Every finding on record at Atrium Nursing and Rehabilitation

Based on observation, interview, record review and policy review, the facility failed to document in the medical record the reason for a facility initiated transfer to another facility when the facility temporarily ceased operations. This affected all 16 residents who had resided in the building and were transferred. Additionally, the facility failed to provide sufficient preparation and involvement with the residents and legal guardians prior to transferring residents. This affected three (#17, #18 and #15) out of three records reviewed for transfers. A total of 16 residents were transferred from the facility. The current census was zero. Findings include:Observation and concurrent interview on 05/27/26 at 7:53 A.M. with the Director of Nursing (DON) revealed there were no residents in the facility. 1. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE] and discharged on 05/08/26. Diagnoses included major depressive disorder, dementia, and generalized anxiety disorder. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #17 had moderately impaired cognition.Review of the care conference dated 04/02/26 for Resident #17 revealed resident was a long term resident.Review of the discharge plan of care dated 05/08/26 for Resident #17 revealed a destination address for the nearby sister facility, signed by DON and Power of Attorney (POA). Review of the nursing progress note dated 05/08/2026 at 5:38 P.M. revealed the Executive Director (ED) spoke to Resident #17's daughter in regard to a transfer. The note revealed the daughter was okay with the resident transferring and Resident #17 will transfer today.Review of the progress notes for Resident #17 revealed no documentation of the reason for the transfer on 05/08/26.Interview on 05/27/26 at 8:21 A.M. with Resident #17's daughter/POA revealed they received the notice of discharge on the day Resident #17 was moved out of the facility. 2. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] and discharged on 05/08/26. Diagnoses included senile degeneration of brain, anxiety disorder, cognitive communication deficit, and dysthymic disorder. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #18 had severely impaired cognition and had a Legal Guardian.Review of the care conference dated 04/09/26 for Resident #18 revealed was a long term care resident. Review of the discharge plan of care dated 05/13/26, five days after discharge, revealed a discharge date of 05/08/26 to a sister facility with the Guardian notified. Interview on 05/27/26 at 10:42 A.M. with Social Service Director (SSD) #2 revealed the discharge summary for Resident #18 was completed five days after discharge.Review of the nursing progress note dated 05/08/26 at 5:53 P.M. revealed the ED spoke to Resident #18's Legal Guardian. The Guardian was okay with transfer to another facility and doesn't want the resident to go anywhere else. Review of the progress notes for Resident #18 revealed no documentation of the reason for the transfer on 05/08/26. 3. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] and discharged on 03/31/26. Diagnoses included unspecified psychosis not due to a substance or known physiological condition, generalized anxiety disorder, dementia, and schizoaffective disorder.Review of the MDS 3.0 assessment dated [DATE] revealed Resident #15 had moderately impaired cognition and had a Legal Guardian.Review of the progress notes for Resident #15 dated 03/19/26 revealed the ED left a voicemail for the Legal Guardian in regard to sending referrals for transfer to other facilities. Review of the progress notes for Resident #15 dated 03/31/26 revealed the resident transferred to another long term care facility with all their belongings.Review of the progress notes for Resident #15 revealed no documentation of the reason for the transfer on 03/31/26. Interview on 05/27/26 at 9:13 A.M., Resident #15's Guardian stated he received an email from the facility on 03/19/26 stating they were going to be doing renovations and needed to transfer the residents. Resident #15's Guardian confirmed this was the first notification he received. Telephone interview on 05/27/26 at 9:17 A.M. with the Administrator revealed the decision was made the beginning of March 2026 to close the building due to renovations. The Administrator notified families and guardians of this via phone calls. The Administrators verified there was no documentation of the phone calls. Interview on 05/27/26 at 10:42 A.M. with SSD #2 revealed the facility started transferring residents on 03/20/26 to the sister facility. Interview on 05/27/26 at 11:22 A.M. with SSD #2 revealed the Administrator started calling Legal Guardians and resident representatives on 03/19/26 to make them aware of the renovations and the need to relocate all residents due to a planned closure. SSD #2 verified the reason for transfer was not identified in the resident records for Resident #17, #18 and #15. Review of discharged list of residents revealed the first resident was transferred on 03/20/26. A total of 16 residents were transferred from the facility with the last two transfers occurring on 05/08/26. Interview on 05/27/26 at 3:41 P.M. with the sister facility DON confirmed the list of 16 residents transferred out of the facility due to closure. Review of the admission Packet for the facility revealed each resident shall have the right to be notified or to have his or her resident representative notified of the transfer or discharge and the reasons therefore at least 30 days before his or her transfer or discharge. Review of the policy titled Discharging the Resident Policy, dated 12/2016, revealed the resident should be consulted about the discharge. Review of the policy titled Temporary Facility Closure Policy, dated 03/15/26, revealed residents and families will be given 30 day written notice and in person meetings. Each resident or their legal representative will receive individualized written notice and discharge/transfer planning assistance. This deficiency represents non-compliance investigated under Complaint Number 3021016.

Based on interview, record review and policy review, the facility failed to provide written notification to residents and the resident's representatives before the transfer of residents to another facility due to a temporary closure, failed notify the State Long-Term Care Ombudsman prior to transferring residents, and failed to notify the State Survey Agency of the plan for the transfers and adequate relocation of the residents. This affected all 16 residents residing in the facility and transferred due to a temporary closure of the facility. The facility census was zero. Findings include:Observation and interview on 05/27/26 at 7:53 A.M. with the Director of Nursing (DON) confirmed there were no residents in the facility. Review of the discharge log revealed the first resident was transferred on 03/20/26. A total of 16 residents were transferred from the facility with the last two transfers occurring on 05/08/26. Interview on 05/27/26 at 8:21 A.M. with Resident #17's Power of Attorney (POA) revealed they received the notice of discharge on the day Resident #17 was moved out of the facility. Resident #17 transferred on 05/08/26. Interview on 05/27/26 at 9:13 A.M., Resident #15's Guardian stated he received an email from the facility on 03/19/26 stating they were going to be doing renovations and needed to transfer the residents. Resident #15's Guardian confirmed this was the first notification he received. Resident #15 was transferred on 03/31/26. Telephone interview on 05/27/26 at 9:17 A.M. with the Administrator revealed the decision was made the beginning of March 2026 to close the building due to renovations. The Administrator notified families and guardians of this via phone calls. The Administrators verified there was no documentation of the phone calls. Interview on 05/27/26 at 9:17 A.M. the Administrator confirmed 30 day written notices were not provided to residents or resident representatives. The Administrator stated she was unaware the notices needed to be given. Interview on 05/27/26 at 9:36 A.M. Regional Administrator #1 stated the policy is to give a 30 day notice if the facility is asking the residents to leave. They did not look at these discharges as a discharge, only a transfer so they didn't think they needed to give the 30 day notice. Review of the Ombudsman notification provided by the facility revealed Ombudsman notification of the closure was made on 04/23/26. Interview on 05/27/26 at 10:42 A.M. with the Social Service Director (SSD) #2 revealed the facility started transferring residents on 03/20/26 to their sister facility. Interview on 05/27/26 at 10:57 A.M. with the DON confirmed the Ombudsman was notified of the closure plans on 04/23/26. Interview on 05/27/26 at 11:06 A.M., the Owner stated residents and/or resident representatives didn't need a 30 day notice because they were given options and it was voluntary. Interview on 05/27/26 at 11:22 A.M. with the SSD #2 revealed all residents who resided in the facility were transferred due to plans for renovation. Review of the submitted documents to the State Agency revealed no receipt of the closure plan for temporary closure of the facility. Review of the admission Packet for the facility revealed each resident shall have the right to be notified or to have his or her resident representative notified of the transfer or discharge and the reasons therefore at least 30 days before his or her transfer or discharge. Review of the policy titled Temporary Facility Closure Policy, dated 03/15/26, revealed the purpose was to establish procedures and guidelines for the temporary closure of the home. Residents and families will be given 30 day written notice and in person meetings. Each resident or their legal representative will receive individualized written notice and discharge/transfer planning assistance. Notification has been or will be submitted to the Ohio Department of Health and the State Long Term Care Ombudsman. This deficiency represents non-compliance investigated under Complaint Number 3021016.

Based on interview, document review, and policy review, the facility failed to submit the appropriate closure plan procedures to the State Agency regarding the temporary closure of the facility and failed to notify the Ombudsman's office prior to the relocation of the residents. This affected all residents previously residing in the facility. The facility census was zero. Findings include-Observation and interview on 05/27/26 at 7:53 A.M. with the Director of Nursing (DON) confirmed there were no residents in the facility. Review of the submitted documents to the State Agency revealed no receipt of the facility's closure plan procedures. Review of the discharge log revealed the first resident was transferred on 03/20/26. A total of 16 residents were transferred from the facility with the last two transfers occurring on 05/08/26.Review of the Ombudsman notification provided by the facility revealed Ombudsman notification of the closure was made on 04/23/26.Interview on 05/27/26 at 10:42 A.M. with the Social Service Director (SSD) #2 revealed the facility started transferring residents on 03/20/26 to their sister facility. Interview on 05/27/26 at 10:57 A.M. with the DON confirmed the Ombudsman was notified of the closure plans on 04/23/26. Interview on 05/27/26 at 11:22 A.M. with the SSD #2 revealed all residents who resided in the facility were transferred due to plans for renovation. Review of the facility policy titled Temporary Facility Closure Policy, dated 03/15/26, revealed the purpose was to establish procedures and guidelines for the temporary closure of the home. Notification has been or will be submitted to the Ohio Department of Health and the State Long Term Care Ombudsman. This deficiency represents non-compliance investigated under Complaint Number 3021016.

Based on staff interview, record review, review of witness statements, review of Self-Reported Incidents (SRI), and policy review, the facility failed to implement their abuse policy with an allegation of sexual abuse. This affected one (Resident #06) out of two residents reviewed for abuse. The facility census was 18. Findings include: Review of Resident #06's chart revealed Resident #49 admitted to the facility on [DATE]. Diagnosis included type two diabetes mellitus, major depressive disorder, generalized anxiety disorder, acquired absence of right leg above the knee, peripheral vascular disease, essential hypertension, dementia in other diseases classified elsewhere unspecified severity with agitation, obesity, and Duchenne or [NAME] muscular dystrophy. Review of Resident #06's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of the facility's self-reported incidents (SRIs) from 08/01/25 to 12/07/25, revealed the facility had not reported any allegations of sexual abuse or Resident #12's allegedly showing Resident #06 her breasts, Resident #12 attempting to kiss Resident #06 or Resident #12 calling Resident #06 unwanted names. Observation of Resident #06 on 12/08/25 at 2:06 P.M. revealed Resident #06 was sitting in his electric wheelchair. Resident #06 appeared clean and dressed appropriately. Interview with Resident #06 at the same time, revealed Resident #12 showed him her breasts and called him baby boo and honey. Resident #06 stated that Resident #12 tried to kiss his hand and his cheek. Resident #06 reported he was uncomfortable with Resident #12 showing him her breasts, trying to kiss him or calling him names and did not like Resident #12 making advances towards him. Resident #06 stated he told the facility staff but Resident #12 continued to make sexual advances towards him. Interview with the Administrator on 12/08/25 at 2:17 P.M., revealed the Administrator was not aware of Resident #12's allegedly showing Resident #06 her breasts or Resident #12 attempting to kiss Resident #06. The Administrator stated she was aware that Resident #12 called other residents boo. The Administrator verified the facility failed to implement their abuse policy once the allegations of sexual abuse were discovered. Interview with Certified Nursing Assistant (CNA) #35 on 12/08/25 4:33 P.M., revealed Resident #06 told her that Resident #12 rolled up to Resident #06, lifted her shirt and said, do you like what you see. CNA #35 stated she was not present on the date of the incident but Resident #06 told her about the incident when she came back to work on her next shift about one month ago. CNA #35 stated she did not report the incident because Administration already was aware of the incident and Resident #06 moved when Resident #12 approached him. Interview with Registered Nurse (RN) #600 on 12/08/25 at 4:34 P.M., revealed RN #600 heard about Resident #12 showing Resident #06 her breasts from other staff members approximately one month ago. RN #600 stated she did not report the incident because Administration was already aware. Interview with CNA #24 on 12/08/25 at 4:35 P.M., revealed CNA #24 heard about Resident #12 showing Resident #06 her breasts from other staff members approximately one month ago. CNA #24 stated she did not report the incident because Administration was already aware. CNA #24 stated staff had been trying to keep Resident #06 and Resident #12 separated. Review of the Administrator's written witness statement dated 12/09/25, revealed the Administrator spoke with Resident #06 in regard to another resident allegedly showing him her breasts. When questioned, Resident #06 stated that the incident happened a month ago. The Administrator asked if he had actually seen her breasts and Resident #06 stated no and said that he only saw her sports bra. The Administrator asked if he tried to stay away from residents and Resident #06 responded yes and he will move away from her when they are in the common area. Review of the Administrator's written witness statement dated 12/09/25, revealed the Administrator spoke with Resident #12 regarding Resident #12 allegedly exposing her breast. Resident #12 was very tearful and denied the allegation. Resident #12 stated she kept items in her bra like chapstick so she always had her hand in there, but she has never exposed herself. Review of AA #55's written witness statement dated 12/09/25, revealed AA #55 was doing activities visits about one month ago. When AA #55 went into Resident #06's room, Resident #06 started to talk to AA #55 about Resident #12 flashing him. AA #55 asked him if he had seen her breasts and Resident #06 told AA #55 no. Resident #06 stated that she pulled down her jumpsuit that she had on and he saw her sports bra. Review of AA #56's written witness statement dated 12/09/25, revealed AA #56 went in Resident #06's room for activities and Resident #06 started telling her that another resident had shown him her sports bra approximately one month ago when the incident happened. Nothing was ever said to AA #56 from the resident about any other exposure of the body parts until later after he spoke with the DON. Resident #06's story started changing after that to full exposure. Interview with RN #27 on 12/10/2025 at 10:58 A.M., revealed RN #27 was not at the facility on the day of the incident, but she heard about Resident #12 showing Resident #06 her breasts in report about three to four weeks ago. RN #27 stated she did not report the incident because Administration also received report of the incident. Interview with Resident #12 on 12/10/25 at 2:21 P.M., revealed the resident denied showing Resident #06 her breasts. Resident #12 denied kissing or attempting to kiss Resident #06. Resident #12 stated that she called all the residents and staff boo because she could not remember other individual's needs due to her medical condition. Resident #12 stated she liked Resident #06 as a friend and had never made any sexual advances towards him. Interview with the Director of Nursing (DON) on 12/10/25 at 2:34 P.M., revealed the DON was not aware of Resident #12's allegedly showing Resident #06 her breasts or Resident #12 attempting to kiss Resident #06 prior to the surveyor notifying the Administrator of the alleged incident on 12/08/25. Interview with Activities Aide (AA) #56 on 12/10/25 at 2:41 P.M., revealed AA #56 went into Resident #06's room to do activities with him approximately one month ago and Resident #06 told AA #56 that Resident #12 showed Resident #06 her sports bra. AA #56 stated that she saw Resident #06 talking to the DON on that date. AA #56 reported she saw Resident #06 again after Resident #06 talked to the DON and he stated that Resident #12 showed him her breasts. AA #56 stated she told the DON when she heard that Resident #12 exposed her sports bra to Resident #06 and again when Resident #06's allegation changed to Resident #12 showing Resident #06 her breasts. AA #56 reported Resident #06 and Resident #12 were not left alone after the incident, and it was common for Resident #12 to call all the residents and staff boo. AA #56 stated that she had never seen Resident #12 expose herself but stated that Resident #12 kept items in her sports bra for storage. Review of the DON's written witness statement dated 12/10/25, revealed the DON spoke with RN #27 who stated that she did not personally see anything but was told in report that Resident #12 was inappropriate and they were keeping residents away from each other. Review of the DON's written witness statement dated 12/10/25, revealed the DON spoke with RN #600 who stated that she did not personally see anything but was told in report that Resident #12 was inappropriate and they were keeping residents away from each other. Review of the DON's written witness statement dated 12/10/25, revealed the DON spoke with CNA #33 and CNA #24 who stated that she did not personally see anything but was told in report that Resident #12 was inappropriate and they were keeping residents away from each other. The DON also spoke with CNA #24 who stated Resident #06 told her that Resident #12 flashed him a long time ago. Review of the facility's Abuse, Neglect, Exploitation & Misappropriation of Resident Property policy dated 01/27/23 revealed the facility will investigate all alleged violations involving abuse. Staff should report allegations immediately to the Administrator or designee. The Administrator or their designee will notify the state agency of all alleged violations involving abuse as soon as possible but no later than 24 hours.

Based on staff interview, record review, review of witness statements, review of Self-Reported Incidents (SRI), and policy review, the facility failed to report an allegation of sexual abuse to the state survey agency in a timely manner. This affected one (Resident #06) out of two residents reviewed for abuse. The facility census was 18.Findings include: Review of Resident #06's chart revealed Resident #49 admitted to the facility on [DATE]. Diagnosis included type two diabetes mellitus, major depressive disorder, generalized anxiety disorder, acquired absence of right leg above the knee, peripheral vascular disease, essential hypertension, dementia in other diseases classified elsewhere unspecified severity with agitation, obesity, and Duchenne or [NAME] muscular dystrophy. Review of Resident #06's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of the facility's self-reported incidents (SRIs) from 08/01/25 to 12/07/25, revealed the facility had not reported any allegations of sexual abuse or Resident #12's allegedly showing Resident #06 her breasts, Resident #12 attempting to kiss Resident #06 or Resident #12 calling Resident #06 unwanted names. Observation of Resident #06 on 12/08/25 at 2:06 P.M. revealed Resident #06 was sitting in his electric wheelchair. Resident #06 appeared clean and dressed appropriately. Interview with Resident #06 at the same time, revealed Resident #12 showed him her breasts and called him baby boo and honey. Resident #06 stated that Resident #12 tried to kiss his hand and his cheek. Resident #06 reported he was uncomfortable with Resident #12 showing him her breasts, trying to kiss him or calling him names and did not like Resident #12 making advances towards him. Resident #06 stated he told the facility staff but Resident #12 continued to make sexual advances towards him. Interview with the Administrator on 12/08/25 at 2:17 P.M., revealed the Administrator was not aware of Resident #12's allegedly showing Resident #06 her breasts or Resident #12 attempting to kiss Resident #06. The Administrator stated she was aware that Resident #12 called other residents boo. The Administrator verified the facility did not report the allegation of sexual abuse to the state survey agency in a timely manner. Interview with Certified Nursing Assistant (CNA) #35 on 12/08/25 4:33 P.M., revealed Resident #06 told her that Resident #12 rolled up to Resident #06, lifted her shirt and said, do you like what you see. CNA #35 stated she was not present on the date of the incident but Resident #06 told her about the incident when she came back to work on her next shift about one month ago. CNA #35 stated she did not report the incident because Administration already was aware of the incident and Resident #06 moved when Resident #12 approached him. Interview with Registered Nurse (RN) #600 on 12/08/25 at 4:34 P.M., revealed RN #600 heard about Resident #12 showing Resident #06 her breasts from other staff members approximately one month ago. RN #600 stated she did not report the incident because Administration was already aware. Interview with CNA #24 on 12/08/25 at 4:35 P.M., revealed CNA #24 heard about Resident #12 showing Resident #06 her breasts from other staff members approximately one month ago. CNA #24 stated she did not report the incident because Administration was already aware. CNA #24 stated staff had been trying to keep Resident #06 and Resident #12 separated. Review of the Administrator's written witness statement dated 12/09/25, revealed the Administrator spoke with Resident #06 in regard to another resident allegedly showing him her breasts. When questioned, Resident #06 stated that the incident happened a month ago. The Administrator asked if he had actually seen her breasts and Resident #06 stated no and said that he only saw her sports bra. The Administrator asked if he tried to stay away from residents and Resident #06 responded yes and he will move away from her when they are in the common area. Review of the Administrator's written witness statement dated 12/09/25, revealed the Administrator spoke with Resident #12 regarding Resident #12 allegedly exposing her breast. Resident #12 was very tearful and denied the allegation. Resident #12 stated she kept items in her bra like chapstick, so she always had her hand in there, but she has never exposed herself. Review of AA #55's written witness statement dated 12/09/25, revealed AA #55 was doing activities visits about one month ago. When AA #55 went into Resident #06's room, Resident #06 started to talk to AA #55 about Resident #12 flashing him. AA #55 asked him if he had seen her breasts and Resident #06 told AA #55 no. Resident #06 stated that she pulled down her jumpsuit that she had on and he saw her sports bra. Review of AA #56's written witness statement dated 12/09/25, revealed AA #56 went in Resident #06's room for activities and Resident #06 started telling her that another resident had shown him her sports bra approximately one month ago when the incident happened. Nothing was ever said to AA #56 from the resident about any other exposure of the body parts until later after he spoke with the DON. Resident #06's story started changing after that to full exposure. Interview with RN #27 on 12/10/2025 at 10:58 A.M., revealed RN #27 was not at the facility on the day of the incident, but she heard about Resident #12 showing Resident #06 her breasts in report about three to four weeks ago. RN #27 stated she did not report the incident because Administration also received report of the incident. Interview with Resident #12 on 12/10/25 at 2:21 P.M., revealed the resident denied showing Resident #06 her breasts. Resident #12 denied kissing or attempting to kiss Resident #06. Resident #12 stated that she called all the residents and staff boo because she could not remember other individual's needs due to her medical condition. Resident #12 stated she liked Resident #06 as a friend and had never made any sexual advances towards him. Interview with the Director of Nursing (DON) on 12/10/25 at 2:34 P.M., revealed the DON was not aware of Resident #12's allegedly showing Resident #06 her breasts or Resident #12 attempting to kiss Resident #06 prior to the surveyor notifying the Administrator of the alleged incident on 12/08/25. Interview with Activities Aide (AA) #56 on 12/10/25 at 2:41 P.M., revealed AA #56 went into Resident #06's room to do activities with him approximately one month ago and Resident #06 told AA #56 that Resident #12 showed Resident #06 her sports bra. AA #56 stated that she saw Resident #06 talking to the DON on that date. AA #56 reported she saw Resident #06 again after Resident #06 talked to the DON and he stated that Resident #12 showed him her breasts. AA #56 stated she told the DON when she heard that Resident #12 exposed her sports bra to Resident #06 and again when Resident #06's allegation changed to Resident #12 showing Resident #06 her breasts. AA #56 reported Resident #06 and Resident #12 were not left alone after the incident, and it was common for Resident #12 to call all the residents and staff boo. AA #56 stated that she had never seen Resident #12 expose herself but stated that Resident #12 kept items in her sports bra for storage. Review of the DON's written witness statement dated 12/10/25, revealed the DON spoke with RN #27 who stated that she did not personally see anything but was told in report that Resident #12 was inappropriate and they were keeping residents away from each other. Review of the DON's written witness statement dated 12/10/25, revealed the DON spoke with RN #600 who stated that she did not personally see anything but was told in report that Resident #12 was inappropriate and they were keeping residents away from each other. Review of the DON's written witness statement dated 12/10/25, revealed the DON spoke with CNA #33 and CNA #24 who stated that she did not personally see anything but was told in report that Resident #12 was inappropriate and they were keeping residents away from each other. The DON also spoke with CNA #24 who stated Resident #06 told her that Resident #12 flashed him a long time ago. Review of the facility's Abuse, Neglect, Exploitation & Misappropriation of Resident Property policy dated 01/27/23 revealed the facility will investigate all alleged violations involving abuse. Staff should report allegations immediately to the Administrator or designee. The Administrator or their designee will notify the state agency of all alleged violations involving abuse as soon as possible but no later than 24 hours.

