Every finding on record at Amberwood Manor

Based on review of medical records, review of facility policies and protocols, and interviews with facility staff and medical providers the facility failed to complete comprehensive assessments of a resident who was experiencing a change in condition and failed to notify the resident's medical provider of the change in condition thereby delaying necessary care and treatment. This affected one (Resident #45) of three residents reviewed for a change in condition. The facility census was 43.Actual harm occurred on 07/16/26 when Resident #45, who was status post cerebral vascular accident (CVA) on from 06/26/26 which resulted in right sided weakness, worsening aphasia (inability to speak) and dysphagia (difficulty swallowing) and who was known to be at high risk for aspiration (inhalation of food or vomit into the lungs) began having signs of having aspirated without staff completing monitoring and assessment of the resident and notifying the resident's medical provider delaying treatment and resulting in Resident #45 experiencing a rapid physical decline over the next 12 hours requiring the use of supplemental oxygen and emergency transport to the hospital on [DATE] where he was treated at the emergency room for acute respiratory failure and subsequently sent to an in-patient hospice facility the same day. Findings Include:Review of the closed medical record for Resident #45 revealed admission to the facility on [DATE] for diagnoses including stroke with right sided weakness, aphasia, dysphagia, heart disease, carotid artery disease, and diabetes. Review of the nursing admission assessment for Resident #45 completed on 07/01/26 revealed Resident #45 had a set of vital signs obtained including temperature of 97.9, heart rate of 76, respiratory rate of 18, and blood pressure of 143/96. According to John Hopkins University School of Medicine, normal vital signs for adults include body temperature of 97.8 to 99.0, heart rate 60-100 beat per minute, respiratory rate 12-18, blood pressure 90/60 to 120/80 and oxygen saturation levels of 95-100%. The assessment also indicated Resident #45 had an oxygen level of 96% on room air, clear lung sounds, normal bowel sounds, was alert to person and place and in a pleasant mood. Further review of the admission assessment revealed Resident #45 required pureed textured foods and nectar thick liquids to drink. It was noted that Resident #45 had some slurred expressive aphasia (difficulty finding words and articulating them) but could usually make self-understood. Resident #45 did not complain of any pain. Review of the comprehensive minimum data set (MDS) 3.0 assessment completed on 07/08/26 revealed Resident #45 had unclear speech but was able to usually understand others and usually able to make self-understood. Review of the MDS 3.0 assessment further revealed a brief interview for mental status was conducted and Resident #45 scored 8/15 indicating moderate cognitive impairment. The assessment also indicated that Resident #45 required a wheelchair pushed by staff for mobility. Further review of the MDS 3.0 comprehensive assessment revealed Resident #45 had shortness of breath or trouble breathing when lying flat and Resident #45 had no signs or symptoms of swallowing disorders but required a mechanically altered diet. Review of the comprehensive care plan for Resident #45 revealed no specific care plan or interventions for dysphagia or aspiration risk. Review of the nursing assessments and evaluations found in the electronic medical record revealed the most recent nursing assessment occurred on 07/14/26 authored by Licensed Practical Nurse (LPN) #212 in which Resident #45 was able to follow commands and denied weakness, tremors, numbness or tingling. Further review revealed Resident #45 had short term memory impairment, was alert to person and place only, continued with unclear speech, and was now sometimes able to make self-understood. Resident #45 had clear lung sounds, no difficulty breathing, no cough present, and did not require oxygen. Review of the nurse practitioner (NP) progress noted dated 07/14/26 and authored by NP#502 for Resident #45 revealed staff reported on 7/14/26 that the resident was having increased aspiration while eating and drinking. The progress note further revealed Resident #45's assessment and plan was to continue speech therapy for dysphagia with pureed diet and nectar consistency liquids in place and that Resident #45 remained at a high risk for aspiration. Review of the resident's medical doctor (MD) #501 progress note dated 07/15/26 for Resident #45 revealed a physical assessment was completed and noted Resident #45 denied cough or shortness of breath and had clear lung sounds. MD #501 further noted he reviewed labs obtained on 07/14/26 that showed worsening acute kidney injury with chronic kidney disease and elevated sodium. Further lab review revealed a blood urea nitrogen (BUN) level greater than 130 (normal 7-20), previous level was 95, creatinine level of 4.4 (normal 0.7-1.3), previous level of 2.7, sodium level of 155 (135-145). It was also noted by MD #501 that Resident #45 was up in a chair during the MD visit with no acute complaints. Further review of the MD progress note dated 07/15/26 revealed the following assessment and plan to include continuing aspiration precautions with puree diet and nectar thick liquids, monitoring closely for aspiration, discontinue lisinopril (blood pressure medication that can affect kidney function) decrease amlodipine (a blood pressure medication that can affect the kidneys and lungs) to 10 milligrams (mg) daily, start hydralazine (shorter acting blood pressure medication) 10 mg twice a day, push oral fluids due to decreased kidney function, obtain a repeat lab for a comprehensive metabolic panel (CMP) to recheck Resident #45's kidney function, monitor blood pressure twice daily for 5 days, and continue to monitor renal function closely. There was no evidence of any further physical assessments of Resident #45 by any medical provider or nursing staff until Resident #45 was seen by NP #500 on 07/17/26. Review of Resident #45's nursing progress note dated 07/17/26 at 12:01 A.M. by the Director of Nursing (DON) revealed Resident #45's oxygen saturation declined to 88% on room air. Oxygen was applied via nasal cannula and resident tolerating well. There was no evidence of a comprehensive nursing assessment that should have included a comprehensive cardiovascular and respiratory assessment of the resident. There was no additional assessment or documentation of Resident #45's condition until the next note 11.5 hours later. The next nursing progress note was dated 07/17/26 at 11:30 A.M. and authored by LPN #216 that revealed the NP #501 was in to see Resident #45 and new orders to send to emergency room immediately due to Resident #45 had no reaction to sternal rub and vital signs obtained revealed temperature of 98.4, heart rate of 140, respiratory rate of 22, blood pressure of 76/54 and oxygen saturation of 90% on 4 liters of oxygen. 911 was dispatched and Resident #45 was subsequently taken to the local hospital. Review of Resident #45's progress note dated 07/17/26 (not timed) authored by NP #500 revealed a notation that there were no repeat lab orders on the MAR. Further review revealed an addended note added after thorough examination was called into the patient's room and patient noted to be significantly lethargic, unable to open eyes, did not respond to verbal or tactile stimuli, eyes did open to sternal rub and were rolled back into his head. Orders were given to call 911 and have Resident #45 sent out to the hospital. Review of the emergency room (ER) medical provider note dated 07/17/26 for Resident #45 revealed upon arrival to the emergency department that the resident was noted to be hypoxic (severely low oxygen levels) on room air, hypotensive (severely low blood pressure), and minimally responsive to painful stimuli. It was also noted that Resident #45 had what appeared to be blood in his mouth and a dry oral cavity, lung sounds that were diminished with rhonchi in the base (coarse sounds indicating infection or fluid present in the lungs), and bruising noted over the left lower abdomen and lower back flank area. Lab work was obtained and revealed a hemoglobin (red blood cell that carry oxygen through the body) level of 5.9 grams per decaliter (g/dl), critically low with normal being 12-17.5 g/dl. The ER note further revealed Resident #45 was diagnosed with acute respiratory failure and acute blood loss anemia and traumatic ecchymosis (bruising) of flank. Further review of the emergency room notes indicated that Resident #45's wife changed his code status to a DNR-CC (do not resuscitate-comfort care only) and asked that only comfort measures be provided and declined further testing or intervention of blood transfusion. Hospice was consulted by the emergency room and Resident #45 was subsequently transferred from the ER on [DATE] to a local hospice facility for comfort care measures. Review of Resident #45's July 2026 heart rate and blood pressure logs dated 07/01/26 to 07/15/26 revealed an average heart rate of 70-95 and a blood pressure range of 111/89 to 164/99. Further review of the blood pressure logs indicated a comment on 7/16/26 at 11:28 P.M. that the blood pressure of 89/50 was out of range for standard blood pressure reading (this was an automated message generated by the automatic blood pressure machine). Review of Resident #45's July 2026 oxygen saturation logs from 07/01/26 to 07/15/26 revealed a range of 93-96% on room air. Further review of the oxygen saturation logs indicated a comment on 07/17/26 at 12:01 A.M. the oxygen saturation of 88% was out of range for standard oxygenation saturations (this was an automated message generated by the machine used to measure the resident's oxygen level). Interview on 08/04/26 at 1:14 P.M. with certified nursing assistant (CNA) #210 revealed she was working 6:00 P.M. to 6:00 A.M. shift on 07/16/26 through 07//17/26. CNA #210 reported that Resident #45 had transferred from the south unit to the north unit earlier that day (07/17/26) and she had not cared for Resident #45 prior to that. CNA #10 revealed she had received report from the day shift that Resident #45 was an aspiration risk. Further interview with CNA #210 revealed between 7:30 P.M. and 8:30 P.M. she was making rounds and passing the evening snack. CNA #210 entered Resident #45 room and noted he was lying almost flat in bed and making a gurgling noise. CNA #210 reported she immediately sat Resident #45 up and noted he had a chocolate-colored substance around his mouth and on his clothes. CNA #210 reported she ensured Resident #45 was still not choking and notified the Director of Nursing (DON) who was covering the shift and responsible for Resident #45 that night. CNA #210 further revealed she informed the DON that she thought Resident #45 had aspirated on a chocolate shake since the DON had asked her earlier in the shift where Resident #45's chocolate shake was. The DON reported to CNA #210 that she did not give him a chocolate shake, and the DON had just given Resident #45 his evening medication with chocolate pudding. CNA #210 also reported at that time she returned to Resident #45 room to clean him up and change his clothes and then attended to Resident #45's roommate. CNA #210 further revealed that the DON did not come to check on Resident #45 for approximately 30 minutes and then entered his room while she (the DON) was on the phone and checked his pulse oximeter oxygenation level and left the room. CNA #210 further reported that later during the shift, maybe 20-30 minutes later, she then saw CNA #206 from the south unit was in Resident #45's room with the light on and CNA #210 entered the room to find out what was going on. CNA #210 reported that CNA #206 was checking vital signs on Resident #45, something the CNAs typically do not do. and that CNA #206 reported that she was asked by the DON to check in on Resident #45 to see if she noticed any changes in his status since CNA #206 provided care for him multiple times while he was residing on the south unit. CNA #210 reported she did notice at this time there was a medicine cup with chocolate pudding and spoon in the trash can in Resident #45's room. Continued interview with CNA #210 revealed during the change of shift around 11:00 P.M. she noticed Resident #45 now had oxygen on. CNA #210 reported she observed Resident #45 appeared to be restless the remainder of the night. CNA #210 further revealed she thought that Resident #45 should have been sent out to the hospital that night and she was so upset about the events that she did not return to work at the facility after that shift. Interview on 08/04/26 at 3:06 P.M. with licensed practical nurse (LPN) #216 revealed she worked a split shift on 07/16/26 to 07/17/26 and came to work around 11:00 PM on 07/16/26 to relieve the DON who was covering from 7:00 P.M. to 11:00 P.M. on 07/16/26 due to a report off and LPN #216 ended her shift at 5:00 A.M. on 07/17/26. LPN #216 recalled that it was reported to her by the DON that CNA #210 was concerned that Resident #45 had aspirated and she was having difficulty obtaining an oxygenation level with the pulse oximeter. LPN #216 further reported she used her pulse oximeter at that time with the DON present short after 11:00 P.M. when she started her shift and it revealed an oxygen saturation in the 80's. LPN #216 reported that the DON put oxygen on Resident #45 and then his saturation increased to the 90's. LPN #216 denied calling any medical provider during her shift regarding the condition of Resident #45 and that Resident #45 appeared to sleep all night. LPN #216 verified she did not reassess the resident's condition. Interview on 08/04/26 at 3:49 P.M. with MD #501 revealed Resident #45 was in very poor health when the resident arrived at the facility after his stroke and had a history of strokes prior to the most recent, was continuing to decline while at the facility and his prognosis was poor. MD #501 confirmed that he saw Resident #45 on 07/15/26 and evaluated him and gave new orders to change his blood pressure medications, push oral fluids due to decreased kidney function, obtain a repeat lab for a CMP to recheck Resident #45 kidney function, and monitor blood pressures twice a day for 5 days. MD #501 also reported his expectation when ordering the lab work was that the facility would obtain the labs the next day. MD #501 confirmed that Resident #45 was a high aspiration risk and revealed in his opinion if a resident had suspicion of aspiration and needed additional oxygen the next step would be to order a chest Xray. MD #501 reported he was not made aware of any change in Resident #45's blood pressure or oxygen level on 07/16/26. MD #501 further reported that he works with a group of nurse practitioners who cover the on-call services and he would only be notified about a resident concern if the facility could not reach the on-call nurse practitioner or if the nurse practitioner called him with concerns. Further interview with MD #501 revealed he has a nurse coordinator that rounds with him while seeing residents and writes the verbal orders he gives then provides them to the nursing staff at the facility to complete and enter into the electronic medical record. It was noted upon further review of the medical record orders that were entered on 07/15/26 by LPN #212, there were no orders for the CMP (laboratory test) or order to push oral fluids noted in the medical record or on the MAR. Interview on 08/04/26 at 4:04 P.M. via phone with LPN #212 revealed she worked 7:00 A.M to 7:00 P.M. shift on 07/17/26. LPN #212 confirmed she provided care to Resident #45 and that she attempted to give him his medications that morning and he would not open his mouth for the medications and the resident just looked, at her. LPN #212 reported she attempted several more times, but Resident #45 would not open his mouth. LPN #212 could not recall the specific time she attempted to administer his medication but thought it was probably after 8:00 (AM) per her usual morning routine. It was noted on the medication administration record (MAR) on 07/17/26 for Resident #45 that vital signs were obtained and revealed a heart rate of 80, a blood pressure of 104/61, a temperature of 98.0 degrees Fahrenheit, a respiratory rate of 16 and a blood sugar reading of 344. It was also noted on the MAR that LPN #212 checked off that she did administer Resident #45 morning medications. Further interview with LPN #212 revealed that the nurse practitioner (NP)#500 was at the facility and evaluated Resident #45 the morning of 07/17/26 and came out of his room and asked her about his baseline status and reported that he wasn't responding to sternal rub. LPN #212 reported she and the NP#500 attempted to get a hold of Resident #45's wife because Resident #45 had a do not resuscitate order- comfort care arrest, (meaning attempt all life saving measures until there was no heartbeat) but was unsuccessful and then the NP #500 gave order to call 911 and send Resident #45 to the hospital. LPN #212 reported that she received a call from the emergency room yelling at her because she could not report to them what his baseline was and she faxed them over all the information they requested from Resident #45's medical record. LPN #212 verified there was no evidence she had completed a comprehensive assessment of the resident on 07/17/26 once she took over care of the resident even though the resident had refused his morning medication and just looked at her without responding to her. Interview on 08/05/26 at 1:35 P.M. with NP #500 revealed it was her expectation that if a resident who had a high risk for aspiration, a change in oxygen level of 88% on room air and needing supplemental oxygen and a blood pressure decline of 89/50, the nursing staff would report that to the on-call provider. Continued interview with NP #500 revealed she rounds at the facility on Fridays and takes call on Fridays from 6:00 A.M. to 8:00 P.M. and after 8:00 P.M. one of the other NP who works with the facility takes turns rotating on-call coverage from 8:00 P.M. to 6:00 A.M. NP #500 further reported that there was no evidence of the facility reporting any concerns with Resident #45 on 07/16/26 or 07/17/26 in the call logs. NP #500 reported she was not aware of or notified by the nursing facility staff of Resident #45 having a potential aspiration episode, low oxygen level of 88% on room air requiring application of oxygen at 4 liters/min via nasal cannula, or the decrease in blood pressure. NP #500 confirmed she was not made aware of events occurring the night before on 07/16/26 when she was at the facility the morning of 07/17/26. Further interview with NP #500 revealed that her company nurse coordinator would have arrived at the facility about an hour before her and reviewed the Resident Concern book (binder where facility nursing staff make notes to the provider about non-urgent concerns that need addressed such a normal lab results, script needing refills), the on-call logs and talked with nursing staff about any specific resident concerns. The nurse coordinator prepares the progress note as well. NP #500 revealed that when she arrives at the facility, she reviews the information gathered and provided by her nurse coordinator prior to physically examining the residents then adds any updates to the progress note after examining the resident. Continued interview with NP #500 revealed that on 07/17/26 she arrived at the facility around 9:00 A.M. and met with her nurse coordinator and reviewed Resident #45 chart prior to physically examining the resident. NP #500 reported that when she entered Resident #45's room probably around 10:00 A.M. he was unresponsive to verbal command or an aggressive sternal rub. NP #500 reported this was the third time she had seen Resident #45 (during the resident's stay at the facility) and immediately had the nurse get a set of vital signs which revealed Temperature of 98.4 degrees Fahrenheit, heart rate of 140, 22 breaths per minute, blood pressure of 76/56, and oxygen level of 90% on 4 liters of oxygen. NP #500 ordered 911 to be called and to send Resident #45 immediately to the hospital. Interview on 08/05/26 at 2:17 P.M. with CNA #206 revealed she worked from 6:00 P.M. to 6:00 A.M. on 07/16/26 through 07/17/26. CNA #206 reported she generally worked night shift on the south unit and had cared for Resident #45 several times and on 07/16/26 Resident #45 had been moved to the north unit earlier on day shift. Further interview with CNA #206 revealed that prior to shift change at 11:00 P.M. the DON asked her to go to the north unit and check on Resident #45 to see if she noticed any changes with him and to obtain vital signs. CNA #206 checked in on Resident #45 and obtained vital signs. CNA #206 confirmed that CNA #210 came into Resident #45's room while she was getting his vital signs and seemed upset with the DON and questioned why CNA #206 was checking on her resident. CNA #206 reported that she was asked to see Resident #45 to determine if he seemed any different since she had cared for him prior. CNA #206 was unable to recall the vital sign she obtained and denied documenting them but did report that the wrist cuff blood pressure machine she was using had an error twice before she could finally get a blood pressure reading. CNA #206 reported she verbally reported to the DON Resident #45's vital signs and that she did not think that Resident #45 was acting any differently than when she cared for him prior and that he wasn't really a talker and that night he just smiled at her but did not attempt to speak. CNA #206 denied providing care for Resident #45 the rest of the shift. Interview on 08/05/26 at 2:30 P.M. with the DON revealed she did not recall if she completed vital signs on Resident #45 prior to administering his evening medication sometime between 7:00 P.M. and 9:00 P.M. on 07/16/26. The DON reported that when she administered Resident #45's medication to him she crushed them up and put them in chocolate pudding and it was a very minimal amount of pudding that she had to use. The DON denied having any concerns or difficulties with Resident #45 consuming the pudding with the crushed medications in it. The DON denied Resident #45 appearing to pocket the pudding (keep stored in his cheek or mouth) or not swallowing the pudding medication mixture. Continued interview revealed that the DON was made aware by CNA #210 that Resident #45 had appeared to have aspirated, and she found him lying in bed making gurgling noise and that he had spit up a chocolate-colored substance all over his clothes and had it around his mouth. The DON reported she told the CNA #210 she had just given Resident #45 his medication with pudding, and she would be in to check him. The DON reported she assessed Resident #45 and listened to his lung sounds and they were diminished (limited air passing through airways). The DON further reported she was having difficulty obtaining an oxygen level reading and the oncoming licensed practical nurse LPN #216 came in the room to assist her and used a different pulse oximeter and that was when then it was noted Resident #45 oxygen level was 88%. The DON then put Resident #45 on supplemental oxygen at 4 Liter/min via nasal cannula and his oxygen level came back up into the 90's. The DON confirmed that there was no evidence in the medical record of any nursing assessments (including lung sounds, heart sounds, abdomen inspection) completed after 07/14/26. The DON confirmed specifically there was no evidence in the medical record of a nursing assessment being completed on Resident #45 on the night shift of 07/16/26 to 07/17/26. The DON confirmed she herself did not document doing a nursing assessment on Resident #45 after receiving a report from CNA #210 that she was concerned that Resident #45 had aspirated. The DON confirmed she did not document a nursing assessment after finding that Resident #45 had a low blood pressure of 89/50 and oxygen level at 88% on room air. Further interview with the DON revealed confirmation there was no evidence in the medical record for Resident #45 that the on-call medical provider was notified of the change in vital signs or possible aspiration of Resident #45 on 07/16/26 or 07/17/26. The DON denied she called any on-call medical provider on her shift from 7:00 P.M. to 11:00 P.M. related to the changes with Resident #45 and now looking at all the information realized she probably should have notified the on-call provider and would expect her staff to call about those changes. At the time of this interview with the DON, review of the Pinnacle On-Call Protocol provided by and confirmed by the DON revealed, the following are examples of situations requiring 'immediate' notification: any significant change in the physical or mental status from baseline, heart less than 50 or greater than 120 or significant change from baseline, systolic blood pressure less than 90 or greater than 180 or significant change from baseline after any scheduled medications are given, respiratory rate greater than 30 , pulse ox less than 90% after applying oxygen or significant change from baseline, and critical labs requiring immediate treatment. Review of the facility policy titled, Resident Change in Condition Policy, and revised on 05/08/26 provided by DON revealed, the facility will inform the resident, consult the medical provider, and notify the resident representative when there is: a significant change in the resident's physical, mental, or psychosocial status (that is, deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications) or a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment. Further review of the policy revealed, the nurse will record the information related to the change in condition and subsequent events and notification in the Resident's health record. This deficiency represents non-compliance investigated under Master Complaint Number 3105690.

Based on review of medical records, review of facility policies and protocols, review of adverse drug interactions provided my Medscape, review of anticoagulation information provided by the Cleveland Clinic, and interviews with facility staff and medical providers the facility failed to ensure a resident was free from unnecessary medications when the staff failed to assess and monitor a resident for bruising when the resident was receiving multiple anti-platelet medications. This affected one resident (#45) of three residents reviewed for medication usage. The facility census was 43.Findings Include: Review of the closed medical record for Resident #45 revealed admission to the facility on [DATE] for diagnoses including stroke with right side weakness, aphasia, dysphagia, heart disease, carotid artery disease, diabetes and history of falls. It was noted there was no evidence of a history of anemia (low blood count).Review of the nursing admission assessment for Resident #45 completed on 07/01/26 revealed Resident #45 had a set of vital signs obtained including temperature of 97.9, heart rate of 76, respiratory rate of 18, and blood pressure of 143/96. The assessment also indicated Resident #45 had an oxygen level of 96% on room air. Further review of the admission assessment revealed there was a notation stating Resident #45 had bruising to bilateral arms, chin, and left abdomen. There were no other skin abnormalities indicated. There was no evidence of measurements of the bruising of the abdomen or cause of the bruising in the medical record.Review of the medical provider orders for Resident #45 revealed an order by the resident's medical doctor (MD) #501 dated 07/01/26 for aspirin 81 milligrams (mg) by mouth daily and Plavix 75 mg by mouth daily. Further review of the provider orders for Resident #45 revealed an order dated 07/04/26 indicating the resident was to be monitored for anticoagulant use including signs of discolored urine, black tarry stool, sudden severe headache, nausea/vomiting, diarrhea, muscle/joint pain, lethargy (excessive sleepiness), bruising, sudden changes in mental status and/or vital signs, shortness of breath, nose bleeds, pain/swelling unexplained in extremities and notify provider of abnormalities.Review of adverse drug reactions for Aspirin and Plavix found on Medscape.com page titled, Plavix (clopidogrel) dosing, indications, interactions, adverse effects, and more, revealed patients should be monitored closely for signs of bleeding when using both aspirin and Plavix concurrently. Further review revealed a significant increase in major bleeding events reported in patients receiving Plavix plus aspirin instead of aspirin alone and a risk of bleeding with a potentially fatal outcome. Review of the Cleveland Clinic website page titled, Internal Bleeding Signs, Symptoms & Treatment revealed symptoms of internal bleeding to include but not limited to confusion and weakness, difficulty breathing, chest pain, coughing up blood, abdominal bruising, and bloody vomit or stool.Review of the comprehensive minimum data set (MDS) 3.0 assessment completed on 07/08/26 revealed Resident #45 had unclear speech but was able to usually understand others and usually able to make himself understood. Review of the MDS 3.0 assessment further revealed a brief interview for mental status was conducted and Resident #45 scored 8/15 indicating moderate cognitive impairment. The assessment also indicated that Resident #45 required a wheelchair pushed by staff for mobility, substantial to maximum assistance with bathing and dressing. Review of the care plan for Resident #45 revealed a care plan initiated on 07/08/26 that Resident #45 was at risk for bleeding secondary to use of NSAIDS (non-steroidal anti-inflammatory drug)/anticoagulants (medications used to prevent blood clots). Interventions included; handle resident gently during activities of daily living care and support the extremities under joints during movement, monitor for signs and symptoms of bleeding (skin bruising, bleeding gums, black stool, coffee ground like emesis (vomit), and administer prescribed medication and monitor for medication effectiveness and observe for adverse reactions.Review of the weekly skin assessments for Resident #45 dated 07/06/26 and 07/13/26 revealed Resident #45 had intact skin. There was no evidence that the areas of bruising identified on the resident's admission were assessed to include measurement or healing status.Review of the facility shower sheets completed and signed by the certified nursing assistants (CNA)s providing the bath or shower and cosigned as reviewed by a licensed nurse revealed a statement that any condition other than completely intact must be reported to the nurse promptly. Further review of the shower sheets revealed multiple check boxes to indicate if skin was completely intact, a rash, bruises, redness, swelling, scratches, or blisters present. Review of Resident #45 shower sheet dated 07/05/26, 07/09/26, 07/12/26, 07/16/26 and signed by CNAs and Licensed nurses revealed no evidence of the skin being marked as intact or abnormal (no check boxes were marked).Review of orders signed by NP #500 on 07/07/26 and 07/09/26 revealed no evidence of a complete blood count (CBC) being ordered. It was noted that on 07/07/26 an order was written for a comprehensive metabolic panel (CMP) and a Vitamin D level. Further review of the medical record revealed no evidence of a CBC lab order being written for Resident #45.Review of the MAR for 07/01/26 through 07/17/26 revealed assessment for signs of bleeding were marked for each shift with no abnormalities noted. Review of the resident's medical doctor (MD) #501 progress note dated 07/15/26 for Resident #45 revealed a physical assessment was completed and noted Resident #45 denied cough or shortness of breath and had clear lung sounds. It was also noted by MD #501 that Resident #45 was up in a chair during the MD visit with no acute complaints. There was no evidence MD #501 identified any bruising of Resident #45 during the physical assessment completed on 07/15/26.There was no evidence of any further physical assessments of Resident #45 by any medical provider or nursing staff until Resident #45 was seen by NP #500 on 07/17/26.Review of Resident #45's nursing progress note was entered on dated 07/17/26 at 12:01 A.M. by the Director of Nursing (DON) revealed Resident #45's oxygen saturation declined to 88% on room air. Oxygen was applied via nasal cannula and resident tolerating well. There was no evidence of a comprehensive nursing assessment completed at this time. The next nursing progress note was dated 07/17/26 at 11:30 A.M. and authored by LPN #216 that revealed the NP #501 was in to see Resident #45 and new orders to send to emergency room immediately due to Resident #45 had no reaction to sternal rub and vital signs obtained revealed temperature of 98.4, heart rate of 140, respiratory rate of 22, blood pressure of 76/54 and oxygen saturation of 90% on 4 liters of oxygen. 911 was dispatched and Resident #45 was subsequently taken to the local hospital.Review of the emergency room (ER) medical provider note dated 07/17/26 for Resident #45 revealed upon arrival to the emergency department he was noted to be hypoxic (severely low oxygen levels) on room air, hypotensive (severely low blood pressure), and minimally responsive to painful stimuli. Bruising was noted over the left lower abdomen and lower back flank area. Lab work was obtained and revealed a hemoglobin (red blood cell that carry oxygen through the body) level of 5.9 grams per deciliter (g/dl), critically low with normal being 12-17.5 g/dl. The ER note further revealed Resident #45 was diagnosed with acute respiratory failure and acute blood loss anemia and traumatic ecchymosis (bruising) of flank. Further review of the emergency room notes indicated that Resident #45's wife changed his code status to a DNR-CC (do not resuscitate-comfort care only) and asked that only comfort measures be provided and declined further testing or intervention of blood transfusion. Hospice was consulted by the emergency room and Resident #45 was subsequently transferred from the ER on [DATE] to a local hospice facility for comfort care measures.Interview on 08/05/26 at 1:15 P.M. with Resident #45's wife revealed she was unaware of the bruising of her husband's abdomen and lower back until she saw it in the emergency room on [DATE] and had no idea how it happened. Resident #45's wife further revealed that the bruises she observed did not appear new and appeared to be starting to fade when she saw it on 07/17/26.Interview on 08/05/26 at 1:35 P.M. with Nurse Practitioner (NP) #500 revealed that her expectations for a resident on aspirin and Plavix would be for the nursing staff to routinely monitor for signs and symptoms bleeding and anemia on a resident. NP #500 further reported that Plavix and aspirin therapy did not require routine blood work like other anticoagulants, but it was good practice to occasionally obtain a complete blood count (CBC) lab for monitoring of anemia. NP #500 reported she ordered a CBC for Resident #45 when she evaluated him on 07/07/26 and this was ordered in addition to the vitamin D level that was also ordered that day. NP #500 reported she saw Resident #45 on 07/07/26, 07/09/26, and then on the morning of 07/17/26 when he was found to need immediate medical attention. NP #500 denied being notified about any concerns of signs and symptoms of bleeding or bruises by the nursing staff for Resident #45.Interview on 08/05/26 at 2:30 P.M. with the DON revealed that residents have a full body skin assessment on admission and then weekly either by the wound nurse or the staff nurse. The DON further reported that the CNA's were expected to report any abnormal skin conditions and mark it on the shower sheets which were then reviewed by a nurse daily. The DON denied being aware of any abnormal skin conditions for Resident #45 and was unaware of the bruising to his left abdomen or left back and hemoglobin level of 5.9 g/dl found at the emergency room visit on 07/17/26. Further interview with the DON revealed verification that the shower sheets provided had nothing marked for skin checks on 07/05/26, 07/12/26, and 07/16/26. The DON referenced that the nursing staff were assessing signs of bleeding and would have documented that on the MAR if there were any abnormalities.Interview on 08/07/26 at 11:40 A.M. with the assistant director of nursing (ADON) #303 revealed she was also the designated facility wound nurse. ADON #303 reported that she rounds with the wound nurse practitioner weekly and does progress notes after rounding. ADON #303 reported that if a resident does not have any wound requiring treatment, then they would have weekly skin sweeps (full body skin inspections) completed by the floor nurses. Further interview with ADON #303 revealed that weekly skin assessment documentation completed by the staff nurse would only identify any new skin issues and would not necessarily have prior skin issues noted such as bruising. The ADON #303 further explained that bruising would be noted on the admission assessment done by the staff nurse but there was not really a practice of following up on bruising other than the nurses marking off on the MAR assessment and monitoring of signs and symptoms of bleeding and adverse drug reactions or side effects for anticoagulants. Continued interview with ADON #303 revealed she could not recall any concerns with Resident #45 and bruising and would have to refer to any documentation she completed. Interview on 08/07/26 at 11:50 A.M. with Licensed Practical Nurse (LPN) #238 revealed she prefers to do her weekly skin sweep when the certified nursing assistants (CNA)'s are providing a bath or shower to residents. LPN #238 reported that she would document any new skin concerns on the weekly form and notify the wound nurse of any concerns. LPN #238 verified she completed a skin sweep on Resident #45 on 07/13/26 and reported she did not recall any new skin issues and could recall he had some bruises when he came from the hospital (07/01/26). Review of the facility policy titled, Anticoagulation Policy, and revised on 01/15/24 revealed on admission nursing staff will assess residents who are prescribed anticoagulant medication. Further review revealed residents will be monitored for possible complications associated with anticoagulants and notify the provider promptly. Any pre-existing signs of bleeding or bruising will be noted in the admission assessment. Review of the facility policy titled, Skin and Wound Care Best Practices, dated 12/17/25 revealed on admission the nurse would conduct a full body skin assessment and would complete weekly skin checks in addition to reviewing of the shower sheet skin reviews.This deficiency represents non-compliance investigated under Master Complaint Number 3105690.

