealed bilateral lower extremities were swollen. The resident was seated in his recliner or his wheelchair during the observations. Review of the pain policy, undated, revealed if pain was identified an individual pain management program was developed, followed by monitoring and evaluation of the effectiveness of the program with changes made as needed. If pain relief was not achieved the doctor was to be notified as needed. Management flow sheet was to be started by the nurse on duty to assist in monitoring of the treatment status and effectiveness of management.

Based on observation, record review and interview the facility failed to ensure all resident care equipment was maintained and utilized in a safe and properly functioning manner to prevent a fall with injury to Resident #100. This resulted in actual harm to Resident #100, when the sit to stand lift being used to transfer the resident broke and the resident fell sustaining a fracture to her cervical spine and left shoulder. This affected one resident (Resident #100) of three residents reviewed for falls. Findings include: Review of the medical record for Resident #100 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review revealed the resident sustained [REDACTED]. The resident suffered a cervical spine fracture at C2 and a left humeral neck fracture as a result of a mechanical lift failure. Review of the nurse's note, dated 10/13/15 revealed the nurse was called to the room by the resident's husband. The resident was found on the floor in the bathroom with the nursing assistant (STNA) present. Both the STNA and resident's husband stated the lift broke and she fell backwards onto the floor and hit her head on the door. The resident complained of her back and neck hurting. Review of the STNA statement revealed the resident was on the sit to stand lift and the STNA was taking her to the restroom. The STNA was pulling down her pants when the machine broke and she fell back against the door and landed on the floor. Her husband was in the room, heard the noise and came in the restroom to see what happened. The STNA stated she asked the resident's husband to get the nurse in charge. The STNA stated prior to the transfer the resident was lifted with the sit to stand lift, with the butt sling put on. The resident was wheeled into the bathroom. When she was about even with the commode and with her back to the other door the STNA began to lower her pants. The lift gave way and the resident fell back into the closed door. Then she started to slide down the door. When she stopped her head was against the door with her chin close to her chest. The STNA opened the door with her hand and behind the resident lowered her head to the ground. The resident's husband came in because he heard the noise. The STNA asked him to get the nurse. The nurse came into the bathroom. Interview with the administrator and Director of Nursing (DON) on 11/18/15 at 12:00 P.M. regarding the sit to stand lift revealed the administrator stated a part broke off which caused the lift handle area to release and drop, causing the resident to fall backwards. The administrator denied any inspection records or preventative maintenance of the lift prior to this incident. He stated he looked for any inspection records and could not find any. The sticker on the lift indicated the lift was capable of holding up to 400 pounds. The resident weighed 304 pounds. They pointed out the part that broke (called an [MEDICATION NAME]) and stated it had been replaced after the incident as well as replacing the same part on a second lift that was in need of replacement. On 11/18/15 at 2:30 P.M. the resident was observed lying in bed, neck brace in place, resident was alert and oriented. Interview with the resident at that time revealed she remembered the accident but only recalled that she was going to the bathroom with an STNA helping her and the next thing she knew she was on the floor. She stated she found out later the lift had broken. She stated she has a fracture of her cervical spine and also fractured her shoulder as a result of the fall. She stated she is doing better but has to wear the cervical collar for another six weeks. Interview with the administrator on 11/18/15 at 1:45 P.M. revealed the lift was approximately [AGE] years old. The administrator was asked to provide any preventative maintenance records for patient care equipment and none was provided. Review of the EZ Way Sit to Stand Lift Operator's Instructions, titled Safety and Maintenance Checklist page 11 and 12 revealed the lift requires minimum servicing to keep it in good working order. Nevertheless, it is important that certain basic checks be periodically made by maintenance staff to ensure on-going safety throughout the lift of the device. The manufacturer suggests that the following components and operating points be scheduled for inspection at intervals not greater than one month. Any detected deficiency must be rectified before the stand is put back into service. Steps 1 through 14 1) check bolts to ensure they are tight, 2) check arm to mast pivot bolt, 3) foot platform assembly pins need to be checked to assure they have not pushed in and still engage into base, 4) Check bolts on back of shin pad, 5) safety tabs need to be checked to make sure they are in place, 6) check mounting bolts of [MEDICATION NAME] top and bottom. Pay particular attention to top of bolt hole for elongation. Check [MEDICATION NAME] for the following, a) inspect the plastic housing for any dents or cracks, b) inspect the cables to see if they have been cut or pinched, c) see if the [MEDICATION NAME] appears deflected when fully extended at full load, d) verify that the mounting points do not have any cracks or other defects, e) apply a heavy grease to [MEDICATION NAME] mounting pins as needed, bf) verify that the inner or outer tubes do not have any dents, dings or large scratches in them. Contact service department if the [MEDICATION NAME] shows any signs of the issues listed above. 7) at six month intervals attach a load equivalent to the rated capacity of the stand to to the unit, raise and lower the load with the stand, listen for any unusual noises while operating the unit. with the test load applied to the stand, check all structural welds for any signs of stress or fatigue cracks. If any unusual noises or cracks are found, stop using the stand and call the EZ way Service Department immediately! 8) Test the Emergency stop switch. 9) Perform a functional test of the emergency lowering feature of the stand [MEDICATION NAME]. 10) Perform a functional test of the anti-pinch feature of the stand [MEDICATION NAME]. 11) Check the wheels and brakes, 12) Do a visual check for any damages, missing or loose parts, 13) check the harness for damage or wear, 14) Cleaning the stand. **Important Notice** It is the responsibility of the purchaser to ensure that regular maintenance inspection is conducted on this device by competent staff. This deficiency substantiates Complaint Number OH 546.

