Every finding on record at Beavercreek Health and Rehab

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure the baseline care plan identified a resident's fall risk and included interventions to reduce the risk of falling. This affected one (#4) of three residents reviewed for falls. The census was 61. Findings include:Review of Resident #4's closed medical record revealed an admission date of 04/06/26. Diagnoses listed included anxiety, hypertension, depression, lung cancer, and seizures. Resident #4 was discharged from the facility on 04/13/26.Review of an admission Minimum Data Set (MDS) dated [DATE] revealed Resident #4 had intact cognition and was dependent on staff for toileting and bathing. Review of a baseline care plan dated 04/06/26 revealed Resident #4 had a history of falls and was at risk. The review also revealed there were no interventions listed regarding Resident #4's fall risk. Review of fall risk assessment dated [DATE] revealed Resident #4 had one to two falls in the past three months and was assessed as being a low risk for falls. Review of progress notes revealed Resident #4 had an unwitnessed fall on 04/13/26 with no apparent injuries. Resident #4 was found on the floor of her room. Interview with the Director of Nursing (DON) on 06/01/26 at 9:08 A.M. confirmed Resident #4 was assessed as being at risk for falling and her baseline care plan did not list any interventions to prevent falls Review of the facility's policy titled Care Plans-Baseline dated 2001 revealed a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident.This deficiency represents non-compliance investigated under Complaint Number 2993131.

Based on observation, resident and staff interview, and policy review, the facility failed to ensure adequate water temperatures throughout the building were maintained. This had the potential to affect all residents. The facility census was 62.Findings included:Observations made throughout the facility on 02/17/26 from 9:00 A.M. to 9:34 A.M. revealed water temperatures measured 99.2 degrees Fahrenheit in the Red spa room. Water temperatures measured above 120 degrees Fahrenheit in resident rooms 105, 108, 205, 216, 307, 308, 310, and 315.During an interview on 02/17/26 at 9:34 A.M., the Director of Maintenance #119 stated water temperatures were expected to be kept between 105 and 120 degrees Fahrenheit throughout the facility.Observations made on 02/18/26 between 4:35 P.M. and 4:52 P.M. revealed the following water temperatures: room [ROOM NUMBER] measured 106 degrees Fahrenheit, room [ROOM NUMBER] measured 116 degrees Fahrenheit, room [ROOM NUMBER] measured 110 degrees Fahrenheit, room [ROOM NUMBER] measured 82 degrees Fahrenheit, room [ROOM NUMBER] measured 52 degrees Fahrenheit, the Red Spa room sink measured 110 degrees Fahrenheit and shower measured 98 degrees Fahrenheit, and the Blue Spa room sink measured 80 degrees Fahrenheit and the shower measured 65 degrees Fahrenheit.During an interview on 02/18/26 at 4:42 P.M. the Certified Nursing Assistant (CNA) #87 verified water temperatures in the Blue Spa Room were not warm enough to provide showers, and stated maintenance had been working on it all day.During an interview on 02/19/26 at 1:32 P.M. Resident #63 said she had staff give her a shower in her room and it was cold. Observations made on 02/19/26 from 1:39 P.M. to 1:42 P.M. revealed the following water temperatures: room [ROOM NUMBER] was 57 degrees Fahrenheit, the Blue Spa room measured 88.1 degrees Fahrenheit in the shower and 82 degrees Fahrenheit in the sink, room [ROOM NUMBER] measured 62 degrees Fahrenheit, room [ROOM NUMBER] measured 59 degrees Fahrenheit.During a follow-up interview on 02/19/26 at 1:42 P.M. the Director of Maintenance #119 verified water temperatures were not consistently maintained within the safe and appropriate temperature range throughout the building.Review of the policy titled, Safety of Water Temperatures dated 12/2009 revealed water supplies to resident rooms, bathrooms, common areas, and tub/shower areas were set to be at temperatures between 105 and 120 degrees Fahrenheit.This deficiency represents noncompliance investigated under Complaint Number 2724861.

Based on record review, review of hospital records, staff interviews, and review of facility policy, the facility failed to ensure a safe transfer via a mechanical Hoyer lift. This resulted in Actual Harm on 12/16/25, when one staff member transferred Resident #63 via Hoyer lift and the Hoyer pad broke causing the resident to fall, which resulted in fractures of her bilateral femurs and a Lumber #1 (L1) fracture to her spine, requiring admission to the hospital for surgical repair to her bilateral femurs. This affected one (Resident #63) of three residents reviewed for accidents. The facility census was 62.Findings include:Review of the medical record for Resident #63 revealed an admission date of 02/27/24 with diagnoses of cerebral palsy, type II diabetes mellitus with diabetic polyneuropathy, morbid (severe) obesity due to excess calories, and hypertensive heart disease with heart failure. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Resident #63 was dependent on staff assistance with toileting hygiene, bathing, dressing, and transfers. Review of the nurse's note dated 12/16/25 at 6:27 P.M. revealed Resident #63 fell from a Hoyer lift due to the Hoyer pad strap breaking. The resident was sent to the emergency room due to complaints of pain. Review of the Interdisciplinary Team (IDT) note dated 12/17/25 at 9:36 A.M. documented Resident #63 was being transferred with a Hoyer lift by two Certified Nursing Assistants (CNAs) #470 and #490 and fell from the Hoyer when the Hoyer strap broke. Review of the hospital documentation dated 12/21/25 revealed Resident #63 admitted from a different hospital after a fall from a Hoyer Lift on 12/16/25 resulting in bilateral femur fractures and L1 compression fracture. On 12/17/25, the resident had surgical procedures to the right distal femur and closed treatment to the left nondisplaced distal femur fracture. X-rays ordered for a sitting up lumbar region for the L1 compression fracture. Interview on 12/21/25 at 11:40 A.M. with Licensed Practical Nurse (LPN) #444 confirmed the Hoyer pads were falling apart prior to Resident #63's fall last week. LPN #444 stated staff had reported their concerns for months to administration, but nothing was done until the fall, then all of a sudden, they got rid of the bad ones and the facility had good ones now. Interview on 12/21/25 at 11:49 A.M. with LPN #416 confirmed the Hoyer pads were falling apart, and multiple staff had reported it to administration, then Resident #63 fell. Since then, staff removed all the bad ones, and the facility has had nice ones now. Staff had been reporting this concern for months, and nothing was done until the fall. Interview on 12/21/25 at 11:31 A.M. with CNA #440 confirmed she had reported to the administration on multiple occasions that the Hoyer pads were not in good repair and needed replaced prior to the 12/16/25 when Resident #63 fell. Interview on 12/21/25 at 11:22 A.M. with CNA #470 confirmed on 12/16/25, Resident #63 fell from the Hoyer lift during a transfer. Interview confirmed she had checked the Hoyer pad prior to using it and didn't see any problems with it. Interview also confirmed when she lifted the Hoyer, the pad broke at one of the handles, and Resident #63 fell to the floor. Interview confirmed CNA #490 was in the room on the other side of the curtain washing her hands when the incident occurred. CNA #470 verified staff were to use two persons at all times with Hoyer transfers. Interview on 12/21/25 at 12:56 P.M. with CNA #491 confirmed the Hoyer pads were in poor condition prior to Resident #63's fall from the Hoyer. Interview confirmed she told the management team multiple times about how bad the Hoyer pads were in a group chat and they didn't do anything about it. Interview on 12/21/25 at 3:03 P.M. with the Director of Nursing (DON) confirmed the facility did not have a plan in place to inspect the Hoyer pads on a routine basis prior to the fall on 12/16/25, where Resident #63 fell from the Hoyer when the Hoyer pad broke. Interview confirmed Resident #63 sustained bilateral femur fractures requiring surgical repair, and an L1 compression fracture. Interview confirmed Resident #63 was still in the hospital at this time. Interview also confirmed the facility did a sweep of all the Hoyer pads in the facility to ensure they were all in good condition and if they weren't in good condition they were thrown away. The DON was unable to give a number of Hoyer pads that were discarded due to not being in good condition. Interview on 12/22/25 at 8:59 A.M. with CNA #490 confirmed on 12/16/25 she was called into Resident #63's room to help with a transfer. Upon entering the room, she stopped on the other side of the curtain, to wash her hands and put on gloves. Before she could get her gloves on, CNA #470 lifted Resident #63 with the Hoyer, the Hoyer pad broke and Resident #63 fell from the Hoyer onto the floor. Interview confirmed she did not see CNA #470 lift Resident #63 in the Hoyer, and she did not see Resident #63 fall out of the Hoyer, she just heard it happen. Interview confirmed staff are to use two persons at all times with Hoyer transfers. Interview on 12/22/25 at 3:17 P.M. with CNA #490 confirmed she, along with other CNAs, had reported the Hoyer pads needing replaced and management didn't do anything about it until the fall happened with Resident #63. Review of the Lifting Machine, Using A Mechanical policy dated July 2017 revealed at least two nursing assistants are needed to safely move a resident with a mechanical lift and make sure that all necessary equipment (slings, hooks, chains, straps and supports) is on hand and in good condition. This deficiency represents non-compliance investigated under Master Complaint Number 2697275 and Complaint Number 2695861.

Based on record review, staff interviews, and policy review, the facility failed to administer medications per physician orders. This affected two (Residents #05 and #08) of three residents reviewed for medication administration. The facility census was 62.Findings include:1.Review of the medical record for Resident #05 revealed an admission date of 03/21/25 with diagnoses of type II diabetes mellitus with foot ulcer, non-pressure chronic ulcer of other part of left foot with fat layer exposed, chronic combined systolic (congestive) and diastolic (congestive) heart failure.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of the physician orders revealed the following:-An order dated 03/22/25 for Repatha Subcutaneous Solution Prefilled Syringe (Evolocumab). Inject 140 mg/ml subcutaneously one time a day every 21 day(s) for hyperlipidemia every 3 weeks with a discontinue date of 05/24/25.-An order dated 05/24/25 for Repatha Subcutaneous Solution Prefilled Syringe (Evolocumab). Inject 140 mg/ml subcutaneously one time a day every 21 day(s) for hyperlipidemia every 3 weeks with a discontinue date of 09/08/25.-An order dated 09/10/25 for Repatha Subcutaneous Solution Prefilled Syringe (Evolocumab). Inject 140 mg/ml subcutaneously one time a day every 21 day(s) for hyperlipidemia every 3 weeks with a discontinue date of 12/05/25.-An order dated 12/05/25 for Repatha Subcutaneous Solution Prefilled Syringe (Evolocumab). Inject 140 mg/ml subcutaneously one time a day every 21 day(s) for hyperlipidemia every 3 weeks.Review of the Medication Administration Records (MAR) revealed on 04/12/25, 05/03/25, 06/16/25, 07/28/25, and 08/18/25 the Repatha was administered. Further review of the MARs revealed on 05/24/25, 07/07/25, 09/12/25, 10/08/25, 11/03/25, 11/14/25, and 11/21/25 the Repatha was not administered and was signed as 'see nurses notes.'Review of the Pharmacy Packing Slip Proof of Deliver forms for Resident #05 revealed Repatha 140 mg/ml quantity of one was delivered on 03/22/25, 04/12/25, 05/05/25, 05/24/25, 07/07/25, 07/28/25, 09/12/25, and 12/11/25.Interview on 12/23/25 at 2:46 P.M. with the Director of Nursing (DON) confirmed Resident #05 did not receive their Repatha as ordered every three weeks starting on 03/22/25. Interview also confirmed the physician orders were routinely, but the pharmacy was not delivering the medication per orders. Interview confirmed when the facility noted it was not available, they would sometimes discontinue the orders and write a new order so the resident would get it delivered. Interview confirmed the medication has a short shelf life so the pharmacy would not deliver it early. Interview also confirmed that the resident received only five of the thirteen doses of Repatha between 03/22/25 and 11/29/25. Interview also confirmed that only eight doses show as delivered.2. Review of the medical record for Resident #08 revealed an admission date of 12/30/24 with diagnoses of respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia, type II diabetes mellitus with diabetic polyneuropathy, major depressive disorder, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and chronic diastolic (congestive) heart failure.Review of the Quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact. Review of the physician orders revealed the following:-An order dated 06/30/25 for Repatha Subcutaneous Solution Prefilled Syringe 140 mg/ml (Evolocumab). Inject 140 mg subcutaneously one time a day every 2 weeks on Monday for hypertriglyceridemia with a discontinue date of 12/01/25.-An order dated 12/02/25 for Repatha Subcutaneous Solution Prefilled Syringe 140 mg/ml (Evolocumab). Inject 140 mg subcutaneously one time a day every 2 weeks on Wednesday for hypertriglyceridemia.Review of the MAR revealed the Repatha was not administered in June 2025. Further review of the MARs revealed the Repatha was administered on 07/28/25, 08/11/25, 08/25/25, and 09/08/25. Further review revealed on 09/22/25, 10/06/25, 10/20/25, 11/03/25, 11/17/25, 12/01/25, and 12/17/25 the Repatha was not administered and signed as, 'see nurses notes.'Review of the Pharmacy Packing Slip Proof of Deliver forms for Resident #05 revealed Repatha Injection 140 mg/ml quantity of one was delivered on 06/28/25, 08/12/25, 08/25/25, 09/22/25, and 12/01/25.Interview on 12/23/25 at 2:46 P.M. with the DON confirmed Resident #08 did not receive their Repatha as ordered every two weeks starting on 06/26/25. Interview also confirmed the physician orders were routinely, but the pharmacy was not delivering the medication per orders. Interview confirmed when the facility noted it was not available, they would sometimes discontinue the orders and write a new order so the resident would get it delivered. Interview confirmed the medication has a short shelf life so the pharmacy would not deliver it early. Interview also confirmed that the resident received only four of the eleven doses of Repatha between 06/26/25 and 12/17/25. Interview also confirmed that only five doses show as delivered.Review of the facility policy, Administering Medication, dated April 2019 revealed medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame.This deficiency represents non-compliance investigated under Master Complaint Number 2697275 and Complaint Number 2695861.

Based on observation, interview, record review, and policy review, the facility failed to assess and implement new interventions after an unstageable pressure ulcer was found on Resident #16's left foot. This affected one (Resident #16) of three residents reviewed for pressure wounds. The facility census was 62. Medical record review for Resident #16 revealed an admission date of 07/17/25 with diagnoses including quadriplegia and polyneuropathy. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #16 was cognitively intact. Her functional status was dependent for bathing, dressing, and positioning. Review of the care plan for Resident #16 revealed the resident is at risk for pressure ulcers. Interventions included weekly skin checks, floating heels, turning and repositioning, pressure reducing mattress, and wheelchair cushion. Review of the nursing notes dated 12/21/25 revealed that while Resident #16 was being provided a bed bath, a wound measuring 2.9 x 2 x.2 was found on the the ball of Resident #16's left foot. Review of the triage notes dated 12/21/25 revealed the facility was instructed to keep a pillow under Resident #16's foot to relieve pressure and contact the primary care provider on Monday for an evaluation. Review of the Interdisciplinary Team note date 12/22/25 revealed that Resident #16 believes her wheelchair's left foot rest caused the wound. Resident #16 has no feeling in her legs and couldn't tell it was rubbing while up in wheelchair. Therapy will evaluate Resident #16 in the wheelchair and adjust the left footrest to not rub against her foot. Observation on 12/22/25 at 2:00 P.M. revealed Resident #16 was in her wheelchair without a pillow placed under her foot. Interview on 12/22/25 at 2:57 P.M. with Resident #16 verified the facility had not started any new interventions to alleviate pressure from her left foot. Review of the Wound Evaluation and Management Summary notes dated 12/23/25 revealed the wound on Resident #16's left foot was unstageable and measured 3 x 3 x 0.1 cm. Interview on 12/23/25 at 10:36 A.M. with Licensed Practical Nurse (LPN) #446 revealed she believed the bolsters on Resident #16's bed caused the pressure ulcer due to how the resident prefers to be positioned. Interview on 12/23/25 at 10:09 A.M. with Director of Nursing (DON) #423 verified they did not evaluate Resident #16 after the pressure ulcer was found. DON #423 verified that they were not sure if the bolsters on the bed or the wheelchair foot pedals caused the pressure injury. DON #423 verified that Resident #16 has not been evaluated by therapy and there have not been any new interventions added. Review of the facility policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, with a revision date of March 2014, revealed nursing staff and attending physician will asses and document a resident's significant risk factors for developing pressure sores.

Based on medical record record review and staff interview the facility failed to document discharge planning for one (Resident #27) of three residents reviewed for discharge planning. The facility census was 69 residents.Findings include: Review of the medical record for Resident #27 revealed an admission date of 09/19/24 with diagnoses including chronic obstructive pulmonary disease, atherosclerotic heart disease, anxiety disorder, hypertension, osteoarthritis, and depression, and a discharge date of 06/11/25. Review of her the care plan for Resident #27 dated 01/08/25 revealed the resident had planned to be at the facility for a short time and wanted assistance in planning steps to be able to return home safely. Review of the Minimum Data Set (MDS) assessment for Resident #27 dated 04/04/25 revealed the resident was cognitively intact and required set-up or supervision with activities of daily living (ADLs.) Review of a 30-day discharge notice for Resident #27 dated 05/12/25 revealed the was being discharged for non-payment of services and would be going to her sister's home. Review of the MDS assessment for Resident #27 dated 06/11/25 revealed the resident was discharged to the community and was not anticipated to return to the facility. Review of the physician's orders for Resident #27 revealed an order dated 06/10/25 for the resident to discharge to home with hospice care. Review of the progress notes for Resident #27 dated 06/11/25 to 08/27/25 revealed there was no documentation regarding the resident's discharge from the facility. Review of the recapitulation of stay form for Resident #27 dated 06/11/25 revealed the resident was independent with mobility and activities of daily living and had participated in self-directed and occasional group activities. All other sections of the form were blank. Interview on 08/27/15 at 11:20 A.M. with Assistant Director of Nursing (ADON) #109 verified there should have been a nursing discharge note for Resident #27 and the recapitulation of stay form should have been fully completed. He stated he was not aware of the details of her discharge planning as that would be the responsibility of the social worker. Interview on 08/27/25 at 11:50 A.M. with the Administrator confirmed Resident #27 had been given a 30-day discharge notice due to non-payment and had gone home with her sister, and he was not sure what discharge planning had taken place. The Administrator verified the staff should have completed a nursing note and the recapitulation of stay document upon discharge for Resident #27. Interview on 09/02/25 at 2:25 P.M. with the former Social Worker (SW) #121 confirmed she was not present when Resident #27 was discharged . SW #121 reported Resident #27's insurance gave notice they would not cover a long-term stay. Resident #27 was planning to try to go to her sister's house and she had recommended home health care and therapy but was not sure what had been set up when Resident #27 actually discharged as the SW was no longer working at the facility. This deficiency represents noncompliance investigated under Complaint Number OH00165679 (iQIES 1344432.)

Based on medical record review, staff interview and online information on pressure ulcers from Medscape the facility failed to timely treat pressure wounds. This affected one (Resident #10) of three residents reviewed for pressure ulcers. The facility census was 69 residents. Findings include:Review of the medical record for Resident #10 revealed admission date of 07/18/25 with diagnoses including stage four pressure ulcer, stroke, liver cirrhosis, and depression and a discharge date of 07/22/25.Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 07/22/25 revealed the resident had severely impaired cognition and was dependent upon staff for activities of daily living (ADLs.)Review of the admission assessment for Resident #10 dated 07/18/25 revealed the resident had a left heel pressure ulcer which measured two centimeters (cm) in length by two in width with the depth not measured and the resident had a left outer ankle pressure ulcer which measured two cm in length by two cm in width with the depth not measured.Review of the physician's orders for Resident #10 revealed orders dated 07/21/25 to cleanse the left heel pressure ulcer and left outer ankle pressure ulcer with normal saline and apply skin prep every shiftInterview on 08/26/25 at 11:02 A.M. with Assistant Director of Nursing (ADON) #109 confirmed Resident #10 was admitted on [DATE] with deep tissue injuries (DTIs) to her left heel and left outer ankle. ADON #109 confirmed the treatment for the pressure ulcers was not initiated until 07/21/25.Review of online resource Medscape at https://emedicine.medscape.com/article/190115-treatment revealed once a pressure ulcer has developed immediate treatment is required.This deficiency represents noncompliance investigated under Complaint Number 2582540 and Complaint Number 2572464.