Based on observation, record review and interview, the facility failed to maintain air temperatures at a comfortable level and failed to ensure floors and bathtubs were cleaned on the South unit. This affected all 22 residents (#2, #3, #5, #8, #9, #10, #11, #13, #15, #16, #17, #19, #20, #22, #24, #26, #28, #29, #31, #32, #238, and #240) who resided on the South unit. Findings Included: 1. Review of an email dated 07/31/24 at 2:35 P.M. revealed the Heating and Cooling company emailed the Administrator indicating the packaged terminal air conditioner (P-TAC ) units needed to be replaced in the facility due to the fact that they were [AGE] years old and could not be repaired anymore. Review of an email dated 09/11/24 at 4:18 P.M. revealed the Administrator emailed the Heating and Cooling company to ask if once the electricity was completed they would have to switch over right away with the new P-TAC units or could they do the electricity and then wait to install the P-TAC units. Review of an email dated 09/16/24 at 10:48 A.M. revealed the Heating and Cooling company emailed the Administrator indicating they would need to make the switch on all P-TAC units at once if the electricity was upgraded at once due to the existing units were not able to function with the increased voltage. Review of an email dated 09/16/24 at 12:38 P.M. revealed the Administrator emailed the Heating and Cooling company indicating it was a huge expense and one they did not believe could be done at this time and what was the ability to do them one at a time. Review of the quote dated 09/17/24 revealed the facility needed 12 new P-TAC units for $18,000.00. Review of an email dated 12/17/24 at 12:52 P.M. revealed the Administrator emailed the Heating and Cooling company indicating she was following up for their visit a few months ago regarding re-doing the electrical for the South P-TAC units. The maintenance director was out on leave so to forward any communication to the Administrator. Review of an email dated 12/26/24 at 9:27 A.M. revealed the Heating and Cooling company emailed the Administrator revealed they were having trouble getting an electrician that had the capacity to do the work and she believed he had spoken to the Maintenance Director concerning this. He was inquiring if the facility had an electrician they had worked with and to please let him know. Review of an email dated 01/02/25 at 6:26 P.M. revealed the Administrator emailed the Director of Environmental Services #400 indicating she believed the facility was working with him on getting all the remaining P-TAC units switched over to the new units. The facility needed an electrical update in order to run the new units and would need someone to remove the old ones and install the new ones. The heating and cooling company stated they do not have an electrician to complete the work and asked if the company had an electrician they used. Also, the local heating and cooling company they use for repairs stated they could continue to keep servicing the units and the facility needed to replace them as soon as possible as there was no way to fix them every time they break because the parts were scare to none. The facility was currently using space heaters in most of the rooms on the South Unit as the boiler pilot light keeps going out and needed a new part which they were working on getting for them and the units in the rooms were individually breaking down on and off as well. Review of an email dated 01/20/25 at 11:43 A.M. revealed the Director of Environmental Services #400 emailed the Administrator and [NAME] President of Operations #410 to send the approved quote for the electrical upgrades for the P-TAC unit replacement project. There were 22 residents, Resident #2, #3, #5, #8, #9, #10, #11, #13, #15, #16, #17, #19, #20, #22, #24, #26, #28, #29, #31, #32, #238, and #240 who resided on the South unit who had the potential to be affected by the lack of functional heating units in the rooms on this unit. Observation during the initial tour on 01/21/25 at 8:50 A.M. revealed there was a small space heater in Resident #5 and #22's room plugged in and sitting on the floor. The air temperature felt cold in the room and bathroom. The bathroom was a shared bathroom with another resident room. An interview at the time of the observation with Resident #22 revealed the bathroom was always cold. On 01/21/25 at 8:57 A.M. an interview with Registered Nurse (RN) #364 verified Resident #5 and #22 had a space heater in their room due to their room being cold. Further observation during the initial tour on 01/21/25 at 9:05 A.M. revealed there was a small space heater sitting on top of the P-TAC unit in Resident #10 and #32's room. On 01/21/25 at 9:10 A.M. an interview with Registered Nurse #364 verified Resident #10 and #32 had a space heater in their room due to their room being. On 01/21/25 at 10:04 A.M. an interview with Resident #9 revealed her room was always cold because the heater was broken. Observation of room temperatures with the Director of Clinical Services #380 and the Life Safety Code surveyor on 01/21/25 at 11:00 A.M. revealed room temperatures as follows: * room [ROOM NUMBER] was 67 degrees Fahrenheit (F) and the bathroom was 61 degrees F * room [ROOM NUMBER] was 69 degrees F * room [ROOM NUMBER] was 69 degrees F and the bathroom was 67 degrees F * room [ROOM NUMBER] was 69 degrees F and the bathroom was 60 degrees with the door open and a space heater running * room [ROOM NUMBER] was 75 degrees F and the bathroom was 67 degrees F * room [ROOM NUMBER] was 69 degrees F and the bathroom was 60 degrees F with the door open and a space heater running * room [ROOM NUMBER] was 69 degrees F and the bathroom was 65 degrees F with the door open and a space heater running On 01/21/25 at 11:!1 A.M. an interview with the Administrator revealed there were 10 resident rooms on the South Unit that were still on the old boiler with P-TAC units. She stated those units have not been working properly. She stated some would work and some would not and when those units go out they would use portable space heaters to heat those rooms. The Administrator revealed this had been an going issue for about an month or two due to the cold (outside) temperatures. She stated they had received the approval to have the units replaced. She stated the heating and cooling company would come out and fix them but they were not able to get parts anymore so they all needed to be replaced. Observations of air temperature with Director of Clinical Services #380 on 01/21/25 at 2:20 P.M. revealed the bathroom temperature in room [ROOM NUMBER] and 112 was 53 degrees F. On 01/21/25 at 2:59 P.M. an interview with Resident #10 revealed her room was always cold and that was why she had a space heater in her room. On 01/21/25 at 4:30 P.M. an interview with Director of Clinical Services #380 revealed they had ordered eight large industrial portable heaters for use in the hallways. On 01/21/25 at 6:00 P.M. the portable heating units that were ordered were observed to be delivered. Review of the facility temperature log dated 01/21/25 at 6:00 P.M. revealed the room temperatures were: * room [ROOM NUMBER] was 65 degrees F and the bathroom was 56 degrees F * room [ROOM NUMBER] was 71 degrees F and the bathroom was 62 degrees F * room [ROOM NUMBER] was 65 degrees F and the bathroom was 53 degrees F * room [ROOM NUMBER] was 62 degrees F and the bathroom was 54 degrees F * room [ROOM NUMBER] was 69 degrees F and the bathroom was 53 degrees F * room [ROOM NUMBER] was 76 degrees F and the bathroom was 57 degrees F * room [ROOM NUMBER] was 68 degrees F and the bathroom was 55 degrees F * room [ROOM NUMBER] was 69 degrees F and the bathroom was 57 degrees F * room [ROOM NUMBER] was 65 degrees F and the bathroom was 55 degrees F * room [ROOM NUMBER] was 63 degrees F and the bathroom was 59 degrees F * room [ROOM NUMBER] was 62 degrees F and the bathroom was 55 degrees F * room [ROOM NUMBER] was 72 degrees F and the bathroom was 68 degrees F * room [ROOM NUMBER] was 69 degrees F and the bathroom was 55 degrees F * room [ROOM NUMBER] was 71 degrees F and the bathroom was 68 degrees F Observation of room temperatures with Housekeeping and Laundry Supervisor #346 on 01/22/25 at 8:27 A.M. revealed the temperature in room [ROOM NUMBER] was 69 degrees F and the bathroom was 55.8 degrees F. On 01/22/25 at 1:10 P.M. an interview with Director of Clinical Services #380 revealed they were still having issues with heating the bathrooms up to a comfortable temperature. She stated they were working with the heating and cooling company to put in vents in the ceilings in the bathrooms. On 01/22/5 at 6:15 A.M. an interview with Certified Nursing Assistant (CNA) #341 revealed several of the residents on the unit had complained about their rooms being cold and that was why they had the space heaters in their rooms. Review of the facility policy titled, Provisions for Temperature and Humidity Extremes, dated 01/16 revealed a comfortable temperature would be maintained in all resident areas within the home. The temperature range would be between 71 an 81 degrees F. The policy did not address what they would do for cold temperatures just temperatures over 81 degrees F. 2. Review of the October 2024 Resident Council Minutes revealed the residents complained about housekeeping and dirty rooms and hallways. Observations on 01/21/25 at 9:00 A.M. revealed the floor were heavily dirty with dirt and ice melt salt build up in the hallways on the South Unit, the Dining room and resident rooms. Interview during the Environmental tour on 01/22/5 at 10:29 AM with the Housekeeping and Laundry Supervisor #346 revealed she had one housekeeper and one laundry girl on staff and both were full time. She stated they do have a girl that would fill in sometime in the evenings and they would sometimes have a CNA who would pick up time but it had to be approved first. She stated she had been off sick and was only working four hours a day. She stated she knows the floors in the dining and resident rooms were dirty. She stated she just does not have the staff to get it all done. She stated they have hired two new housekeepers but she does not know when they were going to start. She verified the residents' floors in room [ROOM NUMBER], 104, 105, 106, 107, 108, 109, 111, 112, 114, and 116 were dirty. 22653 3. On 01/21/25 at 10:04 A.M., Resident #9 reported she was allergic to dust and had asked that her fan be cleaned for three days. The fan was noted with a thick layer of dust. The heating unit was also blowing with debris noted in the heater unit. The bathtub was brown with a rusty appearance and water backed up in the drain area. On 01/22/25 at 10:18 A.M., Housekeeper #372 verified there was standing water in the bathroom with part of inner surface of the tub having a brown discoloration between rooms in which Residents #8, #9, #29 and #240 resided. Housekeeper #372 stated she had discussed this with the Administrator and she was supposed to get someone to fix it. Housekeeper #372 stated no residents use the tubs in their rooms. Observations with Licensed Practical Nurse (LPN) #302 on 01/22/25 at 4:40 P.M. revealed Resident #9's fan had been cleaned. However, the vent of the heater still had debris. LPN #302 verified the debris in the heating unit and stated she would have to reach out to maintenance to determine if the heating unit could be cleaned. 4. On 01/21/25 at 9:19 A.M., observations of the bathroom between rooms [ROOM NUMBERS] revealed the bathtub had a brown/rusty appearance. There was a bucket with water on the floor partially under the toilet tank with a urinal marked with another resident's name (not a resident who resided in room [ROOM NUMBER] or 112) and two toilet brushes. On 01/21/25 at 9:19 A.M., Registered Nurse (RN) #364 verified the tub had a brown discoloration but stated she did not know who was responsible for cleaning the tubs. Upon addressing the sanitation of the urinal and toilet brushes stored in a bucket of water and the sanitation concerns, RN #364 provided no response. On 01/22/25 at 10:18 A.M., Housekeeper #372 stated she had attempted to scrub the tub between rooms [ROOM NUMBERS] without success. The tub would not come clean. This deficiency represents non-compliance investigated under Complaint Number OH00161357.

Based on medical record review, review of personal funds records and interview, the facility failed to obtain appropriate witness signatures on the authorization for handling funds. This affected one (Resident #8) of five residents whose funds were reviewed. Findings include: During an interview on 01/21/25 at 4:11 P.M., Resident #8's granddaughter stated Resident #8 was a Medicaid recipient. The family received no resources for Resident #8 and had never been asked to sign a paper authorizing the facility to handle funds. To the best of the granddaughter's knowledge, Resident #8 did not have a personal funds account with the facility. Review of a list of resident funds handled by the facility revealed Resident #8 did have a personal funds account managed by the facility. Review of the authorization and agreement to handle resident funds indicated recurring social security benefit payments were to be direct deposited into the account with automatic transfer of care cost payments to the facility with Resident #8 receiving a $50.00 monthly allowance. The area for the resident signature had an infinity sign with two witness signatures with one of the signatures having a RN (Registered Nurse) behind the name. The Administrator also signed the form as a representative payee. The form was signed 09/03/24. Review of the quarterly statements indicated the statements were sent to Resident #8 at the facility's address. Review of Resident #8's medical record revealed diagnoses including Alzheimer's disease and vascular dementia. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #8 was rarely/never able to understand others or to make herself understood. On 01/22/25 at 10:05 A.M., the Administrator stated the two witness signatures on Resident #8's authorization to handle her personal funds were the current Director of Nursing (DON) and the interim DON. The Administrator was unable to state who authorized the facility to handle funds but she signed the form because the facility was the rep payee. On 01/22/25 at 2:34 P.M., Revenue cycle field specialist #385 stated the facility applied as Resident #8's rep payee. Stated when the application is filled out the facility listed any other interested parties who might be interested in being rep payee. It was then up to social security to notify any interested person to act as rep payee. Sometimes if there was an issue with misuse of funds the Social Security office asked the facility to apply for rep payee. Revenue cycle field specialist #385 stated she did not know that was the case for this resident. If a resident was not alert and oriented the facility applied for rep payee. It did not matter who the financial Power of Attorney (POA) was. A financial POA was not accepted by social security. Revenue cycle field specialist #385 indicated it was her understanding the facility could use anybody associated with facility to witness authorization for funds as long as they do not handle funds. On 01/22/25 at 3:15 P.M., the Administrator provided a notice dated 08/30/24 from Social Security Administration indicating the facility was chosen to be Resident #8's representative payee. The notice was addressed to Resident #8. The Administrator stated Resident #8 was admitted with a rep payee and recalled talking to that rep payee (could not recall the name) who told the facility they needed to apply for rep payee. The Administrator stated Resident #8's responsible party would have knowledge of the personal funds account through the quarterly statements sent out. Upon reviewing the quarterly statement, the Administrator verified the statements were sent to the facility's address with Resident #8's name.

Based on record review and interviews, the facility failed to administer medications as ordered to Resident #5 and Resident #238. This affected two (Resident #5 and #238) out of six residents reviewed for medications. Facility census was 37. Findings include: 1. Review of the medical record revealed Resident #238 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included type 2 diabetes, severe morbid obesity, history of transient ischemic attack, and major depressive disorder. The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #238 was cognitively intact. Review of physician orders revealed Resident #238 was ordered Lantus (insulin) 15 units at 6:00 A.M. and Lantus 50 units at 7:00 P.M. to 11:00 P.M. Resident #238 had an order from 06/25/24 for metformin (antidiabetic agent) 750 milligrams twice a day. No special instructions or parameters were in place for metformin or Lantus to be held. Review of the medication administration record (MAR) dated 01/12/25 for the 7:00 P.M. to 11:00 P.M. medication time revealed Resident #238's blood glucose was high. Lantus 50 units was not administered due to scheduled metformin. Resident #238's blood glucose was 238 milligrams per deciliter (mg/dl) on 01/12/25 at 9:00 P.M. Review of progress note dated 01/13/25 at 5:44 A.M. revealed Resident #238's blood glucose was 164 mg/dl. The nurse held Resident #238's scheduled Lantus due to Resident #238 had scheduled metformin that morning. Resident #238 became loud and was screaming for the nurse to administer Lantus. The nurse stated she was holding Lantus until day shift arrived and gave report. Review of the MAR revealed on 01/13/25 at 6:00 A.M. revealed Lantus 15 units was not administered to Resident #238 due to Resident #238's behaviors. Resident #238's blood glucose on 01/13/25 at 11:00 A.M. was 213 mg/dl. A concern form dated 01/13/25 revealed Resident #238 reported an agency nurse did not administer scheduled insulin on 01/12/25 and 01/13/25. The MAR was reviewed and revealed insulin was not administered as ordered per nursing judgement. Interview on 01/21/25 at 10:01 A.M. Resident #238 revealed an agency nurse did not administer insulin as ordered on two separate occasions. Interview on 01/23/25 at 8:53 A.M. Social Service Designee #311 revealed a concern form was completed when Resident #238 reported an agency nurse did not administer scheduled Lantus. Interview on 01/23/25 at 11:12 A.M. Director of Nursing (DON) verified the agency nurse held Resident #238's Lantus on 01/12/25 and 01/13/25. DON stated the nurses were able to hold medications based on nursing judgement. DON verified there was not justification for Resident #238's Lantus to be held due to Resident #238's blood glucose levels and oral metformin being administered. 35765 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses chronic kidney disease, respiratory failure, diabetes, hyperlipidemia, hypothyroidism, anemia, atrial fibrillation, mood disorder, peptic ulcer disease, obstructive sleep apnea, stage 4 pressure ulcer, hypertension, insomnia, accidental discharge of firearms, lack of expected normal physiological development in childhood, and vitamin D deficiency. Review of the physicians order dated 10/23/24 revealed Resident #5 prefer to have morning medications by 9:30 A.M. and his evening medications by 6:15 P.M. per his preference. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #5 had intact cognition. Review of the January 2025 medication administration records revealed Resident #5 was not administered his evening medication on 01/16/25 due to he was sleeping. The medications not administered were Buspar 20 milligrams (mg), Colace 100 mg , Eliquis five mg, hydroxyzine 100 mg, metoprolol succinate 12.5 mg, protonix 40 mg, simvastatin 40 mg, and tagamet 400 mg. On 01/21/25 at 9:20 A.M. an interview with Resident #5 revealed the nurses do not give him his medication as ordered. He stated on 01/16/25 the second shift nurse never gave him his medications. He stated he was told they next day he had refused them and he stated he had not refuse them because the nurse never came into his room all night. On 01/22/25 at 2:40 P.M. an interview with Director of Clinical Services #380 revealed she would expect the nurse to go back and try to administer the medications again On 01/22/5 at 5:06 P.M. an interview with Director of Clinical Services #380 revealed the Director of Nursing had called the agency nurse who had not administered the medication to Resident #5 and she stated she had not went back and offered him his medication again Review of the concern log dated 01/17/25 revealed Resident #5 complained his treatment was not completed on 01/15/25 and 01/16/25 and he was not administered his medications at 6:00 P.M. on 01/16/25. Follow up investigation revealed medication were not given by an agency nurse due to the resident was sleeping. Nurse was reeducated.

Based on review of the medical record and interview the facility failed to ensure weekly wound assessments were completed for Resident #5. This affected one resident (Resident #5) of three reviewed for pressure ulcers. Findings included: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, respiratory failure, diabetes, anemia, atrial fibrillation, obstructive sleep apnea, stage 4 pressure ulcer, hypertension and accidental discharge of firearms. Review of the plan of care dated 04/03/24 and edited 01/01/25 revealed Resident #5 had a wound to the left posterior thigh. Interventions included the in-house skin/wound team would see and treat him weekly and as needed. Review of the physician's order dated 10/23/24 revealed Resident #5 was ordered one gram of gentamicin cream 0.1 percent twice a day to the left posterior thigh, cleanse with normal saline, apply the gentamicin cream to the wound bed cover with an abdominal dressing and do not use adhesive or tape. The order was discontinued on 12/12/24. His current treatment order was for gentamicin 0.1 percent apply to the left posterior thigh, Cleanse the thigh with normal saline, apply gentamicin cream to the wound bed, cover with collagen to the wound bed, and cover with a silicone border form every shift dated 12/26/24. Review of the plan of care dated 10/29/24 and edited on 01/16/25 revealed Resident #5 was high risk for pressure injury due to chronic wound due to non-compliance with treatment plan, turning and repositioning and care plan and medications. Review of the weekly skin assessment dated [DATE] revealed Resident #5 had a stage four pressure ulcer to the left posterior thigh which measured 10.5 centimeters (cm) in length by 2.5 cm in width by 0.1 cm in depth. The wound had a moderate amount of serosanguineous (clear, blood tinged) drainage. The wound was covered in 20 percent slough (yellow or white fibrous material in the wound bed). Review of the progress note dated 12/09/24 at 5:00 A.M. revealed the physician from the hospital called and stated the blood cultures for Resident #5 were positive and she should be transported to the hospital to receive intravenous antibiotics. The resident refused. (The resident was evaluated in the emergency room and had returned to the facility) Review of the progress note dated 12/09/24 at 8:34 A.M. revealed Resident #5 agreed to go to the hospital . Review of the progress note dated 12/09/24 at 2:41 P.M. revealed Resident #5 was admitted for bacteremia. Review of the progress notes dated 12/10/24 at 5:45 P.M. revealed Resident #5 was admitted back to the facility for a wound infection. Review of the weekly skin assessments revealed there were no skin measurement or wound assessment for the week of 12/10/14. Review of the weekly skin assessment dated [DATE] revealed the left posterior thigh wound for Resident #5 measured 12 cm in length by 2.5 cm in width by 0.1 cm in depth. The wound had a moderate amount of serosanguineous drainage. The wound was covered in 30 percent slough. The wound had declined. Review of the progress note dated 12/17/24 at 1:21 P.M. revealed Resident #5 was seen by the wound Nurse Practitioner, following a readmittance from the hospital. The wound was worse. It was debrided revealing 100 percent granulation. The treatment was to remain the same with lotrisone cream to the peri wound and gentamicin to wound bed, cover with abdominal dressing, and paper tape to hold dressing in place. Resident is aware that wound was worse and of treatment. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #5 had intact cognition and had one Stage Four pressure ulcer that was there upon admission. On 01/22/25 at 4:05 P.M. an interview with the Director of Clinical Services #380 revealed there was no documentation Resident #5 refused to have the wound nurse assess his wound or they attempted to ask him later. On 01/22/25 at 4:39 P.M. an interview with Licensed Practical Nurse #302 revealed Resident #5 was very regimented and liked things done a specific way. She stated he refused to see the wound nurse if she was not at the facility at the time she said she would be here. She stated she does not remember if she went back and asked him if she could measure his wound. She verified she had not documented that he had refused and there was no assessment of his wound on 12/10/24. She also verified she could have looked at the wound on 12/11/24. On 01/22/25 at 5:30 P.M. an interview with the Director of Clinical Services #380 revealed Resident #5 had gone out to the hospital on 12/07/24 then returned on 12/08/24, back out to the hospital on 12/09/24 and returned on 12/10/24. She believed that was why his weekly skin assessment was not completed on 12/10/24. Review of the facility policy titled, Skin and Wound Care Best Practice, dated 11/05/24 revealed the purpose was to provide evidence based preventative skin care and wound treatment to prevent unavoidable skin complications.

Based on record review and interview the facility failed to ensure fall interventions were in place and appropriate for Resident #14. The facility also failed to ensure Resident #26's wheelchair was not locked when Resident #26 was left unattended. This affected two (Resident #14 and #26) out of five residents reviewed for accidents. The facility census was 37. Findings include: 1. Review of the medical record revealed Resident #14 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included Alzheimer's disease, major depressive disorder, anxiety, manic episode, epilepsy, acute kidney failure, fibromyalgia, and irritable bowel syndrome. A progress note dated 11/22/24 at 8:45 P.M. revealed Resident #14 was found on the bathroom floor in front of the toilet. Care plan for falls revealed an intervention dated 11/26/24 revealed a motion sensor to be placed in the bathroom. A progress note dated 11/29/24 at 12:24 P.M. revealed Resident #14 was found in the bathroom. Review of the fall documentation revealed no evidence of the motion sensor being in place or sounding. A interdisciplinary team (IDT) note dated 12/02/24 at 10:26 A.M. revealed Resident #14 had a fall in the bathroom on 11/29/24. A new intervention for restorative nursing for toileting hygiene and transfers was put in place. Review of the restorative nursing documentation revealed Resident #14 received restorative services for transfers once and there was no documentation of toileting hygiene. A progress note dated 12/02/24 at 5:05 P.M. revealed Resident #14 was lying on the floor in the bathroom. Review of the care plan for falls revealed an intervention dated 12/04/24 was put in place for Resident #14 to receive restorative therapy for transfers and hygiene care and treatment. The care plan for falls revealed an intervention dated 12/05/24 for Resident #14 to have bladder pattern monitoring. An IDT note dated 12/08/24 at 5:18 P.M. revealed Resident #14 was found on the floor in the bathroom on 12/02/24 and all interventions were in place. A new intervention for Resident #14 to be started on a bladder training and pattern tracking was put in place. Review of the bladder tracking documentation from 12/08/24 through 01/01/25 revealed Resident #14 was incontinent of urine 27 times. A progress note dated 01/02/25 at 10:00 A.M. revealed Resident #14 was on the floor beside her bed. Resident #14 stated she was attempting to go to the bathroom. Review of the bowel and bladder assessment dated [DATE] revealed Resident #14 had no incontinence and no program was required due to Resident #14 was continent. The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #14 had moderate cognitive impairment. The MDS also revealed Resident #14 was frequently incontinent of urine. Interview on 01/23/25 at 8:35 A.M. with the Director of Clinical Services #380 verified there was no evidence of the motion sensor being in place or functioning when Resident #14 fell in the bathroom on 11/29/24. The Director of Clinical Services #380 also verified the bladder tracking documentation revealed Resident #14 was incontinent of urine but a toileting program was not put in place. Interview on 01/23/25 at 12:41 P.M. with the Director of Nursing verified that restorative order for transfers and toileting hygiene for Resident #14 was entered wrong and the nursing staff did not know what restorative care to provide or document on. 2. Review of the medical record revealed Resident #26 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included hepatic encephalopathy, traumatic brain injury, major depressive disorder, anxiety disorder, vascular dementia, visual hallucinations, and violent behavior. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #26 had moderately impaired cognition. A progress note dated 10/30/24 at 1:49 P.M. revealed Resident #26 an unwitnessed fall in the dining room. Resident #26 was found sitting on the floor next to his wheelchair. Resident #26 stated the wheelchair was locked and he slipped out when he tried to turn. The post fall huddle revealed Resident #26 was trying to turn his wheelchair and his wheelchair was locked and Resident #26 tipped forward. Interview on 01/23/25 at 8:25 A.M. with the Director of Clinical Services #380 verified Resident #26 could not lock his wheelchair on his own and the wheelchair should not have been locked.

Based on observation, medical record review, staff interview and facility policy the facility failed to ensure Resident #137 was provided fluids to maintain hydration. This affected one resident (Resident #137) of one residents reviewed for hydration. Findings include: Review of Resident #137's medical record revealed the resident was readmitted on [DATE] with diagnoses including congestive heart failure, respiratory failure with hypoxia, type 2 diabetes mellitus, protein-calorie malnutrition, diabetic retinopathy without macular edema, chronic kidney disease stage 4 (severe), non-rheumatic mitral (valve) insufficiency, myocardial infarction, cognitive communication deficit, anxiety, and hypokalemia, Resident #137's nutritional assessment dated [DATE] indicated Resident #137's calculated fluid need was between 1900 milliliters (ml) to 2100 ml per day. Review of Resident #137's fluid intake documentation dated 01/12/25 to 01/21/25 indicated Resident #137's daily intake of fluid was between 480 ml and 960 ml a day. Resident #137's laboratory results dated [DATE] indicated the potassium level was 5.5 milliequivalents per liter (mEq/L) and the blood urea nitrogen level was 51 milligrams per diluent (mg/dL) with a creatinine level of 2.9 mg/dL The normal range levels for the potassium was 3.5 mEq/L to 5.3 mEq/L, normal BUN level was 7 mg/dL to 15 mg/dL and normal creatinine level was between 0.6 mg/dL to 1.2 mg/dL Resident #137's plan of care initiated on 04/13/24 indicated Resident #137 had dehydration or potential fluid deficit related to medication therapy secondary to heart failure, malnutrition, variable oral intakes. The goal of the plan of care was Resident #137 would not exhibit signs of side effects of complications secondary to diuretic medication use. Interventions on the plan of care included: Assess/document/report to the physician/certified nurse practitioner as needed for signs and symptoms of dehydration; Encourage the resident to drink fluids of choice according to orders.; The resident will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor through next review; Assess/report dehydration (dizziness on sitting/standing, change in mental status, decreased urine output, concentrated urine, poor skin turgor, dry, cracked lips, dry mucus membranes, sunken eyes, constipation, fever, infection, electrolyte imbalance); Report abnormal labs indicative of dehydration (e.g., elevated hemoglobin and hematocrit potassium, chloride, sodium, albumin, transferring, blood urea nitrogen [BUN], or urine specific gravity > 1.030); Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Provide education on the importance of fluid intake as per routine or as needed. An observation on 01/22/25 at 10:49 A.M. revealed Resident #137 was seated in a chair beside her bed and there was not a cup of water present in her room. Resident #137 stated she had a dry cough and complained her tongue was very dry. Resident #137 opened her mouth and her tongue was swollen and very dry. An interview on 01/22/25 at 12:05 with Certified Nursing Assistant (CNA) #348 stated water and ice was delivered to the residents three times a day. CNA #348 stated she did not have time to deliver the water to all the residents earlier in the day because she was assisting the staff on the other nursing unit. CNA #348 verified Resident #137 did not have water at her beside. CNA #348 stated she was assigned to provide care for Resident #137 and stated none of the residents assigned to her were at risk for dehydration. An interview on 01/22/25 at 12:09 P.M. with Resident #137 stated she had requested a cup of water and the staff had delivered a box of boost supplement and a small cup of water but had not delivered additional water for the day yet. An observation of Resident #137 on 01/22/5 at 2:26 P.M. revealed there was no cup of water or water pitcher delivered to Resident #137 in her room. An interview with Registered Dietitian (RD) #363 on 01/22/25 at 2:15 P.M. revealed she assessed the residents during her visits on Thursdays in the facility. RD #363 stated she determined the fluid intake of the residents by reviewing the fluid intake documentation in the resident's chart. RD #363 verified the documentation in Resident #137s medical record indicated Resident #137 was not meeting 75 percent (1,425 ml) of her calculated fluid requirement (1900 ml to 2100 ml) to maintain adequate hydration. RD #363 verified Resident #137's lab results had worsened when compared to the last results obtained on 01/11/25. On 01/22/25 at 2:38 P.M. an interview with RD #363 verified Resident #137 did not have a pitcher/cup of water present in her room. Resident #137's Minimum Data Set (MDS) assessment dated [DATE] indicated she had mild cognitive impairment with a Brief Interview Mental Status assessment score of 13. Review of the facility policy titled Resident Hydration Policy revised on 06/22/20 indicated residents would be offered/administered sufficient fluid intake to maintain hydration. A Variety of fluids would be offered to residents, depending on preference and nutritional/diagnosis considerations. Procedure: A dietitian will evaluate resident fluid status within 14 days of admission, quarterly and as needed. This may include laboratory testing by the provider as ordered (chemistries, Beta Naturetic Peptide (monitors for congestive heart failure etc.) Fluids include water, juices, coffee/tea, gelatin, ice cream, soups, popsicles and any other substance which is essentially liquid in nature. Nursing staff will be primarily responsible for resident fluid intake during and between meals. Fluids may be provided by others determined by resident fluid and dietary orders (such as activities, dietary, visitors). Nursing, medical providers, and dieticians will monitor for signs of dehydration and will monitor resident medications which may alter fluid balance. Fluids will be provided with meals, snacks, and at the bedside, unless otherwise ordered by the provider. If resident fluid status is identified as inadequate, the interdisciplinary team will discuss with the resident and provider and determine if alternative (non-oral) methods of hydration are desired/warranted.