Based on observation, record review and interview the facility failed to ensure a safe and properly functioning assistive transferring device (sit to stand lift) was used to transfer Resident #100 to prevent a fall with injury. This resulted in actual harm to Resident #100, when the sit to stand lift being used to transfer the resident broke and the resident fell sustaining a fracture to her cervical spine and left shoulder. This affected one resident (Resident #100) of three residents reviewed for falls. Findings include: Review of the medical record for Resident #100 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The care plan revealed the resident was at risk for falls due to impaired mobility. Goal was to have no injuries from falls. Interventions included adequate lighting, clear pathway to bathroom, keep call light within reach, observe resident for steadiness/balance. Self care deficit was noted with activities of daily living, resident will be receptive in using butt strap with sit to stand lift through target date 10/26/15, if resident declines sit to stand lift, may use full body lift. Care plan, dated 06/15/15 includes to provide assist of two for bed mobility, provide assist of two for transfer mechanical lift, thoracic and pelvic belts to be used and two person assist with toileting. Record review revealed the resident sustained [REDACTED]. The resident suffered a cervical spine fracture at C2 and a left humeral neck fracture as a result of a mechanical lift failure. Review of the nurse's note, dated 10/13/15 revealed the nurse was called to the room by the resident's husband. The resident was found on the floor in the bathroom with the nursing assistant (STNA) present. Both the STNA and resident's husband stated the lift broke and she fell backwards onto the floor and hit her head on the door. The resident complained of her back and neck hurting. A small amount of bright red blood was noted in the resident's mouth, unable to find source. Her legs were extended out straight in front. She was encouraged to lay still as possible. The supervisor was called to the room. At 10:15 A.M., a late entry note revealed the resident was sent to the emergency room at this time per ambulance company, on backboard with cervical collar in place. Residents husband is going to the emergency department with the resident. A late entry note for 10:00 A.M., revealed the charge nurse called this nurse to resident bathroom, upon entry into room, resident is lying on back, legs extended out, state tested nursing assistant reports she was pulling the residents pants and Depends (adult diaper) down, stand up lift breaks and the resident falls backwards into the door and hits her head on the door. Resident complained of head and neck pain, small amount of red blood noted inside of mouth, resident is kept still, resident is alert and oriented times four, speech is clear, skin color is within normal limits, warm and dry. Decreased grip on left hand per usual compared to right, vital signs blood pressure 160/96, pulse 105, respirations 20, temperature 98.1, oxygen saturation 89% lying, resident has no complaint of difficulty breathing, shortness of breath, nurse stays with resident while this nurse calls the physician assistant. A late entry note for 10:15 A.M., ambulance company notified of resident to be transferred to the emergency department and will need extra staff for transfer to gurney. Review of the physician's orders [REDACTED]. She also had an order for [REDACTED]. On 11/18/15 at 3:23 P.M. interview with the Director of Nursing (DON) revealed only one STNA was with the resident at time of the fall even though the care plan stated the resident should have two staff during transfer with the lift and two staff when toileting. Review of the incident accident report, dated 10/13/15 revealed new interventions in place after the fall included to send to emergency department for evaluation, inspection of stand up lift, complete fall risk assessment with date of last fall noted to be 06/05/15. The report revealed the resident was wearing shoes at time of fall. Review of the STNA statement revealed the resident was on the sit to stand lift and the STNA was taking her to the restroom. The STNA was pulling down her pants when the machine broke and she fell back against the door and landed on the floor. Her husband was in the room, heard the noise and came in the restroom to see what happened. The STNA stated she asked the resident's husband to get the nurse in charge. The STNA stated prior to the transfer the resident was lifted with the sit to stand lift, with the butt sling put on. The resident was wheeled into the bathroom. When she was about even with the commode and with her back to the other door the STNA began to lower her pants. The lift gave way and the resident