Every finding on record at Als Woodstock Inc

Based on record review, observation, staff and resident interview, document review and policy review, the facility failed to ensure a physician ordered specialized bed was provided for a resident with Multiple Sclerosis. This affected one (Resident #37) out of three residents reviewed. The facility census was 42.Findings Included:Review of the medical record revealed Resident #37 was admitted on [DATE]. Diagnoses included progressive multiple sclerosis (MS), bipolar disorder, type two diabetes, ileostomy, colostomy, chronic pain, and arthropathy.Review of the plan of care dated 08/08/25 revealed Resident #37 would remain in the facility for long term care. Interventions included allow Resident #37 to voice preferences regarding care and schedule as requested. Resident #37 was at risk for acute and chronic pain related to generalized pain. Interventions included administering analgesics as ordered, assessing residents' pain level as needed, notifying medical providers if interventions were unsuccessful or if current complaint was a significant change from residents past experience of pain, and offer non-pharmacological pain interventions such as repositioning or ice.Review of the physician order dated 03/10/26 by the Neurology Nurse Practitioner #405 revealed Resident #37 had an order for miscellaneous durable medical equipment (DME). Diagnosis was relapsing, remitting multiple sclerosis, and hemiparesis of the right dominant side due to non-cerebrovascular. The DME was a [NAME] bed with a pressure relieving mattress. Review of the quarterly minimum data set (MDS) dated [DATE] revealed Resident #37 had a Brief Interview of Mental Status (BIMS) of 15 which indicated he was cognitively intact. Resident #37 was dependent when sitting to stand, lying to sitting on bed, and sitting to lying. Resident #37 required substantial to maximal assistance with bed mobility rolling left to right. Resident #37 used a specialized wheelchair independently. Review of the plan of care documentation dated from 05/29/26 through 07/22/26 revealed the Certified Nursing Assistant (CNA) documented Not Applicable (N/A) for bed mobility.Observation and interview on 07/22/26 at 9:27 A.M., Resident #37 was sitting in his room in his specialized wheelchair. Resident #37 stated he went to see a neurologist in March 2026 who ordered a specific bed called a [NAME] to help with his pain. Resident #37 stated his neurologist told him this bed was good for his MS. Resident #37 stated he had not slept in his bed for over two years, since they took the last bed away from him in November 2024. Resident #37 said he slept in his bed prior to the bed being taken away in 2024. He was not comfortable, could not sleep, and decided not to sleep in the new bed the facility provided. Resident #37 stated the other bed had features where he could move the head of the bed down while his legs remained elevated. Resident #37 stated he told therapy in March 2026 he had received an order for a new bed and the therapy staff asked questions about the swelling in his legs. Resident #37 said when he went to his wound clinic appointment for his legs, the wound physician asked the resident if he had received his new bed. When Resident #37 told him no, he had not, the wound physician told him his wounds would have healed quicker. Resident #37 said when the facility had an annual survey in May 2026, he spoke to another surveyor from the Ohio Department of Health. He had told her he had pain, and his bed was not comfortable. Resident #37 showed the surveyor the physician order and was told the surveyor took the physicians order for [NAME] bed to the management again. Resident #37 was hopeful he would be able to walk again with the new bed and therapy. Observation and interview on 07/22/26 at 12:53 P.M., the Director of Nursing (DON) verified Resident #37 did have a full electric bed frame. However, the bed Resident #37 currently had would move the head and feet up or down simultaneously when manipulated. Which was not the ordered bed. Interview on 07/22/26 at 2:16 P.M., the Director of Therapy #335 (DOT) stated Resident #37 had stated about a year ago to her that his bed had been switched from a rented bed to a facility bed. DOT #335 said at that time the facility tried to replace his mattress since Resident #37 was uncomfortable and complained about his bed and mattress. DOT #335 said the differences between the facility bed, and the [NAME] bed was that the [NAME] bed could hold more weight, had the degrees of adjustment, and the back rest. DOT #335 stated the [NAME] bed had more adaptive angles, the facility provided bed had only fixed angles. DOT #335 said if she had seen the order for a new bed, she would have notified nursing so they could order the special bed that was ordered. DOT #335 stated in many facility meetings, with the DON, she had mentioned Resident #37 had complained that he was not comfortable in his bed. Interview on 07/23/26 at 9:55 A.M., with CNA #317 said she took care of Resident #37 on 06/02/26 and 06/10/26. CNA #317 verified Resident #37 did not want to sleep in his bed because it caused him pain and was uncomfortable. CNA #317 said she had never told nursing or management, since they had known the residents concern with his bed. Interview on 07/23/26 at 9:44 A.M., CNA #316 verified Resident #37 would not sleep in his bed because it was uncomfortable. CNA #316 said she should have told the nurse that he was still complaining about the bed being uncomfortable.Review of the facility policy titled Federal and Ohio Residents Rights and Facility Responsibilities, dated 10/03/2023 revealed number 18 titled Available Services and Charges, the facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility per diem rate. The resident had the right to adequate medical treatment and nursing care. Review of the facility document titled Difference between a [NAME] Electric Bed and A Standard Electric Bed date unknown revealed the [NAME] was built with Federal Drug Administration compliant safety systems. [NAME] also features Stay Put Bed Frame technology that keeps the patient's position relative to the bed when the head was raised, reducing repositioning needs. The standard frame design without such positioning retention. This deficiency represents non-compliance investigated under Complaint Number 3067801.

Based on record review, observation, staff interviews and policy review, the facility failed to follow infection control protocol when changing a wound dressing. This affected one (#19) of three residents reviewed for wound care. The facility census was 42. Findings include: Medical record review for Resident #19 revealed an admission on [DATE] with diagnoses including rhabdomyolysis, hyponatremia, hypertension, heart disease, diabetes mellitus type two, personality disorder, convulsions, Rickets and right leg amputation. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #19 revealed an intact cognition. Resident #19 required set up assistance for eating, supervision assistance for bed mobility and toileting. Resident #19 requires extensive assistance for transfers. Resident #19 was coded as receiving wound care for diabetic ulcer during the look back period. Review of the plan of care for dated 06/30/25 for Resident #19 revealed resident is at risk for experiencing an alteration in skin related to diabetic foot ulcer. Interventions include administer medications as ordered, monitor for side effects, assess, record and monitor healing as ordered, monitoring nutritional status, and pressure reducing devices. Review of the active physician orders for Resident #19 revealed an order for enhanced barrier precautions (EBP) due to right elbow wound every shift dated 07/22/25 and an order for right elbow: cleanse with wound cleanser, pat dry, apply collagen (cut to fit wound bed), silver alginate (cut to fit wound bed and cover with bordered foam dressing one time a day dated 09/09/25. Observation on 09/09/25 at 1:30 P.M. of wound care by Licensed Practical Nurse (LPN) #11 revealed the LPN entered room and advised Resident #19 of the task. LPN #11 removed old dressing to Resident #19's right posterior elbow, discarded dressing and completed hand hygiene. LPN #11 cleansed wound and applied dressings as ordered. LPN #11 dated and initialed dressing, removed gloves and completed hand hygiene. The observations revealed LPN #11 did not don personal protective equipment (PPE) while providing care to Resident #19. Interview on 09/09/25 at 4:29 P.M. with LPN #11 verified that she was unaware of Resident #11 being in EBP. LPN #11 stated the roommate had an infection and the EBP in place was for him. LPN #11 stated the EBP sign on the door of the room did not indicate which resident was in the EBP. LPN #11 verified she did not wear the required gown when completing the wound care for Resident #19 and should have. Interview on 09/10/25 at 11:30 A.M. with the Director of Nursing (DON) verified the EBP sign at the entrance of Resident #19 failed to identify which resident in the double occupancy room was in the EBP and should have. DON illustrated the corrected sign that was going to be placed on the doors of the residents in EBP. Review of the facility policy titled Enhanced Barrier Precautions dated 04/01/24 stated the EBP referred to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care. Additionally, the policy stated EBP should be initiated for wounds that are chronic in nature that require a dressing. This deficiency represents non-compliance investigated under Complaint Number 2597177.

Based on record review, review of a facility self-reported incident (SRI) and staff interviews, the facility failed to develop a plan of care to address a resident's behaviors. This affected one (#11) of three residents reviewed for care planning. The facility census was 42. Findings include: Review of medical record for Resident #11 revealed admission date of 04/23/25 with diagnoses including Diabetes Mellitus, stroke, ataxia following stroke, depression and anxiety. The resident was discharged on 06/05/25 to another skilled nursing facility. The discharge Minimum Data Set (MDS) dated [DATE] revealed with a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. The resident was required set up of touching assistance for Activities of Daily Living. Review of Resident #11's physician orders revealed an order dated 05/23/25 for one-on-one (1:1) supervision until further notice. Review of Resident #11's Health Status Note dated 06/01/25 at 8:54 A.M. revealed resident continues to be 1:1 with staff. No situations or concerns this morning shift. Will continue to monitor. A Health Status Note dated 06/01/25 at 5:31 P.M. revealed resident continues 1:1 care per staff member with no situations or issues to report for this. Resident #11 has been very compliant today with redirection when needed for simple tasks. A Health Status Note dated 06/03/25 at 5:53 P.M., revealed the resident was on strict 1:1 per order this shift. Further review of Resident #11's plan of care revealed there was no care plan or intervention for the resident's behaviors or related to 1:1 supervision. Review of a facility SRI dated 05/30/25 regarding sexual abuse revealed on 05/23/25, it was reported by staff that a Resident #11 made a gyration motion in the doorway of Resident #1's room. Resident #11 was immediately placed on 1:1 supervision. This Administrator advised him that he was not to go into any resident rooms without invitation. On 05/30/25, Resident #1's daughter came to take the resident to a medical appointment and resident divulged to her that Resident #11 had actually exposed himself. Police were called. An investigation was conducted the allegation was unsubstantiated by the facility. Interview on 06/17/25 at 3:32 P.M. with the Administrator revealed Resident #11 had inappropriate behaviors and an allegation of misappropriate sexual behavior by Resident #11 toward Resident #1 which prompted an order for 1:1 supervision. The Administrator stated Resident #11 was not a registered sexual offender but the facility was aware of a pending court hearing for sexual misconduct for Resident #11 prior to his admission. Interview on 06/17/25 at 4:16 P.M. with MDS Coordinator #109 revealed she was aware of an allegation of sexual misconduct by Resident #11 and she verified there was no behavioral care plan. MDS Coordinator #109 confirmed Resident #11 had behaviors and acknowledged given the 1:1 supervision order a behavioral care plan should have been created. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on observations, staff and resident interviews, review of the facility activity calendar, and review of the facility policy, the facility failed to ensure group activities were conducted as scheduled. This had the potential to affect 22 residents residing in the facility who regularly attend group activities, the facility identified 17 (#02, #03, #04, #05, #06, #08, #10, #14, #16, #19, #22, #24, #25, #26, #30, #34, and #35) residents who chose not to attend and/or are not physically able to attend group activities. The facility census was 39. Findings include: Review of the activity calendar for 01/21/25 revealed documentation to support the facility had a group activity scheduled for 9:00 A.M. The activity planned was coffee time in the activity room. Review of the activity calendar on 01/21/25 at 10:30 A.M. revealed a planned group activity of exercise in the facility dining room. Observation on 01/21/25 at 9:07 A.M. revealed the activity room door to be closed and locked. Observation of the facility common areas and dining room revealed no group activity taking place. Observation on 01/21/25 at 9:23 A.M. revealed the activity room door to be closed and locked. Observation of the facility common areas and dining room revealed no group activity taking place. Observation with interview on 01/21/25 at 9:25 A.M. with Assistant Director of Nursing (ADON) #130 confirmed the 9:00 A.M. group activity planned for 01/21/25 had not occurred because the activity staff were out of the facility bringing a resident to an appointment. Interview on 01/22/25 at 7:30 A.M. with Licensed Practical Nurse (LPN) #100 confirmed group activities are canceled at times so the activity staff can bring residents to their appointments. Interview on 01/22/25 at 7:36 A.M. with Resident #29 confirmed group activities are canceled at times because there is not any activity staff in the building. Interview on 01/22/25 at 9:18 A.M. with Activity Director (AD) #135 confirmed the group activity on 01/21/25 at 9:00 A.M. did not start until after 10:30 A.M. because he was out of the building bringing a resident to an appointment. AD #135 confirmed the group activity of exercise planned for 01/21/25 at 10:30 A.M. did not occur because residents were having coffee in the activity room at that time. The facility identified 22 residents residing in the facility who regularly attend group activities and 17 (#02, #03, #04, #05, #06, #08, #10, #14, #16, #19, #22, #24, #25, #26, #30, #34, and #35) residents who chose not to attend and/or are not physically able to attend group activities. Review of the facility policy titled, Activities, reviewed August 2023, stated the facility was to provide activity programming to promote physical, mental and psychosocial well-being of each resident. Activity programs are designed to meet the interests of the residents and encourage independent and interaction in the community. This deficiency represents non-compliance investigated under Complaint Number OH00161210.

Based on medical record review, staff interview, and policy review, the facility failed to notify a resident representative of change of condition. This affected one (#39) out of the three residents reviewed for change of condition. The facility census was 39. Findings include: Review of the medical record for Resident #39 revealed an admitted [DATE] with medical diagnoses of Alzheimer's disease, alcohol dementia, behavioral disturbances, Wernicke's encephalopathy, and peripheral vascular disease. Review of the medical record for Resident #39 revealed a quarterly Minimum Data Set (MDS) assessment, dated 01/01/25, which indicated Resident #39 had moderate cognitive impairment and required supervision with oral care, toilet hygiene, and bathing. The MDS indicated Resident #39 was independent with eating, bed mobility, and transfers. Review of the medical record for Resident #39 revealed a nurse's note, dated 11/26/24 at 1:40 P.M., which stated Resident #39 tested positive for Coronavirus Disease 2019 (COVID-19) and the physician was notified. Review of the medical record revealed no documentation to support Resident #39's representative was notified positive COVID-19 test result. Review of the medical record for Resident #39 revealed a nurse's note, dated 01/02/25 at 3:13 P.M. which stated Resident #39 had increased behaviors and the physician was notified and ordered Resident #39 to be sent to the hospital for evaluation. Review of the medical record revealed Resident #39 was sent to the hospital on 01/02/25 and returned to the facility on [DATE] at 5:54 P.M. Review of the medical record revealed no documentation to support the facility notified Resident #39's representative on 01/02/25 that Resident #39 was sent to the hospital. Review of the medical record for Resident #39 revealed a nurse's note, dated 01/03/25 at 11:32 A.M., which stated Resident #39's representative was notified Resident #39 was sent to the hospital for evaluation on 01/02/25. The note stated Resident #39's representative expressed concern that he was not notified of clinical changes. Interview on 01/21/24 at 3:50 P.M. with Regional Nurse #140 confirmed the medical record for Resident #39 did not contain documentation to support Resident #39's representative was notified on 11/26/24 of COVID-19 positive test results. Regional Nurse #140 also confirmed the medical record did not contain documentation to support Resident #39's representative was notified on 01/02/25 of Resident #39's transfer to the hospital for evaluation due to behaviors. Review of the facility policy titled, Change in Resident's Condition, reviewed August 2023, stated the facility shall notify the resident, his/her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition. The policy stated except in medical emergencies, notifications will be made timely of a change occurring in the residents medical/mental condition or status. This deficiency represents non-compliance investigated under Complaint Number OH00161210.