Based on medical record review, interview and policy review, the facility failed to ensure monthly drug regimen reviews identified irregularities in a resident's drug regimen and failed to ensure pharmacy recommendations were responded to in a timely manner. This affected two (Residents #17 and #26) of five residents reviewed for medication use. Findings include: 1. Review of Resident #17's medical record revealed diagnoses including Alzheimer's disease, malignant neoplasm of the esophagus, and chronic pain syndrome. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #17 had short and long term memory problems and severely impaired cognitive skills for daily decison making. a. Review of a monthly pharmacy review dated 06/03/24 indicated Resident #17 had orders for both acetaminophen 650 milligrams (mg) every 12 hours as necessary and hydrocodone/acetaminophen (narcotic pain medication) 5/325 mg every six hours as needed for pain. The pharmacy requested clarification of the parameters for drug selection, reserving the hydrocodone/acetaminophen for more severe pain only. The response at the bottom of the form indicated noted. No orders were clarified and there was nothing under the area for physician response indicating whether the physician accepted or declined the recommendation. On 01/23/25 at 2:36 P.M., Regional Director of Clinical Services #380 verified she could not locate evidence of the recommendation being addressed in June 2024. Both orders were discontinued 08/14/24. b. On 08/21/24, an order was written for ativan 1 mg to be administered every six hours as necessary. There was no time limit written on the order or a time frame in which the ativan use would be re-evaluated for continued use. The order was discontinued on 01/07/25. The order for ativan on an as necessary basis without a time limitation was not addressed by the pharmacist in accordance with recommendations provided. On 01/23/25 at 2:51 P.M. Regional Director of Clinical Services #380 acknowledged pharmacy should have addressed the use of the ativan ordered on an as necessary basis without a date limit. 34298 2. Review of the medical record revealed Resident #26 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included hepatic encephalopathy, traumatic brain injury, major depressive disorder, anxiety disorder, epileptic seizures, alcoholic cirrhosis, vascular dementia, visual hallucinations, and violent behavior. a. Review of pharmacy recommendation dated 06/12/24 revealed Resident #26 was ordered Oxycodone (opioid for moderate to severe pain) five milligram (mg) every eight hours as needed for pain. Oxycodone was the only as needed pain medication ordered. A recommendation was made for acetaminophen (for mild pain) 650 mg every six hours as needed for mild to moderate pain with maximum dose for all sources in a 24-hour period and a clarification for Oxycodone to be administered for severe pain. The pharmacy recommendation was not signed or marked as accepted or declined by the physician/prescriber. Review of the medication administration record (MAR) for June and July revealed a total dosage for acetaminophen was not put in place and indication for Oxycodone listed pain and not severe pain as indicated. b. A pharmacy recommendation dated 06/12/24 revealed Resident #26 was ordered Ativan (antianxiety) one mg as needed every four hours and hydroxyzine (antianxiety) 50 mg every eight hours as needed. A recommendation was made to discontinue one order or specifying parameters for drug selection. If both medications were continued it was recommended the prescriber document an assessment of risk verses benefit, indicating it continues to be a valid therapeutic intervention for Resident #26, and the facility ensures ongoing monitoring for effectiveness and potential adverse consequences. The pharmacy recommendation was declined by the facility physician due to medications were ordered by psychiatric doctor. c. A pharmacy recommendation dated 09/12/24 revealed Resident #26's mother asked for medication review because she felt Resident #26 was over medicated. Recommendations were made to decrease mirtazapine (antidepressant) from 45 mg daily to 30 mg daily and venlafaxine 75 mg three times a day to 75 mg twice a day. If clinically appropriate, a recommendation was also made to decrease Buspar (antianxiety) from 10 mg to five mg every 12 hours and decrease hydroxyzine from 25 mg three times a day to twice a day. The recommendation was declined by the facility physician on 09/18/24 without a rationale. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #26 had moderately impaired cognition. The MDS also revealed Resident #26 received antianxiety and antidepressant medications. Plan of care revised 11/24/24 revealed Resident #26 used psychotropic medications. Interventions included to monitor/document/report signs and symptoms of depression, arrange for psychiatric consult/follow up as indicated, assess/record occurrence of behaviors, and administer medications as ordered Interview on 01/23/25 at 10:11 A.M. the Director of Clinical Services #380 verified the one pharmacy recommendation dated 06/12/24 was not signed by the physician, the parameters for the total daily dose of acetaminophen was not added, and the parameter for Oxycodone to be administered for severe pain was not added to the order. Director of Clinical Services #380 also verified an additional pharmacy recommendation dated 06/12/24 for Ativan and hydroxyzine was not addressed by psychiatric physician. Director of Clinical Services #380 verified the pharmacy recommendation on 09/12/24 was declined but a rationale was not provided. The Medication Regimen Review (MRR) policy and procedure revised on 06/01/24 revealed the facility should encourage physician/prescriber to act upon the recommendations contained in the MRR. For those issues that require physician/prescriber intervention, the facility should encourage physician/prescriber to either accept and act upon the recommendations or reject all or some of the recommendations and provide an explanation as to why the recommendation was rejected.

Based on record review, pharmacy recommendations, and interview, the facility failed to ensure as needed psychotropic drugs were limited to 14 days without a rationale for the order to be extended. This affected one (Resident #26) out of five residents reviewed for unnecessary medications. Facility census was 37. Findings include: Review of the medical record revealed Resident #26 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included hepatic encephalopathy, traumatic brain injury, major depressive disorder, anxiety disorder, vascular dementia, visual hallucinations, and violent behavior. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #26 had moderately impaired cognition. The MDS also revealed Resident #26 received antianxiety and antidepressant medications. The pharmacy recommendation dated 09/06/24 revealed Resident #26 was ordered Ativan (psychotropic/antianxiety) one milligram twice a day as needed. The pharmacy recommendation revealed as needed psychotropic medications were to be limited to 14 days unless the prescriber documented the diagnosed specific condition being treated, the rational for the extended time period, and the duration for the as needed order. The pharmacy recommendation was not signed by the physician, the physician did not accept or decline the recommendation, and the physician did not provide a rational for the as needed Ativan to be extended past 14 days. Review of the physician orders revealed Resident #26 was ordered Ativan from 09/06/24 until 10/02/24. Interview on 01/23/25 at 8:26 A.M. Director of Clinical Services #380 verified the pharmacy recommendation was not signed and a rational was not provided why the as needed Ativan was not limited to 14 days for Resident #26. The Medication Regimen Review (MRR) policy and procedure revised on 06/01/24 revealed the facility should encourage physician/prescriber to act upon the recommendations contained in the MRR. For those issues that require physician/prescriber intervention, the facility should encourage physician/prescriber to either accept and act upon the recommendations or reject all or some of the recommendations and provide an explanation as to why the recommendation was rejected.

Based of observations, review of the medical record and interview the facility failed to ensure medications were not left at bedside for Resident #15. This affected one resident ( Resident #15) of five residents reviewed for accidents. Findings included: Review of the medical records revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included diabetes, hypercholesterolemia, hyperkalemia, acute respiratory failure, hypertension , glaucoma, atrial fibrillation, heart failure, kidney disease, dementia, generalized anxiety disorder, retention of urine, and abnormal weight loss. Review of the January 2025 physician's orders revealed Resident #15 had an order for fluticasone propionate nasal spray 50 micrograms one spray each nostril daily. He did not have an order to leave medications at bedside or he could administer himself. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #15 had intact cognition. Observation on 01/21/25 at 8:50 A.M. revealed Resident #15 was in bed and he had a bottle of fluticasone propionate nasal spray on his over the bed table. On 01/21/25 at 8:57 A. M. an interview with Registered Nurse # 364 verified Resident #15 should not have any medication at bedside.

Based on record review, observation, interview and policy review the facility failed to ensure staff performed hand hygiene to prevent possible cross contamination during Resident #7's medication administration. This affected one resident (Resident #7) of five observed for medication administration. The facility census was 37. Findings include: Resident #7 was admitted to the facility on [DATE] with diagnoses including focal traumatic brain injury, contracture, hypertension (high blood pressure), mild intellectual disabilities, hearing loss, dysphagia, oral phase , pain, dysphagia, and oropharyngeal phase. An observation on 01/22/25 at 8:32 A.M. of Registered Nurse (RN) #364 administer medications to Resident #7 revealed RN #364 failed to perform hand hygiene prior to obtaining Resident #7's medications and dispensing the medications in a medication cup. RN #364 obtained a medication cup by placing her index finger inside the medication cup. RN #364 then proceeded to walk to the nursing station and opened a drawer, touching various surfaces while looking for the key to open the refrigerator door lock. RN #364 then walked to the kitchen, touching the kitchen door handle and asked kitchen staff to provide the thickened water needed to administer the medications to Resident #7. A staff member obtained a box of thickened water and RN #364 opened the box and poured the thickened water in a cup for Resident #7 to drink and swallow his medications. The following medications were administered: - Acetaminophen two 500 milligrams (mg) tablets orally - aspirin 81 mg orally - Chlorhexidine gluconate 0.12% 15 milliliters (ml) swish and spit. - Fenofibrate 145 mg orally - Lisinopril 10 mg orally - Metoprolol Succinate extended release 100 mg orally - omeprazole 20 mg orally. On 01/22/25 at 8:45 A.M. after completing the medication administration to Resident #7, RN #364 verfiied she had not performed hand hygiene prior to administering the medications to Resident #7 and verified she she should have performed hand hygiene before dispensing Resident #7's medications due to touching multiple surfaces, including the nurses' station, kitchen door handle and thickened liquid box. The facility policy titled Hand Hygiene/Handwashing Policy revised 02/21/24 indicated hand hygiene is the most important component for preventing the spread of infection. Use of gloves does not replace the need for hand cleaning by either hand rubbing or hand washing. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: - Immediately before touching a patient. - Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices. - Before moving from work on a soiled body site to a clean body site on the same patient. - After touching a patient or the patient's immediate environment. - After contact with blood, body fluids, or contaminated surfaces. - Immediately after glove removal. The facility policy titled General Dose Preparation and Medication Administration revised on 11/15/24 indicated prior to preparing or administering medications, authorized and competent facility staff should follow facility's infection control policy. Appropriate hand hygiene should be performed before and after direct resident contact.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, facility investigation, self-reported incident (SRI) review, policy and procedure for Abuse, Neglect and Exploitation and, policy and procedure for Inventory Control of Controlled Substances review, the facility failed to ensure controlled medication was not misappropriated. This affected six (Residents #1, #2, #3, #4, #5, and #6) out of 41 residents that resided in the facility at the time of misappropriation. Findings include: Review of SRI tracking number 254526 dated 11/27/24, medical records, and facility investigation revealed controlled medications for Residents #1, #2, #3, #4, #5, and #6 had been misappropriated by Registered Nurse (RN) #103. The morning of 11/27/24, Licensed Practical Nurse (LPN) #101 completed the narcotic count with an agency RN #103. The count was correct. LPN #101 was administering medication and noticed some concerns with the documentation the narcotic accountability records. LPN #101 notified the Director of Nursing (DON). The DON initiated an investigation. The DON audited the narcotic accountability records and found signatures that did not match the facility staff. The DON cross referenced the medications on the narcotic accountability record and the medication administration record (MAR). The DON found the following discrepancies: 1. Review of the medical record revealed Resident #1 was admitted on [DATE] with diagnoses that included type two diabetes, anxiety disorder, acute and chronic respiratory failure with hypoxia, history of transient ischemic attack, and pain. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact and received opioid medication. Resident #1 was ordered Oxycodone (opioid for severe pain) five milligrams (mg) twice a day as needed. Review of the narcotic accountability record revealed an unrecognized signature on 11/26/24 at 3:00 A.M. and 3:30 P.M. The MAR did not reveal documentation of Oxycodone being administered to Resident #1. 2. Review of the medical record revealed Resident #2 was admitted on [DATE] and readmitted [DATE] with diagnoses that included Alzheimer's disease, acute respiratory failure, epilepsy, carcinoma of breast, ulcerative colitis, fibromyalgia, irritable bowel, pain in left shoulder, bilateral knees and right hip. The quarterly MDS assessment dated [DATE] revealed Resident #2 was cognitively impaired and received antianxiety medication. Resident #2 was ordered clonazepam (benzodiazepine) one mg three times a day at 5:00 A.M., 1:00 P.M. and 9:00 P.M. The narcotic accountability record revealed clonazepam was signed out on 11/20/24 at 8:00 A.M. with an unrecognizable signature. The MAR did not reveal documentation of clonazepam being administered to Resident #2 on 11/20/24 at 8:00 A.M. 3. Review of the medical record revealed Resident #3 was admitted on [DATE] with diagnoses that included vesicointestinal fistula, chronic kidney disease, pelvic and perineal pain, and acute ischemia of large intestine. The quarterly MDS assessment dated [DATE] revealed Resident #3 was cognitively intact and received opioid medication. Resident #3 was ordered Norco (opioid to treat moderate pain) 10-325 mg three times a day as needed. The narcotic accountability record revealed Norco on 11/26/24 at 6:10 A.M. and 2:00 P.M. were signed out and administered by facility nurses. Further review of the narcotic accountability record revealed after the 2:00 P.M. signature on 11/26/24, unrecognizable signatures signed out Norco on 11/25/24 at 8:00 A.M. and 11/26/24 at 1:00 P.M. The MAR did not reveal documentation of Norco being administered on 11/25/24 at 8:00 A.M. and 11/26/24 at 1:00 P.M. 4. Review of the medical record revealed Resident #4 was admitted [DATE] and discharged [DATE] with diagnoses of abscess of right lower limb, Stage II (partial-thickness skin loss involving the epidermis and dermis) pressure ulcer, lymphedema, and cellulitis. The MDS assessment dated [DATE] revealed Resident #4 had cognitive impairment and received antianxiety and opioid medication. Resident #4 was ordered Percocet (opioid for moderate to severe pain) 5-325 mg every eight hours as needed. A medication card with seven Percocet 5-325 mg arrived at the facility on 11/20/24. Facility nurses administered Percocet on 11/21/24 at 7:33 A.M. and 11/22/24 at 3:25 A.M. The card with the remaining five Percocet and the shift change control count sheet were discovered missing during the investigation. A second medication card of Percocet arrived at the facility on 11/22/24. The narcotic accountability record revealed unrecognizable signatures signed out Percocet on 11/17/24 at 7:15 A.M., 11/18/24 at 10:10 A.M., 11/19/24 at 7:43 P.M., 11/21/24 at 8:35 A.M., 11/21/24 at 8:30 P.M., and 11/22/24 at 8:30 P.M. The MAR did not reveal documentation of Percocet being administered. Resident #4 was not admitted until 11/19/24 and the medication card was not delivered until 11/22/24. 5. Review of the medical record revealed Resident #5 was admitted on [DATE] and readmitted on [DATE] with diagnoses of multiple rib fractures, chronic respiratory failure, anxiety disorder, dementia, sacroiliitis, and spinal stenosis. The MDS assessment dated [DATE] revealed Resident #5 had cognitive impairment and received opioid, antipsychotic, and antianxiety medications. Resident #5 was ordered tramadol (controlled medication for moderate to moderately severe pain) 50 mg three times a day as needed. The narcotic accountability record revealed an unrecognizable signature signed out tramadol on 11/26/24 at 1:00 P.M. The MAR did not reveal tramadol was administered. 6. Review of the medical record revealed Resident #6 was admitted on [DATE] and discharged [DATE] with diagnoses that included fracture of right femur, type two diabetes, and acute pain due to trauma. The MDS assessment dated [DATE] revealed Resident #6 was cognitively intact and received antianxiety, hypnotic, and opioid medication. Resident #6 was ordered tramadol 50 mg every six hours as needed. RN #103 signed the narcotic accountability record on 11/27/24 at 5:00 A.M. The MAR did not reveal tramadol was administered. Interview on 12/20/24 at 10:06 A.M. LPN #101 revealed they discovered the possible drug diversion and immediately notified the DON. LPN #101 stated they looked at the cards of medication while RN #103 looked at the narcotic accountability record. LPN #101 stated the drug count was correct. LPN #101 noticed unknown signatures on controlled medications and medications being administered at unusual times. LPN #101 stated she now looked at the book and the cards of medication prior to her shift for any unusual activity and to make sure the count was correct. Interview on 12/20/24 at 1:45 P.M. the DON verified the attending physicians, medical director, board of nursing, pharmacy board, drug enforcement agency, local police, and agency company were notified of the potential drug diversion. RN #103 did not respond to phone calls or text messages. The agency reported RN #103 did not respond to any of their calls. RN #103's demographic information was requested from the agency company. The facility discovered RN #103 had previous nursing board probationary actions against his nursing license that were lifted in 2021 due to theft charges and possession of marijuana charges from 2007 and 2009. The DON also verified Resident #1 had two Oxycodone that were unaccounted for. Resident #2 had one clonazepam unaccounted for. Resident #3 had two Norco unaccounted for. Resident #4 had 11 Percocet unaccounted for. Resident #5 had one dose tramadol 50 mg unaccounted for. Resident #6 had one dose of tramadol unaccounted for. The DON also stated agency staff were not being used at this time. If the facility needed to use agency staff in the future, the nurse's licenses would be checked by the facility before the nurse could cover a shift. The Inventory Control of Controlled Substances policy and procedure revised on 08/01/24 revealed the facility should ensure incoming and outgoing nurses count all Schedule II controlled substances and other medications with a risk of abuse of diversion at the change of each shift and document the results on a Controlled Substance Count Verification/Shift Count Sheet. The total number of controlled medications on hand and number of doses remaining in the packages should be reconciled. The facility should ensure its staff immediately report suspected theft or loss of controlled substances to their supervisor/manager. The facility should ensure the appropriate facility personnel confirm the discrepancy and follow facility policy and applicable law regarding documentation of the incident. The Abuse, Neglect and Exploitation policy revised 07/11/24 revealed misappropriation is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of resident's belongings or money without the resident's consent. If the facility enters into a contract for the use of temporary (agency) employees, then it will generally require the organization providing such employees to conduct the background checks and to certify that it will not provide any temporary employees that do not have the requisite licensure or certification. The deficiency was corrected on 11/28/24 when the facility implemented the following corrective actions: On 11/27/24 the DON completed narcotic accountability records and narcotic counts on all medication carts. On 11/27/24 Residents #1, #2, #3, #4, and #6 were interviewed about pain management and updated pain observations were completed by DON/Licensed Nurse. Resident #5 was at the hospital on 11/27/24. On 11/27/24 head-to-toe observations were completed by DON/Licensed Nurse for Residents #1, #2, #3, #4, and #6 to ensure there was no physical abuse. On 11/27/24 the attending physician/medical director were notified by the DON of potential drug diversion. On 11/27/24 the Licensed Nursing Home Administrator (LNHA) initiated a SRI to the Ohio Department of Health. On 11/27/24 the LNHA made phone calls to RN #103 and the agency company. On 11/27/24 the DON spoke with the agency company and requested RN #103 have a drug screen completed. On 11/27/24 the LNHA reviewed random employee files for two LPN's and three RNs, and no negative findings were discovered. On 11/27/24 the DON contacted the local police department. On 11/27/24 the DON sent an email to Consultant Pharmacist about the allegation of misappropriation of narcotic mediation. On 11/27/24 the 27 residents that were able to be interviewed were interviewed about pain management and medication being administered. No negative findings were discovered. On 11/27/24 the 14 residents that were not able to be interviewed had head-to-toe skin observations completed. No negative findings were discovered. On 11/27/24 all 41 residents had pain assessments completed by a licensed nurse. On 11/27/24 the LNHA and DON educated all 54 staff on Abuse, Neglect, and Misappropriation. On 11/27/24 the DON/designee educated all 12 licensed nurses (five LPN's and seven RN's) on Drug Diversion and narcotic accountability. On 11/27/24 an in-service for nurses revealed the nurse was to look at the card of controlled medication and the narcotic accountability sheet when narcotics were being counted at shift change. On 11/27/24 an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held with the medical director in attendance. The DON/designee will complete a narcotic count on each medication cart three times a week for four weeks and then monthly for two months. The DON/designee will audit completed narcotic accountability records three times a week for four weeks and then monthly for two months to ensure any as needed controlled medications administered are documented properly on the MAR and the resident validates (if able) the receipt of the medication. This deficiency represents non-compliance investigated under Self-Reported Incident, Control Number OH00160410.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of a facility self-reported incident (SRI), facility investigation, employee personnel file, facility policy review, and interview, the facility failed to ensure a resident was free from misappropriation of medications. This affected one resident (#8) of three residents reviewed for misappropriation. Findings include: Review of the medical record for the Resident #8 revealed an admitted [DATE]. Diagnoses included chronic kidney disease, chronic pain, chronic ulcer of the lower leg, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/23/23, revealed Resident #8 had intact cognition. The resident required extensive assistance from two staff for bed mobility and extensive assistance from one staff for dressing and personal hygiene. Review of Resident #8's physician order, dated 05/02/23, revealed the order for oxycodone HCL oral tablet, give 10 milligrams (mg) every six hours, as needed for pain. Review of the SRI tracking number 236961, dated 07/11/23, revealed on 07/10/23 at 8:40 P.M., as part of a facility Mock Survey being conducted by the Regional Director of Clinical Services, it was noted that documentation revealed Resident #8 received oxycodone 10 mg (narcotic pain medication) on 07/07/23 at 10:20 P.M., 07/08/23 at 8:34 P.M., 07/09/23 at 8:32 P.M., and 07/10/23 at 8:40 P.M. Each dose was signed as administered by Registered Nurse (RN) #201. Resident #8 was interviewed regarding her pain management and indicated that she had been doing well with her pain and stated that she had been taking the pain medication maybe once every two weeks. When asked what pain medication she was referring to, she replied, the oxycodone. When asked if she had taken any oxycodone the previous night, she said she had not, and when asked if she had taken any over the weekend, she said she had not. The Administrator was informed of the concern identified and an investigation initiated. Review of the facility investigation, dated 07/14/23, revealed the investigation included resident assessments, resident interviews, staff interviews, medical record reviews, narcotic record reviews, and hospital drug screen reviews. RN #201 was suspended immediately pending further investigation. RN #201 denied misappropriating any medications and consented to a drug screen which resulted positive for barbiturates and oxycodone. RN #201 did not have any prescribed medications that would result in a positive drug screen. RN #201 was terminated based on the evidence of the investigation. The allegation of misappropriation of narcotic medications was substantiated. Review of RN #201's personnel record revealed she was terminated from employment on 07/13/23 due to misappropriation of narcotic medication. During interview on 08/02/23 at 10:40 A.M., the Regional Director of Clinical Services/RN #300 confirmed RN #201 misappropriated Resident #8's narcotic medication. Review of the facility policy titled, Ohio Resident Abuse Policy, dated 10/03/22, revealed the facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. The definition of misappropriation is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. The facility will not employ or otherwise engage individuals who have been found guilty of abuse, neglect, or mistreatment of resident by a court of law; had a finding of abuse, neglect, mistreatment, exploitation, involuntary seclusion and/or misappropriation of property reported into a state nurse aide registry, or had a disciplinary action taken against a professional license by a state licensure body as a result of a finding of abuse, neglect, or mistreatment of residents or a finding of misappropriation of property. The deficient practice was corrected on 07/14/23 when the facility implemented the following corrective actions: On 07/11/23 RN #201 was suspended. On 07/11/23 Resident #8 was interviewed related to pain management. On 07/11/23 all residents with narcotic pain medications were interviewed related to pain management and receipt of medications with no negative findings. On 07/11/23 all current residents had pain assessments completed by licensed nurses. On 07/11/23 the DON/Designee reviewed completed narcotic accountability records. On 07/11/23 the Attending Physician / Medical Director was informed and gave an order for a urine drug screen for Resident #8 if the resident will consent. On 07/11/23 Resident #8 is her own responsible party and aware of the investigation. On 07/11/23 Resident #8 consented to a drug screen. The facility completed a drug screen on-site with UScreen Drug Test Cup and then took the same urine sample to the local hospital for further drug screening - Onsite testing resulted negative. On 07/11/23 at 7:54 P.M. the local police were notified and requested to be contacted when the investigation was complete. On 07/11/23 the Administrator and DON educated all staff on the Abuse, Neglect and Misappropriation policy and reporting, staff not on duty were educated via phone, those that were unable to be reached will be educated prior to their next shift. All newly hired staff will be educated on said process during orientation. On 07/12/23 the DON/Designee educated all licensed nurses on Drug Diversion, staff not on duty were educated via phone, those that were unable to be reached will be educated prior to their next shift. All newly hired staff will be educated on said process during orientation. On 07/12/23 a statement was obtained from RN #201, and she consented to a drug screen. On 07/12/23 the Ohio Board of Nursing was emailed, faxed, and called informing of the suspension of RN #201. On 07/12/23 the Consulting Pharmacist was notified of the pending investigation. On 07/12/23 the facility completed an Ad Hoc QAPI meeting. The Medical Director was in attendance. On 07/13/23 RN #201's drug screen tested positive for barbiturates and oxycodone. On 07/13/23 RN #201 was terminated. On 07/13/23 a Teams call was conducted with the Ohio Board of Nursing informing of the positive drug scree, and result of the investigation and subsequent termination of RN #201. On 07/13/23 the Consulting Pharmacist was notified of the positive drug screen of and subsequent termination of RN #201. The Consulting Pharmacist completed the reporting to the Drug Enforcement Agency (DEA). On 07/14/23 the local police were notified. The call log number 236596. On 07/14/23 DON/Designee educated all licensed nurses on medical record documentation. The DON/Designee will audit Narcotic Count on medication carts three times a week for four weeks then monthly times two months to ensure narcotic accountability is properly completed. The DON/Designee will audit narcotic accountability records three times a week for four weeks then monthly times two months to ensure any as needed (PRN) controlled medications administered are documented properly and the resident validates receipt of said medication. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations. This deficiency represents non-compliance investigated under Self-Reported Incident Control Number OH00144641.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, and policy review, the facility failed to ensure proper physical assistance was provided to prevent a fall. This affected one resident (#11) of three residents reviewed for falls. Findings include: Review of the Resident #11's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, flaccid hemiplegia affecting right dominant side, aphasia following cerebral infarction, morbid obesity, and repeated falls. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/11/23, revealed the resident's Brief Interview for Mental Status (BIMS) score could not be assessed due to the resident rarely/never being understood. The resident required extensive, two-person physical assistance for bed mobility, transfers, dressing, and personal hygiene; and was totally dependent on two staff for toileting. The assessment indicated there was one fall with injury, and two or more falls without injury since admission or the prior assessment. Review of the plan of care, dated 02/28/18, revealed Resident #11 was at risk for falls characterized by history of falls, injury, and multiple risk factors including impaired balance, impaired cognition, impaired vision, and memory impairments with interventions including two-person assistance with bed mobility. Further review of the plan of care, dated 08/07/20, revealed the resident had an activities of daily living (ADL) self-care performance deficit related to fatigue and hemiplegia. The intervention, dated 08/07/20, revealed the resident required two-person staff assistance for toileting. Review of a nursing progress note, dated 02/27/23 at 7:27 P.M., revealed the State-tested Nursing Assistant (STNA) came to the nurse immediately and stated that she was changing Resident #11 and while she was turning him, he rolled out of the bed. The resident was asked if he was in pain, and he said yes. The resident was transferred to the emergency room (ER) for further evaluation. Review of interdisciplinary team (IDT) progress noted, dated 02/28/23 at 10:03 A.M., revealed the Director of Nursing (DON) was notified at 6:22 P.M. that Resident #11 had rolled off bed during incontinence care onto the right side of the bed to the floor. Resident was noted to verbalize pain but was unable to state where the pain was located secondary to aphasia. The resident was sent to the ER for evaluation and subsequently returned to facility without injury. X-ray and computed tomography (CT) were negative. Intervention implemented for parameter overlay to bed to decrease risk of fall related injury and two-person assistance for all bed mobility. Review of the Fall Investigation, dated 02/28/23, revealed the resident rolled out of bed on 02/27/23 while care was being provided by the nursing assistant. He was transferred via 911 to the ER for further evaluation. Resident #11 returned to the facility on [DATE] at 11:15 P.M. and all testing was negative for any injury. A perimeter overlay was ordered to be applied on air mattress to provide a boundary. Interview on 08/02/23 at 2:22 P.M. with Regional Director of Clinical Services/Registered Nurse (RN) #300 revealed at the time of the fall, Resident #11's Kardex did not specify the level of staff assistance for toileting or bed mobility. Review of the facility's policy titled, Fall Prevention and Management Policy, revision date of 12/09/19, revealed a fall is defined as unintentionally coming to rest on the ground, floor, or other lower level but not as a result of an overwhelming external force. A fall without injury is still a fall. Individualized interventions will be implemented based on fall risk assessments and care planned accordingly. The deficient practice was corrected on 02/28/23 when the facility implemented the following corrective actions: On 02/27/23 at 6:20 P.M. the Physician was at the facility to assess Resident #11 and ordered for him to be transferred to the local emergency room (ER) for further evaluation. The assessment at the time did not reveal obvious injuries. On 02/27/23 Resident #11's sister and Power of Attorney (POA) were notified of the incident and pending transfer to the ER for further evaluation. On 02/27/23 at statement was obtained from the STNA who was performing care at the time of the occurrence. The STNA was removed from the schedule pending the outcome of the investigation. On 02/27/23 Resident #11's plan of care (POC) and Kardex were reviewed for indication of staff assistance. Transfers were documented for a Hoyer (mechanical lift) with assist of two staff, one person assist for bathing, no specified indication for staff assisting for toileting or bed mobility. On 02/27/23 at 11:15 P.M. the local hospital called reported all the testing and evaluation were completed and negative for any injury, and Resident #11 would return to the facility. On 02/27/23 a pain assessment was completed upon return from the hospital with no complaints of or apparent pain at the time of completion. On 02/28/23 a head-to-toe assessment was completed on Resident #11. No areas of redness or discoloration noted, no complaints of pain or discomfort offered. On 02/28/23 Resident #11's POC and Kardez were updated to reflect two-person assistance for toileting and bed mobility. On 02/28/23 a perimeter overlay was ordered to be applied to the air mattress to provide a boundary. On 02/28/23 the Regional Director of Clinical Service spoke with resident #11's sister / POA to review the occurrence and interventions implemented. On 02/28/23 the DON / Designee reviewed all residents that require assist of two staff for transfers and bed mobility care needs to ensure assistance is reflected accurately on the POC and Kardex updating as indicated. On 02/28/23 the DON / Designee reviewed all residents that are currently utilizing an air mattress to ensure a perimeter overlay was in use, those identified to not have a perimeter, will have one ordered an applied. On 02/28/23 the DON / Designee will educate all nursing staff related to 1.) POC and Kardex indication for the number of staff assistance required for activities of daily living and mobility needs, shown how to find the Kardex information listed. 2.) Air mattresses must have a perimeter overlay when in use. Those staff not present in the facility will be educated via phone and those not available will be educated prior to their next scheduled shift. This will also be presented to new nursing as part of the orientation process. DON/ Designee will complete an observation audit for three residents two times weekly for four weeks then monthly for two months to ensure that residents who require assistance of two staff are being cared for appropriately per the POC and Kardex. DON / Designee will audit three residents two times weekly for four weeks then monthly for two months to ensure residents ordered an air mattress have a perimeter overlay in use. Results from the audits will be submitted to the QAPI committee for further review and recommendation. Ad Hoc QAPI was held on 02/28/23 reviewing the occurrence. This deficiency represents non-compliance investigated under Complaint Number OH00144621.

Based on observation, interview, medical record review, and policy review, the facility failed to properly administer medications. This affected one resident (#10) of three residents reviewed for medications. The facility census was 34. Findings include: Review of the medical record for Resident #10 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, severe protein-calorie malnutrition, acute embolism and thrombosis of deep veins of right lower extremity, cellulitis of right lower limb, chronic pain syndrome, dementia, and hemiplegia and hemiparesis following cerebral infarction the affecting right dominant side. Review of the Minimum Data Set (MDS) 3.0 assessment for Resident #10, dated 04/07/23, revealed the Brief Interview for Mental Status (BIMS) score of 06, which indicated the resident was severely cognitively impaired. The assessment revealed there were no behaviors or rejection of care. The resident required extensive, two-person physical assistance for bed mobility, transfers, toileting, and dressing. Review of the plan of care for Resident #10 revealed the resident had chronic pain and potential for pain with interventions including to administer pharmacological interventions as ordered by physician and monitor for effectiveness. Review of Resident #10's Medication Administration Record (MAR), dated August 2023, revealed on 08/02/23 at 6:00 A.M., Licensed Practical Nurse (LPN) #109 documented that she had administered 13 medications. During observation and interview on 08/02/23 at 9:45 A.M., the resident was placing a white pill in her mouth while holding a small, clear medication cup with her room number written in black marker on the cup. There were nine additional pills remaining in the medication cup. The resident did not remember who had given her the cup of medications or when. The resident's roommate, Resident #12 stated LPN #108 had given them their pills earlier that morning. During interview on 08/02/23 at LPN #102 stated that she did not give the medications to the resident and that they appeared to be the medications from the 6:00 A.M. medication pass. Interview on 08/02/23 at 2:15 P.M., with the Regional Director of Clinical Services/Registered Nurse (RN) #300 confirmed Resident #10's medications should never be left in a cup, and the nurse should ensure all medications have been taken by the resident. RN #300 further stated the resident had a history of hoarding. Review of a policy titled, General Dose Preparation and Medication Administration, dated 01/01/22, revealed facility staff should not leave medications or chemicals unattended. Staff should observe the consumption of medication. This deficiency represents non-compliance investigated under Complaint Number OH00144621.

Based on beneficiary protection notification review and staff interview, the facility failed to ensure residents discharged from skilled services were provided appropriate notification of services ending. This affected one Resident (#5) of three Residents reviewed for beneficiary protection notification. The facility census was 41. Findings include: Review of Resident #5's Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form indicated the resident's last covered day of Part A services was on 12/09/22. The form indicated the SNF Advanced Beneficiary Notice (ABN) Form CMS-10055 was not provided to Resident #5 or their responsible party. Interview with the Administrator on 01/18/23 at 1:50 P.M. verified the SNF ABN Form CMS-10055 was not provided due to she was on vacation and the social services designee was new to the position and unaware of the requirement.

Based on interview and record review the facility failed to hold quarterly plan of care meetings for Resident #24 for the developement of and updates to the plan of care for Resident #24. This affected one out of one resident reviewed for care conferences. The facility census was 41. Findings include: Review of Resident #24's medical record revealed an admitted [DATE]. Diagnoses included hallucinations, weakness, hypertension, and chronic obstructive pulmonary disease (COPD). Review of Resident #24's quarterly Minimum Data Set 3.0 assessment, dated 10/19/22, revealed the resident had intact cogitation. Interview on 01/17/23 at 8:56 A.M. Resident #24 revealed she doesn't believe she has had a care conference meeting and hasn't participated in her care planning. Review of a yearly look back of care conferences from admission through 01/2022 revealed Resident #24's last care conference was on 05/19/22. Interview on 01/17/23 at 3:25 P.M. the Administrator confirmed Resident #24's last care conference was on 05/19/22. She continued it was her expectation care conferences were to be done quarterly. Review of the facility policy, Comprehensive Care Planning Policy, dated 07/19/19, revealed the facility will invite the resident and complete a care conference every 90 days.