fell back into the closed door. Then she started to slide down the door. When she stopped her head was against the door with her chin close to her chest. The STNA opened the door with her hand and behind the resident lowered her head to the ground. The resident's husband came in because he heard the noise. The STNA asked him to get the nurse. The nurse came into the bathroom. Interview with the administrator and Director of Nursing (DON) on 11/18/15 at 12:00 P.M. regarding the sit to stand lift revealed the administrator stated a part broke off which caused the lift handle area to release and drop, causing the resident to fall backwards. The administrator denied any inspection records or preventative maintenance of the lift prior to this incident. He stated he looked for any inspection records and could not find any. The sticker on the lift indicated the lift was capable of holding up to 400 pounds. The resident weighed 304 pounds. They pointed out the part that broke (called an actuator) and stated it had been replaced after the incident as well as replacing the same part on a second lift that was in need of replacement. Observation on 11/18/15 at 9:45 A.M., revealed Resident #100 was sitting in her electric wheelchair in the activities room participating in activities, cervical collar in place, left arm in sling and swath. On 11/18/15 at 11:30 A.M. the resident in dining room in electric wheelchair, neck brace off and sling off. Resident eating independently. On 11/18/15 at 2:30 P.M. the resident was lying in bed, neck brace in place, resident was alert and oriented. Interview with the resident at that time revealed she remembered the accident but only recalled that she was going to the bathroom with an STNA helping her and the next thing she knew she was on the floor. She stated she found out later the lift had broken. She stated she has a fracture of her cervical spine and also fractured her shoulder as a result of the fall. She stated she is doing better but has to wear the cervical collar for another six weeks. Interview with the administrator on 11/18/15 at 1:45 P.M. revealed the lift was approximately [AGE] years old. The administrator was asked to provide any preventative maintenance records for patient care equipment and none was provided. Review of the EZ Way Sit to Stand Lift Operator's Instructions, titled Safety and Maintenance Checklist page 11 and 12 revealed the lift requires minimum servicing to keep it in good working order. Nevertheless, it is important that certain basic checks be periodically made by maintenance staff to ensure on-going safety throughout the lift of the device. The manufacturer suggests that the following components and operating points be scheduled for inspection at intervals not greater than one month. Any detected deficiency must be rectified before the stand is put back into service. Steps 1 through 14 1) check bolts to ensure they are tight, 2) check arm to mast pivot bolt, 3) foot platform assembly pins need to be checked to assure they have not pushed in and still engage into base, 4) Check bolts on back of shin pad, 5) safety tabs need to be checked to make sure they are in place, 6) check mounting bolts of actuator top and bottom. Pay particular attention to top of bolt hole for elongation. Check actuator for the following, a) inspect the plastic housing for any dents or cracks, b) inspect the cables to see if they have been cut or pinched, c) see if the actuator appears deflected when fully extended at full load, d) verify that the mounting points do not have any cracks or other defects, e) apply a heavy grease to actuator mounting pins as needed, bf) verify that the inner or outer tubes do not have any dents, dings or large scratches in them. Contact service department if the actuator shows any signs of the issues listed above. 7) at six month intervals attach a load equivalent to the rated capacity of the stand to to the unit, raise and lower the load with the stand, listen for any unusual noises while operating the unit. with the test load applied to the stand, check all structural welds for any signs of stress or fatigue cracks. If any unusual noises or cracks are found, stop using the stand and call the EZ way Service Department immediately! 8) Test the Emergency stop switch. 9) Perform a functional test of the emergency lowering feature of the stand actuator. 10) Perform a functional test of the anti-pinch feature of the stand actuator. 11) Check the wheels and brakes, 12) Do a visual check for any damages, missing or loose parts, 13) check the harness for damage or wear, 14) Cleaning the stand. **Important Notice** It is the responsibility of the purchaser to ensure that regular maintenance inspection is conducted on this device by competent staff. This deficiency substantiates Complaint Number OH 546.