Based on medical record review, review of recorded video footage, staff interview, and review of the facility policy, the facility failed to ensure staff timely reported falls, failed to assess residents for injuries following falls, and failed to investigate falls. This affected one (Resident #17) of three residents reviewed for falls. Based on medical record review, observation, and staff interview, the facility failed to ensure fall prevention interventions were implemented per the resident care plan. This affected one (Resident #12) of three residents reviewed for falls. The facility census was 69 residents.Findings include:1.Review of the medical record for Resident #17 revealed admission date of [DATE] with diagnoses including chronic obstructive pulmonary disease, dementia, depression, anxiety and psychotic disorder with delusions. The resident expired on [DATE].Review of the care plan for Resident #17 initiated on [DATE] revealed the resident was at risk for falls related to multiple comorbidities including weakness, chronic pain, impaired balance, unsteady gait and behaviors. Interventions included to encourage the resident to ask for assistance, ensure resident is wearing appropriate footwear, and keep environment well-lit and free of clutter.Review of the Minimum Data Set (MDS) assessment for Resident #17 dated [DATE] revealed the resident was cognitively impaired and was dependent on staff for assistance with activities of daily living (ADLs.)Review of a video recording undated of Resident #17 revealed a female resident was on the floor opposite the wall, beside her bed which was in low position. A second person bent down and grabbed the resident under her arms and attempted to put the resident back on the bed. Resident #17 kept her left leg straight and did not assist in the transfer. The resident was wearing socks which allowed her feet to slide hindering the transfer. The video showed two attempts of the person to hoist the resident onto the bed without success before ending.Interview on [DATE] at 12:09 P.M. with the Administrator confirmed he was aware of the video of Resident #17's fall and had been informed of the fall by the resident's family member on [DATE]. The Administrator confirmed the aide in the video was Certified Nursing Assistant (CNA) #114. The Administrator stated when he was made aware of the video CNA #114 was suspended pending an investigation on [DATE], and the facility had disciplined the aide and provided education on the fall policy. The Administrator was unsure if CNA #114 had provided a statement regarding the fall circumstances and did not provide a statement by the end of the survey.Review of the facility fall investigation dated [DATE] revealed it included a suspension notice for CNA #114 due to picking a resident up after finding her on the floor during rounding and not reporting to the nurse. The investigation form indicated the facility was unable to investigate the fall due to the timing of the incident reporting. The investigation did not include a statement from CNA#114 regarding the circumstances of the fall.Review of the facility policy titled Falls-Clinical Protocol dated 2001 revealed staff would evaluate and document falls that occurred and the nurse would assess and document vital signs, injury, precipitating factors, and details of how the fall occurred.2.Review of the medical record for Resident #12 revealed admission date of [DATE] with diagnoses including hemiparesis and hemiplegia left dominant side following stroke, COPD, and depression.Review of the care plan for Resident #12 dated [DATE] revealed the resident was at risk for falls due to left sided hemiplegia, weakness tremors and impaired balance. Interventions included to keep the call light within reach, keep the bed in low position, and to place a fall mat to bilateral sides of the bed.Observation on [DATE] at 3:16 P.M. revealed Resident #12 was in bed, and the bed was in the highest position with no floor mat in place to the right side of the bed. Interview and observation on [DATE] at 3:19 P.M. with CNA #101 verified Resident #12's bed was too high and she lowered the bed. CNA #101 stated she was unsure if Resident #12 should have a mat on both sides of the bed and added he probably should because he could roll out on either side. CNA #101 confirmed Resident #12 did not have a fall mat on the floor to the right side of the bed, and there was only one mat present in the room.This deficiency represents noncompliance investigated under Complaint Number 2594984 and Complaint 2582540 and Complaint Number 2572464 and Complaint Number OH00165679 (1344432.)

Based on medical record review, observations, staff interviews, and policy review, the facility failed to follow infection control procedures for a resident in Contact Precautions. This affected one (#13) out of three residents reviewed for wound care. The facility census was 70. Findings include: Review of the medical record for Resident #13 revealed an admitted [DATE] with medical diagnoses of alcoholic cirrhosis of liver, chronic obstructive pulmonary disease, chronic Hepatitis C, resistant to multiple antibiotics, and carrier or suspected carrier of Methicillin-resistant staphylococcus aureus (MRSA). Review of the medical record for Resident #13 revealed an admission Minimum Data Set (MDS) assessment, dated 09/16/24, which indicated Resident #13 was cognitively intact and required set-up assistance for all activities of daily living. Review of the medical record for Resident #13 revealed a physician order dated 09/10/24 for Contact Precautions. Review of the medical record for Resident #13 revealed physician orders dated 09/12/24 to cleanse right lateral calf, right medial shin, left medial calf, left anterior shin with normal saline, apply xerofoam, cover with abdominal pad, and wrap with kerlix daily. Further review, revealed a physician order dated 10/16/24 to right abdominal Pleurex drainage catheter dressing change when drained and to cleanse with normal saline, apply gauze and cover with Tegaderm and an order dated 11/16/24 to cleanse right dorsal second toe with normal saline and apply skin prep daily. Review of the medical record for Resident #13 revealed weekly non-pressure documentation dated 11/13/24 which stated Resident #13 had vascular ulcers to right dorsal second toe, left anterior shin, left medial calf, right lateral calf, and right medial shin with drainage noted. Review of the medical record for Resident #13 revealed a comprehensive care plan dated 09/24/24 which stated Infection actual or at risk related to pneumonia. Carrier or suspected carrier of MRSA. Interventions included isolation cart and signage on the resident's door and to follow standard precautions. Further review revealed a care plan dated 09/12/24 which stated Resident #13 had wounds to left anterior shin, left medial calf, right lateral calf, right lateral ankle, left upper shin and right medial shin. The care plan stated Resident #13 chooses not to allow staff to complete dressing changes at times. Interventions included treatments as ordered. Review of the medical record for Resident #13 revealed no lab results to confirm the MRSA to her wounds was colonized. Review of the medical record for Resident #13 revealed hospital documentation dated 09/10/24 which stated Resident #13 was under Contact Precautions related to MRSA to left and right leg wounds and extended-spectrum beta-lactamase (ESBL) to left and right leg wounds. Observation on 11/18/24 at 8:39 A.M. revealed a Contact Precaution sign posted on Resident #13's door and an isolation cart located outside of Resident #13's room with personal protective equipment (PPE). The observation revealed State tested Nursing Assistant (STNA) #102 enter Resident #13's room without donning any PPE. STNA #102 was observed speaking with Resident #13 and taking Resident #13's breakfast tray out of her room. STNA #102 was not observed performing hand hygiene prior to exiting Resident #13's room or after placing breakfast tray in cart in the hallway. Interview on 11/18/24 at 8:42 A.M. with STNA #102 confirmed Resident #13 had a Contact Precaution sign posted on her door and an isolation cart located outside of the room. STNA #102 confirmed she did not donn PPE prior to entering Resident #13's room nor did she perform hand hygiene after leaving Resident #13's room. STNA #102 stated she thought Resident #13 was only on Enhanced Barrier Precautions not Contact Precautions. Interview on 11/18/24 at 3:18 P.M. with [NAME] President of Clinical (VPC) #108 confirmed the medical record for Resident #13 did not contain documentation to support MRSA was colonized. VPC #108 confirmed Resident #13 continued with vascular wounds to bilateral lower extremities and Resident #13 refused treatments at times and preferred to complete the treatments herself. VPC #108 stated Resident #13 was educated on proper wound care but probably should remain in Contact Precautions due to risk for infection control concerns when Resident #13 completed her own wound care. Review of the facility policy titled, Isolation- Categories of Transmission Based Precautions (TBP), stated TBP are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. The policy stated Contact Precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. The policy stated staff and visitors wear gloves (clean, non-sterile) when entering the room and gloves are to be removed and hand hygiene performed before leaving the room. The policy also stated staff and visitors would wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, staff interviews and policy review, the facility failed to ensure a newly identified skin issue was assessed timely and treatments were initiated. The facility also failed to ensure treatments to a pressure ulcer were completed as ordered. This affected one (#30) out of the three residents reviewed for pressure ulcers. The facility census was 70. Findings include: Review of the medical record for Resident #30 revealed an admitted [DATE] with medical diagnoses of nontraumatic intracerebral hemorrhage, chronic respiratory failure, left hemiplegia, vascular dementia, anxiety, and depression. Review of the medical record for Resident #30 revealed a Minimum Data Set (MDS) assessment, dated 10/01/24, which indicated Resident #30 had severe cognitive impairment and was dependent for all activities of daily living (ADL's). The MDS indicated Resident #30 did not have a pressure ulcer. Review of medical record for Resident #30 revealed physician orders dated 10/10/24 for left knee brace, staff to apply during day shift as tolerated for up to eight hours which was discontinued on 10/30/24 and an order to monitor skin on left knee for any redness due to knee brace every shift. Further review of the physician orders revealed an order dated 11/01/24 to cleanse left knee with normal saline or wound cleanser and apply betadine daily. Review of the medical record for Resident #30 revealed a Braden assessment which indicated Resident #30 was at high risk for skin breakdown. Review of the medical record for Resident #30 revealed Treatment Administration Record (TAR) for October 2024 which revealed no documentation to support the facility completed left knee skin checks as ordered on 10/24/24, 10/26/24, 10/28/24, or 10/29/24. Further review of the October 2024 TAR revealed documentation to support the facility applied Resident #30's left leg brace from 10/10/24 until discontinued on 10/30/24. Review of the November 2024 TAR revealed no documentation to support the facility completed wound care to Resident #30's left knee on 11/02/24, 11/03/24, 11/04/24, 11/05/24, 11/08/24, 11/09/24, 11/15/24, and 11/17/24. Review of the medical record for Resident #30 revealed a Physical Therapy note dated 10/16/24 which stated passive range of motion (PROM) to left knee and left hip were completed. The note stated left orthotic donned with new scab to left knee. The note continued to state left orthotic doffed, and plan was to continue with PROM until left knee healed. The note stated the nurse was notified of the new scab with redness to Resident #30's left knee. Review of the medical record for Resident #30 revealed Physical Therapy notes dated 10/23/24 which stated red scab to left knee, a note dated 10/24/24 which stated checked skin integrity before donning orthotic to left lower extremity, a note dated 10/25/24 which stated Resident #30 tolerated orthotic being donned yesterday for five hours and scab intact to left knee, and lastly a note dated 10/30/24 which stated during PROM Resident #30's left knee appeared to be redder and more inflamed. The note continued to state noted necrotic scab intact but discoloration around area and new thinning of skin noted. The note stated Resident #30's nurse was notified and would not apply orthotic until area was healed. Review of the medical record for Resident #30 revealed a nurses' note dated 10/30/24 at 10:13 A.M. which stated Resident #30's left knee has red area, so therapy notified to discontinue brace. Review of the medical record for Resident #30 revealed weekly skin assessment dated [DATE], 10/22/24, and 10/29/24 all indicated Resident #30's skin was intact, and no skin issues were noted. Further review of the medical record for Resident #30 revealed a Weekly Pressure Ulcer documentation assessment, dated 11/01/24, which stated Resident #30 have an unstageable pressure ulcer to left knee (front) which measured 6 centimeters (cm) by 6 cm by less than 0.1 cm, necrotic. Review of the Weekly Pressure Ulcer documentation assessment dated [DATE] stated Resident #30's left knee unstageable pressure ulcer was healing and measured 3.5 cm by 3.0 cm with necrotic tissue. Review of the medical record for Resident #30 revealed a Wound Physician progress note, dated 10/30/24, which stated Resident #30 had an unstageable pressure ulcer to left knee (necrotic) which measured 6 cm by 6 cm. The note stated Resident #30 was wearing a brace to left leg to straighten her knee and was noted to have a pressure wound to anterior knee where brace was placed. The wound was described as central area of black dry eschar with surrounding deep tissue injury changes. Review of the Wound Physician note dated 11/13/24 stated Resident #30 continued with unstageable pressure ulcer to left knee which measured 3.5 cm by 3 cm and the wound was healing. Interview on 11/19/24 at 8:15 A.M. with Physical Therapy Manager (PTM) #182 confirmed Resident #30's physical therapy note dated 10/16/24 was written by Physical Therapist (PT) #180 and the note indicated Resident #30 had a scab to her left knee, the orthotic was doffed, and the nurse was notified. Interview on 11/19/24 at 8:45 A.M. with Assistant Director of Nursing (DON) #143 confirmed the medical record for Resident #30 did not contain documentation to the facility completed left knee skin checks as ordered on 10/24/24, 10/26/24, 10/28/24, or 10/29/24. ADON #143 also confirmed the medical record for Resident #30 did not contain documentation to support wound care to the left knee unstageable pressure ulcer was completed as ordered on 11/02/24, 11/03/24, 11/04/24, 11/05/24, 11/08/24, 11/09/24, 11/15/24, and 11/17/24. ADON #143 stated he was not aware Resident #30 had any skin breakdown to left knee until after 10/30/24. Interview on 11/19/24 at 10:10 A.M. with [NAME] President of Clinical (VPC) #108 confirmed the physical therapy note, dated 10/16/24, indicated Resident #30 was noted to have a skin issue to left knee and that the nurse was notified. VPC #108 confirmed Resident #30's medical record contained documentation to support the facility continued to place brace to left leg until the order was discontinued on 10/30/24. Interview on 11/19/24 at 10:21 A.M. with PT #180 via phone confirmed she provided treatment for Resident #30 on 10/16/24 when she observed a scab to Resident #30's left knee. PT #180 stated the scab was about the size of a dime and stated she notified the nurse on the hall that day but could not remember the name of the nurse. PT #180 stated the ADON #143 was also present when the nurse was notified of the scab to Resident #30's knee. PT #180 stated the nursing staff were informed to no longer place the brace to Resident #30's left leg until the wound healed. Review of the facility policy titled, Prevention of Pressure Injuries, revised April 2020, stated to inspect resident's skin on a daily basis when performing or assisting with personal cares or ADL's and identify any signs of developing pressure injuries. The policy stated review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application and ability to secure the device and to monitor regularly for comfort and signs of pressure-related injury. This deficiency represents non-compliance investigated under Complaint Number OH00159378 and Complaint Number OH00158451.

Based on medical record review, staff interview, and policy review, the facility failed to ensure medications were administered as ordered. This affected one (#75) out of five residents reviewed for medication administration. The facility census was 70. Findings include: Review of the medical record for Resident #75 revealed an admitted [DATE] with medical diagnoses of chronic obstructive pulmonary disease, heart failure, atrial fibrillation, dementia with psychosis, paranoid schizophrenia, and diabetes mellitus. Review of the medical record revealed Resident #75 enrolled onto Hospice services [DATE] and expired on [DATE]. Review of the medical record for Resident #75 revealed a significant change Minimum Data Set (MDS) assessment, dated [DATE], which indicated Resident #75 had severe cognitive impairment and required substantial/maximum assistance for eating and bed mobility and was dependent upon staff for toilet hygiene and bathing. The MDS indicated Resident #75 did not transfer during the review window. Review of the medical record for Resident #75 revealed a physician order dated [DATE] for Morphine Sulfate (MSO4) 10 milligram (mg) per milliliter (ml) to give 0.25 ml by mouth three times per day for pain or shortness of breath. Review of the medical record for Resident #75 revealed the Medical Administration Record (MAR) for [DATE] which indicated Resident #75 received the MSO4 three times a day as ordered daily from [DATE] to [DATE]. Further review of Resident #75's Controlled Drug Record revealed no documentation to support the facility administered the MSO4 for the 2:00 P.M. on [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of the Controlled Drug Record for Resident #75's MSO4 revealed no concerns related to the amount of MSO4 signed out daily and the amount remaining in the medication bottle daily. Interview on [DATE] at 3:07 P.M. with Licensed Practical Nurse (LPN) #155 confirmed she documented on Resident #75's MAR that he received the 2:00 P.M. doses of MSO4 on [DATE], [DATE], [DATE], [DATE], and [DATE]. LPN #155 confirmed Resident #75's Controlled Drug Record did not contain documentation to support the MSO4 was administered at 2:00 P.M. on [DATE] through [DATE]. LPN #155 stated she did not administer Resident #75's 2:00 P.M. doses of MSO4 on [DATE] through [DATE] because Resident #75 was usually sleeping or resting comfortably at the time of the administration. LPN #155 stated she was not sure why she documented on the MAR that the MSO4 was administered instead of writing a progress note as to why the medication was not administered. Review of the facility policy titled, Medication Administration, revised [DATE], stated medications are administered in a safe and timely manner and as prescribed. The policy stated medications are to be administered in accordance with prescriber's orders, including any required time frame. The policy stated if a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document appropriately on the resident Medication Administration Record (MAR). This deficiency represents non-compliance investigated under Complaint Number OH00158451.

Based on observation, staff interview, and policy review, the facility failed to ensure dairy products were served at the appropriate temperature. This had the potential to affect 68 residents in the facility. The facility identified two residents (#08 and #21) who did not receive food from the kitchen. The facility census was 70. Findings include: Observation on 09/25/34 at 8:06 A.M. of the dining area on the facility's Red unit revealed fifteen trays lined up on the counter. Each tray contained a meal ticket, silverware, insulating covers, and a carton of milk. Observation on 09/25/24 at 8:25 A.M. revealed dietary staff started trayline, plating food and placing it in the insulated covers. Continued observation revealed nine trays were placed on a cart and delivered to the residents by the staff. Further observation revealed dietary staff placed an additional four trays on a cart for delivery. Observation on 09/25/24 at 8:41 A.M. revealed the milk on the tray of Resident #23 was 46.6 degrees Fahrenheit. Interview at the same time, Dietary Aid (DA) #349 verified the milk on Resident #23's tray was 46.6 degrees Fahrenheit. DA #349 stated she did not know what temperature at which the milk should be served. Continued observation on 09/25/24 at 8:42 A.M. revealed DA #349 replaced the milk cartons on the tray of Resident #23 and trays after that; however, the four trays already on the cart received the same milk that was already on the trays during the initial observation at 8:06 A.M. Observation on 09/25/24 beginning at 8:45 A.M. revealed the four trays which had the original milk were delivered to the resident's rooms. Interview on 09/25/24 at 8:54 A.M., Dietary Manager (DM) #345 stated the milk should be maintained at 41 degrees Fahrenheit or less. DM #345 stated the milk was placed in the freezer 30 minutes prior to being brought to the unit. Interview on 09/25/24 at 9:07 A.M. DA #349 verified she did not switch the milk on the four trays that were already on the cart following identifying the milk temped at 46.6 degrees Fahrenheit. Interview on 09/25/24 at 9:22 A.M., Resident #58 stated the milk she received at breakfast could have been a little colder. Review of the facility policy titled, Assistance with Meals, dated 03/2022, revealed cold foods should be held at 41 degrees or below until served.