Based on record review, interview, and policy and procedure review, the facility failed to follow the bowel protocol when Resident #9 went five days without a bowel movement. This affected one Resident (#9) out of five Residents reviewed for bowel elimination. The facility also failed to notify the physician when Resident #26 gained three to five pounds in one day. This affected one Resident (#26) out of six Residents reviewed for weights. The facility census was 41. Findings include: 1. Review of the medical record revealed Resident #9 was admitted on [DATE] with diagnoses that included type two diabetes mellitus, chronic kidney disease, and acute/chronic respiratory failure. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 was cognitively intact. The resident required extensive assistance of one for bed mobility and total dependence of one for toilet use. Resident #9 was always continent of bowel. Review of the documentation for bowel movements revealed Resident #9 did not have a bowel movement on 01/12/23, 01/13/23, 01/14/23, 01/15/23, and 01/16/23. Resident #9 had an order in place for magnesium hydroxide suspension 30 milliliters (ml) by mouth every 24 hours as needed for constipation. Review of the Medication Administration Record (MAR) revealed no evidence of magnesium hydroxide being administered to Resident #9 to treat the lack of bowel movements from 01/12/23 to 01/16/23. Review of the Bowel Tracking policy and procedure dated 02/26/20 revealed the nursing assistant would document the residents bowel activity on the bowel activity tracking document. If a resident did not have a bowel movement, then the space would be marked as none. The Director of Nursing (DON) was responsible for ensuring a daily auditing process was in place to identify residents who have not had a bowel movement in three day (72 hours). If the resident had not had a bowel movement for three full days (72 hours), the nurse would initiate the facility bowel protocol per standing orders for constipation. Review of standing orders for the facility dated 06/13/22 revealed constipation orders included: magnesium hydroxide 30 ml by mouth every day as needed, bisacodyl suppository 10 milligram (mg) every day as needed, and sodium/bisphosphate/sodium phosphate enema once a day if magnesium hydroxide was ineffective. Interview on 01/18/23 at 2:42 P.M. DON verified there was no evidence of Resident #9 being administered magnesium hydroxide suspension, bisacodyl suppository, or sodium/bisphosphate/sodium phosphate enema per the standing orders and bowel protocol. 2. Review of medical record revealed Resident #26 was admitted on [DATE] and 01/06/21 with diagnoses including but not limited to type two diabetes, mellitus, Alzheimer's disease, atherosclerotic heart disease, and bradycardia. The comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #26 had cognitive impairment. The resident required extensive assistance of one for bed mobility and transfers. Review of physician orders revealed Resident #26 had an order in place for daily weights in the morning for heart failure. The physician was to be notified if there was a three pound gain in one day or five pound gain in one week. On 12/14/22 Resident #26 weighed 213 pounds. On 12/15/22 Resident #26 weighed 218 pounds. Review of the medical record revealed no evidence of the physician being notified Resident #26 had a weight gain of five pounds in one day. On 12/23/22 Resident #26 weighed 213 pounds. On 12/24/22 Resident #26 weighed 216 pounds. Review of the medical record revealed no evidence of the physician being notified Resident #26 had a weight gain of three pounds in one day. On 01/02/23 Resident #26 weighed 218 pounds. On 01/03/23 Resident #26 weighed 222 pounds. Review of the medical record revealed no evidence of the physician being notified Resident #26 had a weight gain of four pounds in one day. Interview on 01/18/23 at 1:12 P.M. DON verified the physician was not notified on 12/15/22, 12/24/22, and 01/03/23 as ordered, when Resident #26 had a weight gain of three pounds or more in one day.

Based on observation, family interview, medical record review and staff interview the facility failed to provide care and services to prevent worsening of identified joint contractures. This affected one Resident (#11) of one Resident reviewed for range of motion services. The facility census was 41. Findings include: Observation of Resident #11 on 01/17/23 at 8:30 A.M. and again at 3:40 P.M. identified contractures to the bilateral elbows and bilateral wrists. No evidence of any splint or brace device was observed in place at this time. Interview with Resident #11's power of attorney (POA) on 01/17/23 at 2:40 P.M. revealed Resident #11 had impaired movement to multiple joints for several years. Resident #11's POA was unaware of any services provided for the residents joint movement limitation other than some therapy at times. Review of Resident #11's medical record revealed an admitted [DATE] with admission diagnoses that included contractures, traumatic brain injury and hypertension. Review of a restorative nursing assessment completed on 06/27/22 identified multiple joint contractures to the neck, bilateral elbows, bilateral wrists, bilateral hips, bilateral knees and bilateral ankles. Further review of the restorative nursing assessment found no evidence of a joint contracture management program provided. Review of MDS 3.0 assessments with reference dates of 10/02/22 and 01/02/23 revealed no evidence of any restorative nursing programs for joint contracture management. Review of Resident #11's care plans revealed no evidence of any care plan related to joint contracture or joint contracture management program. Interview with State tested Nurse Aide (STNA) #126 on 01/17/23 at 3:45 P.M. revealed no knowledge of any type of services provided for Resident #11 related to joint contracture management, including range of motion of splint/brace device use. Interview with the Director of Nursing on 01/18/23 at 9:55 A.M. verified there were no services in place for Resident #11 related to joint contracture management, including range of motion of splint/brace device use.

Based on medical record review, review of a facility self-reported incident (SRI), review of facility witness statements, review of facility Abuse policy, review of Hospice incident report, staff interviews, resident interview, physician interview, medical director interview, and hospice staff interviews, the facility failed to effectively and immediately implement their Abuse policy and procedure following an allegation of staff to resident verbal abuse to ensure the allegation was immediately reported and investigated and to ensure residents were protected from the staff member involved in the incident. This resulted in Immediate Jeopardy on 02/04/21 at approximately 6:30 P.M. when the facility's Administrator was witnessed by Licensed Practical Nurse (LPN) #303, State tested Nursing Assistant (STNA) #304, Hospice LPN #302 and Resident #5 to verbally abuse a newly admitted hospice resident (Resident #37) by yelling at the resident and asking who the (expletive) he thought he was and if he could not follow the rules he could get the (expletive) out. The Administrator then told Hospice LPN #302, (in the presence of Resident #37) she did not know who the (expletive) he thought he was and to not bring people like him (Resident #37) into her facility if they could not follow the rules. In addition, Resident #5, a witness to the verbal abuse to Resident #37, was later intimidated and coerced by the Administrator to change her reporting of the verbal abuse resulting in Resident #5 feeling afraid of the Administrator and having panic attacks that she required medication to treat. The Director of Nursing (DON) and Regional Director of Clinical Services #400 were notified of the staff to resident verbal abuse on 02/04/21 but failed to effectively and immediately report and investigate the abuse until 02/11/21 allowing the Administrator to continue to work. This affected two residents (Resident #5 and Resident #37) of three reviewed for abuse but had the potential to affect all 36 residents in the facility who were at risk for potential harm or injury related to staff to resident abuse. On 02/18/21 at 2:10 P.M. Regional Director of Clinical Service #400 was notified Immediate Jeopardy began on 02/04/21 at approximately 6:30 P.M. when the facility's Administrator was witnessed by LPN #303, STNA #304, Hospice LPN #302 and Resident #5 to verbally abuse and use explicit language to a newly admitted hospice resident (Resident #37). This resulted in the resident becoming fearful, refusing to remain in the facility, calling his spouse to come pick him up and returning to the hospice center. The Immediate Jeopardy continued when Resident #5, a witness to the verbal abuse to Resident #37, was later intimidated and coerced by the Administrator to change her reporting of the verbal abuse resulting in Resident #5 feeling afraid of the Administrator and having panic attacks that required medication to treat. The DON and Regional Director of Clinical Service #400 were notified of the verbal abuse on 02/04/21 but failed to effectively and immediately report and investigate the abuse until 02/11/21 allowing the Administrator to continue to work until 02/11/21. The Immediate Jeopardy was removed on 02/23/21 when the facility implemented the following corrective action: · On 02/11/21 at 4:00 P.M. the Administrator was suspended pending investigation by Regional Vice President of Operations #403. · On 02/11/21 at 5:00 P.M. the Regional Vice President of Operation #403 submitted an SRI ( 5) through the Enhanced Information Dissemination Collection in regard to the verbal abuse of Resident #37. · On 02/11/21, completed at 5:00 P.M., Regional Director of Clinical Services #400 interviewed staff members LPN #303 and STNA #304, who were in proximity of the alleged occurrence. · On 02/11/21, no time identified, the DON received education regarding the abuse policy by Regional Director of Clinical Services #400. · On 02/11/21, no time identified, Regional Vice President of Operations #403 assumed the position of acting Licensed Nursing Home Administrator and Abuse Coordinator for the facility. · On 02/11/21 completed at approximately 6:00 P.M. a root cause exercise was performed, and Quality Assurance and Performance Improvement was conducted by the DON, Regional Director of Clinical Services #400, and Regional Vice President of Operations #403. · On 02/12/21, completed at 11:00 A.M., Regional Director of Clinical Services #400 interviewed Residents #10, #13, #29, #17 and #5 who were present at the time of the occurrence. · On 02/11/21 and completed on 02/12/21 at 5:00 P.M. Regional Director of Clinical Services #400 and the Interim Director of Nursing (DON) conducted concern questionnaires with all 33 residents who were able to complete the question. · On 02/12/21, completed at 6:00 P.M., Regional Director of Clinical Services #400 conducted a 24 hour look back review of progress notes, incident, and accident notes for 02/04/21 to identify unreported incident and allegations of abuse. · On 02/11/21 and completed on 02/15/21 at 12:00 P.M. nine nurses, 14 STNAs, four housekeepers, two activity personnel, nine dietary personnel, five therapy personnel and five administrative personnel were educated by the DON/designee to prevent reoccurrence, regarding abuse identification, prevention and reporting utilizing facility Abuse policy with emphasis on reporting requirements, prevention of abuse and investigation of abuse allegations. · On 02/17/21 at approximately 4:00 P.M. the Administrator resigned from employment at the facility. · On 02/18/21 at 3:57 P.M. Divisional Clinical Director #402 provided education to the Regional Director of Clinical Services #400 regarding completing a thorough investigation and obtaining written statements. · On 02/21/22 at approximately 4:50 P.M. the DON was suspended. · On 02/22/21, no time identified, all new hire staff will receive education regarding abuse identification, prevention and reporting by the Director of Nursing/Designee. · On 02/22/21, no time identified, the facility will initiate to evaluate staff knowledge regarding abuse prevention. The staff will complete three Abuse Questionnaires to determine continued education needs. The questionnaires will be completed three times a week for four weeks then twice monthly and reviewed by the Director of Nursing/Designee. · On 02/22/21, no time identified, facility continued compliance will be evaluated through audits of resident progress notes within the electronic medical record and incident/accident logs to identify unreported incidents of abuse. Audits will be conducted three times a week for four weeks then twice monthly by the Director of Nursing/Designee. · On 02/22/21, no time identified, facility audits consisting of three resident interviews to identify unreported incidents of abuse will be conducted three times a week for four weeks then twice monthly by the Director of Nursing/Designee. · On 02/22/21, no time identified, the results of the audits will be forwarded to the facility Quality Assurance and Performance Improvement committee by the Director of Nursing/Designee for further review and recommendations. · On 02/23/21 at 1:30 P.M. the Regional Vice President of Operations #403 amended the SRI to reflect the Administrator as the perpetrator and changed the findings to substantiated. Although the Immediate Jeopardy was removed on 02/23/21, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure continued compliance. Findings include: 1. Review of the closed medical record revealed Resident #37 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged to the hospice house on 02/04/21. There was no Minimum Data Set (MDS) assessment information in the medical record. Review of the nurse progress notes dated 02/04/21 at 8:21 P.M. revealed Resident #37 arrived at the facility at 6:15 P.M. by ambulance. The hospice nurse (Hospice LPN #302) was at the bedside. The resident was up walking the hallway before an assessment could be performed. The Administrator was in the hall when the resident lit a cigarette in the hallway. The smoking supplies were never given to the resident by the facility. The Administrator told the resident he could not smoke in the building. The resident then got upset and walked down the hallway with the hospice nurse at his side. The resident told the hospice nurse he was leaving and pushed on the doors until they opened, and the resident walked out the back door. The hospice nurse walked outside with him. The resident refused to come back into the building. The hospice nurse then called a second nurse and the resident's wife. The resident's wife picked up the resident from the facility and told the hospice nurse she was going to take the resident back to the hospice house. A call was placed to hospice to confirm the resident was back at the hospice house. The Administrator was still in the building and aware of the situation. The director of nursing and physician were notified. Interview on 02/16/21 at 3:15 P.M., with STNA #304 indicated at 6:30 P.M. on 02/04/21 she was getting ready to take the residents who wanted to smoke outside for smoke break and the new hospice resident, Resident #37, wanted to go out and smoke. She indicated while she was getting the residents ready to go out into the courtyard area, Resident #37 had lit a cigarette in the dining room. She indicated she told him he needed to wait until he went outside. STNA #304 indicated she attempted to [NAME] him out the door, but she could not get to him because there were a few residents in wheelchairs between him and her. STNA #304 indicated the Administrator was by him and she told STNA #304 to put the code in the door and let him out. The resident went outside into the courtyard to smoke his cigarette. She indicated the Administrator started to yell at her wanting to know how he had gotten the cigarettes and lighter. She stated the Administrator was telling her to get the resident's cigarette from him and she needed to get them right now. She stated she told the Administrator she was not going to take the resident's cigarettes from him right now because the resident didn't understand what was going on and he had not been explained the rules. She stated the Administrator went up to the resident when he was coming back into the building and told him to give her his cigarettes now. She stated Resident #37 told the Administrator he was not going to give her expletive. STNA #304 indicated the Administrator was yelling loudly at the resident stating to him she was going to call his wife and it was her facility and if he did not like the rules, he could get the (expletive) out. She indicated the Administrator did not introduce herself to the resident or explain the smoking policy to the resident she just demanded his cigarettes and lighter. STNA #304 indicated she had gone outside with the other residents for the smoke break so she did not know what else was said but she could still hear them yelling through the doors. The next thing she knew LPN #303 and the Administrator were outside looking for the resident and LPN #303 was taking a blanket outside. She indicated she does not know anything after that except the nurse brought the blanket back into the building and the resident never came back in. STNA #304 indicated the Administrator was later going around telling everyone the resident was never admitted to the facility and to not chart he was admitted . She indicated the next day the Administrator was going around to the residents who witnessed the incident and told them she never cussed at Resident #37, they had all heard it wrong. Interview on 02/16/21 at 3:53 P.M. with LPN #303 indicated Resident #37 was admitted to the building on Thursday 02/04/21 at approximately 6:15 P.M. STNA #304 was going to take the residents outside for a smoke break. She stated she was with the Administrator and hospice nurse (Hospice LPN #302) at the South nurse's station when Resident #5 yelled, he just lit a cigarette. She indicated the Administrator yelled at the nursing assistant to get his cigarettes and the nursing assistant said no because he was scared and did not understand. She stated the Administrator then yelled at the resident telling him he could not smoke in the building and to give her his cigarettes. The resident yelled at her and said he was not giving her his cigarette. She stated the resident was getting very upset and was yelling at the Administrator asking what he did wrong and why he was being yelled at. LPN #303 indicated the Administrator asked the resident who the (expletive) he thought he was and if he could not follow the rules, he could get the (expletive) out. LPN #303 stated the resident became very defensive, he did not understand what was going on or why he was being yelled at. She indicated the Administrator then started to yell at the hospice nurse (Hospice LPN #302) and said to him, she did not know who the (expletive) he thought he was and to not bring people like him (Resident #37) into her facility if they could not follow the rules. She stated the Administrator told the hospice nurse he and the resident could just leave and furthermore he could just call the resident's wife to come pick his ass up. LPN #303 stated the hospice nurse tried to calm the resident down and he asked Resident #37 to go back to his room for a second and he would be down to see him. She stated a few minutes later they heard the emergency door alarm go off. She indicated Resident #37 had gone out the emergency door and the Administrator and hospice nurse went after him. She stated the Administrator came back in and said they were gone. She asked the Administrator what she meant, and she said they were gone. LPN #303 indicated she ran outside and saw the hospice nurse and the resident out by the road. She indicated she went out to them and asked the resident to come back inside because it was cold. They resident stated he was not going back into a building where he was being yelled and cursed at. The resident told her he called his wife to come get him. She indicated she tried to give the resident a blanket, but the resident refused. She indicated she asked the hospice nurse if he needed anything and he said he did not, he had called the hospice house and they were coming to pick them up. She indicated she had come in and called the director of nursing because she did not know what to do about the resident leaving against medical advice. Interview on 02/16/21 at 4:30 P.M. with Resident #5 revealed on 02/04/21 a new resident (Resident #37) lit a cigarette in the dining room. She indicated she yelled at the resident because she had oxygen on. She indicated the Administrator started to yell at the aide to get his cigarettes from him and the aide told her no because he did not understand what was going on. Resident #5 stated the Administrator came over to the door and started to yell at the resident. She was telling him to give her his cigarettes and the resident had said no he was not giving her (expletive). The resident indicated the Administrator told Resident #37 to give her his (expletive) cigarettes and when the resident said no again the Administrator asked the resident who the (expletive) he thought he was and he could get the (expletive) out if he could not follow the rules. She stated the resident told her he was not going to be treated or yelled at like that and he was going to call his wife. Resident #5 indicated she went outside with STNA #304 then to smoke. She stated the next day the Administrator came to her in the dining room and told her there was going to be people coming around asking her some questions about what had happened, and the Administrator told her she never cussed at the resident. Resident #5 indicated she told the Administrator, yes, she did, and everyone heard her say it to him. She stated the Administrator said to her she did not treat her residents like that, and she knew it. The resident indicated that was the first time she had heard her yell at a resident like that, but she had heard her yell at the aides numerous times. She indicated she heard her tell an aide if she could not do the job, she needed to find a new (expletive) job. Resident #5 indicated she was having trouble sleeping and was scared the Administrator was going to come back and she was going to get in trouble. Interview on 02/17/21 at 8:30 A.M. with LPN #303 indicated she had let the DON know what had happened the night of the incident. She indicated she had called and texted the DON the night it happened and was unable to reach the DON, so she then called Corporate MDS Nurse #401 and told her what had happened. She indicated Regional Director of Clinical Services #400 then called her and she explained to him what had happened. She stated the DON called her back later that night at home and she told her everything that had happened. She asked the DON if she wanted a written statement and she said, no, Regional Director of Clinical Services #400 would handle it. She indicated the Administrator worked in the building until 02/11/21. Interview on 02/17/21 at 9:45 A.M. with Medical Director #301 indicated he had come into the facility on [DATE] and was made aware of the incident (regarding Resident #37) by the facility staff and residents. He indicated he saw the Administrator in the building, but she seemed to be avoiding him. He told LPN #303 she needed to report the incident to corporate. He indicated LPN #303 stated she had reported it the night it happened. He indicated he gave the facility until 02/11/21 to contact him concerning the incident and nobody had reached out to him about the situation, so he turned in his 30-day resignation as Medical Director at the facility. He indicated he sent an email to the facility and corporate. He indicated he then received a call from Regional Director of Clinical Services #400 on 02/11/21 asking him why he was resigning, and he told him what he was told by the staff concerning the incident and the Administrator. Interview on 02/17/21 at 10:40 A.M. with LPN #303 indicated she was the only nurse working the floor on 02/04/21 because the other nurse working down on South unit had a sick child and had to leave around 5:30 P.M. She indicated she called the DON at 7:00 P.M., 7:07 P.M., 7:20 P.M. and 7:57 P.M. to find out what she was supposed to do about Resident #37 leaving the facility against medical advice. She indicated she also asked the Administrator for Regional Director of Clinical Services #400's phone number and the Administrator refused to give it to her and said she would call him herself. She indicated then the Administrator left to go home, and she still did not know what to do about Resident #37 leaving the building and not returning, so she called Corporate MDS Nurse #401 at 7:22 P.M. because she did not know who else to call. LPN #303 indicated she told Corporate MDS Nurse #401 about the incident and she was concerned about the resident's safety. She stated Corporate MDS Nurse #401 called Regional Director of Clinical Services #400 and made her (LPN #303) stay on the line with her until he called her. She indicated Regional Director of Clinical Services #400 called her within a couple minutes. She told him about the incident but had not told him at that time about the Administrator yelling and cussing at the resident. She stated the DON had then texted her, told her she was at dinner with her family and she would call her when she was able. LPN #303 stated on 02/04/21 at 10:16 P.M. the DON called her, and she told her everything that had happened even what the Administrator had said to Resident #37. LPN #303 indicated when she came back to work on Monday 02/08/21, she had offered to write a statement about the incident and the DON told her they did not need one. LPN #303 indicated Regional Director of Clinical Services #400 called her on 02/11/21 and wanted a verbal statement from her. Interview on 02/17/21 at 11:20 A.M. with STNA #304 revealed she only worked Tuesday through Thursday. She stated she spoke to the DON when she came to work on Tuesday 02/09/21 about what had happened on 02/04/21 and had told her everything. She indicated she asked the DON if she wanted a written statement from her and the DON said no, she could talk to Regional Director of Clinical Services #400 about it. She indicated Regional Director of Clinical Services #400 came in either later that day or the next day she could not remember exactly, and she told him everything that had happened on 02/04/21. Interview on 02/17/21 at 3:00 P.M. with Hospice LPN #302 indicated Resident #37 was admitted to the facility on [DATE] and he was at the facility writing the orders. He indicated the resident had been discharged from the hospice house around 5:00 P.M. and had gotten to the facility shortly after. He indicated he had gone back to the resident room with the resident and ambulance crew to get the resident situated in his room and make sure he was comfortable. He then went back up to the nurse's station to finish writing orders and admitting the resident. A short while later the resident came walking up the hall with a staff member to go outside on a smoke break. The resident went around the corner of the nurse's station into the dining room and he could not see the resident anymore, however, the resident must have lit a cigarette inside the dining room. There was a confrontation with the Administrator and the staff member in the dining room about the resident lighting a cigarette. Hospice LPN #302 indicated the Administrator started to yell inappropriately at the resident, however he could not remember what had been said exactly but she (the Administrator) wanted him to give her his cigarettes and the resident had told her no. He indicated he was more concerned about the welfare of the resident then what was being said. He indicated the resident came up to him and the facility nurse at the nurse station and wanted to leave the building. He indicated the resident did not understand what was going on or why he was being yelled and cussed at. He stated then the Administrator walked up to him at the nurses station while the resident was standing there and started to yell at him saying if this is the type of people who hospice was going to bring to the facility they could both leave. He stated he told her he did not know how the resident got the cigarettes and lighter and he asked the resident to go back to his room for a minute and he would be down to see him. He stated he does not remember the Administrator cussing at him; however, he was not really paying much attention to her because he was more concerned with calming his resident down. He stated he was standing there at the nurse's station with the Administrator when the resident went out the emergency exit door at the end of the hallway. He stated by the time he got to him he was right outside the door on the exit ramp, he was with him the whole time he was outside. He stated the nurse came outside and brought a blanket and asked if he needed anything, he said he had the resident calmed down and he had called the office and the resident had called his wife and she was on her way. The resident's wife got there about 20 minutes later and took the resident back to the hospice house. He indicated Regional Director of Clinical Services #400 called him the next day on 02/05/21 and he told him everything that had happened including the Administrator was yelling at the resident in the dining room and that she had also yelled at him. Interview on 02/18/21 at 9:10 A.M. with Registered Nurse (RN) #310 indicated she was working on the south hall on 02/04/21, however she had to leave around 5:45 P.M. because her son had gotten sick. She indicated she saw the resident (Resident #37) come into the building as she was leaving. She indicated the next day when she came in Resident #5 had been very upset because of the situation. She indicated Resident #5 had been terrified ever since the Administrator had told her to lie for her. She indicated the resident was having trouble sleeping and was having panic attacks. The resident had to be placed on [MEDICATION(S)] (a sedative used to treat anxiety and tension) on 02/15/21 because of the situation. Interview on 02/22/21 at 8:30 A.M. with LPN #303 indicated on 02/08/21 she was sitting at the nurse's station on north when the DON came up to her. She indicated she asked the DON at this time if she wanted her to write a statement about the incident on 02/04/21. She indicated the DON told her no, Regional Director of Clinical Services #400 and Hospice was handling the incident. She indicated Regional Director of Clinical Services #400 had texted her on 02/05/21 to ask her if the Administrator had yelled at the hospice nurse (Hospice LPN #302) and she told him, yes. She indicated Regional Director of Clinical Services #400 called her and asked her for the hospice nurses' information and phone number, so she gave it to him. Interview on 02/22/21 at 8:40 A.M. with STNA #306 indicated she did hear STNA #304 ask the DON on 02/09/21 if the DON wanted her to write a statement about the incident on 02/04/21 and the DON said no, the Regional Director of Clinical Services #400 was handling it. Review of the Community Hospice Incident Report dated 02/04/21 at 5:20 P.M. revealed Hospice LPN #302 was performing a Tuck In Visit with Resident #37. Hospice LPN #302 arrived at the facility before the resident to start writing orders. The resident arrived shortly after via ambulance. The resident was transferred out of the cot with one assist and used his cane to walk to the recliner in the room. Hospice LPN #302 set the resident up in the room making sure he was comfortable. The resident rated his pain as a seven out of ten in his head, the facility had no orders yet and no medication for the resident at this time. The resident was comfortable in his room and stated he had no other needs at this time. The hospice nurse went back to the nurse's station on the 100-hall to finish writing orders and while the nurse was there the staff was getting the residents ready to go outside to smoke. Resident #37 walked down the 100 hallway and turned the corner to go smoke. The resident somehow had cigarettes and a lighter on him and lit a cigarette in the building. The facility Administrator found the resident smoking inside the building. The facility Administrator and the resident had a confrontation, then the resident rounded the corner by the 100-hall nurse's station. The resident was agitated and angry, stating he wanted a receipt so he could sign out of facility and leave. The hospice nurse explained to the resident to go sit in his room and he would be down to talk to him, however before the hospice nurse was able to get to the resident the facility Administrator stopped the hospice nurse demanding the hospice nurse go talk to the resident and get his cigarettes away from him. The Administrator was not professional with the hospice nurse and her voice was raised. The Administrator stated to the resident he could sign Against Medical Advice (AMA) paper and go home. The Administrator told the hospice nurse she would not have a resident like that in the facility. The hospice nurse was unsure what words were said between the Administrator and the resident during the confrontation. The hospice nurse did not witness the confrontation. By the time the Administrator finished with the hospice nurse the resident was standing at the emergency exit door down the 100-hall with his supplies and had made the alarm go off. The door opened before the hospice nurse could get to the resident. The resident stormed out walking towards the road. The resident could not be redirected inside, the hospice nurse stayed with the resident and contacted the hospice house around 6:35 P.M. to get a hold of the manger on duty. During this time the resident had called his wife multiple times to come pick him up. The hospice nurse was able to get the resident to relax but he stated he was not going back inside, stating he was not staying at a place where people treated him like that. The hospice nurse stayed with the resident as they walked down the sidewalk. The resident's wife arrived around 7:00 P.M. and the resident walked right up to her car and got into the passenger seat. The resident's wife was very emotional when she pulled up. The hospice nurse explained to the wife to take the resident to the hospice house and the wife was agreeable. The hospice nurse then updated the hospice manger to let her know the resident was on his way back to the hospice house and was safe in the wife's car. The facility staff was unsure of what to do and would call into hospice if they needed anything done due to the resident not returning to the facility. The hospice nurses gathered the rest of the resident's personal supplies and brought them back to the hospice house. Review of SRI # 5 completed 02/17/21 at 6:20 P.M. revealed on 02/11/21 Regional Director of Clinical Services #400 was notified by Medical Director #301 of an alleged incident that was reported to have occurred on 02/04/21, the perpetrator was the facility's Administrator. The alleged incident consisted of the Administrator utilizing explicit language when speaking to Resident #37. The Administrator was suspended, and an investigation initiated. The investigation consisted of interviews of residents and staff reported to have been present at the time of the incident as well as interviews of all residents who were able to be interviewed and skin checks conducted for all residents who were unable to be interviewed. An interview was also conducted of an outside agent, a hospice nurse, who had also been present at the time of the alleged incident. This interview was conducted by the Medical Director. Resident #37 was discharged from the facility on 02/04/21 prior to being interviewed. The incident was described in interviews; facility residents were preparing to smoke when Resident #37 lit a cigarette while still in the facility. Resident #5 attempted to address Resident #37 in an attempt to have him extinguish the cigarette then the Administrator approached Resident #37 at that time in regard to extinguishing the cigarette. Resident #37 declined to do so utilizing explicate language. The Administrator in return communication utilized an explicit word in response, at that time the staff and hospice nurse present intervened. There was no further interaction between Resident #37 and the Administrator. The SRI identified through interview a resident and two staff members present at the time of the alleged incident reported the Administrator had utilized an explicit word when communicating to Resident #37. Four other residents who had been present at the time of incident reported no knowledge of the allegation. The hospice nurse who was also present did not report knowledge of explicit language utilized by the Administrator in communication with Resident #37. The SRI identified no concerns were identified through interviews and skin checks conducted for the remaining residents. Through investigation it was unable to definitely determine abuse occurred but did determine the Administrator did conduct herself in a manner not consistent with the organization standards and when addressed resulted in the resignation of the Administrator. Review of the SRI revealed review of the typed, not signed witness statement dated 02/11/21 revealed as part of an investigation LPN #303 was interviewed regarding her knowledge of the alleged incident that occurred on 02/04/21. LPN #303 reported she was present at the nurses' station in relative proximity to the common dining room where the incident occurr [TRUNCATED]