Based on staff interview, record review, review of witness statements, review of Self-Reported Incidents (SRI), and policy review, the facility failed to thoroughly investigate an allegation of sexual abuse. This affected one (Resident #06) out of two residents reviewed for abuse. The facility census was 18.Findings include: Review of Resident #06's chart revealed Resident #49 admitted to the facility on [DATE]. Diagnosis included type two diabetes mellitus, major depressive disorder, generalized anxiety disorder, acquired absence of right leg above the knee, peripheral vascular disease, essential hypertension, dementia in other diseases classified elsewhere unspecified severity with agitation, obesity, and Duchenne or [NAME] muscular dystrophy. Review of Resident #06's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of the facility's self-reported incidents (SRIs) from 08/01/25 to 12/07/25, revealed the facility had not reported any allegations of sexual abuse or Resident #12's allegedly showing Resident #06 her breasts, Resident #12 attempting to kiss Resident #06 or Resident #12 calling Resident #06 unwanted names. Observation of Resident #06 on 12/08/25 at 2:06 P.M. revealed Resident #06 was sitting in his electric wheelchair. Resident #06 appeared clean and dressed appropriately. Interview with Resident #06 at the same time, revealed Resident #12 showed him her breasts and called him baby boo and honey. Resident #06 stated that Resident #12 tried to kiss his hand and his cheek. Resident #06 reported he was uncomfortable with Resident #12 showing him her breasts, trying to kiss him or calling him names and did not like Resident #12 making advances towards him. Resident #06 stated he told the facility staff but Resident #12 continued to make sexual advances towards him. Interview with the Administrator on 12/08/25 at 2:17 P.M., revealed the Administrator was not aware of Resident #12's allegedly showing Resident #06 her breasts or Resident #12 attempting to kiss Resident #06. The Administrator stated she was aware that Resident #12 called other residents boo. The Administrator verified there was no thorough investigation completed. Interview with Certified Nursing Assistant (CNA) #35 on 12/08/25 4:33 P.M., revealed Resident #06 told her that Resident #12 rolled up to Resident #06, lifted her shirt and said, do you like what you see. CNA #35 stated she was not present on the date of the incident but Resident #06 told her about the incident when she came back to work on her next shift about one month ago. CNA #35 stated she did not report the incident because Administration already was aware of the incident and Resident #06 moved when Resident #12 approached him. Interview with Registered Nurse (RN) #600 on 12/08/25 at 4:34 P.M., revealed RN #600 heard about Resident #12 showing Resident #06 her breasts from other staff members approximately one month ago. RN #600 stated she did not report the incident because Administration was already aware. Interview with CNA #24 on 12/08/25 at 4:35 P.M., revealed CNA #24 heard about Resident #12 showing Resident #06 her breasts from other staff members approximately one month ago. CNA #24 stated she did not report the incident because Administration was already aware. CNA #24 stated staff had been trying to keep Resident #06 and Resident #12 separated. Review of the Administrator's written witness statement dated 12/09/25, revealed the Administrator spoke with Resident #06 in regard to another resident allegedly showing him her breasts. When questioned, Resident #06 stated that the incident happened a month ago. The Administrator asked if he had seen her breasts and Resident #06 stated no and said that he only saw her sports bra. The Administrator asked if he tried to stay away from residents and Resident #06 responded yes and he will move away from her when they are in the common area. Review of the Administrator's written witness statement dated 12/09/25, revealed the Administrator spoke with Resident #12 regarding Resident #12 allegedly exposing her breast. Resident #12 was very tearful and denied the allegation. Resident #12 stated she kept items in her bra like chapstick, so she always had her hand in there, but she has never exposed herself. Review of AA #55's written witness statement dated 12/09/25, revealed AA #55 was doing activities visits about one month ago. When AA #55 went into Resident #06's room, Resident #06 started to talk to AA #55 about Resident #12 flashing him. AA #55 asked him if he had seen her breasts and Resident #06 told AA #55 no. Resident #06 stated that she pulled down her jumpsuit that she had on and he saw her sports bra. Review of AA #56's written witness statement dated 12/09/25, revealed AA #56 went in Resident #06's room for activities and Resident #06 started telling her that another resident had shown him her sports bra approximately one month ago when the incident happened. Nothing was ever said to AA #56 from the resident about any other exposure of the body parts until later after he spoke with the DON. Resident #06's story started changing after that to full exposure. Interview with RN #27 on 12/10/2025 at 10:58 A.M., revealed RN #27 was not at the facility on the day of the incident, but she heard about Resident #12 showing Resident #06 her breasts in report about three to four weeks ago. RN #27 stated she did not report the incident because Administration also received report of the incident. Interview with Resident #12 on 12/10/25 at 2:21 P.M., revealed the resident denied showing Resident #06 her breasts. Resident #12 denied kissing or attempting to kiss Resident #06. Resident #12 stated that she called all the residents and staff boo because she could not remember other individual's needs due to her medical condition. Resident #12 stated she liked Resident #06 as a friend and had never made any sexual advances towards him. Interview with the Director of Nursing (DON) on 12/10/25 at 2:34 P.M., revealed the DON was not aware of Resident #12's allegedly showing Resident #06 her breasts or Resident #12 attempting to kiss Resident #06 prior to the surveyor notifying the Administrator of the alleged incident on 12/08/25. Interview with Activities Aide (AA) #56 on 12/10/25 at 2:41 P.M., revealed AA #56 went into Resident #06's room to do activities with him approximately one month ago and Resident #06 told AA #56 that Resident #12 showed Resident #06 her sports bra. AA #56 stated that she saw Resident #06 talking to the DON on that date. AA #56 reported she saw Resident #06 again after Resident #06 talked to the DON and he stated that Resident #12 showed him her breasts. AA #56 stated she told the DON when she heard that Resident #12 exposed her sports bra to Resident #06 and again when Resident #06's allegation changed to Resident #12 showing Resident #06 her breasts. AA #56 reported Resident #06 and Resident #12 were not left alone after the incident, and it was common for Resident #12 to call all the residents and staff boo. AA #56 stated that she had never seen Resident #12 expose herself but stated that Resident #12 kept items in her sports bra for storage. Review of the DON's written witness statement dated 12/10/25, revealed the DON spoke with RN #27 who stated that she did not personally see anything but was told in report that Resident #12 was inappropriate and they were keeping residents away from each other. Review of the DON's written witness statement dated 12/10/25, revealed the DON spoke with RN #600 who stated that she did not personally see anything but was told in report that Resident #12 was inappropriate and they were keeping residents away from each other. Review of the DON's written witness statement dated 12/10/25, revealed the DON spoke with CNA #33 and CNA #24 who stated that she did not personally see anything but was told in report that Resident #12 was inappropriate and they were keeping residents away from each other. The DON also spoke with CNA #24 who stated Resident #06 told her that Resident #12 flashed him a long time ago. Review of the facility's Abuse, Neglect, Exploitation & Misappropriation of Resident Property policy dated 01/27/23 revealed the facility will investigate all alleged violations involving abuse. Staff should report allegations immediately to the Administrator or designee. The Administrator or their designee will notify the state agency of all alleged violations involving abuse as soon as possible but no later than 24 hours.

Based on medical record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted to the Centers for Medicaid & Medicare Services (CMS) timely. This affected three Residents (#03, #08, and #10) of three residents reviewed for resident assessments. The census was 18.Findings include: 1) Review of Resident #03's medical record revealed an admission date of 10/22/21. Diagnoses listed included type one diabetes mellitus, morbid obesity, and major depressive disorder. Review of MDS assessments revealed a quarterly assessment was completed 10/03/25. There was no record of the MDS assessment being transmitted to or accepted by CMS. The last quarterly MDS was completed and accepted 07/03/25. 2) Review of Resident #08's medical record revealed an admission date of 12/16/24. Diagnoses listed included type one diabetes mellitus, pseudobulbar effect, and Parkinson's disease.Review of MDS assessments revealed a quarterly assessment was completed 09/19/25. There was no record of the MDS assessment being transmitted to or accepted by CMS. The last quarterly MDS was completed and accepted 06/20/25.3) Review of Resident #10's medical record revealed an admission date of 11/09/22. Diagnoses listed included epilepsy, alcohol abuse, and Todd's paralysis.Review of MDS assessments revealed a quarterly assessment was completed 10/03/25. There was no record of the MDS assessment being transmitted to or accepted by CMS. The last quarterly MDS was completed and accepted 07/03/25.Interview with MDS Nurse #26 on 12/09/25 at 2:18 P.M. confirmed MDS assessments for Residents #03, #08 and #10 were not submitted to CMS timely.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure a resident's comprehensive care plan was updated. This affected one (Resident #09) of five residents reviewed for unnecessary medications. The facility census was 18.Findings include: Review of Resident #09's medical record revealed and admission date of 09/29/25. Diagnoses listed included schizophrenia, anxiety disorder, major depressive disorder, and obsessional thoughts and acts. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #09 was cognitively intact. Review of psychiatric physician note dated 11/17/25 for Resident #09 revealed a new diagnosis of schizophrenia was added. Diagnoses of major depression and anxiety were listed upon admission [DATE]. Review of Resident #09's comprehensive care plan dated 12/02/25 revealed no focus, goals, or interventions for schizophrenia, anxiety, or major depressive disorder. Interview with MDS Nurse #26 on 12/09/25 at 2:25 P.M. confirmed no focus, goals, or interventions for schizophrenia, anxiety, or major depressive disorder were listed on Resident #09's care plan. Review the facility's policy titled Care Plans, Comprehensive Person-Centered dated March 2022 revealed assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay, and at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observation, staff interview, and review of a facility census document, the facility failed to ensure adequate hot water was supplied to a common shower room and resident rooms. This affected six (#8, #9, #11, #12, #13, and #19) of 19 residents that resided at the facility. The facility census was 19. Findings include: Observation of Maintenance Aide (MA) #244 taking the water temperatures on 06/22/25 beginning at 10:19 A.M. revealed the hot water temperature in the 500 Hall shower room was 97.8 degrees Fahrenheit (F), the hot water temperature in Resident #8's room was 95.6 degrees F, the hot water temperature in Resident #9's room was 93.1 degrees F, the hot water temperature in Resident #11's room was 88.8 degrees F, and the hot water temperature in Resident #12's room was 88.9 degrees F. Interview with MA #244 on 06/22/25 at 10:19 A.M., during observation of the hot water temperatures, verified the hot water temperature in the 500 Hall shower room, Resident #8, Resident #9, Resident #11, and Resident #12's rooms were not supplying an adequate hot water source. Review of the facility census dated 06/22/25 revealed Resident #8, Resident #9, Resident #11, Resident #12, Resident #13, and Resident #19 all resided on the 500 Hall.

Based on medical record review, staff interview, and review of the Resident Assessment Instrument 3.0 manual, the facility failed to ensure Minimum Data Set (MDS) assessments were completed and submitted per the Centers of Medicare and Medicaid Services requirements. This affected six (#4, #8, #13, #16, #17, and #18) of 19 residents reviewed for resident assessments. The facility census was 19. Findings included: 1. Review of the medical record for Resident #4 revealed an admission on [DATE] with diagnoses including but not limited to muscular dystrophy, heart failure, anxiety disorder, hypertension, and contractures of the hand. Review of the comprehensive Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 04/20/25 for Resident #4 revealed the resident had intact cognition. Resident #4 was coded as dependent for eating, toileting, bed mobility, and transfers. The assessment was completed and locked on 06/02/25 and submitted to the Centers of Medicare and Medicaid (CMS) on 06/04/25. 2. Medical record review for Resident #8 revealed an admission date of 10/31/22 with diagnoses including but not limited to schizoaffective disorder, psychotic disorder with delusions, anxiety, depression, hypertension, history of non-suicidal self-harm, chronic pain, and noncompliance with medication. Review of the quarterly MDS assessment with an ARD of 04/21/25 for Resident #8 revealed the resident had severely impaired cognition. Resident #8 was coded with hallucinations and delusions, verbal behaviors directed at others, rejection of care, and behaviors not directed at others. Resident #8 required assistance for eating and supervision for toileting bed mobility and transfers. The assessment was completed and locked on 06/02/25 and submitted on 06/04/25. 3. Medical record review for Resident #18 revealed an admission date of 01/18/24 with diagnoses including but not limited to paroxysmal atrial fibrillation, mild neurocognitive disorder without behaviors, cerebral infarction without residual, hypertension, cardiomyopathy, late syphilis latent, and myocardial infarction. Review of the quarterly MDS assessment with an ARD of 04/16/25 for Resident #18 revealed the resident had intact cognition. Resident #18 was coded with rejection of care four to six days in the assessment period. The assessment was completed on 06/02/25 and submitted on 06/04/25. 4. Medical record review for Resident #13 revealed an admission date of 11/23/21 with diagnoses that included chronic obstructive pulmonary disease, emphysema, acute and chronic respiratory failure, anxiety disorder, insomnia, major depression, schizoaffective disorder bipolar type, alcohol dependence in remission, hypertension, hallucinations, and anemia. Review of the quarterly MDS assessment dated [DATE] for Resident #13 revealed the resident had intact cognition. Resident #13 required set up for eating, was dependent for toileting, and required moderate assistance for bed mobility. The assessment was completed on 06/02/25 and submitted on 06/04/25. Interview on 06/25/25 at 1:39 P.M. with MDS Nurse/Licensed Practical Nurse (LPN) #270 confirmed the MDS assessments for Resident #4, Resident #8, Resident #13, and Resident #18 were completed and submitted late. Interview on 06/26/25 at 9:26 A.M. with Corporate Registered Nurse (RN) #505 stated the facility's MDS nurse quit during the transition of owners and resident assessments were not completed according to the required time frame. RN #505 verified the assessments for Resident #4, Resident #8, Resident #13, and Resident #18 were completed and submitted late. 5. Review of the medical record for Resident #16 revealed an admission date of 11/09/22 with diagnoses of epilepsy with status epilepticus, essential hypertension, and cerebral infarction without residual deficits. Review of the MDS assessment with an ARD of 04/03/25 revealed Resident #16 was assessed with severe cognitive impairment. Further review of the MDS assessment revealed the assessment was completed on 04/28/25. 6. Review of the medical record for Resident #17 revealed an admission date of 11/27/23 with diagnoses of schizoaffective disorder bipolar type, type II diabetes mellitus without complications, hemiplegia affecting the right dominant side, and anxiety. Review of the MDS assessment with an ARD of 05/08/25 revealed Resident #17 was cognitively intact. Further review of the MDS assessment revealed the assessment was completed on 06/02/25. Interview on 06/25/25 at 1:39 P.M. with MDS Nurse/LPN #270 confirmed Resident #16's MDS assessment with an ARD of 04/03/25 was completed late on 04/28/25 and Resident #17's MDS assessment with an ARD of 05/08/25 was completed late on 06/02/25. MDS Nurse/LPN #270 confirmed the facility was late on a lot of resident MDS assessments and the facility was trying to catch up. Review of the Centers of Medicare and Medicaid Services Resident Assessment Instrument 3.0, dated October 2024, revealed admission assessments should be completed and submitted within fourteen calendar days from admission and quarterly assessments should be completed and submitted within fourteen days of the assessment reference date.

Based on observation, staff interview, review of a facility census document, medical record review, review of water temperature logs, and facility policy review, the facility failed to ensure hot water temperatures were maintained in a safe manner. This affected 13 (#1, #2, #3, #4, #5, #6, #7, #10, #14, #15, #16, #17, and #18) of 19 residents that resided at the facility. The facility census was 19. Findings include: Observation of Maintenance Aide (MA) #244 taking the water temperatures on 06/22/25 at 10:19 A.M. revealed the hot water temperature in the 600 shower room was 136.4 degrees Fahrenheit (F), the hot water temperature in Resident #1 and Resident #10's room was 134.7 degrees F, the hot water temperature in Resident #2's room was 135.9 degrees F, the hot water temperature in Resident #3's room was 134.6 degrees F, the hot water temperature in Resident #4's room was 136.6 degrees F, the hot water temperature in Resident #5's room was 134.1 degrees F, the hot water temperature in Resident #6's room was 133.4 degrees F, the hot water temperature in Resident #7's room was 136.5 degrees F, the hot water temperature in Resident #14's room was 126.4 degrees F, the hot water temperature in Resident #15's room was 136.2 degrees F, the hot water temperature in Resident #16's room was 134.5 degrees F, and the hot water temperature in Resident #18's room was 133.0 degrees F. Interview with MA #244 on 06/22/25 at 10:19 A.M., during observation of the water temperatures, verified the hot water temperature in the 600 shower room, Resident #1 and Resident #10, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #14, Resident #15, and Resident #16's rooms were all elevated and should not be that hot. Review of weekly water temperatures obtained between 02/13/25 and 06/19/25 revealed all water temperatures were below 120 degrees F. Further review of water temperatures obtained on the 600 Hall on 06/19/25 revealed the temperatures ranged between 119 degrees and 120 degrees F. Review of the facility census dated 06/22/25 revealed Resident #1, Resident #5, Resident #6, Resident #10, and Resident #14 resided on the 600 Hall. Review of the medical records for Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #10, Resident #14, Resident #15, Resident #16, Resident #17, and Resident #18 revealed no documented evidence of burns or incidents related to hot water exposure. Review of the facility's safety of water temperatures policy, dated December 2009, revealed tap water in the facility shall be kept within a temperature range to prevent the scalding of residents. Water heaters that service resident rooms, bathrooms, common areas and tub and shower areas shall be set to temperatures of no more than 120 degrees F or the maximum allowable temperature per state regulations.

Based on observation, staff interview, review of resident trust documentation, review of a resident census report, and medical record review, the facility failed to ensure residents whose care was funded by Medicaid had personal funds in excess of fifty dollars ($50.00) deposited and held in an interest bearing account. This affected one (#8) of four residents reviewed for resident funds accounts. The facility census was 19. Findings include: Review of Resident #8's medical record revealed the resident admitted to the facility on [DATE] with diagnoses including schizoaffective disorder bipolar type, psychotic disorder with delusions due to known physiological condition, anxiety disorder, major depressive disorder, and hypertension. Review of Resident #8's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Review of Resident #8's resident funds authorization dated 12/04/23 revealed Resident #8's guardian authorized the facility to hold, safeguard, manage and account for any personal funds that Resident #8 had or deposited with the facility. The authorization revealed funds would be placed in an interest bearing account that was separate from facility accounts. Review of Resident #8's resident funds account statement from 04/01/25 to 06/05/25 revealed Resident #8 had a current account balance of $1.59. Resident #8's statement showed debits from the account of $50.00 on 04/10/25 for personal needs items, $280.00 on 05/07/25 for personal needs items, and $50.00 on 06/05/25 for personal needs items for a total of $380.00 in debits from 04/01/25 to 06/05/25 for personal needs items. Review of the facility's accounting receipts from 04/01/25 to 06/05/25 revealed Resident #8 signed out $50.00 for shopping on 04/11/25, $50.00 for shopping on 04/15/25, $30.00 for pizza on 04/23/25, $100.00 for shopping on 05/08/25 and $50.00 for shopping on 06/11/25 for a total of $280.00 dollars signed out of Resident #08's resident funds account from 04/01/25 to 06/05/25. Review of a resident census dated 06/22/25 revealed Resident #8's primary payor source for care was Medicaid. Observation of the facility's petty cash box on 06/25/25 at 4:30 P.M. revealed Resident #8 had $100.00 dollars in a petty cash envelope that was being held by the facility. Interview with the Administrator on 06/25/25 at 4:30 P.M. verified Resident #8's resident funds account statement from 04/01/25 to 06/05/25 showed a total of $380.00 in debits from 04/01/25 to 06/05/25 for personal needs items and the facility's receipts showed a total of $280.00 was signed out of the resident funds account by Resident #8 from 04/01/25 to 06/05/25. The Administrator confirmed Resident #8's account statement did not match the receipts for debits because the facility withdrew the money from Resident #8's resident funds account when the facility received Resident #8's monthly deposited funds in the account. The Administrator reported the facility put the withdrawn funds in an individual petty cash envelope that was kept by the facility in a petty cash box until Resident #8 signed out the money on the receipt ledger. The Administrator stated the facility had $100.00 in a petty cash envelope for Resident #8. The Administrator verified the $100.00 dollars held by the facility in the petty cash envelope was not an interest bearing account.

Based on medical record review, observations, review of shower schedules, review of shower sheets, resident and staff interview, and review of the Resident Assessment Instrument manual, the facility failed to ensure a resident's Minimum Data Set (MDS) assessment was accurate. This affected one (#13) of five residents reviewed for accurate MDS assessments. The facility censes was 19. Findings included: Medical record review for Resident #13 revealed an admission dated of 11/23/21 with diagnoses that included chronic obstructive pulmonary disease (COPD), emphysema, acute and chronic respiratory failure, anxiety disorder, schizoaffective disorder bipolar type, hallucinations and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #13 revealed the resident had intact cognition. Resident #13 required set up for eating, was dependent for toileting, and required moderate assistance for bed mobility. Resident #13 was not coded with any rejections of care during the assessment period. Review of the plan of care for Resident #13 dated 11/24/21 revealed the resident was resistive to care and refused activities of daily living assistance from staff. Resident #13 will refuse showers and bed baths at times. Interventions include allow to allow the resident to make choices, and if the resident refuses care reapproach at a later time. Review of the undated facility shower schedule in a binder at the nurses station for Resident #13 revealed a shower or bath was to be provided on Wednesday and Saturday on the 7:00 P.M. to 7:00 A.M. shift. Review of the facility shower sheets dated 05/03/25 and 05/07/25 for Resident #13 revealed the resident refused bathing and bed linen change. Further review of the documents revealed staff had reported the refusal to the nurse. The shower sheets for 05/03/25 and 05/07/25 both contained a nurses signature at the bottom of the document. Observation and interview on 06/23/25 at 2:07 P.M. with Resident #13 stated he takes a bath every Friday. Interview on 06/24/25 at 3:36 P.M. with Certified Nurse Aide (CNA) #224 stated Resident #13 will not allow facility staff to bathe him and he will wait for the hospice staff to complete a bath when they come in. CNA #224 stated the facility used shower sheets and if the resident refused that information was put on the sheet and given to the facility nurse to sign. Interview 06/26/25 at 12:46 P.M. with MDS Nurse/Licensed Practical Nurse (LPN) #270 verified he was unaware the facility used shower sheets and Resident #13 refused care during the assessment period. LPN #270 verified the MDS assessment completed on 05/08/25 was inaccurate and should have included the resident's refusals of care. Review of the Resident Assessment Instrument Manual, dated October 2024, revealed in chapter three on page E-15, staff should review the medical record, interview staff across all shifts during the seven day look back period, and code section E (Behavior) of the MDS assessment with the identified findings.

Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure wound care on a resident's surgical wound was completed based on the physician's order. This affected one (#10) of one resident reviewed for surgical wounds. The facility census was 19. Findings include: Review of Resident #10's medical record revealed the resident admitted to the facility on [DATE] with diagnoses including schizoaffective disorder bipolar type, unspecified protein calorie malnutrition, chronic multifocal osteomyelitis, asthma, anxiety disorder, frostbite with tissue necrosis of the left foot, alcohol abuse, peripheral vascular disease, and gangrene. Review of Resident #10's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and the resident required moderate assistance with showers. Resident #10 was independent with eating, rolling left and right, sitting to lying, and lying to sitting and required set up assistance with oral hygiene, upper body dressing, and sitting to standing. Resident #10 required supervision with toileting, lower body dressing, putting on and taking off footwear, personal hygiene, chair transfers, and toilet transfers and Resident #10 had a surgical wound. Review of Resident #10's skin breakdown care plan dated 05/16/25 revealed the resident was at risk for skin breakdown. Interventions included administer medications as ordered, apply lotion to dry skin as needed, assist with turning and repositioning, and a pressure redistribution mattress to the bed. Review of Resident #10's non-compliance care plan dated 06/02/25 revealed Resident #10 refused wound treatments at times. Interventions included to document educational attempts made with the resident, notify the physician of non-compliance, and explain all procedures before starting them. Review of Resident #10's wound care progress note dated 05/13/25 revealed the resident was seen by Wound Care Nurse Practitioner (WCNP) #500 for a non-healing surgical ulceration of the left midline stump that was 1.5 centimeter (cm) in length by 2.5 cm in width by 0.1 cm in depth. The wound was listed as improving. A new treatment order was given to clean with wound cleanser and pat dry, apply tetracyte to the wound be, then collagen and then oil emulsion, cover with an abdominal pad, and wrap with rolled gauze and tape to secure three times a week and as needed. The note was signed by WCNP #500. Review of Resident #10's wound care progress note dated 05/20/25 revealed the resident was seen by WCNP #500 with a non-healing surgical ulceration of the left midline stump that was 1.8 cm in length by 1.3 cm in width by 0.1 cm in depth. The wound was listed as improving. The treatment order was to clean with wound cleanser and pat dry, apply tetracyte to the wound bed then collagen and then oil emulsion, cover with an abdominal pad, and wrap with rolled gauze and tape to secure three times a week and as needed. The note was signed by WCNP #500. Review of Resident #10's wound care progress note dated 05/27/25 revealed the resident was seen by WCNP #500 with a non-healing surgical ulceration of the left midline stump that was 2.0 cm in length by 3.0 cm in width by 0.1 cm in depth. The wound was listed as increasing in size. A new treatment order was given to clean with wound cleanser and pat dry, apply tetracyte to the wound bed and medical honey, cover with an abdominal pad, and wrap with rolled gauze and tape to secure three times a week and as needed. The note was signed by WCNP #500. Review of Resident 108's physician order dated 04/17/25, and discontinued on 05/28/25, revealed the resident was ordered a treatment to the left foot and stump. Resident #10's wound was to be cleansed with wound cleanser and pat dry, apply tetracyte and oil emulsion to the wound, cover with an abdominal pad and secure with kerlix, and an ace bandage three times a week and as needed on Tuesday, Thursday, and Saturday for wound healing. Review of Resident #10's treatment administration record (TAR) from 05/13/25 to 05/27/25 revealed Resident #10's wound to his left foot and stump was cleansed with facility wound cleanser and patted dry, tetracyte and oil emulsion were applied to the wound and the wound was covered with an abdominal pad and secured with kerlix and an ace bandage on 05/13/25, 05/15/25, 05/17/25, 05/20/25, 05/22/25, 05/24/25, and 05/27/25. Interview with Assistant Director of Nursing (ADON) #236 on 06/25/25 at 7:45 A.M. verified WCNP #500 ordered Resident #10's wound to his left foot and stump to be cleaned with wound cleanser and pat dry, apply tetracyte to the wound bed then collagen and then oil emulsion, cover with an abdominal pad and wrap with rolled gauze and tape to secure three times a week and as needed from 05/13/25 to 05/27/25. ADON #236 confirmed Resident #10's wound to his left foot and stump was cleansed with facility wound cleanser and patted dry, tetracyte and oil emulsion were applied to the wound, and the wound was covered with an abdominal pad and secured with kerlix and an ace bandage on 05/13/25, 05/15/25, 05/17/25, 05/20/25, 05/22/25, 05/24/25, and 05/27/25. ADON #236 confirmed Resident #10 did not receive collagen to the left foot surgical ulcer wound as ordered by WCNP #500 from 05/13/25 to 05/27/25. Telephone interview on 06/26/25 at 9:05 A.M. with WCNP #500 revealed Resident #10 had a surgical ulcer to the left foot that was reoccurring due to Resident #10's non-compliance with using the left foot and stump for ambulation and picking at the wound. WCNP #500 verified that she ordered Resident #10's left foot wound to be cleaned with wound cleanser and pat dry, apply tetracyte to the wound bed then collagen and then oil emulsion, cover with an abdominal pad and wrap with rolled gauze and tape to secure three times a week and as needed from 05/13/25 to 05/27/25. WCNP #500 stated she was not aware that collagen was not being applied to the wound as ordered from 05/13/25 to 05/27/25 but WCNP #500 reported the absence of collagen would not impact the wound healing. Review of the facility's wound care policy, dated October 2010, revealed the facility will verify that there was a physician order for the wound care procedure.

