Every finding on record at Addison Healthcare Center

Based on record review, observation, interview and facility policy review, the facility failed to ensure water temperatures were appropriate. This affected one (Resident #25) of three reviewed for environmental concerns and had the potential to affect all 54 residents in the facility.Findings include:Review of the medical record for Resident #25 revealed an admission date of 07/13/23. Diagnoses included kidney disease, depression, glaucoma, hypertension and irritable bowel syndrome.Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #25 was cognitively intact. He required set-up help for eating and oral care and was dependent on staff for toileting, showering, dressing and personal hygiene.Interview on 03/16/26 at 9:08 A.M. with Resident #25 revealed the water in his bathroom sink was never hot.Observation on 03/18/26 at 7:29 A.M. of the sink in Resident #25's room revealed the water reached a temperature of 80 degrees Fahrenheit (F).Interview on 03/18/26 at 9:53 A.M. with Maintenance Director #551 confirmed the water temperature in some of the rooms on the 100-hall, including Resident #25's room, were often not within the required range. He revealed the temperature of 80 degrees F which was obtained was actually warmer than the 50 degrees he often observed. He revealed when the dish washing machine and laundry was being done between the hours of 8:00 A.M. until approximately 2:00 P.M., the water was often not warm. Observation at the time of the interview with Resident #25 revealed he was brushing his teeth at the sink, and he confirmed the water remained cold.Review of the undated facility policy titled Resident Rights revealed residents had the right to a safe, sanitary, and respectful environment which supports their comfort, dignity, and personal well being. That included receiving care in a manner which protected privacy, supports personal choices, and ensured access to essential daily needs such as bathing, grooming, and hygiene. Staff would provide care in a safe and secure setting, respond promptly to resident needs, and maintain conditions that uphold the resident's dignity and overall comfort.

Based on record review and interview, the facility failed to ensure care plans were comprehensive. This affected three Residents (Residents #2, #11 and #50) of 18 reviewed for care plans and had the potential to affect all 54 residents in the facility. Findings include:1. Review of the medical record for Resident #2 revealed an admission date of 02/20/26. Diagnoses included cerebral infarction, diabetes, dementia, heart disease, depression and kidney disease. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was cognitively intact. He required supervision for eating, substantial to maximum assistance for oral care, personal care and showering and was dependent on staff for toileting. Review of the physician's orders for March 2026 revealed an order for Trazadone (an antidepressant) 50 milligrams (mg) at bedtime. The order began on 03/02/26. There was also an order to monitor for side effects of antidepressants including stiffness of neck, dry mouth, sweating or rashes and weakness. The order began on 02/23/26. Review of the care plan dated 03/02/6 revealed no evidence depression was addressed. 2. Review of the medical record for Resident #50 revealed an admission date of 02/06/26. Diagnoses included sepsis, respiratory failure, heart failure, kidney failure and malnutrition. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #50 was cognitively intact. He required set-up help for eating, partial to moderate assistance for oral and personal hygiene, substantial to maximum assistance for showering and was dependent on staff for toileting. He had one Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle; slough may be present on some parts of the wound bed; often include undermining and tunneling), two unstageable pressure ulcers (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) and three unstageable deep tissue injuries (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear). Review of the physicians orders for March 2026 review on an order for wound care to Resident #50's right plantar foot which included cleansing with saline solution, applying a thin layer of hydrogel (gel used to maintain a moist environment) to the black necrotic tissue below the left lateral right great toe and applying Xeroform (gauze designed to maintain a moist environment and protect wounds) to the entire wound, covering it with abdominal dressing (ABD – a thick dressing used for covering large wounds) and Kerlix gauze daily and as needed which began on 02/17/16. There was also an order to encourage the resident to wear Prevalon boots (used to prevent pressure ulcers and keep heels elevated), while in bed which began on 02/06/26 and to float heels and bony prominences while in bed which began on 02/10/26. Review of the care plan dated 02/11/26 revealed Resident #50 had impaired skin integrity. Interventions included completing a skin risk assessment on admission, quarterly and as needed, completing weekly skin checks, encouraging Resident #50 to turn and reposition as needed and providing appropriate offloading mattress and cushioning as applicable. There was no evidence of Prevalon boots or off-loading Resident #50's heels in the care plan. Interview on 03/18/26 at 2:13 P.M. with Registered Nurse (RN) #517 confirmed depression was not addressed in Resident #2's care plan and Resident #50's care plan did not comprehensively address his pressure ulcer risks, interventions and care. 3. Review of Resident #11's medical record revealed an admission date of 01/27/26 with diagnoses including nondisplaced fracture of lateral malleolus of left fibula, unspecified injury of right quadriceps muscle, fascia and tendon, autoimmune thyroiditis, chronic obstructive pulmonary disease and hypertension. A review of Resident #11's comprehensive care plan dated 01/27/26 revealed no care plan was developed to address the Resident's need for medical transportation. Review of the MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. Resident #11 required supervision with toileting, moderate assistance with bathing, supervision with upper extremity dressing, moderate assistance with lower extremity dressing and supervision with personal hygiene. An interview with Resident #11 on 03/16/26 at 11:10 A.M. revealed her need for medical transportation to a follow-up appointment with her orthopedic doctor on 03/12/26. The interview further revealed Resident #11's frustration that facility staff failed to schedule and arrange transportation to the follow-up appointment with her doctor on 03/12/26 which caused a delay in her plans to discharge home from the facility. She further stated the appointment was rescheduled for 03/18/26, and she required medical transportation to get to that appointment. Review of the physician's orders for Resident #11 revealed an order dated 03/13/26 for a follow-up appointment on 03/18/26 at 10:00 A.M. for orthopedic post-op visit, and resident requests facility find transportation. An interview with MDS Nurse #517 on 03/18/26 at 2:28 P.M. revealed she was responsible for initial care plans and updates as needed. She further confirmed she did not include Resident #11's need for medical transportation in her comprehensive care plan. Review of the facility's undated policy titled Plan of Care Overview revealed the facility would provide resident centered care that met the psychosocial, physical and emotional needs and concerns of the residents and included the provision of services to enable the resident to live with dignity and supported the resident's goals, choices, and preferences including, but not limited to, goals related to the their daily routines and goals to potentially return to a community setting.

Based on record review, interview and facility policy review, the facility failed to provide transportation to medical appointments as needed for Resident #11. This affected one resident (#11) of one resident who was investigated for transportation needs. The facility census was 54.Findings include:Review of Resident #11's medical record revealed an admission date of 01/27/26 with diagnoses including nondisplaced fracture of lateral malleolus of left fibula, unspecified injury of right quadriceps muscle, fascia and tendon, autoimmune thyroiditis, chronic obstructive pulmonary disease and hypertension.Review of Resident #11's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. Resident #11 required supervision with toileting, moderate assistance with bathing, supervision with upper extremity dressing, moderate assistance with lower extremity dressing and supervision with personal hygiene.Review of physician's orders for Resident #11 revealed an order for a follow-up appointment on 03/12/26 at 2:30 P.M. for an orthopedic post-op visit.An interview with Resident #11 on 03/16/26 at 11:10 A.M. revealed her need for medical transportation to a follow-up appointment with her orthopedic doctor 03/12/26. The interview further revealed Resident #11's frustration that facility staff failed to schedule and arrange transportation to the follow-up appointment with her doctor on 03/12/26 which caused a delay in her plans to discharge home from the facility. She further stated the appointment was rescheduled for 03/18/26, and she required medical transportation to get to that appointment.An interview with Assistant Director of Nursing (ADON) #577 on 03/18/26 at 11:44 A.M. revealed she was responsible for arranging transportation to medical appointments for residents in the facility. She reported that when residents were admitted with orders for follow-up appointments or when they returned from appointments with orders for future appointments, the floor nurse was expected to put paperwork in her mailbox to notify her transportation was needed. She went on to say she was never notified about an appointment for Resident #11 on 03/12/26, and transportation was never arranged. She further stated she knew the resident and her family were upset that appointment had to be rescheduled. Review of the facility's undated policy titled Resident Transportation revealed the facility would provide resident centered care that met the psychosocial, physical and emotional needs and concerns of the residents and the facility would assist the resident in making transportation arrangements to and from the source of any needed service, such as dental visits, or physician visits in the event the resident requires such assistance.

Based on record review, observation, interview and facility policy review, the facility failed to ensure pressure reducing interventions were in place as ordered by the physician for Resident #50. This affected one resident (#50) of three residents reviewed for pressure ulcers and had the potential to affect five additional residents (#4, #5, #16, #62 and #64) identified by the facility with pressure ulcers. The facility census was 54. Findings include:Review of the medical record for Resident #50 revealed an admission date of 02/06/26. Diagnoses included sepsis, respiratory failure, heart failure, kidney failure and malnutrition.Review of the comprehensive MDS assessment dated [DATE] revealed Resident #50 was cognitively intact. He required set-up help for eating, partial to moderate assistance for oral and personal hygiene, substantial to maximum assistance for showering and was dependent on staff for toileting. He had one Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle; slough may be present on some parts of the wound bed; often include undermining and tunneling), two unstageable pressure ulcers (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) and three unstageable deep tissue injuries (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear).Review of the care plan dated 02/11/26 revealed Resident #50 had impaired skin integrity. Interventions included completing a skin risk assessment on admission, quarterly and as needed, completing weekly skin checks, encouraging Resident #50 to turn and reposition as needed and providing appropriate offloading mattress and cushioning as applicable. There was no evidence of Prevalon boots or offloading Resident #50's heels in the care plan.Review of the physicians orders for March 2026 review on an order for wound care to Resident #50's right plantar foot which included cleansing with saline solution, applying a thin layer of hydrogel (gel used to maintain a moist environment) to the black necrotic tissue below the left lateral right great toe and applying Xeroform (gauze designed to maintain a moist environment and protect wounds) to the entire wound, covering it with abdominal dressing (ABD - a thick dressing used for covering large wounds) and Kerlix gauze daily and as needed which began on 02/17/16. There was also an order to encourage the resident to wear Prevalon boots (used to prevent pressure ulcers and keep heels elevated), while in bed which began on 02/06/26 and to float heels and bony prominences while in bed which began on 02/10/26.Review of the wound assessment report dated 03/10/26 revealed the wound to Resident #50's right plantar foot measured six centimeters (cm) long by 15 cm wide and 0.10 cm deep. It was identified as unstageable, acquired on 02/06/26 and improving with delayed wound closure. It had 20% epithelial tissue appearing as new, light pink tissue migrating from the wound edges, 20% granulation tissue characterized by a moist, red, vascular appearance and 10% slough presenting as moist, yellow, non-viable tissue loosely adherent to the wound surface. The remaining 50% consisted of eschar, noted as firm, dry, black necrotic tissue covering half of the wound bed. No tunneling or undermining was described. Treatment was to cleanse with normal saline, apply a thin layer of hydrogel to the black necrotic tissue below the lateral right great toe, Xeroform, ABD and Kerlix gauze with offloading daily and as needed. Resident #50's left lateral heel measured 0.70 cm long by 0.60 cm wide and 0.10 cm deep. It was identified as unstageable, acquired on 02/06/26 and improving without complications. It has 100% slough with the wound edges attached. Treatment was to cleanse with normal saline, Skin Prep (creates a protective barrier), leave open to air and offload.Observation on 03/17/26 at 6:39 A.M. revealed Resident #50 was lying in bed, awake, his feet were uncovered. No Prevalon boots were observed in place, and his heels were not elevated. Resident #50 revealed he came to the facility with boots to help manage his heel pressure ulcers but did not believe he needed to wear them any longer. He was not sure if his heels were supposed to be elevated at any time. Interview with Business Officer Manager (BOM) #550 at the time of the observation confirmed Resident #50 was not wearing anything on his feet, and his feet were lying on top of a pillow. She confirmed there was no evidence of any kind of boots in Resident #50's room.Review of the undated facility policy titled Skin Care and Wound Management Overview revealed the facility would develop a care plan with individualized interventions to address risk for skin integrity, review the appropriate treatments, communication those interventions to the team, monitor and document the progress of identified interventions and communicate any changes to the caregiving team.

Based on record review, observation, interview and review of the facility policy, the facility failed to ensure that Resident #7's therapy recommendation for built up utensils at all meals was properly assessed, that a corresponding physician's order was obtained, and that the intervention was incorporated into the care plan. This affected one resident (#7) of one resident reviewed for assistive devices and had the potential to affect three additional residents (#16, #20, and #48) identified by the facility as utilizing assistive devices. The facility census was 54.Findings include:Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including type II diabetes mellitus with diabetic polyneuropathy and atherosclerotic heart disease of native coronary artery without angina pectoris.Review of the therapist's order dated 04/21/25 revealed Resident #7 was to have black built-up utensils for all meals.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact and required set up assistance for eating. The MDS did not identify the need for any adaptive equipment or assistive devices for eating.Review of Resident #7 care plan dated 02/16/26 revealed no indication of adaptive utensils for meals.Review of Resident #7's physician orders revealed no physician orders for adaptive utensils for meals.Interview with Resident #7 on 03/16/26 at 11:17 A.M. revealed he does not always get his adaptive utensils for meals and must ask for them.Interview with Certified Nursing Assistant (CNA) #538 on 03/17/26 at 12:08 P.M. revealed Resident #7 used adaptive utensils for all meals.Observation on 03/17/26 at 12:46 P.M. revealed Resident #7 had adaptive utensils on his lunch tray. CNA #572 confirmed Resident #7 had adaptive utensils on his lunch tray.Interview with Occupational Therapist #567 on 03/17/26 at 2:29 P.M. revealed there was a physician order dated April 2025 related to adaptive equipment for eating; however, no occupational therapy evaluation had been completed to assess the resident's need for, or appropriate use of, adaptive utensils.Review of policy named Assistive Eating Devices undated revealed the facility is to provide a resident assessment be completed by Occupational Therapy or Speech Therapy to determine the need for assistive devices, obtain appropriate equipment, educate staff, and ensure proper use is reflected in the resident's care plan.