Based on medical record review, review of a facility self-reported incident (SRI), review of facility witness statements, review of facility Abuse policy, review of Hospice incident report, staff interviews, resident interview, physician interview, medical director interview, and hospice staff interviews, the facility failed to complete a thorough and accurate investigation of staff to resident verbal abuse to prevent further potential abuse and ensure the safety of all residents. This resulted in Immediate Jeopardy on 02/04/21 at approximately 6:30 P.M. when the facility's Administrator was witnessed by Licensed Practical Nurse (LPN) #303, State tested Nursing Assistant (STNA) #304, Hospice LPN #302 and Resident #5 to verbally abuse a newly admitted hospice resident (Resident #37) by yelling at the resident and asking who the (expletive) he thought he was and if he could not follow the rules he could get the (expletive) out. The Administrator then told Hospice LPN #302, (in the presence of Resident #37) she did not know who the (expletive) he thought he was and to not bring people like him (Resident #37) into her facility if they could not follow the rules. In addition, Resident #5, a witness to the verbal abuse to Resident #37, was later intimidated and coerced by the Administrator to change her reporting of the verbal abuse resulting in Resident #5 feeling afraid of the Administrator and having panic attacks that she required medication to treat. The facility failed to immediately and thoroughly investigate the Administrator to resident verbal abuse including not obtaining hand- written witness statements, failing to have witness review and approve of typed statements, and failing to provide complete and accurate witness statements. This affected two residents (Resident #5 and Resident #37) of three reviewed for abuse but had the potential to affect all 36 residents in the facility who were at risk for the potential harm or injury related to incidents of staff to resident abuse. On 02/18/21 at 2:10 P.M. Regional Director of Clinical Service #400 was notified Immediate Jeopardy began on 02/04/21 at approximately 6:30 P.M. when the facility's Administrator was witnessed by LPN #303, STNA #304, Hospice LPN #302 and Resident #5 to verbally abuse and use explicit language to a newly admitted hospice resident (Resident #37). This resulted in the resident becoming fearful, refusing to remain in the facility, calling his spouse to come pick him up and returning to the hospice center. The Immediate Jeopardy continued when Resident #5, a witness to the verbal abuse to Resident #37, was later intimidated and coerced by the Administrator to change her reporting of the verbal abuse resulting in Resident #5 feeling afraid of the Administrator and having panic attacks that required medication to treat. The facility failed to immediately and thoroughly investigate the Administrator to resident verbal abuse including not obtaining hand - written witness statements, failing to have witness review and approve of typed statements, and failing to provide complete and accurate witness statements resulting in the facility determination the Administrator to resident verbal abuse being unsubstantiated. The Immediate Jeopardy was removed on 02/23/21 when the facility implemented the following corrective action: · On 02/11/21 at 4:00 P.M. the Administrator was suspended pending investigation by Regional Vice President of Operations #403. · On 02/11/21 at 5:00 P.M. the Regional Vice President of Operation #403 submitted an SRI ( 5) through the Enhanced Information Dissemination Collection in regard to the verbal abuse of Resident #37. · On 02/11/21, completed at 5:00 P.M., Regional Director of Clinical Services #400 interviewed staff members Licensed Practical Nurse (LPN) #303 and State tested Nurse Aide (STNA) #304, who were in proximity of the alleged occurrence. · On 02/11/21, no time identified, the DON received education regarding the abuse policy by Regional Director of Clinical Services #400. · On 02/11/21, no time identified, Regional Vice President of Operations #403 assumed the position of acting Licensed Nursing Home Administrator and Abuse Coordinator for the facility. · On 02/11/21 completed at approximately 6:00 P.M. a root cause exercise was performed, and Quality Assurance and Performance Improvement was conducted by the DON, Regional Director of Clinical Services #400, and Regional Vice President of Operations #403. · On 02/12/21, completed at 11:00 A.M., Regional Director of Clinical Services #400 interviewed Residents #10, #13, #29, #17 and #5 who were present at the time of the occurrence. · On 02/11/21 and completed on 02/12/21 at 5:00 P.M. Regional Director of Clinical Services #400 and the Interim Director of Nursing (DON) conducted concern questionnaires with all 33 residents who were able to complete the question. · On 02/12/21, completed at 6:00 P.M., Regional Director of Clinical Services #400 conducted a 24 hour look back review of progress notes, incident, and accident notes for 02/04/21 to identify unreported incident and allegations of abuse. · On 02/11/21 and completed on 02/15/21 at 12:00 P.M. nine nurses, 14 STNAs, four housekeepers, two activity personnel, nine dietary personnel, five therapy personnel and five administrative personnel were educated by the DON/designee to prevent reoccurrence, regarding abuse identification, prevention and reporting utilizing facility Abuse policy with emphasis on reporting requirements, prevention of abuse and investigation of abuse allegations. · On 02/17/21 at approximately 4:00 P.M. the Administrator resigned from employment at the facility. · On 02/18/21 at 3:57 P.M. Divisional Clinical Director #402 provided education to the Regional Director of Clinical Services #400 regarding completing a thorough investigation and obtaining written statements. · On 02/21/22 at approximately 4:50 P.M. the DON was suspended. · On 02/22/21, no time identified, all new hire staff will receive education regarding abuse identification, prevention and reporting by the Director of Nursing/Designee. · On 02/22/21, no time identified, the facility will initiate to evaluate staff knowledge regarding abuse prevention. The staff will complete three Abuse Questionnaires to determine continued education needs. The questionnaires will be completed three times a week for four weeks then twice monthly and reviewed by the Director of Nursing/Designee. · On 02/22/21, no time identified, facility continued compliance will be evaluated through audits of resident progress notes within the electronic medical record and incident/accident logs to identify unreported incidents of abuse. Audits will be conducted three times a week for four weeks then twice monthly by the Director of Nursing/Designee. · On 02/22/21, no time identified, facility audits consisting of three resident interviews to identify unreported incidents of abuse will be conducted three times a week for four weeks then twice monthly by the Director of Nursing/Designee. · On 02/22/21, no time identified, the results of the audits will be forwarded to the facility Quality Assurance and Performance Improvement committee by the Director of Nursing/Designee for further review and recommendations. · On 02/23/21 at 1:30 P.M. the Regional Vice President of Operations #403 amended the SRI to reflect the Administrator as the perpetrator and changed the findings to substantiated. Although the Immediate Jeopardy was removed on 02/23/21, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure continued compliance. Findings include: 1. Review of the closed medical record revealed Resident #37 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged to the hospice house on 02/04/21. There was no Minimum Data Set (MDS) assessment information in the medical record. Review of the nurse progress notes dated 02/04/21 at 8:21 P.M. revealed Resident #37 arrived at the facility at 6:15 P.M. by ambulance. The hospice nurse (Hospice LPN #302) was at the bedside. The resident was up walking the hallway before an assessment could be performed. The Administrator was in the hall when the resident lit a cigarette in the hallway. The smoking supplies were never given to the resident by the facility. The Administrator told the resident he could not smoke in the building. The resident then got upset and walked down the hallway with the hospice nurse at his side. The resident told the hospice nurse he was leaving and pushed on the doors until they opened, and the resident walked out the back door. The hospice nurse walked outside with him. The resident refused to come back into the building. The hospice nurse then called a second nurse and the resident's wife. The resident's wife picked up the resident from the facility and told the hospice nurse she was going to take the resident back to the hospice house. A call was placed to hospice to confirm the resident was back at the hospice house. The Administrator was still in the building and aware of the situation. The DON and physician were notified. Interview on 02/16/21 at 3:15 P.M., with STNA #304 indicated at 6:30 P.M. on 02/04/21 she was getting ready to take the residents who wanted to smoke outside for smoke break and the new hospice resident, Resident #37, wanted to go out and smoke. She indicated while she was getting the residents ready to go out into the courtyard area, Resident #37 had lit a cigarette in the dining room. She indicated she told him he needed to wait until he went outside. STNA #304 indicated she attempted to [NAME] him out the door, but she could not get to him because there were a few residents in wheelchairs between him and her. STNA #304 indicated the Administrator was by him and she told STNA #304 to put the code in the door and let him out. The resident went outside into the courtyard to smoke his cigarette. She indicated the Administrator started to yell at her wanting to know how he had gotten the cigarettes and lighter. She stated the Administrator was telling her to get the resident's cigarette from him and she needed to get them right now. She stated she told the Administrator she was not going to take the resident's cigarettes from him right now because the resident didn't understand what was going on and he had not been explained the rules. She stated the Administrator went up to the resident when he was coming back into the building and told him to give her his cigarettes now. She stated Resident #37 told the Administrator he was not going to give her expletive. STNA #304 indicated the Administrator was yelling loudly at the resident stating to him she was going to call his wife and it was her facility and if he did not like the rules, he could get the (expletive) out. She indicated the Administrator did not introduce herself to the resident or explain the smoking policy to the resident she just demanded his cigarettes and lighter. STNA #304 indicated she had gone outside with the other residents for the smoke break so she did not know what else was said but she could still hear them yelling through the doors. The next thing she knew LPN #303 and the Administrator were outside looking for the resident and LPN #303 was taking a blanket outside. She indicated she does not know anything after that except the nurse brought the blanket back into the building and the resident never came back in. STNA #304 indicated the Administrator was later going around telling everyone the resident was never admitted to the facility and to not chart he was admitted . She indicated the next day the Administrator was going around to the residents who witnessed the incident and told them she never cussed at Resident #37, they had all heard it wrong. Interview on 02/16/21 at 3:53 P.M. with LPN #303 indicated Resident #37 was admitted to the building on Thursday 02/04/21 at approximately 6:15 P.M. STNA #304 was going to take the residents outside for a smoke break. She stated she was with the Administrator and hospice nurse (Hospice LPN #302) at the South nurse's station when Resident #5 yelled, he just lit a cigarette. She indicated the Administrator yelled at the nursing assistant to get his cigarettes and the nursing assistant said no because he was scared and did not understand. She stated the Administrator then yelled at the resident telling him he could not smoke in the building and to give her his cigarettes. The resident yelled at her and said he was not giving her his cigarette. She stated the resident was getting very upset and was yelling at the Administrator asking what he did wrong and why he was being yelled at. LPN #303 indicated the Administrator asked the resident who the (expletive) he thought he was and if he could not follow the rules, he could get the (expletive) out. LPN #303 stated the resident became very defensive, he did not understand what was going on or why he was being yelled at. She indicated the Administrator then started to yell at the hospice nurse (Hospice LPN #302) and said to him, she did not know who the (expletive) he thought he was and to not bring people like him (Resident #37) into her facility if they could not follow the rules. She stated the Administrator told the hospice nurse he and the resident could just leave and furthermore he could just call the resident's wife to come pick his ass up. LPN #303 stated the hospice nurse tried to calm the resident down and he asked Resident #37 to go back to his room for a second and he would be down to see him. She stated a few minutes later they heard the emergency door alarm go off. She indicated Resident #37 had gone out the emergency door and the Administrator and hospice nurse went after him. She stated the Administrator came back in and said they were gone. She asked the Administrator what she meant, and she said they were gone. LPN #303 indicated she ran outside and saw the hospice nurse and the resident out by the road. She indicated she went out to them and asked the resident to come back inside because it was cold. They resident stated he was not going back into a building where he was being yelled and cursed at. The resident told her he called his wife to come get him. She indicated she tried to give the resident a blanket, but the resident refused. She indicated she asked the hospice nurse if he needed anything and he said he did not, he had called the hospice house and they were coming to pick them up. She indicated she had come in and called the director of nursing because she did not know what to do about the resident leaving against medical advice. Interview on 02/16/21 at 4:30 P.M. with Resident #5 revealed on 02/04/21 a new resident (Resident #37) lit a cigarette in the dining room. She indicated she yelled at the resident because she had oxygen on. She indicated the Administrator started to yell at the aide to get his cigarettes from him and the aide told her no because he did not understand what was going on. Resident #5 stated the Administrator came over to the door and started to yell at the resident. She was telling him to give her his cigarettes and the resident had said no he was not giving her (expletive). The resident indicated the Administrator told Resident #37 to give her his (expletive) cigarettes and when the resident said no again the Administrator asked the resident who the (expletive) he thought he was and he could get the (expletive) out if he could not follow the rules. She stated the resident told her he was not going to be treated or yelled at like that and he was going to call his wife. Resident #5 indicated she went outside with STNA #304 then to smoke. She stated the next day the Administrator came to her in the dining room and told her there was going to be people coming around asking her some questions about what had happened, and the Administrator told her she never cussed at the resident. Resident #5 indicated she told the Administrator, yes, she did, and everyone heard her say it to him. She stated the Administrator said to her she did not treat her residents like that, and she knew it. The resident indicated that was the first time she had heard her yell at a resident like that, but she had heard her yell at the aides numerous times. She indicated she heard her tell an aide if she could not do the job, she needed to find a new (expletive) job. Resident #5 indicated she was having trouble sleeping and was scared the Administrator was going to come back and she was going to get in trouble. Interview on 02/17/21 at 8:30 A.M. with LPN #303 indicated she had let the DON know what had happened the night of the incident. She indicated she had called and texted the DON the night it happened and was unable to reach the DON, so she then called Corporate MDS Nurse #401 and told her what had happened. She indicated Regional Director of Clinical Services #400 then called her and she explained to him what had happened. She stated the DON called her back later that night at home and she told her everything that had happened. She asked the DON if she wanted a written statement and she said, no, Regional Director of Clinical Services #400 would handle it. She indicated the Administrator worked in the building until 02/11/21. Interview on 02/17/21 at 9:45 A.M. with Medical Director #301 indicated he had come into the facility on [DATE] and was made aware of the incident (regarding Resident #37) by the facility staff and residents. He indicated he saw the Administrator in the building, but she seemed to be avoiding him. He told LPN #303 she needed to report the incident to corporate. He indicated LPN #303 stated she had reported it the night it happened. He indicated he gave the facility until 02/11/21 to contact him concerning the incident and nobody had reached out to him about the situation, so he turned in his 30-day resignation as Medical Director at the facility. He indicated he sent an email to the facility and corporate. He indicated he then received a call from Regional Director of Clinical Services #400 on 02/11/21 asking him why he was resigning, and he told him what he was told by the staff concerning the incident and the Administrator. Interview on 02/17/21 at 10:40 A.M. with LPN #303 indicated she was the only nurse working the floor on 02/04/21 because the other nurse working down on South unit had a sick child and had to leave around 5:30 P.M. She indicated she called the DON at 7:00 P.M., 7:07 P.M., 7:20 P.M. and 7:57 P.M. to find out what she was supposed to do about Resident #37 leaving the facility against medical advice. She indicated she also asked the Administrator for Regional Director of Clinical Services #400's phone number and the Administrator refused to give it to her and said she would call him herself. She indicated then the Administrator left to go home, and she still did not know what to do about Resident #37 leaving the building and not returning, so she called Corporate MDS Nurse #401 at 7:22 P.M. because she did not know who else to call. LPN #303 indicated she told Corporate MDS Nurse #401 about the incident and she was concerned about the resident's safety. She stated Corporate MDS Nurse #401 called Regional Director of Clinical Services #400 and made her (LPN #303) stay on the line with her until he called her. She indicated Regional Director of Clinical Services #400 called her within a couple minutes. She told him about the incident but had not told him at that time about the Administrator yelling and cussing at the resident. She stated the DON had then texted her, told her she was at dinner with her family and she would call her when she was able. LPN #303 stated on 02/04/21 at 10:16 P.M. the DON called her, and she told her everything that had happened even what the Administrator had said to Resident #37. LPN #303 indicated when she came back to work on Monday 02/08/21, she had offered to write a statement about the incident and the DON told her they did not need one. LPN #303 indicated Regional Director of Clinical Services #400 called her on 02/11/21 and wanted a verbal statement from her. Interview on 02/17/21 at 11:20 A.M. with STNA #304 revealed she only worked Tuesday through Thursday. She stated she spoke to the DON when she came to work on Tuesday 02/09/21 about what had happened on 02/04/21 and had told her everything. She indicated she asked the DON if she wanted a written statement from her and the DON said no, she could talk to Regional Director of Clinical Services #400 about it. She indicated Regional Director of Clinical Services #400 came in either later that day or the next day she could not remember exactly, and she told him everything that had happened on 02/04/21. Interview on 02/17/21 at 3:00 P.M. with Hospice LPN #302 indicated Resident #37 was admitted to the facility on [DATE] and he was at the facility writing the orders. He indicated the resident had been discharged from the hospice house around 5:00 P.M. and had gotten to the facility shortly after. He indicated he had gone back to the resident room with the resident and ambulance crew to get the resident situated in his room and make sure he was comfortable. He then went back up to the nurse's station to finish writing orders and admitting the resident. A short while later the resident came walking up the hall with a staff member to go outside on a smoke break. The resident went around the corner of the nurse's station into the dining room and he could not see the resident anymore, however, the resident must have lit a cigarette inside the dining room. There was a confrontation with the Administrator and the staff member in the dining room about the resident lighting a cigarette. Hospice LPN #302 indicated the Administrator started to yell inappropriately at the resident, however he could not remember what had been said exactly but she (the Administrator) wanted him to give her his cigarettes and the resident had told her no. He indicated he was more concerned about the welfare of the resident then what was being said. He indicated the resident came up to him and the facility nurse at the nurse station and wanted to leave the building. He indicated the resident did not understand what was going on or why he was being yelled and cussed at. He stated then the Administrator walked up to him at the nurses station while the resident was standing there and started to yell at him saying if this is the type of people who hospice was going to bring to the facility they could both leave. He stated he told her he did not know how the resident got the cigarettes and lighter and he asked the resident to go back to his room for a minute and he would be down to see him. He stated he does not remember the Administrator cussing at him; however, he was not really paying much attention to her because he was more concerned with calming his resident down. He stated he was standing there at the nurse's station with the Administrator when the resident went out the emergency exit door at the end of the hallway. He stated by the time he got to him he was right outside the door on the exit ramp, he was with him the whole time he was outside. He stated the nurse came outside and brought a blanket and asked if he needed anything, he said he had the resident calmed down and he had called the office and the resident had called his wife and she was on her way. The resident's wife got there about 20 minutes later and took the resident back to the hospice house. He indicated Regional Director of Clinical Services #400 called him the next day on 02/05/21 and he told him everything that had happened including the Administrator was yelling at the resident in the dining room and that she had also yelled at him. Interview on 02/18/21 at 9:10 A.M. with Registered Nurse (RN) #310 indicated she was working on the south hall on 02/04/21, however she had to leave around 5:45 P.M. because her son had gotten sick. She indicated she saw the resident (Resident #37) come into the building as she was leaving. She indicated the next day when she came in Resident #5 had been very upset because of the situation. She indicated Resident #5 had been terrified ever since the Administrator had told her to lie for her. She indicated the resident was having trouble sleeping and was having panic attacks. The resident had to be placed on [MEDICATION(S)] (a sedative used to treat anxiety and tension) on 02/15/21 because of the situation. Interview on 02/22/21 at 8:30 A.M. with LPN #303 indicated on 02/08/21 she was sitting at the nurse's station on north when the DON came up to her. She indicated she asked the DON at this time if she wanted her to write a statement about the incident on 02/04/21. She indicated the DON told her no, Regional Director of Clinical Services #400 and Hospice was handling the incident. She indicated Regional Director of Clinical Services #400 had texted her on 02/05/21 to ask her if the Administrator had yelled at the hospice nurse (Hospice LPN #302) and she told him, yes. She indicated Regional Director of Clinical Services #400 called her and asked her for the hospice nurses' information and phone number, so she gave it to him. Interview on 02/22/21 at 8:40 A.M. with STNA #306 indicated she did hear STNA #304 ask the DON on 02/09/21 if the DON wanted her to write a statement about the incident on 02/04/21 and the DON said no, the Regional Director of Clinical Services #400 was handling it. Review of the Community Hospice Incident Report dated 02/04/21 at 5:20 P.M. revealed Hospice LPN #302 was performing a Tuck In Visit with Resident #37. Hospice LPN #302 arrived at the facility before the resident to start writing orders. The resident arrived shortly after via ambulance. The resident was transferred out of the cot with one assist and used his cane to walk to the recliner in the room. Hospice LPN #302 set the resident up in the room making sure he was comfortable. The resident rated his pain as a seven out of ten in his head, the facility had no orders yet and no medication for the resident at this time. The resident was comfortable in his room and stated he had no other needs at this time. The hospice nurse went back to the nurse's station on the 100-hall to finish writing orders and while the nurse was there the staff was getting the residents ready to go outside to smoke. Resident #37 walked down the 100 hallway and turned the corner to go smoke. The resident somehow had cigarettes and a lighter on him and lit a cigarette in the building. The facility Administrator found the resident smoking inside the building. The facility Administrator and the resident had a confrontation, then the resident rounded the corner by the 100-hall nurse's station. The resident was agitated and angry, stating he wanted a receipt so he could sign out of facility and leave. The hospice nurse explained to the resident to go sit in his room and he would be down to talk to him, however before the hospice nurse was able to get to the resident the facility Administrator stopped the hospice nurse demanding the hospice nurse go talk to the resident and get his cigarettes away from him. The Administrator was not professional with the hospice nurse and her voice was raised. The Administrator stated to the resident he could sign Against Medical Advice (AMA) paper and go home. The Administrator told the hospice nurse she would not have a resident like that in the facility. The hospice nurse was unsure what words were said between the Administrator and the resident during the confrontation. The hospice nurse did not witness the confrontation. By the time the Administrator finished with the hospice nurse the resident was standing at the emergency exit door down the 100-hall with his supplies and had made the alarm go off. The door opened before the hospice nurse could get to the resident. The resident stormed out walking towards the road. The resident could not be redirected inside, the hospice nurse stayed with the resident and contacted the hospice house around 6:35 P.M. to get a hold of the manger on duty. During this time the resident had called his wife multiple times to come pick him up. The hospice nurse was able to get the resident to relax but he stated he was not going back inside, stating he was not staying at a place where people treated him like that. The hospice nurse stayed with the resident as they walked down the sidewalk. The resident's wife arrived around 7:00 P.M. and the resident walked right up to her car and got into the passenger seat. The resident's wife was very emotional when she pulled up. The hospice nurse explained to the wife to take the resident to the hospice house and the wife was agreeable. The hospice nurse then updated the hospice manger to let her know the resident was on his way back to the hospice house and was safe in the wife's car. The facility staff was unsure of what to do and would call into hospice if they needed anything done due to the resident not returning to the facility. The hospice nurses gathered the rest of the resident's personal supplies and brought them back to the hospice house. Review of SRI # 5 completed 02/17/21 at 6:20 P.M. revealed on 02/11/21 Regional Director of Clinical Services #400 was notified by Medical Director #301 of an alleged incident that was reported to have occurred on 02/04/21, the perpetrator was the facility's Administrator. The alleged incident consisted of the Administrator utilizing explicit language when speaking to Resident #37. The Administrator was suspended, and an investigation initiated. The investigation consisted of interviews of residents and staff reported to have been present at the time of the incident as well as interviews of all residents who were able to be interviewed and skin checks conducted for all residents who were unable to be interviewed. An interview was also conducted of an outside agent, a hospice nurse, who had also been present at the time of the alleged incident. This interview was conducted by the Medical Director. Resident #37 was discharged from the facility on 02/04/21 prior to being interviewed. The incident was described in interviews; facility residents were preparing to smoke when Resident #37 lit a cigarette while still in the facility. Resident #5 attempted to address Resident #37 in an attempt to have him extinguish the cigarette then the Administrator approached Resident #37 at that time in regard to extinguishing the cigarette. Resident #37 declined to do so utilizing explicate language. The Administrator in return communication utilized an explicit word in response, at that time the staff and hospice nurse present intervened. There was no further interaction between Resident #37 and the Administrator. The SRI identified through interview a resident and two staff members present at the time of the alleged incident reported the Administrator had utilized an explicit word when communicating to Resident #37. Four other residents who had been present at the time of incident reported no knowledge of the allegation. The hospice nurse who was also present did not report knowledge of explicit language utilized by the Administrator in communication with Resident #37. The SRI identified no concerns were identified through interviews and skin checks conducted for the remaining residents. Through investigation it was unable to definitely determine abuse occurred but did determine the Administrator did conduct herself in a manner not consistent with the organization standards and when addressed resulted in the resignation of the Administrator. Review of the SRI revealed review of the typed, not signed witness statement dated 02/11/21 revealed as part of an investigation LPN #303 was interviewed regarding her knowledge of the alleged incident that occurred on 02/04/21. LPN #303 reported she was present at the nurses' station in relative [TRUNCATED]