Based on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure application of prescribed foot care treatments were completed as ordered. This affected one (#18) of one residents reviewed for prescribed foot treatments. This facility census was 19. Findings included: Medical record review for Resident #18 revealed an admission of 01/18/24 with diagnoses including but not limited to paroxysmal atrial fibrillation, mild neurocognitive disorder without behaviors, cerebral infarction without residual residual, hypertension, late syphilis latent, and myocardial infarction. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #18 revealed the resident had an intact cognition. Resident #18 was coded with behaviors including rejection of care four to six days in the assessment period. Resident #18 was assessed to require supervision for eating, toileting, personal hygiene, bed mobility, and transfers. Resident #18 had no skin issues coded. Review of the current plan of care for Resident #18 revealed the resident was at risk for skin breakdown related to mild neurocognitive disorder and decreased mobility. Interventions include to administer medication as ordered, apply lotion to dry skin as needed, assist the resident to the bathroom as needed, assist the resident with turning and repositioning, and a pressure redistribution mattress to bed. Review of the current physician orders for Resident #18 revealed an order dated 06/03/25 for vitamin A&D ointment (a skin protectant) to bilateral feet every night for dry skin and an order for Eucerin advanced repair external cream (emollient) with instructions to apply to bilateral feet topically one time a day for severe xerosis (rough dry skin with scales or small cracks). Review of the facility's electronic health record for Resident #18 revealed no evaluation for the purpose of the resident self-administering prescribed medication. Review of the June 2025 treatment administration record (TAR) for Resident #18 revealed the order for vitamin A&D ointment to the bilateral feet at bedtime for dry skin revealed facility staff signed the treatment off as completed without refusals every day. Review of the medication administration record (MAR) for Resident #18 revealed the order Eucerin advanced repair external cream (emollient) to apply to bilateral feet topically one time a day for severe xerosis revealed facility staff signed the application as completed with one refusal on 06/26/25. Review of the progress note for Resident #18 dated 06/03/25 at 1:53 P.M. revealed Resident #18 was seen by the physician with new treatment orders given to apply vitamin A&D ointment to the resident's bilateral feet at bedtime. Resident #18 was aware of new orders. Observation and interview on 06/23/25 at 1:23 P.M. with Resident #18 revealed the resident was in bed with feet visible. Resident #18's bilateral feet and ankles had large areas of dry white flaky skin. Resident #18 stated the physician had ordered a lotion but it was not always available. Interview on 06/25/25 at 10:51 A.M. with Registered Nurse (RN) #239 stated she offered the Eucerin cream that morning to Resident #18 and the resident told her he had it in the room and would apply it. Interview on 06/25/25 at 10:55 A.M. with Resident #18 verified he had a tube of lotion that he would apply. When asked about the lotion the resident revealed a tube of vitamin A&D ointment, and stated it was the only tube he had in the room. Observation of the resident's right foot during the interview revealed it was very dry and unchanged from the previous observation. Interview on 06/25/25 at 10:58 A.M. with RN #239 verified she did not have any Eucerin cream in her cart for Resident #18 and would order it from the pharmacy. Interview on 06/25/25 at 11:02 A.M. with facility Pharmacy [NAME] Representative #502 stated the pharmacy received an order on 01/14/25 and sent a one time supply for five days of Eucerin cream for Resident #18. Pharmacy [NAME] Representative #502 verified no other refills were requested or sent for Resident #18. Interview on 06/25/25 at 11:16 A.M. with RN #239 verified the facility conducted an assessment for any self-administration of prescriptions after asking Assistant Director of Nursing (ADON) #236 sitting at the nursing station with the RN. Interview on 06/25/25 at 11:19 A.M. with ADON #236 verified no self-administration evaluation was conducted for Resident #18. Interview on 06/25/25 at 11:26 A.M. with RN #239 stated she worked last Saturday and Sunday and used the tube of cream in Resident #18's room, signing off the medical record for the Eucerin cream. RN #18 confirmed the tube of vitamin A&D ointment in the resident's room was used for the treatment and not the Eucerin cream. RN #239 stated she thought it was same thing only named differently. Review of the facility policy titled, Administering Topical Medication, dated 10/2010, revealed staff will check the label on the medication and confirm the medication name and dose with the MAR.

Based on medical record review, review of a facility provided medication administration time verification document, staff interview, and review of a facility policy, the facility failed to ensure medications were administered within prescribed timeframes. This affected one (#7) of one resident reviewed for pain medication administration. The facility census was 19. Findings include: Review of the medical record for Resident #7 revealed an admission date of 12/28/18 with diagnoses of quadriplegia, morbid (severe) obesity due to excess calories, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact, required supervision assistance with eating, required partial assistance with oral hygiene, required substantial assistance with bed mobility, and was dependent on staff assistance with toileting hygiene, bathing, dressing, personal hygiene, transfers, and wheelchair mobility. Review of the care plan for Resident #7 with a revision date of 11/02/23 revealed the resident was at risk for pain related to decreased mobility and depression with intervention of administer medication as ordered. Review of Resident #7's physician orders revealed an order dated 04/01/25 for the narcotic pain medication hydrocodone-acetaminophen 5-325 milligrams (mg) tablet with instructions to give a 0.5 tablet by mouth two times a day for pain at 9:00 A.M. and 9:00 P.M. Review of the administration times for Resident #7's hydrocodone-acetaminophen 5-325 mg revealed on 06/15/25 the administration time was 10:09 A.M., on 06/16/25 the administration time was 10:19 A.M., on 06/20/25 the administration time was 1:59 P.M., on 06/23/25 the administration time was 10:39 A.M., and on 06/25/25 the administration time was 10:21 A.M. Interview on 06/26/25 at 11:46 A.M. with the Administrator confirmed Resident #7 had an order to receive hydrocodone-acetaminophen 5-325 mg, 0.5 tablet at 9:00 A.M. and 9:00 P.M. daily. The Administrator also confirmed Resident #7 did not receive the medication until 10:09 A.M. on 06/15/25, 10:19 A.M. on 06/16/25, 1:59 P.M. on 06/20/25, 10:39 A.M. on 06/23/25, and 10:21 A.M. on 06/25/25. The Administrator confirmed Resident #7 received this medication late on 06/15/25, 06/16/25, 06/20/25, 06/23/25, and 06/25/25. Review of the facility policy for administering medications, dated April 2019, revealed medications are administered in accordance with prescriber orders, including any required time frame.

Based on medical record review, staff interview, and policy review, the facility failed to ensure pharmacy recommendations were reviewed and addressed in a timely manner. This affected one (#9) of five residents reviewed for unnecessary medications. The facility census was 19. Findings include: Review of Resident #9's medical record revealed the resident admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following other cerebrovascular disease affecting the right non-dominant side, cerebral infarction, insomnia, schizoaffective disorder bipolar type, generalized anxiety disorder, conversion disorder with seizures or convulsions, bipolar disorder, and Behcet's disease. Review of Resident #9's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Review of Resident #9's physician order dated 12/16/24 revealed the resident was ordered the narcotic pain medication tramadol 50 milligrams (mg) every eight hours as needed for pain. Review of Resident #9's pharmacy recommendation dated 04/11/25 revealed the physician should evaluate Resident #9's as needed tramadol for discontinuation. Resident #9's physician disagreed with the recommendation because Resident #9 used the medication as needed. The pharmacy recommendation was signed by the physician on 06/17/25. Interview with the Administrator on 06/24/25 at 3:16 P.M. verified Resident #9's pharmacy recommendation dated 04/11/25 was not addressed by the physician until 06/17/25. Review of the facility's medication regimen review policy, dated May 2019, revealed pharmacy recommendations will be completed within a 30 day timeframe.

Based on observation, medical record review, resident and staff interview, hospice staff interviews, hospice contract review, and facility policy review, the facility failed to ensure collaboration with hospice providers for resident care. This affected two (#1 and #13) of two residents reviewed for hospice care. The facility census was 19. Findings include: 1. Medical record review for Resident #13 revealed an admission dated of 11/23/21 with diagnoses that included chronic obstructive pulmonary disease (COPD), emphysema, acute and chronic respiratory failure, anxiety disorder, schizoaffective disorder bipolar type, hypertension, and hallucinations. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #13 revealed the resident had an intact cognition. Resident #13 required set up for eating, was dependent for toileting, required moderate assistance for bed mobility, and transfers were not applicable. Resident #13 was coded as receiving hospice services during the look back period. Review of the facility plan of care for Resident #13 dated 07/26/24, and revised on 08/13/24, revealed the resident had a terminal prognosis and received hospice services related to COPD. Interventions include medication administration, consultation with the hospice team to ensure needs are met, encourage expression of feelings, hospice to assist with social services, physician, certified nurse aide (CNA), nurse, and pastoral care as needed, involve family, significant other and/or responsible party per resident choice, staff to provided one-on-one as needed, and hospice contact information. Review of the plan of care for Resident #13 dated 11/23/21, and revised on 07/18/24, revealed the resident had an activity of daily living (ADLs) deficit related to decreased mobility and memory impairment. Interventions included the resident needed one person with extensive assistance for bathing. Review of the hospice initial interdisciplinary plan of care dated 07/25/24 for Resident #13 revealed weekly staff frequency to include nurse, social worker, and chaplain. The hospice aide and volunteer schedule were documented as per the plan of care and lacked frequency. Review of the active physicians' orders for Resident #13 revealed an order dated 07/25/24 for admission to a hospice agency with primary diagnosis of COPD. Review of the hospice agency visit description log for Resident #13 revealed a CNA visited the resident on 03/27/25, 04/10/25, 04/17/25, 05/02/25, 05/15/25, 05/30/25, 06/06/25, and 06/13/25. Further review revealed a registered nurse (RN) visited on 04/18/25, 05/30/25, and 06/17/25. No other documentation was present in the hospice binder for Resident #13. Review of the multidisciplinary conference dated 05/07/25 for Resident #13 revealed the resident, a family member, nursing, social services, and business office staff were present for the meeting. Observation and interview on 06/23/25 at 2:07 P.M. with Resident #13 revealed the resident's finger nails were long, jagged and have dark soft material under all nails. Resident #13 stated he received a bath on Friday and did not know where the aide was from, but she did not work for the facility. Interview on 06/24/25 at 3:00 P.M. with Hospice Director of Nursing (DON) #500 verified the hospice agency does not leave any documentation for the facility after each visit and if they would like a copy they can call the office. Interview on 06/24/25 at 3:07 P.M. with the facility Director of Nursing (DON) #278 verified the hospice provider has not provided the facility with any progress notes from visits documented on the visit description log in the hospice binder for Resident #13. Interview on 06/24/25 at 3:12 P.M. with Hospice Social Worker (HSW) #501 stated she just started with the company and stated the hospice staff will talk to the nurse on duty after the visits to collaborate on visit details. HSW #501 stated they do not have a specific staff member at the facility and staff will just talk with the nurse on duty at the time of the visit. Interview on 06/24/25 at 03:36 P.M. with CNA #224 stated the hospice staff do not follow a schedule for Resident #13 and will randomly show up for a bath. Interview on 06/24/25 at 3:46 P.M. with Registered Nursing (RN) #265 stated sometimes she will ask the hospice staff when she sees them, but they will come in and leave without saying a word to her at times. RN #265 stated the hospice aid was here last Friday and gave Resident #13 a bed bath. RN #265 verified the aide did not sign the hospice documentation that she completed any care. RN # 265 verified the hospice binder did not have any documentation for visits for Resident #13. Interview on 06/26/25 at 1:19 P.M. with Business Office Staff Member #275 stated she conducted the care conferences and had not had the hospice staff for Resident #13 participate in any of the meetings. 2. Review of Resident #1's medical record revealed the resident admitted to the facility on [DATE] with diagnoses including cerebral atherosclerosis, polyneuropathy, peripheral vascular disease, chronic pain syndrome, hyperlipidemia, conductive hearing loss, anxiety disorder, epilepsy unspecified not intractable without status epilepticus, and tachycardia. Review of Resident #1's quarterly MDS assessment dated [DATE] revealed the resident was severely cognitively impaired and Resident #1 required supervision with eating, oral hygiene, toileting, showering, upper body dressing, lower body dressing, putting on and taking off footwear, personal hygiene, rolling left and right, sitting to lying, lying to sitting, sitting to standing, chair transfers, toilet transfers, tub transfers, and walking ten feet. Resident #1 also was assessed to receive hospice services. Review of Resident #1's hospice care plan dated 07/12/24 revealed Resident #1 had a terminal prognosis and received hospice services related to cerebral atherosclerosis. Interventions included administer medications as ordered, consultation with the hospice team to ensure needs are met, encourage the resident to express feelings as needed, hospice to assist with care as needed, and staff to provide one-on-one as needed. Review of Resident #1's hospice order dated 07/18/24 revealed the resident was admitted to hospice for cerebral atherosclerosis. Review of Resident #1's hospice provider documentation from 02/07/25 to 06/25/25 revealed the facility did not have any hospice provider notes or communications related to Resident #1's needs and medical status. Interview with Assistant Director of Nursing (ADON) #236 on 06/25/25 at 7:52 A.M. revealed the facility had a hospice communication binder. ADON #236 verified the facility did not have any hospice provider notes or communications related to Resident #1's needs and medical status from 02/07/25 to 06/25/25. Interview with Social Services (SS) #275 on 06/26/25 at 8:20 A.M. revealed the facility had not received any hospice provider notes or communications related to Resident #1's needs and medical status from 02/07/25 to 06/25/25. SS #275 confirmed she had not had any communication with Resident #1's hospice provider from 02/07/25 to 06/24/25. Review of the hospice contract with the facility, dated 02/12/25, revealed under section 2.1.3, Coordination, Supervision, and Evaluation of services, the hospice agency will promote open and frequent communication in person, by telephone, by facsimile, or in writing concerning the hospice plan of care and hospice patient's needs. Review of the facility policy titled, Hospice Program, dated 07/2017, revealed it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative. Communication with the hospice provider and documentation of communication to ensure needs of the residents are met. Additionally, the policy revealed the coordinated care plan for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by the facility.

Based on record review, staff interview, review of the Legionella Environmental Risk Assessment, review of the Water Management Plan, review of the Legionella Control measures and Monitoring, review of water temperature logs, review of weekly monitoring logs, review of the online resources from the Centers for Disease Control and Prevention (CDC), and review of facility policy, the facility failed to follow their Water Management Plan and Legionella Risk Assessment. This had the potential to affect all 18 residents who resided in the facility. The facility census was 18. Findings include: Review of the Water Management Plan-Legionella, dated 11/2021, revealed the facility would establish water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water system by having proactive endeavors to establish and maintain a healthy, infection free environment for the residents, staff and visitors. The facility would develop, implement and maintain an infection prevention and control program in order to prevent, recognize, and control the spread of infections within the facility by performing surveillance, investigation to prevent, prevent and control outbreaks, and use records to improve its infection control procedures. The facility will use a standard approach to risk assessment, implement mechanical, operation and chemical control measures that originate from the Legionella Risk Assessment Review of a facility document titled Legionella Environmental Assessment of Water Systems dated 10/09/24, revealed the facility developed a risk assessment and plan to aid in the prevention of Legionella. The assessment noted areas of concern such as the hot/cold water storage tanks, pipes, valves, shower heads, faucets, water filters, ice machines, and medical devices such as a Continuous Positive Airway Pressure (CPAP) machine. The assessment revealed the facility would complete the following control measures, monitoring and interventions: 1) For rooms taken out of service or resident occupancy changes, water and showers will be turned on for five minutes in each room, and toilets flushed. 2) Hot water temperatures will be measured. 3) The recirculation system for the hot water (a system which water flows continuously through the piping to ensure hot water to all endpoints) would have delivery temperatures at 115 degrees Fahrenheit to 120 degrees Fahrenheit and the return temperatures would be 104 degrees Fahrenheit to 110 degrees Fahrenheit. The hot water temperatures will be monitored regularly. There was no documented evidence that the facility was following their Legionella Risk Assessment Pan for the prevention of Legionella. Review of an undated facility document titled Control Measures and Monitoring, revealed the facility would complete the following procedures: 1) The incoming water supply will be tested as necessary. 2) The hot water tanks, circulating pumps, and tempering valves will be tested weekly throughout all areas of the facility to ensure proper hot water temperatures are maintained. 3) The facility will disinfect sinks and basins at hot and cold-water outlets. 4) All water outlets in vacant resident rooms, resident shower rooms and any other water distribution outlets in areas not in use, will have the hot and cold water ran in all water outlets for five minutes once weekly and flush all toilets. 5) The facility will disinfect all showers and shower heads weekly. 6) The ice machines will be cleaned every six months and visually inspected monthly. 7) Resident medical equipment including oxygen concentrators, Bilevel Positive Airway Pressure (BIPAP) and CPAP machines will be inspected during resident use. The masks and tubing must be disinfected and thoroughly dried and stored in a clean environment when not in use. 8) The air conditioning and air handling units will be routinely serviced, have semi-annual inspections and regular maintenance. Review of an undated facility document titled Legionella Areas of Concerns revealed the following were listed as areas of concern: 1) Hot and cold-water storage tanks. 2) Water heaters. 3) Pipes, valves and fittings. 4) Water filters. 5) Electrical and manual faucets. 6) Faucets and flow restrictors. 7) Showerheads and hoses. 8) Non-steam aerosol humidifiers. 9) Eye wash stations. 10) Ice machines. 11) Medical devices (CPAP, BIPAP, ventilators and humidifiers). Review of the facility documents titled Water Temps - A Unit Audit, revealed a purpose of the document was to confirm that water temperatures in resident's room and showers met the requirements. Numerous rooms were checked on 11/16/24 and 12/09/24. There was no additional documented evidence A unit had any additional water temperatures checked after 12/09/24. Review of facility documents titled Water Temps - B Unit Audit revealed a purpose of the document was to confirm that water temperatures in resident room and showers met the requirements. Numerous rooms were checked on 11/25/24 and 12/02/24. There was no additional documented evidence B unit had any additional water temperatures checked after 12/02/24. Review of the facility document titled, Legionella Program Weekly Report, revealed various rooms were marked as being completed for running water in the sinks and flushing the toilet. The last documentation on the report was dated 11/20/24. There was no documented evidence of the weekly program being followed after 11/20/24. Interview with the Maintenance Supervisor (MS) #150 on 02/05/25 at 1:49 P.M., revealed he had only been working in the facility for approximately three weeks and since being hired, he hasn't done anything with the Legionella policies or procedures or familiar with them. Maintenance Supervisor (MS) #150 stated the only occupied portion of the building is Unit -B which is the secured behavioral unit. Maintenance Supervisor (MS) #150 stated Unit-A is not being utilized by residents and the last left the unit on the 01/20/25. Maintenance Supervisor (MS) #150 verified the facility wasn't following their Legionella Risk Assessment and Water Management Plan. Maintenance Supervisor (MS) #150 verified the last water temperatures were completed on 12/09/24 and the last room checks for running water were completed on 11/20/24. Maintenance Supervisor (MS) #150 stated he wasn't aware of any documentation related to the Legionella procedures. Interview with the Administrator on 02/06/25 at 11:56 A.M., verified the facility wasn't following their Legionella Risk Assessment and Water Management Plan. Review of the online resources from the CDC titled, Water Management in Healthcare Facilities, dated 03/15/24, recommends that healthcare facilities develop and implement comprehensive water management programs to reduce the risk of Legionella growth and transmission. Review of the facility titled, Policy and Procedure: Water Management Plan-Legionella, dated November 2021, revealed the facility establish a water management plan for reducing the risk for Legionella and other opportunistic pathogens in the facility's water system. The facility shall do the following procedures: Complete a facility risk assessment conducted by the water management team to identify where Legionella could grow and spread in the facility' water systems, have a water system schematic/description, complete a Legionella environmental assessment, have rounding observation data , and maintain water temperature logs.