Based on record review, observation, interview and review of facility policies, the facility failed to provide wound care to Resident #16 in a manner to prevent infection. This affected one resident (#16) of two residents observed for wound care. The facility census was 54.Findings include:Review of the medical record for Resident #16 revealed an admission date of 09/03/25 and a readmission date of 01/23/26. Diagnoses included acute respiratory failure with hypoxia, pressure ulcer of the sacral region Stage IV (full thickness tissue loss with exposed bone, tendon or muscle; slough may be present on some parts of the wound bed; often includes undermining and tunneling), and type two diabetes mellitus.Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had severe cognitive impairment. Resident #16 required extensive assistance for all activities of daily living.Review of the physician's order dated 03/12/26 revealed an order to clean the coccyx wound with normal saline solution, lightly pack with quarter strength Dakin's (antiseptic) moist gauze, and cover with superabsorbent dressing every shift and as needed. There was another order for Resident #16 to have enhanced barrier precautions (EBP) every shift for preventative measures.Review of the care plan dated 03/16/26 revealed Resident #16 was currently on intravenous (IV) therapy related to a wound infection. Interventions included administering medications as ordered and providing EBP when providing direct care to Resident #16.Observation of wound care on 03/18/26 at 8:00 A.M. with Registered Nurse (RN) #577 revealed she brought the whole treatment cart into Resident #16's room. She began opening packaging of wound care supplies and placing it wrapper side down on the top of the treatment cart and the bedside table. RN #577 was not observed cleaning or placing a barrier on either surface. RN #577 removed the dressing from Resident #16, removed her gloves and used hand sanitizer and began irrigating Resident #16's wound with normal saline. Resident #16's coccyx wound was very deep with coccyx bone exposed. RN #577 then applied Vaseline gauze over Resident #16's exposed coccyx bone and packed the wound with Dakin's-soaked gauze. She then applied barrier cream to the wound edges and dry dressing. RN #577 then repositioned Resident #16 and cleaned the area and removed the cart from the room. Interview on 03/18/26 at 8:25 A.M. with RN #577 confirmed Resident #16 was to be on EBP. She confirmed that Resident #16 had a deep wound and she irrigated it with normal saline and packed the wound with Dakin's-soaked gauze. RN #577 confirmed she was only wearing glasses and not a mask during the wound care because she was told that a mask was not required with wounds unless there was a splash risk. RN #577 confirmed with the size and the type of treatment for Resident #16's wound there was a splash risk. RN #577 confirmed that Resident #16's wound did pose a splash risk due to the size and treatment. RN #577 confirmed she cleaned the top of the treatment cart before she started caring for residents this morning and confirmed she did not clean the top of Resident #16's bedside table and placed an item on it with the bottom of the wrapper on the surface. Review of the undated facility policy standard precautions and transmission-based precautions revealed staff must wear a mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures and resident-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions. Review of the undated facility policy uncomplicated dressing change revealed staff must prepare a clean, hard surface work area using disinfectant wipes. If used scissors or other reusable equipment must be wiped with a disinfectant wipe.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on interview, record review, review of the facility Self-Reported Incident (SRI) and related facility investigation, and policy review, the facility did not ensure Residents #2, #4, #23, and #35 were free from the misappropriation of their controlled substance narcotic pain medication. This affected four residents (Resident #2, #4, #23, and #35) out of four residents reviewed for misappropriation of property. This had the potential to affect 14 residents (#1, #2, #4, #8, #11, #21, #23, #26, #32, #33, #35, #36, #39, and #153) the facility identified as residing on the A unit and had orders for controlled substances. The facility census was 48. Findings included: 1. Review of the SRI dated 01/03/25 revealed the facility reported an incident of misappropriation. The report revealed Licensed Practical Nurse (LPN) #332 arrived at the facility on 01/03/25 at 3:00 A.M. and was unable to find Former Registered Nurse (RN) #602 as well as seven controlled substance cards were missing from the A unit medication cart including: ten tablets of Oxycodone (narcotic pain medication) 15 milligram (mg), 23 tablets of Percocet (narcotic pain medication) 5-325mg, six tablets of Morphine Sulfate (MS) Contin (narcotic pain medication), seven tablets of Percocet 10-325mg, 82 tablets of Xanax (anti-anxiety medication) 0.5 mg (combined on two cards), and 13 tablets of Oxycodone 5mg. The report revealed the police were notified and residents were assessed for any adverse effects, and none were noted. The report revealed Police Officer #603 had responded and initiated an investigation including driving to Former RN #602's home address but she was not there. Police Officer #603 returned to the facility on [DATE] at approximately 5:00 A.M. and found Former RN #602's vehicle in the facility parking lot. Police Officer #603 then proceeded to complete a facility search and found Former RN #602 unresponsive in the employee bathroom with a cup of pudding, spoon, water bottle and the missing medication cards belonging to Residents #2, #4, #23, and #35. The report revealed Former RN #602 was administered Narcan (medication given to reverse opioid overdose) per Police Officer #603 and was sent to the hospital. The pharmacy was notified and immediately replaced all residents' medications. The facility unsubstantiated the incident. Review of Police Report dated 01/03/25 revealed Police Officer #603 was dispatched to the facility on [DATE] at 3:21 A.M. regarding the theft of drugs from the facility. Police Officer #603 was informed that Former RN #602 had left the facility without telling anyone and she had stolen resident's medications from the medication cart. The following medications were missing per the report: ten tablets Oxycodone 15mg, 23 Percocet 5-325mg tablets, six Morphine Sulfate Contin tablets, seven Percocet 10-325mg, 82 tablets Xanax 0.5mg, and 13 tablets Oxycodone 5mg. Police Officer #603 left to go to Former RN #602's home address and later returned back to the facility at which time searched the facility and found Former RN #602 in the employee bathroom leaned up against the wall hunched over. There were two full packs of Xanax in her hand and the other medication cards were empty in the trash can next to her. Police Officer #603 administered Narcan and she was transported to the hospital by emergency rescue service (EMS). The report revealed after collecting all the medication packs for evidence it was determined Former RN #602 had ingested 81 tablets of the following: 10 tablets of Oxycodone 15mg, 23 tablets of Percocet 5-325mg, six tablets of MS Contin, seven tablets of Percocet 10- 325mg, 22 tablets of Xanax .5mg, and 13 tablets of Oxycodone 5mg. Review of Employee Termination Checklist dated 01/06/25 and completed by the Director of Nursing (DON) revealed Former RN #602 was terminated as she stole controlled substances from residents and overdosed in the facility bathroom. Interview on 02/24/25 at 9:46 A.M. with the Administrator and Director of Nursing (DON) verified Former RN #602 misappropriated the above controlled substances belonging to Residents #2, #4, #23, and #35. 2. Review of the medical record for Resident #23 revealed an admitted [DATE] and diagnoses including rheumatoid arthritis, asthma, and bilateral knee osteoarthritis. Review of the care plan last revised 10/16/23 revealed Resident #23 had osteoporosis and osteoarthritis. Interventions included administer medications as orders, observe for side effects and effectiveness of the medications, and report abnormal findings to medical provider. Review of the Controlled Drug Administration Record for Resident #23 dated 12/06/24 revealed the facility received 58 MS Contin extended release (ER) 15 mg tablets from the pharmacy. The record revealed on 01/03/25 LPN #300 and LPN #332 signed on the sheet that six MS Contin tablets were missing. Review of the Controlled Drug Administration Record for Resident #23 dated 12/26/24 revealed the facility received 30 Percocet 10-325 mg from the pharmacy. The record revealed on 01/03/25 LPN #300 and LPN #332 signed on the sheet that seven Percocet tablets were missing. Review of January 2025 Physician Orders revealed Resident #23 orders included: MS Contin ER 15mg give one tablet by mouth two times a day for chronic pain and Percocet 10-325 mg tablet give one tablet by mouth every six hours as needed for breakthrough pain. Review of the January 2025 Medication Administration Record (MAR) for Resident #23 revealed Resident #23 received her medications as ordered including on 01/03/25. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #23 had intact cognition, had frequent pain and received opioid medications (classification of pain medication derived from the opium poppy plant). Her medication regimen consisted of scheduled and as needed pain medication. Interview on 02/19/25 at 4:17 P.M. with Resident #23 revealed the facility had notified her that Former RN #602 had taken her MS Contin and Percocet. She revealed there was no delay in receiving any of her medications as they had the medications on hand to replace. 3. Review of Resident #35's medical record revealed an admitted [DATE] and his diagnoses included hypertension, arthritis, chronic pain syndrome, and gout. Review of care plan last revised 03/26/24 revealed Resident #35 had complaints of acute and chronic pain related to gout. Interventions included follow physician orders, observe for pain every shift, and pain management consult. Review of the quarterly MDS dated [DATE] revealed Resident #35 had intact cognition, had occasional pain and received opioids. His medication regimen consisted of scheduled and as needed pain medication. Review of the Controlled Drug Administration Record for Resident #35 dated 12/30/24 revealed the facility received 30 Percocet 5-325 mg from the pharmacy. The record revealed on 01/03/25 LPN #300 and LPN #332 signed on the sheet that 23 Percocet tablets were missing. Review of the January 2025 Physician Orders revealed Resident #35 orders included: Oxycontin ER 15mg give one tablet by mouth two times a day for chronic pain, Percocet 5-325mg give one tablet by mouth every four hours as needed for breakthrough pain, and a one-time order for Oxycontin ER 15mg give one tablet by mouth one time only on 01/03/25. Review of the Controlled Drug Administration Record for Resident #35 dated 01/02/25 revealed the facility received ten Oxycontin ER 15mg from the pharmacy. The record revealed on 01/03/25 LPN #300 and LPN #332 signed on the sheet that ten Oxycontin ER tablets were missing. Review of the January 2025 MAR revealed Resident #35 received his as needed Percocet 5-325mg on 01/03/25 at 10:47 A.M. He received his Oxycontin ER 15mg per one time physician order on 01/03/25 at 12:18 P.M. Review of the packing slip revealed on 01/03/25 Resident #35 received 10 tablets of Oxycodone ER as replacement. The slip was signed as received on 01/03/25 at 10:46 A.M. Review of the nursing note dated 01/03/25 at 1:06 P.M. and completed by RN/ Assistant Director of Nursing (ADON) #318 revealed Medical Director/ Primary Care Physician (PCP) #600 was updated and ordered Resident #23's routine Oxycontin dose to be given at 12:00 P.M. Interview on 02/19/25 at 4:01 P.M. with Resident #35 revealed the facility had notified him that Former RN #601 had taken his medications as well as she had taken several other resident's medications. He revealed he could not remember the exact details, including if his medications were delayed. Interview on 02/20/25 at 11:07 A.M. with RN/ ADON #318 revealed Resident #23's replacement Oxycodone ER had arrived at the facility during the time frame to be administered on time but because Resident #35 had received his as needed Percocet so close to when the medication arrived that she had contacted Medical Director/ PCP #600 to get a one-time order to give his routine Oxycodone ER at noon which Resident #23 was in agreement. She revealed Resident #23 displayed no adverse effects because of the incident. 4. Review of medical record for Resident #4 revealed an admitted [DATE] and diagnoses included hypertension, bilateral above the knee amputations, and muscle weakness. Per the nursing notes for 01/03/25 there were no adverse effects as Resident #4 did not complain of pain that required as needed pain medication. Review of the care plan last revised 11/24/20 revealed Resident #4 had pain to legs. Interventions included administering medications as ordered, evaluate the effectiveness of pain interventions, and document and monitor for side effects. Review of the Controlled Drug Administration Record for Resident #4 dated 12/13/24 revealed the facility received 30 Oxycodone ER 5 mg tablets from the pharmacy. The record revealed on 01/03/25 LPN #300 and LPN #332 signed on the sheet that 13 Oxycodone tablets were missing. Review of January 2025 physician orders revealed Resident #4 had an order for Oxycodone 5mg by mouth every eight hours as needed for pain. Review of the quarterly MDS dated [DATE] revealed Resident #4 had intact cognition, and received as needed pain medication. She had no pain present per the assessment in the last five days. Interview on 02/20/25 at 03:59 P.M. with Resident #4 felt she received pain medications any time she requested and never felt any of her pain medications were delayed. 5. Review of medical record for Resident #2 revealed an admitted [DATE] and her diagnoses included anxiety, panic disorder and hypertension. Review of care plan dated 12/01/24 revealed Resident #2 used anti-anxiety medication due to her anxiety disorder. Interventions included medications as ordered, provide calm environment, observe for side effects, and maintain consistent daily routine. Review of the undated Controlled Drug Administration Record for Resident #2 revealed the facility had received 90 Xanax tablets from the pharmacy. The record revealed on 01/03/25 LPN #300 and LPN #332 signed on the sheet that 82 Xanax tablets were missing. Review of January 2025 Physician Orders revealed Resident #2 had an order for Xanax .5mg give one tablet by mouth three times a day for anxiety. Per January 2025 MAR Resident #2 received her Xanax as ordered including on 01/03/25. Review of the quarterly MDS dated [DATE] revealed Resident #2 had intact cognition, and she received antianxiety medications. Interview on 02/20/25 at 4:23 P.M. with Resident #2 revealed that she felt she always received her medications as ordered and that she had not missed any medications because of 01/03/25 incident. Review of undated facility policy labeled, Medication Controlled Drugs and Security revealed controlled drugs were medications that pose a high risk for addiction when improperly taken, and are known to depress the respiratory system and could lead to an overdose. The policy revealed controlled substances would be kept under double lock and would be counted by the oncoming and off going nurse at the end of each shift and before keys were passed to next shift. The policy revealed drug diversion would be treated as misappropriation of resident property and the board of nursing would be notified. Review of undated facility policy labeled, Ohio Abuse, Neglect, and Misappropriation revealed misappropriation was defined as deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings or money without the resident's consent. The deficient practice was corrected on 01/24/25 when the facility implemented the following corrective actions: On 01/03/25 at 6:00 A.M. Medical Director #600 was notified of the incident. On 01/03/25 the DON provided education on Controlled Medication Security and Counseling, and Stress Management for all nurses. On 01/03/25 the DON filed an SRI with the Ohio Department of Health and reported the incident to Ohio Board of Nursing. On 01/03/25 DON completed audits on all controlled substances for discrepancies. On 01/06/25 Former RN #602 was terminated from the facility. On 01/07/25 the DON audited all delivery manifests for the last 30 days for concerns prior to incident of controlled substances discrepancies. The DON completed ongoing audits on controlled substances three times weekly for three weeks including on 01/06/25, 01/08/25, 01/10/25, 01/13/25, 01/15/25, 01/17/25, 01/20/25, 01/22/25, and 01/24/25. On 01/07/25 the Quality Assurance Performance Improvement (QAPI) committee met including Medical Director #600, the Administrator and Director of Nursing to discuss the incident and ongoing monitoring of the audits. There were no further incidents of resident property misappropriation as of the date of this survey completed on 02/25/25.

