Every finding on record at Berea Center

Based on interview, record review, and facility policy review, the facility failed to ensure a care plan was updated to reflect the need and implementation of a therapy-ordered lipped plate for one resident (#4) of three sampled residents reviewed for assistive device use. Findings included:Record review revealed an admission Record that identified the facility admitted Resident #4 on 07/30/25. According to the admission Record, the resident had a medical history that included diagnoses of vascular dementia and mild protein-calorie malnutrition. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/09/2026, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required supervision or touching assistance with eating.Resident #4's Order Summary Report with active orders as of 07/28/2026, revealed an order dated 06/29/2026, for the resident to use a lipped plate for daily meals. Resident #4's Care Plan Report included a focus area revised 07/15/2026, that indicated the resident had a potential for altered nutrition status/nutrition related problems due to encephalopathy, altered mental status, dementia, and mild protein calorie malnutrition. Interventions directed staff to provide assistance with meals as needed (initiated 08/06/2025). The Care Plan Report did not contain an intervention that directed the staff to provide the resident with a lipped plate during their daily meals. During an interview on 07/28/2026 at 5:43 PM, Registered Nurse (RN) #4 stated a nurse could update a resident's care plan and verified the order to have Resident #4 use a lipped plate during meal times was not reflected on the resident's care plan. During an interview on 07/29/2026 at 12:04 PM, the MDS Coordinator stated she was responsible for care plan revisions. The MDS Coordinator stated she did not know Resident #4 was to have a lipped plate during meal times, but added the intervention on the resident's care plan on 07/28/2026. During an interview on 07/29/2026 at 12:36 PM, the Director of Nursing stated she expected the MDS Coordinator to update a resident's care plan in the morning and clinical meetings to reflect assistive devices at mealtimes, when ordered. During an interview on 07/29/2026 at 12:43 PM, the Executive Director stated she expected a resident's care plan to be updated timely. Review of an undated facility policy titled, Assistive Eating Devices, indicated, 4. Provide assistive device information on care plan.Review of an undated facility policy titled, Plan of Care Overview, indicated, 1. The MDS [Minimum Data Set] Coordinator will oversee and coordinate the care team and PoC [plan of care]. 2. Nurses are expected to participate in the resident plan of care for reviewing and revising the care plan of residents they provide care for as the resident's condition warrants.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the medication error rate was 5% or less. There were two errors out of 27 opportunities, which yielded a medication error rate of 7.41%. This affected one resident (#26) of two residents observed for medication administration. Findings included: Review of an admission Record indicated the facility admitted Resident #26 on 05/25/2024. According to the admission Record, the resident had a medical history that included a diagnosis of Alzheimer's disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/25/2026, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. Resident #26's Order Summary Report with active orders as of 07/28/2026, revealed an order dated 08/04/2025, for potassium chloride extended release (ER) 20 milliequivalent tablet, give one tablet by mouth one time a day for supplement and an order dated 07/26/2026, for doxycycline hyclate 100 milligram oral capsule, give one capsule by mouth two times day for seven days for a red swollen toe. During medication administration observation on 07/28/2026 at 9:15 AM, Registered Nurse (RN) #1 crushed Resident #26's potassium chloride ER tablet and placed it in pudding to administer to the resident. RN #1 also opened the doxycycline hyclate capsule and poured the contents of the capsule into pudding and administered the medication to the resident. During an interview on 07/28/2026 at 11:47 AM, RN #1 stated Resident #26 had difficulty swallowing medications, so opened the capsule and added it to the pudding. RN #1 stated she did not see the issue with opening the capsule since the resident was getting the medication. RN #1 reviewed Resident #26's orders and confirmed that the potassium chloride order specified extended release and she was aware extended release medication should not be crushed. During an interview on 07/28/2026 at 12:30 PM, the Pharmacist stated potassium chloride ER should not be crushed because the medication was designed to be released timely, and crushing it would compromise the effect. The Pharmacist stated the type of doxycycline hyclate prescribed for Resident #26 was one that should not be opened or poured/sprinkled in or on anything because by opening the medication it affected the strength of medication the resident received. According to the Pharmacist, Resident #26 might not receive the correct dose of the medication if the capsule was opened. During an interview on 07/28/2026 at 3:11 PM, the Medical Director (MD) stated the nurses should know how to administer medications and an ER medication should