Based on staff interviews, employee file reviews, and review of the facility Activity Director (AD) job description, the facility failed to ensure the employee in the role of AD was qualified as required. This had the potential to affect all 39 residents residing in the facility. The facility census was 39. Findings include: Interview on 01/22/25 at 9:18 A.M. with AD #135 confirmed he was hired at the facility as the AD on October 15, 2024, and was currently enrolled in an activity training course. AD #135 confirmed he was not a qualified therapeutic specialist or an activities professional who was licensed by the state or had a minimum of two years' experience in social or recreational program within the past five years or was a qualified occupational therapist or occupational therapist assistant or completed a training course approved by the State. Interview on 01/22/25 at 9:30 A.M. with Regional Nurse #140 confirmed the employee in the role of AD was currently enrolled in a training course for activities certification and had started some of the online training but had not completed the course yet. Interview on 01/22/25 at 9:50 A.M. with Administrator stated she is a contracted employee and was hired at the facility on 11/27/24 and oversaw the activities department. Administrator stated she had completed the certification for activities prior to starting at the facility. Administrator confirmed the facility contract for her employee did not contain documentation to support her role as the AD. Review of the facility Activity Director job description the purpose of the position was to plan, organize, develop, and direct he overall operations of the Activities Department in accordance with current federal, state, and local standards, guidelines, and regulations, our established policies and procedures, and as may be directed by the Administrator, to assure that an on-going program of activities is designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. The policy stated the qualifications for the position included: must possess a high school diploma and must be a qualified therapeutic specialist or an activities professional who is licensed by the state and is eligible for certification as a recreation specialist or as an activities professional; or must have, as a minimum of two years' experience in social or recreational program within the past five years, one o which was full-time in a patient activities program in a health care setting; or must be a qualified occupational therapist or occupational therapist assistant; or must have completed a training course approved by the State. Review of the employee file for AD #135 revealed a hire date of 10/15/24. The employee file contained confirmation form with enrollment into activity training course but no documentation to support he completion of the course. Review of the employee file for Administrator revealed a company contract which stated Administrator was hired effective 11/27/24. The contract did not contain documentation to support that the Administrator would also serve as the AD. Review of the file revealed documentation to support Administrator had completed the AD's course on 11/04/05. This deficiency was based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, resident and staff interview, review of dental visit documentation, review of hospital documentation, and review of facility policy, the facility failed to ensure residents were provided with timely dental services to address non-restorable and decaying teeth. Actual harm occurred to Resident #33 when the dentist identified the resident's teeth required extraction (removal) and the facility failed to follow up with a referral to an oral surgeon. This resulted in the resident developing fever and chills which prompted a visit to the emergency department where the resident was diagnosed with system inflammatory response syndrome and bacteremia caused by a tooth infection. This affected one (#33) of one residents reviewed for dental services. The census was 35. Findings included: Review of the medical record for Resident #33 revealed an admitted [DATE]. Diagnoses included Parkinson's disease and diabetes mellitus. Further review of the medical record revealed the resident was discharged to the hospital on 08/11/24 and returned to the facility on [DATE]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 had obvious or likely cavities or broken natural teeth. Review of the quarterly MDS assessment dated [DATE] revealed Resident #33 was assessed as cognitively intact. Further review of the MDS assessment revealed the resident had no mouth or facial pain, discomfort, or difficulty with chewing. The resident was on a therapeutic diet. Review of Resident #33's care plan related to oral and dental alteration revealed a notation dated 05/12/21, that the resident had a dental evaluation, and the doctor determined all teeth need extracted and dentures placed. The resident was referred to a dentist. An intervention included coordination of arrangements for dental care, transportation as needed or ordered, and daily oral care per routine and as needed. Review of a dental visit note dated 12/19/23 revealed Resident #33 was seen to have an examination (exam) completed, and the resident was determined to need all remaining teeth extracted with a referral made to an oral surgeon. Review of a dental note dated 02/21/24 revealed Resident #33 was not seen that day by the dental provider because the resident was out of the facility. Review of a dental visit note dated 06/20/24 revealed all remaining teeth needed to be extracted due to being non-restorable and decaying. Further review of the note revealed Resident #33 would like to have only tooth #18 extracted for now. Physician clearance was left at the facility. Review of Resident #33's social services progress note dated 06/25/24 at 7:11 P.M. revealed Resident #33 was seen by the dentist on this date. Physician clearance was left with the Medical Director for tooth #18 to be extracted and Resident #33 was notified. Further review revealed there were no new orders or follow-up related to the request to extract tooth #18. Review of a dental visit note dated 07/15/24 revealed Resident #33 was seen by a dental hygienist only and services provided that day were preventative only. Review of Resident #33's medical record revealed no documentation of the facility addressing the resident's need to have any teeth extracted as care planned on 05/12/21 and as assessed during dental visits on 12/19/23 and 06/20/24. Further review of the medical record revealed no documented evidence of Resident #33 being referred to an oral surgeon or that teeth extraction could not be performed because the resident's blood glucose levels were too high. Review of Resident #33's progress note dated 08/11/24 at 6:22 P.M. revealed the resident was not feeling well and voiced feeling cold and shaking. Emergency Medical Services (EMS) were called, and the resident was sent to the hospital. Review of a progress note dated 08/12/24 at 1:06 P.M. revealed a nurse spoke with the emergency room nurse who indicated the resident was being admitted to the hospital for sepsis. Review of hospital documentation revealed Resident #33 presented to the emergency roiagnom on [DATE] with complaints of fever and chills with associated generalized weakness. On assessment, the resident had an elevated temperature (100 degrees Fahrenheit), elevated pulse (103 beats per minute), elevated respirations (26 breaths per minute), was ill-appearing, and diaphoretic (sweating). The resident was given the pain medication and fever-reducing medication Tylenol, and a full septic workup was completed. The resident was found to have an elevated white blood cell count. Resident #33 was diagnosed with system inflammatory response syndrome (SIRS) and bacteremia (bacteria in the blood) as three out of four blood cultures were positive for streptococcus and staphylococcus. Further review revealed the most likely cause of the bacteremia was a tooth infection and Resident #33 needed immediate follow up with a dentist once discharged from the facility. The resident reported difficulty with eating and swallowing and was noted with poor dentition. Resident #33 was discharged on [DATE] with orders for the antibiotic Augmentin 875-125 milligrams (mg) by mouth two times daily for 14 days. Review of a progress note dated 08/16/24 at 1:15 P.M. revealed Resident #33 returned from hospital at 12:30 P.M. with orders for Augmentin 875-125 mg twice daily for 14 days. Interview with Resident #33 on 10/28/24 at 11:17 A.M. revealed he had a badly infected tooth and could not get permission for oral surgery. The resident stated he still had sensitivity to hot and cold foods. Interview with the Medical Director (MD) on 10/30/24 at 11:18 A.M. stated the oral surgeons would not do surgery on Resident #33's teeth with a high hemoglobin A1C (a blood test that measures the average blood sugar levels over the past two to three months) due to the increased opportunity for infections. The MD stated the oral surgeons suggested the hemoglobin A1C level to be at least down to 7.5 percent (%) to 8% (normal levels are below 5.7%). Interview with Assistant Director of Nursing (ADON) #133 on 10/31/24 at 9:00 A.M. verified there was no documentation of a referral from the MD to an oral surgeon for Resident #33 to have teeth extraction until 10/30/24. ADON #133 also verified there was no documented evidence of oral surgeons refusing to remove Resident #33's teeth due to elevated hemoglobin A1C levels. Review of the facility policy titled, Dental Services from 2016, revealed routine and emergency dental services are available to meet resident's oral health services in accordance with the resident's assessment and plan of care. Routine and 24-hour emergency dental services are provided to facility residents through a contract agreement with a licensed dentist that comes to the facility monthly, referral to a resident's personal dentist, referral to a community dentist, or referral to other health care organizations that provide dental services.

Based on medical record review, staff interview, and policy review, the facility failed to ensure sufficient smoking assessments were completed to determine resident capabilities and deficits regarding smoking safety. This affected four (#2, #13, #16, and #26) of five residents reviewed for smoking. The facility census was 35. Findings include: 1. Review of the medical record for Resident #26 revealed an admitted [DATE]. The resident was admitted with diagnoses including Alzheimer's disease, vascular dementia, and panlobular emphysema (BLE). Review of Resident #26's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed with moderately impaired cognition. Review of Resident #26's most recent smoking evaluation dated 09/03/24 revealed the resident was assessed to use tobacco products; however, there was no additional assessment information to determine resident safety or clinical suggestions related to smoking needs in regard to determining if the resident required supervision with smoking. 2. Review of the medical record for Resident #2 revealed an admitted [DATE] with diagnoses including cerebral palsy, type two diabetes, major depressive disorder, epilepsy, borderline personality disorder, anxiety, paraplegia, and unspecified convulsions. Review of Resident #2's MDS assessment dated [DATE] revealed the resident was cognitively intact and required partial to moderate assistance for activities of daily living (ADLs). Review of Resident #2's smoking evaluations dated 06/15/24 and 08/23/24 revealed the resident was assessed to utilize tobacco productions, and on the 06/15/24 the resident was determined to have balance problems while sitting or standing. Further review of the smoking evaluations revealed no assessment information to determine resident safety or clinical suggestions related to smoking needs in regard to determining if the resident required supervision with smoking. 3. Review of the medical record for Resident #13 revealed an admitted [DATE] with diagnoses including paranoid schizophrenia, obsessive-compulsive disorder, nicotine dependence, and unspecified psychosis. Review of Resident #13's MDS assessment dated [DATE] revealed the resident was cognitively intact and required supervision or touching assistance for ADLs. Review of Resident #13's smoking evaluation dated 03/18/24 revealed the resident was assessed to utilize tobacco products, followed the facility policy on smoking, and was able to light and hold cigarettes by himself without safety concerns. Review of subsequent smoking evaluations dated 05/01/24 and 08/10/24 revealed the facility identified the resident utilized tobacco products but there was no additional assessment information to determine resident safety or clinical suggestions related to smoking needs in regard to determining if the resident required supervision with smoking. 4. Review of the medical record for Resident #16 revealed an admitted [DATE] with diagnoses including cerebral palsy, paranoid schizophrenia, extrapyramidal and movement disorder, and other specified disorders of the brain. Review of Resident #16's MDS assessment dated [DATE] revealed the resident was cognitively intact and required supervision or touching assistance to partial/moderate assistance for ADLs. Review of Resident #16's smoking evaluation dated 04/30/24 revealed the resident was assessed to utilize tobacco products, had balance problems while sitting or standing, and followed the facility policy for smoking. Review of Resident #16's subsequent smoking evaluations dated 08/02/24 and 08/19/24 revealed the resident was assessed to utilize tobacco products but there was no additional assessment information to determine resident safety or clinical suggestions related to smoking needs in regard to determining if the resident required supervision with smoking. Interview on 10/29/24 at 3:30 P.M. with the Director of Nursing (DON) verified the smoking assessments for Resident #2, Resident #13, Resident #16, and Resident #26 were not entirely completed and lacked assessment of each resident's capabilities or deficits to determine whether or not supervision was required for smoking. Review of an undated policy titled, Smoking, revealed the resident will be evaluated upon admission and routinely to determine if he or she was able to smoke safely with or without supervision (per the smoking assessment).

Based on medical record review and staff interview, the facility failed to ensure pharmacy recommendations were reviewed and responded to timely from the physician. This affected four (#2, #7, #9, and #33) of five residents reviewed for unnecessary medications. The current census was 35. Findings include: 1. Record review for Resident #2 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #2 include cerebral palsy, hypertension, chronic obstructive pulmonary disease, and epilepsy. Review of Resident #2's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and was receiving antidepressant medications during the assessment period. Review of Resident #2's medication orders revealed on 03/22/23 the resident received orders to be administered citalopram 10 milligrams (mg) daily for depression and on amitriptyline 10 mg daily for depression. Review of Resident #2's pharmacy recommendation dated 06/12/24 revealed a recommendation made to the physician to consider a reduction dose for the amitriptyline 10 mg daily and the citalopram 10 mg daily or provide documentation regarding the benefit of continuing the medication as it was originally ordered. Further review of Resident #2's medication records, treatment records, progress notes, physician response documentation, and physician orders revealed there was no documentation of a response from the physician to the pharmacy or facility staff regarding the recommendation of reduction of the medications. Interview on 10/30/24 at 11:10 A.M. with the Medical Doctor (MD) revealed if there was no documented response he was not notified of the pharmacy recommendation for the resident. The MD verified there was no response to the recommendations for Resident #2. Interview on 10/30/24 at 11:25 A.M. with Assistant Director of Nursing (ADON) #133 verified there was no evidence in Resident #2's medical record that the physician was made aware of the pharmacy recommendation from 06/12/24. 2. Record review for Resident #7 revealed the resident was admitted to the facility initially on 07/12/17 and readmitted to the facility on [DATE]. Diagnoses for Resident #7 include Parkinson's disease, chronic obstructive pulmonary disease, bipolar disorder, depression, and schizoaffective disorder. Review of Resident #7's quarterly MDS assessment dated [DATE] revealed the resident had intact cognition, and received an antipsychotic and antidepressant medications. Review of Resident #7's physician orders revealed on 02/20/20 the resident was ordered to receive buspirone 10 mg three times a day for behaviors, Depakote 250 mg daily for seizures, Zoloft 200 mg daily for depression, and Trazadone 100 mg at bedtime. Review of the pharmacy monthly medication review dated 11/12/23 for Resident #7 revealed the pharmacy recommended a gradual dose reduction of buspirone to five (5) mg, discontinue Depakote or reduce Zoloft to 75 mg daily, reduce Trazadone to 50 mg at bedtime, or to explain why the gradual dose reduction would be contraindicated. Further review of the medical records for Resident #7 including progress notes, medication orders, and physician progress notes revealed no evidence the physician responded to the 11/12/23 pharmacy recommendation for Resident #7. Interview on 10/30/24 at 9:45 A.M. with ADON #133 verified there was no documented evidence in Resident #7's medical records the physician responded to the 11/12/23 pharmacy recommendation. Interview on 10/30/24 at 11:10 A.M. with the MD verified no responses and stated, if there was no documented response the physician was not notified of the pharmacy recommendation. 3. Record review for Resident #9 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #9 include paranoid schizophrenia, diabetes type two, depression, anxiety, and muscle weakness. Review of Resident #9's quarterly MDS assessment dated [DATE] revealed the resident had impaired cognition. Per the assessment the resident received anti-anxiety and antidepressant medications during the assessment period. Review of Resident #9's physician orders dated 11/01/23 revealed the resident was ordered to receive the anti-anxiety medication lorazepam one (1) mg as needed every eight hours for anxiety with no stop date for the lorazepam included in the order. Review of Resident #9's physician orders dated 03/01/24 revealed the resident was ordered to receive Depakote sprinkles 250 mg twice a day, Zyprexa 15 mg twice a day, Zoloft 100 mg at 5:00 A.M., and Trazadone 50 mg at bedtime. Review of Resident #9's pharmacy recommendation dated 03/11/24 revealed the pharmacist recommended a gradual dose reduction for Depakote sprinkles to 125 mg twice a day, Zyprexa to 10 mg twice a day, Zoloft to 50 mg in morning, and Trazadone to 25 mg at bedtime, or for the physician to document contraindications for reducing the medication. Further review of Resident #9's medical records including physician orders, progress notes, and medication administrations revealed no response from the physician in regards to the pharmacist's 03/11/24 recommendations. Review of Resident #9's pharmacy recommendation dated 06/12/24 revealed the recommendation was for the physician to either discontinue the lorazepam or document a rationale or time frame. Review of the medical records for Resident #9 revealed there was no physician response for the 06/12/24 recommendation. Interview on 10/30/24 at 11:10 A.M. with MD revealed he believed the facility was giving him recommendations monthly for Resident #9. Per MD, if no there was no responses from him it meant there were no recommendation notification from the pharmacy or facility staff. Interview on 10/30/24 at 12:00 P.M. with the Director of Nursing (DON) verified there was no physician response for the 03/12/24 and 06/12/24 pharmacist recommendations for Resident #9. 4. Record review for Resident #33 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #33 include Parkinson's disease, epilepsy, hypertension, heart disease, insomnia, and post-traumatic disorder. Review of Resident #33's quarterly MDS assessment dated [DATE] revealed the resident has intact cognition. Per the assessment the resident was receiving antidepressant, antipsychotic, and hypnotic medications. Review of Resident #33's physician orders as of 03/01/24 revealed the resident was ordered to receive Trazadone 150 mg and Remeron 30 mg at bedtime for insomnia. Review of Resident #33's pharmacy recommendation dated 03/11/24 revealed the pharmacist recommended to discontinue the Trazadone, discontinue the Remeron, or document no change to medications. Further review of the pharmacy recommendations dated 05/12/24 revealed the pharmacist made a recommendation for Resident #33; however, there was no documentation of what the recommendation was noted in the medical record. Further review of Resident #33's medical records revealed no documented response from the physician for the 03/11/24 recommendation. Interview on 10/30/24 at 12:00 P.M. with the DON verified there was no document from the pharmacy for Resident #33's May 2024 medication review. Per the DON, the pharmacy did review Resident #33's medications on 05/12/24 and made a recommendation to the physician; however, the DON stated there was no documented evidence of what the recommendation was in the medical records and the facility had no documented evidence the recommendation was given to the physician. The DON also verified there was no documentation from the physician for the 03/11/24 pharmacist recommendation for Resident #33.

Based on medical record review, staff interview, and policy review, the facility failed to develop comprehensive care plans as required. This affected one (#31) of three residents reviewed for care plans. The facility census was 35. Findings include: Review of the medical record for Resident #31 revealed an admitted [DATE] with diagnoses including Parkinson's disease, type two diabetes, major depressive disorder, bipolar disorder, hypertension, anxiety, seizures, and varicose veins of the left lower extremity with an ulcer of the ankle. Review of Resident #31's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact with one stage one pressure ulcer (non-blanchable erythema of intact skin). Review of Resident #31's care plan dated 07/02/24 revealed there was no care plan developed regarding the wound to the left medial ankle or seeing the wound clinic. Interview on 10/29/24 at 2:52 P.M. with the Director of Nursing (DON) verified Resident #31 did not have a care plan regarding the wound to the left medial ankle prior to 10/29/24 when the facility was made aware of the omission. Review of a policy titled, Care Planning, reviewed on 08/23, revealed the facility's care planning/interdisciplinary team was responsible for the development of an individualized comprehensive care plan for each resident.

Based on observation, medical record review, and resident and staff interview, the failed to ensure physician orders were in place to address wound treatments. This affected one (#31) of one residents reviewed for wounds. The facility census was 35. Findings include: Review of the medical record for Resident #31 revealed an admitted [DATE]. Diagnoses included Parkinson's disease, type two diabetes, major depressive disorder, bipolar disorder, hypertension, anxiety, seizures, and varicose veins of the left lower extremity with an ulcer of the ankle. Review of Resident #31's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact with one stage one pressure ulcer (non-blanchable erythema of intact skin). Review of a health status note dated 07/24/24 revealed Resident #31 was seen by a physician regarding the wound on the left ankle. A new order was received to send the resident to the wound clinic and an appointment was scheduled on 07/30/24 at 3:00 P.M. The resident was aware. Review of wound clinic documentation dated 08/20/24 revealed Resident #31 missed the appointment the previous week due to ride issues and wore the same dressing for the entire time. On 09/10/24, documentation revealed Resident #31 did not come to the schedule appointment the previous week due to ride issues and the wound dressing remained in place for two weeks. Review of wound clinic documentation dated 10/22/24 revealed Resident #31 had not been seen for over a month with no indication of when the last dressing change was completed. Review of a wound clinic note dated 10/29/24 revealed Resident #31's diabetic foot ulcer wound to the left medial ankle was cleansed with soap and water. The wound measured 1.2 centimeters (cm) long by 1.5 cm wide by 0.4 cm in deep. There were no orders but moderate thick yellow drainage was present. The order for the week of 10/29/24 revealed Resident #31's left medial ankle wound was cleansed with mild soap and water, rinsed with normal saline, patted dry with four inch long by four inch wide gauze, apply Desitin and Clobetasol to the peri-wound, apply Stimulen to the wound, then apply silver nitrate damp gauze to the wound, cover the wound with silver alginate, wrap both legs, and secure with tape. Instructions were to leave the wound treatment on for one week and keep dry. Resident #31 was to follow up with certified nurse practitioner (CNP) in one week at the wound care center. Review of Resident #31's current physicians orders dated October 2024 revealed there were no orders in place to direct staff on treatments to apply to the resident's wound if the dressing were to be soiled or come off. Interview and observation on 10/28/24 at 10:34 A.M. with Resident #31 revealed he has wounds on his bilateral lower legs and the facility provided no treatments for them. Resident #31 stated only the wound clinic managed his wounds. Observation at the time of the interview revealed Resident #31's bilateral lower extremities had dressing wraps on them and were covered with stockings. Interview on 10/29/24 at 2:52 P.M. with the Director of Nursing (DON) verified Resident #31 did not have any orders in the medical record to direct staff on what treatment to apply if the wound dressing was soiled or came off prior to the next wound clinic appointment, or if the resident missed appointments at the wound clinic. The DON verified the facility did not measure or document regarding the status of the resident's wound as the resident goes to the wound clinic.

Based on medical record review and staff interview, the facility failed to ensure psychotropic as needed medications had an appropriate stop date or rationale for extending the usage as required. This affected one (#9) of five residents reviewed for unnecessary medications. The census was 35. Findings include: Record review for Resident #9 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #9 include paranoid schizophrenia, diabetes type two, depression, anxiety, and muscle weakness. Review of Resident #9's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. Per the assessment, the resident received anti-anxiety and antidepressant medications during the assessment period. Review of Resident #9's physician orders dated 11/01/23 revealed the resident was ordered to receive the anti-anxiety medication lorazepam one (1) milligram (mg) as needed every eight hours for anxiety with no stop date included in the order. Review of the pharmacy recommendation dated 11/12/23 for Resident #9 revealed the recommendation was for the physician to either discontinue the lorazepam (Ativan) or document a rationale or time frame for usage. Review of the physician response dated 12/03/24 revealed the physician responded to continue the lorazepam writing, She is on prn (pro re nata, or as needed), keep. There was no duration for the order written on the response. Review of the pharmacy recommendation dated 02/12/24 for Resident #9 revealed the recommendation was for the physician to either discontinue the lorazepam (Ativan) or document a rationale or time frame. Review of the physician response dated 03/07/24 revealed the physician responded to continue the lorazepam for three months. Review of the pharmacy recommendation dated 04/10/24 for Resident #9 revealed the recommendation was for the physician to either discontinue the lorazepam (Ativan) or document a rationale or time frame. Review of the physician response dated 04/20/24 revealed the physician responded to continue the lorazepam for 30 more days. There was no rationale for extending the use noted in the medical record. Review of the pharmacy recommendation dated 06/12/24 for Resident #9 revealed the recommendation was for the physician to either discontinue the lorazepam (Ativan) or document a rationale or time frame. Review of the medical records for Resident #9 revealed there was no physician response for the 06/12/24 recommendation. Review of the pharmacy recommendation dated 08/13/24 for Resident #9 revealed the recommendation was for the physician to either discontinue the lorazepam (Ativan) or document a rationale or time frame. Review of the physician response dated 09/04/24 revealed the physician responded to continue the lorazepam for three months. There was no rationale for extending the use noted in the medical record. Interview on 10/30/24 at 11:10 A.M. with the Medical Doctor (MD) revealed he believed the facility was giving him recommendations monthly for Resident #9. The MD stated Resident #9's as needed Ativan needed to continue due to the increased behaviors of the resident when the medication was reduced or discontinued. The MD stated he will continue the as needed medications per guidelines, and verified he did not include a explanation or rationale in the documentation but stated he does tell the staff why he wants to continue to medications.