Based on observation, interview, record review, review of QSO-24-08-NH memorandum, and review of facility policy revealed the facility did not utilize enhance barrier precautions (EBP) when indicated for Residents #17 during the administration of medication through his percutaneous endoscopic gastrostomy (PEG) tube. This affected one Resident (#17) out of two residents observed for EBP. The facility identified 11 Residents (#3, #4, #11, #17, #22, #28, #36, #42, #38, #39, #153) who required EBP. The facility census was 48. Findings include: Review of the medical record for Resident #17 revealed an admitted [DATE] and diagnoses including spastic quadriplegic cerebral palsy, convulsions, dysphagia, and adult failure to thrive. Review of the care plan last revised 05/20/21 revealed Resident #17 required a PEG tube (medical device used to provide nutrition and hydration directly into the stomach) feeding related to dysphagia. Interventions included provide tube feeding per medical provider orders, administer medications PEG tube, and head of bed elevated 30 degrees. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #17 had impaired cognition, and he had impairment to both upper and lower extremities. He was dependent on staff for toileting hygiene, dressing, transfers, personal hygiene, rolling left and right. Review of February 2025 Physician Orders revealed Resident #17 had an order for EBP related to the PEG tube when dressing, bathing, showering, transferring in room or therapy, personal hygiene, changing linen, changing briefs or assisting with toileting. Review of the care plan dated 02/18/25 revealed Resident #17 required EBP for the PEG tube. Intervention included appropriate personal protective equipment would be utilized during high contact care by care givers. Observation on 02/19/25 at 4:05 P.M. revealed on the outside of Resident #17's door there was EBP signage that revealed staff were to clean their hands including before entering and when leaving the room, wear gloves and gown for the following high contact resident care activities: dressing, bathing/ showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting and device care or use including feeding tube. Observation revealed Curriculum Practical Training (CPT) Intern Registered Nurse (RN) #201entered into Resident #17's room with mask and eye protection in place. She then donned gloves but no gown and proceeded to administer Resident #17's medication and flush through his peg tube. During the procedure her uniform came into contact with Resident #17's bedding as she leaned over. She removed her gloves and performed hand hygiene before exiting the room. Interview on 02/19/25 at 4:14 P.M. with CPT/ Intern/ RN #201 verified she did not wear a gown while administering Resident #17's medication and flush through his PEG tube. She verified there was signage on the outside of Resident #17's door indicating he was on EBP. CPT/ Intern/ Registered RN #201 revealed the signage was old as that was the sign when he had COVID-19 and that the signage should have been removed as he no longer had COVID-19. She verified she did not wear a gown for device care including administration of medications through peg tube. She revealed Resident #17 did not have an infection. Interview on 02/19/25 at 4:26 P.M. with the Director of Nursing verified Resident #17 was to be on EBP as he had a PEG tube. She verified CPT/ Intern/ RN #201 should have worn a gown during the administration of his medications and flushes through his peg tube. Review of the memorandum, QSO-24-08-NH, entitled Enhanced Barrier Precautions in Nursing Homes, dated 03/20/24, by the Centers for Medicare & Medicaid Services, Department of Health & Human Services revealed enhanced barrier precautions are indicated for residents with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. The effective date for implementation of enhanced barrier precautions under the guidelines was 04/01/24. Review of undated facility policy labeled, Enhanced Barrier Precautions revealed EBP was defined as an infection control intervention designed to reduce transmission of multi-drug-resistant organisms. The policy revealed employees were to perform hand hygiene, gown and glove use during high contact care activities including dressing, bathing, transferring, changing linens and during device care including central line, urinary catheter, feeding tube, and tracheostomy.

Based on interview, record review and policy review, the facility failed to implement the abuse policy and procedure after receipt of an allegation of staff to resident verbal abuse for Resident #53. This affected one resident (#53) of three residents reviewed for abuse, neglect, and misappropriation. The facility census was 52. Findings include: Review of the medical record for Resident #53 revealed an admitted [DATE] and discharge date of [DATE]. Diagnoses included anoxic brain damage, spastic hemiplegia, major depressive disorder, anxiety disorder, heart failure, and need for assistance with personal care. Review of the Quarterly and State Optional Minimum Data Set (MDS) assessments dated 11/16/23 revealed Resident #53 had moderate cognitive impairment, and required extensive two staff assistance for bed mobility, transfers, and toileting. Resident #53 was frequently incontinent of bowel and bladder. Review of the care plan dated 08/09/23 revealed Resident #53 had a neurologic disorder and impaired cognitive function related to traumatic brain injury with spastic hemiplegia and convulsions. Resident #53 required staff assistance with all activities of daily living which fluctuated based on time of day, mood, pain, or fatigue. There were no behaviors documented in the care plan. Review of the progress note dated 10/26/23 and authored by Assistant Director of Nursing (ADON) #266 indicated Resident #53 reported not liking staff's tone of voice when providing care but denied being fearful or mistreated. Staff were educated. Review of progress note dated 11/13/23 at 11:51 A.M. and authored by the Director of Nursing (DON) indicated interviewing Resident #53 after speaking to the Ombudsman regarding an allegation made to the Ombudsman on 11/10/23. Resident #53 did not voice to the staff at the facility. Discussed with Resident #53 regarding a shower which occurred in the prior week. Resident #53 requested a certain nursing assistant (unnamed) not provide a shower but could assist with other activities including brushing teeth or helping with meals. Resident #53 denied being abused but voiced the nursing assistant (unnamed) was rude with a tone. The DON and Ombudsman inquired if Resident #53 was fearful which Resident #53 replied no but stated, care from the other facility was better. Review of shower documentation revealed Resident #53 received a shower on 11/09/23 by State tested Nursing Assistant (STNA) #240. There were no skin areas noted. Review of a written witness statement by Licensed Practical Nurse (LPN) #287, undated, indicated Resident #53 requested to be brought to ADON #266. LPN #287 asked Resident #53 what was needed because she was the nurse and could help. Resident #53 reported wanting her bath items which were left in the shower room. LPN #287 told Resident #53 it would be retrieved after passing a medication which was already prepared for administration. LPN #287 then retrieved the bath items. LPN #287 told Resident #53 to quit perseverating on things and keep busy, it was not an emergency, and we would take care of it. Review of staff education entitled Teachable Moment, dated 10/26/23, and signed by LPN #287 revealed an identified issue as tone of voice when speaking with a resident, and a solution of staff member educated and apologized to the resident. LPN #287 included a written statement which denied having a bad tone with resident (unnamed) but understood people take things differently. Review of a written witness statement by STNA #240, dated 11/10/23, revealed when STNA #240 approached Resident #53 to assist with oral care, Resident #53 indicated not wanting STNA #240 to provide care anymore due to what happened on 11/09/23. STNA #240 described providing a shower to Resident #53 on 11/09/23. Prior to the shower, Resident #53 toileted and then after the shower during drying, Resident #53 stated she was urinating on the floor. STNA #240 asked why, because she could have assisted her to the toilet. Resident #53 made no response. On 11/10/23, STNA #240 asked Resident #53 about what happened on 11/09/23 and Resident #53 indicated STNA #240 was not being nice when asking her why she urinated on the floor and no longer wanted STNA #240 to care for her. After the shower on 11/09/23, STNA #240 described helping Resident #53 with many things after it happened including lunch and activities. Review of an email dated 11/13/23 at 9:17 A.M. from Ombudsman #294 to the DON stated there was an allegation of verbal abuse that needed follow-up. Resident #53 reported during the previous week on a shower day that STNA #237 was yelling at her. Resident #53 only told her sister. Ombudsman #294 indicated to the DON ability to review what was reported, and a need to ensure the DON followed the facility process for investigation. Review of staff education entitled Teachable Moment, dated 11/13/23, and signed by STNA #240 revealed an identified issue of customer service, and solution as to be mindful of tone of voice when speaking to others. STNA #240 included a written statement which denied raising her voice when offering to put resident (unnamed) on the toilet. Interviews on 01/04/24 from 9:18 A.M. to 9:21 A.M. with LPN #224 and STNA #267 verified all staff mistreatment or abuse was reported to the DON or Administrator. Interview on 01/04/24 at 10:16 A.M. with the DON confirmed receipt of an email from Ombudsman #294 with a statement there was an allegation of abuse. Ombudsman #294 reported STNA #237 yelled at Resident #53. After receipt of the email, I interviewed Resident #53 and looked at the nursing schedule. It was determined it was not STNA #237, but STNA #240 who was educated. STNA #240 denied yelling at Resident #53 during the shower, so she was educated on tone of voice. Resident #53 denied feeling abused but indicated feeling STNA #240 was being rude and did not like STNA #240's tone. Resident #53 voiced feeling safe, and Ombudsman #294 was present during the interview on 11/13/23. The DON indicated following up with administration including a regional staff member. It was decided not to file a Self-Reported Incident (SRI) because it wasn't an allegation of abuse because Resident #53 said it wasn't abuse. It was more of a customer service concern. Interview on 01/04/24 at 10:33 A.M. with STNA #240 verified an incident occurred with Resident #53 on 11/10/23 which involved the events of 11/09/23 during a shower. When STNA #240 approached Resident #53 on 11/10/23 to brush her teeth, Resident #53 stated she did not want me to take care of her anymore but did not explain why. Later, Resident #53 indicated to STNA #240 being upset about the shower on 11/09/23. STNA #240 confirmed reporting the concern to the DON on 11/10/23. Afterward, the DON requested STNA #240 write it a statement of what happened. When Resident #53 was showered, STNA #240 provided toileting and after the shower Resident #53 urinated on the floor. STNA #240 asked her why, and Resident #53 responded because she had to. STNA #240 indicated Resident #53 was on medication for a urinary tract infection at the time. So, using a towel, STNA #240 cleaned it up and told Resident #53 that she could have put Resident #53 on the toilet if Resident #53 had told her. STNA #240 proceeded to get Resident #53 dressed and continued to provide care during the day including lunch assistance and other activities. STNA #240 asked the DON about the incident, and the DON reported talking to Resident #53 who stated not feeling abused, so STNA #240 did not have to stop working for an investigation. STNA #240 confirmed continuing to provide care for Resident #53 after the incident. Interview on 01/04/24 at 10:53 A.M. with the DON verified STNA #240 reported on 11/10/23 of Resident #53 not wanting to receive care from STNA #240 anymore. The DON directed STNA #240 to write a statement which she reviewed. The DON interviewed Resident #53 who reported STNA #240 was rude, and it was about Resident #53 going to the bathroom on the floor. Resident #53 never stated STNA #240 yelled or indicated being threatened, just not wanting STNA #240 to provide showers anymore but could do other care like brushing teeth, meals, and activities. Resident #53 kept stating STNA #240 was rude and did not provide any details. The DON informed the Administrator education was going to be provided to STNA #240. On 11/13/23, Ombudsman #294 sent an email, but the DON indicated already being aware of the incident because of the statement STNA #240 wrote. Ombudsman #294 indicated more details would be provided but it happened in the previous week, so the DON waited for Ombudsman #294 to provide more information. Ombudsman #294 did come to the facility later and we both talked to Resident #53. The Administrator was aware. The DON verified knowledge of Resident #53 reporting to ADON #266 on 10/26/23 of a staff member being rude or mean. The DON indicated Resident #53 thought when people spoke to her, they were being rude or mean. The DON denied memory of interviewing Resident #53 after being made aware of the incident on 10/26/23. Interview on 01/04/24 at 11:07 A.M. with STNA #237 confirmed caring for Resident #53 on multiple occasions but there were no issues. STNA #237 indicated Resident #53 had demanding behaviors. Resident #53 verbalized statements such as staff not wanting to help or did not care for them but nothing specific just things were not done right. STNA #237 verified any report from a resident involving someone being mean verbal or physical would be reported to the DON or Administrator. STNA #237 reported hearing staff talk about Resident #53 reporting people being mean, but the response was Resident #53 always talks that way. Interview on 01/04/24 at 11:20 A.M. with ADON #266 verified on 10/26/23, Resident #53 reported not liking the tone of voice by LPN #287. Resident #53 denied being fearful. ADON #266 indicated talking to LPN #287 and obtaining a written statement. LPN #287 stated Resident #53 wanted supplies from the shower, but LPN #287 was passing medications. What was gathered was Resident #53 wanted it done immediately. ADON #266 confirmed giving LPN #287 education and reported to the DON on 10/26/23. The DON agreed with providing LPN #287 education. With an allegation of abuse, we immediately separate people to make sure of no harm or injury from anyone being accused, and it is reported to the DON. Since Resident #53 requested LPN #287 bring her to me, they were separated, and Resident #53 was not fearful at the time. ADON #266 indicated if she was present during the incident, she would have separated them. ADON #266 stated not feeling the need to investigate because Resident #53 reported not feeling fearful and in danger. ADON #266 verified just interviewing Resident #53 on 10/26/23, and if Resident #53 felt in fear, ADON #266 would have made sure the abuse investigation was executed. ADON #266 stated the facility abuse policy and procedure was executed when a resident stated they were in fear, danger, or abused. ADON #266 indicated just going off residents' wording since they entrust in us. If a resident was not cognitively able to report, ADON #266 would look for witnesses and ask if they were mistreated. ADON #266 stated having to trust what was said to be correct. Interview on 01/04/24 at 12:45 P.M. with the DON verified ADON #266 reported the incident on 10/26/23 with Resident #53. ADON #266 indicated talking to Resident #53 and was directed to do education. The abuse policy would not be implemented because Resident #53 and ADON #266 did not state it was abuse, only Resident #53 complained about tone. Interview on 01/04/24 at 12:55 P.M. with the Administrator confirmed being aware of both incidents with Resident #53. Resident #53 was interviewed regarding whether anything occurred, and Resident #53 stated nothing occurred. We started an investigation by talking to Resident #53 after receipt of the email on 11/13/23 to see if it was valid. Ombudsman #294 sent it four days after it happened and because it was so far back, we wanted to make sure it was an allegation. Ombudsman #294 stated to follow our process which was to investigate. We talk to residents with any allegation, and if a resident does not allege, then there is no allegation. The abuse policy was only implemented if a resident indicated abuse. An abuse allegation would be reported if a resident was not able to state it. The Administrator verified not being aware of the 10/26/23 incident with Resident #53 until the time of the survey. The Administrator stated it must be found out if it is abuse before initiating the policy. If a resident stated someone abused me, then it would be reported and investigated. Ombudsman #294 indicated to follow-up. I took it as to check first, so we talked to Resident #53 and determined it was not abuse. This was because Resident #53 stated it was not abuse, so Resident #53 did not make an allegation. We did not know where Ombudsman #294 received the information. Since Resident #53 was not stating being abused, then I am going to believe the resident. We did do an investigation. We talked to Resident #53. There must be discussion to determine whether it is reportable and whether it falls into those requirements, so I disagree with implementing the abuse policy because Resident #53 did not say she was abused. Review of the facility policy, Abuse, Neglect & Misappropriation, dated 05/25/23, revealed in the event an allegation was made, the facility would take measures to protect residents from harm during an investigation. An employee who is alleged or accused of being a party to abuse, would be immediately removed from the area of resident care, interviewed by facility leadership for a written statement and not left alone after completing the statement. The employee would be asked to vacate the facility until further investigation of the incident was completed, and the employee would be notified of the findings of the investigation. This deficiency represents non-compliance investigated under Complaint Number OH00149488.