not be crushed. The MD stated there were other forms of potassium chloride and doxycycline hyclate available for use if a resident had difficulty swallowing their medications. The MD stated if the doxycycline hyclate capsule was being opened then it decreased the effectiveness of the medication. During an interview on 07/29/2026 at 10:26 AM, the Director of Nursing stated she expected if a nurse had a concern during medication administration, the nurse would either notify her or a nurse practitioner. During an interview on 07/29/2026 at 10:43 AM, the Executive Director (ED) stated it was her expectations that the staff followed policies and procedures and if they had questions regarding medications, they asked them to get clarity. The ED stated she expected residents' medications be administered as prescribed by the doctor. An undated facility policy titled, Medication Administration, indicated, Procedure: I. General Procedures: a. Administer mediation only as prescribed by the provider.

Based on observation, interview, record review, facility document review, and facility policy review, the facility failed to ensure a therapy-ordered lipped plate was used at breakfast and lunch. This affected one resident (#4) of three sampled residents reviewed for assistive device use.Findings included:Review of an admission Record revealed the facility admitted Resident #4 on 07/30/2025. According to the admission Record, the resident had a medical history that included diagnoses of vascular dementia and mild protein-calorie malnutrition. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/09/2026, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required supervision or touching assistance with eating.Resident #4's Care Plan Report included a focus area revised 07/15/2026, that indicated the resident had a potential for altered nutrition status/nutrition related problems due to encephalopathy, altered mental status, dementia, and mild protein calorie malnutrition. Interventions directed staff to provide assistance with meals as needed (initiated 08/06/2025). Resident #4's Order Summary Report with active orders as of 07/28/2026, revealed an order dated 06/29/2026, for the resident to use a lipped plate for daily meals. Resident #4's diet slip for breakfast, lunch, and dinner dated 07/28/2026 did not indicate the resident needed a lipped plate for their daily meals. During an observation of the lunch meal service on 07/27/2026 at 1:05 PM, Resident #4 was served their lunch on a flat, white plate. During an observation of the breakfast meal service on 07/28/2026 at 8:09 AM, Resident #4 was served their breakfast on a flat, white plate. During an observation of the lunch meal service on 07/28/2026 at 1:32 PM, Resident #4 ate their food from a flat, white plate. During an interview on 07/28/2026 at 2:04 PM, the Culinary Director (CD) stated staff knew what diet and assistive equipment a resident required by their diet slip. The CD stated the kitchen staff were not aware of a lipped plate ordered for Resident #4. The CD verified and stated the diet slip for Resident #4 did not indicate the resident needed a lipped plate for their meals. During an interview on 07/28/2026 at 5:10 PM, Occupational Therapist (OT) #5 stated she entered the order for Resident #4 to use a lipped plate for all meals as a trial. OT #5 stated the lipped plate was used to help a resident adjust to scoop food, made it easier to scoop, and it kept food on the utensil. Per OT #5, the lipped place was a strategy to help residents keep and use their independence and maximize their function. During an interview on 07/29/2026 at 10:03 AM, Certified Nurse Aide (CNA) #2 stated staff compared the diet slip with the resident's tray when lunch was served and alerted the kitchen when there was a discrepancy. CNA #2 stated she was not aware Resident #4 should have a lipped plate at mealtimes. CNA #2 stated a lipped plate would be listed on the diet slip if the resident was supposed to have one at mealtimes. During an interview on 07/29/2026 at 10:21 AM, Licensed Practical Nurse Charge Nurse #3 stated she was not aware Resident #4 had a lipped plate ordered and she had not observed the resident be provided one during meals. During an interview on 07/29/2026 at 12:36 PM, the Director of Nursing stated it was her expectation that the nursing staff verified orders and notified the dietary staff of any changes to a residents' dietary orders and for the dietary staff to make any necessary changes to a resident's diet slip. During an interview on 07/29/2026 at 12:43 PM, the Executive Director stated she expected the nursing staff to update the dietary staff of an order change, the dietary staff were expected to update the resident's diet slip, and the staff who served the resident were expected to compare the diet slip to the tray being served for accuracy. Review of an undated facility policy titled, Assistive Eating Devices, indicated, Assistive eating devices: special adaptive eating and drinking utensils for those with low dexterity or other disabilities that prevents residents from otherwise eating and drinking independently-may include bowls, cups, plats, spoons and forks- usually recommended by therapy or nursing for individualized care needs. Review of an undated facility policy titled, Physician Orders, indicated, iii. Notify internal staff of changes/updates as appropriate.