Based on medical record review, resident and staff interview, pharmacy delivery document review, and policy review the facility failed to administer an antibiotic as ordered by the physician. This affected one (#7) of one resident reviewed for urinary tract infections. The facility census was 35. Findings include: Review of the medical record for Resident #7 revealed an admitted [DATE] with diagnoses including Parkinson's disease, type one diabetes, bipolar disorder, major depressive disorder, hypertension, schizoaffective disorder, and generalized anxiety disorder. Review of Resident #7's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #7's physician orders for October 2024 revealed the resident was ordered the antibiotic piperacillin/tazobactum (Zosyn) 3-0.375 gram (gm)/50 milliliter (ml) every six hours for seven days from 10/18/24 through 10/24/24. Resident #7 was ordered Zosyn 3-0.375 gm four times daily for eight administrations from 10/25/24 through 10/27/24. Resident #7 was again ordered Zosyn 3.375 gm intravenously (IV) four times daily for eight administrations from 10/27/24 through 10/28/24 and Zosyn 3.375 gm IV four times daily for two days for eight administrations from 10/29/24 through 10/31/24. Review of Resident #7's medication administration record (MAR) for October 2024 revealed the Zosyn ordered 10/18/24 through 10/24/24 was not documented as administered on 10/18/24 at 12:00 P.M. Further review revealed there was no documentation of the resident receiving the ordered Zosyn on 10/18/24 at 12:00 A.M., 10/23/24 at 6:00 A.M., and 10/23/24 at 12:00 P.M. Resident #7 was documented as not being in the facility for doses due on 10/20/24 at 6:00 P.M. and 10/21/24 at 12:00 P.M., and a dose was held on 10/24/24 at 12:00 P.M. Further review of Resident #7's MAR for October 2024 revealed Zosyn IV that was ordered from 10/25/24 through 10/27/24 was not documented as administered on 10/25/24 at 9:00 P.M. and 10/26/24 at 3:00 A.M. A dose was held on 10/26/24 at 3:00 P.M. Further review of Resident #7's MAR for October 2024 revealed Zosyn IV that was ordered from 10/27/24 through 10/28/24 was not administered on 10/28/24 at 1:00 A.M., 7:00 A.M., 1:00 P.M. and 7:00 P.M. due to the medication being unavailable from pharmacy. Further review of Resident #7's health status notes revealed no communication to the physician of each dose held prior to 10/25/24 to include the seven doses that were missed. Review of pharmacy packing slip proof of delivery documents dated 10/17/24 revealed 28 vials of Zosyn were delivered to the facility along with 28 100 ml normal saline bags to reconstitute the IV prior to administration. Review of Resident #7's health status note dated 10/25/24 revealed the physician was notified the resident missed seven doses of IV antibiotics over the seven day course that completed on 10/24/24 and staff were awaiting response as to extend the order to complete the seven missed doses or not. Review of Resident #7's health status note dated 10/28/24 revealed the IV antibiotic was not available to administer that shift. Pharmacy was contacted and indicated the pharmacy was out of the medication (Zosyn IV) with notation the pharmacy could send the premixed type of the same medication if pre-authorization was signed and returned to pharmacy. A pre-authorization was signed and returned to pharmacy. The physician was notified and stated to administer two days of four doses per schedule when the medication arrived, and he would review during his visit. Review of pharmacy packing slip proof of delivery documents dated 10/29/24 revealed Zosyn 400 ml was delivered to the facility. Interview on 10/28/24 at 1:32 P.M. with Resident #7 revealed the facility ran out of her IV medication (Zosyn) and she was taking the medication for treatment of a urinary tract infection (UTI). Interview on 10/29/24 at 3:34 P.M. with the Director of Nursing (DON) verified Resident #7's Zosyn IV doses were not marked as given on 10/18/24, 10/25/24, and 10/26/24. The DON also verified there was no documentation of communication with the physician regarding the seven missed doses prior to the note on 10/25/24. Interview on 10/30/24 at 9:53 A.M. with Pharmacist #142 verified the pharmacy sent 28 vials of Zosyn to the facility. Pharmacist #142 verified that amount would have been enough doses to complete the order for four times daily for seven days. Pharmacist #142 verified they did not receive any returns of the medication from the facility. Pharmacist #142 verified the pharmacy sent 400 mls of Zosyn IV on 10/29/24 which would complete the eight administrations that were remaining on the current order. Interview on 10/30/24 at 10:51 A.M. with the DON verified 27 of the 28 doses originally sent from the pharmacy were administered between 10/18/24 through 10/27/24. The DON verified she could not explain why the seven missed doses were not administered from the original order of four times daily for seven days to start on 10/18/24 and end on 10/25/24 which would have equaled the 28 vials sent from the pharmacy. Interview on 10/30/24 at 11:00 A.M. with Assistant Director of Nursing (ADON) #133 stated she cleaned the medication room on 10/26/24 and found normal saline (NS) used to mix the powder for the IV antibiotic with the seal broken, but she did not find any vial of antibiotic powder. ADON #133 stated she assumed the staff attempted to mix the Zosyn with the NS and was unable to do it, so they wasted the vial of medication, but there was no proof to back her intuition. Review of policy titled, Administration Procedures For All Medications, dated 07/01/21, revealed staff should provide notification to the physician/prescriber for persistent refusals, held medications for pulse, blood pressure, low or high blood sugar, or other abnormal test results, vital signs, resulting in medications being held, or suspected adverse drug reactions.

Based on observations, staff interviews, review of the medical record, review of the police report, review of the hospital documentation, and review of the facility's wandering and exit-seeking policy and procedure, the facility failed to provide a safe environment and adequate supervision to prevent Resident #8 from exiting the facility without staff knowledge. This affected one (Resident #8) of three residents reviewed for elopement. The facility identified six residents (Resident #8, #19, #20, #23, #25, and #33) at risk for elopement. The facility census was 39. Findings include: Review of Resident #8's medical record revealed he was admitted to the facility on [DATE] with diagnoses including pulmonary nodule, metastatic squamous cell carcinoma, and emphysema. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #8 had severe cognitive impairment, required contact guard assistance from staff with ambulation, exhibited wandering behaviors, and required an elopement alarm. Review of Resident #8's care plan dated 12/02/23 revealed he was at risk of elopement with a wanderguard placed on his left ankle. Interventions included educating family on elopement risks and interventions, utilizing wander guard for safety, and employing distractions to help decrease wandering. Review of the physician orders for Resident #8 revealed an order dated 05/16/24 for WanderGuard (Secure Care device) placement on the left ankle due to increased wandering. Review of Resident #8's elopement assessment dated [DATE] revealed he had a history of wandering and attempting to leave the facility unattended, and he had voiced the desire to go home. Review of the facility incident report revealed on 06/22/24 at 7:30 A.M., Resident #8 had an event of wandering/elopement. Resident #8 was unable to be located within the facility. On 06/22/24 at 7:45 A.M., nursing staff implemented an internal and external search for this resident. The Director of Nursing (DON) was notified immediately; the DON notified the Administrator. Staff were delegated to continue the search and immediately notify the police department and family. When Resident #8 was found, his mental state was at baseline; he denied having pain and had no visible injuries. Review of the timeline of events undated revealed on 06/22/24 at 7:45 A.M., Resident #8 was identified as missing. The internal and external search began at 7:45 A.M. Staff members conducting the search were Licensed Practical Nurse (LPN) #109, LPN #151, and LPN #152, State tested Nursing Assistant (STNA) #102 and STNA #152. Non-direct care staff present were Housekeeping Aide (HA) #141, HA #143, Dietary Aide (DA) #154, and #155. All staff members participating in the search did not stop until Resident #8 was found. Resident #8 was found approximately 250 feet from the facility's front door, behind a tree line, at 10:13 A.M. Resident #8 was assessed for injuries and transported to the hospital for further evaluation at 10:30 A.M. Review of the police report dated 06/22/24 revealed the police were called at 8:16 A.M. and arrived at 8:55 A.M. for a report of a missing [AGE] year-old male with dementia. It was possible he left when another patient was transported earlier that morning. Resident #8 was located at approximately 10:12 A.M. Review of the hospital after-visit summary completed on 06/22/24 revealed Resident #8 did not sustain any injuries. Review of LPN #110's statement dated 06/22/24 revealed she was the night shift nurse. LPN #110's most recent sighting of Resident #8 was on 06/22/24 at 5:45 A.M. when he was seen wandering in the middle hallway. Review of LPN #109's statement dated 06/22/24 revealed she had last seen Resident #8 at shift change around 6:00 A.M. At approximately 7:45 A.M., STNA #102 asked LPN #109 if she knew where Resident #8 was. LPN #109 denied knowing and directed STNA #102 to check the dining room, where she was unable to locate him. LPN #109 initiated a whole-house search within the nursing department. After an initial search was conducted, LPN #109 initiated a ground search with all available staff. At this time, they were unable to locate Resident #8. On 06/22/24 at approximately 8:10 A.M., LPN #109 notified the DON and called the sheriff's office. Review of STNA #102's statement dated 06/22/24 revealed she had begun hourly rounds on her assignment between 6:30 A.M. and 6:45 A.M. At this time, she was unable to locate Resident #8. STNA #102 walked to the kitchen to look for Resident #8 in the dining room. STNA #102 asked Dietary Aide (DA) #154 and #155 if they had seen Resident #8; both dietary aides denied. STNA #102 notified the nurse. Review of DA #155's statement dated 06/22/24 revealed he had entered the facility at 6:00 A.M. On 06/22/24 during breakfast preparation, STNA #102 asked him if he had seen Resident #8 for breakfast. DA #155 assisted STNA #102 with the search immediately, driving around the neighborhood. Review of DA #154's statement dated 06/22/24 revealed upon entering the facility on 06/22/24 at 5:50 A.M., the back door was closed. At approximately 7:50 A.M., STNA #102 asked DA #155 and #154 if they had seen Resident #8; both denied. DA #155 assisted with the search while DA #154 assisted the remaining residents in the dining room. Review of LPN #151's statement dated 06/22/24 revealed they had assisted in the internal and external search for Resident #8. Review of Registered Nurse (RN) #152's statement dated 06/22/24 revealed she was notified when Resident #8 went missing; at that time, she stopped medication administration to assist with the search. RN #152 attempted to contact the family several times to ensure the resident was not on a leave of absence. RN #152 completed notification to the sheriff. Review of HA #141's statement, undated, revealed he and HA #143 looked for Resident #8 for two and a half hours. HA #141 and #143 went door to door before local authorities arrived. Review of HA #143's statement revealed she arrived at 7:55 A.M., where HA #141 had notified her that Resident #8 was missing. HA #141 and #143 began the search. Interview conducted on 06/27/24 at 10:18 A.M. with the DON confirmed emergency medical technicians (EMT) transported a resident out of the facility due to a fall between 7:30 and 7:45 A.M. During the resident's transfer, the EMTs left the door open, giving Resident #8 the opportunity to elope from the facility undetected. Interview conducted on 06/27/24 at 10:20 A.M. with Maintenance Supervisor #145 verified all doors were checked after the elopement and were functioning properly. He contacted the company in charge of the monitoring system to come to the facility to check the system. Following inspection, the company indicated all exit door alarms were functioning as expected. Observation on 06/27/24 at 11:20 A.M. revealed the facility's wanderguard system was functioning properly. The system worked by locking the doors when a resident with a wanderguard ankle bracelet attempted to open the door. Upon exiting the building, a large blacktop parking lot was found, approximately 200 yards away from a dense tree line. Beyond the tree line, at approximately 250 yards from the front entrance, was where Resident #8 was found unharmed. Observation on 06/27/24 at 3:25 P.M. of Resident #8 revealed he was lying in bed with a wanderguard present. Resident #8 was aware of himself but confused about time, place, and situation. Resident #8 was unable to provide meaningful information when interviewed. Interview conducted on 06/27/24 at 5:07 P.M. with STNA #102 confirmed she was the last staff member to see Resident #8 shortly after 6:00 A.M. on 06/22/24. STNA #102 notified the nurse immediately when Resident #8 could not be located. Interview conducted on 06/27/24 at 5:44 P.M. with LPN #152 denied seeing Resident #8 on the morning of the elopement. LPN #152 confirmed the WanderGuard system did not work properly because the EMTs left the door open, allowing Resident #8 the opportunity to elope. LPN #152 denied seeing Resident #8 walk past the front entrance when she was sitting at the desk Interview conducted on 06/27/24 at 6:19 P.M. with LPN #109 denied seeing Resident #8 on the morning of the elopement. LPN #109 confirmed the WanderGuard system did not alarm when Resident #8 left the building. Review of the facility's Wandering and Elopement policy dated 08/2021 revealed the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If a resident is identified at risk for wandering, elopement, or other safety issues, the resident's orders will include strategies and interventions to maintain the resident's safety. This was an incidental finding discovered the course of the complaint investigation.

Based on resident and staff interviews, and record review, the facility failed to ensure resident concerns brought up at the resident council meeting were addressed timely and appropriately. This affected nine (#05, #07, #10, #13, #14, #18, #30, #32, and #36) residents in regular attendance of the resident council meetings. The Facility census was 39. Findings include: Review of the resident council meeting minutes dated 09/2023 revealed concerns related to the Administrator, needing to spend more time in the facility and concerns related to nursing and the staff taking too long to answer call lights. Review of the resident council meeting minutes dated 12/2023 revealed concerns related to the Administrator, messing things up, making promises that were not kept, and he couldn't remember what he was told. The meeting also brought up concerns related to agency nurses. Interview on 01/22/24 at 11:00 A.M. with Resident #23 revealed the facility does not address resident concerns timely and revealed the Administrator was not seen often at the building fixing the concerns. Interview on 01/22/24 at 12:05 P.M. with Activities Director #220 revealed she typically would submit the concern forms that were brought up in the resident council meetings. Activities Director #220 revealed the concern forms were not completed for the nursing concerns or the administration concerns as the facility had no procedure in place for those type of concerns. Activity Director #220 revealed the facility had no evidence of acknowledging or addressing the resident concerns and revealed the facility had no follow- up regarding the concerns for nursing call lights and agency staffing as well as for the administration concerns. Interview on 01/23/24 at 12:00 P.M. with Corporate Administrator #250 and Corporate Nurse #260 confirmed there was no documented evidence of any follow-up related to resident concerns related to the staffing or the administration concerns. Corporate Administrator #250 could not provide the requested call light audits for review. Review of the facility policy titled Resident Council, dated 01/2014, revealed Resident Council meetings would be held monthly and as needed and all concerns would be documented on a Resident concern form and forwarded to the Administrator for appropriate follow up. The concern or grievance form that should be returned should be addressed by the appropriate department and document the outcome of the concern review and return documentation evidence to Activity Director. This deficiency represents non-compliance investigated under Complaint Number OH00149489.

Based on observation, resident interview, staff interview and record review, the facility failed to ensure resident's call lights were answered timely. This affected one (#23) of the three residents reviewed for call lights. The facility census was 39. Findings include: Review of the medical record for the Resident #23 revealed an admitted [DATE]. Diagnoses included cerebral palsy, diabetes, somatization disorder, epilepsy, borderline personality disorder, dysphasia, paraplegia, and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact with a Brief Interview Mental Status (BIMS) of 15 and required partial assistance from staff for mobility and activities of daily living (ADLs). Interview on 01/22/24 at 11:00 A.M. with Resident #23 revealed the facility did not have enough staff to provide needed care for residents and had long waits for the call lights to be answered. Observation at the same time revealed Resident #23 activated his call light at 11:04 A.M. and staff responded to his room at 11:32 A.M. Observation during this time period, over 10 staff members walked by the resident's room including the Director of Nursing (DON), the Social Worker, the Housekeeping Supervisor, along with several aides and nurses and no one answered the resident's call light. Observation at the same time revealed the visible light was illuminated outside the resident's room which indicated the call light was activated. Interview on 01/22/24 at 11:37 A.M. with State tested Nursing Assistant (STNA) #215 revealed she was passing water and when she got to Resident #23's room, she realized the call light was on. STNA #215 revealed the call lights alerted on a screen at the nurse's station and also by a visible light outside the resident's room. STNA#215 revealed she was unaware of the call light going off for over 25 minutes. Interview on 01/22/24 at 5:30 P.M. with Corporate Administrator #250 revealed the call lights should be answered timely and revealed a call light in the 25-30-minute range was not acceptable. Call light audits were requested from Corporate Administrator #250 several times prior to and again at this interview and the facility was unable to provide any documented evidence of the call lights times and /or any audits completed. The subsequent interview on 01/23/24 at 11:24 A.M. with the DON reported the STNA who was responsible to care for Resident #23 when the call light was not timely answered on 01/22/23, was found to have left the facility and was sitting in her car. The DON revealed the agency STNA in question was placed on the do not return list. Review of facility policy titled Call Lights, dated 08/2023, revealed staff should promptly respond to calls for assistance to provide a safe environment and meet care needs. This deficiency represents non-compliance investigated under Complaint Number OH00149489.

Based on resident interview, staff interview and record review, the facility failed to ensure resident's representatives were notified when a change in condition occurred. This affected two (#16 and #21) of three residents reviewed for change in condition. The facility census was 39. Findings include: 1. Review of the medical record for the Resident #16 revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis unspecified cerebrovascular disease, bipolar disorder, dysphasia, and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitively impaired with a Brief Interview Mental Status (BIMS) of six and required moderate assistance from staff with eating. Resident #16 was dependent on staff for mobility and transfers. Review a nurse's progress note dated 11/24/23 for Resident #16 revealed the nurse noticed a change in condition when the resident had an altered mental status, had dark foul-smelling urine and the physician was contacted to obtain laboratory (lab) tests. The note revealed no documented evidence of the resident's representative being notified. Additionally, a nurse's progress note dated 12/27/23 revealed the resident was placed in Coronavirus (COVID-19) quarantine/isolation due to exposure, and there was no documentation of the resident's representative being notified. 2. Review of the medical record for the Resident #21 revealed an admitted [DATE]. Diagnoses included Huntington's disease, repeated falls, dysphasia, muscle weakness, delusions disorder, dementia with behavioral disturbance and major depression. Review of a nurse's progress note dated 11/10/23 revealed Resident #21 had a fall from the bed onto the ground. There was a fall mat in place, but it appeared that the resident had fallen off the mat as well and the mat slipped from its assigned spot. Resident #21 was noted to have abrasions noted to the right forehead and right elbow and a bruising to right cheekbone and knee. Resident #21 reported he was fine and neurological (neuro) checks were initiated. The progress notes revealed no documented evidence the resident's representative was notified concerning the fall with injuries on 11/10/23. Additionally, a nurse's progress note dated 12/27/23 revealed the resident was placed in quarantine/isolation due to COVID-19 exposure and there was no documented evidence of the resident's representative being notified. Review of fall report form dated 11/10/23 for Resident #21 revealed a staff member's statement of the fall; however, the statement did not include any documented evidence of the resident's representative being notified of the fall. Review of the MDS assessment dated [DATE] revealed Resident #21 was cognitively impaired and was dependent on staff for all activities of daily living (ADLS) tasks and mobility including eating. Interview on 01/23/24 at 11:50 A.M. with Corporate Nurse #260 confirmed the facility had no documented evidence of Resident #16 and Resident #21's representatives being notified after they had changes in condition including a fall with injury, changes in their medical symptoms and when the residents were placed in COVID-19 quarantine/isolation. Review of facility policy titled Change in a Resident ' s Condition, dated 08/2023, revealed the facility shall notify the resident, attending and resident representative of changes in condition. Unless otherwise instructed by the resident, the nurse supervisor will notify the resident ' s family or representative. This deficiency represents non-compliance investigated under Complaint Number OH00149489.