Based on observation, staff interview, and policy review, the facility failed to ensure food was stored and prepared in a manner to prevent against the potential spread of foodborne illness. This had the potential to affect 68 residents in the facility. The facility identified two residents (#08 and #21) who did not receive food from the kitchen. The facility census was 70. Findings include: 1) Observation on 09/23/24 at approximately 8:20 A.M. of the facility's walk-in cooler revealed gray and white speckled areas throughout the eight wire shelves and several plastic milk crates. Further observation revealed a puddle of brown liquid, measuring approximately two feet by two feet, on the floor below a box of potatoes, which was positioned on the lowest shelf of a wire rack. A large box of cucumbers was observed on the top shelf of the rack and was leaking onto the shelves below and into the box of potatoes. Interview at the same time, Dietary Staff (DS) #306 stated the gray and white speckled areas throughout the cooler were mold and stated it had just started. DS #306 verified the cooler continued to be utilized to store food. DS #306 further verified liquid from the cucumbers was leaking into the potatoes and caused a subsequent puddle on the floor of the cooler. Interview on 09/23/24 at approximately 8:25 A.M., Dietary Manager (DM) #345 stated the walk-in cooler had just been cleaned and she was told the gray and white speckled areas were coming from a dirty fan. Review of the undated document titled, Timeline for Walk-in, revealed the Maintenance Director (MD) #364 cleaned the fan on 08/27/24. Interview on 09/25/24 at 2:53 P.M., MD #364 stated he was asked to clean the fan of the walk-in cooler and stated he vacuumed off the blades and cleaned the cover to the fan blades at that time. 2) Observation on 09/23/24 at 8:15 A.M. of the walk-in freezer, revealed two boxes of vegetable protein loafs which were open and not sealed, exposing the food to air. Interview at the same time, DS #306 verified the two boxes of vegetable protein loafs were not sealed and open to air. 3) Observation on 09/23/24 at approximately 8:30 A.M. revealed the hood vents were coated in a dark gray fuzzy substance. Further observation revealed a dark gray fuzzy substance coating and dangling from the sprinklers underneath the hood, above the stove. A sticker on the hood indicated the hood was last cleaned 05/2024. Interview at the same time, DS #306 verified the hood vents and sprinklers were coated in a dark gray fuzzy substance. Review of the facility policy titled, Basic Food Storage, undated, revealed food storage areas would be kept clean and free of spills and leaks. Review of the facility policy titled, Food Service, undated, revealed the facility would store, prepare, distribute and serve food under sanitary conditions.

Based on resident interviews, staff interviews, and record review, facility failed to document and follow up on resident concerns from the resident council meetings. This affected seven (#09, #19, #26, #30, #56, #62, and #221) residents who participated in resident council. The facility census was 70. Findings include 1) Review of the medical record for Resident #09 revealed an admitted [DATE]. Resident #09 was cognitively intact. 2) Review of the medical record for Resident #19 revealed an admitted [DATE]. Resident #19 was cognitively intact. 3) Review of the medical record for Resident #26 revealed an admitted [DATE]. Resident #26 was cognitively intact. 4) Review of the medical record for Resident #30 revealed an admitted [DATE]. Resident #30 was cognitively intact. 5) Review of the medical record for Resident #56 revealed an admitted [DATE]. Resident #56 was cognitively intact. 6) Review of the medical record for Resident #62 revealed an admitted [DATE]. Resident #62 had mild cognitive impairment. 7) Review of the medical record for Resident #221 revealed an admitted [DATE]. Resident #221 was cognitively intact. Review of Resident Council meeting minutes dated 08/30/23 revealed resident concerns related to dietary snacks, meat varieties, nursing call lights, showers, night shift concerns and housekeeping concerns. The facility provided no documented evidence of what was discussed including concerns brought up by the residents and plans to address concerns. Review of the correlating concern forms dated 08/30/23 revealed the State tested Nursing Assistants (STNAs) were not giving snacks out at night. The action taken section of the form was left blank. Another concern form dated 08/30/23 revealed call lights were taking a long time on night shift. The response indicated the Administrator, the Director of Nursing (DON) and Assistant DON (ADON) reviewed times and completed random audits. The action taken section of the form was left blank. Another concern form dated 08/30/23 revealed showers were not being done and the STNAs were saying the residents refused when they did not. A response indicated DON and ADON reviewed the shower sheets and noted the STNAs should be completing shower sheets and nurse signs the sheet, then the DON and ADON verify the sheets were complete. The action taken section of the form was left blank. Another concern from dated 08/30/23 revealed the residents wanted more snack varieties for evening snacks and more deli meat varieties with the additional snacks ordered. The action taken section of the form was left blank. Review of Resident Council meeting minutes dated 09/27/23 revealed resident concerns related to dietary (no specifics documented), nursing, snack and drink pass concerns. The facility provided no documented evidence of what was discussed including concerns brought up by residents and plans to address concerns. Review of Resident Council meeting minutes dated 10/17/23 revealed resident concerns related to nursing, tray pass and pick up concerns. It was documented on the form; education would be provided to staff. There was no documented evidence, of any resolution being completed. Review of Resident Council meeting minutes dated 11/22/23 revealed resident concerns related to nursing, snack and drink pass concerns on night shift. Staff education and audits would be completed. There was no documented evidence of any resolutions being completed. Review of Resident Council meeting minutes dated 12/20/23 revealed resident concerns related to showers not being done, call lights and snack and drink pass concerns as well as dietary concerns of snack and drink pass issues. The minutes revealed staff education would be completed for the concerns. There was no documented evidence of any resolutions being completed. Review of Resident Council meeting minutes dated 01/31/24 revealed resident concerns related to passing out snacks and drinks at night and more check-ins throughout the night. The facility provided no documented evidence of what was discussed including concerns brought up by the residents and plans to address concerns. Review of a correlating concern form dated 01/31/24 revealed issues with snack and drink pass on nights and residents reported not getting offered snacks or drinks with response that nurse was assigned to snacks at night and audits would be put in place. The action taken section of the form revealed the Interdisciplinary Team (IDT) was informed of the customer service and snacks were to be offered. There was no documented evidence provided by the facility that indicated the actions were followed up on. Another concern form dated 01/31/24 revealed the residents felt they needed to be checked on more throughout the night. A response indicated that audits would be put in place. The action taken section of the form revealed nursing and aides were given education on customer service and check and changes. There was no documented evidence provided by the facility of the audits and the education being completed. Review of Resident Council meeting minutes dated 02/28/24 revealed resident concerns related to passing out snacks and drinks at night. The facility provided no documented evidence of what was discussed including concerns brought up by the residents and plans to address concerns. Correct Review of Resident Council meeting minutes dated 03/27/24 revealed resident concerns related to nursing with no specific, menu, activity, and maintenance. The facility provided no documented evidence of what was discussed including concerns brought up by the residents and plans to address concerns. Review of Resident Council meeting minutes dated 04/24/24 revealed resident concerns related to nursing, menu, activities, and maintenance. The facility provided no documented evidence of what was discussed including concerns brought up by the residents and plans to address concerns. Review of Resident Council meeting minutes dated 05/29/24 revealed resident concerns related to nursing, menu, activities, and maintenance. The facility provided no documented evidence of what was discussed including concerns brought up by the residents and plans to address concerns. Review of a correlating concern form dated 05/29/24 revealed concerns about aides being on their phones when providing resident care. A response indicated education would be provided to the aides about cellphone usage and policy. There was no documented evidence provided by the facility of the education being completed. Review of Resident Council meeting minutes dated 06/26/24 revealed resident concerns related to nursing, menu, activities, and maintenance. The facility provided no documented evidence of what was discussed including concerns brought up by the residents and plans to address concerns. Review of Resident Council meeting minutes dated 07/30/24 revealed resident concerns related to nursing, menu, activities, and maintenance. The facility provided no documented evidence of what was discussed including concerns brought up by the residents and plans to address concerns. Review of Resident Council meeting minutes dated 08/28/24 revealed resident concerns related to nursing, menus, activities, and maintenance. The facility provided no documented evidence of what was discussed including concerns brought up by the residents and plans to address concerns. Interviews on 09/26/24 from 9:25 A.M. to 9:40 A.M. with Residents #09, #19, #26, #30, #56, #62, and #221 revealed the facility does not follow up timely on concerns brought up by the residents. The residents revealed some of the same things were brought up every meeting including snacks and drinks being passed out at night, showers not being done, call lights timeliness and food palatability concerns. The residents indicated the staff take very detailed notes at each meeting; however, they don't get to see the meeting notes. The residents stated that when they review the previous month's council minutes, they are very general and do not go into much detail about the concerns brought up in the previous meeting and doesn't mention what the facility did to address those concerns. Interview on 09/26/24 at 10:30 A.M. with the Administrator Activity Director (AD) #311 revealed AD #311 takes detailed notes on the concerns brought up during the Resident Council meetings. AD #311 stated the notes were not put in the meeting minutes as she was told not to by management. AD #311 verified the Residents are still making complaints of snack and drink pass, tray pass, call lights, showers and staffing and revealed those are consistent brought up at most meetings. AD #311 verified these concerns were not documented in the Resident Council minutes from 03/2024 to 08/2024. AD #311 verified there was no follow-up documented in the Resident Council meeting notes; however, any issues brought up had concern forms completed and sent to the managers for follow-up. AD #311 and the Administrator acknowledged facility should have evidence and documentation of the concerns being addressed that are brought up by the residents. Interview on 09/26/24 around 12:30 P.M. with Regional Director of Operations (RDO) #400 and the Administrator revealed they looked through files and could only find forms for 08/2023, 01/2024 and 05/2024. RDO #400 confirmed the facility was unable to locate any additional concern forms for 09/2024, 10/2023, 11/2023, 12/2023, 02/2024, 03/2024, 04/2024, 06/2024, 07/2024, and 08/2024 and their resolutions. RDO #400 also verified the facility was unable provide documented evidence of the follow ups, the education and the audits noted on the for. Review of facility policy titled Resident and Family Grievances, dated 09/29/22 revealed the facility shall provide prompt efforts to resolve and include facility acknowledgement for a complaint or grievance and actively work toward a resolution of the complaint or grievance. Facility shall take immediate actions needed to prevent further potential violations of residents rights and record information about the concern and actions taken.

Based on record review, staff interview, and review of hospital records, the facility failed to allow a resident to return to the facility timely following a hospital stay. This affected one (#43) of four residents reviewed for hospitalization . The facility census was 70. Finding included: Review of the medical record for Resident #43 revealed an admitted [DATE]. Diagnoses included osteomyelitis of vertebra, heart failure, cellulitis, kidney failure, and edema. Review of Resident #43 census revealed the resident was hospitalized from 08/13/24 to 08/14/24. Review of a nurse's progress note for Resident #43 dated 08/13/24 at 4:49 P.M., revealed the resident was sent to hospital for critical laboratory findings (labs) per the Nurse Practitioner (NP). Review of a nurse's progress note for Resident #43 dated 08/14/24 at 10:57 A.M. revealed the resident returned home from the hospital with a new order for Levaquin 500 milligrams (mg) once daily for seven days for urinary tract infection (UTI) and Pneumonia. Review of medical record found no evidence of discussions with hospital staff on resident stabilization or concern of return back to the facility and no evidence to support any concerns. Review of an emergency room (ER) discharge note dated 08/13/24 at 5:16 P.M., revealed Resident #43 was diagnosed with a catheter associated UTI and multifocal pneumonia with a plan to discharge back to the facility on an antibiotic and follow up with primary care physician. The physician's note revealed the resident was admitted to the ER with a chief complaint of abnormal labs per the facility. The ER completed various tests including labs and found the resident's white blood cell (WBC) count to be 20.6 (elevated) and blood urea nitrogen (BUN) of 102 (elevated). The physical exam indicated the resident appeared to be at baseline. Resident #43 was given fluids for likely dehydration. Resident #43 had no fever and borderline tachycardia. The suspicion of dehydration should be addressed with fluids and there was a low suspicion of acute kidney injury (AKI) as the resident currently had creatinine of 2.0 (elevated); however, they were improved levels. Resident #43 appeared to have a UTI from the urinalysis and multifocal pneumonia and was started on Levaquin intravenous (IV) antibiotics. The results were discussed with the resident and was comfortable discharging the resident. The resident should follow up with their primary physician to ensure infection and dehydration were improving. Review of an ER note dated 08/13/24 at 8:00 P.M. authored by an ER nurse, revealed she contacted the facility and spoke with the Director of Nursing (DON) who informed the ER that they could not accept the resident back because she was too critical for our care. The ER staff spoke with the ER Physician who reported they had no reason to admit the resident and she was stable for discharge back to the facility and the ER staff should continue with the plan for discharge. Review of an ER note dated 08/13/24 at 8:33 P.M. authored by an ER nurse revealed she spoke with the DON at the facility who informed her the resident could not return because of her labs. The ER nurse spoke with the ER physician who explained that the resident received IV fluid and IV antibiotics and would need to continue antibiotics at facility then have follow up labs completed. The ER physician reported the resident was appropriate for nursing facility level of care. Review of ER note dated 08/13/24 at 8:45 P.M. authored by an ER nurse revealed she attempted to call a report, and the nurse reported it was unnecessary as the facility would refuse for resident to return and send her back to the hospital immediately. Review of ER note dated 08/13/24 at 8:52 P.M. authored by an ER nurse, revealed the resident's discharge instructions were explained, and the resident was discharged in stable condition back to her nursing facility by a stretcher transport. Review of ER note dated 08/13/24 at 9:26 P.M. authored by an ER nurse, revealed Resident #43 arrived back to at the ER after being discharged to the facility an hour ago and. The staff at the facility declined to accept the resident stating the resident was unstable and needed to remain at the hospital. Review of ER note dated 08/13/24 at 9:30 P.M. authored by an ER nurse , revealed he spoke with the facility staff and the resident was sent back to the ER due to the facility refusing to accept the resident back. ER nurse spoke with the facility nurse who stated the DON instructed her to refuse the resident due to being unstable. The ER nurse requested to speak with the DON to clarify the resident's condition and stability concerns and was informed the DON would not speak with ER nurse. The ER nurse was told the facility's Physician informed the staff to refuse the resident and to stop taking calls from hospital regarding this resident. The resident was visibly upset upon return. Review of ER note dated 08/13/24 at 9:36 P.M. authored by the ER physician, revealed Resident #43 was diagnosed with a catheter associated UTI and multifocal pneumonia with a plan to discharge back to the facility on an antibiotic. The ER Physician note revealed the resident was refused at her nursing facility and was sent back without any explanation. Multiple conversations with nursing facility revealed the resident had no new or different symptoms or complaints. The resident denied any new symptoms. Review of ER note dated 08/13/24 at 10:00 P.M. authored by ER nurse revealed the resident was visibly upset and crying stating I want to go back, I belong there. Review of ER note dated 08/13/24 at 10:30 P.M. authored by ER nurse, revealed two messages were sent to facility physician to have a physician-to-physician conversation about the resident's discharge. Review of ER note dated 08/14/24 at 7:10 A.M. authored by ER nurse, revealed Facility Physician #450 contacted the ER to discuss why the resident was refused to return to facility the previous night. The ER nurse indicated the facility nurse deemed the resident was unstable although the ER physician reported the resident was stable and could be discharged . Physician #450 was asked if he had evaluated the resident as per previous conversation with facility's DON, since the physician had been the one to refuse the resident's return. Physician #450 stated he spoke with the DON and was informed of the resident's condition. ER Nurse noted the facility stopped taking calls from the ER staff to discuss the resident's stability, Facility Physician #450 stated he would speak with the DON and would get an update. Interview with LPN #315 on 09/25/24 at 3:57 P.M., revealed she was the nurse working the night shift on 08/13/24 when the resident returned from the hospital and was sent back to the ER from the front entrance of the facility. LPN #315 stated she did not know the resident's condition when she left for the hospital, and revealed the DON had talked with the hospital throughout the evening and ultimately declined the resident to return to the facility. LPN #315 stated the Physician had been reviewing the labs from the hospital and had been in contact with DON. LPN #315 stated she spoke with ambulance transport staff, but the DON was on the phone with them at that time as well and informed them the facility was refusing the resident and instructed them to return her to the hospital. LPN #315 indicated Resident #43 was not brought back into the facility. LPN #315 stated the resident was not assessed and also stated the DON and Physician #450 were not present when the resident returned to the facility on evening of 08/13/24. Interview with Regional Director of Operations (RDO) #400 on 09/25/24 at 4:40 P.M. revealed he spoke with the staff about the incident involving Resident #43 and was under the impression the hospital staff would not respond to the calls from the facility. RDO #490 verified facility had no documentation to support communication or reasoning for refusing to allow Resident #43 to return to the facility following the ER visit on 08/13/24. RDO #400 stated he would have allowed the resident to be brought in, assessed her, and if any concerns arose, then resend her back to the hospital instead of refusing her at the facility entrance. RDO #400 verified the facility physician, and the DON were not at the facility when Resident #43 returned the first time and Resident #43 was not reassessed before being returned to the hospital. Interview with Facility Physician #450 on 09/26/24 at 8:48 A.M. revealed he received one call from the DON about not wanting to accept Resident #43 back following the ER visit on 08/13/24. Physician #450 stated the DON informed him of the resident's labs and stated she had talked with hospital staff and felt the resident was unstable. Physician #450 stated the resident's BUN level was slightly elevated from her baseline and thought she would get fluids and be kept overnight. Physician #450 stated he had a message from the hospital nurse manager from late in the evening about Resident #43 being refused at the entrance of the facility and was sent back to the hospital due to the facility refusing to accept the resident. Physician #450 stated the on-duty nurse, nor the DON had contacted him at any point after the initial conversation. Physician #450 stated the resident had stabilized and was able to return in the morning after speaking with the DON. Review of facility policy titled Transfer of discharge date d 10/2022, revealed if the facility determined a resident cannot return to the facility, the medical record shall indicate the facility made efforts to determine if resident still required services of the facility and was eligible for skilled services and ascertain an accurate status if the resident's condition which can be accomplished via communication between the hospital and facility staff and or through visits by staff to the hospital and work with the hospital to ensure the resident's condition and needs are within the facility's scope of care. This deficiency represents non-compliance investigated under Complaint Number OH00156858.

Based on record review and staff interview, facility failed to ensure residents were provided with bed hold notification upon a transfer to the hospital. This affected three (#21, #43, and #56) residents of four residents reviewed for hospitalization . The facility census was 70. Finding included: 1) Review of the medical record for Resident #43 revealed an admitted [DATE]. Diagnoses included osteomyelitis of vertebra, heart failure, cellulitis, kidney failure, and edema. Review of Resident #43's census record revealed the resident was hospitalized from 01/25/24 to 03/13/24 and again from 04/13/24 to 05/06/24. Review of a Bed Hold Notice dated 03/13/2/4 revealed Resident #43 was hospitalized from 01/25/24 to 03/13/24. The form was provided to the resident on the date of discharge from the hospital and therefore was not provided timely and upon admission to the hospital. Review of a Bed Hold Notice dated 05/06/24 revealed Resident #43 was hospitalized from 04/13/24 to 05/06/24. The form was provided to the resident on the date of discharge from the hospital and therefore was not provided timely and upon admission to the hospital. 2) Review of the medical record for Resident #56 revealed an admitted [DATE]. Diagnoses included cerebral palsy, diabetes, encephalitis, heart failure, and paraplegia. Review of Resident #56 census record revealed the resident was hospitalized from 07/26/24 to 07/29/24. Review of the Bed Hold Notice dated 07/29/24 revealed Resident #56 was hospitalized from 07/26/24 to 07/29/24. The form was provided to the resident on the date of discharge from the hospital and therefore was not provided timely and upon admission to the hospital. It was noted to have been delivered to the resident on 07/29/24. Interview on 09/26/24 at 11:28 A.M. with Director of Nursing (DON), verified the dates on the bed hold notices for Residents (#43 and #56) which included the entire hospital stay. The DON also verified the bed hold notice forms were given to Residents (#43 and #56) after the hospital stay ended. 42731 3) Review of the medical record of Resident #21 revealed an admitted [DATE]. Diagnoses included acute respiratory failure with hypercapnia, severe sepsis, acute and chronic respiratory failure, multiple sclerosis, moderate protein-calorie malnutrition, traumatic subcutaneous emphysema, gastro-esophageal reflux disease, depression, hypertension, myasthenia gravis, pulmonary embolism, congestive heart failure, epilepsy, dysphagia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had moderately impaired cognition. Review of the medical record revealed Resident #21 was transferred to the hospital on 08/13/24 and readmitted to the facility on [DATE]. Review of the Bed Hold Notice revealed Resident #21 had eight bed hold days remaining, which included the hospitalization dated 08/13/24 through 08/28/24. The form was signed and dated 08/29/24. Interview on 09/26/24 at 4:20 P.M., Business Office Manager (BOM) #334 verified bed hold notices were issued following the hospital stay instead of at the time the residents were sent to the hospital. Review of the facility policy titled, Transfer or Discharge, Facility Initiated, dated 10/2022, revealed notice of facility bed hold and return policies are provided to the resident and representative within 24 hours of emergency transfer.