Based on observation, interviews, and policy review, the facility failed to ensure infection control procedures were followed during incontinence care. This affected one resident (#4) of three residents reviewed for incontinence care. The facility census was 47.Findings include:Review of the Medical record for Resident #4 revealed an admission date 04/14/23. Diagnoses included dementia, major depression, chronic kidney disease, and psychotic disorder with delusions due to known physiological condition. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #4 had impaired cognition. Resident #4 was dependent on staff for toileting and was incontinent of bowel and bladder. Observation on 08/06/25 at 9:26 A.M. of incontinence care for Resident #4 with Certified Nurse Assistant (CNA) #327 and CNA #337 revealed the CNA's both put gloves on and positioned Resident #4 in bed for incontinence care. Resident #4 was incontinent of a moderate amount of urine. CNA #327 and CNA #337 rolled Resident #4 side-to-side to remove the soiled brief. CNA #337 removed the soiled brief and threw it on the floor beside the bed. Then, CNA #327 brought over the trash can and CNA #337 picked up the dirty brief off the floor and threw it in the trash can. CNA #337 continued to finish peri care and put a clean brief on Resident #4. After incontinence care was completed, CNA #337 removed her dirty gloves and put them in the trash can and continued to finish up with Resident #4 without washing her hands or putting on clean gloves. CNA #337 and #327 used the mechanical lift to put Resident #4 back into the wheelchair, without washing their hands. After Resident #4 was in the wheelchair, CNA #337 then took the mechanical lift back to storage room and still had not washed her hands. CNA #327 did not wash her hands and pushed Resident #4 back to the dining room without washing her hands. Interview on 08/06/25 at 9:36 A.M. with CNA #327 and CNA #337 verified they did not wash their hands during or after incontinence care for Resident #4, and CNA #337 verified that she threw the soiled brief on the floor and stated she should have put it in the appropriate receptacle. Interview on 08/06/25 at 9:50 A.M. with Director of Nursing (DON) verified when completing incontinence care staff are to wash their hands and then put clean gloves on and after removing dirty gloves staff should be washing their hands. The DON additionally verified dirty linens or soiled briefs should not be thrown on the floor due to infection control. Review of the facility policy, Perineal Care- Male and Female, dated 07/07/18 revealed arrange items at side of bed and perform hand hygiene and put gloves on. Continue to provide incontinence care. Discard disposable items into designated containers. Remove gloves and discard into designated containers, perform hand hygiene and put on clean gloves reposition resident comfortably, clean up resident area and then perform hand hygiene again. This deficiency represents non-compliance investigated under Complaint Number 1283308 (OH00165852).