Based on observation, resident and interviews, and record review, the facility failed to maintain a home like environment for one (#16) of three residents reviewed for physical environment. The facility census was 39. Findings include: Review of the medical record for the Resident #16 revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis unspecified cerebrovascular disease, bipolar disorder, dysphasia, and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitively impaired with a Brief Interview Mental Status (BIMS) of six and was dependent on staff for activities of daily living (ADLS). Interview and observation on 01/22/24 at 12:15 P.M. with Resident #16 revealed an outlet cover above him was hanging out of the wall approximately eight inches and had a cable cord hanging from it. The resident reported it had been that way since he was moved to the room a few weeks ago. Interview on 01/22/24 at 12:34 P.M. with State tested Nursing Aide #212 confirmed Resident #16 had a cable outlet cover hanging out of the wall about eight inches and hanging above the bed. The cable cord was still screwed into the outlet cover and was a safety hazard. Review of facility policy titled Resident Environment Quality, undated, revealed facility shall maintain resident rooms including mechanical electrical and patient care equipment in safe working order.

Based on resident interviews, staff interviews and record review, the facility failed to ensure dependent residents received showers as scheduled. This affected two (#16 and #21) of three residents reviewed for activities of daily living (ADLs). The Facility census was 39. Findings include: 1. Review of the medical record for the Resident #16 revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis unspecified cerebrovascular disease, bipolar disorder, dysphasia, and muscle weakness. Review of the shower preference document revealed Resident #16 was scheduled to get showers on Sundays and Wednesdays. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitively impaired with a Brief Interview Mental Status (BIMS) of six and the resident was dependent on staff for bathing. Review of the shower sheets from the past three months (10/15/23 to 01/23/24) for Resident #16, revealed the resident was offered showers on (Sunday) 10/15/23, (Sunday) 10/29/23, (Monday) 11/06/23, (Wednesday) 11/08/23, (Sunday) 11/12/23, (Sunday) 11/19/23, (Wednesday) 12/06/23, (Wednesday) 12/13/23, (Tuesday) 12/19/23, (Sunday) 01/07/24, (Wednesday) 01/10/24 and (Saturday) 01/20/24. Documents indicated the resident missed 16 shower opportunities. A shower sheet dated 12/31/23 was blank except for a comment saying COVID positive. Interview on 01/22/24 at 12:15 P.M. with Resident #16 revealed he had only had one shower in the last two weeks. The resident revealed he had trouble getting staff to help him with showers. 2. Review of the medical record for the Resident #23 revealed an admitted [DATE]. Diagnoses included cerebral palsy, diabetes, somatization disorder, epilepsy, borderline personality disorder, dysphasia, paraplegia, and muscle weakness. Review of the shower preference document revealed Resident #23 was scheduled to get showers on Mondays and Thursdays Review of the MDS assessment dated [DATE] revealed Resident #23 was cognitively intact with a BIMS of 15 and required maximum assistance with bathing. Review of the shower sheets from the past three months (10/23/23 to 01/23/24) for Resident #23 revealed no documented evidence of any showers from 10/23/23 to 12/04/23. Resident was offered showers on (Monday) 12/04/23, (Monday) 12/12/23, (Wednesday) 12/14/23, (Friday) 12/22/23, (Monday)12/25/23, (Thursday) 12/28/23, (Monday) and (Tuesday) 01/23/24 with only one refusal on 01/22/23 due to the resident complaining of pain. The resident missed 20 shower opportunities in the three months reviewed. Review of a nurse's progress note dated 11/21/23 for Resident #23 revealed the resident takes 60-90 minutes to shower and then another 20-30 minutes after shower for care and was monopolizing the staffs' time. No other notes mentioned showers from 10/01/23 to 01/23/24. Review a nurse's progress note dated 01/23/24 for Resident #23 revealed the resident declined a shower due to pain from a urinary tract infection (UTI) and currently on antibiotics. Interview on 01/22/24 at 11:00 A.M. with Resident #23 revealed he should be scheduled for showers on Mondays and Thursday and his preference was to have a shower twice weekly; however, the facility had been using a lot of agency staffing over the last several weeks and reported he had not been offered showers as scheduled. The resident reported he would go weeks without staff offering a shower and when he asked for one, he was told it was not his day for a shower, the staff didn't have time and /or it was not the staff member's job. Observation at the same time revealed the resident had some shaggy, unkempt facial hair and his hair was pulled back into a braid and appeared to be slick and greasy. Interview on 01/23/24 at 11:24 A.M. with Director of Nursing (DON) confirmed Residents #16 and #23 had missed bathing/showers. The DON reported she was not sure why the residents were missing bathing/showers as the facility had enough staffing to complete those tasks. The DON indicated the shower sheets provided to the Surveyor for Residents #16 and #23 were all the facility had. Interview on 01/23/24 at 11:40 A.M. with State tested Nursing Aides (STNA) #208 and #212 revealed they are aware of residents not getting bathing/showers as scheduled. STNAs #208 and #212 indicated residents complained that agency aides were not providing showers as requested and as scheduled. STNAs #208 and #212 reported they were instructed by management that residents who were in isolation/quarantine for COVID, were not to receive bathing/showers as scheduled so they would mark COVID on the resident's shower sheets. Review of facility policy titled Bathing Policy, dated 08/2022, revealed residents had the option to take a bath or shower as often as they would like and choose the time of day to have it completed.

Based on observation, staff interviews, resident interview, and record review, the facility failed to ensure residents received their diet as ordered. This affected one (#35) of three residents reviewed for nutrition. The facility census was 39. Findings include: Review of the medical record for the Resident #35 revealed an admitted [DATE]. Diagnoses included sepsis, morbid obesity, hyperlipidemia, gastro esophageal reflux disease (GERD), diabetes, intellectual disability, and muscle weakness. Review of a dietary note dated 10/03/22 revealed Resident #35 was recommended to receive half portioned meals for lunch and dinner. Review of a physician's order dated 10/04/22 revealed Resident #35 was ordered to receive half portioned meals. Review of a dietary note dated 12/20/23 revealed Resident #35 had stable weights and received half portion meals for lunch and dinner. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively intact with a Brief Interview Mental Status (BIMS) of 15 and required set up assistance from the staff for eating. Interview on 01/22/24 at 5:19 P.M. with Resident #35 and State tested Nursing Assistant (STNA) #205 revealed the resident nor the staff were aware that the resident was ordered to receive half portioned meals. STNA #205 confirmed resident was served a regular portioned meal. Interview on 01/23/24 at 11:21 A.M. with Director of Nursing (DON) revealed Resident #35 was put on half portioned meals for lunch and dinner as a weight loss plan and verified the order was made on 10/2022. Review of facility policy titled therapeutic diets, dated 08/2023, revealed resident's diets are determined by the physician and dietician to support resident treatment and plan of care.