Based on observation, staff interview, and review of facility policy, the facility failed to provide a clean and homelike environment. This had the potential to affect all 18 residents residing on the secured behavioral unit. The facility census was 18. Findings included: Observation of the common areas of the secured behavioral unit on 02/03/25 at 10:15 A.M., revealed a fur like material and dirt hanging off of the large heat register/vents affixed to the walls. The floors throughout the unit were soiled and appeared dirty. Observation of the secured behavioral unit on 02/05/25 at 8:22 A.M. with the Registered Nurse (RN) #127, revealed an unlocked, unoccupied resident room with multiple stacks of supplies that ran the entire length of the room and numerous boxes were stacked to the ceiling. There were multiple trash bags of unopened incontinence briefs, trash and various debris scattered throughout the floor, and large metal rails leaned up against the walls. Interview with RN #127 at same time, verified the condition of the room. RN #127 stated the unoccupied, resident's room was being used as a storage room and should be secured since it was on a behavioral unit. Observation of the common areas of the secured behavioral unit on 02/05/25 at 8:57 A.M. with RN #127, revealed a fur like material and dirt hanging from the large heat register/vents affixed to the walls. The floors throughout the unit were soiled and appeared dirty. Interview with RN #127 at the same time verified the conditions of the common areas of the secured unit. Review of the facility policy titled, Safe, Clean, Comfortable, Homelike Environment, undated, confirmed the Resident has the right to a safe, clean, comfortable, and homelike environment. This included the physical layout of the facility maximizes resident independence and does not pose a safety risk. Further review of the policy confirmed housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of the medical record, review of a facility self-reported incident (SRI), observations, resident and staff interviews, and policy review, the facility failed to provide supervision and intervention to prevent Resident #31, who had impaired cognition, was at risk for elopement and resided on a secured behavioral unit, from leaving the facility unsupervised. This resulted in Immediate Jeopardy when one resident (Resident #31) was placed at potential risk for serious life-threatening harm and/or injury when the resident eloped from his bedroom window without staff knowledge and was found 2.6 miles from the facility pushing a shopping cart in a shopping center parking lot. This affected one (#31) of five residents reviewed for risk for elopement. The facility identified a total of 11 residents who were at risk for elopement. The facility census was 45. On 06/20/24 at 2:01 P.M., the Administrator, Director of Nursing (DON), Regional Registered Nurse (RRN) #20, and Regional Director of Operations (RDO) #25 were notified Immediate Jeopardy began on 06/04/24 at approximately 4:14 A.M. when Laboratory (Lab) Technician #09 reported to Licensed Practical Nurse (LPN) #154 that she was unable to locate Resident #31 in his room to draw his blood for labs. LPN #154 accompanied Lab Technician #09 to Resident #31's room and discovered the bedroom window was open and both the screen and the resident were missing. Staff on duty searched the building and the building perimeter and discovered Resident #31 was missing from the facility. Staff contacted the DON on 06/04/24 at 4:54 A.M. and the DON contacted the police at 5:07 A.M. Police located Resident #31 on 06/04/24 at 12:49 P.M. approximately 2.6 miles from the facility pushing a shopping cart in a shopping center parking lot. Resident #31 was sent to the hospital via emergency medical services (EMS) for evaluation before returning to the facility on [DATE] at approximately 3:50 P.M. with no injuries. Upon returning to the facility, Resident #31 was placed on one-on-one supervision and voiced concerns thought someone was trying to kill him and he stated he was trying to return home to Columbus, Ohio. The Immediate Jeopardy was removed on 06/04/24 when the resident returned to the facility and was placed on one-on-one supervision and all resident windows were secured with special hardware to ensure they were not able to be opened greater than six inches. The deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until the deficiency was corrected on 06/11/24, when the facility implemented the following corrective actions: On 06/04/24 at approximately 4:14 A.M., LPN #154 identified Resident #31 was not in his room and the facility began searching for the resident. On 06/04/24 at 12:49 P.M., police located Resident #31 at a local shopping center parking lot. Resident #31 was transferred to the hospital for evaluation. Upon returning to the facility on [DATE] at approximately 3:50 P.M., Resident #31 was placed on one-on-one supervision. On 06/04/24, maintenance staff completed audits of all doors and windows for functionality and security. All resident windows were secured with special hardware to ensure they were not able to be opened greater than six inches. On 06/04/24, the DON assessed all residents for elopement risk and care plans were revised as indicated. There were no concerns identified regarding elopements. On 06/04/24, the Administrator educated all maintenance staff regarding door and window security. On 06/04/24, the DON/designee educated all current staff in person about policies and procedures related to elopement, missing residents, supervision of residents, and abuse/neglect. Assistant Director of Nursing (ADON) #85 and Human Resources (HR) #92 assisted in educating all remaining staff via telephone. The education was completed on 06/04/24. On 06/05/24 at 5:00 A.M. and again at 8:00 A.M., the Administrator/designee conducted elopement drills with staff scheduled to work on night shift on 06/04/24 and staff scheduled to work dayshift on 06/05/24. On 06/05/24, the facility-initiated audits of all windows to be performed by maintenance personnel. All windows on the B-Unit were audited five times a week for one week, and a minimum of five windows on the A-unit five times a week for one week. All variances will be corrected upon discovery and education/follow-up will be provided as deemed necessary. Further continued ongoing compliance will be further maintained through audits as dictated by the facility quality assurance committee. On 06/07/24, the facility-initiated audits of exit doors to be performed by maintenance personnel three times a week for one week. All variances will be corrected upon discovery and education/follow-up will be provided as deemed necessary. Further continued ongoing compliance will be further maintained through audits as dictated by the facility quality assurance committee. On 06/07/24, the facility held a Quality Assessment and Performance Improvement (QAPI) meeting with the Administrator, DON, Medical Director, and RRN #20 to review the elopement investigation and approve the plan of correction. All protocols were followed and there were no issues noted. On 06/11/24, the facility held a QAPI meeting with the Administrator, DON, Medical Director, ADON #85, ADON #94, and RRN #20. Elopement audits were reviewed, and there were no new issues identified. On 06/20/24 from 3:00 P.M. to 3:55 P.M., interviews with Scheduler #110, LPN #153, STNA #133, STNA #121, and Human Resources #93 confirmed they received education after Resident #31's elopement on 06/04/24 regarding policies for elopement, missing resident, supervision, and abuse. The staff were knowledgeable regarding the training. Findings include: Review of the medical record for Resident #31 revealed the resident was originally admitted to the facility on [DATE] and recently readmitted on [DATE]. Diagnoses included unspecified hypothyroidism, type II diabetes, unspecified schizophrenia, unspecified psychosis, unspecified extrapyramidal and movement disorder, and schizoaffective disorder bipolar type. Review of the care plan dated 01/12/24 revealed Resident #31 resided on a secured unit related to schizoaffective disorder and was at risk for elopement. Interventions included quarterly assessments related to secured unit placement, provide diversional activities, allow resident to express feelings related to being on a secured unit, and refer to psychiatric services as needed. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of eight out of 15 indicating the resident had moderate cognitive impairment. Resident #31 had self-directed behaviors, occasionally rejected care, and did not wander. Resident #31 was independent with activities of daily living (ADL's) and required staff supervision and setup assistance as needed. Review of the Admission Skilled Unit Assessment completed on 01/12/24 revealed Resident #31 had history of psychiatric hospitalization with recent medication adjustments to stabilize psychiatric conditions. Review of the medical record revealed Resident #31 was screened for elopement risk on 01/12/24, 04/13/24, and 05/13/24 and scored a low risk for elopement. Review of the Quarterly Secured Unit assessment dated [DATE] revealed Resident #31 had a history of psychiatric hospitalization and received psychiatric services. Resident #31 had auditory and visual hallucinations, and occasionally displayed aggressive and combative behaviors towards other residents and staff. Resident #31 also expressed the belief that staff was trying to poison him. Resident #31 was at risk for elopement and did not want to live on a secured unit but was considered unsafe to live alone. Review of progress note dated 06/04/24 at 8:04 A.M. revealed Resident #31 was last observed on the unit on 06/03/24 between 9:00 P.M. and 10:00 P.M. Resident #31 wore a black short-sleeved T-shirt, and black sweatpants. The lab technician went to Resident #31's room to draw labs on 06/04/24 at 4:00 A.M. Resident #31's window was open, and the window screen was missing. Resident #31 was not in his room. The nurse and State tested Nursing Assistant (STNA) searched the unit, perimeter, and areas surrounding the facility and did not locate Resident #31. The nurse called the DON, police, Resident #31's guardian, and the physician. All other residents were accounted for in the facility. The DON collected witness statements. Review of progress note dated 06/04/24 at 1:22 P.M. revealed Resident #31 was located, and the physician, guardian, and family were notified. Review of an SRI titled Neglect/Mistreatment revealed on 06/04/24 at approximately 4:20 A.M. a lab technician went to draw labs on Resident #31, and the resident was unable to be located. Staff searched the facility and grounds but were unable to locate Resident #31. The physician, guardian, and local police were notified. Staff continued to search the community. Witness statements from staff revealed Resident #31 was at his baseline behavior and was last seen on 06/03/24 around 10:00 P.M. in the hallway wearing black pants, black shoes, and a black T-shirt. Police located Resident 31 on 06/04/24 at around 12:10 P.M. Staff responded to the location, and EMS were on scene transporting Resident #31 to the local hospital for evaluation where the resident was found to be without injury. Upon return to the facility, Resident #31 was assessed and was noted to be at baseline with delusions. Resident #31 was placed on one-on-one supervision. Upon interview, Resident #31 stated he had crawled out the window and was searching for his home. The facility assessed Resident #31 for elopement risk and updated his care plan. During an interview on 06/17/24 at 9:25 A.M., the Administrator stated Resident #31 went out his window in the middle of the night sometime on 06/03/24 into 06/04/24. The Administrator confirmed Resident #31 resided on the facilities secured behavioral unit. The Administrator stated prior to the elopement, all resident windows could be opened completely. The Administrator confirmed Resident #31 was discovered missing on 06/04/24 around 5:00 A.M. The Administrator confirmed Resident #31 was located on 06/04/24 in the afternoon in a local shopping center parking lot near the local Bureau of Motor Vehicles (BMV). Police found Resident #31 with a shopping cart. The Administrator stated Resident #31 was transferred to the hospital for evaluation before returning to the facility. During an interview on 06/17/24 at 9:49 A.M., RRN #20 stated the facility had no suspicions before Resident #31's elopement. RRN #20 stated Resident #31 had made statements infrequently about wanting to visit his mother in Columbus, Ohio but it was unsure if his mother was still living. RRN #20 confirmed Resident #31 had schizophrenia and exhibited typical behaviors. RRN #20 stated Resident #31 was a loner who stayed in his room mostly and had no prior exit-seeking behaviors. RRN #20 stated when Resident #31 returned to the facility, he was responding to internal stimuli and was fixated on wanting to go back to Columbus, Ohio and also stated someone was trying to kill him. Resident #31 made statements that his family was crazy, and they were doing crazy things to his mom. RRN #20 stated Resident #31 was placed on one-on-one supervision for agitation and exit seeking upon return to the facility on [DATE]. During an interview on 06/17/24 at 1:53 P.M., Maintenance Director #93 confirmed prior to 06/04/24 all resident windows including resident windows in the secured behavioral unit could be opened completely and a resident could exit from a window if they desired. During an interview on 06/18/24 at 3:18 P.M., RRN #20 stated the facility did not have a policy for supervision; however, staff are expected to observe and supervise every resident for safety at a minimum of once every two to three hours. RRN #20 confirmed per witness statements staff had last visualized Resident #31 on 06/03/24 at approximately 10:00 P.M. and no staff observed the resident again before he was discovered missing on 06/04/24 at around 4:00 A.M. Observations on 06/20/24 at 8:26 A.M. revealed Resident #31 approached the medication cart and was dancing and giggling while talking to LPN #155. Resident #31 was observed dancing and singing to himself. Attempts to interview Resident #31 revealed he was not interviewable. Review of the facility policy titled Elopement: Missing Resident Policy and Procedure dated 01/01/2016 revealed residents were assessed to identify risk for elopement, and care plans were implemented as indicated. If a resident was found to be missing, the facility would take prompt action to locate the resident and bring them back to safety. This deficiency represents non-compliance investigated under Complaint Numbers OH00154874 and OH00154600.

Based on medical record review, review of hospital records, review of a fall investigation, observations, staff interview, and review of facility policy, the facility failed to ensure fall interventions were in place for a resident identified at high risk for falls and failed to conduct a thorough investigation to determine root cause analysis to identify potential hazards and resident-specific interventions to reduce and/or eliminate falls and falls with injury. This resulted in Actual Harm when Resident #07 fell from the bed that was not in the lowest position and sustained a leg fracture requiring surgical intervention. This affected one (#07) of three residents reviewed for falls. The census was 72. Findings include: Review of Resident #07's medical record revealed an admitted [DATE]. Diagnoses included schizoaffective disorder, dementia, muscle wasting and atrophy, hypertension, anxiety disorder, and epilepsy. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #07 was significantly cognitively impaired with an brief interview for mental status (BIMS) score of zero out of 15 and was receiving Hospice services. Review of a care plan initiated 07/24/20 revealed Resident #07 was at risk for falls related to schizoaffective disorder, bipolar disorder, history of depression with psychotic symptoms, and shortness of breath. An intervention for Resident #07's bed in the lowest position was added to the care plan on 08/08/20. An intervention of educating staff on keeping bed in the lowest position when not providing Resident #07 care was added on 03/08/24. Resident #07 had activities of daily living (ADL) self-care performance deficit related to nicotine dependence, history of restlessness and/or agitation, shortness of breath, and verbal and or physical aggression. An intervention of mechanical aid of Hoyer (mechanical lift) for transfers with two staff participation and two staff participation for bed mobility to reposition up and turn in bed were added 07/24/20. Review of progress notes revealed Resident #07 had a history of falling from the bed. Resident #07 fell from his bed on 02/27/24, 03/04/24, and 03/08/24. Review of progress notes dated 03/08/24 revealed Resident #07 was heard yelling from his room and when the nurse entered the room, the resident was observed laying on the floor on his left side. Resident #07 complained of pain and was unable to move his left leg. Resident #07 was alert with confusion. The physician was notified, and orders were received to send Resident #07 to the emergency room (ER). Review of ER documentation dated 03/08/24 revealed Resident #07 was negative for fracture to the left leg. Review of progress notes dated 03/12/24 revealed when the nurse went to do wound treatment Resident #07 complained of pain when moved and touched. The nurse went with the physician to assess Resident #07 and an x-radiation (x-ray) to the left pelvis, left hip, left femur, left knee, left tibula, and left fibula were ordered. Review of Resident #07's x-ray results dated 03/13/24 revealed a subacute left introchanteric femoral fracture with various malalignment. Review of progress note dated 03/13/24 revealed Resident #07 was transferred to the ER due to x-ray findings of left femur fracture. Review of hospital documentation dated 03/13/24 revealed Resident #07 had a left introchanteric femoral fracture and was scheduled to have surgical repair on 03/14/24 with a left hip intramedullary nail. Review of Post-Fall Investigation revealed Resident #07 had an unwitnessed fall from bed on 03/08/24. A new intervention of staff to keep bed in the lowest position when providing care was added. State tested Nursing Assistants (STNA's) were educated on 03/11/24. The Director of Nursing (DON), Regional Nurse #100, and Assisted Director of Nursing (ADON) #150 were interviewed on 03/14/24 at 11:30 A.M. ADON #150 stated that the agency nurse on duty 03/08/24 told her that Resident #07's bed was not in the lowest position when he was found on the floor. The DON and Regional Nurse #100 confirmed Resident #07's bed was not in the lowest position when he fell on [DATE]. The DON and Regional Nurse #100 confirmed Resident #07 sustained a leg fracture from a fall on 03/08/24. The DON and Regional Nurse #100 confirmed STNA's were educated on keeping Resident #07's bed in the lowest positions; however, no nurses were educated. There were no further interviews and/or further investigation as to who left the bed above the lowest position. Beds that go lower to the floor than Resident #07's bed were available in the facility. Resident #07 had fallen from bed on 02/27/24, 03/04/24, and 03/08/24. Observation of Resident #07's bed on 03/14/24 at 11:57 A.M. revealed bed controls were located at the foot of the bed. Review of the facility's Fall Response & Procedure dated 11/04/22 revealed it is the policy of this facility to ensure to the best of its ability the safety and well-being of residents who are at risk for falls and implement action steps post fall. A fall is considered a change in plane, an incident where if staff had not intervened i.e. lowering to the floor the resident would have fallen. If a resident is found down on the floor and was not witnessed, it will be investigated and treated as a fall. Nursing staff will initiate an investigation by observing the immediate environment for potential causes, obtain statement from resident as indicated, staff on duty, make note of position of residents, equipment, footwear, and evidence of action resident prior/at time of fall. Intervention will be added to guard against another fall of the same type. This deficiency represents non-compliance investigated under Complaint Number OH00152013.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed record review, hospital record review, laboratory results review, staff and physician interview, and policy review, the facility failed to properly monitor Coumadin (an anticoagulant medication) use for Resident #20. Resident #20 had a high Prothrombin Time/International Normalized Ratio (PT/INR) (a laboratory test to measure how long it takes for blood to clot) of 52.4 seconds (PT) and 4.9 (INR) that was drawn on [DATE] and was not reported to the physician until [DATE]. Resident #20 was to have the next PT/INR drawn on [DATE]; however, it was not obtained. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, negative health outcomes, and/or death when Resident #20 was having nausea, vomiting, and diarrhea on [DATE] and was hospitalized where she received seven units of Packed Red Blood Cells (PRBC) via transfusion and KCentra (a Coumadin reversal agent medication) and had visible bleeding in the emergency room (ER). Resident #20 subsequently expired in the hospital on [DATE]. This affected one (Resident #20) of seven residents reviewed who received anticoagulant (blood thinning) medication. The facility census was 59. On [DATE] at 3:10 P.M., the Administrator, Regional Director of Clinical Operations (RDCO) #150, and Chief Clinical Officer #103 were notified Immediate Jeopardy began on [DATE] when the facility failed to timely notify the physician that Resident #20 had an elevated PT level of 52.4 (normal reference range of ,d+[DATE] seconds) and INR lab value of 4.9 (normal therapeutic range of 2.0 to 3.0). The resident continued to receive Coumadin 3 milligrams (mg) until it was reported to the Physician on [DATE]. Resident #20 was hospitalized on [DATE] and expired on [DATE]. The Immediate Jeopardy was removed, and the deficient practice corrected on [DATE] when the facility implemented the following corrective actions: On [DATE] at approximately 10:00 A.M., the facility identified an issue with results of PT/INR not being reported in a timely manner for Resident #20. On [DATE] at approximately 11:00 A.M., the Regional Director of Clinical Operations (RDCO) # 150 educated the Director of Nursing (DON) #102, on morning clinical follow up to include results, physician notification of labs and new admission/re-admission chart reviews. On [DATE] at approximately 11:00 A.M., the Chief Clinical Officer #103 reviewed and revised the policy for coumadin monitoring as well as anticoagulant policy. On [DATE] at approximately 12:00 P.M., the RDCO #150 completed a whole house audit for all lab orders. Any missing orders were added to emed lab. There were seven (Resident #20, #31, #37, #45, #51, #120, and #60) residents that were identified as having missed lab orders. There were eight (Resident #9, #23, #24, #30, #31, #41, #62, and #120) residents identified on anticoagulants. All eight identified residents were assessed for signs and symptoms of bleeding as well as educated to report to the nurse if they have any signs or symptoms of bleeding. There were no other residents on coumadin. There were no negative outcomes. RDCO #150 ensured all eight residents on anticoagulants had orders to monitor for signs and symptoms of bleeding. On [DATE] at approximately 4:00 P.M., the DON #102 completed education with all (14) nurses on the process for labs and identifying a change in condition and when to notify the physician. 14 nurses were educated on entering labs into Point Click Care (PCC) ( facilities electronic medical system) and emed lab ( electronic lab system) , notifying the physician as soon as the results are in, entering new orders in PCC, educating and re-educating the residents on reporting signs and symptoms of bleeding, follow orders to monitor for signs and symptoms of bleeding daily, updating the coumadin log and always checking the INR results before administering coumadin. The nurses were also educated on what the signs and symptoms of bleeding are: dark stools, bloody nose, coffee ground emesis, bright red blood in stools, bloody urine, clots in urine. Red sclera, complaints of abdominal pain, bleeding from wounds, any unexpected bleeding, discomfort that is sudden onset or bruises that cannot be explained. On [DATE] by 4:00 P.M., all eight residents on anticoagulants were educated by Assistant Director of Nursing/Licensed Practical Nurse (ADON/LPN) #104 on informing the nurse if they have any signs or symptoms of bleeding. On [DATE] by 4:00 P.M., 64 in-house residents were assessed for change of condition by DON #102. Any abnormalities were reported to the physician. On [DATE] by approximately 4:00 P.M. a Quality Assurance and Performance Improvement (QAPI) was done with the Medical Director (MD) #100, RDCO #150, Chief Clinical Officer #103, Administrator, and DON #102. Discussed the steps that were being taken to ensure this does not happen again in the future. Discussed the whole house audit, staff education, resident assessments as well as resident education. On [DATE], every morning (Monday through Friday), all new orders will be reviewed by the Intradisciplinary Team and will ensure that all orders are in the emed system. This practice will be ongoing. On [DATE] at 9:30 A.M., the new clinical meeting process was updated, including auditing all labs that were due and ensuring they were drawn as well as follow up on the results. DON #102, RDCO #150, ADON/LPN #104, and Administrator was present for the meeting. Audits are completed every Wednesday and Friday morning. Routine labs are drawn on Tuesday and Thursdays. If it is discovered that lab orders were not entered into the emed lab, reeducation will be provided to the nurse that did not follow through with the process. On [DATE], QAPI meeting was held with RDCO #150, DON #102, ADON/LPN #102, and the Administrator to discuss the plan of care put in place and all the steps being followed: new morning clinical process, lab monitoring, ongoing audits, and weekly review of the audits. Ongoing lab audit to be completed by DON #102. On [DATE], six residents (excluding Resident #20) that were identified by the facility as having missed labs were reviewed with no negative findings. On [DATE] from 11:17 A.M. to 11:20 A.M., interviews with LPN #215, LPN #256, and LPN #205 verified they were educated and trained on coumadin monitoring, signs and symptoms of bleeding, checking INR results before administering Coumadin, notifying the physician when lab results are in, putting lab orders in the electronic system, and keeping log updated. Findings include: Closed record review of Resident #20 revealed an admitted [DATE] and a discharge to hospital on [DATE] and she passed away on [DATE] with pertinent diagnosis of: dementia, history of covid-19, insomnia, disorder of peripheral nervous system, altered mental status, history of venous thrombosis and embolism, schizophrenia, bipolar disorder, bacterial infection, chronic obstructive pulmonary disease, congestive heart failure, urinary tract infection, encephalopathy, peripheral vascular disease, acquired absence of left leg below knee, seizures, cardiac murmur, congenital renal artery stenosis, atherosclerotic heart disease of native coronary artery without angina pectoris, hypertension, hyperlipidemia, gastroesophageal reflux disease, major depressive disorder, anxiety disorder, nicotine dependence, muscle wasting and atrophy, and need for assistance with personal care. Review of the [DATE] quarterly Minimum Data Set (MDS) assessment revealed the resident is cognitively intact and used a wheelchair to aid in mobility, required supervision for toilet transfer, and she was always continent of bladder and bowel. Review of a Physician Order dated [DATE] revealed Coumadin Oral Tablet three milligrams (Warfarin Sodium). Give three milligrams (mgs) by mouth one time a day related to personal history of other venous thrombosis and embolism. Review of a Physician Order dated [DATE] revealed Clopidogrel Bisulfate Oral Tablet 75 mgs (Clopidogrel Bisulfate). Give 75 mgs by mouth one time a day related to personal history of other venous thrombosis and embolism. Review of a Physician Order dated [DATE] revealed to draw PT/INR weekly every shift every Tuesday for long term anticoagulant use. Contact Physician with results before giving 5:00 P.M. dose. Review of laboratory value report dated [DATE] revealed an INR value of 3.7 which was high. Review of the [DATE] Medication Administration Record (MAR) revealed Coumadin was held on [DATE]. Review of laboratory value report dated [DATE] revealed an INR lab value of 3.0 which was high. Review of PT/INR Coumadin Flow Sheet revealed the last entry for Resident #20's lab results were on [DATE]. Review of laboratory value report dated [DATE] revealed there were no results for the INR. Review of laboratory value report dated [DATE] revealed an INR of 4.9 which was high. Review of the [DATE] MAR from [DATE] to [DATE] revealed Resident #20 received three milligrams of coumadin from [DATE] to [DATE] at 5:00 P.M. Review of Resident #20's medical record revealed no evidence of monitoring for signs and symptoms of bleeding for Coumadin use. Review of MD #100 Progress Notes dated [DATE] revealed Resident #20 was seen for reports of a nosebleed that lasted a couple minutes and fatigue. Reports mild nausea earlier today but denied any diarrhea of abdominal pain. Of note nursing reports INR elevated at 4.9 on [DATE] just reported today thus patient continued to receive coumadin. INR to be redrawn today and will recheck again on [DATE], hold coumadin until resulted. Nurse to call with INR result today. Review of the medical record for a laboratory report dated [DATE] revealed there was no evidence the lab was drawn. Review of a Progress Note dated [DATE] at 9:00 A.M. revealed Resident #20 complained of not feeling well, complained of nausea, vomiting, and diarrhea, and body aches. Blood Pressure was ,d+[DATE] manually, pulse 86 beats per minute, respirations 24 a minute, temperature 97.3 degrees Fahrenheit, oxygen saturation 95% on room air. MD #100 made aware with new order for Zofran as needed, complete blood count and basic metabolic panel next lab day. Review of a Progress Note dated [DATE] at 5:51 P.M. revealed called to residents' room by State tested Nurse Aide (STNA), resident complained of shortness of breath, resident cool, clammy, and pale. MD #100 notified with new order to send to emergency room for evaluation and treatment. 911 notified and daughter made aware. Review of a Progress Note dated [DATE] at 3:32 A.M., nurse called Hospital to check the status of the resident. The Intensive Care Unit (ICU) nurse stated that the patient was being admitted to another hospital and was given 6 liters of blood for low hemoglobin level. ICU nurse also said a CT scan was done, to check for a possible bleed. Review of the Hospital Record admitted d [DATE] revealed complaints of shortness of breath. Resident #20 was confused and partially awake upon arrival and then became bradycardic with a low blood pressure and pulseless electrical activity arrest ensued. Advanced cardiac life support was started and return of spontaneous circulation was achieved. She was intubated there was concern at that time for hemorrhagic shock with a hemoglobin of 3. She was given two units of emergency release blood in route upon arrival to hospital. Review of Hospital emergency room records dated [DATE] revealed Resident #20 arrived at 6:02 P.M. a complete blood count lab was drawn at 8:30 P.M. the lab value records revealed a hemoglobin lab value of 3.1 grams per deciliter (g/dl) with normal ranges being 12.1 to 15.8 g/dl. An elevated white blood cell count of 59.9 and elevated Platelets of 459. Review of hospital records dated [DATE] revealed Resident #20 coded at 8:52 P.M. and was revived at 8:56 P.M Review of Hospital Records dated [DATE] at 9:46 P.M. revealed the Resident #20 received Kcentra human PCC 4-factor prothrombin complex (a warfarin/coumadin reversal agent) 1021 units. Review of hospital records dated [DATE] revealed the Resident #20 INR value was 3.9 on [DATE] at 11:32 P.M and Resident #20 received three units packed red blood cells (PRBC) and Kcentra in the emergency room and given four additional units of PRBC in the intensive care unit for persistent shock. Review of hospital gastroenterology records dated [DATE] revealed Resident #20 was admitted four days ago. Resident #20 had severe low hemoglobin of 3.1 and there was melena (black, tarry stool that comes from bleeding in your upper gastrointestinal tract) on digital rectal exam in the emergency department on [DATE]. On [DATE] at 10:27 A.M., interview with the RDCO #150 verified there was no INR drawn on [DATE] due to a staff member did not print off the lab slips for the lab company to draw the lab. RDCO #150 also stated the INR lab draw from [DATE] had hemolyzed (breakdown of red blood cells from mishandling of blood samples during routine blood collection and transport) and was not redrawn. On [DATE] at 12:54 P.M., the interview with MD #100 verified no one reported the elevated INR values for Resident #20 for the [DATE] lab until [DATE]. She stated she would expect the high INR value to be called into her and that she would have held the coumadin and redrawn the labs. MD #100 stated she was unaware that the INR lab value had not been drawn for Resident #20 on the morning of [DATE]. Physician #100 verified that critical high lab values for INR usually start at 5.0. On [DATE] at 2:40 P.M., an interview with RDCO #150 verified there was no evidence of monitoring of bleeding in Resident #20 medical record. RDCO #150 stated monitoring for bleeding was usually documented in the medication administration records. Review of an undated facility policy titled lab results revealed the staff will process test requisitions and arrange for tests. If a test was obtained to monitor the blood level of a medication and the level is reported as high (above therapeutic range) the nurse will notify the physician promptly and will not give the next dose until the situation had been reviewed with the physician. This deficiency represents non-compliance investigated under Complaint Number OH00149140.