Based on medical record review, staff interview, and facility policy review, the facility failed to comprehensively assess as well as monitor non-pressure skin areas. This affected two (Residents #13 and #14) of three residents reviewed for skin issues. The census was 50. Findings include: 1. Review of Resident #13's medical record revealed Resident #13 was admitted to the facility on [DATE]. His diagnoses included but were not limited to Alzheimer's disease, type two diabetes, atherosclerotic heart disease, anemia, schizophrenia, vitamin D deficiency, chronic kidney disease, dementia, hypertensive heart and chronic kidney disease, and hyperlipidemia. Review of Resident #13's Minimum Data Set (MDS) assessment, dated 01/06/24, revealed Resident #13 had a severe cognitive impairment. Review of Resident #13 skin assessment, dated 03/12/24, revealed the facility documented he had no new or existing skin issues. Review of Resident #13's physician orders, dated 03/15/24, revealed he was ordered Hydrocortisone (steroid) External Cream 2.5 percent for contact dermatitis for seven days. There were no skin assessments or progress notes to support the initial diagnosis of dermatitis, and there were no ongoing skin assessments or progress notes to support monitoring of the dermatitis/rash/skin issue. Review of Resident #13 skin assessments, dated 03/19/24 and 03/27/24, revealed the facility documented he had no new or existing skin issues. Review of Resident #13's skin assessment, dated 04/02/24, revealed there was a skin issue documented, but the assessment also stated that the skin issue was not new. It did not indicate what the skin issue was, where it was located, or any description of the skin issue. Review of Resident #13 physician orders, dated 04/03/24, revealed he was ordered Permethrin External Cream five percent (medication used to treat scabies) to be spread over his whole body one time for a rash. There was no documentation indicating where the rash was located. 2. Review of Resident #14's medical record revealed Resident #14 was admitted to the facility on [DATE]. His diagnoses included but were not limited to dementia, need for assistance with personal care, dysphagia, major depressive disorder, anxiety disorder, retention of urine, single subsegmental pulmonary embolism, history of falling, long term use of anticoagulants, and hyperlipidemia. Review of Resident #14's MDS assessment, dated 01/04/24, revealed he had a severe cognitive impairment. Review of Resident #14's skin assessments, dated 02/28/24, 03/06/24, 03/12/24, 03/19/24, and 03/27/24, revealed the facility documented he had no new or existing skin issues. Review of Resident #14's physician orders, dated 03/02/24 to 03/07/24, revealed he was ordered Hydrocortisone External Cream 2.5 percent for contact dermatitis for five days. There were no skin assessments or progress notes to support the initial diagnosis of dermatitis and there were no ongoing skin assessments or progress notes to support monitoring of the dermatitis/rash/skin issue. Review of Resident #14's physician orders, dated 03/08/24 to 03/13/24, revealed he was ordered Hydrocortisone External Cream 2.5 percent for contact dermatitis for five days. There were no skin assessments or progress notes to support the initial diagnosis of dermatitis and there were no ongoing skin assessments or progress notes to support monitoring of the dermatitis/rash/skin issue. Review of Resident #14's physician orders, dated 03/14/24 to 03/21/24, revealed he was ordered Hydrocortisone External Cream 2.5 percent for contact dermatitis for seven days. There were no skin assessments or progress notes to support the initial diagnosis of dermatitis and there were no ongoing skin assessments or progress notes to support monitoring of the dermatitis/rash/skin issue. Review of Resident #14's skin assessment, dated 04/02/24, revealed there was a skin issue documented, but the assessment also stated that the skin issue was not new. It did not indicate what the skin issue was, where it was located, or any description of the skin issue. Review of Resident #14's physician orders, dated 04/03/24, revealed he had a dermatology appointment to determine the cause/extent of the skin issues that had not been resolved. Review of Resident #14's physician orders, dated 04/03/24, revealed he was ordered Permethrin External Cream five