Based on observation, medical record review, staff and resident interviews, review of facility Self-Reported Incidents (SRIs) and subsequent investigations, review of a police report, hospital documentation, Resident Council meeting minutes, the facility ' s Bureau of Criminal Investigation log, employee personnel records, and review of the facility ' s abuse policy, the facility failed to ensure incidents of suspected physical and verbal abuse toward residents were immediately reported to the administrator of the facility, immediately initiate a thorough investigation, and subsequently failed to ensure residents were protected from further potential physical abuse and harm by Resident #28. This resulted in Immediate Jeopardy for five residents (#6, #12, #22, #24, and #49) who were physically abused by Resident #28. In addition, the facility failed to ensure incidents of suspected physical and verbal abuse were immediately reported to the administrator of the facility, immediately initiate a thorough investigation, and subsequently failed to ensure residents were protected from further potential physical and verbal abuse by State tested Nursing Assistant (STNA) #106. This resulted in Immediate Jeopardy for three residents (#5, #18, and #44) who were physically and/or verbally abused by STNA #106. Consequently, this resulted in Immediate Jeopardy for eight (#5, #6, #12, #18, #22, #24, #44, #49) of nine residents reviewed for abuse and 31 additional residents (#1, #2, #3, #6, #7, #8, #9, #10, #13, #14, #15, #16, #17, #19, #21, #23, #26, #27, #29, #30, #31, #32, #33, #34, #35, #37, #38, #39, #41, #42, #43, #47 and #48) residing in the facility. On 01/21/16 at 12:47 P.M., the Administrator, Director of Nursing (DON), Corporate Nurse #110 and Corporate Nurse #111 were notified Immediate Jeopardy began on 08/05/15 when Resident #49 was punched repeatedly in the face by Resident #28 and received a bruise to her forehead. On 11/11/15, Resident #28 assaulted Resident #24 causing multiple bleeding scratches to the resident's face. On 12/31/15, Resident #28 struck Resident #6, unprovoked, in the side of her face. On 01/10/16, Resident #28 struck Resident #22 in the face resulting in a laceration to the resident's left cheek. This assault resulted in Resident #22 being sent to the emergency room for evaluation and treatment. She was diagnosed with [REDACTED]. On 01/17/16, Resident #12 was attacked by Resident #28 causing bruising to her arms bilaterally. Additionally, on 08/13/15, Resident #18 reported verbal abuse from STNA #106, stating she spoke mean to her and did not want her to be her STNA any longer. Resident #5 reported STNA #106 presses on his head and brushes his teeth hard, making his gums bleed. On 01/19/16 it was reported STNA #106 told Resident #44 to shut up, slammed his door, and grabbed his head, forcing his head onto a pillow. The Immediate Jeopardy was removed on 01/21/16 at 2:00 P.M. when Resident #28 was discharged to the hospital for psychiatric care and will not be returning to the facility, and STNA #106 was terminated. The deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 01/24/16 when the facility implemented the following corrective actions: · On 01/20/16 at 3:00 P.M., STNA #106 was suspended and an abuse investigation was initiated. STNA #106 was subsequently terminated from employment on 01/20/16. · On 01/21/16 at 10:38 A.M., the facility placed Resident #28 on one-to-one supervision. · On 01/21/16 at 12:30 P.M., the facility initiated abuse education with all current staff members utilizing the facility abuse policy. 60 of 62 staff were educated by 01/22/16. The two remaining PRN (as needed) staff were informed of the in-service via phone on 01/22/16 and are required to complete the abuse education prior to the start of their next scheduled shift. The Regional Director of Clinical Services provided the training. · On 01/21/16 at 12:45 P.M., the facility Administrator and DON were educated on abuse protection, reporting, investigation and implementing appropriate interventions for behaviors by Regional Director of Clinical Services. · On 01/21/16 at 2:00 P.M., Resident #28 was transferred to the hospital for psychiatric care and will not be returning to the facility. · On 01/21/16, the facility Regional Director of Clinical Services reviewed all residents' medical records to identify residents with aggressive behaviors to ensure behavior interventions were appropriate and in place. · On 01/21/16, the facility Regional Director of Clinical Services completed interviews with all 38 current residents regarding abuse utilizing the Centers for Medicare and Medicaid Services (CMS) resident interview and observation tool. There was no further indication of abuse. · On 01/21/16, the facility's Regional Director of Clinical Services provided in-service education to Business Office Manager (BOM) #110 regarding requirements for background checks. · On 01/21/16 at 3:00 P.M., BOM #110 audited all employee files to ensure background checks were completed. No further issues were identified. · On 01/24/16, Licensed Practical Nurse (LPN) #85 and #113, and STNA #95, #98, and #100 were interviewed and were able to accurately articulate the facility abuse policy. · Corporate Nurse #110 or designee will audit background check logs, behavior documentation, and abuse allegations/investigations weekly for three months. All findings will be reported to the Quality Assurance Committee on a quarterly basis. Findings include: 1. Review of the medical record for Resident #28 revealed she was admitted to the facility on [DATE]. Medical [DIAGNOSES REDACTED]. Review of Resident #28's psychiatric consultation progress note dated 06/12/15 revealed the resident was having pseudo [MEDICAL CONDITION]. A psychiatric consultation progress note dated 09/22/15 revealed the resident fakes [MEDICAL CONDITION] per staff and was experiencing physical aggression. A psychiatric consultation progress note dated 12/22/15 also revealed staff thinks she fakes [MEDICAL CONDITION] and the resident was experiencing impulsivity. A physician progress notes [REDACTED]. Review of the resident's comprehensive assessment dated [DATE] identified the resident as having moderate cognitive impairment. The resident was assessed as having physical and verbal behaviors toward others. She was independent for her activities of daily living and required supervision for locomotion and walking in the corridor. Review of an emergency room visit dated 12/31/15 revealed the resident's [DIAGNOSES REDACTED]. Review of an emergency room visit dated 01/18/16 revealed a review of Resident #28's medical record did not indicate any grand mal [MEDICAL CONDITION] activity, any tonic-clonic activity or change of mental status, any fever or chills, any inability to take oral medications, or any patient complaints. No behavioral disturbances were noted while in the emergency room . Review of the nursing notes revealed multiple entries indicating aggressive behavior. On 08/25/15, it was documented the nurse entered Resident #28's room and the resident was throwing her arms up in the air and yelling. Resident #28 did not respond to this nurse's questions and continued to bump into the nurse. Resident #28 then started moving boxes and throwing items around her room. Resident #28 refused medications and again slammed her body into the nurse, causing the nurse to stumble. On 08/26/15, the resident was sitting in the front hall common area coughing obsessively and was refusing to cover her mouth. The nurse attempted to educate the resident on the importance of preventing the spread of germs. The resident punched the nurse in the right eye several times and scratched her face. On 09/30/15, the resident was informed Activity Director (AD) #60 would be riding along with her to an appointment. The resident began yelling that (expletive) ain't taking me anywhere she won't take me any other time and she ain't taking me now. Staff stated they would send another staff member. AD #60 walked near Resident #28 to get the snack cart and the resident called her an expletive and hit AD #60 in the left side of her face with her casted hand. On 10/30/15 the resident was in the activities room for a Halloween party with multiple other residents. Resident #28 began to scream and flap her arms around in the air in a windmill motion and cleared the snack table in the activity room. She was redirected and stopped the [MEDICAL CONDITION] activity. No signs or symptoms of an actual [MEDICAL CONDITION] were noted. On 12/09/15 the resident was in the therapy room and became upset with the therapist and began faking a [MEDICAL CONDITION] by throwing her arms around in a windmill motion and picking items up off the table and throwing them at the therapist. Also on 12/09/15, while being introduced to her new roommate and roommate's family she began screaming, moaning, and throwing her arms around as if having a [MEDICAL CONDITION]. This scared the roommate and family to the point of tears. Resident #28 did this repeatedly until the roommate was moved to a different room. Review of Resident #49's medical record revealed she was admitted on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. A review of the resident's comprehensive assessment dated [DATE] revealed she had mild cognitive impairment, experienced delusions, had no physical behaviors to others but did have verbal behaviors to others. The resident was independent or required supervision only for all care. Review of nursing notes dated 08/05/15 described Resident #28 getting up and hitting Resident #49 repeatedly in the face with a closed fist. This resulted in a bruise to Resident #49's forehead and neurological checks were initiated. Resident #28 was placed on one-to-one observation until calm and then fifteen minute checks for 72 hours for aggressive behavior. Review of the facility's SRI dated 08/05/15 regarding this incident revealed Resident #28 and #49 were involved in a verbal altercation, staff attempted to intervene, and Resident #28 got up and ran over to Resident #49 and hit her in the face. Resident #28 subsequently received a medication change. The facility concluded abuse was unsubstantiated as they were unable to substantiate an attempt to do harm. Review of Resident #24's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. A review of the resident's comprehensive assessment dated [DATE] revealed severely impaired cognition. The resident experienced verbal behaviors to others, but no physical behaviors to others. He was independent or required supervision for all care. Review of the nursing notes revealed a late entry for 11/11/15 dated 11/12/15 indicating Resident #24 was found on the floor with Resident #28 standing over him. He had multiple bleeding scratches noted. Review of the facility's SRI dated 11/10/15 regarding this incident revealed Resident #28 stated she hit Resident #24. It further stated both residents were assessed for injuries and none were noted. Resident #28 was placed on one-to-one supervision until she was sent to the emergency room for a psychiatric evaluation. The emergency room immediately sent Resident #28 right back to the facility and she was placed on fifteen minute checks for 72 hours. Resident #24 was placed on every fifteen minute checks. The facility concluded abuse was unsubstantiated as they were unable to substantiate intent to do harm. Review of Resident #6's medical record revealed the resident was admitted [DATE]. [DIAGNOSES REDACTED]. Review of Resident #6's comprehensive assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident is supervised for transfers, requires limited assistance of one staff for personal hygiene, dressing and bed mobility. Review of Resident #6's nursing progress note dated 12/31/15 at 4:34 P.M. revealed Resident #6 attended a New Year's Eve Party in the activity room. Resident #28 started swinging her arms and hit Resident #6 in the face and the resident was upset. Review of a nursing note in Resident #28's medical record revealed Resident #28 was at the New Year's Eve party in the activity room and, unprovoked, began swinging her arms around and punched Resident #6 in the face. Review of a facility SRI dated 12/31/15 regarding the incident revealed Resident #28 began to have [MEDICAL CONDITION] type activity of flailing of arms over her head, at which time Resident #28 inadvertently struck Resident #6 on the side of the face. The facility did not substantiate abuse as they felt Resident #28 stuck Resident #6 as a result of uncontrollable involuntary movements/[MEDICAL CONDITION] type activity. Resident #28 was sent to the hospital emergency room for evaluation, then returned to the facility and placed on fifteen minute checks. Activities were moved to the dining area to keep a three foot distance between residents. Review of facility witness statements revealed AD #60 stated Resident #28 started flailing her arms, hitting Resident #6 in the side of her face. Resident #28 was told to stop and she did so and was told to leave the area. Review of Resident #22's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's comprehensive assessment dated [DATE] revealed her cognition was moderately impaired. She required extensive assist for transferring, toileting, and personal hygiene and limited assistance for bed mobility and dressing. Review of Resident #22's nursing notes dated 01/10/16 revealed the resident yelled you (expletive) from her room. Upon walking to the room, LPN #85 saw her sitting in her room in her wheelchair with a bleeding laceration to her left cheek. Resident #28 was standing a few feet in front of Resident #22 and said I told you not to yell help. The nurse applied pressure and a dressing to Resident #22's face to stop the bleeding. LPN #85 told Resident #28 you cannot hit people to which she replied She deserved it. Resident #22 was sent to the emergency room for evaluation and treatment of [REDACTED]. Neurological checks were restarted. Review of Resident #28's nursing notes revealed she was placed on one-to-one until removed from the facility for a psychiatric evaluation. Resident #28 was transported to the emergency room at 7:48 P.M. and returned to the facility with no further orders at 11:45 P.M. One-to-one supervision was resumed until 01/11/16 at 11:45 A.M. She was then placed on every fifteen minute checks and placed in a private room. Review of a facility SRI dated 01/10/16 regarding the incident revealed Resident #22 was involved in a verbal altercation with Resident #28 which led to Resident #28 striking Resident #22 on the face. There were no witnesses to the incident. The facility did not identify any injuries in the SRI. The facility determined abuse was not substantiated. A police report dated 01/10/16 regarding Resident #28 was reviewed. The report documented Resident #28 hit Resident #22 in the face causing injury resulting in Resident #22's transport to the emergency room . The facility advised the officer that Resident #28 was not mentally stable and had a history of [REDACTED]. Resident #22 was interviewed on 01/20/16 at 3:30 P.M. She stated Resident #28 hit her in the face. She further stated she is scared of her and does not want to be around her. The resident was observed with steri-strips under her left eye. Review of Resident #12's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's comprehensive assessment dated [DATE] revealed the resident had no impairment in cognition and no verbal or physical behaviors to others. Resident #12 was independent to limited assistance for all care. Review of Resident #12's nursing notes dated 01/17/16 revealed an entry from Registered Nurse (RN) #90 indicating the resident was threatened with physical harm in her room by Resident #28 who was displaying [MEDICAL CONDITION] activity. Resident #12 stated Resident #28 wanted to tip her out of her wheelchair and has tried to before. Review of the facility SRI dated 01/17/16 revealed Resident #12 reported that after a few minutes of talking with Resident #28 in Resident #12's room, Resident #28 became quiet and started flailing her arms about and knocking items off of the table. Resident #12 then alleged Resident #28 grabbed her wheelchair and then her arms, shaking her. Resident #12 yelled out and staff intervened immediately separating the two residents. Staff led Resident #28 to the lobby and provided one-to-one supervision until transport to the emergency room for evaluation of continuous [MEDICAL CONDITION] activity. No injuries were reported in the SRI. The facility did not substantiate abuse documenting unable to establish intent to do harm on the part of Resident #28 or if she was suffering a [MEDICAL CONDITION]. Upon return from the hospital, Resident #28 was placed on one-to-one supervision until such time the facility was able to safely discharge to another healthcare facility. On 01/22/16, Resident #28 was discharged from facility. Review of a facility witness statement written by RN #90 revealed he heard Resident #12 yelling stop it. He opened the door to Resident #12's room and found Resident #28 physically grabbing Resident #12 and acting like she wanted to injure her. RN #90 pulled Resident #28 off of Resident #12, who was in her wheelchair. He further stated it took a lot of exertion on his part to pull her off and Resident #28 kept trying to grab Resident #12. A police report dated 01/19/16 revealed Resident #28 was accused of physically attacking Resident #12. Upon speaking with Resident #28's nurse, the police officer was advised the resident suffers from [MEDICAL CONDITION] disorder and [MEDICAL CONDITION]. Resident #28 has a history of violent outbursts against the staff and residents at the care center. Interview with Resident #12 on 01/19/16 at 11:16 A.M. revealed Resident #28 came in her room on Sunday, 01/17/16 in the evening, and slammed her wheelchair into the bathroom door and then grabbed her by the arms and squeezed her very hard. She stated she had to scream loudly for help and a nurse came running in to help her. She stated she called the sheriff to report the assault. She also stated she talked to the DON on Monday 01/18/16 about the incident. Observation of the resident's arms did reveal bruises on her right and left upper arms. She stated she is scared of Resident #28 and so are other residents. Interview and observation with LPN #86 on 01/20/16 at 3:44 P.M. verified Resident #12 had four small round bruises on her upper right arm and three small bruises on her upper left arm. LPN #86 was not aware of these bruises and stated they were not monitoring them. Interview with STNA #101 on 01/20/16 at 6:20 P.M. revealed she assisted in separating Resident #12 and #28. She stated Resident #28 was squeezing Resident #12's arms. She also stated she would be the only STNA working 01/20/16 and therefore cannot observe Resident #28 every fifteen minutes as she is supposed to. She stated there are three smoke breaks that last a half hour each so she cannot visualize Resident #28 during these smoke breaks. She stated she has been unable to complete the fifteen minute checks every time she is the only STNA working the floor. Interview with LPN #76 on 01/20/16 at 3:10 P.M. revealed Resident #28 has a long history of becoming physically abusive. She stated the facility has sent her out multiple times to the hospital trying to seek other placement. She further stated she does have [MEDICAL CONDITION]; however, she also fakes [MEDICAL CONDITION] activity. LPN #76 stated her physical aggression is mostly when she feels other residents are getting attention. Interview with LPN #86 on 01/20/16 at 3:44 P.M. revealed Resident #28 does have [MEDICAL CONDITION], however, when she strikes other residents, it is an adverse behavior and not a [MEDICAL CONDITION]. LPN #86 stated they placed Resident #28 on fifteen minute checks and they try to keep her busy to keep the other residents safe. Interview with AD #60 on 01/20/16 at 3:57 P.M. revealed the resident has been physically assaultive during activities when she does not feel she is the center of attention. She stated her corporate person told her to try to keep Resident #28 three feet away from the other residents. She did move the activities to the dining room for more space and the resident was still assaultive. She stated all the residents seem to be afraid of Resident #28 and they have stated this in Resident Council. Observation of Resident #28 at this time revealed she was in the small activities room sitting closer than three feet from several residents. AD #60 verified the resident was not currently being kept three feet from other residents during activities. Interview with the DON on 01/20/16 at 5:30 P.M. revealed she felt the bulk of Resident #28's incidents occurred during [MEDICAL CONDITION] activity. She further stated the facility has tried to get someone to diagnose her with pseudo [MEDICAL CONDITION] but have not been able to. When asked what the facility has implemented to protect the other residents, she stated they gave Resident #28 her own room and placed her on every fifteen minute checks. The facility has also attempted to obtain other placement for the resident, however they have had no success obtaining placement. She also stated the activities had been moved to the dining room to keep more distance between Resident #28 and the other residents. She stated she was unaware Resident #28 was in the small activities room on 01/20/16. LPN #74 was interviewed on 01/20/16 at 6:23 P.M. She stated Resident #28 has to be monitored because she goes after other residents and acts as if she is having a convulsion episode. She stated if she tells her to stop and pays attention to her, she will generally stop. She stated the STNA's are responsible for the fifteen minute checks of the resident. On 01/21/16 at 10:38 A.M. the facility notified the survey team that Resident #28 was placed on one-to-one supervision. On 01/21/16 at 11:00 A.M., Resident #28 was again observed in the small activity room with other residents present. There was not a three foot distance between Resident #28 and the other residents. Interview with Social Service Coordinator (SSC) #111 on 01/21/16 at 11:15 A.M. revealed Resident #42 shares a bathroom with Resident #28 and has complained to SSC #111 of Resident #28 giving her queer looks and stated she feels intimidated. SSC #111 further stated Resident #28 is so unpredictable she does not feel one-to-one supervision would stop her aggressive behavior. She does not feel they can manage her behaviors and keep other residents safe. Surveyor observation on 01/21/16 at 4:55 P.M. revealed Resident #28 sitting in the dining room at a table with a male resident. STNA #109 was conducting the one-to-one supervision for Resident #28. She was sitting three tables away from the resident. STNA #109 stated she had just begun employment at the facility today and was not told how far she had to be from Resident #28. She verified the resident was not in arm's length of her. Interview and observation with the Administrator on 01/21/16 at 5:11 P.M. revealed Resident #28 continued to sit at a table in the dining room with a male resident. STNA #109 was passing dinner trays to other residents. The Administrator stated as long as STNA #109 could see the resident, this was acceptable. Observation of Resident #28 on 01/21/16 at 5:40 P.M. revealed she was being monitored one-to-one by STNA #109. Interview with Assistant Director of Nursing (ADON) #81 on 01/22/16 at 10:02 A.M. revealed she discussed Resident #28 ' s behaviors during the last Quality Assurance meeting. She stated she asked what they were going to do about Resident #28's physical behaviors to others and they stated they were working on it. She further stated the facility was not capable of managing a resident with physical aggression to others, whether it was a result of medical problems or behavioral issues. She stated Resident #28 attacks the innocent and not the residents who would protect themselves. On 01/22/16 at 2:25 P.M., Medical Director (MD) #1 was interviewed via telephone. MD #1 was asked if he was aware of Resident #28's physical abuse to other residents. He stated he was aware she had attacked other residents and stated he had sent her to the emergency room three times and spoke to the emergency room doctor about getting her to a psychiatric hospital. He stated the emergency room just ends up sending her back and the resident needs psychiatric care where they can use restraints on her. 2. Review of Resident #18's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's comprehensive assessment dated [DATE] revealed the resident had moderate cognitive impairment. The resident had no physical behaviors to others and was totally dependent on staff for bed mobility, transferring, dressing, toileting, and personal hygiene. Interview with Resident #18 on 01/19/16 at 11:57 A.M. revealed some of the STNA staff was nasty and rude with her. She stated they holler at her. Review of a facility SRI and investigation dated 08/13/15 regarding verbal abuse of Resident #18 revealed there was a report from staff that Resident #18 stated STNA #106 had spoken mean to her and the resident did not want STNA #106 assigned to her care anymore. STNA #106 was immediately suspended pending investigation. The facility indicated the resident did not like the STNA ' s tone and did not want her assigned to her care. The facility found the allegation to be unsubstantiated. STNA #106 was provided customer service in-service by the DON which included body language and voice tone. A review of the facility investigation of the incident revealed Resident #18's roommate was interviewed and stated STNA #106 and another staff member say weird things to Resident #18, not right things and yell at her all the time, it hurts my feelings for her but nothing other than that. LPN #77 wrote a witness statement indicating Resident #18 was yelling out for help, crying, and stating STNA #106 was abusing her. The resident stated STNA #106 shut her door and would not empty her urinary catheter bag, which was full. LPN #77 noted resident's urinary catheter bag contained 1000 plus cubic centimeters (cc) of urine in it and LPN #77 emptied the urinary catheter bag. The resident again stated STNA #106 was abusing her and yells at her and shuts her door when the resident wants it open. The resident further stated STNA #106 threatens her, saying if she does not do something she will shut her door or she will make her get up. She told LPN #77 she was scared. Interview with STNA #101 on 01/20/16 at 6:20 P.M. revealed she has worked with STNA #106 for approximately a month and a half. She stated she has reported STNA #106 to the nurse every time she has worked with her as she is very verbally abusive to a couple of the residents. She has seen STNA #106 stand at Resident #18's door and yell at her. She stated she stands at the door and yells at her as she is not supposed to work with Resident #18. She has reported this to LPN #74. The nurse has never removed STNA #106 from the floor. Review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #5's annual comprehensive assessment dated [DATE] revealed the resident was alert and oriented. The resident is independent with bed mobility, transfers, and walking in her room. The resident requires supervision for personal hygiene. There was no pertinent information with regards to resident abuse found during record review. Interview with Resident #5 on 01/19/16 at 4:02 P.M. revealed STNA #106 treats him badly when brushing his teeth. He stated she grabs his hand and applies pressure, making his gums bleed. He also stated she presses on his head and he cannot stand STNA #106. He stated the DON told STNA #106 not to interact with him anymore so he doesn't have to worry about her anymore. He thought this happened a couple months ago. Interview with the DON on 01/22/16 at 10:40 A.M. revealed she talks to Resident #5 all the time and did not consider this an allegation of abuse and therefore it was not investigated or reported to the Ohio Department of Health. Interview with Staff #112 on 01/22/16 at 3:10 P.M. revealed when she was working with Resident #5, he stated STNA #106 had brushed his teeth too hard and made his gums bleed. Staff #112 stated she reported this to the DON one to two weeks ago. Review of Resident #44's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #43's comprehensive assessment dated [DATE] revealed the resident was moderately cognitively impaired, was extensive assist of one person for bed mobility and transfers and total dependent of one staff for personal hygiene. He had no behaviors. There was no pertinent information with regards to resident abuse found during record review. The resident was not interviewable. Interview on 01/19/16 at 11:25 A.M. with Resident #12 revealed STNA #106 was verbally abusive to residents, yelling abusively and cursing at them, specifically Resident #44. She stated she has reported this to the DON a couple times and it has been discussed at Resident Council and even brought the DON in to the meeting and told her about STNA #106. During a subsequent interview with the resident on 01/20/16 at 3:44 P.M. with LPN # 86 present, the resident stated STNA #106 went in Resident #44's room and yelled at the top of her lungs for him to shut up and slammed his door hard last evening (01/18/16). She stated Resident #44 was making the humming noises he always makes. Interview with STNA #10