Based on interview, record review and policy review, the facility failed to report an allegation of staff-to-resident verbal abuse for Resident #53 to the state agency. This affected one resident (#53) of three residents reviewed for abuse, neglect, and misappropriation. The facility census was 52. Findings include: Review of the medical record for Resident #53 revealed an admitted [DATE] and discharge date of [DATE]. Diagnoses included anoxic brain damage, spastic hemiplegia, major depressive disorder, anxiety disorder, heart failure, and need for assistance with personal care. Review of the Quarterly and State Optional Minimum Data Set (MDS) assessments dated 11/16/23 revealed Resident #53 had moderate cognitive impairment, and required extensive two staff assistance for bed mobility, transfers, and toileting. Resident #53 was frequently incontinent of bowel and bladder. Review of the care plan dated 08/09/23 revealed Resident #53 had a neurologic disorder and impaired cognitive function related to traumatic brain injury with spastic hemiplegia and convulsions. Resident #53 required staff assistance with all activities of daily living which fluctuated based on time of day, mood, pain, or fatigue. There were no behaviors documented in the care plan. Review of the progress note dated 10/26/23 and authored by Assistant Director of Nursing (ADON) #266 indicated Resident #53 reported not liking staff tone of voice when providing care but denied being fearful or mistreated. Staff were educated. Review of the progress note dated 11/13/23 at 11:51 A.M. and authored by Director of Nursing (DON) indicated interviewing Resident #53 after speaking to the Ombudsman regarding an allegation made to the Ombudsman on 11/10/23. Resident #53 did not voice to the staff at the facility. Discussed with Resident #53 regarding a shower which occurred in the prior week. Resident #53 requested a certain nursing assistant (unnamed) not provide a shower but could assist with other activities including brushing teeth or helping with meals. Resident #53 denied being abused but voiced the nursing assistant (unnamed) was rude with a tone. DON and Ombudsman inquired if Resident #53 was fearful which Resident #53 replied no but stated, care from the other facility was better. Review of shower documentation revealed Resident #53 received a shower on 11/09/23 by State tested Nursing Assistant (STNA) #240. There were no skin areas noted. Review of a written witness statement by Licensed Practical Nurse (LPN) #287, undated, indicated Resident #53 requested to be brought to ADON #266. LPN #287 asked Resident #53 what was needed because she was the nurse and could help. Resident #53 reported wanting her bath items which were left in the shower room. LPN #287 told Resident #53 it would be retrieved after passing a medication which was already prepared for administration. LPN #287 then retrieved the bath items. LPN #287 told Resident #53 to quit perseverating on things and keep busy, it was not an emergency, and we would take care of it. Review of staff education entitled Teachable Moment, dated 10/26/23, and signed by LPN #287 revealed an identified issue as tone of voice when speaking with a resident, and a solution of staff member educated and apologized to the resident. LPN #287 included a written statement which denied having a bad tone with resident (unnamed) but understood people take things differently. Review of a written witness statement by STNA #240, dated 11/10/23, revealed when STNA #240 approached Resident #53 to assist with oral care, Resident #53 indicated not wanting STNA #240 to provide care anymore due to what happened on 11/09/23. STNA #240 described providing a shower to Resident #53 on 11/09/23. Prior to the shower, Resident #53 toileted and then after the shower during drying, Resident #53 stated she was urinating on the floor. STNA #240 asked why, because she could have assisted her to the toilet. Resident #53 made no response. On 11/10/23, STNA #240 asked Resident #53 about what happened on 11/09/23, and Resident #53 indicated STNA #240 was not being nice when asking her why she urinated on the floor and no longer wanted STNA #240 to care for her. After the shower on 11/09/23, STNA #240 described helping Resident #53 with many things after it happened including lunch and activities. Review of an email dated 11/13/23 at 9:17 A.M. from Ombudsman #294 to the DON stated there was an allegation of verbal abuse that needed follow-up. Resident #53 reported during the previous week on a shower day, STNA #237 was yelling at her. Resident #53 only told her sister. Ombudsman #294 indicated to the DON ability to review what was reported, and a need to ensure the DON followed the facility process for investigation. Review of staff education titled Teachable Moment, dated 11/13/23, and signed by STNA #240 revealed an identified issue of customer service, and solution as to be mindful of tone of voice when speaking to others. STNA #240 included a written statement which denied raising her voice when offering to put resident (unnamed) on the toilet. There was no evidence that the facility filed a Self-Reported Incident (SRI) for Resident #53. Interviews on 01/04/24 from 9:18 A.M. to 9:21 A.M. with LPN #224 and STNA #267 verified all staff mistreatment or abuse was reported to the DON or Administrator. Interview on 01/04/24 at 10:16 A.M. with the DON confirmed receipt of an email from Ombudsman #294 with a statement there was an allegation of abuse. Ombudsman #294 reported STNA #237 yelled at Resident #53. After receipt of the email, I interviewed Resident #53 and looked at the nursing schedule. It was determined it was not STNA #237, but STNA #240 who was educated. STNA #240 denied yelling at Resident #53 during the shower, so she was educated on tone of voice. Resident #53 denied feeling abused but indicated feeling STNA #240 was being rude and did not like STNA #240's tone. Resident #53 voiced feeling safe, and Ombudsman #294 was present during the interview on 11/13/23. The DON indicated following up with administration including a regional staff member. It was decided not to file an SRI because it wasn't an allegation of abuse because Resident #53 said it wasn't abuse. It was more customer service. Interview on 01/04/24 at 10:33 A.M. with STNA #240 verified an incident occurred with Resident #53 on 11/10/23 which involved the events of 11/09/23 during a shower. When STNA #240 approached Resident #53 on 11/10/23 to brush her teeth, Resident #53 stated she did not want me to take care of her anymore but did not explain why. Later, Resident #53 indicated to STNA #240 being upset about the shower on 11/09/23. STNA #240 confirmed reporting the concern to the DON on 11/10/23. Afterward, the DON requested STNA #240 write a statement of what happened. When Resident #53 was showered, STNA #240 provided toileting and after the shower Resident #53 urinated on the floor. STNA #240 asked her why, and Resident #53 responded because she had to. STNA #240 indicated Resident #53 was on medication for a urinary tract infection at the time. So, using a towel, STNA #240 cleaned it up and told Resident #53 that she could have put her on the toilet if Resident #53 had told her. STNA #240 proceeded to get Resident #53 dressed and continued to provide care during the day including lunch assistance and other activities. STNA #240 asked the DON about the incident, and the DON reported talking to Resident #53 who stated not feeling abused, so STNA #240 did not have to stop working for an investigation. STNA #240 confirmed continuing to provide care for Resident #53 after the incident. Interview on 01/04/24 at 10:53 A.M. with the DON verified STNA #240 reported on 11/10/23 of Resident #53 not wanting to receive care from STNA #240 anymore. The DON directed STNA #240 to write a statement which she reviewed. The DON interviewed Resident #53 who reported STNA #240 was rude, and it was about Resident #53 going to the bathroom on the floor. Resident #53 never stated STNA #240 yelled or indicated being threatened, just not wanting STNA #240 to provide showers anymore but could do other care like brushing teeth, meals, and activities. Resident #53 kept stating STNA #240 was rude and did not provide any details. The DON informed the Administrator education was going to be provided to STNA #240. On 11/13/23, Ombudsman #294 sent an email, but the DON indicated already being aware of the incident because of the statement STNA #240 wrote. Ombudsman #294 indicated more details would be provided but it happened in the previous week, so the DON waited for Ombudsman #294 to provide more information. Ombudsman #294 did come to the facility later and we both talked to Resident #53. The Administrator was aware. The DON verified knowledge of Resident #53 reporting to ADON #266 on 10/26/23 of a staff member being rude or mean. The DON indicated Resident #53 thought when people spoke to her, they were being rude or mean. The DON denied memory of interviewing Resident #53 after being made aware of the incident on 10/26/23. Interview on 01/04/24 at 11:07 A.M. with STNA #237 confirmed caring for Resident #53 on multiple occasions, but there were no issues. STNA #237 indicated Resident #53 had demanding behaviors. Resident #53 verbalized statements such as staff not wanting to help or did not care for them but nothing specific just things were not done right. STNA #237 verified any report from a resident involving someone being mean, verbal, or physical, would be reported to the DON or Administrator. STNA #237 reported hearing staff talk about Resident #53 reporting people being mean, but the response was Resident #53 always talks that way. Interview on 01/04/24 at 11:20 A.M. with ADON #266 verified on 10/26/23, Resident #53 reported not liking the tone of voice by LPN #287. Resident #53 denied being fearful. ADON #266 indicated talking to LPN #287 and obtaining a written statement. LPN #287 stated Resident #53 wanted supplies from the shower, but LPN #287 was passing medications. What was gathered was Resident #53 wanted it done immediately. ADON #266 confirmed giving LPN #287 education and reported to the DON on 10/26/23. The DON agreed with providing LPN #287 education. With an allegation of abuse, we immediately separate people to make sure of no harm or injury from anyone being accused, and it is reported to the DON. Since Resident #53 requested LPN #287 bring her to me, they were separated, and Resident #53 was not fearful at the time. ADON #266 indicated if she was present during the incident, she would have separated them. ADON #266 stated not feeling the need to investigate because Resident #53 reported not feeling fearful and in danger. ADON #266 verified just interviewing Resident #53 on 10/26/23, and if Resident #53 felt in fear, ADON #266 would have made sure the abuse investigation was executed. ADON #266 stated the facility abuse policy and procedure was executed when a resident stated they were in fear, danger, or abused. ADON #266 indicated just going off residents' wording since they entrust in us. If a resident was not cognitively able to report ADON #266 would look for witnesses and ask if they were mistreated. ADON #266 stated having to trust what was said to be correct. Interview on 01/04/24 at 12:45 P.M. with the DON verified ADON #266 reported the incident on 10/26/23 with Resident #53. ADON #266 indicated talking to Resident #53 and was directed to do education. The abuse policy would not be implemented because Resident #53 and ADON #266 did not state it was abuse, only Resident #53 complained about tone. Interview on 01/04/24 at 12:55 P.M. with the Administrator confirmed being aware of both incidents with Resident #53. Resident #53 was interviewed regarding whether anything occurred, and Resident #53 stated nothing occurred. We started an investigation by talking to Resident #53 after receipt of the email on 11/13/23 to see if it was valid. Ombudsman #294 sent it four days after it happened and because it was so far back, we wanted to make sure it was an allegation. Ombudsman #294 stated to follow our process which was to investigate. We talk to residents with any allegation, and if a resident does not allege, then there is no allegation. The abuse policy was only implemented if a resident indicated abuse. An abuse allegation would be reported if a resident was not able to state it. The Administrator verified not being aware of the 10/26/23 incident with Resident #53 until the time of the survey. The Administrator stated it must be found out if it is abuse before initiating the policy. If a resident stated someone abused me, then it would be reported and investigated. Ombudsman #294 indicated to follow-up. I took it as to check first, so we talked to Resident #53 and determined it was not abuse. This was because Resident #53 stated it was not abuse, so Resident #53 did not make an allegation. We did not know where Ombudsman #294 received the information. Since Resident #53 was not stating being abused, then I am going to believe the resident. We did do an investigation. We talked to Resident #53. There must be discussion to determine whether it is reportable and whether it falls into those requirements, so I disagree with implementing the abuse policy because Resident #53 did not say she was abused. Review of the facility policy, Abuse, Neglect & Misappropriation, dated 05/25/23, revealed in the event an allegation was made, the facility would make accurate and timely reporting of incidents both alleged and substantiated to officials in accordance with the state law. All alleged violations involving abuse are reported immediately, but not later than two hours after the allegation is made, for those alleged violations that do not result in serious bodily injury, the facility must report the allegation no later than 24 hours. The results of the facility's investigation must be reported to the survey agency. This deficiency represents non-compliance investigated under Complaint Number OH00149488.