Based on record review, staff interview, and policy review, the facility failed to ensure residents were provided with notification indicating the reason for transfer upon a transfer to the hospital. This affected three (#21, #43, and #56) residents of the four residents reviewed for hospitalization . The facility census was 70. Finding included: 1) Review of the medical record for Resident #43 revealed an admitted [DATE]. Diagnoses included osteomyelitis of vertebra, heart failure, cellulitis, kidney failure, and edema. Review of Resident #43's admission census record revealed the resident was hospitalized from 01/25/24 to 03/13/24, again from 04/13/24 to 05/06/24 and 08/13/24 to 08/14/24. Further record review found no documented evidence of Resident #43 nor Resident #43's representative being provided with a notification for reason of transfer for any of these three hospitalization s. 2) Review of the medical record for Resident #56 revealed an admitted [DATE]. Diagnoses included cerebral palsy, diabetes, encephalitis, heart failure, and paraplegia. Review of Resident #56's census record revealed the resident was hospitalized from 07/26/24 to 07/29/24. Further record review found no documented evidence of Resident #56 being provided with a notification for reason of transfer for hospitalization from [DATE] to 07/29/24. Interview on 09/25/24 at 4:40 P.M. with Regional Director of Operations (RDO) #400 revealed the facility was unable to find any documented evidence of Residents' (#43 and #56) nor their representatives being provided with a notification for reason of transfer to the hospital. 42731 3). Review of the medical record of Resident #21 revealed an admitted [DATE]. Diagnoses included acute respiratory failure with hypercapnia, severe sepsis, acute and chronic respiratory failure, multiple sclerosis, moderate protein-calorie malnutrition, traumatic subcutaneous emphysema, gastro-esophageal reflux disease, depression, hypertension, myasthenia gravis, pulmonary embolism, congestive heart failure, epilepsy, dysphagia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had moderately impaired cognition. Review of the medical record revealed Resident #21 was transferred to the hospital on 08/13/24 and readmitted to the facility on [DATE]. Further review of the medical record revealed no documented evidence of Resident #21 nor the resident's representative being notified of the reason for transfer to the hospital in writing prior to the hospitalization . Interview on 09/26/24 at 4:20 P.M., Business Office Manager (BOM) #334 verified Resident #21 nor the resident's representative were not notified in writing of the reason for discharge to the hospital prior to the hospitalization . Review of the facility policy titled, Transfer or Discharge, Facility Initiated, dated 10/2022, revealed a notice of transfer would be issued as soon as practicable before the transfer.

Based on observations, staff interview and record review, the facility failed to ensure residents had to a safe, clean, comfortable and homelike environment. This affected one (#18) resident of one reviewed for physical environment. The facility census was 70. Findings include Review of the medical record for Resident #18 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), diabetes, dysphagia, heart failure, unspecified psychosis, respiratory failure and morbid obesity. Observation on 09/23/24 at 1:18 P.M., revealed Resident #18 had a large hole in the drywall behind her bed. Resident had a bariatric bed and a board affixed to the wall behind her bed to protect the drywall from damage from the bed. On the right side of the board was damage to the drywall with estimated size of about six inches by 18 inches. Interview on 09/26/24 at 12:50 P.M. with Maintenance Director (MD) #364, verified damage to the drywall. MD #364 revealed he had not been informed of the damage. MD #364 stated the damage was significant enough where a patch would not work and to do a repair, he would need to order drywall and cut out a large section and replace it. Review of facility policy, Homelike Environment, dated 02/2021 revealed resident shall be provided a safe clean comfortable and homelike environment. Facility shall maintain a clean and orderly environment.

Based on medical record review, staff interview, and policy review, the facility failed to ensure accuracy of code status in the medical record. This affected three (#29, #32, and #58) of nineteen residents reviewed for advanced directives. This had the potential to affect all 70 residents in the facility. Findings include: 1) Review of the medical record of Resident #58 revealed an admitted [DATE]. Diagnoses included metabolic encephalopathy, alcoholic cirrhosis of liver, respiratory failure, chronic obstructive pulmonary disease (COPD), anxiety, depression, obsessive-compulsive disorder (OCD), and hypertension. Review of the Do Not Resuscitate (DNR) order form located in the paper (hard) chart dated 09/28/23 for Resident #58, revealed the resident was to be a DNR-Comfort Care-Arrest (CCA). Review of the physician orders in the electronic medical record (EMR) for Resident #58 revealed an order dated 10/05/23 for the resident to be a Full Code. Interview on 09/23/24 at 3:45 P.M., Licensed Practical Nurse (LPN) #319, verified Resident #58's code status differed between the EMR and the signed DNR order form in the paper (hard) chart. LPN #319 further stated, when checking a code status, she would most likely refer to the EMR to check a resident's code status. 2) Review of the medical record of Resident #32 revealed an admitted [DATE]. Diagnoses included chronic atrial fibrillation, major depressive disorder, paranoid schizophrenia, mild cognitive impairment, nondisplaced fracture of middle phalanx of right middle finger, essential hypertension, epilepsy, hyperlipidemia, anxiety, human immunodeficiency virus (HIV), gastro-esophageal reflux disease, and irritable bowel syndrome. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 had impaired cognition. Review of the DNR order form located in the paper (hard) chart dated 01/12/24 revealed Resident #32 was to be a DNR-Comfort Care (CC) Review of the physician orders in the EMR for Resident #32, revealed an order dated 01/15/24 for the resident to be a full code. Interview on 09/24/24 at 10:27 A.M. LPN #319, verified the EMR status did not match the code status in the paper (hard) chart. 44070 3) Review of the medical record for Resident #29 revealed an admitted [DATE]. Diagnoses included osteomyelitis, chronic pulmonary disease, diabetes, emphysema, dysphagia and failure to thrive. Review of the physician orders in the EMR dated 09/20/24 for Resident #29 revealed a code status of DNR-CC. Review of an undated DNR signed physician form in the paper (hard) chart revealed Resident #29 had DNR-CC-A on file. Interview on 09/25/24 at 9:34 A.M. with Director of Nursing (DON) verified Resident #29's code status was mismatched in medical record with the documents and orders saying both DNRCC and DNR-CC-A. Review of the facility policy titled, Advance Directives, dated 09/2022, revealed the residents' advance directive wishes would be communicated to the resident's direct care staff and physician by placing the advance directive documents in a prominent, accessible location in the medical record.

Based on observation, record review, and staff interviews, the facility failed to treat all residents with dignity and respect. This affected two (#28, and #29) of three residents reviewed for dignity. The facility census was 70. Findings Include: 1) Review of Resident #28's medical record revealed an admitted [DATE]. Diagnoses included dysphasia, atrial fibrillation, and hemiplegia. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #28 was severely cognitively impaired and required substantial assistance with eating. Observation of Resident #28 on 09/23/24 at 11:30 A.M., revealed he was in the dining room/lounge area with other residents and the afternoon meal was being served by the staff. All the other residents were served their lunch, and they were eating with the exception of Resident #28. Resident #28 continued to face the other residents as they were eating, including another resident seated at the same table. At 12:10 P.M., Resident #28 still wasn't served his lunch and continued to face other residents while they were eating. All the other residents finished eating and were leaving the dining room while Resident #28 remained in the dining room without being served a lunch. Interview with State tested Nursing Assistant (STNA) #362 on 09/23/24 at 12:15 P. M., revealed Resident #28 needed assistance to eat his meal. STNA #362 verified Resident #28 wasn't served lunch at the same as the other residents. Interview with Resident #28 at 12:20 P.M. revealed he was hungry, and the food smelled good. Observation at 12:25 P.M., revealed Resident #28 received his tray after STNA #362 asked for it. The resident ate 75 percent of his meal. 44070 2) Review of the medical record for Resident #29 revealed an admitted [DATE]. Diagnoses included osteomyelitis, chronic pulmonary disease, diabetes, emphysema, dysphagia and failure to thrive. Review of the physician's order dated 09/20/24 revealed Resident #29 had a catheter with instructions for catheter care daily. Observation on 09/23/24 at 10:24 A.M. revealed Resident #29's foley catheter bag was full of urine, visible form the hallway and without a proper dignity cover in place. Interview on 09/23/24 at 10:46 A.M. with STNA #324 verified the facility had privacy covers for the foley catheter bags and Resident #29 did not have one in place. Interview on 09/23/24 at 4:38 P.M. with Administrator and Director of Nursing (DON) verified Resident #29's foley catheter bag was uncovered and visible from the hallway. Review of the facility policy titled Dignity dated 02/21 revealed residents were to provided with a dignified and respect. This deficiency represents non-compliance investigated under Complaint Number OH00157658.

Based on record review, observation, staff interview, review of facility policy, and review of guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to implement physician-recommended interventions for residents with pressure ulcers, failed to thoroughly assess resident's skin, and failed to identify pressure ulcers until they had already reached an advanced stage. This resulted in actual harm to one resident (#24) who was admitted to the facility without pressure ulcers and who developed an avoidable unstageable pressure ulcer to her coccyx and actual harm to a second resident (#34) who was admitted to the facility without pressure ulcers and developed a suspected deep tissue injury (unstageable) avoidable pressure ulcer to his right heel. This affected two (#24 and #34) of three residents reviewed for pressure ulcers. The facility identified four residents with pressure ulcers. The facility census was 66. Findings include: Review of the medical record for Resident #24 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment for Resident #24 dated 09/21/22, revealed the resident was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADLs). Further review of the MDS revealed the resident was coded as negative for the presence of pressure ulcers and was coded as being at risk for the development of pressure ulcers. Review of the pressure ulcer risk assessments for Resident #24 dated 09/16/22 and 10/20/22, revealed the resident was at moderate risk for the development of pressure ulcers. Review of the skin assessment for Resident #24 dated 09/16/22, revealed resident's skin was intact. Review of the care plan for Resident #24 initiated 09/22/22, revealed the resident was at pressure ulcer risk due to assistance required in bed mobility, bed fast, bowel incontinence, and thin aging skin. Interventions included the following: complete Braden Scale per policy, conduct weekly skin inspection, for residents who are ambulatory encourage activity as tolerated, provide pressure reducing wheelchair cushion, provide pressure reduction/relieving mattress, provide thorough skin care after incontinent episodes, and apply barrier cream, referral to therapy, treatments as ordered (added 10/18/22), and weekly wound assessment (added 10/18/22). Review of the care plan revealed it did not include interventions to float resident's heels. Review of weekly skin checks for Resident #24 dated 09/27/22, 10/04/22, 10/11/22, and 10/18/22 revealed resident's skin was assessed as intact with no new areas noted. Review of a nurse progress note for Resident #24 dated 10/18/22, revealed therapy brought to the nurse's attention resident had a new area on her coccyx which measured 2.0 centimeters (cm) in length by 1.5 cm in width with no depth and no drainage. Area was red in color. Review of wound physician's assessment for Resident #24 dated 10/19/22, revealed resident had an unstageable (due to necrosis) pressure ulcer to her coccyx which measured 4.0 cm in length by 4.0 cm in width with no depth. Wound was noted to have a moderate amount of serous exudate and the wound bed was 100 percent (%) slough. Physician recommended to float resident's heels while in bed. Review of wound physician notes for Resident #24 dated 10/26/22 and 11/09/22, revealed the physician made the recommendation to float resident's heels while in bed. Review of the October and November 2022 Treatment Administration Record (TARs) for Resident #24 revealed there was no record of interventions to float resident's heels as recommended by the wound physician. Review of the TARs revealed an order dated 10/18/22 to wash area to coccyx with soap and water, pat dry, apply calcium alginate and cover with dry dressing and change once daily. Observation on 11/09/22 at 12:35 P.M. of Resident #24 with State tested Nursing Assistant (STNA) #173 revealed resident's heels were laying directly on the mattress. Heels were not floated. Interview on 11/09/22 at 12:35 P.M. with STNA #173 confirmed Resident #24's heels were not floated and she was unaware of any orders or physician recommendations to do so. Observation of wound care on 11/14/22 at 10:40 A.M. per Licensed Practical Nurse (LPN) #149 revealed resident had a dime-sized open area to her coccyx which appeared to be of superficial depth with minimal drainage and the wound bed was red in color. Resident #24's heels were laying directly on the mattress. Heels were not floated. Interview on 11/14/22 at 10:50 A.M. with LPN #149 confirmed Resident #24 had a pressure ulcer to her coccyx. LPN #149 further confirmed Resident #24's heels were not floated and she was unaware of any orders or physician recommendations to do so. Interview on 11/14/22 at 11:23 A.M. with the Director of Nursing (DON) confirmed Resident #24 was admitted to the facility without pressure ulcers and developed a preventable unstageable pressure ulcer to her coccyx which was first identified by the therapy department on 10/18/22. The DON further confirmed the weekly skin checks performed by licensed nurses on 09/27/22, 10/04/22, 10/11/22, and 10/18/22 revealed resident's skin was assessed as intact with no new areas noted. The DON confirmed the wound physician made the recommendation to float resident's heels on 10/19/22, 10/26/22 and 11/09/22 and the facility had not implemented any orders to float the resident's heels. 2. Review of the medical record for Resident #34 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .) Review of the MDS assessment for Resident #34 dated 09/20/22 revealed the resident was cognitively intact and was independent with ADLs. Further review of the MDS revealed resident was coded as negative for the presence of pressure ulcers and was coded as being at risk for the development of pressure ulcers. Review of the care plan for Resident #34 dated 08/01/22, revealed resident was at pressure ulcer risk due to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included the following: complete Braden Scale per policy, conduct weekly skin inspection, monitor labs as ordered by practitioner, provide low air loss mattress as ordered, skin assessment to be completed per policy, treatments as ordered, and weekly wound assessment. Review of the care plan revealed it did not include interventions to float heels. Review of the most recent weekly skin assessment for Resident #34 dated 09/26/22, revealed resident's skin was intact. There were no weekly skin checks for Resident #34 after 09/26/22. Review of nurse progress note for Resident #34 dated 10/19/22, revealed resident had an unstageable pressure ulcer to his right heel which measured 3.0 cm in length by 3.0 cm in width with no depth. Review of wound physician's assessment for Resident #34 dated 10/26/22, revealed resident had an unstageable deep tissue injury (DTI) to the right heel which measured 2.0 cm in length by 2.0 cm in width with no depth. The physician recommended to float resident's heels while in bed and to offload the wound. Review of the October and November 2022 TARs for Resident #34 revealed there was no record of interventions to float resident's heels as recommended by the wound physician. Review of the TARs revealed an order dated 10/21/22 to apply [MEDICATION(S)] to right heel and leave open to air once daily. Interview on 11/09/22 at 11:23 A.M. with the DON confirmed Resident #34's most recent weekly skin check was completed on 09/26/22 and showed no new open areas. The DON confirmed the facility had identified a preventable unstageable pressure ulcer to Resident #34's right heel on 10/19/22. The DON further confirmed the wound physician had made the recommendation on 10/26/22 to offload the wound to resident's right heel and to float resident's heels when in bed. The DON confirmed the facility had no orders indicating the wound physician's recommendations had been implemented. Observation on 11/09/22 at 3:00 P.M. of Resident #34 revealed the resident had a nickel-sized pressure ulcer to his right heel. Resident #34 was up in his wheelchair but did not have devices in his room to float his heels while in bed or offload the wound. Resident #34 was wearing non-skid socks and had just returned from [CONDITION(S)]. Interview on 11/09/22 at 3:00 P.M. with Resident #34 confirmed he had developed a pressure ulcer to his right heel sometime last month. Resident #34 confirmed he had just returned from [CONDITION(S)] and had worn his non-skid socks on his feet for the appointment. Resident #34 confirmed the facility had not offered him any devices such as heel protectors or other devices to offload the wound and/or to float his heels. Interview on 11/09/22 at 3:19 P.M. with STNA #120 confirmed Resident #34 did not have heel protectors or orders for other devices or interventions to take the pressure off the wound on his right heel. Review of the facility policy titled Pressure Injury Prevention Guidelines dated 09/29/22 revealed the facility would prevent the formation of avoidable pressure injuries and would promote healing of existing pressure injuries. The facility would implement evidence-based interventions for all residents who were assessed at risk or who had a pressure injury present. Interventions would be implemented in accordance with physician orders, including the type of prevention devices to be used and, for tasks, the frequency for performing them. Review of the NPUAP guidelines dated 2014 pages 70-71 at https://npiap.com/general/custom.asp?page=2014Guidelines revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, [CONDITION(S)], and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for [CONDITION(S)] (redness of the skin) was the first component of every skin inspection. Skin redness and tissue [CONDITION(S)] resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. This deficiency represents non-compliance investigated under Complaint Number OH 183.