Based on observation, medical record review, staff and resident interviews, review of facility Self-Reported Incidents (SRI) and subsequent investigations, review of a police report, hospital documentation, Resident Council meeting minutes, the facility's Bureau of Criminal Investigation log, employee personnel records, and review of the facility's abuse policy, the facility failed to ensure residents were protected from physical abuse and harm by Resident #28. This resulted in Immediate Jeopardy for five residents (#6, #12, #22, #24 and #49) who were physically abused by Resident #28. In addition, the facility failed to ensure residents were protected from physical and verbal abuse by State tested Nursing Assistant (STNA) #106. This resulted in Immediate Jeopardy for three residents (#5, #18 and #44) who were physically and/or verbally abused by STNA #106. This affected eight (#5, #6, #12, #18, #22, #24, #44 and #49) of nine residents reviewed for abuse and had the potential to affect all 40 residents residing in the facility. On 01/21/16 at 12:47 P.M., the Administrator, Director of Nursing (DON), Corporate Nurse #110 and Corporate Nurse #111 were notified Immediate Jeopardy began on 08/05/15 when Resident #49 was punched repeatedly in the face by Resident #28 and received a bruise to her forehead. On 11/11/15, Resident #28 assaulted Resident #24 causing multiple bleeding scratches to the resident's face. On 12/31/15, Resident #28 struck Resident #6, unprovoked, in the side of her face. On 01/10/16, Resident #28 struck Resident #22 in the face resulting in a laceration to the resident's left cheek. This assault resulted in Resident #22 being sent to the emergency room for evaluation and treatment. She was diagnosed with [REDACTED]. On 01/17/16, Resident #12 was attacked by Resident #28 causing bruising to her arms bilaterally. Additionally, on 08/13/15, Resident #18 reported verbal abuse from STNA #106, stating she spoke mean to her and did not want her to be her STNA any longer. Resident #5 reported STNA #106 presses on his head and brushes his teeth hard, making his gums bleed. On 01/19/16 it was reported STNA #106 told Resident #44 to shut up, slammed his door, and grabbed his head, forcing his head onto a pillow. The Immediate Jeopardy was removed on 01/21/16 at 2:00 P.M. when Resident #28 was discharged to the hospital for psychiatric care and will not be returning to the facility, and STNA #106 was terminated. The deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 01/24/16 when the facility implemented the following corrective actions: · On 01/20/16 at 3:00 P.M., STNA #106 was suspended and an abuse investigation was initiated. STNA #106 was subsequently terminated from employment on 01/20/16. · On 01/21/16 at 10:38 A.M., the facility placed Resident #28 on one-to-one supervision. · On 01/21/16 at 12:30 P.M., the facility initiated abuse education with all current staff members utilizing the facility abuse policy. 60 of 62 staff were educated by 01/22/16. The two remaining PRN (as needed) staff were informed of the in-service via phone on 01/22/16 and are required to complete the abuse education prior to the start of their next scheduled shift. The Regional Director of Clinical Services provided the training. · On 01/21/16 at 12:45 P.M., the facility Administrator and DON were educated on abuse protection, reporting, investigation and implementing appropriate interventions for behaviors by Regional Director of Clinical Services. · On 01/21/16 at 2:00 P.M., Resident #28 was transferred to the hospital for psychiatric care and will not be returning to the facility. · On 01/21/16, the facility Regional Director of Clinical Services reviewed all residents' medical records to identify residents with aggressive behaviors to ensure behavior interventions were appropriate and in place. · On 01/21/16, the facility Regional Director of Clinical Services completed interviews with all 38 current residents regarding abuse utilizing the Centers for Medicare and Medicaid Services (CMS) resident interview and observation tool. There was no further indication of abuse. · On 01/21/16, the facility's Regional Director of Clinical Services provided in-service education to Business Office Manager (BOM) #110 regarding requirements for background checks. · On 01/21/16 at 3:00 P.M., BOM #110 audited all employee files to ensure background checks were completed. No further issues were identified. · On 01/24/16, Licensed Practical Nurse (LPN) #85 and #113, and STNA #95, #98, and #100 were interviewed and were able to accurately articulate the facility abuse policy. · Corporate Nurse #110 or designee will audit background check logs, behavior documentation, and abuse allegations/investigations weekly for three months. All findings will be reported to the Quality Assurance Committee on a quarterly basis. Findings include: 1. Review of the medical record for Resident #28 revealed she was admitted to the facility on [DATE]. Medical [DIAGNOSES REDACTED]. Review of Resident #28's psychiatric consultation progress note dated 06/12/15 revealed the resident was having pseudo [MEDICAL CONDITION]. A psychiatric consultation progress note dated 09/22/15 revealed the resident fakes [MEDICAL CONDITION] per staff and was experiencing physical aggression. A psychiatric consultation progress note dated 12/22/15 also revealed staff thinks she fakes [MEDICAL CONDITION] and the resident was experiencing impulsivity. A physician progress notes [REDACTED]. Review of the resident's comprehensive assessment dated [DATE] identified the resident as having moderate cognitive impairment. The resident was assessed as having physical and verbal behaviors toward others. She was independent for her activities of daily living and required supervision for locomotion and walking in the corridor. Review of an emergency room visit dated 12/31/15 revealed the resident's [DIAGNOSES REDACTED]. Review of an emergency room visit dated 01/18/16 revealed a review of Resident #28's medical record did not indicate any grand mal [MEDICAL CONDITION] activity, any tonic-clonic activity or change of mental status, any fever or chills, any inability to take oral medications, or any patient complaints. No behavioral disturbances were noted while in the emergency room . Review of the nursing notes revealed multiple entries indicating aggressive behavior. On 08/25/15, it was documented the nurse entered Resident #28's room and the resident was throwing her arms up in the air and yelling. Resident #28 did not respond to this nurse's questions and continued to bump into the nurse. Resident #28 then started moving boxes and throwing items around her room. Resident #28 refused medications and again slammed her body into the nurse, causing the nurse to stumble. On 08/26/15, the resident was sitting in the front hall common area coughing obsessively and was refusing to cover her mouth. The nurse attempted to educate the resident on the importance of preventing the spread of germs. The resident punched the nurse in the right eye several times and scratched her face. On 09/30/15, the resident was informed Activity Director (AD) #60 would be riding along with her to an appointment. The resident began yelling that (expletive) ain't taking me anywhere she won't take me any other time and she ain't taking me now. Staff stated they would send another staff member. AD #60 walked near Resident #28 to get the snack cart and the resident called her an expletive and hit AD #60 in the left side of her face with her casted hand. On 10/30/15 the resident was in the activities room for a Halloween party with multiple other residents. Resident #28 began to scream and flap her arms around in the air in a windmill motion and cleared the snack table in the activity room. She was redirected and stopped the [MEDICAL CONDITION] activity. No signs or symptoms of an actual [MEDICAL CONDITION] were noted. On 12/09/15 the resident was in the therapy room and became upset with the therapist and began faking a [MEDICAL CONDITION] by throwing her arms around in a windmill motion and picking items up off the table and throwing them at the therapist. Also on 12/09/15, while being introduced to her new roommate and roommate's family she began screaming, moaning, and throwing her arms around as if having a [MEDICAL CONDITION]. This scared the roommate and family to the point of tears. Resident #28 did this repeatedly until the roommate was moved to a different room. Review of Resident #49's medical record revealed she was admitted on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. A review of the resident's comprehensive assessment dated [DATE] revealed she had mild cognitive impairment, experienced delusions, had no physical behaviors to others but did have verbal behaviors to others. The resident was independent or required supervision only for all care. Review of nursing notes dated 08/05/15 described Resident #28 getting up and hitting Resident #49 repeatedly in the face with a closed fist. This resulted in a bruise to Resident #49's forehead and neurological checks were initiated. Resident #28 was placed on one-to-one observation until calm and then fifteen minute checks for 72 hours for aggressive behavior. Review of the facility's SRI dated 08/05/15 regarding this incident revealed Resident #28 and #49 were involved in a verbal altercation, staff attempted to intervene, and Resident #28 got up and ran over to Resident #49 and hit her in the face. Resident #28 subsequently received a medication change. The facility concluded abuse was unsubstantiated as they were unable to substantiate an attempt to do harm. Review of Resident #24's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. A review of the resident's comprehensive assessment dated [DATE] revealed severely impaired cognition. The resident experienced verbal behaviors to others, but no physical behaviors to others. He was independent or required supervision for all care. Review of the nursing notes revealed a late entry for 11/11/15 dated 11/12/15 indicating Resident #24 was found on the floor with Resident #28 standing over him. He had multiple bleeding scratches noted. Review of the facility's SRI dated 11/10/15 regarding this incident revealed Resident #28 stated she hit Resident #24. It further stated both residents were assessed for injuries and none were noted. Resident #28 was placed on one-to-one supervision until she was sent to the emergency room for a psychiatric evaluation. The emergency room immediately sent Resident #28 right back to the facility and she was placed on fifteen minute checks for 72 hours. Resident #24 was placed on every fifteen minute checks. The facility concluded abuse was unsubstantiated as they were unable to substantiate intent to do harm. Review of Resident #6's medical record revealed the resident was admitted [DATE]. [DIAGNOSES REDACTED]. Review of Resident #6's comprehensive assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident is supervised for transfers, requires limited assistance of one staff for personal hygiene, dressing and bed mobility. Review of Resident #6's nursing progress note dated 12/31/15 at 4:34 P.M. revealed Resident #6 attended a New Year's Eve Party in the activity room. Resident #28 started swinging her arms and hit Resident #6 in the face and the resident was upset. Review of a nursing note in Resident #28's medical record revealed Resident #28 was at the New Year's Eve party in the activity room and, unprovoked, began swinging her arms around and punched Resident #6 in the face. Review of a facility SRI dated 12/31/15 regarding the incident revealed Resident #28 began to have [MEDICAL CONDITION] type activity of flailing of arms over her head, at which time Resident #28 inadvertently struck Resident #6 on the side of the face. The facility did not substantiate abuse as they felt Resident #28 stuck Resident #6 as a result of uncontrollable involuntary movements/[MEDICAL CONDITION] type activity. Resident #28 was sent to the hospital emergency room for evaluation, then returned to the facility and placed on fifteen minute checks. Activities were moved to the dining area to keep a three foot distance between residents. Review of facility witness statements revealed AD #60 stated Resident #28 started flailing her arms, hitting Resident #6 in the side of her face. Resident #28 was told to stop and she did so and was told to leave the area. Review of Resident #22's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's comprehensive assessment dated [DATE] revealed her cognition was moderately impaired. She required extensive assist for transferring, toileting, and personal hygiene and limited assistance for bed mobility and dressing. Review of Resident #22's nursing notes dated 01/10/16 revealed the resident yelled you (expletive) from her room. Upon walking to the room, LPN #85 saw her sitting in her room in her wheelchair with a bleeding laceration to her left cheek. Resident #28 was standing a few feet in front of Resident #22 and said I told you not to yell help. The nurse applied pressure and a dressing to Resident #22's face to stop the bleeding. LPN #85 told Resident #28 you cannot hit people to which she replied She deserved it. Resident #22 was sent to the emergency room for evaluation and treatment of [REDACTED]. Neurological checks were restarted. Review of Resident #28's nursing notes revealed she was placed on one-to-one until removed from the facility for a psychiatric evaluation. Resident #28 was transported to the emergency room at 7:48 P.M. and returned to the facility with no further orders at 11:45 P.M. One-to-one supervision was resumed until 01/11/16 at 11:45 A.M. She was then placed on every fifteen minute checks and placed in a private room. Review of a facility SRI dated 01/10/16 regarding the incident revealed Resident #22 was involved in a verbal altercation with Resident #28 which led to Resident #28 striking Resident #22 on the face. There were no witnesses to the incident. The facility did not identify any injuries in the SRI. The facility determined abuse was not substantiated. A police report dated 01/10/16 regarding Resident #28 was reviewed. The report documented Resident #28 hit Resident #22 in the face causing injury resulting in Resident #22's transport to the emergency room . The facility advised the officer that Resident #28 was not mentally stable and had a history of [REDACTED]. Resident #22 was interviewed on 01/20/16 at 3:30 P.M. She stated Resident #28 hit her in the face. She further stated she is scared of her and does not want to be around her. The resident was observed with steri-strips under her left eye. Review of Resident #12's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's comprehensive assessment dated [DATE] revealed the resident had no impairment in cognition and no verbal or physical behaviors to others. Resident #12 was independent to limited assistance for all care. Review of Resident #12's nursing notes dated 01/17/16 revealed an entry from Registered Nurse (RN) #90 indicating the resident was threatened with physical harm in her room by Resident #28 who was displaying [MEDICAL CONDITION] activity. Resident #12 stated Resident #28 wanted to tip her out of her wheelchair and has tried to before. Review of the facility SRI dated 01/17/16 revealed Resident #12 reported that after a few minutes of talking with Resident #28 in Resident #12's room, Resident #28 became quiet and started flailing her arms about and knocking items off of the table. Resident #12 then alleged Resident #28 grabbed her wheelchair and then her arms, shaking her. Resident #12 yelled out and staff intervened immediately separating the two residents. Staff led Resident #28 to the lobby and provided one-to-one supervision until transport to the emergency room for evaluation of continuous [MEDICAL CONDITION] activity. No injuries were reported in the SRI. The facility did not substantiate abuse documenting unable to establish intent to do harm on the part of Resident #28 or if she was suffering a [MEDICAL CONDITION]. Upon return from the hospital, Resident #28 was placed on one-to-one supervision until such time the facility was able to safely discharge to another healthcare facility. On 01/22/16, Resident #28 was discharged from facility. Review of a facility witness statement written by RN #90 revealed he heard Resident #12 yelling stop it. He opened the door to Resident #12's room and found Resident #28 physically grabbing Resident #12 and acting like she wanted to injure her. RN #90 pulled Resident #28 off of Resident #12, who was in her wheelchair. He further stated it took a lot of exertion on his part to pull her off and Resident #28 kept trying to grab Resident #12. A police report dated 01/19/16 revealed Resident #28 was accused of physically attacking Resident #12. Upon speaking with Resident #28's nurse, the police officer was advised the resident suffers from [MEDICAL CONDITION] disorder and [MEDICAL CONDITION]. Resident #28 has a history of violent outbursts against the staff and residents at the care center. Interview with Resident #12 on 01/19/16 at 11:16 A.M. revealed Resident #28 came in her room on Sunday, 01/17/16 in the evening, and slammed her wheelchair into the bathroom door and then grabbed her by the arms and squeezed her very hard. She stated she had to scream loudly for help and a nurse came running in to help her. She stated she called the sheriff to report the assault. She also stated she talked to the DON on Monday 01/18/16 about the incident. Observation of the resident's arms did reveal bruises on her right and left upper arms. She stated she is scared of Resident #28 and so are other residents. Interview and observation with LPN #86 on 01/20/16 at 3:44 P.M. verified Resident #12 had four small round bruises on her upper right arm and three small bruises on her upper left arm. LPN #86 was not aware of these bruises and stated they were not monitoring them. Interview with STNA #101 on 01/20/16 at 6:20 P.M. revealed she assisted in separating Resident #12 and #28. She stated Resident #28 was squeezing Resident #12's arms. She also stated she would be the only STNA working 01/20/16 and therefore cannot observe Resident #28 every fifteen minutes as she is supposed to. She stated there are three smoke breaks that last a half hour each so she cannot visualize Resident #28 during these smoke breaks. She stated she has been unable to complete the fifteen minute checks every time she is the only STNA working the floor. Interview with LPN #76 on 01/20/16 at 3:10 P.M. revealed Resident #28 has a long history of becoming physically abusive. She stated the facility has sent her out multiple times to the hospital trying to seek other placement. She further stated she does have [MEDICAL CONDITION]; however, she also fakes [MEDICAL CONDITION] activity. LPN #76 stated her physical aggression is mostly when she feels other residents are getting attention. Interview with LPN #86 on 01/20/16 at 3:44 P.M. revealed Resident #28 does have [MEDICAL CONDITION], however, when she strikes other residents, it is an adverse behavior and not a [MEDICAL CONDITION]. LPN #86 stated they placed Resident #28 on fifteen minute checks and they try to keep her busy to keep the other residents safe. Interview with AD #60 on 01/20/16 at 3:57 P.M. revealed the resident has been physically assaultive during activities when she does not feel she is the center of attention. She stated her corporate person told her to try to keep Resident #28 three feet away from the other residents. She did move the activities to the dining room for more space and the resident was still assaultive. She stated all the residents seem to be afraid of Resident #28 and they have stated this in Resident Council. Observation of Resident #28 at this time revealed she was in the small activities room sitting closer than three feet from several residents. AD #60 verified the resident was not currently being kept three feet from other residents during activities. Interview with the DON on 01/20/16 at 5:30 P.M. revealed she felt the bulk of Resident #28's incidents occurred during [MEDICAL CONDITION] activity. She further stated the facility has tried to get someone to diagnose her with pseudo [MEDICAL CONDITION] but have not been able to. When asked what the facility has implemented to protect the other residents, she stated they gave Resident #28 her own room and placed her on every fifteen minute checks. The facility has also attempted to obtain other placement for the resident, however they have had no success obtaining placement. She also stated the activities had been moved to the dining room to keep more distance between Resident #28 and the other residents. She stated she was unaware Resident #28 was in the small activities room on 01/20/16. LPN #74 was interviewed on 01/20/16 at 6:23 P.M. She stated Resident #28 has to be monitored because she goes after other residents and acts as if she is having a convulsion episode. She stated if she tells her to stop and pays attention to her, she will generally stop. She stated the STNA's are responsible for the fifteen minute checks of the resident. On 01/21/16 at 10:38 A.M. the facility notified the survey team that Resident #28 was placed on one-to-one supervision. On 01/21/16 at 11:00 A.M., Resident #28 was again observed in the small activity room with other residents present. There was not a three foot distance between Resident #28 and the other residents. Interview with Social Service Coordinator (SSC) #111 on 01/21/16 at 11:15 A.M. revealed Resident #42 shares a bathroom with Resident #28 and has complained to SSC #111 of Resident #28 giving her queer looks and stated she feels intimidated. SSC #111 further stated Resident #28 is so unpredictable she does not feel one-to-one supervision would stop her aggressive behavior. She does not feel they can manage her behaviors and keep other residents safe. Surveyor observation on 01/21/16 at 4:55 P.M. revealed Resident #28 sitting in the dining room at a table with a male resident. STNA #109 was conducting the one-to-one supervision for Resident #28. She was sitting three tables away from the resident. STNA #109 stated she had just begun employment at the facility today and was not told how far she had to be from Resident #28. She verified the resident was not in arm's length of her. Interview and observation with the Administrator on 01/21/16 at 5:11 P.M. revealed Resident #28 continued to sit at a table in the dining room with a male resident. STNA #109 was passing dinner trays to other residents. The Administrator stated as long as STNA #109 could see the resident, this was acceptable. Observation of Resident #28 on 01/21/16 at 5:40 P.M. revealed she was being monitored one-to-one by STNA #109. Interview with Assistant Director of Nursing (ADON) #81 on 01/22/16 at 10:02 A.M. revealed she discussed Resident #28 ' s behaviors during the last Quality Assurance meeting. She stated she asked what they were going to do about Resident #28's physical behaviors to others and they stated they were working on it. She further stated the facility was not capable of managing a resident with physical aggression to others, whether it was a result of medical problems or behavioral issues. She stated Resident #28 attacks the innocent and not the residents who would protect themselves. On 01/22/16 at 2:25 P.M., Medical Director (MD) #1 was interviewed via telephone. MD #1 was asked if he was aware of Resident #28's physical abuse to other residents. He stated he was aware she had attacked other residents and stated he had sent her to the emergency room three times and spoke to the emergency room doctor about getting her to a psychiatric hospital. He stated the emergency room just ends up sending her back and the resident needs psychiatric care where they can use restraints on her. 2. Review of Resident #18's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's comprehensive assessment dated [DATE] revealed the resident had moderate cognitive impairment. The resident had no physical behaviors to others and was totally dependent on staff for bed mobility, transferring, dressing, toileting, and personal hygiene. Interview with Resident #18 on 01/19/16 at 11:57 A.M. revealed some of the STNA staff was nasty and rude with her. She stated they holler at her. Review of a facility SRI and investigation dated 08/13/15 regarding verbal abuse of Resident #18 revealed there was a report from staff that Resident #18 stated STNA #106 had spoken mean to her and the resident did not want STNA #106 assigned to her care anymore. STNA #106 was immediately suspended pending investigation. The facility indicated the resident did not like the STNA ' s tone and did not want her assigned to her care. The facility found the allegation to be unsubstantiated. STNA #106 was provided customer service in-service by the DON which included body language and voice tone. A review of the facility investigation of the incident revealed Resident #18's roommate was interviewed and stated STNA #106 and another staff member say weird things to Resident #18, not right things and yell at her all the time, it hurts my feelings for her but nothing other than that. LPN #77 wrote a witness statement indicating Resident #18 was yelling out for help, crying, and stating STNA #106 was abusing her. The resident stated STNA #106 shut her door and would not empty her urinary catheter bag, which was full. LPN #77 noted resident's urinary catheter bag contained 1000 plus cubic centimeters (cc) of urine in it and LPN #77 emptied the urinary catheter bag. The resident again stated STNA #106 was abusing her and yells at her and shuts her door when the resident wants it open. The resident further stated STNA #106 threatens her, saying if she does not do something she will shut her door or she will make her get up. She told LPN #77 she was scared. Interview with STNA #101 on 01/20/16 at 6:20 P.M. revealed she has worked with STNA #106 for approximately a month and a half. She stated she has reported STNA #106 to the nurse every time she has worked with her as she is very verbally abusive to a couple of the residents. She has seen STNA #106 stand at Resident #18's door and yell at her. She stated she stands at the door and yells at her as she is not supposed to work with Resident #18. She has reported this to LPN #74. The nurse has never removed STNA #106 from the floor. Review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #5's annual comprehensive assessment dated [DATE] revealed the resident was alert and oriented. The resident is independent with bed mobility, transfers, and walking in her room. The resident requires supervision for personal hygiene. There was no pertinent information with regards to resident abuse found during record review. Interview with Resident #5 on 01/19/16 at 4:02 P.M. revealed STNA #106 treats him badly when brushing his teeth. He stated she grabs his hand and applies pressure, making his gums bleed. He also stated she presses on his head and he cannot stand STNA #106. He stated the DON told STNA #106 not to interact with him anymore so he doesn't have to worry about her anymore. He thought this happened a couple months ago. Interview with the DON on 01/22/16 at 10:40 A.M. revealed she talks to Resident #5 all the time and did not consider this an allegation of abuse and therefore it was not investigated or reported to the Ohio Department of Health. Interview with Staff #112 on 01/22/16 at 3:10 P.M. revealed when she was working with Resident #5, he stated STNA #106 had brushed his teeth too hard and made his gums bleed. Staff #112 stated she reported this to the DON one to two weeks ago. Review of Resident #44's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #43's comprehensive assessment dated [DATE] revealed the resident was moderately cognitively impaired, was extensive assist of one person for bed mobility and transfers and total dependent of one staff for personal hygiene. He had no behaviors. There was no pertinent information with regards to resident abuse found during record review. The resident was not interviewable. Interview on 01/19/16 at 11:25 A.M. with Resident #12 revealed STNA #106 was verbally abusive to residents, yelling abusively and cursing at them, specifically Resident #44. She stated she has reported this to the DON a couple times and it has been discussed at Resident Council and even brought the DON in to the meeting and told her about STNA #106. During a subsequent interview with the resident on 01/20/16 at 3:44 P.M. with LPN # 86 present, the resident stated STNA #106 went in Resident #44's room and yelled at the top of her lungs for him to shut up and slammed his door hard last evening (01/18/16). She stated Resident #44 was making the humming noises he always makes. Interview with STNA #101 on 01/20/16 at 6:20 P.M. revealed she has worked with STNA #106 for approximately a month and a half. She stated she has reported STNA #106 to the nurse every time she has worked with her as she is very verbally abusive to a couple of the residents. She has seen STNA #106 grab Resident #44 by his head and push him back on the pillow and hold his head down on the pillow. She also reported she yells at Resident #44 stating he needs to be back in prison. She has reported this to LPN #74 and the nurse has never removed STNA #106 from the floor. Interview with STNA #92 on 01/20/16 at 3:08 P.M. revealed there are