percent to be spread over his whole body one time for suspected scabies. There was no documentation to support where the rash/skin issues/suspected scabies was located. Interview with the Director of Nursing and Administrator on 04/05/24 at 12:50 P.M. confirmed there were no skin assessments, monitoring, or initial documentation of both Resident #13 and Resident #14's dermatitis/rash/skin issues. They confirmed the Residents #13 and #14 had skin issues that were found by staff and treated but were not included on the skin assessments. They confirmed Resident #14 was sent to the dermatologist and was diagnosed with and treated for suspected scabies. They also confirmed they treated Resident #13's skin issues/rash in the same manner as Resident #14 and Resident #14 was suspected of having scabies. Neither Resident #13 or Resident #14 were confirmed to have scabies since the dermatologist declined to scrape Resident #14's skin in order to confirm it was scabies and it was decided the best course of action was to treat the skin issues as if they did have scabies. Interview with Registered Nurse (RN) #102 and Licensed Practical Nurse (LPN) #103 on 04/05/24 at 1:00 P.M. revealed they were spoosed to perform skin assessments on the residents each week. If the resident had a new skin issue then they were to document it on the weekly skin assessment form. They were supposed to describe the type of skin issue, where it was, and who they contacted about the skin issue. They also revealed they were supposed to document the progression/regression of the resident's skin issues in the residents medical record, and document if/when a skin issue moves to another area of the body. Interview with Nurse Practitioner #101 on 04/05/24 at 1:15 P.M. confirmed the order for hydrocortisone for Resident #14 was ordered each time because Resident #14's rash was moving to different areas. She was not sure if the facility documented where the rashes were located each time they notified her of the changes to the rash and received a new order for hydrocortisone. She confirmed she saw the rash on his back and his chest; but she confirmed she did not describe what the rash looked like each time she assessed it. Review of the facility policy titled Scabies Management and Care, dated 07/07/17, revealed scabies was defined as a common, contagious, intensely itchy skin condition caused by a tiny, burrowing parasitic mites. Staff are to perform visual skin assessments on admission. If noted with red, raised areas with tracks or crusted, rash areas particularly on hands, fingers, toes, buttocks, and belt, sock, and bra area, contact the physician/provider. All abnormalities are noted and documented. The attending physician will be notified, as well as the attending physician of the roommate and other close contacts. The physician may order prophylactic treatment depending on each circumstance. The resident's responsible party will be notified as well. If scabies is diagnosed , notify the responsible party that those who had recent contact, including roommates with the resident, should follow up with their physician for treatment including possible prophylactic treatment to prevent spreading the mite to others. There is no effective, recommended over-the-counter treatment for scabies. The facility is to implement contact precautions. A private room is desirable, if the resident is not cognitively intact, update the care plan, obtain labs as ordered including skin scraping for identification, staff to wear appropriate PPE (personal protective equipment) when providing direct care, and discontinue contact precautions 24 hours after initial treatment. The incubation period can be two to six weeks before signs or symptoms occur. Clinical signs of infestation may include tiny vesicles or blisters where the scabies mite has penetrated the skin and tiny, slightly elevated, linear burrows, about 0.5 millimeters (mm) in diameter and three to 15 mm in length, containing the mites and their eggs. Failure to identify positive scrapings does not indicate a negative diagnosis. It is very difficult to obtain a positive scraping because only one or two mites may cause multiple lesions. Often diagnosis is made from signs and symptoms and treatment is followed without scraping sent to lab. This deficiency represents non-compliance investigated under Complaint Number OH00152194.