Based on interview and record review, the facility failed to ensure authorization was obtained prior to the facility opening a resident funds account for Resident #249 and Resident #250. This affected two residents (Resident #249 and #250) out of seven residents reviewed for resident funds. Findings include: 1. Review of closed medical record for Resident #249 revealed an admitted [DATE] and a discharge date of [DATE]. His diagnoses included diabetes, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, hypertension, and muscle weakness. His medical record revealed he was his own responsible person. Review of facility Admission Agreement revealed the agreement was dated 02/03/22 and signed by Resident #249 and Former Licensed Social Worker (LSW)/ Admissions #600. The agreement revealed under personal funds that a resident can choose to deposit his personal funds with the facility and Resident #249 marked that he was not interested in initiating a personal fund account through the facility. Review of undated blank facility form labeled Resident Fund Management Service Authorization and Agreement to Handle Resident Funds revealed by signing below a resident and/ or resident representative authorized the named facility to establish and manage an insured interest-bearing resident fund and that the resident can have his re-occurring checks direct deposited to their resident funds account. Resident #249 did not have an authorization per his medical record. Review of facility form labeled; Resident Fund Management Service Statement dated from 03/22/22 through 03/31/22 revealed the facility opened a resident funds account on 03/22/22 for Resident #249. Review of facility form labeled; Resident Fund Management Service Statement dated from 04/01/22 through 06/30/22 revealed the facility continued to have a resident funds account for Resident #249 as on 04/01/22 Resident #249's social security check of one thousand five hundred seventy-five dollars and fifty cents was direct deposited into the account . The statement revealed then Resident #249 was personally reimbursed seven hundred, eighty-seven dollars and fifty cents and seven hundred eighty-seven dollars and fifty cents went towards his patient liability. The statement revealed on 05/03/22 Resident #249's social security check of one thousand five hundred and five dollars was deposited into the account and then on 05/04/22 Resident #249 was refunded the same amount. The statement revealed on 05/26/22 and 06/03/22 Resident #249's social security check of a a total of two thousand four hundred twenty-five dollars and forty-two cents was deposited into his account and then on 06/09/22 Resident #249 was personally reimbursed this amount. Review of facility form labeled; Resident Fund Management Service Statement dated from 07/01/22 through 09/30/22 revealed on 07/01/22 Resident #249's social security check of one thousand seven hundred and forty-five dollars was deposited into the account and on 07/05/22 he was personally reimbursed this amount. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #249 had intact cognition. Interview on 11/07/22 at 9:19 A.M. with Ombudsman #700 revealed she had two residents, Resident #249 and Resident #250, that had voiced a concern to her that the facility automatically opened up a resident account for them through the facility without their authorization. Interview on 11/09/22 at 2:17 P.M. with Administrator and Business Office Manager #601 verified when Resident #249 was admitted on [DATE] he had signed an Admission Agreement dated 02/03/22 that he was not interested in initiating a personal funds account through the facility. Business Office Manager #601 revealed she went into the resident management service software, and she hit to have his social security check direct deposited to personal fund account that was managed by the facility. Business Office Manager #601 verified she did not have Resident #249 sign the facility authorization form; Resident Fund Management Service Authorization and Agreement to Handle Resident Funds. They verified Resident #249 never signed authorization for the facility to open a resident's fund account and to have the facility manage his funds but that an account was opened on 03/22/22. They verified the authorization form should have been signed prior to any resident fund being opened and his funds managed by the facility. 2. Review of closed medical record for Resident #250 revealed an admitted d of 02/15/22 and discharge date of [DATE]. His diagnoses included hypertension, anxiety disorder, and muscle weakness. His medical record revealed he was his own responsible person. Review of facility Admission Agreement revealed the agreement was dated 02/16/22 and signed by Resident #250 and Former Licensed Social Worker (LSW)/ Admissions #600. The agreement revealed under personal funds that a resident can choose to deposit his personal funds with the facility and that Resident #250 marked to have the business office present him with the necessary paperwork to open a personal fund account. Review of undated blank facility form labeled Resident Fund Management Service Authorization and Agreement to Handle Resident Funds revealed by signing below a resident and/ or resident representative authorized the named facility to establish and manage an insured interest-bearing resident fund and that the resident can have his recurring checks direct deposited to their resident fund account. Resident #250 did not have this authorization per his medical record. Review of facility form labeled; Resident Fund Management Service Statement dated from 03/22/22 through 03/31/22 revealed the facility opened a resident fund's account on 03/22/22 for Resident #250. Review of facility form labeled; Resident Fund Management Service Statement dated from 04/01/22 through 06/30/22 revealed on 04/01/22 Resident #250's social security check was direct deposited into his resident fund of one thousand eight hundred and fifty-seven dollars. The statement revealed on 04/11/22 Resident #250 agreed to have one hundred dollars go towards his patient liability but then he was refunded the rest of the money (one thousand seven hundred and fifty-seven dollars). Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #250 had an intact cognition. Interview on 11/07/22 at 9:19 A.M. with Ombudsman #700 revealed she had two residents, Resident #249 and Resident #250, that had voiced a concern to her that the facility automatically opened up a resident account for them without their authorization. Interview on 11/09/22 at 2:17 P.M. with Administrator and Business Office Manager #601 revealed when Resident #250 was admitted on [DATE] he had signed an Admission Agreement dated 02/16/22 that he wanted the business office to present him with the necessary paperwork to open a personal fund's account. Business Office Manager #601 revealed she went into the resident management service software, and she hit to have his social security check direct deposited to a personal fund account prior to having Resident #250 sign the facility authorization form; Resident Fund Management Service Authorization and Agreement to Handle Resident Funds. They verified Resident #250 never signed authorization for the facility to open a resident fund's account and to have the facility manage Resident #250's funds but that an account was opened on 03/22/22. They verified the authorization form should have been signed prior to any resident fund being opened and his funds managed by the facility. Review of facility policy labeled, Resident Trust Fund dated 10/17/17 revealed upon admission or at any time upon the resident's request the resident would be given the opportunity to open a resident fund account with the facility. The policy revealed in order for the facility to maintain the residents funds the business office manager must receive a completed authorization and agreement from the resident. The policy revealed all authorization forms would require a witness. This deficiency represents non-compliance investigated under Master Complaint Number OH00135749 and Complaint Number OH00134249.

Based on observation, interview, and record review, the facility failed to ensure Resident #25 had bilateral hand splints as ordered. This affected one resident (Resident #25) out of one resident reviewed for splints. Findings included: Review of medical record for Resident #25 revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of care plan dated 05/11/21 revealed Resident #25 had an activities of daily living self- care performance deficit that required assistance related to spastic quadriplegic [CONDITION(S)]. Interventions included total assistance of two staff with bed mobility, transfers, and dressing. There was no documentation in the care plan regarding contracture's to his bilateral hands and bilateral splinting carrots (a fabric splint device in the shape of a carrot to prevent contracture's to hand) to his hands were to be implemented. Review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Occupational Therapy Discharge Summary dated 07/06/22 and completed by Occupational Therapist #608 revealed Resident #25 had bilateral hand contractures and was to have bilateral hand rolled wash clothes or carrot splints to his bilateral hands to increase range of motion. Review of Treatment Administration Record (TAR) for September 2022 for Resident #25 revealed no documentation that a splinting device was implemented for Resident #25 as ordered. Review of TAR for October 2022 for Resident #25 revealed no documentation that a splinting device was implemented for Resident #25 as ordered. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #25 had impaired cognition as he was rarely and/ or never understood. He required total dependence of two people with bed mobility and transfers. There was no documentation under restorative nursing that Resident #25 received splint and/ or brace assistance. Review TAR for November 2022 for Resident #25 revealed no documentation that a splinting device was implemented for Resident #25 as ordered. Observation on 11/08/22 at 8:20 A.M., 9:55 A.M., and 12:18 P.M. revealed Resident #25's bilateral hands were contracted with no splinting device in place. Interview on 11/08/22 at 12:34 P.M. with State tested Nursing Assistant (STNA) #606 revealed Resident #25 was supposed to have carrot splinting devices placed in his bilateral hands but that the carrots had been broken approximately two weeks ago and they did not place anything then in his bilateral hands. She revealed they were unable to place washcloths or any other devices in his hands as the carrots were the only device that could fit inside his hands. STNA #606 revealed she reported to a nurse that the carrot splinting devices were broken but could not remember the date and to who she specifically reported this to. She revealed she did not document anywhere in his medical record regarding the implementation of his splints. Interview on 11/08/22 at 1:02 P.M. with Licensed Practical Nurse (LPN) #604 revealed she was the charge nurse for Resident #25 today, 11/08/22, and was not aware Resident #25 did not have his carrot splinting devices and/ or that they were broke. She revealed they did not document anywhere in his medical record regarding the implementation of his splints. Interview on 11/08/22 at 1:49 P.M. with Rehabilitation Director #607 revealed she was not aware that Resident #25's carrot splinting devices were broken and that they were not utilizing any splinting devices in his bilateral hands. She revealed Central Supply #605 ordered new replacement carrot splinting devices and she was unsure if she was aware they were broken. She revealed per their last Occupational Therapy Discharge Summary dated 07/06/22 revealed Resident #25 was to have bilateral hand rolled wash clothes or carrot splints to his bilateral hands to increase range of motion. She revealed if the carrot splinting devices were broken that the staff should have been using rolled up washed clothes as replacement. Interview on 11/08/22 at 1:52 P.M. with the Director of Nursing revealed she was not aware Resident #25's carrot splinting devices were broken and was not aware how long they had been broken. She revealed the order should have been on the TAR and the nurses documenting that the splints were applied, and she was unsure why the order was not on the TAR for September 2022, October 2022 and November 2022. She verified she had no documentation of the splints being implemented for Resident #25 from 09/01/22 through 11/08/22. Interview on 11/08/22 at 2:04 P.M. with Central Supply #605 revealed she ordered the needed supplied including carrot splinting devices and was not aware Resident #25's carrot splinting devices were broken as she was not notified. She revealed she did not have any back up carrot splinting devices and /or had ordered any replacements. Review of facility policy labeled, Restorative Program dated 11/08/22 revealed the purpose of this policy was to provide direction and guidance to the clinical team to assess and implement a plan of action for resident-specific care to maintain or improve mobility with the maximum practicable independence. The policy revealed based upon the assessment and evaluation necessary equipment including splints or braces should be addressed in the care plan.