Based on closed medical record review, hospital record review, staff and family interview, the facility failed to ensure skin assessments to monitor for bleeding and bruising were completed for a resident who had repeated falls with an International Normalized Ratio (INR/lab to measure clotting time) of greater than 10 (therapeutic levels are 2-3 when on an anti-coagulant). This resulted in actual harm when the resident was sent to the hospital and was found with multiple rib fractures on the left side, spine fracture, chest wall hematoma with active bleeding, bruising to her back, left arm, and legs. This affected one resident (#01) of three reviewed for [MEDICATION NAME] (anti-coagulant) monitoring. The facility census was 68. Findings include: Closed medical record review revealed Resident #01 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #01's baseline plan of care dated 05/24/19 related to [MEDICATION NAME] use revealed interventions included to monitor for signs and symptoms of bleeding. There was no evidence a comprehensive care plan was developed related to the resident's [MEDICATION NAME] use. Review of Resident #01's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had cognitive impairment. She required supervision for walking in her room and the corridor and for locomotion on and off the unit. Review of Resident #01's physician orders [REDACTED]. Review of Resident #01's progress note dated 06/07/19 revealed the resident fell while she was in the dining room. The resident had no noted injuries and denied pain. Review of Resident #01's progress noted dated 06/16/19 revealed the resident fell and did not complain of pain. No injuries were noted. Review of Resident #01's progress note dated 06/19/19 at 5:30 A.M. revealed the resident was found on the floor near her doorway. The resident said she was trying to go get a glass of water. The resident complained of neck and upper back pain. The physician was notified and ordered an x-ray. The results of the x-ray were negative for any fracture. The resident then had another fall the same day. She was found on the floor with her back against the bed in a sitting position. The resident said she was trying to get out of bed. Review of Resident #01's progress note dated 06/20/19 revealed the physician was made aware the resident was found on the floor in her room. The resident had complained of pain due to recent prior falls. The facility indicated the resident had several falls in the last 30 days. Review of Resident #01's lab results dated 06/20/19 revealed her INR was at a critical level of 7.3 and the physician ordered the [MEDICATION NAME] to be held and to recheck the INR on 06/21/19. Review of the lab results dated 06/21/19 revealed resident's INR was now greater than 10. The physician was notified and gave an order for [REDACTED]. Review of Resident #01's shower sheet dated 06/21/19 revealed the resident refused her shower. Review of Resident #01's progress note dated 06/21/19 at 3:40 A.M. revealed the resident was calling out and sleeping intermittently during the night. The resident was unable to specify any needs when questioned. Review of Resident #01's progress note dated 06/21/19 at 8:33 P.M. revealed the resident was transferred to the local hospital per family request. There was no evidence any skin assessments were completed to monitor for bleeding and bruising after the resident had fallen five times since 06/07/19. Review of the hospital medical record revealed Resident #01 arrived at the hospital on [DATE] and was complaining of left lateral chest and rib tenderness. Upon assessment bruising was noted to her back, left arm and legs. The resident was moaning in pain with movement. A Computerized Topography (CT) of the chest without contrast was completed. The results were a large hematoma in left mid and lower chest wall measuring 8.9 centimeters (cm) x 6.2 x 11.4 cm with active bleeding. The resident was also noted with fractures of the left seventh, eight, and ninth ribs, and a cervical [MEDICAL CONDITION] vertebrae (C7). The resident was admitted to the Intensive Care Unit (ICU) and was administered one unit of packed red blood cells. The resident was discharged to a different skilled nursing facility on 07/03/19. Interview on 08/19/19 at 9:55 A.M. with Registered Nurse (RN) #5 revealed she remembered Resident #01 had bruising after her falls, however could not remember where. The RN further revealed the resident's care plan included to monitor the resident's skin for active signs of bleeding due to the use of [MEDICATION NAME]. Interview on 08/19/19 at 11:39 A.M. with State tested Nursing Assistant (STNA) #17 revealed Resident #01 had fallen on 06/20/19 and hurt her back. STNA #17 revealed the resident had a lot of pain after she fell and was not hungry that day. Interview on 08/19/19 at 12:22 P.M. with STNA #21 revealed she had been asked by the nurse to get Resident #01 ready on 06/21/19 as she was being sent out to the hospital. The STNA revealed the resident had a bruise under her left arm. Interview on 08/19/19 at 2:40 P.M. with STNA #27 revealed the nurse wanted her to get Resident #01 up for breakfast on 06/21/19, however when she moved her, she was in pain and wanted to lay back down. STNA #27 revealed she told the nurse the resident was in pain. She further confirmed the resident did have a bruise on her back. Interview on 08/19/19 at 4:42 P.M. with the Director of Nursing (DON) confirmed she did not have the facility's incident forms for the five fall investigations for Resident #01. The DON confirmed she did not have any copies of any skin assessments for the resident after her falls. She revealed they were all sent to their Corporate Office. Interview on 08/20/19 at 9:25 A.M. with the family member of Resident #01 revealed when she went to the facility to visit the resident on 06/21/19, STNA #3 told her she should look at the resident's back. The family member found a large red, deep purple area from her armpit to the waist on the left side towards the front, rib area. She revealed it looked like an active bleed. The family member said she told the facility she wanted the resident sent to the hospital for an evaluation and treatment. The family member revealed LPN #10 told her she was glad the resident was being sent to the hospital as she had wanted to send her out for a couple of days. When the resident arrived at the hospital, the resident was found to have an active bleed, neck fracture and broken ribs. This deficiency substantiates Complaint Control Number OH 855.

Based on observation, medical record review, resident, staff and former medical director interview, and policy review, facility failed to effectively manage a resident's pain. This resulted in actual harm when Resident #79 experienced increased pain that was not effectively managed or treated by the facility. This affected one (#79) out of three residents assessed for urinary tract infections. The facility census was 80. Findings include: Medical record review for Resident #79 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of admission minimum data set (MDS) assessment dated [DATE] revealed Resident #79 had no cognitive deficits, received scheduled and as needed pain medications, and stated she had pain on a scale of six (on a scale of zero to ten with zero being no pain and ten as the worst pain). She was coded that pain made it hard for her to sleep at night and limited her day to day activities. Review of hospital discharge instructions dated 11/07/18 revealed orders for [MEDICATION NAME] 325 milligrams (mg) take one to two tablets every six hours as needed for pain and for [MEDICATION NAME]-[MEDICATION NAME] 5/325 mg take one to two tablets every four hours as needed for pain. Review of nurses' notes dated 11/16/18 revealed Resident #79 requested Foley catheter to be removed and a urinalysis to be done to ensure infection was gone and physician was faxed. Review of nurses' notes dated 11/17/18 revealed resident was in severe pain and crying and requesting pain medication. Review of nurses note dated 11/21/18 revealed [MEDICATION NAME]-[MEDICATION NAME] was administered for severe pain and was ineffective. Review of physician progress notes [REDACTED].#79 was complaining of dysuria and was recently treated for [REDACTED]. Will add [MEDICATION NAME] and [MEDICATION NAME], and check urinalysis. Review of physician orders [REDACTED]. Review of nurses' notes dated 11/22/18 revealed urinalysis to rule out UTI and to be collected later today. Review of nurses' notes dated 11/24/18 revealed [MEDICATION NAME]-[MEDICATION NAME] administered as needed for severe pain per resident request for pain of eight out of ten. Review of physician progress notes [REDACTED].#79 had ongoing complaints of dysuria and stated a nurse just collected a urine specimen from her last night but she has had symptoms for one week. She has long history of chronic UTI's. She completed a course of [MEDICATION NAME] for vaginal yeast infection. Urinalysis is still pending so will resume a three day course of [MEDICATION NAME] pending results of urinalysis. Resident #79 stated she is having left sided pelvic pain and more incontinence. Assessment revealed dysuria and pelvic and perineal pain. Review of physician orders [REDACTED]. Review of urine culture dated 12/03/18 revealed urine specimen was collected on 11/30/18 and results revealed 10,000 to 50,000 Escherichia Coli, and abnormalities of amber colored urine with cloudiness and positive for blood and was resistant to [MEDICATION NAME]. Review of physician progress notes [REDACTED]. Culture positive Escherichia Coli 50,000 resistant to [MEDICATION NAME]. Further review of the (MONTH) (YEAR) medication administration record (MAR) revealed Resident #79 received [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg two tablets for severe pain once on 11/08/18; three times on 11/09/18; twice on 11/11/18; once on 11/12/18, 11/14/18, 11/15/18, 11/17/18, and 11/18/18; twice on 11/19/18 and 11/21/18; once on 11/23/18, 11/24/18, 11/26/18, and 11/29/18; twice on 11/25/18, 11/27/18, and 11/28/18. Resident #79 rated her pain at a 10 out of 10 on 11/17/18 and pain medication was documented as ineffective on 11/21/18. She received [MEDICATION NAME]-[MEDICATION NAME] 5/325 mg one tablet for mild pain 11/12/18, 11/13/18, 11/16/18, 11/26/18 and on 11/30/18. Review of (MONTH) (YEAR) MAR revealed Resident #79 received [MEDICATION NAME]-[MEDICATION NAME] 5/325 mg two tablets for severe pain every day from 12/01/18 through 12/06/18 and received it twice on the days of 12/02/18, 12/03/18, 12/04/18, and 12/05/18. Pain was rated from four to nine out of 10. Resident #79 received pain medication daily from 11/23/18 through 12/06/18. Resident #79 received [MEDICATION NAME] from 11/22/18 through 11/24/18 and then a second round of [MEDICATION NAME] again starting 11/28/18. Review of care plan for Resident #79 revealed there was no alteration in comfort or pain care planned. Interview was conducted on 12/05/18 at 2:51 P.M. with Resident #79 stated she was upset because the doctor had wrote her an order to get antibiotics for her UTI and she was not able to start them until her urine was checked and it took her awhile to get a collection hat after she asked repeatedly to several nurses and then when she did get one she stated none of the nurses would collect it so she had to keep throwing it away. She stated a week and a half went by and her husband came in to the facility and had to get mad at someone to get them to collect her urine and send it to the lab. She stated one nurse collected it once and she was told it must have gotten thrown away and then after two weeks the nurse finally collected her urine. Resident #79 stated she was just told yesterday that it came back positive for UTI and that the nurse called physician and left a message. She stated she did receive her first pill last night and did receive one this morning. During the interview, observations revealed Resident was grimacing during the conversation and stated she does not feel well. She stated she had increased incontinence, odor to her urine, pain that was so bad it was cringing pain as she described. She stated her pain was so bad to lower abdomen that she had to hold onto the handle bars in the bathroom to urinate. She stated she reported the pain to the nurse and her increased incontinence. Interview was conducted on 12/11/18 at 9:54 A.M. with Resident #79 revealed she had always had chronic pain but nothing like now with her UTI and stated the pain was unbearable and there was just no excuse why she had to wait to get treated and she stated she was told that the reason was because they had nurses working from agency. She stated she is just now starting to feel better since she has been receiving antibiotic. Interview was conducted on 12/05/18 at 5:05 P.M. with Former Medical Director revealed he was not aware that Resident #79's urine was not sent out to lab until 11/30/18 and that he ordered it to be collected on 11/21/18. He stated there was a concern with labs not getting done as ordered right away and that he could not place her on antibiotics right away until urinalysis was back. He stated he saw Resident #79 again on 11/27/18 and was not aware the urine sample had not been sent out that he thought the results were still pending from the lab. He stated waiting nine days for obtaining a urine sample was unacceptable. He stated Resident #79 was having pain and that is why he ordered [MEDICATION NAME] two different times as he was still awaiting urine culture results. Interview was conducted on 12/06/18 at 10:31 A.M. with Licensed Practical Nurse (LPN) #109 and she stated she took of the physician's orders [REDACTED].#79 and she did not collect it. She stated she worked second shift and that the next shift on day shift would collect it. Interview was conducted on 12/06/18 at 10:35 A.M. with Registered Nurse (RN) #89 stated she remembers giving Resident #79 a hat to collect urine on 11/22/18. RN #89 stated when she went to collect the urine it had toilet tissue in it so she could not use it and passed it onto the next shift that it still needed collected. Interview was conducted on 12/11/18 at 10:05 A.M. with the Director of Nursing (DON) verified the order for urinalysis was written on 11/21/18 and urinalysis result in chart revealed urine was collected on 11/30/18. The DON confirmed Resident #79 experienced unrelieved pain as documented in the medical record. Review of facilities Pain Assessment Policy dated (MONTH) (YEAR) revealed residents will be assessed for pain upon admission, readmission, quarterly, annually, upon significant change, when resident experiences a new onset of pain or experiencing uncontrolled pain. A weekly review of pain will be completed on a weekly progress note. A pain flow record will be maintained with the residents MAR and completed when the resident has identified they have pain and record the following: date and time, site and location, type of pain, intensity, precipitating and aggravating factors, non-medication and medication interventions, intensity of pain after intervention, side effects, and initials.

Based on medical record review, family interview, staff interview, review of Lippincott's 2013 nursing procedures sixth edition and review of facility policy, the facility failed to provide appropriate care and treatment. Actual harm occurred to Resident #74 when there was a delay in treatment when she had to be hospitalized for [REDACTED]. This affected two residents (Resident #38 and #74) out of five residents reviewed for quality care and treatment. The facility census was 80. Findings include: 1. Review of medical record for Resident #74 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/08/18, revealed the resident had severe cognitive impairment, had the [DIAGNOSES REDACTED]. Review of a physician order, dated 10/26/18, documented an order to check Resident #74's blood glucose four times a day, document the results and report if blood glucose was greater than 300. Review of the resident's comprehensive care plan documented Resident #74 had alterations in blood glucose due to insulin dependent diabetes mellitus. She had an intervention to report abnormal results per the physician parameters/guidelines. Review of the treatment record from 11/17/18 through 11/21/18 documented Resident #74's blood glucose was over 300 14 times during the time period reviewed. There was no evidence in the medical record the physician was notified of the increased blood glucose as physician ordered during this period until 11/21/18 at 8:00 A.M. Review of nurse's notes, dated 11/21/18, documented the Certified Nurse Practitioner (CNP) was notified at 8:00 A.M. that the resident's blood glucose was 582 at 12:00 A.M. and 587 at 6:00 A.M. The CNP ordered immediate (STAT) lab work including a complete blood count (CBC) and basic metabolic panel (BMP). She also ordered a urinalysis (UA) with culture and sensitivity to rule out urinary tract infection [MEDICAL CONDITION]. Review of the STAT laboratory work for CBC and BMP documented it was reported to the facility on [DATE] at 12:57 P.M. All the labs were abnormal with a glucose of 499 documented as high, sodium of 155 milliequivalents per liter (mEq/L) documented as repeated high and a chloride of 115 mEq/L documented as repeated high. The medical record lacked any documentation the facility notified the physician of the abnormal labs until the facility faxed over the results to the physician's office over two hours later at 3:05 P.M. Review of the nursing note, dated 11/21/18 at 2:55 P.M., documented the physician was in to see Resident #74 and received new orders for STAT chest x ray, CBC, BMP, and to check an UA also. The insulin orders were increased and administered as ordered. The medical record lacked any documentation the facility notified the physician while present in the facility of the abnormal STAT labs the resident had earlier that morning. Review of the STAT laboratory work, dated 11/21/18, documented it was faxed to the physician at 3:05 P.M. Review of the cover sheet faxed with the STAT results documented labs were obtained that morning per CNP orders. STAT CBC and BMP were canceled, and the STAT chest X-ray were in progress. The faxed information was signed by Licensed Practical Nurse (LPN) #22. Further review it was documented the laboratory work was faxed back to the facility at 4:31 P.M. by the physician with an order to send the resident out to the hospital for abnormal labs and lethargy. Review of nursing notes, dated 11/21/18 at 5:00 P.M., documented Resident #74 was sent to the hospital for evaluation and treatment. The medical record lacked any documentation of the UA being obtained to send to the laboratory as ordered prior to the resident's hospitalization . Review of the hospitalization history and physical, dated 11/21/18, documented the resident was admitted to the hospital with [REDACTED]. Review of the hospital discharge summary, dated 11/26/18, documented [DIAGNOSES REDACTED]. She was discharged with an order for [REDACTED]. On 12/05/18 at 5:03 P.M., an interview with Former Medical Director #600 verified if labs orders were ordered STAT, they were to be completed immediately and he would expect to be notified by telephone for abnormal values. He then revealed any abnormal labs should be called to him or the CNP to ensure proper care and treatment. He verified he was no longer [MEDICATION NAME] in the facility as the Medical Director, and his group left the facility because he had concerns about laboratory work, proper care and treatment were not getting completed as ordered. On 12/06/18 at 9:05 A.M., an interview with the Director of Nursing (DON) verified Resident #74's blood glucose levels were documented as over 300 on several occasions per the treatment record from 11/17/18 through 11/21/18. She also verified there was no documentation of the physician being notified or any changes in orders for the increased blood glucose levels. She further verified on 11/21/18 the CNP was not notified of the increased blood glucose until 8:00 A.M. as documented. She stated without any documentation, she cannot verify the physician was notified as ordered in an appropriate manner to ensure quality care and treatment. She also verified the facility does not have a policy for handling low or high blood sugars. She stated they use Lippincott's nursing procedure sixth edition as their procedure guide. She verified all physician's orders should be followed and she would expect the nurses to call the physician if STAT labs came back abnormal, and the nurses should not fax them. She verified the UA was never obtained after it was ordered. She stated the facility has to develop a policy on how to handle abnormal laboratory results. On 12/06/18 at 10:12 P.M., an interview with LPN #22 verified she was the nurse who received the laboratory results back from the lab. She stated typically she would call they physician about Resident #74's abnormal lab values because they were very abnormal. She then verified she faxed them but was not sure of the time. She also stated the whole facility was a mess and nothing was organized so she wasn't surprised the laboratory results got mishandled. On 12/10/18 at 12:53 P.M., an interview with the Administrator verified there were no policies to follow physician orders. She expected the nurses to follow them as ordered, provide documentation the orders were completed, and notifications have been done appropriately as ordered. Review of Lippincott's 2013 nursing procedures sixth edition documented nursing alert documents if you obtain an extremely low or high blood glucose monitoring reading result, obtain a serum level to confirm the result. Further review lacked any documentation of what level a high or low reading was identified as. Review of the facility policy and procedure titled notifications and reporting of changes in health status, illness, injury, and death of a resident, dated 01/01/18, documented the Administrator or administrator designee will immediately notify the physician for a significant change in the resident's physical status such as deterioration in health either life threatening or clinical complications. Further review documented the physician will be notified for a need to alter treatment significantly to discontinue or commence a new form or treatment. 2. Review of medical record for Resident #38 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 10/16/18, documented Resident #38 had moderately impaired cognition. He was also assessed as having a diabetic ulcer with treatments in place. Review of the comprehensive care plan documented Resident #38 had altered skin integrity non-pressure related to diabetic ulcer/vascular wound. The interventions included to conduct weekly skin inspections and provide treatments as ordered. Review of hospital discharge summaries, dated 10/31/18 through 11/02/18, documented the resident was admitted to the hospital for a schedule carotid surgery and was discharged to the extended care facility two days post carotid procedure. Review of nursing noted dated 11/02/18 documented Resident #38 had a bandage to his right toe and the dressing was completed prior to leaving the hospital. There lacked any assessment of the area or treatment order in place for dressing in place at the time of the resident's readmission. Review of wound evaluation and management summary dated 11/08/18 documented Resident #38 had a diabetic wound to the right lateral foot. It documented he had the wound greater than 91 days. He ordered a treatment to the right lateral foot. Review of physician orders and treatment administration record revealed they lacked any documentation of a treatment order being completed per the wound specialist treatment plan, until 11/18/18. Review of physician order dated 11/18/18 documented an order was put into place at this time to cleanse the right foot with normal saline pat dry, apply calcium alginate and cover with a dry dressing every day and as needed. Review of physician order dated 11/15/18 documented to check blood pressure manually ever shift and record results. Further directions were to notify the physician if systolic blood pressure (BP) was greater than 160 or diastolic BP was greater than 100. Review of entire medical record from 11/15/18 through 12/09/18 lacked any documentation of the BP being completed as ordered. On 12/04/18 at 10:10 AM., an interview with Resident #38's family member revealed the nurses were not checking his blood pressure three times a day as ordered. She verified she has not seen them check it at all. She also revealed he was not getting his dressing changes done as ordered in (MONTH) (YEAR). On 12/10/18 at 12:00 P.M., an interview with LPN #505 verified the resident's blood pressures were not being completed as physician ordered. She stated the order was not entered into the software to trigger for nursing to check his blood pressures. On 12/11/18 at 9:35 A.M. via telephone interview with Wound Specialist Physician #200 verified Resident #38 has had the wound since he returned from the hospital as far as he knows. He verified it was diagnosed as a diabetic ulcer due to chronic diabetes mellitus affecting his micro circulation and verified it was not healed before going to the hospital or after returning from the hospital. He also verified he has had a plan in place since Resident #38 was first seen for his wound. He verified he would except the facility to complete an order based on his treatment plan documented on his wound notes. He then verified an order should have been in place between 11/02/18 to 11/17/18 to properly treat his wound. He denied any deterioration to the wound. On 12/11/18 at 9:20 A.M., an interview with the Director of Nursing (DON) verified a treatment order for the resident's diabetic ulcer was not ordered or in place from 11/02/18 upon readmission from the hospital through 11/17/18. She further verified she was not able to verify the treatment was completed since there was no order for it and no documentation of it being completed. She was not sure what happened because she was not the DON at that time, but it looked like someone forgot to put the order back in place upon his readmission on 11/02/18. She further verified they have no policy on assessing, treating and monitoring diabetic wounds. This deficiency substantiates Complaint Number OH 175.