Based on observation, medical record review, staff and resident interviews, review of facility Self-Reported Incidents (SRIs) and subsequent investigations, review of a police report, hospital documentation, Resident Council meeting minutes, the facility ' s Bureau of Criminal Investigation log, employee personnel records, and review of the facility ' s abuse policy, the facility failed to implement their abuse policy when incidents of suspected physical and verbal abuse to residents were not immediately reported to the administrator of the facility, an initiation of a thorough investigation was not started, and residents were not protected from further potential physical abuse and harm by Resident #28. This resulted in Immediate Jeopardy for five residents (#6, #12, #22, #24, and #49) who were physically abused by Resident #28. In addition, the facility failed to ensure allegations of staff to resident abuse were immediately reported to the administrator of the facility, thoroughly investigated, and subsequently ensure residents were protected from further potential physical and verbal abuse by State tested Nursing Assistant (STNA) #106. This resulted in Immediate Jeopardy for three residents (#5, #18, and #44) who were physically and/or verbally abused by STNA #106. Consequently, this resulted in Immediate Jeopardy for eight (#5, #6, #12, #18, #22, #24, #44, #49) of nine residents reviewed for abuse and 31 additional residents (#1, #2, #3, #6, #7, #8, #9, #10, #13, #14, #15, #16, #17, #19, #21, #23, #26, #27, #29, #30, #31, #32, #33, #34, #35, #37, #38, #39, #41, #42, #43, #47 and #48) residing in the facility. On 01/21/16 at 12:47 P.M., the Administrator, Director of Nursing (DON), Corporate Nurse #110 and Corporate Nurse #111 were notified Immediate Jeopardy began on 08/05/15 when Resident #49 was punched repeatedly in the face by Resident #28 and received a bruise to her forehead. On 11/11/15, Resident #28 assaulted Resident #24 causing multiple bleeding scratches to the resident's face. On 12/31/15, Resident #28 struck Resident #6, unprovoked, in the side of her face. On 01/10/16, Resident #28 struck Resident #22 in the face resulting in a laceration to the resident's left cheek. This assault resulted in Resident #22 being sent to the emergency room for evaluation and treatment. She was diagnosed with [REDACTED]. On 01/17/16, Resident #12 was attacked by Resident #28 causing bruising to her arms bilaterally. Additionally, on 08/13/15, Resident #18 reported verbal abuse from STNA #106, stating she spoke mean to her and did not want her to be her STNA any longer. Resident #5 reported STNA #106 presses on his head and brushes his teeth hard, making his gums bleed. On 01/19/16 it was reported STNA #106 told Resident #44 to shut up, slammed his door, and grabbed his head, forcing his head onto a pillow. The Immediate Jeopardy was removed on 01/21/16 at 2:00 P.M. when Resident #28 was discharged to the hospital for psychiatric care and will not be returning to the facility, and STNA #106 was terminated. The deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 01/24/16 when the facility implemented the following corrective actions: · On 01/20/16 at 3:00 P.M., STNA #106 was suspended and an abuse investigation was initiated. STNA #106 was subsequently terminated from employment on 01/20/16. · On 01/21/16 at 10:38 A.M., the facility placed Resident #28 on one-to-one supervision. · On 01/21/16 at 12:30 P.M., the facility initiated abuse education with all current staff members utilizing the facility abuse policy. 60 of 62 staff were educated by 01/22/16. The two remaining PRN (as needed) staff were informed of the in-service via phone on 01/22/16 and are required to complete the abuse education prior to the start of their next scheduled shift. The Regional Director of Clinical Services provided the training. · On 01/21/16 at 12:45 P.M., the facility Administrator and DON were educated on abuse protection, reporting, investigation and implementing appropriate interventions for behaviors by Regional Director of Clinical Services. · On 01/21/16 at 2:00 P.M., Resident #28 was transferred to the hospital for psychiatric care and will not be returning to the facility. · On 01/21/16, the facility Regional Director of Clinical Services reviewed all residents' medical records to identify residents with aggressive behaviors to ensure behavior interventions were appropriate and in place. · On 01/21/16, the facility Regional Director of Clinical Services completed interviews with all 38 current residents regarding abuse utilizing the Centers for Medicare and Medicaid Services (CMS) resident interview and observation tool. There was no further indication of abuse. · On 01/21/16, the facility's Regional Director of Clinical Services provided in-service education to Business Office Manager (BOM) #110 regarding requirements for background checks. · On 01/21/16 at 3:00 P.M., BOM #110 audited all employee files to ensure background checks were completed. No further issues were identified. · On 01/24/16, Licensed Practical Nurse (LPN) #85 and #113, and STNA #95, #98, and #100 were interviewed and were able to accurately articulate the facility abuse policy. · Corporate Nurse #110 or designee will audit background check logs, behavior documentation, and abuse allegations/investigations weekly for three months. All findings will be reported to the Quality Assurance Committee on a quarterly basis. Findings include: 1. Review of the medical record for Resident #28 revealed she was admitted to the facility on [DATE]. Medical [DIAGNOSES REDACTED]. Review of Resident #28's psychiatric consultation progress note dated 06/12/15 revealed the resident was having pseudo [MEDICAL CONDITION]. A psychiatric consultation progress note dated 09/22/15 revealed the resident fakes [MEDICAL CONDITION] per staff and was experiencing physical aggression. A psychiatric consultation progress note dated 12/22/15 also revealed staff thinks she fakes [MEDICAL CONDITION] and the resident was experiencing impulsivity. A physician progress notes [REDACTED]. Review of the resident's comprehensive assessment dated [DATE] identified the resident as having moderate cognitive impairment. The resident was assessed as having physical and verbal behaviors toward others. She was independent for her activities of daily living and required supervision for locomotion and walking in the corridor. Review of an emergency room visit dated 12/31/15 revealed the resident's [DIAGNOSES REDACTED]. Review of an emergency room visit dated 01/18/16 revealed a review of Resident #28's medical record did not indicate any grand mal [MEDICAL CONDITION] activity, any tonic-clonic activity or change of mental status, any fever or chills, any inability to take oral medications, or any patient complaints. No behavioral disturbances were noted while in the emergency room . Review of the nursing notes revealed multiple entries indicating aggressive behavior. On 08/25/15, it was documented the nurse entered Resident #28's room and the resident was throwing her arms up in the air and yelling. Resident #28 did not respond to this nurse's questions and continued to bump into the nurse. Resident #28 then started moving boxes and throwing items around her room. Resident #28 refused medications and again slammed her body into the nurse, causing the nurse to stumble. On 08/26/15, the resident was sitting in the front hall common area coughing obsessively and was refusing to cover her mouth. The nurse attempted to educate the resident on the importance of preventing the spread of germs. The resident punched the nurse in the right eye several times and scratched her face. On 09/30/15, the resident was informed Activity Director (AD) #60 would be riding along with her to an appointment. The resident began yelling that (expletive) ain't taking me anywhere she won't take me any other time and she ain't taking me now. Staff stated they would send another staff member. AD #60 walked near Resident #28 to get the snack cart and the resident called her an expletive and hit AD #60 in the left side of her face with her casted hand. On 10/30/15 the resident was in the activities room for a Halloween party with multiple other residents. Resident #28 began to scream and flap her arms around in the air in a windmill motion and cleared the snack table in the activity room. She was redirected and stopped the [MEDICAL CONDITION] activity. No signs or symptoms of an actual [MEDICAL CONDITION] were noted. On 12/09/15 the resident was in the therapy room and became upset with the therapist and began faking a [MEDICAL CONDITION] by throwing her arms around in a windmill motion and picking items up off the table and throwing them at the therapist. Also on 12/09/15, while being introduced to her new roommate and roommate's family she began screaming, moaning, and throwing her arms around as if having a [MEDICAL CONDITION]. This scared the roommate and family to the point of tears. Resident #28 did this repeatedly until the roommate was moved to a different room. Review of Resident #49's medical record revealed she was admitted on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. A review of the resident's comprehensive assessment dated [DATE] revealed she had mild cognitive impairment, experienced delusions, had no physical behaviors to others but did have verbal behaviors to others. The resident was independent or required supervision only for all care. Review of nursing notes dated 08/05/15 described Resident #28 getting up and hitting Resident #49 repeatedly in the face with a closed fist. This resulted in a bruise to Resident #49's forehead and neurological checks were initiated. Resident #28 was placed on one-to-one observation until calm and then fifteen minute checks for 72 hours for aggressive behavior. Review of the facility's SRI dated 08/05/15 regarding this incident revealed Resident #28 and #49 were involved in a verbal altercation, staff attempted to intervene, and Resident #28 got up and ran over to Resident #49 and hit her in the face. Resident #28 subsequently received a medication change. The facility concluded abuse was unsubstantiated as they were unable to substantiate an attempt to do harm. Review of Resident #24's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. A review of the resident's comprehensive assessment dated [DATE] revealed severely impaired cognition. The resident experienced verbal behaviors to others, but no physical behaviors to others. He was independent or required supervision for all care. Review of the nursing notes revealed a late entry for 11/11/15 dated 11/12/15 indicating Resident #24 was found on the floor with Resident #28 standing over him. He had multiple bleeding scratches noted. Review of the facility's SRI dated 11/10/15 regarding this incident revealed Resident #28 stated she hit Resident #24. It further stated both residents were assessed for injuries and none were noted. Resident #28 was placed on one-to-one supervision until she was sent to the emergency room for a psychiatric evaluation. The emergency room immediately sent Resident #28 right back to the facility and she was placed on fifteen minute checks for 72 hours. Resident #24 was placed on every fifteen minute checks. The facility concluded abuse was unsubstantiated as they were unable to substantiate intent to do harm. Review of Resident #6's medical record revealed the resident was admitted [DATE]. [DIAGNOSES REDACTED]. Review of Resident #6's comprehensive assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident is supervised for transfers, requires limited assistance of one staff for personal hygiene, dressing and bed mobility. Review of Resident #6's nursing progress note dated 12/31/15 at 4:34 P.M. revealed Resident #6 attended a New Year's Eve Party in the activity room. Resident #28 started swinging her arms and hit Resident #6 in the face and the resident was upset. Review of a nursing note in Resident #28's medical record revealed Resident #28 was at the New Year's Eve party in the activity room and, unprovoked, began swinging her arms around and punched Resident #6 in the face. Review of a facility SRI dated 12/31/15 regarding the incident revealed Resident #28 began to have [MEDICAL CONDITION] type activity of flailing of arms over her head, at which time Resident #28 inadvertently struck Resident #6 on the side of the face. The facility did not substantiate abuse as they felt Resident #28 stuck Resident #6 as a result of uncontrollable involuntary movements/[MEDICAL CONDITION] type activity. Resident #28 was sent to the hospital emergency room for evaluation, then returned to the facility and placed on fifteen minute checks. Activities were moved to the dining area to keep a three foot distance between residents. Review of facility witness statements revealed AD #60 stated Resident #28 started flailing her arms, hitting Resident #6 in the side of her face. Resident #28 was told to stop and she did so and was told to leave the area. Review of Resident #22's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's comprehensive assessment dated [DATE] revealed her cognition was moderately impaired. She required extensive assist for transferring, toileting, and personal hygiene and limited assistance for bed mobility and dressing. Review of Resident #22's nursing notes dated 01/10/16 revealed the resident yelled you (expletive) from her room. Upon walking to the room, LPN #85 saw her sitting in her room in her wheelchair with a bleeding laceration to her left cheek. Resident #28 was standing a few feet in front of Resident #22 and said I told you not to yell help. The nurse applied pressure and a dressing to Resident #22's face to stop the bleeding. LPN #85 told Resident #28 you cannot hit people to which she replied She deserved it. Resident #22 was sent to the emergency room for evaluation and treatment of [REDACTED]. Neurological checks were restarted. Review of Resident #28's nursing notes revealed she was placed on one-to-one until removed from the facility for a psychiatric evaluation. Resident #28 was transported to the emergency room at 7:48 P.M. and returned to the facility with no further orders at 11:45 P.M. One-to-one supervision was resumed until 01/11/16 at 11:45 A.M. She was then placed on every fifteen minute checks and placed in a private room. Review of a facility SRI dated 01/10/16 regarding the incident revealed Resident #22 was involved in a verbal altercation with Resident #28 which led to Resident #28 striking Resident #22 on the face. There were no witnesses to the incident. The facility did not identify any injuries in the SRI. The facility determined abuse was not substantiated. A police report dated 01/10/16 regarding Resident #28 was reviewed. The report documented Resident #28 hit Resident #22 in the face causing injury resulting in Resident #22's transport to the emergency room . The facility advised the officer that Resident #28 was not mentally stable and had a history of [REDACTED]. Resident #22 was interviewed on 01/20/16 at 3:30 P.M. She stated Resident #28 hit her in the face. She further stated she is scared of her and does not want to be around her. The resident was observed with steri-strips under her left eye. Review of Resident #12's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's comprehensive assessment dated [DATE] revealed the resident had no impairment in cognition and no verbal or physical behaviors to others. Resident #12 was independent to limited assistance for all care. Review of Resident #12's nursing notes dated 01/17/16 revealed an entry from Registered Nurse (RN) #90 indicating the resident was threatened with physical harm in her room by Resident #28 who was displaying [MEDICAL CONDITION] activity. Resident #12 stated Resident #28 wanted to tip her out of her wheelchair and has tried to before. Review of the facility SRI dated 01/17/16 revealed Resident #12 reported that after a few minutes of talking with Resident #28 in Resident #12's room, Resident #28 became quiet and started flailing her arms about and knocking items off of the table. Resident #12 then alleged Resident #28 grabbed her wheelchair and then her arms, shaking her. Resident #12 yelled out and staff intervened immediately separating the two residents. Staff led Resident #28 to the lobby and provided one-to-one supervision until transport to the emergency room for evaluation of continuous [MEDICAL CONDITION] activity. No injuries were reported in the SRI. The facility did not substantiate abuse documenting unable to establish intent to do harm on the part of Resident #28 or if she was suffering a [MEDICAL CONDITION]. Upon return from the hospital, Resident #28 was placed on one-to-one supervision until such time the facility was able to safely discharge to another healthcare facility. On 01/22/16, Resident #28 was discharged from facility. Review of a facility witness statement written by RN #90 revealed he heard Resident #12 yelling stop it. He opened the door to Resident #12's room and found Resident #28 physically grabbing Resident #12 and acting like she wanted to injure her. RN #90 pulled Resident #28 off of Resident #12, who was in her wheelchair. He further stated it took a lot of exertion on his part to pull her off and Resident #28 kept trying to grab Resident #12. A police report dated 01/19/16 revealed Resident #28 was accused of physically attacking Resident #12. Upon speaking with Resident #28's nurse, the police officer was advised the resident suffers from [MEDICAL CONDITION] disorder and [MEDICAL CONDITION]. Resident #28 has a history of violent outbursts against the staff and residents at the care center. Interview with Resident #12 on 01/19/16 at 11:16 A.M. revealed Resident #28 came in her room on Sunday, 01/17/16 in the evening, and slammed her wheelchair into the bathroom door and then grabbed her by the arms and squeezed her very hard. She stated she had to scream loudly for help and a nurse came running in to help her. She stated she called the sheriff to report the assault. She also stated she talked to the DON on Monday 01/18/16 about the incident. Observation of the resident's arms did reveal bruises on her right and left upper arms. She stated she is scared of Resident #28 and so are other residents. Interview and observation with LPN #86 on 01/20/16 at 3:44 P.M. verified Resident #12 had four small round bruises on her upper right arm and three small bruises on her upper left arm. LPN #86 was not aware of these bruises and stated they were not monitoring them. Interview with STNA #101 on 01/20/16 at 6:20 P.M. revealed she assisted in separating Resident #12 and #28. She stated Resident #28 was squeezing Resident #12's arms. She also stated she would be the only STNA working 01/20/16 and therefore cannot observe Resident #28 every fifteen minutes as she is supposed to. She stated there are three smoke breaks that last a half hour each so she cannot visualize Resident #28 during these smoke breaks. She stated she has been unable to complete the fifteen minute checks every time she is the only STNA working the floor. Interview with LPN #76 on 01/20/16 at 3:10 P.M. revealed Resident #28 has a long history of becoming physically abusive. She stated the facility has sent her out multiple times to the hospital trying to seek other placement. She further stated she does have [MEDICAL CONDITION]; however, she also fakes [MEDICAL CONDITION] activity. LPN #76 stated her physical aggression is mostly when she feels other residents are getting attention. Interview with LPN #86 on 01/20/16 at 3:44 P.M. revealed Resident #28 does have [MEDICAL CONDITION], however, when she strikes other residents, it is an adverse behavior and not a [MEDICAL CONDITION]. LPN #86 stated they placed Resident #28 on fifteen minute checks and they try to keep her busy to keep the other residents safe. Interview with AD #60 on 01/20/16 at 3:57 P.M. revealed the resident has been physically assaultive during activities when she does not feel she is the center of attention. She stated her corporate person told her to try to keep Resident #28 three feet away from the other residents. She did move the activities to the dining room for more space and the resident was still assaultive. She stated all the residents seem to be afraid of Resident #28 and they have stated this in Resident Council. Observation of Resident #28 at this time revealed she was in the small activities room sitting closer than three feet from several residents. AD #60 verified the resident was not currently being kept three feet from other residents during activities. Interview with the DON on 01/20/16 at 5:30 P.M. revealed she felt the bulk of Resident #28's incidents occurred during [MEDICAL CONDITION] activity. She further stated the facility has tried to get someone to diagnose her with pseudo [MEDICAL CONDITION] but have not been able to. When asked what the facility has implemented to protect the other residents, she stated they gave Resident #28 her own room and placed her on every fifteen minute checks. The facility has also attempted to obtain other placement for the resident, however they have had no success obtaining placement. She also stated the activities had been moved to the dining room to keep more distance between Resident #28 and the other residents. She stated she was unaware Resident #28 was in the small activities room on 01/20/16. LPN #74 was interviewed on 01/20/16 at 6:23 P.M. She stated Resident #28 has to be monitored because she goes after other residents and acts as if she is having a convulsion episode. She stated if she tells her to stop and pays attention to her, she will generally stop. She stated the STNA's are responsible for the fifteen minute checks of the resident. On 01/21/16 at 10:38 A.M. the facility notified the survey team that Resident #28 was placed on one-to-one supervision. On 01/21/16 at 11:00 A.M., Resident #28 was again observed in the small activity room with other residents present. There was not a three foot distance between Resident #28 and the other residents. Interview with Social Service Coordinator (SSC) #111 on 01/21/16 at 11:15 A.M. revealed Resident #42 shares a bathroom with Resident #28 and has complained to SSC #111 of Resident #28 giving her queer looks and stated she feels intimidated. SSC #111 further stated Resident #28 is so unpredictable she does not feel one-to-one supervision would stop her aggressive behavior. She does not feel they can manage her behaviors and keep other residents safe. Surveyor observation on 01/21/16 at 4:55 P.M. revealed Resident #28 sitting in the dining room at a table with a male resident. STNA #109 was conducting the one-to-one supervision for Resident #28. She was sitting three tables away from the resident. STNA #109 stated she had just begun employment at the facility today and was not told how far she had to be from Resident #28. She verified the resident was not in arm's length of her. Interview and observation with the Administrator on 01/21/16 at 5:11 P.M. revealed Resident #28 continued to sit at a table in the dining room with a male resident. STNA #109 was passing dinner trays to other residents. The Administrator stated as long as STNA #109 could see the resident, this was acceptable. Observation of Resident #28 on 01/21/16 at 5:40 P.M. revealed she was being monitored one-to-one by STNA #109. Interview with Assistant Director of Nursing (ADON) #81 on 01/22/16 at 10:02 A.M. revealed she discussed Resident #28 ' s behaviors during the last Quality Assurance meeting. She stated she asked what they were going to do about Resident #28's physical behaviors to others and they stated they were working on it. She further stated the facility was not capable of managing a resident with physical aggression to others, whether it was a result of medical problems or behavioral issues. She stated Resident #28 attacks the innocent and not the residents who would protect themselves. On 01/22/16 at 2:25 P.M., Medical Director (MD) #1 was interviewed via telephone. MD #1 was asked if he was aware of Resident #28's physical abuse to other residents. He stated he was aware she had attacked other residents and stated he had sent her to the emergency room three times and spoke to the emergency room doctor about getting her to a psychiatric hospital. He stated the emergency room just ends up sending her back and the resident needs psychiatric care where they can use restraints on her. 2. Review of Resident #18's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's comprehensive assessment dated [DATE] revealed the resident had moderate cognitive impairment. The resident had no physical behaviors to others and was totally dependent on staff for bed mobility, transferring, dressing, toileting, and personal hygiene. Interview with Resident #18 on 01/19/16 at 11:57 A.M. revealed some of the STNA staff was nasty and rude with her. She stated they holler at her. Review of a facility SRI and investigation dated 08/13/15 regarding verbal abuse of Resident #18 revealed there was a report from staff that Resident #18 stated STNA #106 had spoken mean to her and the resident did not want STNA #106 assigned to her care anymore. STNA #106 was immediately suspended pending investigation. The facility indicated the resident did not like the STNA ' s tone and did not want her assigned to her care. The facility found the allegation to be unsubstantiated. STNA #106 was provided customer service in-service by the DON which included body language and voice tone. A review of the facility investigation of the incident revealed Resident #18's roommate was interviewed and stated STNA #106 and another staff member say weird things to Resident #18, not right things and yell at her all the time, it hurts my feelings for her but nothing other than that. LPN #77 wrote a witness statement indicating Resident #18 was yelling out for help, crying, and stating STNA #106 was abusing her. The resident stated STNA #106 shut her door and would not empty her urinary catheter bag, which was full. LPN #77 noted resident's urinary catheter bag contained 1000 plus cubic centimeters (cc) of urine in it and LPN #77 emptied the urinary catheter bag. The resident again stated STNA #106 was abusing her and yells at her and shuts her door when the resident wants it open. The resident further stated STNA #106 threatens her, saying if she does not do something she will shut her door or she will make her get up. She told LPN #77 she was scared. Interview with STNA #101 on 01/20/16 at 6:20 P.M. revealed she has worked with STNA #106 for approximately a month and a half. She stated she has reported STNA #106 to the nurse every time she has worked with her as she is very verbally abusive to a couple of the residents. She has seen STNA #106 stand at Resident #18's door and yell at her. She stated she stands at the door and yells at her as she is not supposed to work with Resident #18. She has reported this to LPN #74. The nurse has never removed STNA #106 from the floor. Review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #5's annual comprehensive assessment dated [DATE] revealed the resident was alert and oriented. The resident is independent with bed mobility, transfers, and walking in her room. The resident requires supervision for personal hygiene. There was no pertinent information with regards to resident abuse found during record review. Interview with Resident #5 on 01/19/16 at 4:02 P.M. revealed STNA #106 treats him badly when brushing his teeth. He stated she grabs his hand and applies pressure, making his gums bleed. He also stated she presses on his head and he cannot stand STNA #106. He stated the DON told STNA #106 not to interact with him anymore so he doesn't have to worry about her anymore. He thought this happened a couple months ago. Interview with the DON on 01/22/16 at 10:40 A.M. revealed she talks to Resident #5 all the time and did not consider this an allegation of abuse and therefore it was not investigated or reported to the Ohio Department of Health. Interview with Staff #112 on 01/22/16 at 3:10 P.M. revealed when she was working with Resident #5, he stated STNA #106 had brushed his teeth too hard and made his gums bleed. Staff #112 stated she reported this to the DON one to two weeks ago. Review of Resident #44's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #43's comprehensive assessment dated [DATE] revealed the resident was moderately cognitively impaired, was extensive assist of one person for bed mobility and transfers and total dependent of one staff for personal hygiene. He had no behaviors. There was no pertinent information with regards to resident abuse found during record review. The resident was not interviewable. Interview on 01/19/16 at 11:25 A.M. with Resident #12 revealed STNA #106 was verbally abusive to residents, yelling abusively and cursing at them, specifically Resident #44. She stated she has reported this to the DON a couple times and it has been discussed at Resident Council and even brought the DON in to the meeting and told her about STNA #106. During a subsequent interview with the resident on 01/20/16 at 3:44 P.M. with LPN # 86 present, the resident stated STNA #106 went in Resident #44's room and yelled at the top of her lungs for him to shut up and slammed his door hard last evening (01/18/16). She stated Resident #44 was making the humming noises he always makes. Interview with STNA #101 on 01/20/16 at 6:20 P.M. re