Based on record review and interview, the facility failed to ensure the pharmacy delivered medications in a timely manner to ensure Resident #44 and Resident #99 received intravenous antibiotics as scheduled. This affected two residents (Resident #44 and Resident #99) out of five residents reviewed for medication administration. Findings include: 1. Resident #44 was admitted to the facility at 5:45 P.M. on 10/27/22 with diagnoses including [CONDITION(S)] of the lower extremities, bacteremia, elevated white blood cell count, heart failure, [CONDITION(S)] and obesity. A review of a nurse progress note dated 10/27/22 indicated the physician verified the admission medication orders at 6:45 P.M. A review of Resident #44's clinical nurse practitioner (CNP) progress note dated 10/28/22 indicated Resident #44 was admitted from the hospital for intravenous infusion of antibiotics for the lower leg [CONDITION(S)] with associated bacteremia infection. The CNP progress note indicated Resident #44 had a peripheral intravenous central line (PICC) in the right upper forearm for the intravenous infusion. The CNP note indicated the plan of care included to continue the intravenous antibiotic administration started while in the hospital. A review of the hospital Medication Administration Record (MAR) dated 10/27/22 indicated the last dose of [MEDICATION(S)] (antibiotic) 2 grams was administered intravenously in the hospital at 11:16 A.M. prior to transfer to the facility. Resident #44's admission physician order dated 10/27/22 indicated to administer [MEDICATION(S)] 2 grams intravenously every eight hours for infection. The next dose was due to be administered at 7:16 P.M. on 10/27/22. A review of Resident #44's MAR dated 10/01/22 to 10/31/22 indicated he received the first dose in the facility of Cefepine 2 grams intravenously on 10/28/22 at 4:00 P.M. Electronic medication administration note dated 10/28/22 at 5:51 A.M. and 10:59 A.M. indicated the facility was waiting for delivery of the [MEDICATION(S)] antibiotic medication from pharmacy. An interview with Resident #44 on 11/07/22 at 10:50 A.M. indicated he did not receive his intravenous antibiotic for at least 24 hours after he was admitted to the facility. Resident #44 stated the nursing staff had informed him they had called the pharmacy several times to have them deliver the intravenous antibiotic but they failed to deliver the antibiotic until the next day. An interview with Licensed Practical Nurse (LPN) #500 on 11/08/22 at 3:30 P.M. and with LPN #501 and LPN #502 on 11/09/22 at 6:15 A.M. indicated they had worked for the facility for more than two years and the the pharmacy routinely failed to deliver medications in a timely manner after residents were admitted to the facility. LPN #500 stated she often had to wait 24 hours or more for medications to be delivered from the pharmacy after a resident arrived to the facility. LPN #500 stated some medications were stocked in the facility and could be signed out to administer to the residents as needed. If the facility did not stock a particular medication then the resident had to wait an extended period of time to have their prescription medications administered. An interview with Assistant Director of Nursing (ADON) on 11/08/22 at 11:29 A.M. verified the above findings and indicated she was unaware if the administrative personnel had contacted the pharmacy to implement changes to ensure the residents received their medications from the pharmacy in a timely manner. ADON stated the nurses had called the pharmacy several times to have Resident #44's intravenous antibiotic delivered immediately on 10/27/22 but did not receive the antibiotic until the following day. An interview with Physician #503 on 11/09/22 at 7:15 A.M. indicated the staff notified him of the failure of the pharmacy to deliver the intravenous (IV) antibiotics for Resident #44 within the first few hours after their admission. Physician #503 stated when the staff notified him the intravenous antibiotics were not available to administer the staff were informed by the pharmacy the intravenous antibiotics would be delivered by the pharmacy buy the next morning. Physician #503 stated this had been an ongoing problem and should have been addressed by the facility. Physician agreed residents should receive IV antibiotics as soon as possible to treat their specific infections. An interview with Administrator on 11/09/22 at 8:00 A.M. indicated upon admission to the facility the physician ordered medications were faxed to the pharmacy after verified with the physician. If a resident's medication was not available when scheduled to administer the staff could withdraw the medication from the facility stock if available. If the facility did not have the medication stocked, the nurse would call the pharmacy and inquire of the time of delivery for the resident's medication. The nurse would then notify the physician of the missing medication. Administrator indicated she had informed the corporation of the problem and there had been no resolution. An interview on 11/09/22 at 9:12 A.M. with the Quality Assurance Pharmacist (QAP) from the pharmacy the facility used to provide the medications to the residents in the facility revealed she was recently notified of the problem with timeliness of delivery of Resident #44's intravenous antibiotics to the facility on [DATE]. QAP indicated the pharmacy should be able to deliver intravenous medications immediately to the facility when needed. QAP agreed it was unacceptable for the pharmacy to delay the delivery of intravenous antibiotics and could not identify the root cause of the problem. An interview with Director of Nursing (DON) on 11/09/22 at 10:52 A.M. indicated the pharmacy was expected to deliver IV antibiotic medications to the facility as soon as possible after receiving the physician order. DON indicated the expectation was the resident would receive the IV antibiotic with in four to six hours after their admission to the facility. DON verified the pharmacy was contacted by the facility staff and continued to fail to deliver the IV antibiotic in a timely manner. A review of the Ohio Pharmacy Information (undated) from the pharmacy company who provided services to the facility indicated resident's medications would be delivered at 12:00 P.M. and 12:00 A.M. from Monday through Friday and 12:00 P.M. and 5:00 P.M. on Saturday, Sunday and holidays. New order requests received before 12:00 P.M. would arrive with the first scheduled delivery. Order requests after 12:00 A.M. would be delivered on the first scheduled delivery the following day. 2. Resident #99 was admitted on [DATE] with diagnoses including [CONDITION(S)] with kidney cancer, bacteremia, enterococcus as the cause of diseases classified elsewhere, heart disease and [CONDITION(S)]. Resident #99's nursing progress note dated 11/04/22 at 6:19 P.M. indicated Resident #99 was admitted and had a right chest single lumen central venous line port for intravenous infusion. A review of Resident #99's physician order dated 11/05/22 indicated to administer [MEDICATION(S)] 1 gram intravenously every eight hours for bacterial infection. Review of nursing progress note dated 11/05/22 at 1:46 A.M., 10:57 P.M., revealed the [MEDICATION(S)] intravenous antibiotic had not arrived from the pharmacy and the physician was aware. Review of Resident #99's MAR dated 11/01/22 to 11/20/22 revealed the [MEDICATION(S)] antibiotic was not administered until 11/06/22 at 6:00 A.M. An interview with Resident #99 on 11/07/22 at 10:09 A.M. indicated he was admitted to receive intravenous antibiotics and the pharmacy did not deliver the intravenous antibiotic until approximately 48 hours after he was admitted to the facility. An interview with Physician #503 on 11/09/22 at 7:15 A.M. indicated the staff notified him of the failure of the pharmacy to deliver the IV antibiotics for Resident #99 with in the first few hours after their admission. Physician #503 stated when the staff notified him the intravenous antibiotics were not available to administer the staff were informed by the pharmacy the intravenous antibiotics would be delivered by the pharmacy buy the next morning. Another nurse called and notified him the antibiotic was not available the next morning and the pharmacy told the staff the IV antibiotic would be delivered in the afternoon. Physician #503 stated this had been an ongoing problem and should have been addressed by the facility. Physician agreed residents should receive IV antibiotics as soon as possible to treat their specific infections. An interview with Administrator on 11/09/22 at 8:00 A.M. indicated upon admission to the facility the physician ordered medications were faxed to the pharmacy after verified with the physician. If a resident's medication was not available when scheduled to administer the staff could withdraw the medication from the facility stock if available. If the facility did not have the medication stocked, the nurse would call the pharmacy and inquire of the time of delivery for the resident's medication. The nurse would then notify the physician of the missing medication. Administrator indicated she had informed the corporation of the problem and there had been no resolution. An interview on 11/09/22 at 9:12 A.M. with the QAP from the pharmacy the facility used to provide the medications to the residents in the facility revealed she was recently notified of the problem with timeliness of delivery of Resident #44's intravenous antibiotics to the facility on [DATE]. QAP indicated the pharmacy should be able to deliver intravenous medications immediately to the facility when needed. QAP agreed it was unacceptable for the pharmacy to delay the delivery of intravenous antibiotics and could not identify the root cause of the problem. An interview with DON on 11/09/22 at 10:52 A.M. indicated the pharmacy was expected to deliver IV antibiotic medications to the facility as soon as possible after receiving the physician order. DON indicated the expectation was the resident would receive the IV antibiotic with in four to six hours after their admission to the facility. DON verified the pharmacy was contacted by the facility staff and continued to fail to deliver the IV antibiotic in a timely manner. A review of the Ohio Pharmacy Information (undated) from the pharmacy company who provided services to the facility indicated resident's medications would be delivered at 12:00 P.M. and 12:00 A.M. from Monday through Friday and 12:00 P.M. and 5:00 P.M. on Saturday, Sunday and holidays. New order requests received before 12:00 P.M. would arrive with the first scheduled delivery. Order requests after 12:00 A.M. would be delivered on the first scheduled delivery the following day.

Based on interview and record review, the facility failed to submit complete and accurate staffing information for the Payroll-Based Journal (PBJ) report to Centers for Medicare and Medicaid Services (CMS). This had the potential to affect all 51 residents in the facility. Findings include: Review of emails of 05/11/22 and 07/30/22 between the Administrator and the corporate office revealed missing nursing hours for the PBJ reports for 01/01/22 to 03/31/22 and 04/01/22 to 06/30/22. The DON or the Assistant DON provided direct care on 01/09/22, 01/15/22, 02/12/22, 02/13/22, 02/26/22, 03/13/22, 03/20,22, 03/26/22, 03/27/22, 07/02/2022, 07/09/2022, 07/10/2022, 07/16/2022, 07/17/2022, 07/23/2022, 07/24/2022, 07/30/2022, 07/31/2022, 08/06/2022, 08/07/2022, 08/13/2022, 08/20/2022, 08/21/2022, 08/27/2022, 09/03/2022, 09/04/2022, 09/17/2022 and 09/18/2022. Interview on 11/14/22 12:45 P.M. with the Administrator revealed the Director of Nursing (DON) provided direct care to ensure facility staffing was not low, particularly on the weekends. The hours when the DON provided direct care were not entered into the PBJ since she was salary. The Administrator reported she provided those hours to the corporate office when requested but they were not entered in time and the PBJ report did not accurately reflect the staffing data. Interview on 11/1422 at 1:10 P.M. with the DON verified she provided direct care on the dates reported to the corporate office. Interview on 11/15/22 at 1:44 P.M. with Corporate Manager (CM) # 801 revealed staffing hours cannot be entered beyond a certain date. He verified the facility triggered for low weekend staffing and a one-star staffing rating because not all hours were reported to CMS in the PBJ report for 04/01/22 to 06/30/22.

Based on observation, interview, record, resident council and review of shower/bathing records, the facility failed to act upon grievances of the residents. This affected at five (#7, #8, #22, #33 and #42) of six residents (#43) reviewed with the potential to affect all 47 residents. Findings include: 1. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly comprehensive assessment (MDS 3.0) dated 01/27/21 indicated she was independent in daily decision making ability, displayed no behavioral symptoms, required the extensive assistance of two plus staff for personal hygiene and totally dependent on two plus staff for bathing. The care plan indicated she was totally dependent on staff for bathing. Review of the progress notes since her admission lacked indication of refusal of care or services. Interview with Resident #7 on 04/28/21 at 10:00 A.M. reported it had been a week since her last shower. She reported she was not getting her showers as scheduled and it was taking a long time for call lights to be answered. Observation of Resident #4 on 04/28/21 at 10:00 A.M. revealed her hair was flat to her head, greasy and separated. Review of the shower schedule revealed she was to receive a shower/bath on the first shift on Thursdays and Sundays. Review of the shower/bathing sheets provided by the facility revealed she had three of nine shower for March 2021 and two showers and two bed baths of eight showers in April 2021. 2. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS 3.0 dated 11/19/20 indicated she was independent in daily decision making ability, displayed no behavioral symptoms and required the extensive assistance of two plus staff for personal hygiene and one person for bathing. The assessment indicated it was not very important for her to choose the type of bathing she received. Review of the care plan indicated she required the extensive assistance of one for a bed bath and two for transfers. Review of the progress notes since January 2021 revealed she occasionally refused her wound treatments but no refusals of care. Interview with Resident #8 on 04/27/21 at 2:40 P.M. indicated she was not getting her bed baths as she was supposed to the aides told her they didn't have enough time. She reported an aide on second shift last week took her off the bed bad and urine had spilled onto the bed pad and requested for it to be changed. The aide said she would be back and the resident observed her go to her car to smoke then leave the grounds for her lunch break leaving her on a wet pad for two hours. She reported this happened with more frequency than she liked. Review of the shower schedule revealed Resident #8 was to receive a shower/bath on Mondays and Wednesdays on the first shift. Review of the shower/bathing sheets provided by the facility revealed she received one of 10 showers/baths in March 2021 and four bed baths and one shower of eight in April 2021. 3. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS 3.0 dated 01/13/21 indicated she had moderate decision making ability, displayed no behaviors and required the extensive assistance of two plus staff for hygiene and was totally dependent on one staff for bathing. The assessment indicated it was very important to her to choose they type of bathing. Review of the behavior care plan revised on 10/20/20 indicated she refused care at times and had repetitive complaints/concerns and criticism of staff. She required the extensive to dependent assistance of one for bathing/showering. Review of the progress notes since admission lacked indication of refusal of care or services. Interview with Resident #22 on 04/28/21 at 8:30 A.M. indicated when there were only two aides scheduled she would not get her shower because she needed the assistance of two staff. She also reported waiting a half hour for her call light to be answered. Review of the shower schedule revealed Resident #22 was scheduled to receive a shower/bath on Tuesdays, Thursdays and Saturdays on the second shift. Review of the shower/bathing sheets provided by the facility revealed she received seven of 13 showers/baths in March 2021 and seven of 10 showers in April 2021. 4. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS 3.0 dated 02/24/21 indicated he was independent in daily decision making ability, displayed no behavioral symptoms and required the limited assistance of one staff for hygiene. Bathing did not occur during the assessment period. Review of the care plan indicated he required assistance for activities of daily living. Resident #33 was observed on 04/27/21 at 4:45 P.M. lying in bed fully clothed. He appeared disheveled and his hair was not combed. Review of the shower/bath schedule revealed Resident #33 was scheduled to receive a shower/bath on Mondays, Wednesdays and Fridays on the second shift. Review of the shower/bathing records provided by the facility revealed he received five of 14 shower/baths in March 2021 and five showers and one refusal of 11 in April 2021. 5. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS 3.0 dated 11/06/20 indicated she had moderate daily decision making ability, displayed no behaviors and required the extensive assistance of two plus staff for personal hygiene and total dependence on two plus staff for bathing. The assessment indicated it was very important for her to choose the type of bath she received. Review of the care plan indicated she required a mechanical lift for transfers and the extensive assistance of two staff for bathing. Review of progress notes since her admission lacked indication of refusal of care or services. Interview with Resident #42 on 04/27/21 at 2:40 P.M. reported there were not enough staff to provide her care. She reported often on night shift there was only one nurse aide. Resident #42 wanted a shower between 1:30 P.M. and 2:00 P.M. but if she got a shower it wouldn't be until 6:00 P.M. or 7:00 P.M. at night. She voiced concern that she had to lay in her urine and feces for up to an hour before an aide would come to clean her up. Review of the shower/bath schedule revealed Resident #42 was to receive a shower on Tuesdays and Fridays on the second shift. Review of the shower/bathing sheets provided by the facility revealed she received six of nine showers in March 2021 and five of seven in April 2021. Interview with State tested Nurse Aide (STNA) #105, 107, #108, #113 and #114 on 04/27/28 at 2:35 P.M. and 04/28/21 at 5:29 A.M. all reported having difficulty meeting the resident's needs reported a multitude of residents required two person assistance for activities of daily living. The staff reported either not having time to give showers or not being able to provide showers as per the resident's preference. Several have spoken with the administrator regarding hiring new staff, using agency staff and not taking any new admissions due to the staffing shortage. Interview with the administrator on 04/27/21 at 2:30 P.M. reported all of the management team took the eight hour temporary nurse aide course so they could assist with care, went to a liberal medication pass, additional nurse hours for the evening medication pass. Her expectation was for the non medical administration team to assist with answering call lights and providing the care the residents needed. She was unsure of why the complaints persisted but admitted she was not sure how much time her management team spent providing direct care. The administrator reported staff became critical of her for taking in more admissions since they were low on staff. She indicated the admissions she took were readmissions not new admissions. She was aware of the complaints of a lack of staff to meet the residents needs and completed assessments on residents bathing preferences and updated the bathing schedule within the last month to meet the resident's needs. Review of the resident council minutes dated 01/31/21 indicated residents reported waiting long periods of time when they put on their call light, on 03/08/21 staff were taking too long to get them dressed and ready for the day and on 03/26/21 staff at times do not have residents up and ready on time. Resident rights revised 05/19/16 indicated it was the policy of the facility to promote resident centered care by protecting and promoting the rights of each resident that fell within the standard of care. This deficiency substantiates complaint master control number OH 779 and OH 657.