Based on medical record review, review of a facility self-reported incident (SRI), review of facility witness statements, review of the Administrator job description, review of facility Abuse policy, review of Hospice incident report, staff interviews, resident interview, physician interview, Medical Director interview, and hospice staff interviews, the facility administration failed to take appropriate action resulting in substandard quality of care deficiencies identified under Freedom from Abuse, Neglect and Exploitation. Immediate Jeopardy resulted when the facility failed to complete a thorough investigation including failing to accurately identify an abuse situation, remove the alleged perpetrator from resident contact, and ensure accurate information was submitted to the State Agency regarding a verbal abuse altercation between the facility's Administrator and a resident (Resident #37). In addition, Resident #5, a witness to the verbal abuse to Resident #37, was later intimidated and coerced by the Administrator to change her reporting of the verbal abuse resulting in Resident #5 feeling afraid of the Administrator and having panic attacks that she required medication to treat. The facility's inaction had the likelihood of causing serious harm or injury to all residents. The facility census was 36. On 02/18/21 at 2:10 P.M. Regional Director of Clinical Service #400 was notified Immediate Jeopardy began on 02/04/21 at approximately 6:30 P.M. when the facility's Administrator was witnessed by Licensed Practical Nurse (LPN) #303, State tested Nurse Aide (STNA) #304, Hospice LPN #302 and Resident #5 to verbally abuse and use explicit language to a newly admitted hospice resident (Resident #37). This resulted in the resident becoming fearful, refusing to remain in the facility, calling his spouse to come pick him up and returning to the hospice center. The Immediate Jeopardy continued when Resident #5, a witness to the verbal abuse to Resident #37, was later intimidated and coerced by the Administrator to change her reporting of the verbal abuse resulting in Resident #5 feeling afraid of the Administrator and having panic attacks that required medication to treat. The Director of Nursing (DON) and Regional Director of Clinical Service #400 were notified of the verbal abuse on 02/04/21 but failed to effectively and immediately report and investigate the abuse until 02/11/21 allowing the Administrator to continue to work until 02/11/21. In addition, the facility's investigation of the Administrator for resident verbal abuse was inaccurate and incomplete and failed to include a complete and accurate recording of the witness accounts of the incident and the facility inaccurately identified the verbal abuse as unsubstantiated even with three witness reports of the abuse. The Immediate Jeopardy was removed on 02/23/21 when the facility implemented the following corrective action: · On 02/11/21 at 4:00 P.M. the Administrator was suspended pending investigation by Regional Vice President of Operations #403. · On 02/11/21 at 5:00 P.M. the Regional Vice President of Operation #403 submitted an SRI ( 5) through the Enhanced Information Dissemination Collection in regard to the verbal abuse of Resident #37. · On 02/11/21, completed at 5:00 P.M., Regional Director of Clinical Services #400 interviewed staff members LPN #303 and STNA #304, who were in proximity of the alleged occurrence. · On 02/11/21, no time identified, the DON received education regarding the abuse policy by Regional Director of Clinical Services #400. · On 02/11/21, no time identified, Regional Vice President of Operations #403 assumed the position of acting Licensed Nursing Home Administrator and Abuse Coordinator for the facility. · On 02/11/21 completed at approximately 6:00 P.M. a root cause exercise was performed, and Quality Assurance and Performance Improvement was conducted by the DON, Regional Director of Clinical Services #400, and Regional Vice President of Operations #403. · On 02/12/21, completed at 11:00 A.M., Regional Director of Clinical Services #400 interviewed Residents #10, #13, #29, #17 and #5 who were present at the time of the occurrence. · On 02/11/21 and completed on 02/12/21 at 5:00 P.M. Regional Director of Clinical Services #400 and the Interim Director of Nursing (DON) conducted concern questionnaires with all 33 residents who were able to complete the question. · On 02/12/21, completed at 6:00 P.M., Regional Director of Clinical Services #400 conducted a 24 hour look back review of progress notes, incident, and accident notes for 02/04/21 to identify unreported incident and allegations of abuse. · On 02/11/21 and completed on 02/15/21 at 12:00 P.M. nine nurses, 14 STNAs, four housekeepers, two activity personnel, nine dietary personnel, five therapy personnel and five administrative personnel were educated by the DON/designee to prevent reoccurrence, regarding abuse identification, prevention and reporting utilizing facility Abuse policy with emphasis on reporting requirements, prevention of abuse and investigation of abuse allegations. · On 02/17/21 at approximately 4:00 P.M. the Administrator resigned from employment at the facility. · On 02/18/21 at 3:57 P.M. Divisional Clinical Director #402 provided education to the Regional Director of Clinical Services #400 regarding completing a thorough investigation and obtaining written statements. · On 02/21/22 at approximately 4:50 P.M. the DON was suspended. · On 02/22/21, no time identified, all new hire staff will receive education regarding abuse identification, prevention and reporting by the Director of Nursing/Designee. · On 02/22/21, no time identified, the facility will initiate to evaluate staff knowledge regarding abuse prevention. The staff will complete three Abuse Questionnaires to determine continued education needs. The questionnaires will be completed three times a week for four weeks then twice monthly and reviewed by the Director of Nursing/Designee. · On 02/22/21, no time identified, facility continued compliance will be evaluated through audits of resident progress notes within the electronic medical record and incident/accident logs to identify unreported incidents of abuse. Audits will be conducted three times a week for four weeks then twice monthly by the Director of Nursing/Designee. · On 02/22/21, no time identified, facility audits consisting of three resident interviews to identify unreported incidents of abuse will be conducted three times a week for four weeks then twice monthly by the Director of Nursing/Designee. · On 02/22/21, no time identified, the results of the audits will be forwarded to the facility Quality Assurance and Performance Improvement committee by the Director of Nursing/Designee for further review and recommendations. · On 02/23/21 at 1:30 P.M. the Regional Vice President of Operations #403 amended the SRI to reflect the Administrator as the perpetrator and changed the findings to substantiated. Although the Immediate Jeopardy was removed on 02/23/21, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure continued compliance. Findings include: 1. Review of the closed medical record revealed Resident #37 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged to the hospice house on 02/04/21. There was no Minimum Data Set (MDS) assessment information in the medical record. Review of the nurse progress notes dated 02/04/21 at 8:21 P.M. revealed Resident #37 arrived at the facility at 6:15 P.M. by ambulance. The hospice nurse (Hospice LPN #302) was at the bedside. The resident was up walking the hallway before an assessment could be performed. The Administrator was in the hall when the resident lit a cigarette in the hallway. The smoking supplies were never given to the resident by the facility. The Administrator told the resident he could not smoke in the building. The resident then got upset and walked down the hallway with the hospice nurse at his side. The resident told the hospice nurse he was leaving and pushed on the doors until they opened, and the resident walked out the back door. The hospice nurse walked outside with him. The resident refused to come back into the building. The hospice nurse then called a second nurse and the resident's wife. The resident's wife picked up the resident from the facility and told the hospice nurse she was going to take the resident back to the hospice house. A call was placed to hospice to confirm the resident was back at the hospice house. The Administrator was still in the building and aware of the situation. The DON and physician were notified. Interview on 02/16/21 at 3:15 P.M., with STNA #304 indicated at 6:30 P.M. on 02/04/21 she was getting ready to take the residents who wanted to smoke outside for smoke break and the new hospice resident, Resident #37, wanted to go out and smoke. She indicated while she was getting the residents ready to go out into the courtyard area, Resident #37 had lit a cigarette in the dining room. She indicated she told him he needed to wait until he went outside. STNA #304 indicated she attempted to [NAME] him out the door, but she could not get to him because there were a few residents in wheelchairs between him and her. STNA #304 indicated the Administrator was by him and she told STNA #304 to put the code in the door and let him out. The resident went outside into the courtyard to smoke his cigarette. She indicated the Administrator started to yell at her wanting to know how he had gotten the cigarettes and lighter. She stated the Administrator was telling her to get the resident's cigarette from him and she needed to get them right now. She stated she told the Administrator she was not going to take the resident's cigarettes from him right now because the resident didn't understand what was going on and he had not been explained the rules. She stated the Administrator went up to the resident when he was coming back into the building and told him to give her his cigarettes now. She stated Resident #37 told the Administrator he was not going to give her expletive. STNA #304 indicated the Administrator was yelling loudly at the resident stating to him she was going to call his wife and it was her facility and if he did not like the rules, he could get the (expletive) out. She indicated the Administrator did not introduce herself to the resident or explain the smoking policy to the resident she just demanded his cigarettes and lighter. STNA #304 indicated she had gone outside with the other residents for the smoke break so she did not know what else was said but she could still hear them yelling through the doors. The next thing she knew LPN #303 and the Administrator were outside looking for the resident and LPN #303 was taking a blanket outside. She indicated she does not know anything after that except the nurse brought the blanket back into the building and the resident never came back in. STNA #304 indicated the Administrator was later going around telling everyone the resident was never admitted to the facility and to not chart he was admitted . She indicated the next day the Administrator was going around to the residents who witnessed the incident and told them she never cussed at Resident #37, they had all heard it wrong. Interview on 02/16/21 at 3:53 P.M. with LPN #303 indicated Resident #37 was admitted to the building on Thursday 02/04/21 at approximately 6:15 P.M. STNA #304 was going to take the residents outside for a smoke break. She stated she was with the Administrator and hospice nurse (Hospice LPN #302) at the South nurse's station when Resident #5 yelled, he just lit a cigarette. She indicated the Administrator yelled at the nursing assistant to get his cigarettes and the nursing assistant said no because he was scared and did not understand. She stated the Administrator then yelled at the resident telling him he could not smoke in the building and to give her his cigarettes. The resident yelled at her and said he was not giving her his cigarette. She stated the resident was getting very upset and was yelling at the Administrator asking what he did wrong and why he was being yelled at. LPN #303 indicated the Administrator asked the resident who the (expletive) he thought he was and if he could not follow the rules, he could get the (expletive) out. LPN #303 stated the resident became very defensive, he did not understand what was going on or why he was being yelled at. She indicated the Administrator then started to yell at the hospice nurse (Hospice LPN #302) and said to him, she did not know who the (expletive) he thought he was and to not bring people like him (Resident #37) into her facility if they could not follow the rules. She stated the Administrator told the hospice nurse he and the resident could just leave and furthermore he could just call the resident's wife to come pick his ass up. LPN #303 stated the hospice nurse tried to calm the resident down and he asked Resident #37 to go back to his room for a second and he would be down to see him. She stated a few minutes later they heard the emergency door alarm go off. She indicated Resident #37 had gone out the emergency door and the Administrator and hospice nurse went after him. She stated the Administrator came back in and said they were gone. She asked the Administrator what she meant, and she said they were gone. LPN #303 indicated she ran outside and saw the hospice nurse and the resident out by the road. She indicated she went out to them and asked the resident to come back inside because it was cold. The resident stated he was not going back into a building where he was being yelled and cursed at. The resident told her he called his wife to come get him. She indicated she tried to give the resident a blanket, but the resident refused. She indicated she asked the hospice nurse if he needed anything and he said he did not, he had called the hospice house and they were coming to pick them up. She indicated she had come in and called the DON because she did not know what to do about the resident leaving against medical advice (AMA). Interview on 02/16/21 at 4:30 P.M. with Resident #5 revealed on 02/04/21 a new resident (Resident #37) lit a cigarette in the dining room. She indicated she yelled at the resident because she had oxygen on. She indicated the Administrator started to yell at the aide to get his cigarettes from him and the aide told her no because he did not understand what was going on. Resident #5 stated the Administrator came over to the door and started to yell at the resident. She was telling him to give her his cigarettes and the resident had said no he was not giving her (expletive). The resident indicated the Administrator told Resident #37 to give her his (expletive) cigarettes and when the resident said no again the Administrator asked the resident who the (expletive) he thought he was and he could get the (expletive) out if he could not follow the rules. She stated the resident told her he was not going to be treated or yelled at like that and he was going to call his wife. Resident #5 indicated she went outside with STNA #304 then to smoke. She stated the next day the Administrator came to her in the dining room and told her there was going to be people coming around asking her some questions about what had happened, and the Administrator told her she never cussed at the resident. Resident #5 indicated she told the Administrator, yes, she did, and everyone heard her say it to him. She stated the Administrator said to her she did not treat her residents like that, and she knew it. The resident indicated that was the first time she had heard her yell at a resident like that, but she had heard her yell at the aides numerous times. She indicated she heard her tell an aide if she could not do the job, she needed to find a new (expletive) job. Resident #5 indicated she was having trouble sleeping and was scared the Administrator was going to come back and she was going to get in trouble. Interview on 02/17/21 at 8:30 A.M. with LPN #303 indicated she had let the DON know what had happened the night of the incident. She indicated she had called and texted the DON the night it happened and was unable to reach the DON, so she then called Corporate MDS Nurse #401 and told her what had happened. She indicated Regional Director of Clinical Services #400 then called her and she explained to him what had happened. She stated the DON called her back later that night at home and she told her everything that had happened. She asked the DON if she wanted a written statement and she said, no, Regional Director of Clinical Services #400 would handle it. She indicated the Administrator worked in the building until 02/11/21. Interview on 02/17/21 at 9:45 A.M. with Medical Director #301 indicated he had come into the facility on [DATE] and was made aware of the incident (regarding Resident #37) by the facility staff and residents. He indicated he saw the Administrator in the building, but she seemed to be avoiding him. He told LPN #303 she needed to report the incident to corporate. He indicated LPN #303 stated she had reported it the night it happened. He indicated he gave the facility until 02/11/21 to contact him concerning the incident and nobody had reached out to him about the situation, so he turned in his 30-day resignation as Medical Director at the facility. He indicated he sent an email to the facility and corporate. He indicated he then received a call from Regional Director of Clinical Services #400 on 02/11/21 asking him why he was resigning, and he told him what he was told by the staff concerning the incident and the Administrator. Interview on 02/17/21 at 10:40 A.M. with LPN #303 indicated she was the only nurse working the floor on 02/04/21 because the other nurse working down on South unit had a sick child and had to leave around 5:30 P.M. She indicated she called the DON at 7:00 P.M., 7:07 P.M., 7:20 P.M. and 7:57 P.M. to find out what she was supposed to do about Resident #37 leaving the facility against medical advice. She indicated she also asked the Administrator for Regional Director of Clinical Services #400's phone number and the Administrator refused to give it to her and said she would call him herself. She indicated then the Administrator left to go home, and she still did not know what to do about Resident #37 leaving the building and not returning, so she called Corporate MDS Nurse #401 at 7:22 P.M. because she did not know who else to call. LPN #303 indicated she told Corporate MDS Nurse #401 about the incident and she was concerned about the resident's safety. She stated Corporate MDS Nurse #401 called Regional Director of Clinical Services #400 and made her (LPN #303) stay on the line with her until he called her. She indicated Regional Director of Clinical Services #400 called her within a couple minutes. She told him about the incident but had not told him at that time about the Administrator yelling and cussing at the resident. She stated the DON had then texted her, told her she was at dinner with her family and she would call her when she was able. LPN #303 stated on 02/04/21 at 10:16 P.M. the DON called her, and she told her everything that had happened even what the Administrator had said to Resident #37. LPN #303 indicated when she came back to work on Monday 02/08/21, she had offered to write a statement about the incident and the DON told her they did not need one. LPN #303 indicated Regional Director of Clinical Services #400 called her on 02/11/21 and wanted a verbal statement from her. LPN #303 stated the DON came to her today (02/17/21) and asked her if she knew what the chain of command was and told her as a nurse it was her responsibility to contact the state. LPN #303 stated she was very upset with what the DON had stated to her and felt like they were trying to blame the incident on her. LPN #303 stated she did exactly what she had been instructed to do in previous in-services and that was to notify the Administrator or DON if abuse was suspected. Interview on 02/17/21 at 11:20 A.M. with STNA #304 revealed she only worked Tuesday through Thursday. She stated she spoke to the DON when she came to work on Tuesday 02/09/21 about what had happened on 02/04/21 and had told her everything. She indicated she asked the DON if she wanted a written statement from her and the DON said no, she could talk to Regional Director of Clinical Services #400 about it. She indicated Regional Director of Clinical Services #400 came in either later that day or the next day she could not remember exactly, and she told him everything that had happened on 02/04/21. STNA #304 indicated on 02/16/21 Regional Human Resource #417 called her and asked her for a written statement and asked her if she knew what the facility's chain of command was. She indicated she told him yes, she knew what the chain of command was, however they did not have a social worker or DON at this time and the Administrator was the perpetrator. She indicated to him the nurse (LPN #303) did the right thing by calling the DON then the Corporate MDS nurse. STNA #304 indicated she felt they were trying to blame this all on them and they (STNA #304 and LPN #303) did what they were supposed to do. Interview on 02/17/21 at 3:00 P.M. with Hospice LPN #302 indicated Resident #37 was admitted to the facility on [DATE] and he was at the facility writing the orders. He indicated the resident had been discharged from the hospice house around 5:00 P.M. and had gotten to the facility shortly after. He indicated he had gone back to the resident room with the resident and ambulance crew to get the resident situated in his room and make sure he was comfortable. He then went back up to the nurse's station to finish writing orders and admitting the resident. A short while later the resident came walking up the hall with a staff member to go outside on a smoke break. The resident went around the corner of the nurse's station into the dining room and he could not see the resident anymore, however, the resident must have lit a cigarette inside the dining room. There was a confrontation with the Administrator and the staff member in the dining room about the resident lighting a cigarette. Hospice LPN #302 indicated the Administrator started to yell inappropriately at the resident, however he could not remember what had been said exactly but she (the Administrator) wanted him to give her his cigarettes and the resident had told her no. He indicated he was more concerned about the welfare of the resident then what was being said. He indicated the resident came up to him and the facility nurse at the nurse station and wanted to leave the building. He indicated the resident did not understand what was going on or why he was being yelled and cussed at. He stated then the Administrator walked up to him at the nurses station while the resident was standing there and started to yell at him saying if this is the type of people who hospice was going to bring to the facility they could both leave. He stated he told her he did not know how the resident got the cigarettes and lighter and he asked the resident to go back to his room for a minute and he would be down to see him. He stated he does not remember the Administrator cussing at him; however, he was not really paying much attention to her because he was more concerned with calming his resident down. He stated he was standing there at the nurse's station with the Administrator when the resident went out the emergency exit door at the end of the hallway. He stated by the time he got to him he was right outside the door on the exit ramp, he was with him the whole time he was outside. He stated the nurse came outside and brought a blanket and asked if he needed anything, he said he had the resident calmed down and he had called the office and the resident had called his wife and she was on her way. The resident's wife got there about 20 minutes later and took the resident back to the hospice house. He indicated Regional Director of Clinical Services #400 called him the next day on 02/05/21 and he told him everything that had happened including the Administrator was yelling at the resident in the dining room and that she had also yelled at him. Interview on 02/18/21 at 9:10 A.M. with Registered Nurse (RN) #310 indicated she was working on the south hall on 02/04/21, however she had to leave around 5:45 P.M. because her son had gotten sick. She indicated she saw the resident (Resident #37) come into the building as she was leaving. She indicated the next day when she came in Resident #5 had been very upset because of the situation. She indicated Resident #5 had been terrified ever since the Administrator had told her to lie for her. She indicated the resident was having trouble sleeping and was having panic attacks. The resident had to be placed on [MEDICATION(S)] (a sedative used to treat anxiety and tension) on 02/15/21 because of the situation. Interview on 02/22/21 at 8:30 A.M. with LPN #303 indicated on 02/08/21 she was sitting at the nurse's station on north when the DON came up to her. She indicated she asked the DON at this time if she wanted her to write a statement about the incident on 02/04/21. She indicated the DON told her no, Regional Director of Clinical Services #400 and Hospice was handling the incident. She indicated Regional Director of Clinical Services #400 had texted her on 02/05/21 to ask her if the Administrator had yelled at the hospice nurse (Hospice LPN #302) and she told him, yes. She indicated Regional Director of Clinical Services #400 called her and asked her for the hospice nurses' information and phone number, so she gave it to him. Interview on 02/22/21 at 8:40 A.M. with STNA #306 indicated she did hear STNA #304 ask the DON on 02/09/21 if the DON wanted her to write a statement about the incident on 02/04/21 and the DON said no, the Regional Director of Clinical Services #400 was handling it. Review of the Community Hospice Incident Report dated 02/04/21 at 5:20 P.M. revealed Hospice LPN #302 was performing a Tuck In Visit with Resident #37. Hospice LPN #302 arrived at the facility before the resident to start writing orders. The resident arrived shortly after via ambulance. The resident was transferred out of the cot with one assist and used his cane to walk to the recliner in the room. Hospice LPN #302 set the resident up in the room making sure he was comfortable. The resident rated his pain as a seven out of ten in his head, the facility had no orders yet and no medication for the resident at this time. The resident was comfortable in his room and stated he had no other needs at this time. The hospice nurse went back to the nurse's station on the 100-hall to finish writing orders and while the nurse was there the staff was getting the residents ready to go outside to smoke. Resident #37 walked down the 100 hallway and turned the corner to go smoke. The resident somehow had cigarettes and a lighter on him and lit a cigarette in the building. The facility Administrator found the resident smoking inside the building. The facility Administrator and the resident had a confrontation, then the resident rounded the corner by the 100-hall nurse's station. The resident was agitated and angry, stating he wanted a receipt so he could sign out of facility and leave. The hospice nurse explained to the resident to go sit in his room and he would be down to talk to him, however before the hospice nurse was able to get to the resident the facility Administrator stopped the hospice nurse demanding the hospice nurse go talk to the resident and get his cigarettes away from him. The Administrator was not professional with the hospice nurse and her voice was raised. The Administrator stated to the resident he could sign Against Medical Advice (AMA) paper and go home. The Administrator told the hospice nurse she would not have a resident like that in the facility. The hospice nurse was unsure what words were said between the Administrator and the resident during the confrontation. The hospice nurse did not witness the confrontation. By the time the Administrator finished with the hospice nurse the resident was standing at the emergency exit door down the 100-hall with his supplies and had made the alarm go off. The door opened before the hospice nurse could get to the resident. The resident stormed out walking towards the road. The resident could not be redirected inside, the hospice nurse stayed with the resident and contacted the hospice house around 6:35 P.M. to get a hold of the manger on duty. During this time the resident had called his wife multiple times to come pick him up. The hospice nurse was able to get the resident to relax but he stated he was not going back inside, stating he was not staying at a place where people treated him like that. The hospice nurse stayed with the resident as they walked down the sidewalk. The resident's wife arrived around 7:00 P.M. and the resident walked right up to her car and got into the passenger seat. The resident's wife was very emotional when she pulled up. The hospice nurse explained to the wife to take the resident to the hospice house and the wife was agreeable. The hospice nurse then updated the hospice manger to let her know the resident was on his way back to the hospice house and was safe in the wife's car. The facility staff was unsure of what to do and would call into hospice if they needed anything done due to the resident not returning to the facility. The hospice nurses gathered the rest of the resident's personal supplies and brought them back to the hospice house. Review of SRI # 5 completed 02/17/21 at 6:20 P.M. revealed on 02/11/21 Regional Director of Clinical Services #400 was notified by Medical Director #301 of an alleged incident that was reported to have occurred on 02/04/21, the perpetrator was the facility's Administrator. The alleged incident consisted of the Administrator utilizing explicit language when speaking to Resident #37. The Administrator was suspended, and an investigation initiated. The investigation consisted of interviews of residents and staff reported to have been present at the time of the incident as well as interviews of all residents who were able to be interviewed and skin checks conducted for all residents who were unable to be interviewed. An interview was also conducted of an outside agent, a hospice nurse, who had also been present at the time of the alleged incident. This interview was conducted by the Medical Director. Resident #37 was discharged from the facility on 02/04/21 prior to being interviewed. The incident was described in interviews; facility residents were preparing to smoke when Resident #37 lit a cigarette while still in the facility. Resident #5 attempted to address Resident #37 in an attempt to have him extinguish the cigarette then the Administrator approached Resident #37 at that time in regard to extinguishing the cigarette. Resident #37 declined to do so utilizing explicate language. The Administrator in return communication utilized an explicit word in response, at that time the staff and hospice nurse present intervened. There was no further interaction between Resident #37 and the Administrator. The SRI identified through interview a resident and two staff members present at the time of the alleged incident reported the Administrator had utilized an explicit word when communicating to Resident #37. Four other residents who had been present at the time of incident reported no knowledge of the allegation. The hospice nurse who was also present did not report knowledge of explicit language utilized by the Administrator in communication with Resident #37. The SRI identified no concerns were identified through interviews and skin chec [TRUNCATED]

Based on medical record review, review of a facility self-reported incident (SRI), review of facility witness statements, review of facility Abuse policy, review of Hospice incident report, staff interviews, resident interview, physician interview, medical director interview, and hospice staff interviews, the facility failed to prevent staff to resident verbal abuse by the facility's Administrator and failed to ensure a resident was free from intimidation and coercion. This resulted in Immediate Jeopardy on 02/04/21 at approximately 6:30 P.M. when the facility's Administrator was witnessed by Licensed Practical Nurse (LPN) #303, State tested Nursing Assistant (STNA) #304, Hospice LPN #302 and Resident #5 to verbally abuse a newly admitted hospice resident (Resident #37) by yelling at the resident and asking who the (expletive) he thought he was and if he could not follow the rules he could get the (expletive) out. The Administrator then told Hospice LPN #302, (in the presence of Resident #37) she did not know who the (expletive) he thought he was and to not bring people like him (Resident #37) into her facility if they could not follow the rules. This resulted in likelihood for serious harm or injury as evidenced by Resident #37 becoming fearful, refusing to remain in the facility, calling his spouse to come pick him up and returning to the hospice center. In addition, Resident #5, a witness to the verbal abuse to Resident #37, was later intimidated and coerced by the Administrator to change her reporting of the verbal abuse resulting in Resident #5 feeling afraid of the Administrator and having panic attacks that she required medication to treat. This affected two residents (Resident #5 and Resident #37) of three reviewed for abuse but had the potential to affect all 36 residents in the facility. On 02/18/21 at 2:10 P.M. Regional Director of Clinical Service #400 was notified Immediate Jeopardy began on 02/04/21 at approximately 6:30 P.M. when the facility's Administrator was witnessed by LPN #303, STNA #304, Hospice LPN #302 and Resident #5 to verbally abuse and use explicit language to a newly admitted hospice resident (Resident #37). This resulted in the resident becoming fearful, refusing to remain in the facility, calling his spouse to come pick him up and returning to the hospice center. The Immediate Jeopardy continued when Resident #5, a witness to the verbal abuse to Resident #37, was later intimidated and coerced by the Administrator to change her reporting of the verbal abuse resulting in Resident #5 feeling afraid of the Administrator and having panic attacks that required medication to treat. The Immediate Jeopardy was removed on 02/23/21 when the facility implemented the following corrective action: · On 02/11/21 at 4:00 P.M. the Administrator was suspended pending investigation by Regional Vice President of Operations #403. · On 02/11/21 at 5:00 P.M. the Regional Vice President of Operation #403 submitted an SRI ( 5) through the Enhanced Information Dissemination Collection in regard to the verbal abuse of Resident #37. · On 02/11/21, completed at 5:00 P.M., Regional Director of Clinical Services #400 interviewed staff members LPN #303 and STNA #304, who were in proximity of the alleged occurrence. · On 02/11/21, no time identified, the DON received education regarding the abuse policy by Regional Director of Clinical Services #400. · On 02/11/21, no time identified, Regional Vice President of Operations #403 assumed the position of acting Licensed Nursing Home Administrator and Abuse Coordinator for the facility. · On 02/11/21 completed at approximately 6:00 P.M. a root cause exercise was performed, and Quality Assurance and Performance Improvement was conducted by the DON, Regional Director of Clinical Services #400, and Regional Vice President of Operations #403. · On 02/12/21, completed at 11:00 A.M., Regional Director of Clinical Services #400 interviewed Residents #10, #13, #29, #17 and #5 who were present at the time of the occurrence. · On 02/11/21 and completed on 02/12/21 at 5:00 P.M. Regional Director of Clinical Services #400 and the Interim Director of Nursing (DON) conducted concern questionnaires with all 33 residents who were able to complete the question. · On 02/12/21, completed at 6:00 P.M., Regional Director of Clinical Services #400 conducted a 24 hour look back review of progress notes, incident, and accident notes for 02/04/21 to identify unreported incident and allegations of abuse. · On 02/11/21 and completed on 02/15/21 at 12:00 P.M. nine nurses, 14 STNAs, four housekeepers, two activity personnel, nine dietary personnel, five therapy personnel and five administrative personnel were educated by the DON/designee to prevent reoccurrence, regarding abuse identification, prevention and reporting utilizing facility Abuse policy with emphasis on reporting requirements, prevention of abuse and investigation of abuse allegations. · On 02/17/21 at approximately 4:00 P.M. the Administrator resigned from employment at the facility. · On 02/18/21 at 3:57 P.M. Divisional Clinical Director #402 provided education to the Regional Director of Clinical Services #400 regarding completing a thorough investigation and obtaining written statements. · On 02/21/22 at approximately 4:50 P.M. the DON was suspended. · On 02/22/21, no time identified, all new hire staff will receive education regarding abuse identification, prevention and reporting by the Director of Nursing/Designee. · On 02/22/21, no time identified, the facility will initiate to evaluate staff knowledge regarding abuse prevention. The staff will complete three Abuse Questionnaires to determine continued education needs. The questionnaires will be completed three times a week for four weeks then twice monthly and reviewed by the Director of Nursing/Designee. · On 02/22/21, no time identified, facility continued compliance will be evaluated through audits of resident progress notes within the electronic medical record and incident/accident logs to identify unreported incidents of abuse. Audits will be conducted three times a week for four weeks then twice monthly by the Director of Nursing/Designee. · On 02/22/21, no time identified, facility audits consisting of three resident interviews to identify unreported incidents of abuse will be conducted three times a week for four weeks then twice monthly by the Director of Nursing/Designee. · On 02/22/21, no time identified, the results of the audits will be forwarded to the facility Quality Assurance and Performance Improvement committee by the Director of Nursing/Designee for further review and recommendations. · On 02/23/21 at 1:30 P.M. the Regional Vice President of Operations #403 amended the SRI to reflect the Administrator as the perpetrator and changed the findings to substantiated. Although the Immediate Jeopardy was removed on 02/23/21, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure continued compliance. Findings include: 1. Review of the closed medical record revealed Resident #37 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged to the hospice house on 02/04/21. There was no Minimum Data Set (MDS) assessment information in the medical record. Review of the nurse progress notes dated 02/04/21 at 8:21 P.M. revealed Resident #37 arrived at the facility at 6:15 P.M. by ambulance. The hospice nurse (Hospice LPN #302) was at the bedside. The resident was up walking the hallway before an assessment could be performed. The Administrator was in the hall when the resident lit a cigarette in the hallway. The smoking supplies were never given to the resident by the facility. The Administrator told the resident he could not smoke in the building. The resident then got upset and walked down the hallway with the hospice nurse at his side. The resident told the hospice nurse he was leaving and pushed on the doors until they opened, and the resident walked out the back door. The hospice nurse walked outside with him. The resident refused to come back into the building. The hospice nurse then called a second nurse and the resident's wife. The resident's wife picked up the resident from the facility and told the hospice nurse she was going to take the resident back to the hospice house. A call was placed to hospice to confirm the resident was back at the hospice house. The Administrator was still in the building and aware of the situation. The director of nursing and physician were notified. Interview on 02/16/21 at 3:15 P.M., with STNA #304 indicated at 6:30 P.M. on 02/04/21 she was getting ready to take the residents who wanted to smoke outside for smoke break and the new hospice resident, Resident #37, wanted to go out and smoke. She indicated while she was getting the residents ready to go out into the courtyard area, Resident #37 had lit a cigarette in the dining room. She indicated she told him he needed to wait until he went outside. STNA #304 indicated she attempted to [NAME] him out the door, but she could not get to him because there were a few residents in wheelchairs between him and her. STNA #304 indicated the Administrator was by him and she told STNA #304 to put the code in the door and let him out. The resident went outside into the courtyard to smoke his cigarette. She indicated the Administrator started to yell at her wanting to know how he had gotten the cigarettes and lighter. She stated the Administrator was telling her to get the resident's cigarette from him and she needed to get them right now. She stated she told the Administrator she was not going to take the resident's cigarettes from him right now because the resident didn't understand what was going on and he had not been explained the rules. She stated the Administrator went up to the resident when he was coming back into the building and told him to give her his cigarettes now. She stated Resident #37 told the Administrator he was not going to give her expletive. STNA #304 indicated the Administrator was yelling loudly at the resident stating to him she was going to call his wife and it was her facility and if he did not like the rules, he could get the (expletive) out. She indicated the Administrator did not introduce herself to the resident or explain the smoking policy to the resident she just demanded his cigarettes and lighter. STNA #304 indicated she had gone outside with the other residents for the smoke break so she did not know what else was said but she could still hear them yelling through the doors. The next thing she knew LPN #303 and the Administrator were outside looking for the resident and LPN #303 was taking a blanket outside. She indicated she does not know anything after that except the nurse brought the blanket back into the building and the resident never came back in. STNA #304 indicated the Administrator was later going around telling everyone the resident was never admitted to the facility and to not chart he was admitted . She indicated the next day the Administrator was going around to the residents who witnessed the incident and told them she never cussed at Resident #37, they had all heard it wrong. Interview on 02/16/21 at 3:53 P.M. with LPN #303 indicated Resident #37 was admitted to the building on Thursday 02/04/21 at approximately 6:15 P.M. STNA #304 was going to take the residents outside for a smoke break. She stated she was with the Administrator and hospice nurse (Hospice LPN #302) at the South nurse's station when Resident #5 yelled, he just lit a cigarette. She indicated the Administrator yelled at the nursing assistant to get his cigarettes and the nursing assistant said no because he was scared and did not understand. She stated the Administrator then yelled at the resident telling him he could not smoke in the building and to give her his cigarettes. The resident yelled at her and said he was not giving her his cigarette. She stated the resident was getting very upset and was yelling at the Administrator asking what he did wrong and why he was being yelled at. LPN #303 indicated the Administrator asked the resident who the (expletive) he thought he was and if he could not follow the rules, he could get the (expletive) out. LPN #303 stated the resident became very defensive, he did not understand what was going on or why he was being yelled at. She indicated the Administrator then started to yell at the hospice nurse (Hospice LPN #302) and said to him, she did not know who the (expletive) he thought he was and to not bring people like him (Resident #37) into her facility if they could not follow the rules. She stated the Administrator told the hospice nurse he and the resident could just leave and furthermore he could just call the resident's wife to come pick his ass up. LPN #303 stated the hospice nurse tried to calm the resident down and he asked Resident #37 to go back to his room for a second and he would be down to see him. She stated a few minutes later they heard the emergency door alarm go off. She indicated Resident #37 had gone out the emergency door and the Administrator and hospice nurse went after him. She stated the Administrator came back in and said they were gone. She asked the Administrator what she meant, and she said they were gone. LPN #303 indicated she ran outside and saw the hospice nurse and the resident out by the road. She indicated she went out to them and asked the resident to come back inside because it was cold. The resident stated he was not going back into a building where he was being yelled and cursed at. The resident told her he called his wife to come get him. She indicated she tried to give the resident a blanket, but the resident refused. She indicated she asked the hospice nurse if he needed anything and he said he did not, he had called the hospice house and they were coming to pick them up. She indicated she had come in and called the director of nursing because she did not know what to do about the resident leaving against medical advice. Interview on 02/16/21 at 4:30 P.M. with Resident #5 revealed on 02/04/21 a new resident (Resident #37) lit a cigarette in the dining room. She indicated she yelled at the resident because she had oxygen on. She indicated the Administrator started to yell at the aide to get his cigarettes from him and the aide told her no because he did not understand what was going on. Resident #5 stated the Administrator came over to the door and started to yell at the resident. She was telling him to give her his cigarettes and the resident had said no he was not giving her (expletive). The resident indicated the Administrator told Resident #37 to give her his (expletive) cigarettes and when the resident said no again the Administrator asked the resident who the (expletive) he thought he was and he could get the (expletive) out if he could not follow the rules. She stated the resident told her he was not going to be treated or yelled at like that and he was going to call his wife. Resident #5 indicated she went outside with STNA #304 then to smoke. She stated the next day the Administrator came to her in the dining room and told her there was going to be people coming around asking her some questions about what had happened, and the Administrator told her she never cussed at the resident. Resident #5 indicated she told the Administrator, yes, she did, and everyone heard her say it to him. She stated the Administrator said to her she did not treat her residents like that, and she knew it. The resident indicated that was the first time she had heard her yell at a resident like that, but she had heard her yell at the aides numerous times. She indicated she heard her tell an aide if she could not do the job, she needed to find a new (expletive) job. Resident #5 indicated she was having trouble sleeping and was scared the Administrator was going to come back and she was going to get in trouble. Interview on 02/17/21 at 8:30 A.M. with LPN #303 indicated she had let the DON know what had happened the night of the incident. She indicated she had called and texted the DON the night it happened and was unable to reach the DON, so she then called Corporate MDS Nurse #401 and told her what had happened. She indicated Regional Director of Clinical Services #400 then called her and she explained to him what had happened. She stated the DON called her back later that night at home and she told her everything that had happened. She asked the DON if she wanted a written statement and she said, no, Regional Director of Clinical Services #400 would handle it. She indicated the Administrator worked in the building until 02/11/21. Interview on 02/17/21 at 9:45 A.M. with Medical Director #301 indicated he had come into the facility on [DATE] and was made aware of the incident (regarding Resident #37) by the facility staff and residents. He indicated he saw the Administrator in the building, but she seemed to be avoiding him. He told LPN #303 she needed to report the incident to corporate. He indicated LPN #303 stated she had reported it the night it happened. He indicated he gave the facility until 02/11/21 to contact him concerning the incident and nobody had reached out to him about the situation, so he turned in his 30-day resignation as Medical Director at the facility. He indicated he sent an email to the facility and corporate. He indicated he then received a call from Regional Director of Clinical Services #400 on 02/11/21 asking him why he was resigning, and he told him what he was told by the staff concerning the incident and the Administrator. Interview on 02/17/21 at 10:40 A.M. with LPN #303 indicated she was the only nurse working the floor on 02/04/21 because the other nurse working down on South unit had a sick child and had to leave around 5:30 P.M. She indicated she called the DON at 7:00 P.M., 7:07 P.M., 7:20 P.M. and 7:57 P.M. to find out what she was supposed to do about Resident #37 leaving the facility against medical advice. She indicated she also asked the Administrator for Regional Director of Clinical Services #400's phone number and the Administrator refused to give it to her and said she would call him herself. She indicated then the Administrator left to go home, and she still did not know what to do about Resident #37 leaving the building and not returning, so she called Corporate MDS Nurse #401 at 7:22 P.M. because she did not know who else to call. LPN #303 indicated she told Corporate MDS Nurse #401 about the incident and she was concerned about the resident's safety. She stated Corporate MDS Nurse #401 called Regional Director of Clinical Services #400 and made her (LPN #303) stay on the line with her until he called her. She indicated Regional Director of Clinical Services #400 called her within a couple minutes. She told him about the incident but had not told him at that time about the Administrator yelling and cussing at the resident. She stated the DON had then texted her, told her she was at dinner with her family and she would call her when she was able. LPN #303 stated on 02/04/21 at 10:16 P.M. the DON called her, and she told her everything that had happened even what the Administrator had said to Resident #37. LPN #303 indicated when she came back to work on Monday 02/08/21, she had offered to write a statement about the incident and the DON told her they did not need one. LPN #303 indicated Regional Director of Clinical Services #400 called her on 02/11/21 and wanted a verbal statement from her. Interview on 02/17/21 at 11:20 A.M. with STNA #304 revealed she only worked Tuesday through Thursday. She stated she spoke to the DON when she came to work on Tuesday 02/09/21 about what had happened on 02/04/21 and had told her everything. She indicated she asked the DON if she wanted a written statement from her and the DON said no, she could talk to Regional Director of Clinical Services #400 about it. She indicated Regional Director of Clinical Services #400 came in either later that day or the next day she could not remember exactly, and she told him everything that had happened on 02/04/21. Interview on 02/17/21 at 3:00 P.M. with Hospice LPN #302 indicated Resident #37 was admitted to the facility on [DATE] and he was at the facility writing the orders. He indicated the resident had been discharged from the hospice house around 5:00 P.M. and had gotten to the facility shortly after. He indicated he had gone back to the resident room with the resident and ambulance crew to get the resident situated in his room and make sure he was comfortable. He then went back up to the nurse's station to finish writing orders and admitting the resident. A short while later the resident came walking up the hall with a staff member to go outside on a smoke break. The resident went around the corner of the nurse's station into the dining room and he could not see the resident anymore, however, the resident must have lit a cigarette inside the dining room. There was a confrontation with the Administrator and the staff member in the dining room about the resident lighting a cigarette. Hospice LPN #302 indicated the Administrator started to yell inappropriately at the resident, however he could not remember what had been said exactly but she (the Administrator) wanted him to give her his cigarettes and the resident had told her no. He indicated he was more concerned about the welfare of the resident then what was being said. He indicated the resident came up to him and the facility nurse at the nurse station and wanted to leave the building. He indicated the resident did not understand what was going on or why he was being yelled and cussed at. He stated then the Administrator walked up to him at the nurses station while the resident was standing there and started to yell at him saying if this is the type of people who hospice was going to bring to the facility they could both leave. He stated he told her he did not know how the resident got the cigarettes and lighter and he asked the resident to go back to his room for a minute and he would be down to see him. He stated he does not remember the Administrator cussing at him; however, he was not really paying much attention to her because he was more concerned with calming his resident down. He stated he was standing there at the nurse's station with the Administrator when the resident went out the emergency exit door at the end of the hallway. He stated by the time he got to him he was right outside the door on the exit ramp, he was with him the whole time he was outside. He stated the nurse came outside and brought a blanket and asked if he needed anything, he said he had the resident calmed down and he had called the office and the resident had called his wife and she was on her way. The resident's wife got there about 20 minutes later and took the resident back to the hospice house. He indicated Regional Director of Clinical Services #400 called him the next day on 02/05/21 and he told him everything that had happened including the Administrator was yelling at the resident in the dining room and that she had also yelled at him. Interview on 02/18/21 at 9:10 A.M. with Registered Nurse (RN) #310 indicated she was working on the south hall on 02/04/21, however she had to leave around 5:45 P.M. because her son had gotten sick. She indicated she saw the resident (Resident #37) come into the building as she was leaving. She indicated the next day when she came in Resident #5 had been very upset because of the situation. She indicated Resident #5 had been terrified ever since the Administrator had told her to lie for her. She indicated the resident was having trouble sleeping and was having panic attacks. The resident had to be placed on [MEDICATION(S)] (a sedative used to treat anxiety and tension) on 02/15/21 because of the situation. Interview on 02/22/21 at 8:30 A.M. with LPN #303 indicated on 02/08/21 she was sitting at the nurse's station on north when the DON came up to her. She indicated she asked the DON at this time if she wanted her to write a statement about the incident on 02/04/21. She indicated the DON told her no, Regional Director of Clinical Services #400 and Hospice was handling the incident. She indicated Regional Director of Clinical Services #400 had texted her on 02/05/21 to ask her if the Administrator had yelled at the hospice nurse (Hospice LPN #302) and she told him, yes. She indicated Regional Director of Clinical Services #400 called her and asked her for the hospice nurses' information and phone number, so she gave it to him. Interview on 02/22/21 at 8:40 A.M. with STNA #306 indicated she did hear STNA #304 ask the DON on 02/09/21 if the DON wanted her to write a statement about the incident on 02/04/21 and the DON said no, the Regional Director of Clinical Services #400 was handling it. Review of the Community Hospice Incident Report dated 02/04/21 at 5:20 P.M. revealed Hospice LPN #302 was performing a Tuck In Visit with Resident #37. Hospice LPN #302 arrived at the facility before the resident to start writing orders. The resident arrived shortly after via ambulance. The resident was transferred out of the cot with one assist and used his cane to walk to the recliner in the room. Hospice LPN #302 set the resident up in the room making sure he was comfortable. The resident rated his pain as a seven out of ten in his head, the facility had no orders yet and no medication for the resident at this time. The resident was comfortable in his room and stated he had no other needs at this time. The hospice nurse went back to the nurse's station on the 100-hall to finish writing orders and while the nurse was there the staff was getting the residents ready to go outside to smoke. Resident #37 walked down the 100 hallway and turned the corner to go smoke. The resident somehow had cigarettes and a lighter on him and lit a cigarette in the building. The facility Administrator found the resident smoking inside the building. The facility Administrator and the resident had a confrontation, then the resident rounded the corner by the 100-hall nurse's station. The resident was agitated and angry, stating he wanted a receipt so he could sign out of facility and leave. The hospice nurse explained to the resident to go sit in his room and he would be down to talk to him, however before the hospice nurse was able to get to the resident the facility Administrator stopped the hospice nurse demanding the hospice nurse go talk to the resident and get his cigarettes away from him. The Administrator was not professional with the hospice nurse and her voice was raised. The Administrator stated to the resident he could sign Against Medical Advice (AMA) paper and go home. The Administrator told the hospice nurse she would not have a resident like that in the facility. The hospice nurse was unsure what words were said between the Administrator and the resident during the confrontation. The hospice nurse did not witness the confrontation. By the time the Administrator finished with the hospice nurse the resident was standing at the emergency exit door down the 100-hall with his supplies and had made the alarm go off. The door opened before the hospice nurse could get to the resident. The resident stormed out walking towards the road. The resident could not be redirected inside, the hospice nurse stayed with the resident and contacted the hospice house around 6:35 P.M. to get a hold of the manger on duty. During this time the resident had called his wife multiple times to come pick him up. The hospice nurse was able to get the resident to relax but he stated he was not going back inside, stating he was not staying at a place where people treated him like that. The hospice nurse stayed with the resident as they walked down the sidewalk. The resident's wife arrived around 7:00 P.M. and the resident walked right up to her car and got into the passenger seat. The resident's wife was very emotional when she pulled up. The hospice nurse explained to the wife to take the resident to the hospice house and the wife was agreeable. The hospice nurse then updated the hospice manger to let her know the resident was on his way back to the hospice house and was safe in the wife's car. The facility staff was unsure of what to do and would call into hospice if they needed anything done due to the resident not returning to the facility. The hospice nurses gathered the rest of the resident's personal supplies and brought them back to the hospice house. Review of SRI # 5 completed 02/17/21 at 6:20 P.M. revealed on 02/11/21 Regional Director of Clinical Services #400 was notified by Medical Director #301 of an alleged incident that was reported to have occurred on 02/04/21, the perpetrator was the facility's Administrator. The alleged incident consisted of the Administrator utilizing explicit language when speaking to Resident #37. The Administrator was suspended, and an investigation initiated. The investigation consisted of interviews of residents and staff reported to have been present at the time of the incident as well as interviews of all residents who were able to be interviewed and skin checks conducted for all residents who were unable to be interviewed. An interview was also conducted of an outside agent, a hospice nurse, who had also been present at the time of the alleged incident. This interview was conducted by the Medical Director. Resident #37 was discharged from the facility on 02/04/21 prior to being interviewed. The incident was described in interviews; facility residents were preparing to smoke when Resident #37 lit a cigarette while still in the facility. Resident #5 attempted to address Resident #37 in an attempt to have him extinguish the cigarette then the Administrator approached Resident #37 at that time in regard to extinguishing the cigarette. Resident #37 declined to do so utilizing explicate language. The Administrator in return communication utilized an explicit word in response, at that time the staff and hospice nurse present intervened. There was no further interaction between Resident #37 and the Administrator. The SRI identified through interview a resident and two staff members present at the time of the alleged incident reported the Administrator had utilized an explicit word when communicating to Resident #37. Four other residents who had been present at the time of incident reported no knowledge of the allegation. The hospice nurse who was also present did not report knowledge of explicit language utilized by the Administrator in communication with Resident #37. The SRI identified no concerns were identified through interviews and skin checks conducted for the remaining residents. Through investigation it was unable to definitely determine abuse occurred but did determine the Administrator did conduct herself in a manner not consistent with the organization standards and when addressed resulted in the resignation of the Administrator. Review of the SRI revealed the typed, not signed witness statement dated 02/11/21 revealed as part of an investigation LPN #303 was interviewed regarding her knowledge of the alleged incident that occurred on 02/04/21. LPN #303 reported she was present at the nurses' station in relative proximity to the common dining room where the incident occurred. LPN #303 stated she had been aware Resident #37 had lit a cigarette within the facility and was confronted by the Administrator. LPN #303 stated she was able to hear the interaction between Resident #37 and the Administrator but was unable to see it. As part of their interaction LPN #303 stated she heard the Administrator utilize explicit language in stating I don't know who the (expletive) you think you are. At that time other staff attempted to redirect Resident #37. LPN #303 then stated the Administrator instructed the hospice nurse that if Resident [TRUNCATED]