Based on observations, medical record review, staff interview, review of the facility's self-reported incidents (SRIs), review of personnel records, review of the facility investigation, review of a police report, and review of facility policy, the facility failed to implement their abuse policy, recognize sexual abuse of a resident by a staff member, thoroughly investigate an allegation sexual abuse and failed to protect one resident (#28) from continued sexual abuse and exploitation due to staff failing to intervene when they learned of Housekeeper #100 having a sexual encounter with Resident #28 in his room. This resulted in Immediate Jeopardy on [DATE] at approximately 5:13 P.M., when Resident #28 who had a history of anoxic brain damage, psychoactive substance abuse with psychoactive substance induced mood disorder, encephalopathy, and paranoid schizophrenia was found having a sexual encounter with Housekeeper #100 in his room. This affected one (#28) of three residents reviewed for abuse in the facility. The facility census was 70. On [DATE] at 5:34 P.M., the Administrator, the Director of Nursing (DON), Regional Director of Clinical Operations (RDCO) #800, and Chief Clinical Officer (CCO) #801 were notified Immediate Jeopardy began on [DATE] at approximately 5:13 P.M., when State tested Nursing Assistant (STNA) #503 entered Resident #28's room to deliver a food tray and became aware of the sexual encounter between Resident #28 and Housekeeper #100, then left the room and failed to protect the resident by leaving Resident #28 and Housekeeper #100 unsupervised in order to summon STNA #504 and to call the Assistant Director of Nursing (ADON)/Licensed Practical Nurse (LPN) #21. STNAs #503 and #504 reentered Resident #28's room and heard the resident and Housekeeper #100 involved in a sexual encounter and again failed to protect the resident by leaving the room to summon the on-duty nurses. When LPNs #505 and #35 reentered Resident #28's room, they observed the resident and Housekeeper #100 engaged in sexual activity on the residents' bed and Housekeeper #100 was instructed to get dressed and leave the facility. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at approximately 5:17 P.M., LPNs #35 and #72 and STNAs #503 and #504 responded to Resident #28's room. STNA #503 and LPN #505 instructed Housekeeper #100 to get dressed and leave the premises. STNAs #503 and #504 and LPNs #72 and #35 proceeded to observe Housekeeper #100 get dressed. Housekeeper #100 assisted Resident #28 with transferring into a wheelchair and Resident #28 attempted to leave with Housekeeper #100. The staff intervened and prevented Resident #28 from leaving. Housekeeper #100 left the premises at approximately 5:30 P.M. On [DATE] at 5:37 P.M., STNA#503 contacted the Xenia Police Department and Police Officers #600 and #506 arrived on scene at 5:40 P.M. Police Officers #600 and #506 got statements from the five staff members on duty at the time of the alleged incident. Resident #28 informed the Police Officers that he was in a relationship with Housekeeper #100, and they had been dating for several weeks. Housekeeper #100 was no longer on scene for a statement. A report was created, and no further action was taken by the Police Officers. On [DATE] at approximately 5:40 P.M., ADON/LPN #21 got statements from the five staff members on duty at the time of the alleged incident. On [DATE] at approximately 5:50 P.M., Resident #28 was interviewed by ADON/LPN #21 and the statement was recorded on paper. Resident #28 reported to ADON/LPN #21 that the sexual contact was consensual, and he was not harmed. Resident #28 reported he was in a relationship with Housekeeper #100. Resident #28 refused to be assessed by ADON/LPN #21. On [DATE] at approximately 6:00 P.M., Medical Director #610 was notified by LPN #505 of the incident. No new orders or directions were given. On [DATE] at 6:02 P.M., an SRI was created by the Administrator. The SRI was marked completed on [DATE] at 4:54 P.M. and was unsubstantiated. On [DATE] at 11:37 P.M., Housekeeper#100 returned to the building to retrieve an automated teller machine (ATM) card. The staff told her to leave the premises and she left the premises within two to three minutes. On [DATE] between 8:00 A.M. and 1:00 P.M., those residents on the unit who were interviewable, were interviewed by Social Services Designee (SSD) #28 regarding abuse and there were no negative findings. On [DATE] between 9:00 A.M. and 2:30 P.M., those residents on the unit who were not interviewable, had skin checks completed by Registered Nurse (RN) #53 with no negative findings. On [DATE] at approximately 9:30 A.M., the front door alarm/keypad was examined by Regional Maintenance Director #601. The panel was found in need of repair and the replacement part was ordered on this date. On [DATE], the panel was replaced, and the door code was updated. All of the facility staff were aware and observant to the fact that Housekeeper #100 was not to be on the property or in the building. Housekeeper #100 has not returned. On [DATE] between 11:00 A.M. and 2:00 P.M., multiple calls were made to Housekeeper #100 by the Administrator and the calls were not returned. On [DATE] at 12:33 P.M., SSD #28 completed a Brief Interview for Mental Status (BIMS) assessment on Resident #28 and scored a 15, which indicated the resident had intact cognition. On [DATE] at 12:37 P.M., SSD #28 completed a psychosocial assessment on Resident #28 with no negative affect. On [DATE], a written statement by Housekeeper #100 was obtained by the Administrator. On [DATE] at 6:30 P.M., CCO # 801 educated RDCO #800, the DON and the Administrator on completing a thorough investigation of allegations of abuse specifically sexual abuse. The education included safeguarding of the residents, and provision of education. On [DATE] at 7:00 P.M., an Ad Hoc Quality Assurance and Performance Improvement (QAPI) committee meeting was conducted. Participants included: Medical Director #610, CCO #801, RDCO #800, the Administrator and DON. On [DATE] at 7:30 P.M., the DON and the Administrator reviewed the other residents in house for the potential for sexual activity. There were four residents identified and their care plans were reviewed and updated if indicated. On [DATE] at 8:00 P.M., staff education on the abuse policy was initiated by the DON and the Administrator. The education included the safeguarding of residents. The education also included that staff will not engage in any sexual relations with any resident. As of [DATE] at 8:30 P.M., all facility staff had received education on the abuse policy. On [DATE] at 8:00 P.M., the Guardian Angels rounds (originally implemented on [DATE]) was reviewed and the assignments and the accountability for completion were revised. The facility is monitoring for ongoing abuse via Guardian Angel rounds being conducted by the facility leadership Monday through Friday. The Guardian Angel rounds include the on-duty staff completing direct observation of their assigned resident's environment, evidence of care completion and questioning residents regarding concerns and care and this is documented on Guardian Angel forms. On [DATE] at 8:30 P.M., those residents who were interviewable, were interviewed by SSD #28 for any concerns with potential for abuse and the non-interviewable residents had skin assessments completed by ADON/LPN #21 with no negative findings. On [DATE] at 8:45 P.M., CCO #801 reviewed other SRI reports that occurred in the past week to ensure investigations were completed. There was one variance identified which included getting a witness statement. The statement was obtained and added to the investigation packet. On [DATE], ongoing, the agency staff will be educated on the facility's abuse policy upon arrival for their scheduled shift. A facility charge nurse will be assigned to each shift to ensure the education is completed. The DON/Designee will monitor the ongoing education five times a week for four weeks then weekly for four additional weeks. On [DATE], to monitor ongoing compliance, the facility's Interdisciplinary Team (IDT) will monitor staff understanding of the abuse policy via completion of a minimum of three abuse quizzes, three times a week for four weeks then weekly for two additional weeks. An Ad Hoc education will occur with any incorrect answers. On [DATE], to monitor ongoing compliance, SSD #28/Designee will complete a minimum of three resident abuse questionnaires three times a week for four weeks then weekly for two additional weeks. On [DATE] at 9:00 A.M., CCO #801 updated the abuse policy to include language that states staff will not engage in any sexual relations with any resident. On [DATE], to monitor ongoing compliance, CCO #801/Designee will review all investigations of abuse, neglect, and mistreatment weekly for six weeks to ensure investigations are complete and thorough. On [DATE], to monitor ongoing compliance, the QAPI committee will review results of the audits, quizzes, and questionnaires weekly and will make recommendations for any adjustments to the quizzes and questionnaires or need for further education as needed. On [DATE] at 10:40 A.M., the Administrator added an addendum to the SRI noting the investigation revealed that prior relationship status between resident and housekeeper could not be confirmed or disputed therefore the facility has substantiated the inappropriate sexual activity. On [DATE], RDCO #800 added an addendum to the SRI noting the investigation concluded that Housekeeper #100 did in fact engage in consensual sexual activity with Resident #28 on [DATE] and as an employee, this activity would substantiate the allegation of sexual abuse. Although the Immediate Jeopardy was removed on [DATE], the facility remained 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 was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #28, revealed the resident was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia, anoxic brain damage, other psychoactive substance abuse with psychoactive substance induced mood disorder, encephalopathy, severe sepsis with septic shock, rhabdomyolysis, acute metabolic acidosis, and respiratory failure with hypoxia. Review of the mood, behavior and psychosocial well-being care plan dated [DATE] for Resident #28, revealed the resident had a history of psychoactive substance abuse with psychoactive substance induced mood disorder. Interventions included administer medications as ordered, attempt to identify what triggers behaviors, offer activities which resident has shown interest and observe and report any changes in mental status. Review of the personnel file for Housekeeper #100, revealed Housekeeper #100 was hired at the facility on [DATE] as Environmental Services. Housekeeper #100 was tasked with assuring the facility is maintained in a clean, safe, and comfortable manner. Housekeeper #100's Bureau of Criminal Investigations (BCI) was requested on [DATE] and received on [DATE] and the research results indicted she was cleared. Housekeeper #100 was educated on the abuse policy, acknowledged the policy, and electronically signed the statement on [DATE]. Housekeeper #100's STNA licensure expired on [DATE] and the last known employer was listed as this same facility. Review of the staff schedules dated [DATE] through [DATE], revealed Housekeeper #100 worked in the facility on [DATE]. Review of the nurse's progress note dated [DATE] at 3:32 P.M. for Resident #28, revealed a referral was faxed to a brain and spine specialist for the resident's anoxic brain injury. Review of the Minimum Data Set (MDS) assessment 3.0 dated [DATE] for Resident #28, revealed the resident to be cognitively intact with a BIMS score of 13 and Resident #28 required limited assistance with bed mobility and transfers. Resident #28 also required supervision with eating, dressing, toileting, and personal hygiene. Review of Housekeeper #100's time punch dated [DATE], revealed Housekeeper #100 worked on [DATE] from 10:00 A.M. to 2:29 P.M. Review of the police report dated [DATE] at 5:37 P.M., revealed the police were dispatched to the facility on [DATE] at 5:37 P.M. and arrived at the facility on [DATE] at 5:40 P.M. The police report stated officers responded to the facility in reference to an incident. Upon arrival, the officers spoke with staff that worked at the facility. The staff advised Housekeeper #100 was caught having sexual intercourse with Resident #28 at the facility by the staff. Housekeeper #100 worked in housekeeping. Housekeeper #100 was behind the curtain with Resident #28, and they could hear the bed squeaking. Housekeeper #100 and Resident #28 were confronted, and Housekeeper #100 left the facility. Housekeeper #100's daughter was also in the facility visiting the housekeeper's grandmother (daughters great-grand mother) in another room. The staff had Housekeeper #100's daughter with her when the officers arrived. Housekeeper #100's daughter contacted her father who responded to the facility and took custody of her. The officers spoke with ADON/LPN #21, who advised Resident #28 had a brain injury; however, he scored a 13 out of 15 on the BIMs on [DATE]. ADON/LPN #21 advised that Resident #28 was capable of making his own decisions and made his own decisions. The officers spoke with Resident #28 in his room. Resident #28 was alert and stated that he and Housekeeper #100 were in a relationship, and they had been dating for several weeks. Review of the facility's SRI, created on [DATE] at 6:02 P.M., revealed an allegation of sexual abuse between Housekeeper #100/alleged perpetrator and Resident #28 (resident/victim). The summary indicated Resident #28 had a BIMs of 13 and was observed in in his bed with Housekeeper #100. Housekeeper #100 was suspended, and the physician was notified. There were no injuries noted. The conclusion indicated the allegation of sexual abuse was unsubstantiated, evidence indicates abuse or neglect did not occur. Prior to Housekeeper #100's employment at the facility, the housekeeper had a family member that was also a resident at the facility who she frequently visited, which was how Housekeeper #100 and Resident #28 met and began their relationship. Managerial staff were unaware of their relationship when Housekeeper #100 obtained employment at the facility. Housekeeper #100 was unaware that it would be a conflict. The relations they shared were consensual for both individuals. Resident #28 did not have any adverse effects from the incident. Law enforcement was notified and was made aware of the incident. The SRI was unsubstantiated by the facility and marked completed on [DATE] at 4:54 P.M. On [DATE], the facility created addendum information which noted ongoing investigation revealed that prior relationship status between resident and housekeeper, could not be confirmed or disputed, therefore the facility has substantiated the inappropriate sexual activity. On [DATE], the facility created an addendum which noted ongoing investigation revealed Housekeeper #100 engaged in consensual sexual activity with Resident #28 on [DATE] and as an employee, this would substantiate the allegation of sexual abuse. Review of the nurse's progress note dated [DATE] at 6:49 P.M. for Resident #28 and authored by LPN #505, revealed at approximately 5:00 P.M. an aide came to the nurse's station to report Resident #28 was having sex in his room. Two nurses and several STNAs went to the room and found Resident #28 dressing with a woman also dressing. The female was asked to leave the premises. The STNA asked if she was an employee and the female stated no. Another STNA stated the woman was an employee and often comes to work and brings her daughter with her to visit her grandmother who was a resident across the hallway. The woman dressed and left the premises but left her underage daughter. The daughter stated she called her father, and he was on the way to pick her up. The nurse sat down to chart about the incident but was interrupted when the police arrived to attend to the minor child. The police took witness statements. The other nurse on the hall attempted to obtain a urine sample from the resident to perform a drug screen but the resident refused. The nurse notified the Administrator and was told to obtain witness statements. The police obtained witness statements and the DON arrived on scene by 6:00 P.M. to obtain copies. Resident #28 stated the sexual encounter was consensual. Resident #28 was listed as his own power of attorney (POA) in the chart and was designated as responsible for himself. Review of the nurse's progress note dated [DATE] at 7:15 P.M. for Resident #28 and authored by LPN #505, revealed Resident #28's physician was called, and a message was left notifying the on call of the incident. Review of a witness statement dated [DATE] by STNA #503, revealed she walked into Resident #28's room to pass dinner trays and the curtain was closed and she heard them having sex. STNA #503 walked out and went to get the other STNA (#504). STNA #503 called ADON/LPN #21. ADON/LPN #21 told her to tell the nurse and the nurse walked in and they were both naked. Housekeeper #100 stated that Resident #28 was her husband but stated earlier while she was checking him out of the facility to take him to the store that Resident #28 was her brother. Housekeeper #100 got dressed and got Resident #28 dressed and wheeled him out. Housekeeper #100 left her daughter, and her daughter was screaming. The staff told Housekeeper #100 that she could not take Resident #28 out without signing him out and they told Resident #28 to come back in, and Housekeeper #100 drove off leaving her daughter. Housekeeper #100's daughter was crying so they called the police and were able to get the father to pick her up. Review of a written statement dated [DATE] by STNA #504, revealed she was approached by STNA #503 that one of the residents had the housekeeper in the bed. STNA #504 heard the bed squeaking and walked out and stated they sound like they were having sex. Staff walked back into the room and pulled the curtain back and Housekeeper #100 was naked from the back, and he was humping her. Staff proceeded to tell her to leave the premises and she proceeded to get dressed and pushed Resident #28 upfront and out the doors. In doing so, she left her child and staff called the police and notified the child's father. Review of a witness statement dated [DATE] by LPN #72, revealed one of her coworkers informed her that an employee was having sex with a resident. She went to the room and saw Resident #28 with no pants on and Housekeeper #100 with her breast exposed and her pants off. They all went and informed the nurse of what they saw. Review of a witness statement dated [DATE] by LPN #505, revealed at approximately 5:00 P.M. an STNA came to the nurse and reported that Resident #28 was having sexual relations in his room. LPN #505 went to Resident #28's room with another nurse and several STNAs. Resident #28 was dressing and so was Housekeeper #100. Housekeeper #100 stated it was okay and Resident #28 did not say anything. Housekeeper #100 was asked to leave the premises. Housekeeper #100 had been visiting her grandmother across the hall with her underage daughter. An STNA asked the women as she was getting dressed if she was an employee and she stated no. Housekeeper #100 eventually left but left her underage daughter on the premises. The daughter stated she had called her father to come and pick her up. LPN #505 went to the computer to chart on the incident but was interrupted before finished by the arrival of the police. The police took a statement from the daughter and the father arrived. Another nurse attempted to obtain a urine sample from the resident, but Resident #28 refused. ADON/LPN #21 arrived about 6:00 P.M. The nurse attempted to call the DON, but the mailbox was full. The nurse then called the Administrator and was able to get the Administrator on the phone. Review of a witness statement dated [DATE] by LPN #35, revealed she was called to Resident #28's room and when she entered the room, she observed three staff members standing at the foot of the bed and she observed Resident #28 sitting up on the side of the bed with his shirt off and shorts on. At the head of the bed, Housekeeper #100 was sitting on the bed facing the male resident. Housekeeper #100 had a bra on and was putting her shirt on. Housekeeper #100 was asked to leave the room and Housekeeper #100 stated they were married. LPN #35 asked Housekeeper #100 if she was employed by the facility and she stated no. LPN #35 and the other nurse left the room to call Administration. Housekeeper #100 was observed putting Resident #28 in the wheelchair. Review of a witness statement dated [DATE] by RN #42, revealed she was told to ask Housekeeper #100 to leave Resident #28's room. RN #42 entered Resident #28's room and asked Housekeeper #100 to leave Resident #28's room and she did but when RN #42 was on her way back to the secured unit, Housekeeper #100 was wheeling Resident #28 outside and placing him in her red minivan. RN #42 went outside and said to Resident #28 let's go back inside and again asked Housekeeper #100 to leave the property to which she backed up her van and left the property. RN #42 wheeled Resident #28 back to his room and then she returned to the secured unit. Review of a written statement dated [DATE] by Resident #28 and recorded by ADON/LPN #21, revealed the resident stated he was okay; he was not hurt, and he was not forced to do anything with Housekeeper #100. Resident #28 stated he was just doing what boys and girls do and Resident #28 stated the contact was consensual. Review of the nurse's progress dated [DATE] at 6:04 A.M. for Resident #28 authored by RN #33, revealed on [DATE] Resident #28 had his night medications at 8:30 P.M. Resident #28 took his roommate's walker and stated he was going out to a hotel room for the lady (Housekeeper #100) he had intercourse with that day. Staff stopped him and took the walker out of the room. Around 11:37 P.M., the lady (Housekeeper #100) walked in and went directly into Resident #28's room. Resident #28 was outside smoking, so the lady (Housekeeper #100) went out and met him. ADON/LPN #21 was notified, and she stated staff should ask her to leave the building. The staff told her to leave, and she did. On her way out she stated she just came in to get her bank card. Resident #28 put himself to bed around 1:00 A.M. on [DATE] and only got up once to smoke. No other issues were observed or reported. Review of the nurse's progress note dated [DATE] at 12:36 P.M. for Resident #28 authored by the DON, revealed Resident #28's grandmother was called and notified of the incident that occurred on [DATE]. Review of the BIMS assessment dated [DATE] for Resident #28, revealed the resident had a BIMs of 15 indicating he was cognitively intact. Review of the personnel file for Housekeeper #100, revealed a corrective action form dated [DATE] indicating Housekeeper #100 was terminated on [DATE] for inappropriate conduct. The form indicated Resident #28, and Housekeeper #100 were in the resident's room together. Review of a statement dated [DATE] by the Administrator, revealed under no circumstances should any staff member have any type of sexual relationship with a resident in any manner. Review of a statement dated [DATE] by Housekeeper #100, revealed a question at the top stating please write out when did relationship start. Housekeeper #100's statement indicated relationship status - friends/partners known and been affiliated with each other for many years. Housekeeper #100 was helping Resident #28 change and out of nowhere staff did not knock, they did not state who they were and started to say insane things, so she left. Interview on [DATE] at 7:39 A.M. with Housekeeper #60, revealed she had heard that a staff member was having sexual intercourse with a resident, but she did not know the names of the staff or any details. Interview on [DATE] at 7:44 A.M. with SSD #28, revealed she was aware of a sexual encounter between a resident and a former employee, but she was not aware of any details of the incident. Observation of Resident #28 on [DATE] at 8:36 A.M., revealed the resident was lying in bed. Resident #28 was clean and dressed appropriately. Interview with Resident #28 on [DATE] at 8:36 A.M., revealed the resident denied any type of sexual relationship with any current or prior staff member at the facility including having a sexual relationship with a staff member prior to them becoming employed at the facility. Resident #28 denied ever having sexual intercourse or performing any sexual acts at the facility and Resident #28 denied being abused or sexually abused at the facility. Interview with the Administrator and DON on [DATE] at 9:27 A.M., revealed the facility did not have any camera footage of the incident between Housekeeper #100 and Resident #28 on [DATE] and Resident #28 was not sent to the hospital after the incident. Attempted to call Housekeeper #100 on [DATE] at 9:59 A.M. with no response to the attempt. Attempted to call LPN #35 on [DATE] at 10:02 A.M. with no response. Telephone interview with STNA #503 on [DATE] at 10:03 A.M., revealed STNA #503 was working at the facility on [DATE]. STNA #503 stated Housekeeper #100 tried to take Resident #28 out of the facility to the store earlier in the day and staff stated it was unprofessional for Housekeeper #100 to take Resident #28 out of the facility since she was employed by the facility. STNA #503 reported Housekeeper #100 stated Resident #28 was her brother and staff allowed her to take him out of the facility because they did not know the protocol for employees that were family members of residents. STNA #503 stated Resident #28 and Housekeeper #100 returned from the store, and she was passing trays on Resident #28's hallway. STNA #503 reported she took Resident #28's roommate (Resident #24) his dinner tray on [DATE] around 5:00 P.M. when she heard Resident #28's bed squeaking. STNA #503 stated Resident #24 told her that Resident #28 and Housekeeper #100 were having sex. STNA #503 reported she left the room and called ADON/LPN #21 on her phone and went and got STNA #504. STNA #503 stated ADON/LPN #21 told her to get the nurse and she, LPN #35, LPN #505, and STNA #504 knocked on Resident #28's door, announced themselves and found Housekeeper #100 against the back board of Resident #28's bed and Resident #28 sitting on the side of his bed. STNA #503 stated Housekeeper #100 was undressed and was trying to cover herself up with the sheet and STNA #503 stated it was obvious that Resident #28 and Housekeeper #100 were having sexual intercourse in Resident #28's bed. STNA #503 reported Housekeeper #100 then stated her and Resident #28 were married, and Resident #28 would be discharging on Friday. STNA #503 stated Housekeeper #100 appeared under the influence of a substance because she was sweaty, and her eyes were blood shot. STNA #503 reported staff confronted Housekeeper #100 about working at the facility and Housekeeper #100 stated she no longer worked at the facility. STNA #503 also stated that staff confronted Housekeeper #100 about stating that Resident #28 was her brother earlier that day. STNA #503 reported Housekeeper #100 stated she was going across the hallway to her grandmother's room and staff left Resident #28 and Housekeeper #100 in the room again despite STNA #503 telling the nurse that they could not be left alone. STNA #503 stated Housekeeper #100 was told she had to leave the facility, but she continued to stay in the room and got Resident #28 dressed. STNA #503 reported she went back to passing trays and Housekeeper #100 attempted to wheel Resident #28 out of his room and towards the exit door. STNA #503 stated nursing staff stopped Housekeeper #100 from leaving the facility with Resident #28 and stated that the police were called. Housekeeper #100 then left the facility and left her [AGE] year-old daughter at the facility. STNA #503 reported Housekeeper #100 had a history of bringing her daughter to work with her and that she had left her daughter at the facility in Housekeeper #100's grandmother's room while Housekeeper #100 took Resident #28 to the store and had sexual intercourse with Resident #28. STNA #503 stated Housekeeper #100's daughter was upset and was saying my mom is over there having sex with that man. Telephone interview with STNA #504 on [DATE] at 10:18 A.M., revealed STNA #504 was working on the facility on [DATE]. STNA #504 reported Resident #28 had signed himself out of the facility several times that day and he had been talking to and smoking with Housekeeper #100. STNA #504 stated she was passing food trays when STNA #503 came to her, and stated Housekeeper #100 was in the room with Resident #28 and the door was closed and the curtain was pulled. STNA #504 stated she had Resident #28's roommate (Resident #18's) tray so she knocked on Resident #28's door and announced herself. STNA #504 reported she dropped off Resident #18's food tray and she heard the bed rocking. STNA #504 stated she and STNA #503 went to get LPN #505 and she, STNA #503, LPN #505 and LPN #35 went to Resident #28's room, opened the door, and found Housekeeper #100 was undressed and was only wearing a sports bra and Resident #28 was undressed from the waist down and was only wearing a white t-shirt without sleeves. STNA #504 reported Resident #28 and Housekeeper #100 were surprised when they walked in, and the staff asked what they were doing and confronted Housekeeper #100 about having sexual intercourse with a resident with other residents in the room. STNA #504 stated Housekeeper #100 was told that she had to leave, and she was not sure what happened after that because she let the nurse handle the situation. STNA #504 reported Housekeeper #100's grandmother was a resident across the hallway and her daughter was in the room with Housekeeper #100's grandmother at the time of the incident. STNA #504 stated Housekeeper #100's daughter was crying and asking Housekeeper #100 how could you do this and stated it was very embarrassing. Attempted to call LPN #72 on [DATE] at 11:06 A.M. with no response. Interview with the DON, ADON/LPN #21, and the Administrator on [DATE] at 11:43 A.M., revealed ADON/LPN #21 received a phone call from STNA #503 around dinner time on [DATE]. STNA #503 told ADON/LPN #21 that she thought Resident #28 was having sex with a female and she thought it was Housekeeper #100. ADON/LPN #21 stated she told STNA #503 to get the nurse and see what was going on in Resident #28's room. ADON/LPN #21 stated she remained on the phone when STNA #503, LPN #505 and other staff went into Resident #28's room and found Resident #28 and Housekeeper #100 putting their clothes back on in Resident #28's room. ADON/LPN #21 stated she then went to the facility and asked staff to write statements. ADON/LPN #21 reported she interviewed Resident #28 and he stated that he and Housekeeper #100 were doing what boys and girls do and he laughed and stated it was consensual. ADON/LPN #21 stated Resident #28 did not say if he was in a relationship with Housekeeper #100. ADON/LPN #21 reported she did a skin assessment on Resident #28