Based on review of medical records, review of facility Self-Reported Incidents (SRI), observation of photographs from a personal cell phone saved to a company laptop, interviews with a police detective, review of personnel files, review of time card punches, staff interviews and review of the facility's Social Media, Abuse and Handheld Device policies and procedures, the facility staff failed to immediately report inappropriate photographs that were taken of residents involving nudity found on a coworkers phone. The photographs were taken during the provision of personal care. This resulted in Immediate Jeopardy and potential for psychosocial harm for two resident's (#53 and #58) when Licensed Practical Nurse (LPN) #5 engaged in an act meant to humiliate and dehumanize residents by taking inappropriate photographs of one resident's exposed breasts and of one resident cupping a penis with both of her hands without permission from the resident and not in accordance with facility policy. The photographs were discovered on the personal cell phone of LPN #5 by State tested Nursing Assistant (STNA) #10 who had a personal relationship with LPN #5. This affected two (#53 and #58) of four residents reviewed for abuse. The facility identified 20 cognitively impaired female residents residing on the unit where LPN #5 worked. On 07/20/17 at 3:37 P.M., the Administrator, Chief Operating Officer (COO) #88, Chief Clinical Officer (CCO) #89 and Clinical Compliance Specialist (CCS) #90 were notified Immediate Jeopardy began on 07/09/17 at 10:00 A.M. when LPN #5 took inappropriate photographs of Residents #53 and #58. Both residents are cognitively impaired and were not able to give consent for photographs being taken. The facility was able to identify in the photographs Resident #58's exposed breasts and Resident #53 cupping a penis with both of her hands. STNA #10 failed to immediately report the nude photographs involving exposed female breasts she had observed on LPN #5's personal cell phone the prior evening, 07/16/17. The Immediate Jeopardy was removed on 07/17/17 at 5:00 P.M. when all staff were in-serviced regarding the identification of abuse, the abuse policy and social media policy. The deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not immediate jeopardy) until it was corrected on 07/31/17 when the facility implemented the following corrective actions: · On 07/17/17 between 2:00 P.M. and 3:00 P.M, the facility Administrator initiated an investigation into LPN #5 taking inappropriate photographs of residents and LPN #5 was removed from direct resident care and observed/monitored by the Director of Nursing (DON). · On 07/17/17 between 3:30 P.M. and 5:00 P.M., the Administrator notified COO #88 and CCO #89 of the allegation, the Administrator suspended STNA #10 and notified the local police department. The Administrator, COO #88 and CCO #89 interviewed LPN #5 per the request of the police department. LPN #5 was arrested by the local police department. · On 07/17/17 between 3:30 P.M. and 5:00 P.M. the following was also completed: the Administrator and the DON completed resident interviews of alert and oriented female residents on the 400 unit (the unit LPN#5 worked on). The DON, Registered Nurses (RN) #44 and #45, and LPNs # 46 and #57 began head to toe skin assessments on the cognitively impaired female residents on the 400 unit. · On 07/17/17 between 3:30 P.M. and 5:00 P.M., the DON and Social Services Director (SSD) #15 began re-educating all staff members on the social media policy, reporting abuse policy and procedure, cellular phone use in the work place and explained cellular phone use in work areas and taking pictures of residents was prohibited. Staff were also interviewed regarding if any employee had been observed taking pictures of residents. · On 07/17/17 at 6:32 P.M., the facility reported the incident to the Ohio Department of Health. · On 07/18/17 at 10:15 A.M., Detective #92 came to the facility and requested STNA #10 to come to the facility for an interview. The facility requested the photographs from LPN #5's cellular phone, but Detective #92 indicated he was unable to release the photographs due to forensic review and an on-going investigation. · On 07/18/17, STNA #10 brought her personal cell phone to the facility per the request of the Administrator and the photographs were viewed again. Residents #53 and #58 were identified in some of the photographs by a night gown and an afghan. · On 07/19/17, Medical Doctor (MD) #1 examined Residents #53 and #58. · On 07/19/17 through 07/20/17, interviews were conducted with STNA #72, LPNs #55 and #60 and RN #50. All reported they have not observed any staff photographing residents on the units with their cell phones. They were aware of the strict prohibition of such actions and to report anyone seen photographing residents to the charge nurse. They all stated they received training by reviewing the Abuse policy and Social Media procedure regarding privacy. · On 07/19/17 through 07/20/17 interviews were conducted with Residents #50, #57, #59 and #63. All reported no abuse or unwanted photography in regards to their privacy. · On 07/20/17, review of the medical records of Resident #57 and #60 revealed no concerns with potential abuse. Findings include: Review of Resident #53's medical record revealed she was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment completed on 05/10/17 assessed the resident to have severe impairment with cognition. Review of Resident #58's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the MDS assessment completed on 07/26/17 assessed the resident to have severe impairment with cognition. Review of the facility SRI, dated 07/17/17 under the category of emotional and verbal abuse, revealed a staff member reported a concern to the Administrator that LPN #5 had photographed residents without their permission. STNA #10 identified Residents #57, #58 and #60 as potential residents. During the facility investigation Residents #53 and #58 were the only two residents identified in the photographs. The local police were notified and were still in the process of their investigation. During an interview on 07/19/17 at 9:20 A.M., the Administrator stated STNA #10 shared a concern with him of LPN #5 having inappropriate pictures on his personal cell phone. STNA #10 was dating LPN #5 and STNA #10 was concerned LPN #5 was cheating on her so she went through his personal cell phone. She found pictures of women with their breasts exposed and was concerned the pictures were of residents at the facility. STNA #10 took pictures with her personal cell phone of the pictures she found on LPN #5's phone and reported what she had discovered to the facility on [DATE] at approximately 2:00 P.M. The Administrator stated there were no faces in the photographs but there were pictures of female breasts and in some of the photos, hospital gowns were visible. The Administrator stated STNA #10 and LPN #5 were both suspended and the local police department was notified. He further stated STNA #10 was cleared on 07/18/17 by the police and she was going to come back to work but she requested a few days off. The Administrator stated the local police were still investigating the issue. STNA #10 identified three residents who she thought were in the pictures. The Administrator stated two of the residents named in the SRI were identified by a blanket and by their hands. He further stated the local police took possession of both phones and arrested LPN #5. The Administrator stated LPN #5 had worked at the facility for a few years and always worked first shift on the 400 hall. The Administrator stated only one of the three residents identified in the SRI were interviewable. The facility interviewed other residents on the 400 hall and they denied being photographed without their permission. The Administrator stated the day they were made aware of the situation, they began in-servicing all staff on the cell phone, abuse and social media policies. The Administrator stated the Ombudsman came out and interviewed residents as well and got the same results as the facility. The Administrator stated the facility notified the local police, in-serviced all staff on the cell phone, abuse and social medial policy, interviewed residents and preformed skin and body checks on the residents on the 400 hall where LPN # 5 worked as corrective action since notification of the pictures being taken. During an interview on 07/19/17 at 11:15 A.M. with COO #88 and CCO #89 they stated Resident #58 was identified as one of the residents in the photographs because her personal afghan was visible in the photographs. They further stated Resident #53 was identified as one of the residents because her personal gown and her watch were visible in the photographs. They stated there were other photographs but they were unable to identify who the residents were. One of the photographs had a red velour shirt that was visible and despite checking resident rooms and the laundry, they have not been able to identify the resident who owned this shirt. They stated STNA #10 was also able to identify LPN #5's watch in at least one of the pictures. They stated they believed LPN #5 took the pictures of the residents during medication administration. They stated the facility was in the process of notifying family members of the residents who were identified in the pictures. The Administrator had a family meeting scheduled for 07/19/17 during the evening to discuss concerns. They stated the facility's Information Technology (IT) helpdesk did a computer check and found no evidence the pictures had been posted from any of the facility's computers. During a telephone interview on 07/19/17 at 1:30 P.M., Detective #92 stated he could not divulge any information about the case involving LPN #5 as it was still under active investigation. He stated he could not give a time line for completion of the investigation. He stated the only pages of the police report he would be able to release would only have the address of the facility. He stated more information could be provided once the investigation was completed. On 07/19/17 at 2:01 P.M., an observation was made of the photographs on a facility laptop with COO #88, CCO #89 and CCS #90. During the observation COO #88 stated the photographs were from STNA #10's personal cell phone and STNA #10 had taken photographs of photographs she found on LPN #5's personal cell phone. Two photographs dated 06/15/17 at 9:58 A.M. and 9:59 A.M. revealed an exposed female breast with a hospital gown surrounding the breast. A photograph dated 06/21/17 at 10:28 A.M. was of an exposed female breast with a red velour shirt surrounding the breast. Two photographs dated 06/25/17 at 1:05 P.M. revealed an exposed female breast with a hospital gown surrounding the breast. Several pictures dated on 07/09/17 at 10:00 A.M. and 10:03 A.M. of an exposed female breast with a pink colored nightgown surrounding the breast. In one of the photographs, a male hand is noted with a black watch around the wrist. Observation of a photograph on 07/09/17 at 10:06 A.M. revealed an exposed female breast with a blue afghan noted in the photograph. A photograph on 07/09/17 at 10:11 A.M. noted a female resident wearing a pink nightgown cupping a penis in both of her hands. A watch was also noted on the wrist of the female resident. COO #88 and CCO #89 identified Residents #53 and #58 in the photographs from 07/09/17. They also stated STNA #10 identified the black watch as belonging to LPN #5. On 07/20/17 at 11:05 A.M., an attempt was made to contact STNA #10 via phone. A message indicated the voice mail was full and messages could not be left. At approximately 11:20 A.M., CCO #89 reported STNA #10 would come to the facility for a 1:30 P.M. interview. During an interview on 07/20/17 at 11:45 A.M., COO #88 verified STNA #10 had found the photographs on LPN #5's phone the evening before reporting it to the facility. She stated STNA #10 had found other pictures of children on the phone, was distraught, and did not look completely through all the pictures until the next day as the explanation for why her knowledge of the pictures was not reported to the facility until around 2:00 P.M. the next day. During an interview on 07/20/17 at 11:55 A.M. with COO #88, she stated the time clock system clocks a staff member out and back in at shift change times such as 7:00 A.M. and 3:00 P.M. to ensure payment for shift differential. She stated LPN #5 clocked out from 1:48 P.M. to 2:18 P.M. for lunch. She stated the facility clocked him out at 4:30 P.M. as he had left earlier with the police. She stated their records show he was charting for a long time that day starting at 11:00 A.M. She reported once they became aware of the report of the pictures, they were detaining him per police request and he was being monitored by the DON. On 07/20/17 at 1:20 P.M., CCO #89 stated STNA #10 was at the facility but was having personnel issues and did not feel she could complete the interview. STNA #10 provided a written statement. Review of a written statement dated 07/20/17 by STNA #10 revealed she came into work on Monday (07/17/17) and put the dailies (resident census and number of staff working for the day) at the front desk. She proceeded to go through her phone and noticed she could identify some of the residents in the pictures. She identified a personal blanket that belonged to one resident and identified a personal gown and watch another resident wore. She indicated she started to panic and she called her therapist and left a message. Her therapist called her back and informed her she needed to notify the Administrator immediately. She requested a meeting to talk to the Administrator but it was scheduled for later in the day. She informed the Administrator it couldn't wait and she got her phone and showed him the photographs she had on her phone. Review of the time card punches for LPN #5 revealed a clock in on 07/17/17 at 6:57 A.M., clock out at 7:00 A.M., clock in at 7:00 A.M., clock out at 1:48 P.M, clock in at 2:18 P.M., clock out at 3:00 P.M., clock in at 3:00 P.M. and a clock out at 4:30 P.M. Review of the time card punches for STNA #10 revealed a clock in on 07/17/17 at 8:05 A.M., clock out at 8:46 A.M., clock in at 9:14 A.M., clock out at 3:00 P.M, clock in at 3:00 P.M. and a clock out at 4:30 P.M. Review of LPN #5's personnel file revealed a hire date of 02/12/15. LPN # 5 acknowledged he had received in-service on abuse and cell phone usage on 01/03/17 and again on 06/29/17. Review of STNA #10's personnel file revealed a hire date of 02/25/16. STNA #10 acknowledged she had received in-service on 01/03/17 and again on 06/29/17. Review of the facility policy titled Social Media Policy with a revised date of 04/2017 revealed staff are prohibited from posting any content that has personal health information including patient images without a written and signed consent form from the patient or the legal guardian of the patient. Review of the facility policy titled Abuse Prohibition Policy and Procedure, undated, revealed it is the policy of the facility to maintain an environment free from abuse and neglect, residents will not be subjected to such events by anyone, this facility will comply with all federal and state requirements to screen, train, prevent, identify, investigate, protect and report any event that is not consistent with the nursing facility standard of care. Review of the facility policy titled General policy for Handheld Devices, undated, revealed employees are strictly prohibited from taking a handheld device into any resident care area without the prior approval of management. Employees permitted to use a handheld device in resident care areas are strictly prohibited from using handheld devices to take or distribute photographs, audio, video or any other type of recording of residents (regardless of whether a resident gives consent). Employees may not use a handheld device to take photographs, video, or audio recordings anywhere at any time within the workplace.