Based on observation, interview, record, resident council and review of shower/bathing records, the facility failed to provide showers/baths to residents who were unable to shower independently. This affected at least five (#7, #8, #22, #33 and #42) of six residents (#43) reviewed with the potential to affect all 47 residents. Findings include: 1. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly comprehensive assessment (MDS 3.0) dated 01/27/21 indicated she was independent in daily decision making ability, displayed no behavioral symptoms, required the extensive assistance of two plus staff for personal hygiene and totally dependent on two plus staff for bathing. The care plan indicated she was totally dependent on staff for bathing. Review of the progress notes since her admission lacked indication of refusal of care or services. Interview with Resident #7 on 04/28/21 at 10:00 A.M. reported it had been a week since her last shower. She reported she was not getting her showers as scheduled and it was taking a long time for call lights to be answered. Observation of Resident #4 on 04/28/21 at 10:00 A.M. revealed her hair was flat to her head, greasy and separated. Review of the shower schedule revealed she was to receive a shower/bath on the first shift on Thursdays and Sundays. Review of the shower/bathing sheets provided by the facility revealed she had three of nine shower for March 2021 and two showers and two bed baths of eight showers in April 2021. 2. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS 3.0 dated 11/19/20 indicated she was independent in daily decision making ability, displayed no behavioral symptoms and required the extensive assistance of two plus staff for personal hygiene and one person for bathing. The assessment indicated it was not very important for her to choose the type of bathing she received. Review of the care plan indicated she required the extensive assistance of one for a bed bath and two for transfers. Review of the progress notes since January 2021 revealed she occasionally refused her wound treatments but no refusals of care. Interview with Resident #8 on 04/27/21 at 2:40 P.M. indicated she was not getting her bed baths as she was supposed to the aides told her they didn't have enough time. She reported an aide on second shift last week took her off the bed bad and urine had spilled onto the bed pad and requested for it to be changed. The aide said she would be back and the resident observed her go to her car to smoke then leave the grounds for her lunch break leaving her on a wet pad for two hours. She reported this happened with more frequency than she liked. Review of the shower schedule revealed Resident #8 was to receive a shower/bath on Mondays and Wednesdays on the first shift. Review of the shower/bathing sheets provided by the facility revealed she received one of 10 showers/baths in March 2021 and four bed baths and one shower of eight in April 2021. 3. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS 3.0 dated 01/13/21 indicated she had moderate decision making ability, displayed no behaviors and required the extensive assistance of two plus staff for hygiene and was totally dependent on one staff for bathing. The assessment indicated it was very important to her to choose they type of bathing. Review of the behavior care plan revised on 10/20/20 indicated she refused care at times and had repetitive complaints/concerns and criticism of staff. She required the extensive to dependent assistance of one for bathing/showering. Review of the progress notes since admission lacked indication of refusal of care or services. Interview with Resident #22 on 04/28/21 at 8:30 A.M. indicated when there were only two aides scheduled she would not get her shower because she needed the assistance of two staff. She also reported waiting a half hour for her call light to be answered. Review of the shower schedule revealed Resident #22 was scheduled to receive a shower/bath on Tuesdays, Thursdays and Saturdays on the second shift. Review of the shower/bathing sheets provided by the facility revealed she received seven of 13 showers/baths in March 2021 and seven of 10 showers in April 2021. 4. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS 3.0 dated 02/24/21 indicated he was independent in daily decision making ability, displayed no behavioral symptoms and required the limited assistance of one staff for hygiene. Bathing did not occur during the assessment period. Review of the care plan indicated he required assistance for activities of daily living. Resident #33 was observed on 04/27/21 at 4:45 P.M. lying in bed fully clothed. He appeared disheveled and his hair was not combed. Review of the shower/bath schedule revealed Resident #33 was scheduled to receive a shower/bath on Mondays, Wednesdays and Fridays on the second shift. Review of the shower/bathing records provided by the facility revealed he received five of 14 shower/baths in March 2021 and five showers and one refusal of 11 in April 2021. 5. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS 3.0 dated 11/06/20 indicated she had moderate daily decision making ability, displayed no behaviors and required the extensive assistance of two plus staff for personal hygiene and total dependence on two plus staff for bathing. The assessment indicated it was very important for her to choose the type of bath she received. Review of the care plan indicated she required a mechanical lift for transfers and the extensive assistance of two staff for bathing. Review of progress notes since her admission lacked indication of refusal of care or services. Interview with Resident #42 on 04/27/21 at 2:40 P.M. reported there were not enough staff to provide her care. She reported often on night shift there was only one nurse aide. Resident #42 wanted a shower between 1:30 P.M. and 2:00 P.M. but if she got a shower it wouldn't be until 6:00 P.M. or 7:00 P.M. at night. She voiced concern that she had to lay in her urine and feces for up to an hour before an aide would come to clean her up. Review of the shower/bath schedule revealed Resident #42 was to receive a shower on Tuesdays and Fridays on the second shift. Review of the shower/bathing sheets provided by the facility revealed she received six of nine showers in March 2021 and five of seven in April 2021. Interview with State tested Nurse Aide (STNA) #105, 107, #108, #113 and #114 on 04/27/28 at 2:35 P.M. and 04/28/21 at 5:29 A.M. all reported having difficulty meeting the resident's needs reported a multitude of residents required two person assistance for activities of daily living. The staff reported either not having time to give showers or not being able to provide showers as per the resident's preference. Several have spoken with the administrator regarding hiring new staff, using agency staff and not taking any new admissions due to the staffing shortage. Interview with the administrator on 04/27/21 at 2:30 P.M. reported all of the management team took the eight hour temporary nurse aide course so they could assist with care, went to a liberal medication pass, additional nurse hours for the evening medication pass. Her expectation was for the non medical administration team to assist with answering call lights and providing the care the residents needed. She was unsure of why the complaints persisted but admitted she was not sure how much time her management team spent providing direct care. The administrator reported staff became critical of her for taking in more admissions since they were low on staff. She indicated the admissions she took were readmissions not new admissions. She was aware of the complaints of a lack of staff to meet the residents needs and completed assessments on residents bathing preferences and updated the bathing schedule within the last month to meet the resident's needs. Review of the resident council minutes dated 01/31/21 indicated residents reported waiting long periods of time when they put on their call light, on 03/08/21 staff were taking too long to get them dressed and ready for the day and on 03/26/21 staff at times do not have residents up and ready on time. Resident rights revised 05/19/16 indicated it was the policy of the facility to promote resident centered care by protecting and promoting the rights of each resident that fell within the standard of care. This deficiency substantiates complaint master control number OH 779 and OH 657.

Based on interview, record review and policy review, the facility failed to ensure Resident #19, who had a [DIAGNOSES REDACTED].#19) of three residents reviewed for medication administration. The facility census was 34. Findings include: Review of the medical record for Resident #19 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) 3.0 assessment, dated 12/01/20, revealed Resident #19 had severely impaired cognition and [MEDICAL CONDITION]. The resident required extensive one staff assistance for bed mobility, transfers, eating, and was dependent on one staff with toileting. Review of the care plan dated 11/24/20 revealed Resident #19 had a [MEDICAL CONDITION] disorder. Interventions included to give [MEDICAL CONDITION] medication, and to monitor and document for effectiveness and side effects. Record review revealed Resident #19 had a physician's orders [REDACTED]. Review of Medication Administration Record [REDACTED].M. Review of MAR for December 2020 revealed no documented evidence of administration for the scheduled dose of levetiracetam on 12/11/20 at 6:00 P.M. Interview on 12/21/20 at 1:22 P.M. with the Director of Nursing confirmed there was no evidence in Resident #19's MAR indicated [REDACTED].M. and on 12/11/20 at 6:00 P.M. were administered as ordered. Review of nurse's notes dated 12/16/20 revealed Resident #19 was observed to exhibit [MEDICAL CONDITION] activity at approximately 1:30 P.M. Resident #19 was transferred to the hospital and admitted for observation. Review of hospital neurology consult note dated 12/17/20 revealed Resident #19 was admitted after witnessed generalized tonic-clonic [MEDICAL CONDITION] and received levetiracetam solution at home but a very low dose not enough to cover therapeutic range. Review of facility's policy, Medication Administration, revised 12/14/17, revealed administer medication only as prescribed by the provider; and medications will be charted when given. This deficiency substantiates Master Complaint Number OH 392 and Complaint Number OH 962.