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of a closed medical record, review of the facility investigation, review of the death certificate, interviews with facility staff, and review of the facility policy, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) for one resident (Resident #8) when the resident was found unresponsive, without a pulse or respirations, and was identified as a Full Code status. This resulted in Immediate Jeopardy and life-threatening harm when Resident #8 did not receive CPR and expired at the facility. This affected one (Resident #8) of three residents reviewed who had a Full Code status. The facility did not identify any other residents who were full code status who expired at the facility. The facility identified 18 current residents who were designated as having a Full Code status. The facility census was 39 residents. On [DATE] at 4:05 P.M., the Administrator was notified Immediate Jeopardy began on [DATE] at 12:03 P.M. when Resident #8 was found unresponsive by State tested Nursing Assistant (STNA) #100, who then notified Licensed Practical Nurse (LPN) #200 that the resident was unresponsive. LPN #200 did not initiate CPR on Resident #8 who had a Full Code status. LPN #200 documented that the resident did not have any vital signs at the time of assessment. LPN #200 called the Director of Nursing (DON) #2 who also assessed for vital signs. DON #2 determined that vital signs were absent, however, failed to initiate CPR on Resident #8. LPN #200 then called the physician, who gave a verbal order to release the body to the funeral home. The Immediate Jeopardy was removed, and the deficiency was corrected on [DATE] when the facility implemented the following corrective actions: · On [DATE], Physician #2 (attending physician) was notified by RN #26 that Resident #8 expired in the facility, was Full Code status, and CPR was not administered. · On [DATE], the Medical Director (Physician #1) was notified by RN #26 that Resident #8 expired in the facility, was a Full Code status, and CPR was not administered. · On [DATE], RN #26 obtained statements from DON #2, LPN #200, STNA #100, STNA #22, STNA #20, and the administrator. · On [DATE], LPN #200 and DON #2 were suspended and later terminated on [DATE]. · On [DATE], Social Service Designee (SSD) #4 completed a 100 percent audit of current residents to ensure current code status and advance directive status were accurate. · On [DATE], RN #26 completed an audit of all in house deaths in the last 30 days to ensure resident advanced directives were followed. The audits will continue following each in house death for three months. · On [DATE], Regional Director of Clinical Services (RDCS) #6 checked the facility crash cart to ensure availability of all supplies required for CPR and equipment was ordered as needed. Crash cart audits will be conducted after each event requiring use by DON or designee. The crash cart supplies were confirmed by the surveyor on [DATE]. · On [DATE], RDCS #6 conducted a mock code for day shift and night shift staff. Mock codes were completed weekly for 4 weeks and then monthly for two months. · On [DATE], a Quality Assurance and Performance Improvement (QAPI) meeting was conducted to review the action plan. In attendance were the Medical Director (Physician #1), Administrator, RN #26, Physician #2, Human Resource Designee #3, and SSD 4. Ongoing results of the mock codes and audits will be submitted to the QAPI committee for further review and recommendations. · From [DATE] to [DATE], the Administrator and Regional Director of Clinical Services (RDCS) #6 completed in house education with all staff on the process to follow when a resident is found absent of vital signs, verification of code status, order entry of code status, overall code process, and education for the RN to verify code status if called by the LPN via phone. Newly hired staff will be educated by DON #1 or designee during orientation. · On [DATE] and [DATE], interviews with RN #14, RN #27, STNA #20, STNA #22, STNA #77, STNA #100, and LPN #4 all confirmed they received training regarding code status, when to initiate CPR, the procedure to initiate CPR, and the location of the resident's code status. Findings include: Review of the closed record for Resident #8 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #8's physician order dated [DATE] revealed Full Code status. Review of Resident #8's progress note revealed on [DATE] at 12:03 P.M. LPN #200 was in the hallway passing medication when STNA #100 alerted her she needed assistance STAT (immediately). LPN #200 entered the room and discovered Resident #8 lying across the bed with brown liquid coming from his mouth. LPN #200 assessed the resident's vital signs and found them to be absent. She then notified DON #2 who also assessed Resident #8's vital sounds and found them to be absent. Further review of the progress notes revealed on [DATE] at 12:20 P.M., LPN #200 contacted Physician #2 and received a verbal order to discharge Resident #8's body to the funeral home. Review of the facility's investigation of Resident #8's death dated [DATE] revealed on [DATE] at 12:03 P.M., LPN #200 was in the hallway passing medications when STNA #100 alerted out she needed assistance STAT. LPN #200 entered the room and discovered the resident lying across the bed with brown liquid coming out of his nostrils and mouth. Vital signs were taken and noted to be absent. LPN #200 informed DON #2 who did come to the resident's room and confirmed the absence of vital signs. On [DATE] at 12:08 P.M. DON #2 documented the resident was lying across the bed unresponsive, assessed no vital signs present, and the time of death at 12:10 P.M. On [DATE] at 12:20 P.M., DON #2 documented Physician #2 was notified that the resident expired, and it was okay to release the body to the funeral home. Review of Resident #8's Death Certificate signed on [DATE] by the residents' attending physician (Physician #2) revealed the cause of death was an immediate result of [MEDICAL CONDITION]. Review of a statement from STNA #100, dated [DATE], revealed on [DATE] at around 12:00 P.M. she walked into Resident #8's room and found him lying on his back unresponsive. She yelled for LPN #200 who entered the room with STNA #22. At no time was CPR was initiated. Interview on [DATE] at 10:47 A.M. with the Administrator revealed on [DATE], STNA #100 found Resident #8 in his room unresponsive. She alerted LPN #200. LPN #200 entered the room obtained vitals and none were present. LPN #200 contacted DON #2 who confirmed the absent vitals. She confirmed Resident #8 was a full code and CPR was not performed and Emergency Medical Services (EMS) was not called. Interview on [DATE] at 11:20 A.M. with STNA #100 confirmed taking care of Resident #8 on [DATE]. STNA #100 revealed she checked on Resident #8 throughout the day and 30 minutes prior to finding him unresponsive. She reported he was alert and seemed okay. She further reported that around 12:00 P.M. she walked into Resident #8's room to deliver his lunch tray and found the resident unresponsive. She alerted LPN #200 who entered the room with STNA #22. She denied seeing LPN #200 initiate CPR on the resident. Telephone interview on [DATE] at 12:33 P.M. with STNA #22 revealed she was working with STNA #100 on [DATE]. She reported that both STNA #100 and herself were frequently checking on Resident #8. She further reported that STNA #100 called for help, she cannot remember the time, and she responded with LPN #200. She confirmed that LPN #200 then checked his vitals and called for DON #2. At no time was CPR initiated or EMS called. After DON #2 confirmed the resident was absent of vitals, STNA #22 was instructed to start postmortem care. Interviews on [DATE] with RN #14, STNA #22, STNA #77, STNA #100, and LPN #4, and on [DATE] with RN #27, STNA 20, and STNA #88, confirmed they received training regarding code status and when to initiate CPR. They further revealed knowledge of the procedure to initiate CPR, and the location of the residents' code status in their charts. Observations on [DATE] at 3:10 P.M. revealed that the facility had a fully equipped crash cart located centrally between the North and South halls. Supplies present on the cart included, a backboard, suctioning equipment, tubing, glucometer, oxygen tank on full, ambu bag, stethoscope, and blood pressure cuff. Observation on [DATE] at 3:20 P.M. of Residents #6, #21, #22, and #26 revealed they all had correct code status sheets present in the front of their charts. On [DATE], review of the CPR training dated [DATE] revealed that the training was completed for all facility staff by [DATE]. The training included reeducation of the facility policy Cardiopulmonary Resuscitation, code blue bedside documentation, review of the DNR order form, review of the Full Measure Order form, and review of a mock code blue inservice done on [DATE]. Also reviewed were the all resident audit completed [DATE] verifying resident code status, and the [DATE] QAPI investigation. Interview on [DATE] at 4:40 P.M. with the Administrator verified that all staff were trained verbally by [DATE]. She revealed that only one staff member (RN #27) has started working in the facility since [DATE]. She further provided evidence that RN #27 was trained about CPR and code status on [DATE]. Review of the facility policy entitled, Cardiopulmonary Resuscitation (CPR), dated ,[DATE] and revised [DATE], revealed CPR will be provided to all residents/patients who experience cardiopulmonary arrest unless one or more of the following is present: a valid advanced directive or physician orders for life sustaining treatment/medical orders for life sustaining treatment/physician orders for scope of treatment/medical orders for scope of treatment (identified in the policy as POLST/MOLST/POST/MOST) requesting withholding CPR, a properly and witnessed DO NOT Resuscitate order, documented verbal wishes by the resident/surrogate decision maker indicating the desire to be DNR but physician order is pending, dependent lividity, rigor mortis, decapitation, or transection. This deficiency substantiates Complaint Number OH 625.

Based on Self-Reported Incident (SRI) review, record review, interview, and policy review the facility failed to ensure Resident #2 received non-invasive interventions for constipation. Actual harm occurred when Registered Nurse (RN) #50 performed an unordered rectal examination and digitally stimulated Resident #2 resulting in rectal pain and discomfort that affected the residents' activities of daily living for three days. This affected one resident (#2) of one resident reviewed for constipation. Findings include: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's plan of care dated 07/07/20 revealed the resident was at risk for constipation related to a decrease in mobility and side effects of medication. The goal was that the resident would have a bowel movement every three days. Interventions included, administered medications as ordered; consult dietary for assistance in meeting dietary needs; encourage exercise as tolerated; encourage fluids if diet permits; and monitor for constipation and causes. Review of Resident #2's quarterly MDS dated [DATE] revealed the resident had intact cognition, was continent of bowel, and needed extensive two plus persons assistance for bed mobility and toilet use. Review of Resident #2's nursing note dated 01/06/21 at 1:07 P.M. revealed the resident was constipated but the constipation was resolved with a polyethylene [MEDICATION(S)] stool softener. There was no signs or symptoms of distress noted. Interview on 01/26/21 at 9:05 A.M. with Resident #2 revealed on 01/06/21 she had not had a bowel movement for a day or so and she had reported this to RN #50. Resident #2 reported that RN #50 told her that massage helps, and then gave her oral medication to help her have a bowel movement. When RN #50 came back in to check on her, Resident #2 reported that she had still not had a bowel movement. RN #50 then had the resident roll to her side and the nurse started to dig the stool out of the resident. The resident reported she asked the nurse to stop due to pain. After the incident the resident further reported that she was unable to sit on her bed or participate in therapy for three days due to the pain the nurse caused when she tried to manually remove the stool from her. Further review of the nursing notes revealed no evidence Resident #2 had a fecal impaction or that RN #50 performed a digital rectal exam or rectal stimulation. Review of Resident #2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and 01/09/21 at 12:17 A.M. Further review revealed she also received [MEDICATION(S)] 4 mg for pain on 01/07/21 at 10:50 A.M. and on 01/09/21 at 9:50 P.M. Interview on 01/26/21 at 11:30 A.M., with Physical Therapy Assistant (PTA) #50 revealed that Resident #2 was unable to complete some of her therapy on 01/06/21, 01/07/21, and 01/08/21 due to discomfort resulting from RN #50 rectally stimulating the resident to have a bowel movement. Review of physical therapy note dated 01/06/21 revealed that Resident #2 was unable to sit on the edge of bed due to her bottom feeling sore. Interview 01/26/21 at 4:05 P.M., with RN #50 revealed that on 01/06/21 Resident #2 complained of not being able to have a bowel movement resulting in abdominal discomfort. Resident #2 rolled over for RN #50 to do an examination. At that time RN #50 visualized some feces. RN #50 proceeded to do a digital exam and digital rectal stimulation on the resident. The resident then asked RN #50 to stop. RN #50 reported she stopped and then put a bed pan under the resident. RN #50 further reported she did not know that she was not allowed to rectal stimulation at this nursing home. She lastly revealed that she did not notify the physician of the impaction and did not receive a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 01/26/21 at 6:00 P.M., with Physician #60 revealed RN #50 did not contact him on 01/06/21 to inform him of the resident's impaction, or to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 01/27/21 at 11:51 AM with the Director of Nursing revealed the facility does not have standing orders or a bowel protocol. Interventions related to constipation/bowel regimen are determined by the physician upon each occurrence. Review of the facility's SRI revealed RN #50 was re-educated on 01/11/21. The re-education form revealed any bowel/stimulation was against the facility's policy and guidelines. Manual dis-impaction should not be done, it increases resident risk for vasovagal response and potential trauma to the rectal lining. If a resident is experiencing constipation, please follow bowel regimen and contact the physician if not results. The list included: oral [MEDICATION(S)]- milk of magnesia, rectal suppository, and rectal enema. This deficiency substantiates Complaint Number OH 245.

Based on medical record review and interview, the facility failed to prevent a resident (who required extensive assistance of two staff for bed mobility and bathing) fall during the delivery of personal care. This resulted in actual harm on 05/04/20 when Resident #45 was being assisted by one staff and rolled out of bed from a height of three feet which resulted in a right femur fracture. This affected one (Resident #45) of three residents reviewed for accidents. Findings include: Review of Resident #45's medical record revealed [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #45 required extensive assist of two staff for bed mobility and was dependent for bathing with two staff assist. A nursing note dated 05/04/20 at 9:16 A.M. indicated a state tested nursing assistant (STNA) stated Resident #45 rolled out of bed while being washed. Resident #45 was found lying on her stomach with her head against the dresser. A nursing note dated 05/21/20 at 2:45 P.M. indicated an STNA reported Resident #45 was having significant pain in her right knee during care and repositioning. The physician ordered a right knee x-ray. A nursing note dated 05/21/20 at 6:44 P.M. indicated the x-ray results revealed a displaced and comminuted fracture ( A comminuted fracture is a break or splinter of the bone into more than two fragments.) involving the transcondylar distal femur. There was extensive soft tissue swelling and osteopenic changes as well as [MEDICAL CONDITION] changes of the knee joint. The x-ray results indicated the age of the fracture was indeterminate but was likely recent. Review of the facility's investigation included a form titled, Falls: In the event of a fall, you must do the following:, indicated interventions in place prior to the fall included bilateral grab bars on the bed and staff had to assist with all mobility. A Post Fall Huddle Fall Scene Investigation dated 05/04/20 revealed the root cause of the fall was to be investigated by asking three times why a resident fell . Entries to this question revealed: rolled too far over during the bath (did not indicate if staff rolled the resident or if the resident rolled herself). The second entry indicated the fall occurred because one STNA was providing care/bed bath. The third entry indicated Resident #45 was a total care with bathing. The Post Fall Huddle Fall Scene Investigation indicated Resident #45 fell from the bed to the floor, approximately 36 inches height. The investigation asked if all interventions were in place, why the fall occurred. The nurse documented: rolled too far over in bed while STNA (state tested nursing assistant) was bathing her. STNA #135 wrote a witness statement which indicated she was changing Resident #45 and she rolled to the side but rolled too far and fell off the bed. A statement by the Director of Nursing (DON) indicated on 05/04/20, at approximately 8:40 A.M., she was notified of Resident #45's fall. The DON documented when she asked STNA #135 what happened, STNA #135 stated as Resident #45 was rolling to her right side during her bath Resident #45 did not stop herself by holding onto the assist bar as she usually did. STNA #135 stated Resident #45 continued to roll all the way out of bed onto the floor. Review of the emergency room report revealed a note by a registered nurse (RN) from the hospital dated 05/21/20 at 8:06 P.M. which indicated according to the nursing home Resident #45 had a fall on 05/04/20 when she was rolled over in the bed and fell out due to not having enough staff assistance at the facility. On 08/03/20 at 10:48 A.M., during interview, STNA #135 stated Resident #45 was totally dependent on staff for activities of daily living. STNA #135 stated prior to the fall on 05/04/20, Resident #45 was able to roll herself in bed, stating she would use her leg to push herself over. On 05/04/20 when the fall occurred, Resident #45's leg slipped and she fell . STNA #135 stated the fall occurred so quickly she wasn't sure but she may have given Resident #45 a little push. STNA #135 stated the bed was raised as she was providing care to Resident #45 and stated she had provided the same type of assistance to Resident #45 multiple times with no safety concerns. On 08/03/20 at 11:03 A.M., during interview, STNA #140 stated prior to Resident #45's fall she was able to use the grab bar and help turn herself but was unable to turn herself independently. On 08/03/20 at 11:15 A.M., during interview, STNA #100 stated prior to Resident #45's fall she could turn with one assist with the use of bed rails but required staff assistance. On 08/03/20 at 1:57 P.M., during interview, Licensed Practical Nurse (LPN) #145 stated prior to Resident #45's fall on 05/04/20 she would grab the rail and hold herself in position but could not turn independently. LPN #145 stated Resident #45's care could be provided by one assist prior to the fall but there were times, especially if she had an urinary tract infection, when she required two staff assist. This deficiency is cited as an incidental finding to Complaint Number OH 512.

Based on medical record review, interview with staff, resident, resident's power of attorney, physician and pharmacist, observations, review of gradual dose reduction policy for [MEDICAL CONDITION] medication, drug regimen (including [MEDICAL CONDITION] drug requirements) policy, review of behavior management grid policy, behavior monthly flow record protocol and review of a self -reported incident the facility failed to ensure one resident (Resident #12), had a qualifying [DIAGNOSES REDACTED]. This resulted in Immediate Jeopardy when Resident #12's physician prescribed a [MEDICAL CONDITION] medication without a supporting [DIAGNOSES REDACTED]. Actual harm occurred when Resident #12 was observed with lethargy, decreased oral intake, excessive sleeping, decreased physical abilities and decreased participation in activities. The facility failed to monitor the resident for effectiveness or adverse effects of the antipsychotic medication. This affected one of one resident (Resident #12) reviewed for antipsychotic medication use. The facility identified seven residents residing in the facility who received antipsychotic medications (Residents #15, #22, #18, #14, #19, #12, and #8). On 03/12/18 at 1:40 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 01/28/18 when Resident #12's psychiatrist (Psychiatrist #60) ordered Resident #12 an antipsychotic medication based on incorrect information that Resident #12 was delusional thinking he was marrying a staff person. Actual Harm occurred when Resident #12 was not monitored for adverse effects from the drug sustaining a decrease in nutritional intake with weight loss, decrease in physical abilities, increased sleepiness and lethargy, and a decline in quality of life as evidenced by decreased participation in smoking which was his activity of choice. The Immediate Jeopardy was removed on 03/14/18 when the facility implemented the following corrective actions: · On 03/12/18 at 10:17 A.M. Psychiatrist #60 discontinued the order for the [MEDICAL CONDITION] medication ([MEDICATION NAME]) for Resident #12 due to no indication for the use of the medication. · On 03/12/18 by 5:00 P.M., the DON completed an audit of the seven residents (Residents #15, #22, #18, #14, #19, #12, and #8) who received Antipsychotic medications, for indication and proper diagnoses. All residents audited had the proper [DIAGNOSES REDACTED]. · On 03/12/18 at 5:00 P.M., staff education was initiated by the DON and the Administrator for all facility staff regarding recognizing changes in condition of residents and reporting changes to the charge nurse. On 03/13/18 at 5:30 P.M. 38 of the 49 staff had been educated including three housekeepers, four registered nurses (RNs), one social service designee (SSD), the Administrator, 15 state tested nursing assistants (STNAs), four licensed practical nurses (LPNs), two activities staff, one administrator assistant, one maintenance director and six dietary staff. The remaining 11 staff will be educated prior to working their next scheduled shift. · On 03/12/18 at 5:00 P.M., the DON/designee started education with all the RNs and LPNs on ensuring residents who received psychoactive medications were being assessed properly, the proper [DIAGNOSES REDACTED]. This education was completed on 03/13/18 by the DON/designee. · On 03/12/18 at 5:00 P.M., the Administrator/designee started education with all non-direct care staff on identifying changes in condition or normal routines and notifying the charge nurse. This was completed on 03/13/18. · On 03/12/18 at 6:15 P.M., a special quality assurance improvement committee meeting was held with the Medical Director, the Administrator, the DON, the business office manager, the director of housekeeping, the activities director, admissions and marketing person and the assistant DON to review the concern with Resident #12, and implement a comprehensive plan of correction. · On 03/12/18 at 5:00 P.M., the Administrator and DON/designee began in-service with all staff to review the following policies: antipsychotic medication alert, change in resident condition, [MEDICAL CONDITION] medication documentation review, drug regimen review, resident review meeting, behavior management, and behavioral management grid and behavior management. This was completed on 03/13/18. · On 03/13/18 between 5:00 P.M. and 8:00 P.M., all staff working were interviewed by the DON/designee to ensure all residents receiving psychoactive medications were monitored for any adverse outcomes from the medications. Staff interviews included 15 STNAs, two RNs, two LPNs, one laundry person, one social service designee, one activities person, three housekeepers, three dietary staff and one maintenance director. · On 03/13/18 between 3:30 P.M. and 4:15 P.M., interview with RN #29, LPN #25, STNAs #22, #30, #38, Activities Director #19, Cook #43, Maintenance Director #26, Housekeeping Supervisor #18 and Therapy Manager #54 revealed they all had been inserviced and were knowledgeable regarding education they received on policies and procedures, monitoring for side effects of psychoactive medications and reporting any changes in condition to ensure they were knowledgeable about identifying changes and reporting. · On 03/13/18 at 4:30 P.M., Psychiatrist #60 re-assessed Resident #12 to ensure he was not receiving any unnecessary medications. · On 03/14/18 the facility implemented a new directive for the Administrator to interview three to five staff members weekly for four weeks on identifying changes of condition and reporting them to the charge nurse as educated and ensuring charge nurses are able to correctly obtain the proper indication and [DIAGNOSES REDACTED]. · On 03/14/18 the facility implemented a new directive for the DON/designee to audit all residents on psychoactive medications twice per week for four weeks to include a review of the resident's behavior flow sheet, review of the resident's weights, and an interview with the facility activity department to see if the resident has had a decline in interest in relation to receiving the prescribed medication. Declines or changes in condition will be reported to the facility doctor and the resident's responsible party. · On 03/14/18 the facility implemented a new directive for all new admissions with [MEDICAL CONDITION] medications or all new orders for [MEDICAL CONDITION] medications to be reviewed during clinical stand up daily and the pharmacist and/or doctor will be notified if resident's [DIAGNOSES REDACTED]. Monitoring will occur for eight weeks. · On 03/14/18 the facility implemented a new directive for monthly quality assurance improvement committee meetings to be conducted to review the status of the internal action plan and any resident to resident incidents. Although the Immediate Jeopardy was removed on 03/14/18, the facility remains out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan to investigate and identify justification and appropriate [DIAGNOSES REDACTED]. Findings include: Record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was not ordered any [MEDICAL CONDITION] medications. Review of the annual Minimum Data Set (MDS) 3.0 dated 10/08/17 revealed Resident #12's brief interview for mental status was a score of two which indicated severe cognitive impairment. The resident did not have any mood or behavior concerns including delusions. Review of the self-reported incident dated 11/22/17 revealed STNA #63 was found to be sexually inappropriate with Resident #12 on multiple occasions including kissing the resident on the lips and all over the face, sitting on his lap and providing long, frequent incontinence care which included changing all his clothes. The STNA was terminated for her behavior. Review of the physician progress notes [REDACTED]. The progress note did not indicate the resident was having any delusional activity. Review of the nursing notes from 12/04/17 through 12/13/17 revealed there was no evidence the resident was having any behaviors including being easily agitated or in need of medication for behaviors. There was no evidence the resident was having delusions. Review of the 12/08/17 quarterly dietary assessment revealed the resident was eating 70 to 100 percent of his meals and no concerns were noted. Review of Psychiatrist #60's progress note dated 12/13/17 revealed Resident #12 was easily agitated and attempted to get up out of his wheelchair. No concerns with mood or delusions were noted and Psychiatrist #60 stated the resident was coherent. The resident's [DIAGNOSES REDACTED]. The plan was to add the medication [MEDICATION NAME], an anti-anxiety medication, for agitation. Review of Psychiatrist #60's order dated 12/13/17 revealed an order for [REDACTED]. Review of the quarterly MDS 3.0 dated 12/18/17 revealed no mood or behavior concerns including delusions. Review of the nursing notes from 12/19/17 through 01/03/18 revealed on 12/24/17 Resident #12 became agitated but was easily redirected. This was the only behavior noted in the reference period and there was no evidence of delusions. Review of the meal intake records from 01/01/18 until 01/28/18 revealed the resident ate 50 to 100 percent with some refusals. Review of the 01/01/18 quarterly activities assessment revealed the resident actively participated in groups when he attended. He especially liked to attend when entertainers visited and enjoyed his smoke times. Review of the 01/03/18 quarterly MDS 3.0 revealed the resident had other behaviors not directed towards others that were exhibited daily. No delusions were noted. Review of the nursing notes from 01/04/18 to 01/17/18 revealed on 01/11/18 the resident was upset with another confused resident and the residents were separated. This was the only behavior noted in the reference period. There was no evidence of delusions. Review of the 01/24/18 monthly nursing note revealed the resident could get easily frustrated and could become angry with staff at times but was generally easy to redirect. He slept sporadically throughout the day and night. There was no evidence of delusions. Review of Psychiatrist #60's note dated 01/27/18 revealed it was reported the resident was having delusions of being married and was not able to be redirected. During the assessment the psychiatrist stated the resident was not having delusions or concerns with his mood; however, the psychiatrist started the resident on Trilofan, an antipsychotic medication indicated for [MEDICAL CONDITION], 2.0 milligrams in the evenings for delusions. Review of the warnings for Trilofan on the website Medscape indicated the FDA has issued a warming for use with elderly patients with dementia and a Black Box warning that it is not approved for dementia related [MEDICAL CONDITION] and may cause death in the elderly. Review of the behavior flow sheets for January, (YEAR) revealed there was no evidence the resident had behavior tracking completed. Further review of the abnormal involuntary movement scale (AIMS), a test used to identify side effects with the use of anti-psychotic medications revealed it was not completed. Review of the nursing notes from 02/01/18 through 02/28/18 revealed there were no behaviors noted, including delusions, for the reference period. Review of the physician progress notes [REDACTED]. Review of the behavior flow sheets for February, (YEAR) revealed there was no evidence the resident had behavior tracking completed. Further review of the AIMS test revealed it was not completed. Review of the February, (YEAR) meal intake records revealed the facility was not able to locate any documentation for the resident meal intakes for the month of February, (YEAR). Review of the resident's weight on 02/23/18 revealed he weighed 133.5 pounds. This was a 5.9 pound weight loss from 02/05/18 to 02/23/18. Review of the nursing notes from 03/01/18 until 03/12/18 revealed there were no behaviors noted, including delusions, for the reference period. Review of the behavior flow sheets for March, (YEAR) revealed there was no evidence the resident had behavior tracking completed. Further review of the AIMS test revealed it was not completed. Review of the dietitian progress note dated 03/02/18 revealed the resident triggered for a significant weight loss in the past month with a 5.9 percent loss in 2 ½ weeks. The resident was recently started on Trilofan which had a loss of appetite as a potential side effect. Review of the meal intakes for March, (YEAR) revealed the resident refused the majority of his meals. On 03/05/18 at 9:40 A.M., Resident #12 was observed standing in front of his wheelchair holding onto the hand rail with his right hand. He was very unsteady and trying to take steps but not able to move. There was a strong smell of urine around the resident. The resident was staring and could not state what he wanted to do. LPN #25 approached the resident and asked him why he missed his smoke break. With much effort, LPN #25 was able to get the resident to sit in his wheelchair. Resident #12 was very slow and unsure about sitting down. On 03/05/18 at 10:00 A.M., Resident #12 was observed in his room in the wheelchair with his head down, leaning far to the right with his head next to the arm rest. On 03/05/18 at 1:25 P.M., an attempt to interview Resident #12 revealed he was not able to provide any meaningful information. On 03/05/18 at 3:25 P.M., the resident was observed sleeping in his bed. On 03/05/18 at 3:30 P.M., interview with STNA #23 verified they had specific smoke times and the residents had to come to the nurse's station if they wanted to smoke. When asked if there were any residents who were confused and could not come to the nurses' station on their own STNA #23 verified Resident #12 would have to be asked and assisted outside. She verified he did not attend this smoke break because he was in bed sleeping and he missed most smoke breaks recently because he was sleeping a lot. She verified he did have a decline in participation in smoking because he was sleeping so much and verified he was not eating very much because he was sleeping most of the time. STNA #23 stated this was a change in the past couple of months. On 03/05/18 at 5:42 P.M., Resident #12 was observed standing at the nursing station with staff not in the area. He was very unsteady on his feet holding onto the desk with one hand and going through the rolodex with the other hand. He had drool coming from his mouth. He was a little shaky while standing. RN #46 was standing in the corridor near the dining room about 30 feet from the resident but did not make any attempt to assist the resident. Corporate RN #56 entered the area and immediately assisted the resident to sit back into his chair. Corporate RN #56 asked RN #46 if she could take him into the dining room for dinner. Resident #12 was observed not eating any food. On 03/06/18 at 7:10 A.M., Resident #12 was observed lying in bed sleeping with his head at the foot of the bed. At 7:20 A.M., the resident's breakfast tray was observed sitting on the overbed table and Resident #12 was sleeping. Resident #12 did not eat any breakfast. On 03/06/18 at 11:35 A.M., Resident #12 was found on the floor in the dining room. It was not observed how the resident got on the floor. On 03/06/18 at 12:40 P.M., the resident was observed sleeping in his wheelchair in his doorway with his head down by the arm rest. Resident #12 was drooling. On 03/06/18 at 1:20 P.M., phone interview with Resident #12's power of attorney (POA #59) verified he visited frequently and Resident #12 recognized him but was not able to provide him any meaningful information. POA #59 stated Resident #12 did not talk much. POA #59 stated the resident liked to sleep in the wheelchair. When POA #59 came in Friday (03/02/18) the resident was sleeping in the wheelchair by the nurse's station and it looked like he was going to fall out. POA #59 stated his head was close to the floor. POA #59 verified several times when he had visited the resident had been lying on the floor matt with his head on the bed. He stated Resident #12 cannot get off of the floor. POA #59 stated the resident had gotten very weak lately and was sleeping a lot more. He used to love to watch baseball on TV and bands when they had them. He also used to love to smoke and POA #59 took him out every time he was there. On 03/06/18 at 2:00 P.M., the resident was observed in the doorway of his room in his wheelchair with his head down almost on his knees with his eyes closed. His hat fell off and he lifted his head and had a large amount of drool. He then put his head back down and closed his eyes again. On 03/08/18 at 7:40 A.M., Resident #12 was lying in bed with his eyes closed. His breakfast tray was on the overbed table and was untouched. The resident woke up and took one bite of French toast and fell back asleep. On 03/08/18 at 9:00 A.M., Resident #12 was observed lying in bed with his eyes closed. He did not attend the 9:00 A.M. smoke break. On 03/09/18 at 7:12 A.M., Resident #12 was observed standing in front of his wheelchair holding on to the railing and LPN #25 was trying to get the resident to sit back down in his chair. The resident was very unsteady, very slow moving, slow to react and did not understand what the nurse wanted him to do. The nurse was finally able to get the resident to sit in his chair and he was given a bottle of Pepsi to drink, a pack of crackers and was wheeled to the dining room unsupervised. On 03/09/18 at 7:55 A.M., the resident was observed sleeping in his wheelchair in the dining room. The resident did not eat his breakfast On 03/09/18 at 12:32 P.M., the resident was sleeping in his bed with his lunch tray covered and untouched on the overbed table. Review of the nursing note dated 03/12/18 at 7:45 A.M., revealed the DON spoke with Psychiatrist #60 on 03/08/18 in regards to the resident's initiation of the antipsychotic and he indicated it was due to delusions. On 03/12/18 at 10:04 A.M., phone interview with Psychiatrist #60 verified he saw Resident #12 in January, (YEAR). Psychiatrist #60 was told by staff the resident was infatuated with a staff member and was having delusions about getting married. He verified no one in the facility informed him of a recent allegation of a staff member being sexually inappropriate with the resident or he would have reported the allegation. When Psychiatrist #60 came in to the facility they had a list of residents for him to see with a scant amount of information next to the resident's name. He verified Resident #12 was not interviewable and he was not able to get any meaningful information from the resident. The information regarding Resident #12's delusions was obtained from the nursing staff. He verified increased lethargy and decreased nutritional intake could be a side effect of the [MEDICAL CONDITION] medication Trilofan. Psychiatrist #60 verified the resident had not had any delusions prior to this allegation from the nursing staff and he had not been aware of the resident having any behaviors beside some anxiety for which the resident was started on an antianxiety medication in December, (YEAR). Psychiatrist #60 verified prior to initiating the [MEDICAL CONDITION] medication Resident #12 was up in his wheelchair more and liked to be outside and was more active. Psychiatrist #60 verified he was not made aware of any side effects Resident #12 was experiencing. Psychiatrist #60 stated he needed to talk to nursing staff to discontinue the use of the [MEDICAL CONDITION] medication Trilofan as he felt he was not given the correct information. Psychiatrist #60 verified Resident #12 was not on any psychoactive medications prior to the Trilofan. Review of the nursing note dated 03/12/18 at 10:17 A.M.; revealed Psychiatrist #60 discontinued the use of the antipsychotic medication Trilofan for Resident #12. On 03/12/18 observations from 12:00 until 12:30 P.M., revealed room trays were delivered and had all been collected by 12:30 P.M., except Resident #12 who had only taken a few bites of his cheeseburger. He was moving very slowly and kept falling asleep. No staff were observed assisting the resident. STNA #23 came in the room a couple times to collect his tray but he said he was still eating. She did not offer to assist the resident. On 03/12/18 at 12:32 P.M., interview with STNA #23 verified the resident had not been eating much in the last couple of months but no one was assisting him with his meals. She verified he had a change in condition but she was not instructed to assist the resident. On 03/12/18 at 2:10 P.M., interview with POA #59 verified he was never informed the resident was started on the antipsychotic medication Trilofan and verified he visited the resident regularly and was not aware of the resident having any delusions. He said he had always been a ladies man and would talk about girlfriends. On 03/12/18 at 3:06 P.M., interview with Corporate Administrator #61, the Administrator and the DON verified the concerns identified with the resident. On 03/12/18 at 3:41 P.M., phone interview with Pharmacist #62 revealed she started working at the facility the end of December, (YEAR). She verified she did not review the Trilofan order dated 01/28/18 because she would not review it until the resident was on the medication for three months. Pharmacist #62 verified the resident did not have a [DIAGNOSES REDACTED]. His [DIAGNOSES REDACTED]. On 03/13/18 at 8:00 A.M., the resident was observed in the dining room at a table by himself sleeping with his breakfast in front of him untouched. RN #46 was observed sitting on a bench talking with STNA #23 who was feeding a resident. No one interacted with Resident #12. Interview with STNA #23 verified the breakfast trays were delivered about 7:15 A.M. and Resident #12 had been sleeping and no one attempted to assist him. At 8:05 A.M., all other residents were finished eating and the breakfast trays were removed from the tables, except for Resident #12. At 8:07 A.M., STNA #23 went over to the table and woke up Resident #12. Observation revealed he would eat when the STNA was sitting with him encouraging him. On 03/13/18 at 3:50 P.M., interview with Activities Director #19 verified the resident had declined in participation in activities and attending smoke breaks the last couple months because he had been sleeping so much. Review of the [MEDICAL CONDITION] gradual dose reduction policy, revised (MONTH) (YEAR), revealed the interdisciplinary team would ensure appropriate use, evaluation and monitoring to ensure each resident was free from unnecessary medications. An unnecessary medication is any drug when used as follows: in excessive dose, without adequate monitoring or without adequate indications for its use or in the presence of adverse consequences which indicate the dose should be reduced or discontinued. Review of the drug regimen review, including [MEDICAL CONDITION] drug requirements, policy, revised 07/05/17, revealed the drug regimen of each resident would be reviewed at least once a month by a licensed pharmacist. The review would include review of the resident's medical chart. All residents receiving [MEDICAL CONDITION] medications would have a chart and drug regimen review to include review of appropriate [MEDICAL CONDITION] drug requirements and documentation. A resident who had not used [MEDICAL CONDITION] drugs are not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. Review of the behavior/intervention monthly flow record protocol, not dated, revealed this tool was used to quantify and as a monitor to show results of interventions on behaviors. It assists in altering medications and dosages and choosing appropriate interventions and their effects. Further review of the directions for behavior management grid completion revealed grids would be utilized for any resident receiving [MEDICAL CONDITION] medications. Select the appropriate behaviors that are being monitored for the ordered [MEDICAL CONDITION] medication. This should be recorded every shift. The behavior grid would be reviewed monthly to identify any trends in the identified behaviors. The team would identify any increase or decrease in behaviors and address accordingly on the resident behavior/[MEDICAL CONDITION] review form. Review of the abnormal involuntary movement scale sample assessment indicated it was used to monitor for side effects of psychoactive medications. Further review of the policies revealed there was no policy for completion of the assessment.