Based on medical record review, staff interviews, and facility policy review, the facility failed to ensure residents attended outside medical appointments as ordered. This resulted in actual harm when the facility failed to ensure Resident #53 was transported to a follow-up appointment on 03/09/23 with a vascular surgeon for treatment/assessment of a vascular wound to Resident #53's left lower leg. The appointment was rescheduled for 03/23/23 (two weeks later) and Resident #53's wound was found to have worsened with necrotic tissue present during that timeframe. This affected two (Resident #53 and #66) out of three residents reviewed for transportation. Additionally, the facility also failed to ensure residents were assessed for placement on a secured unit. This affected one (Resident #95) out of three residents reviewed for secured unit assessments. The facility census was 68. Findings include: 1. Review of the medical record for Resident #53 revealed an admitted [DATE] to the secured unit. Resident #53 was transferred to the hospital on 04/04/23 and had not returned. Resident #53's diagnoses included unspecified open wound left lower leg, heart failure, peripheral vascular disease (PVD), chronic obstructive pulmonary disease, and cellulitis. Review of the care plan for Resident #53 revealed Resident #53 had an actual wound related to a vascular wound to left lower extremity. Interventions included administer medications as ordered, administer treatment as ordered, measure wounds weekly as ordered, observe for signs of infection, and obtain lab work as ordered. Attending outside appointments was not addressed in the resident's care plan. Review of the Admission Minimum Data Set (MDS) 3.0 assessment, dated 02/22/23, revealed Resident #53 had intact cognition. Resident #53 had one venous/arterial ulcer noted on the assessment. Review of Resident #53's progress notes dated 02/23/23 at 8:46 A.M., revealed Resident #53 was seen by the wound physician who ordered a wound culture and sensitivity (C & S) and a Doppler study. Resident #53 also needed to be referred to the vascular clinic in order to check Resident #53's left leg circulation. Review of Resident #53's physician order, dated 02/28/23, revealed Resident #53 had an appointment with the vascular surgeon at the local hospital and would need transportation. The order was discontinued on 03/09/23. Review of Resident #53's physician order, dated 02/28/23, revealed transportation was set up for 03/09/23 with a pick up time of 12:15 P.M. The order was discontinued on 03/10/23 due to the appointment being rescheduled. Review of Resident #53's progress notes, dated 02/28/23 at 11:08 A.M., revealed Resident #53 had an appointment on 03/09/23 at 1:15 P.M. with the vascular surgeon. Transportation needed to be scheduled. Review of Resident #53's progress notes, dated 02/28/23 at 5:10 P.M., revealed Resident #53's transportation for 03/09/23 was scheduled with a pick up time of 12:15 P.M. Review of Resident #53's progress notes, dated 03/07/23 at 11:11 A.M., revealed the transportation company was contacted to verify they received the facility's promise to pay. Transportation was set for 03/09/23 at 12:15 P.M. Review of the Skin Grid Non-Pressure assessment, dated 03/09/23, revealed Resident #53 had a venous wound which was acquired on 02/16/23. The wound was on the front of Resident #53's left lower leg and measured 6.1 centimeters (cm) long by 3.4 cm wide by 0.2 cm deep with moderate drainage. The periwound was discolored. Review of the Wound Physician (WP) #400 note, dated 03/09/23, revealed Resident #53 was seen for a left lower leg venous ulcer which was complicated by a localized wound infection. The tissue bed was 50 percent (%) slough and 50% granular non-pressure wound full thickness. The wound was clean with healthy granulation tissue and moderate wound slough. The slough was yellow and soft with a moderate amount of serous drainage. The wound measurements were 6.1 cm long by 3.4 cm wide by 0.2 cm deep. The wound status had declined. The wound was debrided and bleeding was within normal limits. A dressing was applied. The plan included a recommendation for an assessment of the left lower extremity at the vascular clinic and intervention if necessary for his PVD. Review of Resident #53's physician order, dated 03/10/23, revealed Resident #53 had an appointment with the vascular surgeon on 03/23/23 at 1:15 P.M. and would need transportation. Review of the WP #400 note, dated 03/16/23, revealed Resident #53's left lower leg venous ulcer was assessed by WP #400. The tissue bed was 50% granular, 25% slough, and 25% necrotic non-pressure wound full thickness. The wound was covered by necrotic tissue and moderate wound slough which was debrided to expose some areas of granulation tissue. The measurements were 6.7 cm long by 4.3 cm wide by 0.2 cm deep. The wound status had declined. The recommendation was for an assessment of the left lower extremity at the vascular clinic and intervention if necessary for PVD. Review of Resident #53's progress notes dated 03/20/23 at 2:01 P.M., revealed a medical transportation company was contacted to schedule transportation to a vascular appointment on 03/23/23 at 1:15 P.M. and was waiting for a return call. Review of the WP #400 note, dated 03/23/23, revealed Resident #53's left lower leg venous ulcer was assessed by WP #400. The tissue bed remained the same as 03/16/23 with necrotic tissue covering the wound and moderate wound slough. The wound measurements were 7.9 cm long by 4.7 cm wide by 0.3 cm deep. The wound status was declined. The wound was debrided and a dressing was applied. The recommendation was for an assessment of the left lower extremity at the vascular clinic and intervention if necessary for PVD. Review of the Vascular Surgeon note, dated 03/23/23, revealed Resident #53 was seen for a post operation appointment status post left lower extremity wound debridement with puraply graft. A aortobifemoral bypass with possible left femoropopliteal bypass graft was discussed with Resident #53 and Resident #53 was to be scheduled for an aortobifemoral bypass with left femoral popliteal bypass graft. Review of the Skin Grid Non-Pressure assessment, dated 03/24/23, revealed Resident #53's left lower leg wound had measurements of 7.9 cm long by 4.7 cm wide by 0.3 cm deep with moderate amount of serous drainage. The periwound was discolored, erythematous (redness) with edema (swollen), and the status had declined. Review of the WP #400 note, dated 03/30/23, revealed Resident #53's left lower leg venous ulcer was assessed by WP #400. The tissue bed remained the same as 03/16/23 and 03/23/23. The wound measurements were 12.2 cm long by 6.3 cm wide by 0.3 cm deep. The wound status was declined. The wound was debrided and a dressing was applied. Review of the Skin Grid Non-Pressure assessment, dated 03/31/23, revealed Resident #53's left lower leg wound had measurements of 12.2 long by 6.3 wide by 0.3 deep with a moderate amount of serous drainage. The periwound was discolored and the status was declined. Interview on 04/12/23 at 3:15 P.M. with Licensed Practical Nurse (LPN) #291 revealed the medical transportation company the facility utilized for outside appointments was absolutely horrible. LPN #291 stated the transportation company cancelled scheduled transportation at the last minute due to not having enough drivers. LPN #291 confirmed Resident #53 missed a scheduled follow up appointment following surgery. The appointment was originally scheduled for 03/09/23 and was rescheduled in 03/23/23. LPN #291 confirmed the Director of Nursing (DON) and Administrator were aware of the transportation issues with outside appointments. Interview on 04/12/23 at 5:15 P.M. with Regional Nurse (RGN) #303 confirmed Resident #53 missed medical appointments due to not having medical transportation and the appointments needed to be rescheduled. RGN #303 stated the facility did not have a medical transportation contract in place and had been completing Google searches in order to try to find available medical transportation for outside appointments. Interview on 04/13/23 at 1:26 P.M. via telephone with Wound Physician (WP) #400 revealed delayed intervention due to Resident #53 missing the appointment with the vascular surgeon on 03/09/23 was definitely a contributing factor to the resident's wound declining. There is no doubt about that. Interviews on 04/13/23 at 2:23 P.M. with State tested Nurse Aide (STNA) #326 and STNA #341 confirmed medical transportation for outside medical appointments had been an issue for the facility for the last three to four months and residents had missed scheduled outside appointments due to medical transportation issues. 2. Review of the medical record for Resident #66 revealed an admitted [DATE]. Resident #66's diagnoses included traumatic brain injury (TBI), dementia, bipolar disorder, anoxic brain damage, and encephalopathy. Review of the quarterly MDS 3.0 assessment, dated 03/10/23, revealed Resident #66 had impaired cognition. Review of Resident #66's physician order dated 02/08/23 revealed Resident #66 had a Gynecology consult for pap smear. Review of Resident #66's physician orders revealed Resident #66 had a Gynecology appointment on 03/10/23 at 10:30 A.M. The order was discontinued on 03/10/23 due to needing rescheduled. Review of Resident #66's physician orders revealed Resident #66 had a Gynecology appointment scheduled on 04/05/23 at 2:00 P.M. The order was discontinued on 04/05/23 due to transportation cancelling and the appointment needing rescheduled. Review of Resident #66's physician orders revealed Resident #66 had a Gynecology appointment scheduled on 05/03/23 at 2:00 P.M. Review of the progress notes dated from 02/04/23 to 04/11/23 revealed there were no notes related to Resident #66's missed Gynecology appointments. Review of Resident #66's progress note dated 04/12/23 at 12:30 P.M., revealed transportation was scheduled for the Gynecology appointment on 05/03/23. Interview on 04/12/23 at 3:15 P.M. with LPN #291 confirmed Resident #66 missed a scheduled gynecologist appointment three times due to transportation issues. Resident #66 was sexually active and was scheduled for a regular pap smear examination. Resident #66 was not experiencing any pain or other symptoms. The appointment was originally scheduled in February 2023 and was now scheduled in May 2023. LPN #291 stated when the appointment was scheduled, Resident #66 was rescheduled the following month because Resident #66 was a new patient. Interview on 04/12/23 at 5:15 P.M. with RGN #303 confirmed Resident #66 missed scheduled Gynecology appointments due to transportation issues. RGN #303 confirmed the facility did not have a current medical transportation contract in place for outside medical appointments. Interviews on 04/13/23 at 2:23 P.M. with STNA #326 and STNA #341 confirmed residents had missed outside medical appointments due to transportation issues for the last three to four months. Review of the facility policy titled Transportation Policy and Procedure, dated 08/01/18, revealed the policy stated, it is the policy of the facility to arrange and ensure transportation is provided for doctors and specialist appointments. 3. Review of the medical record for Resident #95 revealed an original admitted [DATE] and a readmitted [DATE]. Resident #95 had diagnoses which included affective disorder, delusional disorder, violent behaviors, anxiety disorder, bipolar disorder, auditory hallucinations, and schizoaffective disorder. Review of the admission MDS 3.0 assessment revealed Resident #95 had intact cognition. Resident #95 required supervision without assistance from staff to complete Activities of Daily Living (ADLs). Resident #95 displayed delusions, physical behavioral symptoms toward others, and verbal behaviors toward others. Resident #95's behaviors significantly interfered with the resident's care and social interactions. Review of the physician orders dated April 2023 revealed Resident #95 had an order to be admitted to the secured unit. Review of the Resident #95's assessments completed since 03/07/23 revealed no secure unit assessments were completed for Resident #95. Interview on 04/17/23 at 3:52 P.M. with RGN #303 confirmed secured unit assessment was not completed for Resident #95 who resided on the secured unit and should be completed upon admission to the secured unit, quarterly, and annually. Interview on 04/18/23 at 4:30 P.M. with RGN #303 confirmed it was expected that staff complete the secured unit assessment for all residents who resided on the secured unit. Review of the facility policy titled Secure Environment Guidelines, undated, revealed the policy stated, although some residents in the facility exhibit inappropriate or non-typical behaviors, the facility determines if the resident will benefit from a secured environment. Furthermore, except in an emergency situation to meet the safety needs of a resident, they are not placed in a secured environment without the completion of the appropriate assessments. Review of the facility policy titled Assessment Types Policy & Procedure, undated, revealed the policy stated, each facility will designate who is responsible for the completion of each assessment type: Secured Unit Assessment: at admission to the secured unit, quarterly, and annually. This deficiency represents non-compliance investigated under Complaint Number OH00141206 and OH00142043.

Based on record review, observation, resident and staff interviews, family interviews and review of the Resident Bill of Rights, the facility failed to ensure Resident #37 received timely assistance with incontinence care. This resulted in actual harm when Resident #37 was found emotionally distraught and crying because she was left in urine overnight as the night shift state tested nursing aide (STNA) did not provide incontinence care. In addition, the facility failed to provide timely incontinence care to Resident #39 when the day shift STNA found the resident to be soaked in urine. This affected two (#37 and #39) of two residents reviewed for incontinence care. There were 36 residents identified to be occasionally or frequently incontinent of urine. The facility census was 54. Findings include: 1. Review of Resident #37's medical record revealed she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 10/17/19, revealed the resident had a moderate cognitive impairment. She required extensive assistance from staff for toileting and was frequently incontinent of urine. Review of the care plan, last revised 10/14/19, revealed she was at risk for an activities of daily living (ADL) decline related to a stroke. The care plan stated the resident's ADL needs would be met. Interventions included for staff to anticipate her needs and to assist as needed and to provide peri-care with each incontinent episode as needed. Interview on 01/12/20 at 10:41 [NAME]M. with Resident #37 and her Daughter-in-Law (DIL) revealed she had had two incontinent episodes during the previous night. State tested Nursing Assistant (STNA) #117 had been her assigned aide for the night shift. Resident #37 stated STNA #117 did come into her room last night, but that when Resident #37 informed her she had urinated twice, Resident #37 stated STNA #117 glanced at her and said, No, you are dry, and did not provide incontinence care throughout the entire night shift. Resident #37 stated she had been crying all morning while she laid in her urine as she did not feel like she was being treated in a dignified manner. Resident #37 stated she had not been changed until STNA #142 came to her room around 9:00 [NAME]M. She stated STNA #142 immediately provided incontinence care, stripped her urinated bedsheets and consoled her. Interview on 01/12/20 at 10:55 [NAME]M. with STNA #142 confirmed when she had arrived to the facility around 9:00 [NAME]M. after being called in at 8:15 [NAME]M. by administration, she had observed Resident #37 lying in her bed. STNA #142 stated her sheets and blankets were soaked in urine and that you could smell the urine from the hallway. STNA #142 stated Resident #37's adult incontinence brief was so saturated in urine that it had begun to disintegrate. She stated when she arrived to Resident #142's room, she had been crying because she had been left in her urine overnight by staff. STNA #142 confirmed Resident #37 had not been provided incontinence care overnight. STNA #142 confirmed she had to remove Resident #37's sheets and bed linens as they were saturated in urine. STNA #142 confirmed Resident #37 was incontinent of urine, required extensive assistance from staff for toileting and personal hygiene, and that she should have been changed by nursing staff during the time. STNA #142 revealed the facility was short staffed. She stated she had not been originally scheduled to work that morning, but had been called in by administration once the State Survey began. STNA #142 began crying and stated she does not feel the facility scheduled enough staff to care for the residents how they deserved. An attempt to interview STNA #117 during the survey was unsuccessful. 2. Review of Resident #39's medical record revealed he was admitted to the facility 03/02/17 with [DIAGNOSES REDACTED]. Review of the MDS assessment, dated 11/19/19, revealed he had moderate cognitive impairment and required extensive assistance of one staff member for toileting. The resident was frequently incontinent during the seven day look back period. Review of the care plan, dated 08/08/19, revealed the resident had bladder incontinence related to decreased mobility. Interventions included checking Resident #39 at least every two hours and providing peri-care as needed for incontinence. Interview and observation on 01/12/20 at 11:12 [NAME]M. with STNA #70 revealed at 11:00 [NAME]M. she observed Resident #39 lying in bed and his clothing and bed linens had been soaked in urine. Observation revealed a pile of wet, yellow-stained bed-linens lying on Resident #39's bed. STNA #70 revealed Resident #39 was cognitively impaired, required extensive assistance from staff for ADLs, including incontinence care, and that he was supposed to be checked and changed every two hours. Interview on 01/13/20 at 7:15 P.M. with Licensed Practical Nurse (LPN) #141 revealed the facility was often short-staffed. She revealed because of the short staffing during the evening, residents often have to lay in their urine all night long. Review of the facility's policy titled Activities of Daily Living (ADLs), last revised (MONTH) (YEAR), revealed the residents would be provided with care, treatment, and services as appropriate. The policy stated appropriate care and services would be provided to residents who were unable to carry out their ADLs independently, including incontinence care. Review of the facility's undated copy of the Resident Bill of Rights revealed the residents had the right to be treated at all times with courtesy, respect, and full recognition of dignity and individuality. This deficiency substantiates Complaint Number OH 180.