Based on review of medical records, review of facility Self-Reported Incidents (SRI), observation of a photographs from a personal cell phone saved to a company laptop, interviews with a police detective, review of personnel files, review of time card punches, staff interviews and review of the facility's Social Media, Abuse and Handheld Device policies and procedures, the facility staff failed to implement the facility's policy to ensure residents were free from mental and emotional abuse by a facility staff member and to immediately report inappropriate photographs found on a coworkers phone. The photographs were taken during the provision of personal care. This resulted in Immediate Jeopardy and potential for psychosocial harm for two Resident's (#53 and #58) when Licensed Practical Nurse (LPN) #5 engaged in an act meant to humiliate and dehumanize residents by taking inappropriate photographs of one resident's exposed breasts and of one resident cupping a penis with both of her hands without permission from the residents and not in accordance with facility policy. The photographs were discovered on the personal cell phone of LPN #5 by State tested Nursing Assistant (STNA) #10 who had a personal relationship with LPN #5. This affected two (#53 and #58) of four residents reviewed for abuse. The facility identified 20 cognitively impaired female residents residing on the unit where LPN #5 worked. On 07/20/17 at 3:37 P.M., the Administrator, Chief Operating Officer (COO) #88, Chief Clinical Officer (CCO) #89 and Clinical Compliance Specialist (CCS) #90 were notified Immediate Jeopardy began on 07/09/17 at 10:00 A.M. when LPN #5 took inappropriate photographs of Residents #53 and #58. Both residents are cognitively impaired and were not able to give consent for photographs being taken. The facility was able to identify in the photographs Resident #58's exposed breasts and Resident #53 cupping a penis with both of her hands. STNA #10 failed to immediately report the nude photographs involving exposed female breasts she had observed on LPN #5's personal cell phone the prior evening, 07/16/17. The Immediate Jeopardy was removed on 07/17/17 at 5:00 P.M. when all staff were in-serviced regarding the identification of abuse, the abuse policy and social media policy. The deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not immediate jeopardy) until it was corrected on 07/31/17 when the facility implemented the following corrective actions: · On 07/17/17 between 2:00 P.M. and 3:00 P.M, the facility Administrator initiated an investigation into LPN #5 taking inappropriate photographs of residents and LPN #5 was removed from direct resident care and observed/monitored by the Director of Nursing (DON). · On 07/17/17 between 3:30 P.M. and 5:00 P.M., the Administrator notified COO #88 and CCO #89 of the allegation, the Administrator suspended STNA #10 and notified the local police department. The Administrator, COO #88 and CCO #89 interviewed LPN #5 per the request of the police department. LPN #5 was arrested by the local police department. · On 07/17/17 between 3:30 P.M. and 5:00 P.M. the following was also completed: the Administrator and the DON completed resident interviews of alert and oriented female residents on the 400 unit (the unit LPN#5 worked on). The DON, Registered Nurses (RN) #44 and #45, and LPNs # 46 and #57 began head to toe skin assessments on the cognitively impaired female residents on the 400 unit. · On 07/17/17 between 3:30 P.M. and 5:00 P.M., the DON and Social Services Director (SSD) #15 began re-educating all staff members on the social media policy, reporting abuse policy and procedure, cellular phone use in the work place and explained cellular phone use in work areas and taking pictures of residents was prohibited. Staff were also interviewed regarding if any employee had been observed taking pictures of residents. · On 07/17/17 at 6:32 P.M., the facility reported the incident to the Ohio Department of Health. · On 07/18/17 at 10:15 A.M., Detective #92 came to the facility and requested STNA #10 to come to the facility for an interview. The facility requested the photographs from LPN #5's cellular phone, but Detective #92 indicated he was unable to release the photographs due to forensic review and an on-going investigation. · On 07/18/17, STNA #10 brought her personal cell phone to the facility per the request of the Administrator and the photographs were viewed again. Residents #53 and #58 were identified in some of the photographs by a night gown and an afghan. · On 07/19/17, Medical Doctor (MD) #1 examined Residents #53 and #58. · On 07/19/17 through 07/20/17, interviews were conducted with STNA #72, LPNs #55 and #60 and RN #50. All reported they have not observed any staff photographing residents on the units with their cell phones. They were aware of the strict prohibition of such actions and to report anyone seen photographing residents to the charge nurse. They all stated they received training by reviewing the Abuse policy and Social Media procedure regarding privacy. · On 07/19/17 through 07/20/17 interviews were conducted with Residents #50, #57, #59 and #63. All reported no abuse or unwanted photography in regards to their privacy. · On 07/20/17, review of the medical records of Resident #57 and #60 revealed no concerns with potential abuse. Findings include: Review of Resident #53's medical record revealed she was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment completed on 05/10/17 assessed the resident to have severe impairment with cognition. Review of Resident #58's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the MDS assessment completed on 07/26/17 assessed the resident to have severe impairment with cognition. Review of the facility SRI, dated 07/17/17 under the category of emotional and verbal abuse, revealed a staff member reported a concern to the Administrator that LPN #5 had photographed residents without their permission. STNA #10 identified Residents #57, #58 and #60 as potential residents. During the facility investigation Residents #53 and #58 were the only two residents identified in the photographs. The local police were notified and were still in the process of their investigation. During an interview on 07/19/17 at 9:20 A.M., the Administrator stated STNA #10 shared a concern with him of LPN #5 having inappropriate pictures on his personal cell phone. STNA #10 was dating LPN #5 and STNA #10 was concerned LPN #5 was cheating on her so she went through his personal cell phone. She found pictures of women with their breasts exposed and was concerned the pictures were of residents at the facility. STNA #10 took pictures with her personal cell phone of the pictures she found on LPN #5's phone and reported what she had discovered to the facility on [DATE] at approximately 2:00 P.M. The Administrator stated there were no faces in the photographs but there were pictures of female breasts and in some of the photos, hospital gowns were visible. The Administrator stated STNA #10 and LPN #5 were both suspended and the local police department was notified. He further stated STNA #10 was cleared on 07/18/17 by the police and she was going to come back to work but she requested a few days off. The Administrator stated the local police were still investigating the issue. STNA #10 identified three residents who she thought were in the pictures. The Administrator stated two of the residents named in the SRI were identified by a blanket and by their hands. He further stated the local police took possession of both phones and arrested LPN #5. The Administrator stated LPN #5 had worked at the facility for a few years and always worked first shift on the 400 hall. The Administrator stated only one of the three residents identified in the SRI were interviewable. The facility interviewed other residents on the 400 hall and they denied being photographed without their permission. The Administrator stated the day they were made aware of the situation, they began in-servicing all staff on the cell phone, abuse and social media policies. The Administrator stated the Ombudsman came out and interviewed residents as well and got the same results as the facility. The Administrator stated the facility notified the local police, in-serviced all staff on the cell phone, abuse and social medial policy, interviewed residents and preformed skin and body checks on the residents on the 400 hall where LPN # 5 worked as corrective action since notification of the pictures being taken. During an interview on 07/19/17 at 11:15 A.M. with COO #88 and CCO #89 they stated Resident #58 was identified as one of the residents in the photographs because her personal afghan was visible in the photographs. They further stated Resident #53 was identified as one of the residents because her personal gown and her watch were visible in the photographs. They stated there were other photographs but they were unable to identify who the residents were. One of the photographs had a red velour shirt that was visible and despite checking resident rooms and the laundry, they have not been able to identify the resident who owned this shirt. They stated STNA #10 was also able to identify LPN #5's watch in at least one of the pictures. They stated they believed LPN #5 took the pictures of the residents during medication administration. They stated the facility was in the process of notifying family members of the residents who were identified in the pictures. The Administrator had a family meeting scheduled for 07/19/17 during the evening to discuss concerns. They stated the facility's Information Technology (IT) helpdesk did a computer check and found no evidence the pictures had been posted from any of the facility's computers. During a telephone interview on 07/19/17 at 1:30 P.M., Detective #92 stated he could not divulge any information about the case involving LPN #5 as it was still under active investigation. He stated he could not give a time line for completion of the investigation. He stated the only pages of the police report he would be able to release would only have the address of the facility. He stated more information could be provided once the investigation was completed. On 07/19/17 at 2:01 P.M., an observation was made of the photographs on a facility laptop with COO #88, CCO #89 and CCS #90. During the observation COO #88 stated the photographs were from STNA #10's personal cell phone and STNA #10 had taken photographs of photographs she found on LPN #5's personal cell phone. Two photographs dated 06/15/17 at 9:58 A.M. and 9:59 A.M. revealed an exposed female breast with a hospital gown surrounding the breast. A photograph dated 06/21/17 at 10:28 A.M. was of an exposed female breast with a red velour shirt surrounding the breast. Two photographs dated 06/25/17 at 1:05 P.M. revealed an exposed female breast with a hospital gown surrounding the breast. Several pictures dated on 07/09/17 at 10:00 A.M. and 10:03 A.M. of an exposed female breast with a pink colored nightgown surrounding the breast. In one of the photographs, a male hand is noted with a black watch around the wrist. Observation of a photograph on 07/09/17 at 10:06 A.M. revealed an exposed female breast with a blue afghan noted in the photograph. A photograph on 07/09/17 at 10:11 A.M. noted a female resident wearing a pink nightgown cupping a penis in both of her hands. A watch was also noted on the wrist of the female resident. COO #88 and CCO #89 identified Residents #53 and #58 in the photographs from 07/09/17. They also stated STNA #10 identified the black watch as belonging to LPN #5. On 07/20/17 at 11:05 A.M., an attempt was made to contact STNA #10 via phone. A message indicated the voice mail was full and messages could not be left. At approximately 11:20 A.M., CCO #89 reported STNA #10 would come to the facility for a 1:30 P.M. interview. During an interview on 07/20/17 at 11:45 A.M., COO #88 verified STNA #10 had found the photographs on LPN #5's phone the evening before reporting it to the facility. She stated STNA #10 had found other pictures of children on the phone, was distraught, and did not look completely through all the pictures until the next day as the explanation for why her knowledge of the pictures was not reported to the facility until around 2:00 P.M. the next day. During an interview on 07/20/17 at 11:55 A.M. with COO #88, she stated the time clock system clocks a staff member out and back in at shift change times such as 7:00 A.M. and 3:00 P.M. to ensure payment for shift differential. She stated LPN #5 clocked out from 1:48 P.M. to 2:18 P.M. for lunch. She stated the facility clocked him out at 4:30 P.M. as he had left earlier with the police. She stated their records show he was charting for a long time that day starting at 11:00 A.M. She reported once they became aware of the report of the pictures, they were detaining him per police request and he was being monitored by the DON. On 07/20/17 at 1:20 P.M., CCO #89 stated STNA #10 was at the facility but was having personnel issues and did not feel she could complete the interview. STNA #10 provided a written statement. Review of a written statement dated 07/20/17 by STNA #10 revealed she came into work on Monday (07/17/17) and put the dailies (resident census and number of staff working for the day) at the front desk. She proceeded to go through her phone and noticed she could identify some of the residents in the pictures. She identified a personal blanket that belonged to one resident and identified a personal gown and watch another resident wore. She indicated she started to panic and she called her therapist and left a message. Her therapist called her back and informed her she needed to notify the Administrator immediately. She requested a meeting to talk to the Administrator but it was scheduled for later in the day. She informed the Administrator it couldn't wait and she got her phone and showed him the photographs she had on her phone. Review of the time card punches for LPN #5 revealed a clock in on 07/17/17 at 6:57 A.M., clock out at 7:00 A.M., clock in at 7:00 A.M., clock out at 1:48 P.M, clock in at 2:18 P.M., clock out at 3:00 P.M., clock in at 3:00 P.M. and a clock out at 4:30 P.M. Review of the time card punches for STNA #10 revealed a clock in on 07/17/17 at 8:05 A.M., clock out at 8:46 A.M., clock in at 9:14 A.M., clock out at 3:00 P.M, clock in at 3:00 P.M. and a clock out at 4:30 P.M. Review of LPN #5's personnel file revealed a hire date of 02/12/15. LPN # 5 acknowledged he had received in-service on abuse and cell phone usage on 01/03/17 and again on 06/29/17. Review of STNA #10's personnel file revealed a hire date of 02/25/16. STNA #10 acknowledged she had received in-service on 01/03/17 and again on 06/29/17. Review of the facility policy titled Social Media Policy with a revised date of 04/2017 revealed staff are prohibited from posting any content that has personal health information including patient images without a written and signed consent form from the patient or the legal guardian of the patient. Review of the facility policy titled Abuse Prohibition Policy and Procedure, undated, revealed it is the policy of the facility to maintain an environment free from abuse and neglect, residents will not be subjected to such events by anyone, this facility will comply with all federal and state requirements to screen, train, prevent, identify, investigate, protect and report any event that is not consistent with the nursing facility standard of care. Review of the facility policy titled General policy for Handheld Devices, undated, revealed employees are strictly prohibited from taking a handheld device into any resident care area without the prior approval of management. Employees permitted to use a handheld device in resident care areas are strictly prohibited from using handheld devices to take or distribute photographs, audio, video or any other type of recording of residents (regardless of whether a resident gives consent). Employees may not use a handheld device to take photographs, video, or audio recordings anywhere at any time within the workplace.

Based on review of medical records, review of facility Self-Reported Incidents (SRI), observation of photographs from a personal cell phone saved to a company laptop, interviews with a police detective, review of personnel files, review of time card punches, staff interviews and review of the facility's Social Media, Abuse and Handheld Device policies and procedures, the facility failed to ensure a resident's right to privacy and confidentiality were maintained by a facility staff member during the provision of care and services. This resulted in Immediate Jeopardy and potential for psychosocial harm for two residents (#53 and #58) when Licensed Practical Nurse (LPN) #5 engaged in an act meant to humiliate and dehumanize residents by taking inappropriate photographs of one resident's exposed breasts and of one resident cupping a penis with both of her hands without permission from the residents and not in accordance with facility policy. The photographs were discovered on the personal cell phone of LPN #5 by State tested Nursing Assistant (STNA) #10 who had a personal relationship with LPN #5. This affected two (#53 and #58) of four residents reviewed for abuse. The facility identified 20 cognitively impaired female residents residing on the unit where LPN #5 worked. On 07/20/17 at 3:37 P.M., the Administrator, Chief Operating Officer (COO) #88, Chief Clinical Officer (CCO) #89 and Clinical Compliance Specialist (CCS) #90 were notified Immediate Jeopardy began on 07/09/17 at 10:00 A.M. when LPN #5 took inappropriate photographs of Residents #53 and #58. Both residents are cognitively impaired and were not able to give consent for photographs being taken. The facility was able to identify in the photographs Resident #58's exposed breasts and Resident #53 cupping a penis with both of her hands. STNA #10 failed to immediately report the nude photographs involving exposed female breasts she had observed on LPN #5's personal cell phone the prior evening, 07/16/17. The Immediate Jeopardy was removed on 07/17/17 at 5:00 P.M. when all staff were in-serviced regarding the identification of abuse, the abuse policy and social media policy. The deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not immediate jeopardy) until it was corrected on 07/31/17 when the facility implemented the following corrective actions: · On 07/17/17 between 2:00 P.M. and 3:00 P.M, the facility Administrator initiated an investigation into LPN #5 taking inappropriate photographs of residents and LPN #5 was removed from direct resident care and observed/monitored by the Director of Nursing (DON). · On 07/17/17 between 3:30 P.M. and 5:00 P.M., the Administrator notified COO #88 and CCO #89 of the allegation, the Administrator suspended STNA #10 and notified the local police department. The Administrator, COO #88 and CCO #89 interviewed LPN #5 per the request of the police department. LPN #5 was arrested by the local police department. · On 07/17/17 between 3:30 P.M. and 5:00 P.M. the following was also completed: the Administrator and the DON completed resident interviews of alert and oriented female residents on the 400 unit (the unit LPN#5 worked on). The DON, Registered Nurses (RN) #44 and #45, and LPNs # 46 and #57 began head to toe skin assessments on the cognitively impaired female residents on the 400 unit. · On 07/17/17 between 3:30 P.M. and 5:00 P.M., the DON and Social Services Director (SSD) #15 began re-educating all staff members on the social media policy, reporting abuse policy and procedure, cellular phone use in the work place and explained cellular phone use in work areas and taking pictures of residents was prohibited. Staff were also interviewed regarding if any employee had been observed taking pictures of residents. · On 07/17/17 at 6:32 P.M., the facility reported the incident to the Ohio Department of Health. · On 07/18/17 at 10:15 A.M., Detective #92 came to the facility and requested STNA #10 to come to the facility for an interview. The facility requested the photographs from LPN #5's cellular phone, but Detective #92 indicated he was unable to release the photographs due to forensic review and an on-going investigation. · On 07/18/17, STNA #10 brought her personal cell phone to the facility per the request of the Administrator and the photographs were viewed again. Residents #53 and #58 were identified in some of the photographs by a night gown and an afghan. · On 07/19/17, Medical Doctor (MD) #1 examined Residents #53 and #58. · On 07/19/17 through 07/20/17, interviews were conducted with STNA #72, LPNs #55 and #60 and RN #50. All reported they have not observed any staff photographing residents on the units with their cell phones. They were aware of the strict prohibition of such actions and to report anyone seen photographing residents to the charge nurse. They all stated they received training by reviewing the Abuse policy and Social Media procedure regarding privacy. · On 07/19/17 through 07/20/17 interviews were conducted with Residents #50, #57, #59 and #63. All reported no abuse or unwanted photography in regards to their privacy. · On 07/20/17, review of the medical records of Resident #57 and #60 revealed no concerns with potential abuse. Findings include: Review of Resident #53's medical record revealed she was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment completed on 05/10/17 assessed the resident to have severe impairment with cognition. Review of Resident #58's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the MDS assessment completed on 07/26/17 assessed the resident to have severe impairment with cognition. Review of the facility SRI, dated 07/17/17 under the category of emotional and verbal abuse, revealed a staff member reported a concern to the Administrator that LPN #5 had photographed residents without their permission. STNA #10 identified Residents #57, #58 and #60 as potential residents. During the facility investigation Residents #53 and #58 were the only two residents identified in the photographs. The local police were notified and were still in the process of their investigation. During an interview on 07/19/17 at 9:20 A.M., the Administrator stated STNA #10 shared a concern with him of LPN #5 having inappropriate pictures on his personal cell phone. STNA #10 was dating LPN #5 and STNA #10 was concerned LPN #5 was cheating on her so she went through his personal cell phone. She found pictures of women with their breasts exposed and was concerned the pictures were of residents at the facility. STNA #10 took pictures with her personal cell phone of the pictures she found on LPN #5's phone and reported what she had discovered to the facility on [DATE] at approximately 2:00 P.M. The Administrator stated there were no faces in the photographs but there were pictures of female breasts and in some of the photos, hospital gowns were visible. The Administrator stated STNA #10 and LPN #5 were both suspended and the local police department was notified. He further stated STNA #10 was cleared on 07/18/17 by the police and she was going to come back to work but she requested a few days off. The Administrator stated the local police were still investigating the issue. STNA #10 identified three residents who she thought were in the pictures. The Administrator stated two of the residents named in the SRI were identified by a blanket and by their hands. He further stated the local police took possession of both phones and arrested LPN #5. The Administrator stated LPN #5 had worked at the facility for a few years and always worked first shift on the 400 hall. The Administrator stated only one of the three residents identified in the SRI were interviewable. The facility interviewed other residents on the 400 hall and they denied being photographed without their permission. The Administrator stated the day they were made aware of the situation, they began in-servicing all staff on the cell phone, abuse and social media policies. The Administrator stated the Ombudsman came out and interviewed residents as well and got the same results as the facility. The Administrator stated the facility notified the local police, in-serviced all staff on the cell phone, abuse and social medial policy, interviewed residents and preformed skin and body checks on the residents on the 400 hall where LPN # 5 worked as corrective action since notification of the pictures being taken. During an interview on 07/19/17 at 11:15 A.M. with COO #88 and CCO #89 they stated Resident #58 was identified as one of the residents in the photographs because her personal afghan was visible in the photographs. They further stated Resident #53 was identified as one of the residents because her personal gown and her watch were visible in the photographs. They stated there were other photographs but they were unable to identify who the residents were. One of the photographs had a red velour shirt that was visible and despite checking resident rooms and the laundry, they have not been able to identify the resident who owned this shirt. They stated STNA #10 was also able to identify LPN #5's watch in at least one of the pictures. They stated they believed LPN #5 took the pictures of the residents during medication administration. They stated the facility was in the process of notifying family members of the residents who were identified in the pictures. The Administrator had a family meeting scheduled for 07/19/17 during the evening to discuss concerns. They stated the facility's Information Technology (IT) helpdesk did a computer check and found no evidence the pictures had been posted from any of the facility's computers. During a telephone interview on 07/19/17 at 1:30 P.M., Detective #92 stated he could not divulge any information about the case involving LPN #5 as it was still under active investigation. He stated he could not give a time line for completion of the investigation. He stated the only pages of the police report he would be able to release would only have the address of the facility. He stated more information could be provided once the investigation was completed. On 07/19/17 at 2:01 P.M., an observation was made of the photographs on a facility laptop with COO #88, CCO #89 and CCS #90. During the observation COO #88 stated the photographs were from STNA #10's personal cell phone and STNA #10 had taken photographs of photographs she found on LPN #5's personal cell phone. Two photographs dated 06/15/17 at 9:58 A.M. and 9:59 A.M. revealed an exposed female breast with a hospital gown surrounding the breast. A photograph dated 06/21/17 at 10:28 A.M. was of an exposed female breast with a red velour shirt surrounding the breast. Two photographs dated 06/25/17 at 1:05 P.M. revealed an exposed female breast with a hospital gown surrounding the breast. Several pictures dated on 07/09/17 at 10:00 A.M. and 10:03 A.M. of an exposed female breast with a pink colored nightgown surrounding the breast. In one of the photographs, a male hand is noted with a black watch around the wrist. Observation of a photograph on 07/09/17 at 10:06 A.M. revealed an exposed female breast with a blue afghan noted in the photograph. A photograph on 07/09/17 at 10:11 A.M. noted a female resident wearing a pink nightgown cupping a penis in both of her hands. A watch was also noted on the wrist of the female resident. COO #88 and CCO #89 identified Residents #53 and #58 in the photographs from 07/09/17. They also stated STNA #10 identified the black watch as belonging to LPN #5. On 07/20/17 at 11:05 A.M., an attempt was made to contact STNA #10 via phone. A message indicated the voice mail was full and messages could not be left. At approximately 11:20 A.M., CCO #89 reported STNA #10 would come to the facility for a 1:30 P.M. interview. During an interview on 07/20/17 at 11:45 A.M., COO #88 verified STNA #10 had found the photographs on LPN #5's phone the evening before reporting it to the facility. She stated STNA #10 had found other pictures of children on the phone, was distraught, and did not look completely through all the pictures until the next day as the explanation for why her knowledge of the pictures was not reported to the facility until around 2:00 P.M. the next day. During an interview on 07/20/17 at 11:55 A.M. with COO #88, she stated the time clock system clocks a staff member out and back in at shift change times such as 7:00 A.M. and 3:00 P.M. to ensure payment for shift differential. She stated LPN #5 clocked out from 1:48 P.M. to 2:18 P.M. for lunch. She stated the facility clocked him out at 4:30 P.M. as he had left earlier with the police. She stated their records show he was charting for a long time that day starting at 11:00 A.M. She reported once they became aware of the report of the pictures, they were detaining him per police request and he was being monitored by the DON. On 07/20/17 at 1:20 P.M., CCO #89 stated STNA #10 was at the facility but was having personnel issues and did not feel she could complete the interview. STNA #10 provided a written statement. Review of a written statement dated 07/20/17 by STNA #10 revealed she came into work on Monday (07/17/17) and put the dailies (resident census and number of staff working for the day) at the front desk. She proceeded to go through her phone and noticed she could identify some of the residents in the pictures. She identified a personal blanket that belonged to one resident and identified a personal gown and watch another resident wore. She indicated she started to panic and she called her therapist and left a message. Her therapist called her back and informed her she needed to notify the Administrator immediately. She requested a meeting to talk to the Administrator but it was scheduled for later in the day. She informed the Administrator it couldn't wait and she got her phone and showed him the photographs she had on her phone. Review of the time card punches for LPN #5 revealed a clock in on 07/17/17 at 6:57 A.M., clock out at 7:00 A.M., clock in at 7:00 A.M., clock out at 1:48 P.M, clock in at 2:18 P.M., clock out at 3:00 P.M., clock in at 3:00 P.M. and a clock out at 4:30 P.M. Review of the time card punches for STNA #10 revealed a clock in on 07/17/17 at 8:05 A.M., clock out at 8:46 A.M., clock in at 9:14 A.M., clock out at 3:00 P.M, clock in at 3:00 P.M. and a clock out at 4:30 P.M. Review of LPN #5's personnel file revealed a hire date of 02/12/15. LPN # 5 acknowledged he had received in-service on abuse and cell phone usage on 01/03/17 and again on 06/29/17. Review of STNA #10's personnel file revealed a hire date of 02/25/16. STNA #10 acknowledged she had received in-service on 01/03/17 and again on 06/29/17. Review of the facility policy titled Social Media Policy with a revised date of 04/2017 revealed staff are prohibited from posting any content that has personal health information including patient images without a written and signed consent form from the patient or the legal guardian of the patient. Review of the facility policy titled Abuse Prohibition Policy and Procedure, undated, revealed it is the policy of the facility to maintain an environment free from abuse and neglect, residents will not be subjected to such events by anyone, this facility will comply with all federal and state requirements to screen, train, prevent, identify, investigate, protect and report any event that is not consistent with the nursing facility standard of care. Review of the facility policy titled General policy for Handheld Devices, undated, revealed employees are strictly prohibited from taking a handheld device into any resident care area without the prior approval of management. Employees permitted to use a handheld device in resident care areas are strictly prohibited from using handheld devices to take or distribute photographs, audio, video or any other type of recording of residents (regardless of whether a resident gives consent). Employees may not use a handheld device to take photographs, video, or audio recordings anywhere at any time within the workplace. This deficiency substantiates Complaint Number OH 424.