Based on interview, self-reported incident review, and record review the facility failed to ensure Resident #12 was free from sexual abuse by staff. This affected one of three residents reviewed for abuse. Actual Harm occurred to Resident #12 when direct care staff was observed kissing the resident resulting in the resident's belief he had a relationship with the staff and the resident was subsequently prescribed an anti-psychotic medication for delusions that were based on the resident's belief of what was an actual relationship. Findings include: Record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) 3.0 dated 10/08/17 revealed a brief interview for mental status (BIMS) was a score of two which indicated severe cognitive impairment. Review of Psychiatrist #60's note dated 01/27/18 revealed it was reported to him Resident #12 was having delusions of being married and was not able to be redirected. During the assessment the psychiatrist stated the resident was not having delusions or concerns with his mood; however, the psychiatrist started the resident on Trilofan, an antipsychotic medication indicated for [MEDICAL CONDITION], 2.0 milligrams in the evenings for delusions. Review of the self-reported incident submitted to the State Agency on 11/22/17 revealed State tested Nursing Assistant (STNA) #63 was terminated from employment for inappropriately kissing Resident #12. Further review of the witness statement from Licensed Practical Nurse (LPN) #13 dated 11/22/17 revealed on 11/21/17 Resident #20 informed her that STNA #63 was kissing Resident #12 inappropriately. Review of the witness statement from LPN #25, not dated, stated at 7:30 P.M. on 11/19/17 STNA #35 and STNA #27 observed STNA #63 kissing Resident #12 on the mouth. They stated they had already notified the director of nursing (DON) of the incident. On 11/21/17 LPN #13 informed the DON of Resident #20's statement. On 11/21/17 both LPN #13 and LPN #25 informed the Administrator of Resident #20's allegation. Review of the Administrator's summary revealed on 11/22/17 LPN #13 and LPN #25 approached him about Resident #20's allegation. LPN #25 also stated STNA #35 and STNA #27 informed her of their observation of STNA #63 kissing Resident #12 on the mouth. She stated the two STNAs also went to the DON at that time. The Administrator interviewed the DON and she verified she did not interview STNA #63 and it was her understanding from the two STNAs it was a light peck on the resident's cheek. The Administrator interviewed Resident #20 who stated the kiss was over 20 seconds long, slobbering and very inappropriate. The Administrator interviewed Resident #12 who stated he had a girlfriend for about two months who worked at the facility and they have kissed. The Administrator interviewed STNA #27 who said she had a bad vide regarding the relationship between STNA #63 and Resident #12. She verified she had observed more than once STNA #63 grab the resident around the neck and kiss him on the mouth and she (STNA #63) always wanted to take care of Resident #12. The Administrator interviewed STNA #35 who stated she observed STNA #63 lean over and kiss Resident #12 on the mouth. She also heard STNA #63 was sitting on the resident's lap while out on a smoke break. STNA #35 also stated STNA #63 was obsessed with Resident #12 and was constantly around him and calling him baby. The Administrator interviewed STNA #63 who said Resident #12 liked her and followed her around. She verified she had on occasion kissed the resident on the cheek. She stated the resident once pulled her down on his lap in the hallway. Review of Resident #12's nursing notes for November, (YEAR) revealed there was no documented evidence of the allegation. On 03/08/18 at 11:10 A.M., interview with the Administrator verified STNA #63 was sexually inappropriate with Resident #12 and was terminated from employment for her actions. On 03/09/18 at 11:16 A.M. interview with the DON revealed she never received any notes under her door related to the interaction between Resident #12 and STNA #63. She was just told she pecked him on the cheek. She verified she did not conduct an investigation nor did she inform the Administrator. On 03/09/18 at 11:42 A.M. interview with Resident #20 verified he saw STNA #63 kissing Resident #12 on the neck. He reported it because she wasn't going to do that (expletive) to me. On 03/09/18 at 11:47 A.M. interview with LPN #25 verified she was informed of STNA #63 being sexually inappropriate with Resident #12 on 11/19/17 by STNAs #35 and #27. She verified she did not report the allegation because STNAs #35 and #27 stated they already reported it to the DON. She verified STNA #63 continued to work her full shift that evening after the allegation. On 03/09/18 at 11:53 A.M. interview with LPN #13 verified she first became aware of the concern from Resident #20. Then STNAs #35 and #27 informed her STNA #63 was sitting on Resident #12's lap during the smoke break and they told the DON. She thought it was handled and did not do anything about it. On 03/12/18 at 10:04 A.M., phone interview with Psychiatrist #60 verified he saw Resident #12 in January, (YEAR). Psychiatrist #60 was told by staff the resident was infatuated with a staff member and was having delusions about getting married. He verified no one in the facility informed him of a recent allegation of a staff member being sexually inappropriate with the resident or he would have reported the allegation. Psychiatrist #60 stated he needed to talk to nursing staff to discontinue the use of the [MEDICAL CONDITION] medication Trilofan as he felt he was not given the correct information. Psychiatrist #60 verified Resident #12 was not on any psychoactive medications prior to the Trilofan.

Based on record review and interview the facility failed to ensure ongoing weight monitoring was completed and failed to ensure the timely implementation of nutritional interventions to prevent a severe weight loss for Resident #6. This affected one resident (Resident #6) of three residents reviewed for weight loss. Actual harm occurred when Resident #6 sustained a 14.1 pound severe weight loss from [DATE] when she weighed 159.7 pounds to the week of [DATE] when she weighed 145.6 pounds without evidence the facility recognized the weight loss or implemented appropriate and individualized interventions timely to prevent additional weight loss. On [DATE] the resident was assessed to sustain an additional weight loss of 10.5 pounds with a weight of 135.1 pounds. Findings include: Review of Resident #6's closed medical record revealed the resident was admitted to the facility on [DATE] and expired on [DATE] at the hospital. The resident had [DIAGNOSES REDACTED]. Resident #6 was cognitively impairment. The resident ate independently with set up assistance. Review of Resident #6's care plan for activities of daily living (ADL), nutrition, and hydration revealed staff were to offer alternatives if 50% or less of meal was eaten, supplements per order, monitor dietary intake, monitor weights, notify physician and registered dietician of weight changes per policy. Review of ADL [DATE] tracking form dated [DATE] to [DATE] revealed for breakfast the resident refused one meal and ate ,[DATE]%; lunch the resident refused four meals and ate ,[DATE]%, and dinner refused four meals and ate ,[DATE]%. Record review revealed documentation the resident had refused meal substitutes except for on one occasion when she ate 100% of the substitute. Review of Resident #6 's progress notes, weights, and activities of daily living (ADL) tracking form revealed: On [DATE] (admission) the resident weighed 159.7 pounds. Her admission assessment indicated she had no problems with dentures/bridge. Her usual food intake pattern was adequate and she eats over half of most meals including four servings of protein. Occasionally she would refuse a meal but would take a supplement if offered. On [DATE] and [DATE] there was no evidence the resident was weighed per policy. The week of the [DATE] (actual date not provided) review of a paper weight log revealed the resident weighed 145.6 pounds, which was a 14.1 pound weight loss from the previous week. There was no evidence the family or physician were notified at that time or evidence any type of nutritional interventions were ordered. There was no evidence the weight was entered in the electronic medical record. On [DATE] the dietary manger reviewed Resident #6's dietary history and preferences with the resident's son. The son reported the resident currently had a poor appetite. She had upper and lower dentures and reported she frequently could did not have any feeding or swallowing concerns and preferred not to have finger foods. The resident drank glucose control Ensure supplements at home and preferred coffee, milk and cranberry juice. She liked fried eggs for breakfast and cookies and pretzels for snacks. She preferred no beef. Her son requested water be sent on all trays. On [DATE] a dietician note revealed Resident #6 was on a low concentrated sweet (LCS), no added salt (NAS) diet with ground texture. The note reflected her current weight of 159.7 pounds which was documented on [DATE]. The note stated the resident's protein intake didn't meet her needs due to poor appetite and difficulty chewing which was present on admission. The resident was at nutritional risk with meal intakes of ,[DATE]% with one meal refusal daily. The note indicated to send water and whole milk on all trays to increase fluid consumption and to increase kilocalories and protein intakes. The note indicated to monitor weights and meal intakes. There was no evidence the note referenced the resident's current weight of 145.6 which reflected a severe (greater than five percent) 14.1 pound weight loss in one week. Review of ADL [DATE] tracking form dated [DATE] to [DATE] revealed for breakfast the resident refused twelve times and ate ,[DATE]%; lunch she refused fifteen times and ate 25%, and dinner she refused 16 times and ate 25%. There was no evidence the resident was offered a substitute for breakfast and lunch. Review of the [DATE] daily meal records and ADL tracker information revealed discrepancies in the recorded documentation. The daily meal records revealed on [DATE], [DATE] and [DATE] the resident had refused dinner, however the ADL tracker indicated she ate 25%. On [DATE] the daily meal intake records indicated the resident ate 25% however the ADL tracker indicated 75% was consumed for dinner. Staff were not able to provide daily meal intake records for [DATE] to [DATE] and [DATE] to [DATE]. There were 7 days total the resident had refused all meals and days she ate one meal that was 50% or less. The week of [DATE] (actual date not provided) the paper weight log revealed the resident weighed 145.6 pounds. There was no evidence the weight was documented in the electronic medical record. There was no evidence the resident's physician or dietician were notified of the weight loss at that time. There was no evidence the resident was weighed the week of the [DATE], [DATE] or [DATE] per policy for a resident with significant weight loss. On [DATE] Resident #6 was started on [MEDICATION NAME] 15 milligrams (mg) and [MEDICATION NAME] 5 mg daily for depression, [MEDICATION NAME] 5 mg daily for dementia, and glucose monitoring. Further review revealed on [DATE] (over 30 days after the weight loss was identified) the resident was ordered a nutritional supplement, Boost plus twice daily. There was no evidence staff documented the amount of Boost plus the resident consumed. On [DATE] the resident weighed 135.1 pounds, which reflected an additional 10.5 pound weight loss. The resident was subsequently hospitalized and expired at the hospital on [DATE]. Review of the progress notes dated [DATE] to [DATE] revealed no evidence the resident had [MEDICAL CONDITION]. The resident was on antibiotic [DATE] to [DATE] for a urinary tract infection. There was no evidence the family or physician were noted of significant weight loss or meal refusals. Interview on [DATE] at 3:30 P.M., with Dietitian #9 revealed he reviewed the intake binders at the nurse's station and was not aware of the daily meal intake records. He stated weights were obtained from the electronic medical records. He reported having the correct intake records for supplements and meals would affect his nutritional assessment and recommendations. Interview on [DATE] at 5:00 P.M., with the Director of Nursing (DON) and Administrator revealed they were recently aware of Resident #6's dietary/nutritional concerns. She reported the facility had spent two days with the ombudsman reviewing the medical record. She confirmed there was lack of documentation with meal and supplement intakes and offering a substitute meal when a meal was refused or the resident ate less than 50% of a meal. She confirmed Resident #6 had a severe weight loss the week of [DATE] and there was no evidence the family, physician, or dietician was notified because the weights were not entered in the electronic medical record. The facility was providing education to the dietician regarding where to locate weights and meal intakes and the DON was going to enter the weights weekly in the electronic medical record herself. The DON confirmed accurate weights, supplements and meal intakes would affect the resident's nutritional needs and dietary recommendations. Interview on [DATE] from 12:59 P.M. to 5:00 P.M., with Licensed Practical Nurse (LPN) #11 revealed the night nurse should have entered the resident's weights in the computer and also indicated the dietician was responsible for reviewing the weights and implementing recommendations. Review of the weight policy, dated ,[DATE] revealed weights would be obtained routinely to monitor parameters of nutrition over time. Everyone's weight would be determined upon admission/readmission to the facility, weekly for the first four weeks after admission/readmission, and monthly or more often if risk was identified. Obtaining accurate weights was vital for nutritional assessment of each resident and was used as the basis for Medical Nutrition Therapy intervention. Nursing was responsible for the determination of everyone's weight. Upon admission the resident would be weighed each day for the first three days. After admission weights were obtained weekly for four weeks. After the first four weeks, the resident review committee or nutrition at risk committee will determine the need for continuation of weekly weights or a change to monthly weights, or more often per physician order. The day following weekly weight day the weights would be reviewed by the director of nursing (DON) or designee to ensure compliance to (facility) standards and to determine if any re-weights were required. Any resident with a significant weight change must be weighted weekly until stable. All significant weight changes must be communicated to the resident if appropriate, the attending physician and responsible party. All weights for each resident are to be recorded in one central weight record. This deficiency substantiates Complaint Number OH 023.

Based on record review and interview the facility failed to provide the necessary care and treatment to prevent the development of and/or the necessary treatment to promote the healing of pressure ulcers. This affected three residents (Resident #30, #46 and #27) of three residents reviewed for pressure ulcers. The facility identified five residents with pressure ulcers. Harm occurred when the facility failed to implement preventative measures for Resident #30, who was assessed to be at risk for skin breakdown on admission, when the resident developed pressure ulcers to the left buttock and an unstageable pressure ulcer to the right heel. Harm also occurred when the facility failed to implement preventative measures for Resident #46, who was also assessed to be at high risk for skin breakdown on admission, when the resident developed a deep tissue injury (unstageable) pressure ulcer to the left buttock. Findings include: 1. Review of Resident #30's medical record revealed the resident was admitted [DATE] with [DIAGNOSES REDACTED]. The 01/16/14 admission Minimum Data Set (MDS) 3.0 assessment revealed Resident #30 was independent for decisions of daily living, required extensive assistance from two staff for bed mobility, had lower extremity impairment on one side and utilized a wheelchair. Review of the 01/09/14 admission skin assessment revealed Resident #30 did not have any pressure ulcers assessed on admission, had three plus [MEDICAL CONDITION] (swelling) of bilateral lower extremities and left sided weakness. admission orders [REDACTED]. The admission skin risk assessments (Braden Scale) dated 01/10/14 and 01/16/14 revealed Resident #30 was a moderate risk for pressure ulcers indicating the resident was bedfast with limited mobility with shearing and friction concerns. The assessment dated [DATE] revealed the resident's mobility and nutrition had improved assessing him at mild risk for skin breakdown. Review of the admission interim potential for altered skin integrity plan of care revealed an intervention to report any skin redness or skin breakdown to charge nurse. On 01/21/14 a pressure ulcer, caused by shearing was noted to the left buttock. The pressure ulcer was assessed to measure 9.4 centimeters (cm) in length by 4.2 cm width with less than 0.01 cm depth with sanguious scant drainage and red wound margins. Orders were obtained for [MEDICATION NAME] cleansing foam then Sensicare Barrier ointment daily and as needed until healed. On 01/24/14 a pressure ulcer area was identified to the resident's right heel. The ulcer was assessed to measure four cm in length by two cm in width with no depth noted. The wound was described as a deep tissue injury (a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler compared to adjacent tissue, and also as a fluid filled callous). The pressure ulcer was noted to be unstageable. The intervention initiated following the development of the unstageable pressure ulcer was to elevate on pillow and wound nurse to evaluate. On 03/24/14 the resident started being treated by a consultant wound clinic. The right heel was currently assessed to be 3.5 cm in length by 0.1 cm width. On 01/24/14 a left outer buttock pressure ulcer was identified measuring six cm in length by one cm width with 0.01 cm depth. The area was assessed as beefy red with a yellow center. On 01/24/14 the consultant wound nurse assessed the areas and identified a right heel blister/medial ankle pressure ulcer, deep tissue injury (blood filled blister) measuring 1.0 cm in length by 2.5 cm width with 0.00 cm depth, a left lateral buttock Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a pink wound bed, pressure ulcer) measuring 5.0 cm in length by 2.0 cm width with 0.10 cm depth with serous drainage that was beefy red, a left mid buttock Stage II pressure ulcer measuring 6.0 cm in length by 2.0 cm width with 0.10 cm depth. The consultant nurse ordered a low air loss bariatric mattress, [MEDICATION NAME] to left buttock wounds three times a week and as needed, encourage to turn side to side, float heels off bed and monitor right heel daily. Orders were also obtained for Zinc Oxide 220 milligrams one tablet twice a day for 14 days, Vitamin C 500 milligrams daily for 14 days and Prostat supplement one ounce daily. An at risk for skin breakdown plan of care developed on 01/23/14 indicated the resident was at risk for skin breakdown related to decreased mobility, weakness and disease process. The goal was to have no preventable breakdown through next review. The interventions included to keep clean and dry, monitor for skin breakdown, notify physician with any changes, pressure reducing surface to bed/chair if ordered and encourage resident to turn in bed per routine and as needed. The plan of care was not updated for a 02/01/14 order to utilize a wedge pillow for positioning or for 03/24/14 orders for non weight bearing to right heel, waffle foothold with secure stick insole to keep pressure off heel at all times and for the resident to not wear regular shoes. Review of the bi-weekly skin checks revealed checks were completed on 01/14/14, 01/16/14, 01/23/14, 02/06/14, 02/10/14 and 02/24/14. There was a seven day period between 01/16/14 and 01/23/14 without a skin check, a 14 day period between 01/23/14 and 02/06/14 without a skin check and between 02/10/14 and 02/24/14 without a skin check. Review of the facilities July 2012 Skin and Wound Care guidelines revealed the facility would provide pressure prevention for those at risk including offload/suspend heels for at risk or red skin findings, reposition frequently to avoid pressure to bony prominence's such as heels, elbows, sacral and any red areas with red non blanching or open wound and to apply a protective ointment with each incontinence episode and follow physician orders [REDACTED]. On 05/13/14 at 11:39 A.M. interview with Resident #30 revealed he was admitted [DATE] for rehabilitation post meningitis. Resident #30 indicated while residing in the facility, he developed a pressure ulcer on his right heel. Resident #30 indicated they facility said he rubbed his heel on the sheets and ordered him a special bed after he got the pressure ulcers. Resident #30 also stated the facility had just started to use a wedge and started turning him every two hours with a wedge about the middle of January after he developed an ulcer on his buttock and heel. Resident #30 stated prior to the pressure ulcers developing he tried to turn himself or his sister tried to help him. He said the staff tried to position him but not every two hours. Resident #30 stated the facility did not put his feet up on pillows when he first arrived but started after he had skin issues. On 05/13/14 at 6:30 P.M. the director of nursing (DON) revealed the facility utilized Panacea pressure redistribution mattresses and Resident #30 had one initially on admission. The DON verified there was no evidence the facility put any other preventative measures in place for this resident, who had a [DIAGNOSES REDACTED]. The DON further verified biweekly skin check orders were not followed when a seven day and and two 14 day periods elapsed between biweekly skin checks. The DON further verified the facility Skin and Wound Care policy was not followed when preventative measures were not in place for an at risk resident. The DON also verified the resident's pressure ulcer plan of care was not updated with new interventions. 2. Review of Resident #46's medical record revealed the resident was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the resident's admission assessment revealed the resident had no skin issues or pressure ulcers present on admission. The admission skin risk assessment (Braden scale) assessed Resident #46 at high risk for pressure ulcers. Admission physician orders [REDACTED]. The resident also had an order for [REDACTED]. Review of the 03/14/14 admission MDS assessment revealed Resident #46 was moderately impaired for decisions of daily living, required limited assistance of one staff for bed mobility, had lower extremity impairment on one side, utilized a walker and wheelchair and was continent of bowel and bladder. Record review revealed the resident began exhibiting episodes of incontinence starting on 03/25/14. The interim potential for altered skin integrity plan of care included to follow skin protocol, immediately report any skin redness or skin breakdown to charge nurse and provide incontinence care as needed. On 03/18/14 an at risk for skin breakdown plan of care was developed related to decreased mobility and weakness. The goal was to have no preventable breakdown through the next review. The interventions included to keep clean and dry, monitor for skin breakdown, notify physician with any changes, pressure reducing surface to bed/chair if ordered and weights per routine and as needed. Bowel and bladder records revealed Resident #46 was continent of urine until 03/25/14 when he began having daily incontinence of urine. There was no evidence the facility addressed or implemented interventions to decrease the incontinence or to protect the resident's skin related to the incontinence. On 03/31/14 a pressure ulcer area measuring 2.5 cm in length by 0.4 cm width with no depth was noted on the left buttock. The facility assessed the ulcer as a deep tissue injury with a crusty, leathery feel and intact wound margins. Orders obtained on 03/31/14 included to leave the area open to air, get up for meals only, turn every two hours, float heels off bed, Prostat 30 milliliters twice a day, support hose to bilateral lower extremities and a multivitamin daily. On 03/31/14 a gluteal crease moisture associated area measuring 2.5 cm in length by 0.3 cm width with 0.1 cm depth was noted as being pink and moist. Calcium alginate was ordered to the gluteal crease twice a day and as needed until healed and skin barrier to surrounding skin twice a day and as needed until healed. On 03/31/14, the consultant wound nurse assessed the pressure ulcer as a deep tissue injury(a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler compared to adjacent tissue). Review of the treatment record revealed biweekly skin checks were signed off as completed on 03/05/14, 03/08/14 and 03/12/14. However there was no evidence on the biweekly skin sheet that a skin check had actually been completed on 03/08/14 as ordered, which reflected a seven day period between skin checks. Behaviors documented for the use of the anti-psychotic medication, [MEDICATION NAME] did not identify any refusal of care by the resident until a period between 04/04/14 and 04/11/14. The plan of care developed on 03/18/14 related to the risk for skin breakdown was not updated when Resident #46 developed the pressure ulcers on 03/31/14. On 05/13/14 at 6:15 P.M. the DON verified Resident #46 developed a pressure ulcer that presented as a deep tissue injury while residing in the facility. The DON verified the facility policy was not followed to use preventative measures for those at risk, that biweekly skin checks were not recorded on the body sheets as ordered and the skin plan of care was not updated when the resident developed pressure ulcers. The DON further verified Resident #46 developed urinary incontinence with no evidence incontinence skin protection was provided or that the resident was evaluated to determine the risk between incontinence and the development of pressure ulcers. 3. Review of Resident #27's medical record revealed the resident was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the 04/22/14 admission skin risk assessment (Braden scale) revealed Resident #27 was at mild risk for pressure ulcers. Review of the admission skin assessment revealed Resident #27 was admitted to the facility with pressure ulcers to the right outer ankle, left bunion and right elbow which were the result of laying at home on the floor for three days prior to receiving medical treatment. The right elbow pressure ulcer measured one cm in length by 0.2 cm width. The pressure ulcer was assessed to be dark round and unstageable. Review of the 04/22/14 admission physician orders [REDACTED]. Review of the 04/30/14 admission MDS assessment revealed Resident #27 was independent for decisions of daily living and required extensive assistance from two staff for bed mobility. Review of the treatment record revealed the elbow dressing change with [MEDICATION NAME] had not been completed as ordered during any day in April 2014. Review of the remainder of the resident's medical record including the nurse's notes revealed no evidence Resident #27 received the ordered dressing changes to the elbow. On 05/13/14 at 4:30 P.M. the DON verified there was no evidence Resident #27 received her dressing change to the right elbow as ordered. The DON verified Resident #27 should have had a dressing change to the elbow by 04/25/14 prior to the new order obtained on 04/28/14. This deficiency substantiates Complaint Number OH 563.