Based on observation, medical record review, review of staffing schedules, resident and staff interviews, the facility failed to provide sufficient and adequate licensed nursing and direct care staff to ensure all residents received the necessary care and services to attain their highest level of well-being. This lack of sufficient and adequate staff resulted in lack of supervision of physically aggressive residents and substandard safety prevention for all residents. This lack of staffing to provide for the safety of residents resulted in not only resident to resident abuse but staff to resident abuse as well. The inadequate staffing levels lead to no accountability of direct care staff treatment of [REDACTED]. This resulted in Immediate Jeopardy for 40 of 40 residents residing in the facility. On 01/22/16 at 4:00 P.M., the Administrator, Director of Nursing (DON) and Regional Vice President were notified Immediate Jeopardy began on 01/11/16 when review of the facility staffing schedules for the dates of 01/11/16 through 01/20/16 revealed an inadequate number of direct care personnel working during the hours of 6:00 P.M. and 6:00 A.M. frequently throughout that time period. In addition to the inadequate number of staff available between those hours, review of the facility's Self-Reported Incidents (SRIs) submitted to the State Agency for October 2015, November 2015, and December 2015 through January 21, 2016 revealed seven of eleven allegations of abuse that were reported occurred between the above identified hours. Furthermore, five of the resident to resident altercations cited in the Immediate Jeopardy abuse citation at Data Tag F223 occurred during that same timeframe. State tested Nursing Assistant (STNA) #106, named in the allegations of abuse, found in the Immediate Jeopardy abuse citation at Data Tag F223 worked the 6:00 P.M. to 6:00 A.M. shift. STNA #106 frequently worked as the only STNA in the facility between those hours. The facility identified seven (#5, #14, #18, #22, #25, #34 and #37) residents that required two person staff assistance for activities of daily living (ADL). The facility identified four (#15, #25, #37 and #43) current residents on the sex offender registry. The facility resident Census and Condition form dated 01/19/16 revealed 29 residents on behavior management programs residing in the facility. Moreover, on 01/22/16 at 12:04 P.M. the staffing schedule was reviewed and an interview conducted with the DON which revealed that only two licensed nursing staff and no STNA staff were scheduled to work the 6:00 P.M. to 6:00 A.M. shift on that date. The DON reported at that time there were current calls out requesting staff to work that night. The Immediate Jeopardy was removed on 01/22/16 when the facility provided evidence of the updated schedules to reflect increased staffing levels, Resident #28 had been discharged , and STNA #106 was terminated. Although the Immediate Jeopardy was removed, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not immediate jeopardy) until it was corrected on 01/24/16, when weekend oversight by the State Agency verified sufficient and adequate licensed nursing and direct care staff were on site to ensure all residents received the necessary care and services to attain their highest level of well-being and the facility implemented the following corrective actions: · On 01/21/16, Corporate Nurse #110 and the DON reviewed all residents ' medical records to verify staffing levels were sufficient to effectively implement behavior plans in place. · On 01/22/16, the Regional Vice President of Operations reviewed staffing schedules for 01/22/16 through 01/28/16 to ensure minimum staffing levels were met. · On 01/22/16, the facility developed a written protocol for staffing coverage. This protocol established responsibilities for reporting up to the DON to ensure minimum levels were maintained at all times. · On 01/22/16, the facility Regional Director of Clinical Services educated 12 of the 14 licensed nurses employed on the new protocol. The two remaining nurses were notified of the new protocol via telephone and were required to complete the education prior to the start of their next scheduled shift. · The DON or designee will contact the building every shift to verify staffing levels are at appropriate levels for four weeks. · The Regional Director of Clinical Services or designee will audit staffing schedules weekly for three months and abuse allegations/investigations weekly for three months. All findings will be reported to the Quality Assurance Committee on a quarterly basis. · On 01/22/16, the facility signed a contract with a staffing agency to provide supplemental staffing as needed (Note: Agency staffing was verified to be utilized on 01/24/16 from 5:45 A.M. to 9:38 A.M.) · On 01/22/16, the Regional Vice President of Operations approved a sign-on bonus for new hires. · On 01/23/16 and 01/24/16, the facility utilized staff from sister facilities of the corporation to ensure appropriate staffing levels were maintained. · Refer to Data Tags F223, F225, and F226 for associated facility actions implemented to address Immediate Jeopardy citations regarding Abuse/Staff treatment of [REDACTED]. Findings include: Resident interviews conducted during Stage I of the survey process, on 01/19/16 and 01/20/16, revealed six of 21 residents interviewed reported insufficient staffing levels to meet their needs. Residents with negative responses were as follows: 1) On 01/19/16 at 10:35 A.M., Resident #14 stated the facility needed more aides, all shifts; 2) On 01/19/16 at 11:00 A.M., Resident #34 stated he had to wait a good hour and that there was only one aide on last Saturday night (01/16/16); 3) On 01/19/16 at 11:30 A.M., Resident #12 stated that approximately five months ago, she fell twice and did not get help until she crawled to the door and yelled for help; 4) On 01/19/16 at 1:10 P.M., Resident #30 stated there was not enough staff; 5) On 01/19/16 at 3:00 P.M., Resident #33 stated just this morning she had urinated in her pants because she had waited too long for staff; 6) On 01/20/16 at 10:40 A.M., Resident #18 stated she waits too long to get out of bed in the mornings. The resident stated she has to wait one-half to one hour and sometimes she has to wait an hour to get changed. Staff interview with Licensed Practical Nurse (LPN) #80 on 01/19/16 at 6:45 P.M. revealed the 6:00 P.M. to 6:00 A.M. shift frequently worked with only one STNA. Staff interview with STNA #106 on 01/19/16 at 6:50 P.M. revealed it was a regular occurrence for this STNA to work alone (referring to no other STNA on duty). In addition, SNTA #106 reported always feeling rushed , unable to spend time with residents and short staffed . During observations on 01/19/16 between the hours of 6:00 P.M. and 7:00 P.M. the surveyor conducted a visual check on each staff member listed on the schedule for that shift. Three staff, LPN #80, STNA #106, and RN #90 were quickly identified. However, STNA #103, scheduled to work in the Back Hall, was unable to be found. The Back Hall night shift LPN #80 and the Back Hall day shift staff member LPN #85 (remaining in the building to complete charting) repeatedly informed this surveyor the unseen STNA #103 must be in a resident room somewhere . After touring both the Front Hall and Back Hall several times, the surveyor was informed by LPN #86 (also from day shift, completing charting) that STNA #103 had called off work and was not in the building. This was confirmed during interview with the DON at 7:00 P.M. In addition, the DON verified that two licensed nursing staff and one STNA were the expected total staff to work in the facility until 6:00 A.M. During an interview with Assistant Director of Nursing (ADON) #81 on 1/19/16 at 4:20 P.M. she verified that on Saturday 01/16/16 there was only one STNA on duty from 6:00 P.M. to 6:00 A.M. Activity Director (AD) #60, also an STNA, filled in on the floor from 5:00 P.M. to 10:00 P.M. that night. In addition, the schedule reflected only one licensed nurse on duty from 6:00 P.M. to 11:00 P.M. with a second nurse (ADON #81) assisting on the floor from 6:00 P.M. to 11:00 P.M. Review of the schedule verified only two staff (one nurse and one STNA) were on duty in the facility from 11:00 P.M. to 6:00 A.M. on Saturday (into Sunday) 01/16/16. Upon further review it was noted during the dates of 01/11/16 through 01/20/16 there were six additional nights (01/11/16, 01/13/16, 01/14/16, 01/15/16, 01/19/16 and 01/20/16) that only one aide and two nurses were on duty in the facility with a census of 40. These findings were verified during an interview with ADON #81 on 01/22/16 at 2:30 P.M. Review of facility SRI's for October 2015, November 2015 and December 2015 through January 21, 2016 revealed 11 allegations of abuse were reported. Review of the incidents revealed seven of the 11 incidents occurred between the hours of 6:25 P.M. and 1:30 A.M. The direct care nursing and STNA staff worked twelve hour shifts from 6:00 P.M. to 6:00 A.M. Additionally, five of the resident to resident altercations cited in the Immediate Jeopardy abuse citation at Data Tag F223 occurred during that same timeframe. During record reviews and review of the facility SRI ' s it was noted that residents were often placed on every 15 minute checks due to behaviors. Residents involved in incidents of physical and/or verbal altercations reported on the SRI ' s reviewed which resulted in every 15 minute and/or one-to-one observations as part of the resulting treatment plan included Residents #28, #22, #36, #44, #10, #16 and #24. Staff interview with night shift LPN #74 on 01/20/16 at 6:23 P.M. revealed the resident 15 minute monitoring checks were the responsibility of the STNA staff. Staff interview with night shift STNA #101 on 01/20/16 at 6:20 P.M. revealed three resident smoke breaks were supervised by STNA staff between the hours of 6:00 P.M. and 6:00 A.M. Each smoke break was 30 minutes long. During the interview the staff member explained, as the only aide on duty, she would be unable to do actual 15 minute checks on a resident during smoke breaks. The exception would be if the resident was also a smoker. (Resident #28, cited at Data Tag F223 for assaulting other residents, was a non-smoker). STNA #101 stated she had been unable to complete the fifteen minute checks on residents every time she was the only STNA working the floor. STNA #106, named in the allegations of abuse found in the Immediate Jeopardy abuse citation at Data Tag F223, worked the 6:00 P.M. to 6:00 A.M. shift. Review of facility schedules, and verification during interview with ADON #81 on 01/19/16 at 4:20 P.M. revealed the alleged perpetrator worked as the only STNA in the facility on 01/15/16 and 01/19/16. Resident #28 had a history of [REDACTED]. Police notification of assault incidents were completed on two occasions involving Resident #28 (see Data Tag F223 for specific information). In addition, the facility identified seven (#5, #14, #18, #22, #25, #34 and #37) residents that required two person staff assistance for Activities of Daily Living. The facility also identified four (#15, #25, #37 and #43) current residents who were on the sex offender registry due to previous conviction of sexually oriented crimes. The facility resident Census and Condition form dated 01/19/16 revealed 29 residents are on behavior management programs residing in the facility. The facility census was 40 at that time. Staff interview with AD #60 (who is also an STNA) on 01/20/16 at 3:57 P.M. revealed she was pulled to work as an STNA frequently and activities were cancelled. During the interview, STNA/AD #60 stated the two prior weeks she had worked her hours as an STNA three and four days of the scheduled five day work week, instead of fulfilling duties as the Activities Director. Furthermore, STNA/AD #60 reported that no one filled in on those dates and therefore, the activities just didn ' t happen . Observation on 01/22/16 at 9:16 A.M. revealed the STNA/AD #60 was conducting the one-to-one observation of a resident instead of conducting planned activities with the residents of the facility. Review of Resident Council meeting minutes for November 2015 revealed staffing concerns of Need more STNA's Aides and nurses not answering call lights . Nurses not fulfilling resident needs . Resident Council meeting minutes for December 2015 reported resident concerns of Need more STNA ' s . Resident Council meeting minutes for January 2016 reflect inadequate staffing levels as residents reported, Having to wait 45 minutes or longer on medications . On 01/22/16 at 2:40 P.M., interview with Corporate Nurse #110 revealed there is no facility policy regarding staffing available. Additionally, the facility did not have the staffing levels posted during the survey. Review of the facility policy titled Resident Observation/Intervention , dated May, 2011 revealed the procedure to include: C) If a resident is on 1:1 monitoring additional staff member assigned will remain with the resident in view at all times. This deficiency substantiates Complaint Number OH 522.

Based on record review and staff interview, the facility failed ensure residents assessed at risk for falls had care planned fall interventions in place to prevent falls with injuries. This affected one (#28) of three residents reviewed for falls when the resident fell from his bed and sustained a fractured nose with a laceration. The facility census was 38. Findings include: Review of the medical record of Resident #28 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had short and long term memory impairment, had difficulty making decisions in new situations, required extensive assistance of two staff for bed mobility and transfers and was dependent for toileting. The resident's fall plan of care identified the resident as being at risk for falls due to poor coordination, poor decision making skills, cerebral vascular accident, impaired cognition, psychoactive drug use, bowel and bladder incontinence, history of turning off the alarms, and attempts to reposition self in bed and putting his feet on head board of bed. The care planned interventions included assistance of 1 to 2 with all transfers, assist with mobility as needed, check placement and function of alarms every shift, provide assistance with toileting, offer to elevate feet with pillows and frequently assess for proper positioning in bed. Review of the nurse's notes dated 05/10/13 at 3:16 PM, revealed the nurse entered the resident's room for medication pass and found the resident on the floor wrapped in a blanket. When asked what happened, Resident #28 pulled the blanket off his face and revealed a laceration on his nose. The resident stated he had fallen out of bed. The physician was called and an order was obtained to send the resident to the emergency room for treatment. Nurse's notes dated 05/10/13 at 9:56 P.M. stated the resident returned from the hospital at 6:30 P.M. with a nasal fracture. Interview with State tested Nurse Aide (STNA) #39 on 05/24/13 at 12:14 P.M. revealed Resident #28 was on her assignment at the time of his fall. STNA #39 stated the resident had put himself to bed without his personal alarm going off to alert staff he was transferring independently. She stated the resident was laying in bed with his head toward the foot of the bed. She stated she checked and changed the resident and covered him with a blanket. STNA #39 stated she ensured the resident did not need anything, gave him his call light and left the room. She stated as she was coming back down the hall she was told the resident had fallen from his bed. STNA #39 stated the resident's personal alarm was unplugged (from the box to the pad) and the bed was slightly raised at the time of the fall. STNA #39 stated she and "other STNA's" reported the resident's alarms was not functioning correctly. She stated she had reported this to nurses but was unsure which nurses. She stated the nurses were to check the residents' alarms every month and change the batteries but there were no batteries in the facility and they were waiting on a shipment. STNA #39 stated the cord on the resident's alarm was faulty and kept sliding out. She stated they should have done something sooner to fix the alarms. Observation of Resident #28 in his wheelchair in the hall on 05/24/13 at 1:08 P.M., revealed the bridge of the resident's nose was swollen with a small healing laceration. The resident did not respond to verbal and gestures attempts to ask if his nose hurt. Interviews with STNA's #14 and #15 on 05/24/13 at 1:15 PM, revealed both stated they had reported to "several" nurses the resident's alarm did not work, that the cord came out on it's own. The STNA's were unable to state which nurses they had reported the alarms to. They also stated the facility did not have batteries for the alarms as needed. During interview on 05/24/13 at 1:35 P.M., Licensed Practical Nurse (LPN) stated she had not been told the resident's alarm was not functioning properly. Interview with the Administrator and the Director of Nursing (DON) on 05/24/13 at 1:54 PM confirmed the resident's fall with injury on 05/10/13 but denied knowledge of the resident's alarm not functioning properly. The DON stated batteries were being kept in the housekeeping department because they disappear. This certification deficiency substantiates Facility Self Reported Incident Number OH 200.