Based on review of medical records, interviews with residents and staff, review of employee personnel files, review of facility Self-Reported Incidents (SRI), review of the facility's plan of correction, review of in-service records and review of the facility's abuse policy and procedure, the facility failed to ensure residents were free from verbal and physical abuse. This resulted in Immediate Jeopardy and the potential for serious injury for one resident (#01) when he was observed by State tested Nursing Assistant (STNA) #152 having his chin grabbed and shook by Licensed Practical Nurse (LPN) #120 while stating, you are not going to hit me, and then getting punched in the stomach with a closed fist by LPN #120, after the resident was placed in his Geri chair. STNA #152 failed to immediately report the observed incident of resident abuse thus allowing LPN #120 to continue providing care for her assigned residents. This affected one (#01) of three residents reviewed for abuse and placed 18 additional residents (#18, #23, #29, #31, #34, #36, #40, #42, #44, #49, #51, #55, #62, #63, #73, #75, #78 and #83) at risk for the likelihood of serious harm or injury who were assigned LPN #120 as their care giver. On 02/22/19 at 2:40 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 02/15/19 at 2:57 P.M. when STNA #152 observed Resident #01 having his chin grabbed and shook by LPN #120 while stating you are not going to hit me and then getting punched in the stomach with a closed fist by LPN #120, after the resident was placed in his Geri chair. STNA #152 then failed to immediately report the observed incident of resident abuse thus allowing LPN #120 to continue providing care for her assigned residents. LPN #120 continued providing care for residents after the initial witnessed incident of abuse until she was removed from her assignment at 4:54 P.M. pending an investigation. LPN #120 was terminated on 02/19/19. The Immediate Jeopardy was removed on 02/22/19 when the facility implemented the following corrective actions: · On 02/15/19 at 4:54 P.M., LPN #120 was suspended indefinitely until the facility was able to complete a thorough abuse investigation. · On 02/15/19, all 23 severely cognitively impaired residents had head-to-toe assessments completed by LPN #135 and the DON. There were no negative findings. · On 02/15/19, 49 alert and oriented residents were interviewed for any abuse or if they had witnessed any abuse. The interviews were completed by LPN #135 and the DON. All 49 residents responded No to all the questions. · On 02/15/19 beginning at 6:30 P.M. to 10:00 P.M., the facility in-serviced the nursing staff and nursing assistants on abuse and reporting. The nursing staff and nursing assistants not working were contacted by phone for verbal education. There were no ancillary staff in-serviced. · On 02/15/19, an immediate Quality Assurance (QA) meeting was held to review the facility's corrective action plan. The facility corrective action plan was to in-service the nursing staff on the abuse policy, to run all employees through the Nurse Aide Registry to check for possible abuse or criminal allegations, and to complete weekly questionnaire audits with residents. · On 02/19/19, LPN #120 was terminated from employment. Review of LPN #120's employee personnel file contained a written notice of termination dated 02/19/19. · On 02/22/19, the QA meeting was held to update the plan. The QA committee will review findings after two weeks and determine the need to continue, modify or complete as demonstrated by effectiveness of interventions through the audit process. Staff will continue with skin sweeps and skin observations as care is rendered for signs and symptoms of potential abuse. Notification is to be made to the DON of any suspected abuse or unusual occurrence. Social Services will interview three residents weekly using the abuse questionnaire for four weeks. An audit of staff understanding of the in-service will be completed three times per week for four weeks by the DON. · On 02/22/19, at 3:15 P.M. the Administrator, DON, and Assistant Director of Nursing (ADON) #12 began mandatory staff in-servicing on abuse with the facility's 92 employees. The content of the education included the Abuse Policy, reporting immediately, and the alleged perpetrator needs to be removed immediately from the building pending investigation. All staff were educated before working their next shift. All staff were in-serviced by 7:03 P.M. on 02/22/19 via in person or via telephone. Review of staff sign-in sheets verified the completion of the training. · On 02/22/19, interviews between 5:01 P.M. and 5:08 P.M., with Dietary Assistant (DA) #202, LPN #201 and STNA #221 and on 02/26/19 between 10:18 A.M. and 10:21 A.M., with Housekeeping Assistant (HA) #24, STNA #32 and LPN #79 revealed they were knowledgeable of the facility's abuse policy and reporting requirements for abuse. Although the Immediate Jeopardy was removed on 02/22/19, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Review of the Resident #01's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment, dated 02/09/19, indicated the resident had no or mild cognitive impairment, required extensive assistance with activities of daily living including bed mobility, transferring, dressing, eating, toileting and personal hygiene. The MDS also indicated the resident was assessed to hallucinate. Review of a facility SRI indicated on 02/15/19 at 2:50 P.M., Resident #01 was crawling on the floor. LPN #120 requested assistance from STNA #152. Resident #01 was confused, disoriented and combative. Resident #01 kicked and slapped LPN #120 in the ear. STNA #152 witnessed LPN #120 grab the resident's chin and state, you will not hit me and punch the resident in the stomach. Resident #01 was sent to the emergency room (ER) for evaluation. LPN #120 was sent to the ER for evaluation due to ear bleeding because of being slapped. STNA #152 immediately reported to the Administrator her observations. The facility substantiated abuse when the SRI was finalized. Review of the witness statements within the facility's abuse investigation revealed the following: Review of STNA #152's statement, dated 02/15/19, indicated Resident #01 had been screaming and cussing all day with a lot of confusion. At approximately 2:50 P.M., Resident #01, while yelling, stood up, bent down to the ground and began crawling. LPN #120 tried to get the resident off the floor, from crawling. STNA #152 then assisted LPN #120 to lift the resident back into the chair. While transferring him the resident tried to hit LPN #120. LPN #120 then grabbed the resident's chin saying, you are not going to hit me. The resident tried to bite LPN #120 and then swung and hit LPN #120 in the right side of the head. LPN #120 then punched him in the stomach. Review of LPN #141's witness statement, dated 02/15/19, indicated on 02/15/19 at approximately 2:30 to 2:40 P.M., she heard LPN #120 say Resident #01 was crawling on the floor. LPN #120 yelled for STNA #152 to come help her. LPN #141 stated she observed LPN #120 and STNA #152 pick up the resident and put him back into the Geri chair. There were loud voices between Resident #01 and LPN #120. Resident #01 kicked LPN #120 on the right side of her face. LPN #120 with her right hand, swung it towards the resident. LPN #141 came over to LPN #120 and said, I got it. Then LPN #135 came and started to talk to Resident #01. Then, the Administrator and DON arrived on the unit. Review of LPN #120's witness statement, dated 02/15/19, indicated at approximately 3:00 P.M., Resident #01was observed crawling on the floor after having an attempt to draw blood for laboratory testing and he was very upset. This nurse and STNA #152 went to pick the resident up and he started fighting. He kicked me in the head and grabbed my hand and cut it. It all happened so fast. Review of the hospital records indicated on 02/15/19, Resident #01 was examined in the ER. The chief complaint was aggressive behavior. The resident was found to have abrasions and skin tears to bilateral forearms. No abdomen tenderness was noted. The resident was found to have malignant otitis externa (infection of the ear canal), treated with antibiotics. Review of a progress noted dated 02/19/19, as a late entry for 02/15/19 at 2:50 P.M., indicated the resident had slapped a staff nurse. The resident was hallucinating. The resident was not alert or oriented. The resident was refusing laboratory work and x-rays that day and the previous day. The resident was screaming and not in touch with reality. The resident was assessed for vital signs and they were found within normal limits. The resident had two skin tears, measuring two centimeters by two centimeters. The site was cleansed, and a dressing applied. The physician was called and ordered the resident sent to the ER. During an interview with the Administrator on 02/22/19 at 8:01 A.M. revealed the facility had submitted an SRI related to an incident on 02/15/19 involving Resident #01 and LPN #120. The Administrator stated, the resident had hollered out during a behavior that, she is beating me up. The Administrator verified STNA #125 reported around 3:30 P.M. an allegation of abuse. The Administrator verified the facility substantiated abuse after an investigation. LPN #120 was then terminated on 02/19/19 after the investigation. Interview on 02/22/19 at 9:41 A.M. with LPN #135 revealed Resident #01 is a [MEDICAL CONDITION] patient, always agitated and hallucinates. He was having increased agitation and falls. Around 2:30 P.M., she went out of her office a couple of times to see Resident #01 in the lobby area. He was using foul language and trying to stand. She heard LPN #120 say, You need to sit. Around 3:30 P.M., she heard a loud slap. STNA #152 said the resident slapped LPN #120 in the head. LPN #120 was walking back to her cart. He was yelling, they are just a bunch of wife beaters around here. He was crying. The DON came out and sat with him and LPN #135 went back into her office. She was not sure what happened right after that. He was just going wild, then he got much wilder. At 2:30 P.M., she asked him about his arm. The resident's arm looked like someone had grabbed it. Then someone called 911. He was extremely agitated and crying. As soon as the DON found out LPN #120 had hit the resident, the DON got LPN #120 out of the building. LPN #135 went with the DON to get LPN #120 and LPN #120 was in the room with Resident #23 providing care. Interview with STNA #152 on 02/22/19 at 10:10 A.M., revealed on the day of the incident, Resident #01 was not acting right. He was usually mouthy and disrespectful, but it was like he was somewhere else. STNA #152 stated she was working on the 600 Hall near the 500 Hall. Both LPN #141 and LPN #120, were in the kitchenette/medication room. Resident #01 was in a Geri chair in front of the door to the 400 Hall. He was trying to get up from the Geri chair. He was in the Geri chair because he wanted to lay down, but he was too agitated. Normally he is in a regular wheelchair. When he got up, he took two to three steps and then he bent down and started crawling on the floor. He maybe crawled a foot or two. STNA #152 stated she told him to sit down and calm down. She told LPN #120 he was crawling on the floor so she came out and went right to him. By herself, without help, she put one arm around him and attempted to lift him up. STNA #152 told her to hold on, she would help. STNA #152 went to put on gloves because he had band-aides on his arms. STNA #152 went over and got on his left side and together, we put him back in the chair. LPN #120 was holding Resident #01's right arm and he tried to hit her. LPN #120 grabbed his chin and started shaking it and said, you are not going to hit me. Then Resident #01 tried to bite LPN #120. At that point, STNA #152 let go of his left arm. Resident #01 was in his chair and was trying to hit and kick. Then there was a slapping noise and LPN #120's ear was bright red. After LPN #120 got hit, LPN #120 punched Resident #01 in the stomach. Resident #01 was laying down in the Geri chair. Resident #01 was yelling, and LPN #120's hand was bleeding. Immediately after LPN #120 punched Resident #01, she walked away and went into the kitchenette/medication room. STNA #152 stated LPN #120 could have stepped back instead of punching him. Resident #01 was in his chair before she grabbed his chin. LPN #120 hit him in the right lower stomach area with a closed fist. STNA #152 stated she was in shock, had tunnel vision and went to the bathroom for a couple minutes to calm herself down. Then STNA #152 went to assist another resident get into her wheelchair. When STNA #152 came back there were two paramedics and a police officer at the facility. They were here to transport Resident #01 to the hospital. The Administrator and DON were there. After Resident #01 left, STNA #152 went to the Administrator and told her about LPN #120 hitting Resident #01. STNA #152 stated she felt very uncomfortable and did not really want everyone to know she was reporting it. STNA #152 stated she worked with LPN #120 a lot and she was nice. Interview via telephone on 02/22/19 at 10:35 A.M. with LPN #120 revealed she had worked on the night of the incident and Resident #01 had fallen. His medications had been changed and the doctor added more medication. Resident #01 was just out of it and was sitting up in a Geri chair. Resident #01 was yelling, cursing and hollering about a train coming through the dining room. Resident #01 then began crawling across the floor. LPN #120 stated she called the aide to help her. LPN #120 stated when she had her arm under his arm, the resident started biting her hand. Resident #01 then kicked her in the head. LPN #120 stated she had blood on her hand and does not remember what she did after that. LPN #120 stated she was told she hit Resident #01 but does not remember it. LPN #120 stated all she remembers is after he kicked her in the head, she had blood on her hand, so she went to wash her hands. LPN #120 stated she then started her medication pass. Interview on 02/22/19 at 12:33 P.M. with Medical Director #01 revealed when the facility first admitted Resident #01, he was very aggressive, agitated and was hitting staff. The facility was medicating him to decrease his aggressiveness, but he then became very sleepy and had falls. Therefore, the decision to cut back on the medications was made. Interview on 02/22/19 at 12:48 P.M. with LPN #141 revealed she was working on the jammed facsimile machine, when she heard LPN #120 yell for STNA #152's help. By the time LPN #141 got to them, LPN #120 and STNA #152 had Resident #01 in the Geri chair. Resident #01 and LPN #120 were yelling. LPN #141 stated she observed Resident #01 hit LPN #120 in the right ear. LPN #141 was not sure if LPN #120 took a step back or if LPN #120 was pushed back, but then her right hand went up to her face and her arm went down towards Resident #01's abdomen. LPN #141 stated she did not see LPN #120's hand make contact and/or hit the resident. The motion was a downward motion like it could have been a hitting motion. It all happened so fast. LPN #141 stated she did not know if or where LPN #120's hand hit Resident #01. Interview on 02/26/19 at 8:58 A.M. with the DON revealed at 3:00 P.M. on 02/15/19, she was sent a text message by LPN #135 telling the DON that Resident #01 was being combative and it was very chaotic. The resident had torn off his cushion of the Geri chair. Everyone was trying to get him to calm down. He was bleeding and had skin tears. Everything was going on very quickly. The DON tried to talk to Resident #01 and he was not able to say anything. Resident #01 was very upset, and his sentences did not make sense. Resident #01 told the Administrator, He was roughed up. He never named anyone specifically. The Administrator called 911 after the DON asked the Administrator to call. The squad came and transported the resident to the hospital. Afterwards, STNA #152 went to the Administrator and told the Administrator about alleged abuse. The DON was then called to the office and informed of the abuse allegation. The DON stated she did not remember the time. She then immediately went to get LPN #120. LPN #120 was in Resident #23's room talking to him. He also has behaviors and he was trying to take his clothes off. LPN #135 took over his care. Interview on 02/26/19 at 5:30 P.M. with Regional Director of Clinical Operations #800 indicated the facility's abuse policy stated all allegations of abuse should be reported to the employee's supervisor immediately. Regional Director of Clinical Operations #800 verified the facility did not follow their policy when STNA #152 failed to immediately report the observed incident of resident abuse when LPN #120 abused a resident. Interview on 02/27/19 at 12:40 P.M. with Resident #01 indicated the resident did not remember everything that happened before he was sent out to the hospital on [DATE]. Resident #01 stated he remembered being mean to folks by talking hard to them. He stated it was because of his medicines. He remembered the staff holding him to keep him from hurting someone or myself. Resident #01 did not remember hitting anyone or being hit but he remembered the female worker mauling his arm with her fingernails. He stated the worker has since been fired, he feels safe here now and is glad to be back. Review of the facility's policy, Freedom from Abuse, Neglect and Exploitation, revised 11/2018 indicated Residents must not be subjected to abuse by anyone, including, but not limited to; facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family member or legal guardians, friend and/or other individuals. The policy stated any allegations of abuse/injuries of unknown origin will be reported to the employee's supervisor without fear of reprisal and the supervisor will report to the Administrator immediately. Upon knowledge of any reported concern, the facility will provide for the immediate safety of the resident, suspend suspected employee(s) pending the outcome of the investigation. This deficiency substantiates Complaint Number OH 758.

Based on review of medical records, interviews with residents and staff, review of employee personnel files, review of facility Self-Reported Incidents (SRI), review of the facility's plan of correction, review of in-service records and review of the facility's abuse policy and procedure, the facility staff failed to implement the abuse policy during the provision of care and services to ensure residents were free from verbal and physical abuse, and immediately report allegations of abuse to the facility's administrator. This resulted in Immediate Jeopardy and the potential for serious injury for one resident (#01) when he was observed by State tested Nursing Assistant (STNA) #152 having his chin grabbed and shook by Licensed Practical Nurse (LPN) #120 while stating you are not going to hit me and then getting punched in the stomach with a closed fist by LPN #120, after the resident was placed in his Geri chair. STNA #152 failed to immediately report the observed incident of staff to resident abuse thus allowing LPN #120 to continue providing care for her assigned residents. This affected one (#01) of three residents reviewed for abuse and placed 18 additional residents (#18, #23, #29, #31, #34, #36, #40, #42, #44, #49, #51, #55, #62, #63, #73, #75, #78 and #83) at risk for the likelihood of serious harm or injury who were assigned LPN #120 as their care giver. Additionally, two other staff members (LPN #250 and Maintenance Assistant #300) failed to immediately report a witnessed resident to resident physical altercation to the facility administrator, that did not rise to the level of Immediate Jeopardy, when Resident #06 attempted to pull off Resident #04's oxygen tubing and kick and hit the resident. This affected one (#04) of three residents reviewed for abuse. On 02/22/19 at 2:40 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 02/15/19 at 2:57 P.M., when STNA #152 observed Resident #01 having his chin grabbed and shook by LPN #120 while stating you are not going to hit me and then getting punched in the stomach with a closed fist by LPN #120, after the resident was placed in his Geri chair. STNA #152 then failed to immediately report the observed incident of resident abuse thus allowing LPN #120 to continue providing care for her assigned residents. LPN #120 continued providing care for residents after the initial witnessed incident of abuse until she was removed from her assignment at 4:54 P.M., pending an investigation. LPN #120 was terminated from employment on 02/19/19. The Immediate Jeopardy was removed on 02/22/19 when the facility implemented the following corrective actions: · On 02/15/19 at 4:54 P.M., LPN #120 was suspended indefinitely until the facility was able to complete a thorough abuse investigation. · On 02/15/19, all 23 cognitively impaired residents had head-to-toe assessments completed by LPN #135 and the DON. There were no negative findings. · On 02/15/19, 49 alert and oriented residents were interviewed for any abuse or if they had witnessed any abuse. The interviews were completed by LPN #135 and the DON. All 49 residents responded No to all the questions. · On 02/15/19 beginning at 6:30 P.M. to 10:00 P.M., the facility in-serviced the nursing staff and nursing assistants on abuse and reporting. The nursing staff and nursing assistants not working were contacted by phone for verbal education. There were no ancillary staff in-serviced. · On 02/15/19, an immediate Quality Assurance (QA) meeting was held to review the facility's corrective action plan. The facility corrective action plan was to in-service the nursing staff on the abuse policy, to run all employees through the Nurse Aide Registry to check for possible abuse or criminal allegations, and to complete weekly questionnaire audits with residents. · On 02/19/19, LPN #120 was terminated from employment. Review of LPN #120's employee personnel file contained a written notice of termination dated 02/19/19. · On 02/22/19, the QA meeting was held to update the plan. The QA committee will review findings after two weeks and determine the need to continue, modify or complete as demonstrated by effectiveness of interventions through the audit process. Staff will continue with skin sweeps and skin observations as care is rendered for signs and symptoms of potential abuse. Notification is to be made to the DON of any suspected abuse or unusual occurrence. Social Services will interview three residents weekly using the abuse questionnaire for four weeks. An audit of staff understanding of the in-service will be completed three times per week for four weeks by the DON. · On 02/22/19, at 3:15 P.M. the Administrator, DON, and Assistant Director of Nursing (ADON) #12 began mandatory staff in-servicing on abuse with the facility's 92 employees. The content of the education included the Abuse Policy, reporting immediately, and the alleged perpetrator needs to be removed immediately from the building pending investigation. All staff were educated before working their next shift. All staff were in-serviced by 7:03 P.M. on 02/22/19 via in person or via telephone. Review of staff sign-in sheets verified the completion of the training. · On 02/22/19, interviews between 5:01 P.M. and 5:08 P.M., with Dietary Assistant (DA) #202, LPN #201 and STNA #221 and on 02/26/19 between 10:18 A.M. and 10:21 A.M., with Housekeeping Assistant (HA) #24, STNA #32 and LPN #79 revealed they were knowledgeable of the facility's abuse policy and reporting requirements for abuse. Although the Immediate Jeopardy was removed on 02/22/19, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: 1. Review of the Resident #01's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment, dated 02/09/19, indicated the resident had no or mild cognitive impairment, required extensive assistance with activities of daily living including bed mobility, transferring, dressing, eating, toileting and personal hygiene. The MDS also indicated the resident was assessed to hallucinate. Review of a facility SRI indicated on 02/15/19 at 2:50 P.M., Resident #01 was crawling on the floor. LPN #120 requested assistance from STNA #152. Resident #01 was confused, disoriented and combative. Resident #01 kicked and slapped LPN #120 in the ear. STNA #152 witnessed LPN #120 grab the resident's chin and state, you will not hit me and punch the resident in the stomach. Resident #01 was sent to the emergency room (ER) for evaluation. LPN #120 was sent to the ER for evaluation due to ear bleeding because of being slapped. STNA #152 immediately reported to the Administrator her observations. The facility substantiated abuse when the SRI was finalized. Review of the witness statements within the facility's abuse investigation revealed the following: Review of STNA #152's statement, dated 02/15/19, indicated Resident #01 had been screaming and cussing all day with a lot of confusion. At approximately 2:50 P.M., Resident #01, while yelling, stood up, bent down to the ground and began crawling. LPN #120 tried to get the resident off the floor, from crawling. STNA #152 then assisted LPN #120 to lift the resident back into the chair. While transferring him the resident tried to hit LPN #120. LPN #120 then grabbed the resident's chin saying, you are not going to hit me. The resident tried to bite LPN #120 and then swung and hit LPN #120 in the right side of the head. LPN #120 then punched him in the stomach. Review of LPN #141's witness statement, dated 02/15/19, indicated on 02/15/19 at approximately 2:30 to 2:40 P.M., she heard LPN #120 say Resident #01 was crawling on the floor. LPN #120 yelled for STNA #152 to come help her. LPN #141 stated she observed LPN #120 and STNA #152 pick up the resident and put him back into the Geri chair. There were loud voices between Resident #01 and LPN #120. Resident #01 kicked LPN #120 on the right side of her face. LPN #120 with her right hand, swung it towards the resident. LPN #141 came over to LPN #120 and said, I got it. Then LPN #135 came and started to talk to Resident #01. Then, the Administrator and DON arrived on the unit. Review of LPN #120's witness statement, dated 02/15/19, indicated at approximately 3:00 P.M., Resident #01was observed crawling on the floor after having an attempt to draw blood for laboratory testing and he was very upset. This nurse and STNA #152 went to pick the resident up and he started fighting. He kicked me in the head and grabbed my hand and cut it. It all happened so fast. Review of the hospital records indicated on 02/15/19, Resident #01 was examined in the ER. The chief complaint was aggressive behavior. The resident was found to have abrasions and skin tears to bilateral forearms. No abdomen tenderness was noted. The resident was found to have malignant otitis externa (infection of the ear canal), treated with antibiotics. Review of a progress noted dated 02/19/19, as a late entry for 02/15/19 at 2:50 P.M., indicated the resident had slapped a staff nurse. The resident was hallucinating. The resident was not alert or oriented. The resident was refusing laboratory work and x-rays that day and the previous day. The resident was screaming and not in touch with reality. The resident was assessed for vital signs and they were found within normal limits. The resident had two skin tears, measuring two centimeters by two centimeters. The site was cleansed, and a dressing applied. The physician was called and ordered the resident sent to the ER. During an interview with the Administrator on 02/22/19 at 8:01 A.M. revealed the facility had submitted an SRI related to an incident on 02/15/19 involving Resident #01 and LPN #120. The Administrator stated, the resident had hollered out during a behavior that, she is beating me up. The Administrator verified STNA #125 reported around 3:30 P.M. an allegation of abuse. The Administrator verified the facility substantiated abuse after an investigation. LPN #120 was then terminated on 02/19/19 after the investigation. Interview on 02/22/19 at 9:41 A.M. with LPN #135 revealed Resident #01 is a [MEDICAL CONDITION] patient, always agitated and hallucinates. He was having increased agitation and falls. Around 2:30 P.M., she left her office a couple of times to see Resident #01 in the lobby. He was using foul language and trying to stand. She heard LPN #120 say, You need to sit. Around 3:30 P.M., she heard a loud slap. STNA #152 said the resident slapped LPN #120 in the head. LPN #120 was walking back to her cart. He was yelling, they are just a bunch of wife beaters around here. He was crying. The DON came out and sat with him and LPN #135 went back into her office. She was not sure what happened right after that. He was just going wild, then he got much wilder. At 2:30 P.M., she asked him about his arm. The resident's arm looked like someone had grabbed it. Then someone called 911. He was extremely agitated and crying. As soon as the DON found out LPN #120 had hit the resident, the DON got LPN #120 out of the building. LPN #135 went with the DON to get LPN #120 and LPN #120 was in the room with Resident #23 providing care. Interview with STNA #152 on 02/22/19 at 10:10 A.M., revealed on the day of the incident, Resident #01 was not acting right. He was usually mouthy and disrespectful, but it was like he was somewhere else. STNA #152 stated she was working on the 600 Hall near the 500 Hall. Both LPN #141 and LPN #120, were in the kitchenette/medication room. Resident #01 was in a Geri chair in front of the door to the 400 Hall. He was trying to get up from the Geri chair. He was in the Geri chair because he wanted to lay down, but he was too agitated. Normally he is in a regular wheelchair. When he got up, he took two to three steps and then he bent down and started crawling on the floor. He maybe crawled a foot or two. STNA #152 stated she told him to sit down and calm down. She told LPN #120 he was crawling on the floor so she came out and went right to him. By herself, without help, she put one arm around him and attempted to lift him up. STNA #152 told her to hold on, she would help. STNA #152 went to put on gloves because he had band-aides on his arms. STNA #152 went over and got on his left side and together, we put him back in the chair. LPN #120 was holding Resident #01's right arm and he tried to hit her. LPN #120 grabbed his chin and started shaking it and said, you are not going to hit me. Then Resident #01 tried to bite LPN #120. At that point, STNA #152 let go of his left arm. Resident #01 was in his chair and was trying to hit and kick. Then there was a slapping noise and LPN #120's ear was bright red. After LPN #120 got hit, LPN #120 punched Resident #01 in the stomach. Resident #01 was laying down in the Geri chair. Resident #01 was yelling, and LPN #120's hand was bleeding. Immediately after LPN #120 punched Resident #01, she walked away and went into the kitchenette/medication room. STNA #152 stated LPN #120 could have stepped back instead of punching him. Resident #01 was in his chair before she grabbed his chin. LPN #120 hit him in the right lower stomach area with a closed fist. STNA #152 stated she was in shock, had tunnel vision and went to the bathroom for a couple minutes to calm herself down. Then STNA #152 went to assist another resident get into her wheelchair. When STNA #152 came back there were two paramedics and a police officer at the facility. They were here to transport Resident #01 to the hospital. The Administrator and DON were there. After Resident #01 left, STNA #152 went to the Administrator and told her about LPN #120 hitting Resident #01. STNA #152 stated she felt very uncomfortable and did not really want everyone to know she was reporting it. STNA #152 stated she worked with LPN #120 a lot and she was nice. Interview via telephone on 02/22/19 at 10:35 A.M. with LPN #120 revealed she had worked on the night of the incident and Resident #01 had fallen. His medications had been changed and the doctor added more medication. Resident #01 was just out of it and was sitting up in a Geri chair. Resident #01 was yelling, cursing and hollering about a train coming through the dining room. Resident #01 then began crawling across the floor. LPN #120 stated she called the aide to help her. LPN #120 stated when she had her arm under his arm, the resident started biting her hand. Resident #01 then kicked her in the head. LPN #120 stated she had blood on her hand and does not remember what she did after that. LPN #120 stated she was told she hit Resident #01 but does not remember it. LPN #120 stated all she remembers is after he kicked her in the head, she had blood on her hand, so she went to wash her hands. LPN #120 stated she then started her medication pass. Interview on 02/22/19 at 12:33 P.M. with Medical Director #01 revealed when the facility first admitted Resident #01, he was very aggressive, agitated and was hitting staff. The facility was medicating him to decrease his aggressiveness, but he then became very sleepy and had falls. Therefore, the decision to cut back on the medications was made. Interview on 02/22/19 at 12:48 P.M. with LPN #141 revealed she was working on the jammed facsimile machine, when she heard LPN #120 yell for STNA #152's help. By the time LPN #141 got to them, LPN #120 and STNA #152 had Resident #01 in the Geri chair. Resident #01 and LPN #120 were yelling. LPN #141 stated she observed Resident #01 hit LPN #120 in the right ear. LPN #141 was not sure if LPN #120 took a step back or if LPN #120 was pushed back, but then her right hand went up to her face and her arm went down towards Resident #01's abdomen. LPN #141 stated she did not see LPN #120's hand make contact and/or hit the resident. The motion was a downward motion like it could have been a hitting motion. It all happened so fast. LPN #141 stated she did not know if or where LPN #120's hand hit Resident #01. Interview on 02/26/19 at 8:58 A.M. with the DON revealed at 3:00 P.M. on 02/15/19, she was sent a text message by LPN #135 telling the DON that Resident #01 was being combative and it was very chaotic. The resident had torn off his cushion of the Geri chair. Everyone was trying to get him to calm down. He was bleeding and had skin tears. Everything was going on very quickly. The DON tried to talk to Resident #01 and he was not able to say anything. Resident #01 was very upset, and his sentences did not make sense. Resident #01 told the Administrator, He was roughed up. He never named anyone specifically. The Administrator called 911 after the DON asked the Administrator to call. The squad came and transported the resident to the hospital. Afterwards, STNA #152 went to the Administrator and told the Administrator about alleged abuse. The DON was then called to the office and informed of the abuse allegation. The DON stated she did not remember the time. She then immediately went to get LPN #120. LPN #120 was in Resident #23's room talking to him. He also has behaviors and he was trying to take his clothes off. LPN #135 took over his care. Interview on 02/26/19 at 5:30 P.M. with Regional Director of Clinical Operations #800 indicated the facility's abuse policy stated all allegations of abuse should be reported to the employee's supervisor immediately. Regional Director of Clinical Operations #800 verified the facility did not follow their policy when STNA #152 failed to immediately report the observed incident of resident abuse when LPN #120 abused a resident. Interview on 02/27/19 at 12:40 P.M. with Resident #01 indicated the resident did not remember everything that happened before he was sent out to the hospital on [DATE]. Resident #01 stated he remembered being mean to folks by talking hard to them. He stated it was because of his medicines. He remembered the staff holding him to keep him from hurting someone or myself. Resident #01 did not remember hitting anyone or being hit but he remembered the female worker mauling his arm with her fingernails. He stated the worker has since been fired, he feels safe here now and is glad to be back. 2. Review of Resident #04's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the resident's MDS assessment, dated 01/20/19, indicated the resident had no or mild cognitive impairment and required limited assistance with activities of daily living including bed mobility, transferring and extensive assistance with toileting and personal hygiene. The resident was independent with locomotion. Review of a facility SRI dated 01/28/19, indicated on 01/24/19 time unclear, there was a resident to resident interaction when Resident #06 was attempting to kick, hit and pull off Resident #04's oxygen tubing. Resident #04 yelled, Get away. Stop pulling that! and LPN #250 came over and separated the two residents. MA #300 witnessed the incident between the residents. The SRI further indicates the Administrator was not aware of the incident until on 01/28/19 when the resident's guardian called to report that Resident #04 had told the guardian that Resident #06 pulled off her oxygen tubing, and kicked and hit her. The incident was not reported to the Administrator because Resident #04 insisted nursing not report it. During an interview on 02/26/19 at 9:45 A.M., Resident #04 stated a couple weeks ago she had to holler for help when Resident #06 grabbed her oxygen tubing. Resident #04 stated the staff came quickly and got him. Interview on 02/26/19 at 10:50 A.M. with Regional Director of Clinical Operations #525 verified the staff had not immediately reported the witnessed physical altercation between the two residents to their supervisors/administrator and verified the facility did not follow their abuse policy. Review of the facility's policy, Freedom from Abuse, Neglect and Exploitation, revised 11/2018 indicated Residents must not be subjected to abuse by anyone, including, but not limited to; facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family member or legal guardians, friend and/or other individuals. The policy stated any allegations of abuse/injuries of unknow origin will be reported to the employee's supervisor without fear of reprisal and the supervisor will report to the Administrator immediately. Upon knowledge of any reported concern, the facility will provide for the immediate safety of the resident, suspend suspected employee(s) pending the outcome of the investigation. This deficiency substantiates Complaint Number OH 758.