Based on record review, interview and review of the facility Abuse Prohibition policy the facility failed to protect Resident #45 from physical abuse by Resident #2 and failed to prevent Resident #13 from verbal abuse by State tested Nurse Aide (STNA) #100. This affected two (Residents #2 and #13) of six residents (Residents #2, #7, #11, #12, #13 and #45) reviewed for abuse. The facility census was 26. Findings include: 1. Medical record review for Resident #2 revealed a birth date of 12/11/64, an initial admission into the facility on [DATE] and was his own representative. [DIAGNOSES REDACTED]. The comprehensive assessment, Minimum Data Set (MDS 3.0) dated 10/04/20 revealed a brief interview for mental status (BIMS) score of 15 of a possible 15 which indicated intact cognition. Resident #2 was independently ambulatory with the use of a wheelchair. Medical record review for Resident #45 revealed a birth date of 01/06/43 and initial admission into the facility on [DATE]. The wife of Resident #45 was listed as the guardian. [DIAGNOSES REDACTED]. Resident #45 had not been in the facility for a long enough length of time to complete the MDS 3.0 at the time of the complaint investigation. Review of the nursing note dated 10/07/20 revealed Resident #45 was admitted under hospice care. Resident #45 had a care plan that included keeping his bed in the low position or close to the floor to help prevent accidents. A social service note dated 10/08/20 revealed Resident #45 was not able to participate in his initial assessment due to cognitive deficits. An email dated 10/08/02 at 12:24 P.M. revealed Resident #2 emailed Social Worker (SW) #88, stating he would not stay in the facility past 90 days and either the staff should let him out or throw him out. It was their choice. Resident #2 stated in the email, he would fondle someone if that's what it takes. A behavior note dated, 10/09/20 at 9:00 P.M. revealed Resident #45 was found laying in his bed, on his back, with the bed in a low position. Resident #2 was in his wheelchair, at the bedside, positioned with both of his feet in Resident #45's perineal area and his torso and head still resting on the wheelchair as though sliding out of the wheelchair. Resident #2 was immediately transferred out of the room. Resident #45 was assessed for injury and none was discovered. The physician for both Resident #2 and Resident #45 were notified with orders to monitor Resident #45. Orders to send Resident #2 to the emergency department for evaluation and treatment and an immediate discharge from the facility were obtained. Review of an email dated 10/09/20 at 4:42 P.M. sent to SW #88 revealed Resident #2 stated he was going to leave either by the facility taking him out or making trouble until 911 was called. Resident #2 wrote, tonight I am going to fondle someone. Charges can't be pressed against a resident anyway and even if you do press charges, the victim's family will sue you for having a sex offender here. The Administrator and physician were notified, and Resident #2 was put on one to one care. This meant a staff member would sit with Resident #2 and the responsibility was to provide one to one care and monitor the actions of Resident #2 to ensure safety for the resident and other residents in the facility. Review of the facility reported incident (FRI) # 1 and attached investigation revealed a statement completed by State tested Nurse Aide (STNA) #50. This statement revealed on 10/09/20 STNA #50 went to check on Resident #2 and the resident was not in his room. Resident #2 was found across the hall in Resident #45's room next to the bed. Resident #2's head was in the wheelchair and his feet/legs were lying vertically across the waist area of Resident #45. Resident #2 was removed from the area and replied, thank you. A witness statement taken from Registered Nurse (RN) #90 revealed this nurse had looked across the hall and observed Resident #2's wheelchair up against Resident #45's bed. Resident #2 was lying across Resident #45 with his feet in the perineal area of Resident #45. Resident #2 was immediately removed for safety. Resident #45 was asymptomatic of any trauma, injuries or pain. A statement completed on 10/09/20 by STNA #95 revealed shortly after taking a break, she observed Licensed Practical Nurse (LPN) #55 waving her arm for immediate help. STNA #95 entered the room and saw Resident #2 lying in bed and Resident #45 with his feet in Resident #45's private area. STNA #95 repositioned Resident #2 in his wheelchair and moved his feet away from Resident #45. Resident #2 was removed from the room and she stayed with him until the police and ambulance had arrived and transferred him to the emergency department. The statement revealed during the wait time for ambulance and police department response, Resident #2 repeatedly stated, he wanted out of the facility and to not let them bring him back. A witness statement dated 10/09/20 from LPN #55 revealed this nurse last saw Resident #2 at 7:30 P.M. and was sitting at the nurses' station at the time of the incident. She did not witness the incident but heard another nurse yell out to call 911 and she did. Interview completed on 10/15/20 at 7:00 A.M. with the Administrator and Director of Nursing (DON) revealed Resident #2, had a history of [REDACTED]. Recently, Resident #2 had been sending emails to the social worker stating he would do whatever it takes to get out of the facility or be discharged back to the community as he was concerned about obtaining his social security checks. The Administrator and DON revealed on 10/09/20, Resident #2 was placed under one to one sitter care at approximately 5:00 P.M. after the Administrator was notified of the email he had sent to SW #88. STNA #50 was assigned the duty of sitting with Resident #2 for the purpose of monitoring his actions. On 10/09/20 at approximately 8:00 P.M., Resident #2 was in his wheelchair and on a tablet computer, video conferencing with a friend. STNA #50 exited the room of Resident #2 to notify LPN #55, who was at the nurses station, she was going on a work break and would need someone to cover the break and sit with Resident #2. LPN #55 was giving report on another resident's situation at the time and did not immediately attend to covering the one to one sitter and a period of 10 minutes had lapsed when at 8:10 P.M., LPN #55 went to Resident#2's room and discovered he was not in his room and Resident #2 was found in Resident #45's room. Resident #2 had exited his room through a shared bathroom to the attached empty room and then went across the hall to Resident #45's room. Further interview revealed RN #90 entered Resident #2's room at approximately 8:10 P.M. to deliver paperwork and after knocking on the door and entering the room, found Resident #2 had exited the room through the shared bathroom and found him across the hall in Resident #2's room. RN #90 observed Resident #2 on the left side of Resident #45's bed with his body sliding out of the wheel-chair and the lower part of his legs were across the waist of Resident #45. No skin to skin contact was observed. Resident #2 had a urinary catheter and had an adult brief intact around his waist at the time of the discovery. Resident #2 was removed from the room immediately. Resident #45 remained asleep throughout the incident. Resident assessment and skin sweep were completed for Resident #45 and no negative findings were discovered. The physicians for both residents were contacted. Resident #2 was sent to the hospital for evaluation and immediate discharge from the facility. Resident #45 remained in the facility for further monitoring and observation. Immediate investigation into the incident was initiated. During the interview it was verified the incident occurred due to lack of communication or a communication breakdown. It was confirmed the incident was their fault as they failed to protect Resident #45. Training on one to one should have been provided and LPN #55 was ultimately at fault due to her error in not immediately observing and supervising Resident #2. Phone interview on 10/15/20 at 12:34 P.M. with the police detective (PD) #100 who verified he had responded to the call revealed he had not finalized his report at the time of this investigation. Interview on 10/15/20 at 12:38 P.M. with SW #88 confirmed she had received the emails from Resident #2 threatening to fondle another resident as a means of getting discharged from the facility. Phone interview was attempted on 10/15/20 at 12:40 P.M. with STNA #50. A message was left but no return call was received. Phone interview was attempted on 10/15/20 at 12:51 P.M. with STNA #95 and the voice mail box was full. Review of the FRI # 1 revealed the facility had initiated a timely investigation including assessments, interviews and education on resident rights, abuse, neglect and misappropriation was provided house wide on 10/10/20. Review of the state sex offender list and attached results revealed the facility had obtained the required search for sex offences attached to Resident #2 on 09/16/20 and the date base had found no offenders under the resident's name. 2. Record review revealed Resident #13 was admitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. review of the (MDS) 3.0 of 06/22/20 revealed the resident was moderately cognitively impaired and required extensive assist for Activities of Daily Living (ADL) and used a wheelchair for mobility. A care plan dated 03/23/20 revealed care areas for impaired communication and cognitive deficits following a stroke, and ADL self care deficit due to a stroke requiring total dependence for bathing. Review of the facility incident report dated 05/23/20 completed by LPN #201 revealed an incident occurred on 05/23/20 at 6:15 P.M. and was witnessed by STNA #101 and LPN #201. STNA #100 pushed Resident #13 to the nurses' station and told the resident it was time for his shower. The resident stated he did not want a shower, turned his wheelchair around and headed back towards his room. At that point STNA #100 leaned over the resident and pushed him backwards in his wheelchair yelling I said you are getting a shower and getting it now. At that point LPN #201 intervened, told STNA #100 she cannot talk to someone like that and took the resident to a quiet area. The resident was shaken up and reported he didn't want STNA #100 to care for him any longer because she was too rough. He stated I've been afraid to tell anyone because I didn't want it to get worse. Interview on 09/30/20 at 3:00 P.M. with STNA #101 revealed she and LPN #201 witnessed STNA #100 arguing with Resident #13 after dinner because the STNA wanted the resident to shower and the resident did not want a shower. He stated he showered the day before. STNA #100, standing in front of the resident grabbed the arms of the resident's wheel chair, and pushed him backwards towards the shower room and screamed Shower now! STNA #101 completed an incident report and gave it to the charge nurse, LPN #201. Interview on 10/06/20 at 5:20 P.M. with LPN #201 verified she witnessed STNA #100 screaming at Resident #13 and shoving the resident in his wheelchair towards the shower room. The LPN intervened and took Resident #13 to another unit. The resident was visibly shaken and reported he did not want the STNA to work with him because she was too rough and he was afraid of her. He stated he was afraid to tell anyone for fear it would get worse. The LPN calmed and provided assurance to the resident. He required no medical care or counseling after the event. The LPN then called the Director of Nursing (DON), who is no longer employed at the facility to report the incident. The LPN asked if STNA #100 should be removed form the building and was told no, to write up the incident and the DON would deal with it. Interview on 10/06/20 at 9:26 A.M. with STNA #100 verified the incident with Resident #13. She reported the resident was refusing a shower and she had to make him take one. She disputed the resident had a right to refuse a shower. She stated she had to be firm with him , like a child in defense of her screaming at the resident and pushing his wheelchair. Interview on 10/06/20 at 11:53 A.M. with RN # 207, the former Director of Nursing, verified receiving a call from LPN #201, discussing the incident with the Executive Director (ED) and Human Resource (HR) #304 but did not recall the outcome of that discussion. Review of the facility Abuse Policy of 09/02/16 defined abuse to include willful intimidation and verbal abuse to include disparaging terms to residents. This deficiency substantiates Complaint Numbers OH 419, OH 409, OH 861 and OH 586.

Based on record review, interview and review of the facility abuse prohibition policy the facility failed to implement their abuse policy to thoroughly investigate a incidence of verbal abuse of Resident #13 by State tested Nurse Aide (STNA) #100. This affected one of three residents reviewed for abuse. Findings include: Record review revealed Resident #13 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was moderately cognitively impaired, required extensive assist for Activities of Daily Living (ADL) and used a wheelchair for mobility. A care plan dated 03/23/20 revealed care areas for impaired communication and cognitive deficits following a stroke, and ADL self care deficit due to a stroke requiring total dependence for bathing. Review of a facility incident report dated 05/23/20 completed by Licensed Practical Nurse (LPN) #201 revealed the incident occurred at 6:15 P.M. on 05/23/20 and was witnessed by STNA #101 and LPN #201. STNA #100 pushed Resident #13 to the nurses' station and told the resident it was time for his shower. The resident stated he did not want a shower, turned his wheelchair around and headed back towards his room. At that point STNA #100 leaned over the resident and pushed him backwards in his wheelchair yelling I said you are getting a shower and getting it now. At that point LPN #201 intervened, told STNA #100 she cannot talk to someone like that and took the resident to a quiet area. The resident was shaken up and reported he didn't want STNA #100 to care for him any longer because she was too rough. He stated I've been afraid to tell anyone because I didn't want it to get worse. The LPN then reported the incident to the Director of Nursing (DON). Interview on 09/30/20 at 3:00 P.M. with STNA #101 revealed she and LPN #201 witnessed STNA #100 arguing with Resident #13 after dinner because the STNA wanted the resident to shower and the resident did not want a shower. He stated he showered the day before. STNA #100, standing in front of the resident grabbed the arms of the resident's wheel chair, pushed him back towards the shower room and yelled Shower now! STNA #101 completed an incident report and gave it to the charge nurse, LPN #201. Interview on 09/30/20 at 3:45 P.M. with the Executive Director (ED) revealed the ED had no knowledge of a report of abuse from staff towards Resident #13. Interview on 10/06/20 at 5:20 P.M. with LPN #201 verified she witnessed STNA #100 yelling at Resident #13 and shoving the resident in his wheelchair towards the shower room. LPN #210 intervened and took Resident #13 to another unit. The resident appeared shaken and reported he did not want the STNA to work with him because she was too rough and he was afraid of her. He stated he was afraid to tell anyone for fear it would get worse. The LPN calmed and provided assurance to the resident. He required no medical care or counseling after the event. The LPN then called the DON (who was no longer employed at the facility) to report the incident. The LPN asked if STNA #100 should be removed form the building and was told no, to write up the incident, and the DON would deal with it. Phone interview on 10/06/20 at 9:26 A.M. with STNA #100 verified the incident with Resident #13 as reported by STNA #101 and LPN #201. STNA #100 reported the resident was refusing getting a shower and she had to make him take one. She disputed the resident had a right to refuse a shower. She stated she had to be firm with him , like a child in defense of her yelling at the resident and pushing his wheelchair. The STNA verified she continued working that day in the facility and until mid August when she left to work at a sister facility. She denied being abusive toward the resident. Phone interview on 10/06/20 at 11:53 A.M. with Registered Nurse (RN) #207 (the former Director of Nursing) revealed she confirmed receiving a call from LPN #201, discussing the incident with the ED and Human Resource (HR) #304 but did not recall specific details or the outcome of that discussion. Interview on 10/07/20 at 10:30 A.M. with HR #304 and the ED revealed that neither of them had received the incident report regarding the incident with STNA #100 and Resident #13. They reported it was not mentioned to them by RN #207, and they had received no complaints from Resident #13. Therefore, no investigation occurred and STNA #100 continued working in the facility until she transferred to work in the adjacent Intermediate Care Facility (ICF) on 08/16/20. The STNA's employment was terminated shortly after this interview and the facility submitted a Self Reported Incident to the State Agency. There had been no further incidents with STNA #100 or any allegations of abuse against her. Review of the facility Abuse Policy dated 09/02/16 revealed an employee accused of abuse will be immediately removed from the area(s) of resident care, interviewed by facility leadership for a written statement and not left alone .After completing the statement, the employee will be asked to vacate the facility until further investigation of the incident is complete. This deficiency substantiates Complaint Numbers OH 861 and OH 586.

Based on record review, interview and review of the Abuse prohibition policy the facility failed to investigate and report an incidence of verbal abuse of Resident #13 by State tested Nursing Assistant (STNA) #100. This affected one of three residents reviewed for abuse. Findings include: Record review revealed Resident #13 was admitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) 3.0 dated 06/22/20 revealed the resident was moderately cognitively impaired, required extensive assist for Activities of Daily Living (ADL) and used a wheelchair for mobility. A care plan dated 03/23/20 revealed care areas for impaired communication and cognitive deficits following a stroke, and ADL self care deficit due to a stroke requiring total dependence for bathing. Review of the facility incident report dated 05/23/20 by Licensed Practical Nurse (LPN) #201 revealed the incident occurred at 6:15 P.M. on 05/23/20 and was witnessed by STNA #101 and LPN #201. STNA #100 pushed Resident #13 to the nurses' station and told the resident it was time for his shower. The resident stated he did not want a shower, turned his wheelchair around and headed back towards his room. At that point STNA #100 leaned over the resident and pushed him backwards in his wheelchair yelling I said you are getting a shower and getting it now. At that point LPN #201 intervened, told STNA #100 she cannot talk to someone like that and took the resident to a quiet area. The resident was shaken up and reported he didn't want STNA #100 to care for him any longer because she was too rough. He stated I've been afraid to tell anyone because I didn't want it to get worse. The LPN then reported the incident to the Director of Nursing (DON). Interview on 09/30/20 at 3:00 P.M. with STNA #101 revealed she and LPN #201 witnessed STNA #100 arguing with Resident #13 after dinner because the STNA wanted the resident to shower and the resident did not want a shower. He stated he showered the day before. STNA #100, standing in front of the resident grabbed the arms of the resident's wheel chair, pushed him back towards the shower room and yelled Shower now! STNA #101 completed an incident report and gave it to the charge nurse, LPN #201. Interview on 09/30/20 at 3:45 P.M. with the Executive Director (ED) revealed he had no knowledge of a report of abuse from staff towards Resident #13. The ED initiated a Self Reported Incident (SRI) the following day for the reported abuse towards Resident #13. Interview on 10/06/20 at 5:20 P.M. with LPN #201 verified xhe witnessed STNA #100 yelling at Resident #13 and shoving the resident in his wheelchair backwards towards the shower room. The LPN intervened and took Resident #13 to another unit. The resident was shaken and reported he did not want the STNA to work with him because she was too rough and he was afraid of her. He stated he was afraid to tell anyone for fear it would get worse. The LPN calmed and provided assurance to the resident. He required no medical care or counseling after the event. The LPN then called the DON (who was no longer employed at the facility) to report the incident. The LPN asked if STNA #100 should be removed form the building and was told no, to write up the incident and the DON would deal with it. Phone interview on 10/06/20 at 9:26 A.M. with STNA #100 verified the incident with Resident #13 as reported by STNA #101 and LPN #201. STNA #100 reported the resident was refusing getting a shower and she had to make him take one. She disputed the resident had a right to refuse a shower. She stated she had to be firm with him, like a child in defense of her screaming at the resident and pushing his wheelchair. The STNA verified she continued working that day in the facility and until mid August. She denied being abusive toward the resident. Phone interview on 10/06/20 at 11:53 A.M. with Registered Nurse (RN) #207, the former DON, revealed she confirmed receiving a call from LPN #201, discussing the incident with the ED and Human Resource (HR) #304 but did not recall any details or the outcome of that discussion. Interview on 10/07/20 at 10:30 A.M. with HR #304, the DON and the ED revealed that none of them had received any incident reports regarding the incident with STNA #100 and Resident #13 nor been made aware of any concerns by Resident #13. They verified the incident should have been investigated and reported to the Ohio Department of Health in an SRI. Review of the facility Abuse Policy of 09/02/16 revealed all incidents were reported to the ED and the DON immediately and within 24 hours direct required notification of agencies. This deficiency substantiates Complaint Numbers OH 861 and OH 586.