Based on review of medical records, review of facility Self-Reported Incidents (SRI), observation of photographs from a personal cell phone saved to a company laptop, interviews with a police detective, review of personnel files, review of time card punches, staff interviews and review of the facility's Social Media, Abuse and Handheld Device policies and procedures, the facility failed to ensure cognitively impaired residents were free from mental and emotional abuse by a facility staff member during the provision of personal care. This resulted in Immediate Jeopardy and potential for psychosocial harm for two residents (#53 and #58) when Licensed Practical Nurse (LPN) #5 engaged in an act meant to humiliate and dehumanize residents by taking inappropriate photographs of one resident's exposed breasts and of one resident cupping a penis with both of her hands without permission from the residents and not in accordance with facility policy. The photographs were discovered on the personal cell phone of LPN #5 by State tested Nursing Assistant (STNA) #10 who had a personal relationship with LPN #5. This affected two (#53 and #58) of four residents reviewed for abuse. The facility identified 20 cognitively impaired female residents residing on the unit where LPN #5 worked. On 07/20/17 at 3:37 P.M., the Administrator, Chief Operating Officer (COO) #88, Chief Clinical Officer (CCO) #89 and Clinical Compliance Specialist (CCS) #90 were notified Immediate Jeopardy began on 07/09/17 at 10:00 A.M. when LPN #5 took inappropriate photographs of Residents #53 and #58. Both residents are cognitively impaired and were not able to give consent for photographs being taken. The facility was able to identify in the photographs Resident #58's exposed breasts and Resident #53 cupping a penis with both of her hands. STNA #10 failed to immediately report the nude photographs involving exposed female breasts she had observed on LPN #5's personal cell phone the prior evening, 07/16/17. The Immediate Jeopardy was removed on 07/17/17 at 5:00 P.M. when all staff were in-serviced regarding the identification of abuse, the abuse policy and social media policy. The deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not immediate jeopardy) until it was corrected on 07/31/17 when the facility implemented the following corrective actions: · On 07/17/17 between 2:00 P.M. and 3:00 P.M, the facility Administrator initiated an investigation into LPN #5 taking inappropriate photographs of residents and LPN #5 was removed from direct resident care and observed/monitored by the Director of Nursing (DON). · On 07/17/17 between 3:30 P.M. and 5:00 P.M., the Administrator notified COO #88 and CCO #89 of the allegation, the Administrator suspended STNA #10 and notified the local police department. The Administrator, COO #88 and CCO #89 interviewed LPN #5 per the request of the police department. LPN #5 was arrested by the local police department. · On 07/17/17 between 3:30 P.M. and 5:00 P.M. the following was also completed: the Administrator and the DON completed resident interviews of alert and oriented female residents on the 400 unit (the unit LPN#5 worked on). The DON, Registered Nurses (RN) #44 and #45, and LPNs # 46 and #57 began head to toe skin assessments on the cognitively impaired female residents on the 400 unit. · On 07/17/17 between 3:30 P.M. and 5:00 P.M., the DON and Social Services Director (SSD) #15 began re-educating all staff members on the social media policy, reporting abuse policy and procedure, cellular phone use in the work place and explained cellular phone use in work areas and taking pictures of residents was prohibited. Staff were also interviewed regarding if any employee had been observed taking pictures of residents. · On 07/17/17 at 6:32 P.M., the facility reported the incident to the Ohio Department of Health. · On 07/18/17 at 10:15 A.M., Detective #92 came to the facility and requested STNA #10 to come to the facility for an interview. The facility requested the photographs from LPN #5's cellular phone, but Detective #92 indicated he was unable to release the photographs due to forensic review and an on-going investigation. · On 07/18/17, STNA #10 brought her personal cell phone to the facility per the request of the Administrator and the photographs were viewed again. Residents #53 and #58 were identified in some of the photographs by a night gown and an afghan. · On 07/19/17, Medical Doctor (MD) #1 examined Residents #53 and #58. · On 07/19/17 through 07/20/17, interviews were conducted with STNA #72, LPNs #55 and #60 and RN #50. All reported they have not observed any staff photographing residents on the units with their cell phones. They were aware of the strict prohibition of such actions and to report anyone seen photographing residents to the charge nurse. They all stated they received training by reviewing the Abuse policy and Social Media procedure regarding privacy. · On 07/19/17 through 07/20/17 interviews were conducted with Residents #50, #57, #59 and #63. All reported no abuse or unwanted photography in regards to their privacy. · On 07/20/17, review of the medical records of Resident #57 and #60 revealed no concerns with potential abuse. Findings include: Review of Resident #53's medical record revealed she was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment completed on 05/10/17 assessed the resident to have severe impairment with cognition. Review of Resident #58's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the MDS assessment completed on 07/26/17 assessed the resident to have severe impairment with cognition. Review of the facility SRI, dated 07/17/17 under the category of emotional and verbal abuse, revealed a staff member reported a concern to the Administrator that LPN #5 had photographed residents without their permission. STNA #10 identified Residents #57, #58 and #60 as potential residents. During the facility investigation Residents #53 and #58 were the only two residents identified in the photographs. The local police were notified and were still in the process of their investigation. During an interview on 07/19/17 at 9:20 A.M., the Administrator stated STNA #10 shared a concern with him of LPN #5 having inappropriate pictures on his personal cell phone. STNA #10 was dating LPN #5 and STNA #10 was concerned LPN #5 was cheating on her so she went through his personal cell phone. She found pictures of women with their breasts exposed and was concerned the pictures were of residents at the facility. STNA #10 took pictures with her personal cell phone of the pictures she found on LPN #5's phone and reported what she had discovered to the facility on [DATE] at approximately 2:00 P.M. The Administrator stated there were no faces in the photographs but there were pictures of female breasts and in some of the photos, hospital gowns were visible. The Administrator stated STNA #10 and LPN #5 were both suspended and the local police department was notified. He further stated STNA #10 was cleared on 07/18/17 by the police and she was going to come back to work but she requested a few days off. The Administrator stated the local police were still investigating the issue. STNA #10 identified three residents who she thought were in the pictures. The Administrator stated two of the residents named in the SRI were identified by a blanket and by their hands. He further stated the local police took possession of both phones and arrested LPN #5. The Administrator stated LPN #5 had worked at the facility for a few years and always worked first shift on the 400 hall. The Administrator stated only one of the three residents identified in the SRI were interviewable. The facility interviewed other residents on the 400 hall and they denied being photographed without their permission. The Administrator stated the day they were made aware of the situation, they began in-servicing all staff on the cell phone, abuse and social media policies. The Administrator stated the Ombudsman came out and interviewed residents as well and got the same results as the facility. The Administrator stated the facility notified the local police, in-serviced all staff on the cell phone, abuse and social medial policy, interviewed residents and preformed skin and body checks on the residents on the 400 hall where LPN # 5 worked as corrective action since notification of the pictures being taken. During an interview on 07/19/17 at 11:15 A.M. with COO #88 and CCO #89 they stated Resident #58 was identified as one of the residents in the photographs because her personal afghan was visible in the photographs. They further stated Resident #53 was identified as one of the residents because her personal gown and her watch were visible in the photographs. They stated there were other photographs but they were unable to identify who the residents were. One of the photographs had a red velour shirt that was visible and despite checking resident rooms and the laundry, they have not been able to identify the resident who owned this shirt. They stated STNA #10 was also able to identify LPN #5's watch in at least one of the pictures. They stated they believed LPN #5 took the pictures of the residents during medication administration. They stated the facility was in the process of notifying family members of the residents who were identified in the pictures. The Administrator had a family meeting scheduled for 07/19/17 during the evening to discuss concerns. They stated the facility's Information Technology (IT) helpdesk did a computer check and found no evidence the pictures had been posted from any of the facility's computers. During a telephone interview on 07/19/17 at 1:30 P.M., Detective #92 stated he could not divulge any information about the case involving LPN #5 as it was still under active investigation. He stated he could not give a time line for completion of the investigation. He stated the only pages of the police report he would be able to release would only have the address of the facility. He stated more information could be provided once the investigation was completed. On 07/19/17 at 2:01 P.M., an observation was made of the photographs on a facility laptop with COO #88, CCO #89 and CCS #90. During the observation COO #88 stated the photographs were from STNA #10's personal cell phone and STNA #10 had taken photographs of photographs she found on LPN #5's personal cell phone. Two photographs dated 06/15/17 at 9:58 A.M. and 9:59 A.M. revealed an exposed female breast with a hospital gown surrounding the breast. A photograph dated 06/21/17 at 10:28 A.M. was of an exposed female breast with a red velour shirt surrounding the breast. Two photographs dated 06/25/17 at 1:05 P.M. revealed an exposed female breast with a hospital gown surrounding the breast. Several pictures dated on 07/09/17 at 10:00 A.M. and 10:03 A.M. of an exposed female breast with a pink colored nightgown surrounding the breast. In one of the photographs, a male hand is noted with a black watch around the wrist. Observation of a photograph on 07/09/17 at 10:06 A.M. revealed an exposed female breast with a blue afghan noted in the photograph. A photograph on 07/09/17 at 10:11 A.M. noted a female resident wearing a pink nightgown cupping a penis in both of her hands. A watch was also noted on the wrist of the female resident. COO #88 and CCO #89 identified Residents #53 and #58 in the photographs from 07/09/17. They also stated STNA #10 identified the black watch as belonging to LPN #5. On 07/20/17 at 11:05 A.M., an attempt was made to contact STNA #10 via phone. A message indicated the voice mail was full and messages could not be left. At approximately 11:20 A.M., CCO #89 reported STNA #10 would come to the facility for a 1:30 P.M. interview. During an interview on 07/20/17 at 11:45 A.M., COO #88 verified STNA #10 had found the photographs on LPN #5's phone the evening before reporting it to the facility. She stated STNA #10 had found other pictures of children on the phone, was distraught, and did not look completely through all the pictures until the next day as the explanation for why her knowledge of the pictures was not reported to the facility until around 2:00 P.M. the next day. During an interview on 07/20/17 at 11:55 A.M. with COO #88, she stated the time clock system clocks a staff member out and back in at shift change times such as 7:00 A.M. and 3:00 P.M. to ensure payment for shift differential. She stated LPN #5 clocked out from 1:48 P.M. to 2:18 P.M. for lunch. She stated the facility clocked him out at 4:30 P.M. as he had left earlier with the police. She stated their records show he was charting for a long time that day starting at 11:00 A.M. She reported once they became aware of the report of the pictures, they were detaining him per police request and he was being monitored by the DON. On 07/20/17 at 1:20 P.M., CCO #89 stated STNA #10 was at the facility but was having personnel issues and did not feel she could complete the interview. STNA #10 provided a written statement. Review of a written statement dated 07/20/17 by STNA #10 revealed she came into work on Monday (07/17/17) and put the dailies (resident census and number of staff working for the day) at the front desk. She proceeded to go through her phone and noticed she could identify some of the residents in the pictures. She identified a personal blanket that belonged to one resident and identified a personal gown and watch another resident wore. She indicated she started to panic and she called her therapist and left a message. Her therapist called her back and informed her she needed to notify the Administrator immediately. She requested a meeting to talk to the Administrator but it was scheduled for later in the day. She informed the Administrator it couldn't wait and she got her phone and showed him the photographs she had on her phone. Review of the time card punches for LPN #5 revealed a clock in on 07/17/17 at 6:57 A.M., clock out at 7:00 A.M., clock in at 7:00 A.M., clock out at 1:48 P.M, clock in at 2:18 P.M., clock out at 3:00 P.M., clock in at 3:00 P.M. and a clock out at 4:30 P.M. Review of the time card punches for STNA #10 revealed a clock in on 07/17/17 at 8:05 A.M., clock out at 8:46 A.M., clock in at 9:14 A.M., clock out at 3:00 P.M, clock in at 3:00 P.M. and a clock out at 4:30 P.M. Review of LPN #5's personnel file revealed a hire date of 02/12/15. LPN # 5 acknowledged he had received in-service on abuse and cell phone usage on 01/03/17 and again on 06/29/17. Review of STNA #10's personnel file revealed a hire date of 02/25/16. STNA #10 acknowledged she had received in-service on 01/03/17 and again on 06/29/17. Review of the facility policy titled Social Media Policy with a revised date of 04/2017 revealed staff are prohibited from posting any content that has personal health information including patient images without a written and signed consent form from the patient or the legal guardian of the patient. Review of the facility policy titled Abuse Prohibition Policy and Procedure, undated, revealed it is the policy of the facility to maintain an environment free from abuse and neglect, residents will not be subjected to such events by anyone, this facility will comply with all federal and state requirements to screen, train, prevent, identify, investigate, protect and report any event that is not consistent with the nursing facility standard of care. Review of the facility policy titled General policy for Handheld Devices, undated, revealed employees are strictly prohibited from taking a handheld device into any resident care area without the prior approval of management. Employees permitted to use a handheld device in resident care areas are strictly prohibited from using handheld devices to take or distribute photographs, audio, video or any other type of recording of residents (regardless of whether a resident gives consent). Employees may not use a handheld device to take photographs, video, or audio recordings anywhere at any time within the workplace. This deficiency substantiates Complaint Number OH 424.

Based on closed record review, staff interview and review of personnel file the facility failed to provide the necessary care and assistance to residents to prevent falls. This affected one Resident (#84) of four reviewed for falls. This resulted in actual harm to Resident #84 who had an avoidable fall, from his bed, during personal care and sustained a fracture to his right arm and right hip. The facility census was 83. Findings include: Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Documentation in the functioning section of the hospital transfer form dated 01/21/17 revealed Resident #84 was dependent upon staff and required full staff performance with bathing, bed mobility (lying side to side), dressing, grooming, and transferring between surfaces. An acute care plan dated 01/21/17 revealed Resident #84 was at risk for falls related to actual falls and a history of falls. Review of a Physical Therapist (PT) Evaluation completed on 01/23/17 by PT #30 revealed short term goals were for the resident to roll to his left side with the assistance of one staff and the target date was 01/29/17. Further review of the PT the resident was totally dependent on two persons to roll to the right or left in bed related to impaired strength to the right and left upper and lower extremities. Review of PT discharge summary dated 01/27/17 revealed Resident #84 continued to be maximum assist of two persons for bed mobility during his six days at the facility. Review of the Minimum Data Set (MDS) 3.0 discharge assessment dated [DATE] revealed the resident was totally dependent and required full staff performance of two staff on how the resident turns side to side and positions self in bed. Review of a tracking form entitled CNA ADL (Certified Nursing Assistant /Activities of Daily Living) used by the State tested Nursing Assistants (STNA's) to document the amount of assistance the resident required for bed mobility revealed during the day, evening and night Resident #84 was totally dependent on staff and required two staff to turn from side to side in bed. Review of nurses notes dated on 01/27/17 at 7:30 A.M., Licensed Practical Nurse (LPN) #22 documented she was called to Resident #84's room by STNA #20. When she entered the room she observed Resident #84 lying on the floor on the left side of the bed. LPN #22 documented Resident #84 had a laceration to his left forehead, the resident denied pain , neurological assessment was within normal limits, and the residents vital signs were within normal limits for the resident. The resident's spouse and the physician were notified. Review of the physician progress notes [REDACTED]. The physcian ordered to send Resident #84 to the hospital for evaluation. Review of the nursing notes dated on 01/27/17 at 9:30 A.M. revealed an order was Resident #84 was assessed by the physician and an order was received to send the resident to be sent to the hospital for evaluation. Review of the hospital encounter form dated 01/27/17 at 11:37 A.M. revealed Resident #84 presented to the emergency department with altered mental status. The resident complained of right shoulder pain. The resident had a history of [REDACTED]. The resident had a small cut on the left side of his forehead which was steri stripped by the facility. The resident was alert and oriented to person but not place or time. Resident #84 was nonsurgically treated for [REDACTED]. Review of STNA #20's written statement dated 01/31/17 revealed she provided patient care to Resident #84. She documented she went to roll the resident over and he rolled out of bed. She called for the nurse to assist her with the resident. She documented the resident had a skin tear on his forehead and arm. On 06/06/17 at 10:00 A.M., an interview with the Director of Nursing (DON) revealed she completed an investigation of the fall. Her investigation revealed STNA #20 was providing care to Resident #84 by herself. STNA #20 positioned the resident on his left side while she provided incontinence care and the resident rolled out of bed. The DON revealed STNA #20 resigned after the incident. On 06/06/17 at 11:00 A.M. and 4:00 P.M., two attempts were made to contact STNA #20. A voice message was left for STNA #20 but she did not return the phone calls. On 06/07/17 at 1:00 P.M., MDS coordinator Registered Nurse (RN) #6 and the Administrator were interviewed. RN #6 revealed the purpose of the CNA ADL Tracking Form was for the STNA's who provided care to the residents to document the amount of assistance the resident required and how many staff were required to provide assistance. The information on the from was used to assist in determining resident's level care for functional status on the MDS. RN #6 and the Administrator confirmed STNA #20 documented on 01/27/17, during the A.M. shift, on Resident #84's CNA ADL Tracking Form under bed mobility a number 4. RN #6 verified a number 4 meant Resident #84 was total dependence, full staff performance, and a number 3 meant he required two plus staff physical assist. RN #6 confirmed on the MDS MDS discharge assessment dated [DATE] indicated the resident required total dependence per two staff for bed mobility. On 06/08/17 at 10:30 A.M., an interview with LPN #22 revealed she worked the morning of 01/27/17 when Resident #84 fell out of bed. LPN #22 revealed she was called to the resident's room at approximately 7:00 A.M., by STNA #20. LPN #20 stated when she entered the room Resident #84 was lying on his left side on the left side of the bed. LPN #22 stated STNA #20 said she had turned the resident on his left side in bed to provide incontinence care and the resident rolled out of bed. LPN #22 could not verify if STNA #20 had turned the resident away from her. LPN #22 did verify STNA #20 was alone when she provided care to the resident. LPN #22 stated she assessed Resident #84 and the resident was alert. She indicated the resident denied pain, but had a small laceration approximately 0.5 centimeters on the left side of his forehead. LPN #22 indicated she placed steri strips on the laceration and assisted STNA #20 to place the resident back into bed. LPN #22 stated she called the spouse of Resident #84 and the physician. The physician informed her he would be in later that morning and would assess Resident #84. LPN # 22 indicated she was still at work when the physcian arrived (at approximately 9:00 A.M.) Resident #84 was not in distress and only complained of pain when the physician assessed him. The physician ordered for the resident to be sent to the hospital for evaluation. LPN #22 revealed STNA #20 no longer worked at the facility. On 06/08/17 at 11:05 A.M., an interview with PT #30 revealed she completed an initial evaluation of Resident #84 and he was totally dependent on staff for bed mobility and required two staff to assist. PT #30 revealed Resident #84 had been bed bound for five years and the recent hospitalization prior to coming to the facility caused him to be weaker. PT #30 stated Resident #84's spouse informed PT #30 that Resident #84 could assist her (the spouse) in turning prior to his hospitalization . PT #30 revealed the goal was for the resident to be able to assist in turning when he was able to go home as his spouse was his primary caregiver at home. PT #30 revealed the therapy notes provided to the facility by the hospital confirmed during Resident #84's last hospitalization he was totally dependent on two persons for bed mobility. Review of STNA #20's personnel file revealed no disciplinary actions during her employment at the facility and her STNA certificate remained in good standing. This deficiency substantiates Complaint Number OH 513.