Based on review of medical records, interviews with residents and staff, review of employee personnel files, review of facility Self-Reported Incidents (SRI), review of the facility's plan of correction, review of in-service records and review of the facility's abuse policy and procedure, the facility staff failed to immediately report a witnessed incident of physical abuse to the administrator of the facility. This resulted in Immediate Jeopardy and the potential for serious injury for one resident (#01) when he was observed by State tested Nursing Assistant (STNA) #152 having his chin grabbed and shook by Licensed Practical Nurse (LPN) #120 while stating you are not going to hit me and then getting punched in the stomach with a closed fist by LPN #120, after the resident was placed in his Geri chair. STNA #152 failed to immediately report the observed incident of staff to resident abuse thus allowing LPN #120 to continue providing care for her assigned residents. This affected one (#01) of three residents reviewed for abuse and placed 18 additional residents (#18, #23, #29, #31, #34, #36, #40, #42, #44, #49, #51, #55, #62, #63, #73, #75, #78 and #83) at risk for the likelihood of serious harm or injury who were assigned LPN #120 as their care giver. Additionally, two other staff members (LPN #250 and Maintenance Assistant #300) failed to immediately report a witnessed resident to resident physical altercation to the facility administrator, that did not rise to the level of Immediate Jeopardy, when Resident #06 attempted to pull off Resident #04's oxygen tubing and kick and hit the resident. This affected one (#04) of three residents reviewed for abuse. On 02/22/19 at 2:40 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 02/15/19 at 2:57 P.M., when STNA #152 observed Resident #01 having his chin grabbed and shook by LPN #120 while stating you are not going to hit me and then getting punched in the stomach with a closed fist by LPN #120, after the resident was placed in his Geri chair. STNA #152 then failed to immediately report the observed incident of resident abuse thus allowing LPN #120 to continue providing care for her assigned residents. LPN #120 continued providing care for residents after the initial witnessed incident of abuse until she was removed from her assignment at 4:54 P.M., pending an investigation. LPN #120 was terminated from employment on 02/19/19. The Immediate Jeopardy was removed on 02/22/19 when the facility implemented the following corrective actions: · On 02/15/19 at 4:54 P.M., LPN #120 was suspended indefinitely until the facility was able to complete a thorough abuse investigation. · On 02/15/19, all 23 cognitively impaired residents had head-to-toe assessments completed by LPN #135 and the DON. There were no negative findings. · On 02/15/19, 49 alert and oriented residents were interviewed for any abuse or if they had witnessed any abuse. The interviews were completed by LPN #135 and the DON. All 49 residents responded No to all the questions. · On 02/15/19 beginning at 6:30 P.M. to 10:00 P.M., the facility in-serviced the nursing staff and nursing assistants on abuse and reporting. The nursing staff and nursing assistants not working were contacted by phone for verbal education. There were no ancillary staff in-serviced. · On 02/15/19, an immediate Quality Assurance (QA) meeting was held to review the facility's corrective action plan. The facility corrective action plan was to in-service the nursing staff on the abuse policy, to run all employees through the Nurse Aide Registry to check for possible abuse or criminal allegations, and to complete weekly questionnaire audits with residents. · On 02/19/19, LPN #120 was terminated from employment. Review of LPN #120's employee personnel file contained a written notice of termination dated 02/19/19. · On 02/22/19, the QA meeting was held to update the plan. The QA committee will review findings after two weeks and determine the need to continue, modify or complete as demonstrated by effectiveness of interventions through the audit process. Staff will continue with skin sweeps and skin observations as care is rendered for signs and symptoms of potential abuse. Notification is to be made to the DON of any suspected abuse or unusual occurrence. Social Services will interview three residents weekly using the abuse questionnaire for four weeks. An audit of staff understanding of the in-service will be completed three times per week for four weeks by the DON. · On 02/22/19, at 3:15 P.M. the Administrator, DON, and Assistant Director of Nursing (ADON) #12 began mandatory staff in-servicing on abuse with the facility's 92 employees. The content of the education included the Abuse Policy, reporting immediately, and the alleged perpetrator needs to be removed immediately from the building pending investigation. All staff were educated before working their next shift. All staff were in-serviced by 7:03 P.M. on 02/22/19 via in person or via telephone. Review of staff sign-in sheets verified the completion of the training. · On 02/22/19, interviews between 5:01 P.M. and 5:08 P.M., with Dietary Assistant (DA) #202, LPN #201 and STNA #221 and on 02/26/19 between 10:18 A.M. and 10:21 A.M., with Housekeeping Assistant (HA) #24, STNA #32 and LPN #79 revealed they were knowledgeable of the facility's abuse policy and reporting requirements for abuse. Although the Immediate Jeopardy was removed on 02/22/19, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: 1. Review of the Resident #01's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment, dated 02/09/19, indicated the resident had no or mild cognitive impairment, required extensive assistance with activities of daily living including bed mobility, transferring, dressing, eating, toileting and personal hygiene. The MDS also indicated the resident was assessed to hallucinate. Review of a facility SRI indicated on 02/15/19 at 2:50 P.M., Resident #01 was crawling on the floor. LPN #120 requested assistance from STNA #152. Resident #01 was confused, disoriented and combative. Resident #01 kicked and slapped LPN #120 in the ear. STNA #152 witnessed LPN #120 grab the resident's chin and state, you will not hit me and punch the resident in the stomach. Resident #01 was sent to the emergency room (ER) for evaluation. LPN #120 was sent to the ER for evaluation due to ear bleeding because of being slapped. STNA #152 immediately reported to the Administrator her observations. The facility substantiated abuse when the SRI was finalized. Review of the witness statements within the facility's abuse investigation revealed the following: Review of STNA #152's statement, dated 02/15/19, indicated Resident #01 had been screaming and cussing all day with a lot of confusion. At approximately 2:50 P.M., Resident #01, while yelling, stood up, bent down to the ground and began crawling. LPN #120 tried to get the resident off the floor, from crawling. STNA #152 then assisted LPN #120 to lift the resident back into the chair. While transferring him the resident tried to hit LPN #120. LPN #120 then grabbed the resident's chin saying, you are not going to hit me. The resident tried to bite LPN #120 and then swung and hit LPN #120 in the right side of the head. LPN #120 then punched him in the stomach. Review of LPN #141's witness statement, dated 02/15/19, indicated on 02/15/19 at approximately 2:30 to 2:40 P.M., she heard LPN #120 say Resident #01 was crawling on the floor. LPN #120 yelled for STNA #152 to come help her. LPN #141 stated she observed LPN #120 and STNA #152 pick up the resident and put him back into the Geri chair. There were loud voices between Resident #01 and LPN #120. Resident #01 kicked LPN #120 on the right side of her face. LPN #120 with her right hand, swung it towards the resident. LPN #141 came over to LPN #120 and said, I got it. Then LPN #135 came and started to talk to Resident #01. Then, the Administrator and DON arrived on the unit. Review of LPN #120's witness statement, dated 02/15/19, indicated at approximately 3:00 P.M., Resident #01was observed crawling on the floor after having an attempt to draw blood for laboratory testing and he was very upset. This nurse and STNA #152 went to pick the resident up and he started fighting. He kicked me in the head and grabbed my hand and cut it. It all happened so fast. Review of the hospital records indicated on 02/15/19, Resident #01 was examined in the ER. The chief complaint was aggressive behavior. The resident was found to have abrasions and skin tears to bilateral forearms. No abdomen tenderness was noted. The resident was found to have malignant otitis externa (infection of the ear canal), treated with antibiotics. Review of a progress noted dated 02/19/19, as a late entry for 02/15/19 at 2:50 P.M., indicated the resident had slapped a staff nurse. The resident was hallucinating. The resident was not alert or oriented. The resident was refusing laboratory work and x-rays that day and the previous day. The resident was screaming and not in touch with reality. The resident was assessed for vital signs and they were found within normal limits. The resident had two skin tears, measuring two centimeters by two centimeters. The site was cleansed, and a dressing applied. The physician was called and ordered the resident sent to the ER. During an interview with the Administrator on 02/22/19 at 8:01 A.M. revealed the facility had submitted an SRI related to an incident on 02/15/19 involving Resident #01 and LPN #120. The Administrator stated, the resident had hollered out during a behavior that, she is beating me up. The Administrator verified STNA #125 reported around 3:30 P.M. an allegation of abuse. The Administrator verified the facility substantiated abuse after an investigation. LPN #120 was then terminated on 02/19/19 after the investigation. Interview on 02/22/19 at 9:41 A.M. with LPN #135 revealed Resident #01 is a [MEDICAL CONDITION] patient, always agitated and hallucinates. He was having increased agitation and falls. Around 2:30 P.M., she left her office a couple of times to see Resident #01 in the lobby. He was using foul language and trying to stand. She heard LPN #120 say, You need to sit. Around 3:30 P.M., she heard a loud slap. STNA #152 said the resident slapped LPN #120 in the head. LPN #120 was walking back to her cart. He was yelling, they are just a bunch of wife beaters around here. He was crying. The DON came out and sat with him and LPN #135 went back into her office. She was not sure what happened right after that. He was just going wild, then he got much wilder. At 2:30 P.M., she asked him about his arm. The resident's arm looked like someone had grabbed it. Then someone called 911. He was extremely agitated and crying. As soon as the DON found out LPN #120 had hit the resident, the DON got LPN #120 out of the building. LPN #135 went with the DON to get LPN #120 and LPN #120 was in the room with Resident #23 providing care. Interview with STNA #152 on 02/22/19 at 10:10 A.M., revealed on the day of the incident, Resident #01 was not acting right. He was usually mouthy and disrespectful, but it was like he was somewhere else. STNA #152 stated she was working on the 600 Hall near the 500 Hall. Both LPN #141 and LPN #120, were in the kitchenette/medication room. Resident #01 was in a Geri chair in front of the door to the 400 Hall. He was trying to get up from the Geri chair. He was in the Geri chair because he wanted to lay down, but he was too agitated. Normally he is in a regular wheelchair. When he got up, he took two to three steps and then he bent down and started crawling on the floor. He maybe crawled a foot or two. STNA #152 stated she told him to sit down and calm down. She told LPN #120 he was crawling on the floor so she came out and went right to him. By herself, without help, she put one arm around him and attempted to lift him up. STNA #152 told her to hold on, she would help. STNA #152 went to put on gloves because he had band-aides on his arms. STNA #152 went over and got on his left side and together, we put him back in the chair. LPN #120 was holding Resident #01's right arm and he tried to hit her. LPN #120 grabbed his chin and started shaking it and said, you are not going to hit me. Then Resident #01 tried to bite LPN #120. At that point, STNA #152 let go of his left arm. Resident #01 was in his chair and was trying to hit and kick. Then there was a slapping noise and LPN #120's ear was bright red. After LPN #120 got hit, LPN #120 punched Resident #01 in the stomach. Resident #01 was laying down in the Geri chair. Resident #01 was yelling, and LPN #120's hand was bleeding. Immediately after LPN #120 punched Resident #01, she walked away and went into the kitchenette/medication room. STNA #152 stated LPN #120 could have stepped back instead of punching him. Resident #01 was in his chair before she grabbed his chin. LPN #120 hit him in the right lower stomach area with a closed fist. STNA #152 stated she was in shock, had tunnel vision and went to the bathroom for a couple minutes to calm herself down. Then STNA #152 went to assist another resident get into her wheelchair. When STNA #152 came back there were two paramedics and a police officer at the facility. They were here to transport Resident #01 to the hospital. The Administrator and DON were there. After Resident #01 left, STNA #152 went to the Administrator and told her about LPN #120 hitting Resident #01. STNA #152 stated she felt very uncomfortable and did not really want everyone to know she was reporting it. STNA #152 stated she worked with LPN #120 a lot and she was nice. Interview via telephone on 02/22/19 at 10:35 A.M. with LPN #120 revealed she had worked on the night of the incident and Resident #01 had fallen. His medications had been changed and the doctor added more medication. Resident #01 was just out of it and was sitting up in a Geri chair. Resident #01 was yelling, cursing and hollering about a train coming through the dining room. Resident #01 then began crawling across the floor. LPN #120 stated she called the aide to help her. LPN #120 stated when she had her arm under his arm, the resident started biting her hand. Resident #01 then kicked her in the head. LPN #120 stated she had blood on her hand and does not remember what she did after that. LPN #120 stated she was told she hit Resident #01 but does not remember it. LPN #120 stated all she remembers is after he kicked her in the head, she had blood on her hand, so she went to wash her hands. LPN #120 stated she then started her medication pass. Interview on 02/22/19 at 12:33 P.M. with Medical Director #01 revealed when the facility first admitted Resident #01, he was very aggressive, agitated and was hitting staff. The facility was medicating him to decrease his aggressiveness, but he then became very sleepy and had falls. Therefore, the decision to cut back on the medications was made. Interview on 02/22/19 at 12:48 P.M. with LPN #141 revealed she was working on the jammed facsimile machine, when she heard LPN #120 yell for STNA #152's help. By the time LPN #141 got to them, LPN #120 and STNA #152 had Resident #01 in the Geri chair. Resident #01 and LPN #120 were yelling. LPN #141 stated she observed Resident #01 hit LPN #120 in the right ear. LPN #141 was not sure if LPN #120 took a step back or if LPN #120 was pushed back, but then her right hand went up to her face and her arm went down towards Resident #01's abdomen. LPN #141 stated she did not see LPN #120's hand make contact and/or hit the resident. The motion was a downward motion like it could have been a hitting motion. It all happened so fast. LPN #141 stated she did not know if or where LPN #120's hand hit Resident #01. Interview on 02/26/19 at 8:58 A.M. with the DON revealed at 3:00 P.M. on 02/15/19, she was sent a text message by LPN #135 telling the DON that Resident #01 was being combative and it was very chaotic. The resident had torn off his cushion of the Geri chair. Everyone was trying to get him to calm down. He was bleeding and had skin tears. Everything was going on very quickly. The DON tried to talk to Resident #01 and he was not able to say anything. Resident #01 was very upset, and his sentences did not make sense. Resident #01 told the Administrator, He was roughed up. He never named anyone specifically. The Administrator called 911 after the DON asked the Administrator to call. The squad came and transported the resident to the hospital. Afterwards, STNA #152 went to the Administrator and told the Administrator about alleged abuse. The DON was then called to the office and informed of the abuse allegation. The DON stated she did not remember the time. She then immediately went to get LPN #120. LPN #120 was in Resident #23's room talking to him. He also has behaviors and he was trying to take his clothes off. LPN #135 took over his care. Interview on 02/26/19 at 5:30 P.M. with Regional Director of Clinical Operations #800 indicated the facility's abuse policy stated all allegations of abuse should be reported to the employee's supervisor immediately. Regional Director of Clinical Operations #800 verified the facility did not follow their policy when STNA #152 failed to immediately report the observed incident of resident abuse when LPN #120 abused a resident. Interview on 02/27/19 at 12:40 P.M. with Resident #01 indicated the resident did not remember everything that happened before he was sent out to the hospital on [DATE]. Resident #01 stated he remembered being mean to folks by talking hard to them. He stated it was because of his medicines. He remembered the staff holding him to keep him from hurting someone or myself. Resident #01 did not remember hitting anyone or being hit but he remembered the female worker mauling his arm with her fingernails. He stated the worker has since been fired, he feels safe here now and is glad to be back. 2. Review of Resident #04's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the resident's MDS assessment, dated 01/20/19, indicated the resident had no or mild cognitive impairment and required limited assistance with activities of daily living including bed mobility, transferring and extensive assistance with toileting and personal hygiene. The resident was independent with locomotion. Review of a facility SRI dated 01/28/19, indicated on 01/24/19 time unclear, there was a resident to resident interaction when Resident #06 was attempting to kick, hit and pull off Resident #04's oxygen tubing. Resident #04 yelled, Get away. Stop pulling that! and LPN #250 came over and separated the two residents. MA #300 witnessed the incident between the residents. The SRI further indicates the Administrator was not aware of the incident until on 01/28/19 when the resident's guardian called to report that Resident #04 had told the guardian that Resident #06 pulled off her oxygen tubing, and kicked and hit her. The incident was not reported to the Administrator because Resident #04 insisted nursing not report it. During an interview on 02/26/19 at 9:45 A.M., Resident #04 stated a couple weeks ago she had to holler for help when Resident #06 grabbed her oxygen tubing. Resident #04 stated the staff came quickly and got him. Interview on 02/26/19 at 10:50 A.M. with Regional Director of Clinical Operations #525 verified the staff had not immediately reported the witnessed physical altercation between the two residents to their supervisors/administrator and verified the facility did not follow their abuse policy. Review of the facility's policy, Freedom from Abuse, Neglect and Exploitation, revised 11/2018 indicated Residents must not be subjected to abuse by anyone, including, but not limited to; facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family member or legal guardians, friend and/or other individuals. The policy stated any allegations of abuse/injuries of unknow origin will be reported to the employee's supervisor without fear of reprisal and the supervisor will report to the Administrator immediately. Upon knowledge of any reported concern, the facility will provide for the immediate safety of the resident, suspend suspected employee(s) pending the outcome of the investigation. This deficiency substantiates Complaint Number OH 758.

Based on medical record review, observation, staff interview, review of a personnel file and and policy review, the facility failed to provide a resident with a mechanical lift (hoyer) transfer per the residents care plan. This resulted in Actual Harm when Resident #1 was transferred without the mechanical lift (hoyer) and the resident subsequently sustained [REDACTED].#1) out of three residents reviewed for accidents. The facility identified 14 residents requiring a mechanical lift for transfers with a total census of 77. Findings include: Review of the Resident #1's medical record revealed the resident was admitted [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition, was totally dependent on two staff for transfers, did not ambulate and had no recent falls. Review of the resident's care plan revealed a mechanical lift (hoyer) was initiated on 12/01/16 for all transfers. Review of the Resident Care Card used by the staff revealed the resident was totally dependent on staff for hoyer transfers. Review of the progress note dated 09/22/18 at 12:42 P.M. revealed Licensed Practical Nurse (LPN) #99's was informed that while Resident #1 was transferred from her bed to her wheelchair, the resident's right leg was bent backwards and she sat on her leg. The physician was notified and ordered an X-ray of the leg. The resident's daughter who was her power of attorney (POA) and Registered Nurse (RN) #97 who was the former Director of Nursing (DON) were also notified. The X ray result revealed a right distal femur fracture and the resident went to the hospital the morning of 09/23/18. Review of the hospital notes revealed the resident was treated with intravenous narcotic ([MEDICATION NAME]) due to a closed [MEDICAL CONDITION] femur and leg splinted in a position of comfort. The resident returned to the facility on [DATE] with new physician orders [REDACTED]. Observation of Resident #1 on 10/10/18 at 9:15 A.M. revealed she was sitting up in her bed and appeared clean and comfortable with a splint on her right leg. This resident was not able to provide any information to the surveyor due to her confusion. Interview with the Administrator on 10/10/18 at 12:30 P.M. verified on 09/22/18 at 11:30 A.M. STNA #98 completed an improper transfer by herself with Resident #1 without using the mechanical lift as required. This was an isolated accident that resulted in a right femur fracture for the resident. On 10/10/18 at 2:00 P.M. the surveyor attempted to contact STNA #98 on the phone and the mailbox was full. Review of the employee file for State tested Nursing Assistant (STNA) #98 revealed a hire date of 07/20/16 and was in good standings with the nurse aide registry. Review of STNA #98's personnel file revealed evidence of a competency evaluation for the use of the mechanical lift completed dated 12/01/16 by a nurse indicating this STNA met the criteria for completing appropriate two staff transfers with residents using the mechanical lift with both STNA #98 and nurse signing off on this competency evaluation. Review of STNA #98's statement related to the incident revealed she picked up the resident to do a one person pivot transfer from the bed to the wheelchair and accidentally sat the resident down on top of her leg. Review of the policy titled Lifts- Sit to Stand and Passive Sling Style (hoyer) revised 08/2014 revealed the passive swing style lift (hoyer) may be used by two staff for a resident who was unable to assist with transfers. This deficiency substantiates Complaint Number OH 305.