Based on record review, observation and interview, the facility failed to ensure Resident #26 was free of significant medication errors. This affected one (Resident #26) of four residents reviewed for medication administration. The facility census was 47. Findings include: Review of the medical record for Resident #26 revealed she was admitted on [DATE] with diagnoses including dementia, dysphagia (difficulty swallowing), and hypertension (high blood pressure). Review of the physician's orders and Medication Administration Record (MAR) for Resident #26 revealed she had an order for Metoprolol Succinate 100 milligrams (mg) Extended Release (ER) in the morning for hypertension dated 08/24/22. Observation was made on 08/21/23 at 8:45 A.M. with Licensed Practical Nurse (LPN) #113 of medication administration to Resident #26. LPN #113 prepared the medications, including Acetaminophen (for pain), Buspirone (for depression), Depakote (for seizures), Magnesium, Potassium, Torsemide (diuretic) and Metoprolol Succinate ER 100 mg. She placed the Potassium in a separate cup and added water to assist in dissolving. She opened the Depakote capsules and placed it in with the Potassium. She then crushed the remaining medications and placed them in the cup with the other medications. LPN #113 then administered Resident #26 her medications. Interview on 08/21/23 at 8:50 A.M. with LPN #113 verified she crushed the Metoprolol Succinate ER 100 mg. even though it should not have been crushed as it was extended release. Review of the nursing progress note dated 08/21/23 at 9:45 A.M. for Resident #26 revealed nursing staff documented the nurse crushed a medication that was not to be crushed and administered it to the resident. The nurse practitioner was updated. Review of the prescribing information for Toprol-XL (Metoprolol Succinate ER) on the manufacturer's website (www.toprol-xl.com), dated 2022, revealed the medication can be divided, however, patients are not to crush or chew the tablet. Review of the facility policy titled, Medication Administration, undated, revealed nursing staff should follow the manufacturer's recommendations for medications that note do not crush.

Based on observation and interview, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect all 47 residents residing in the facility. Findings included: Tour of the kitchen on 05/30/23 from 8:56 A.M. through 9:15 A.M. with Dietary Manager (DM) #857 revealed the wall where the prep table that housed the microwave had various dried splatters and red streaks running down the wall at the point of the middle shelf toward the floor. Next to the microwave was the knife holder that had various stains and debris. Observed DM #857 pickup the knife holder and underneath were various food debris and a butter knife. The commercial can opener holder had dark brownish black build up. Also on the prep table was a toaster that had various splatters and stains. On the top shelf of the prep table were various food crumbs. The front of the stove had various stains; the grease trap had a moderate amount of burnt grease build up. Next to the stove was a table that housed the steamer that had a large brownish and whitish dried on stain. The floor under this table and along with side of it near the wall had various debris and dirt. In the dry storage room area underneath the racks were various debris including plastic fork and spoon, styrofoam cup, and individual condiment packets. The floor of the walk-in cooler had a moderate amount of debris on black floor mat. The floor of the walk-in freezer had a minimal amount of debris on black floor mat. Interview on 05/30/23 between 8:56 A.M. and 9:15 A.M. with DM #857 verified the above findings.

Based on record review, staff interview, review of facility Self-Reported Incident (SRIs), and review of the policy titled OHIO Abuse, Neglect, and Misappropriation the facility failed to monitor resident-to-resident interactions that may limit residents' autonomy or choice. This affected four (#6, #47, #48, and #50) of four residents reviewed for sexual abuse. The facility census was 48. Findings include: 1. Review of the medical record for Resident #6 revealed an admitted [DATE]. Diagnoses included dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, senile degeneration of brain, and personal history of COVID-19. Review of the quarterly, Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 6 that indicated cognitive impairment. Review of the MDS 3.0 assessment revealed Resident #6 required set-up help only with supervision from staff for activities of daily living (ADL). Review of the care plan dated 01/01/23 revealed Resident #6 had a behavior problem related to impaired cognition, depression, senile degeneration, and insomnia that included being sexually inappropriate, aggressive, wandering, refusal of care, and agitation. Resident #6 also required a secured unit due to poor cognition and wandering. Interventions included intervene as necessary to protect the rights and safety of others, offer task to divert attention, apply secured device, administer medications as ordered, monitor, observe, and report to physician. Review of the physician orders dated 06/21/22 revealed an order to check Wanderguard (wander management system to protect residents at risk for elopement) placement on left ankle every shift. Review of the physician orders dated 07/19/22 revealed an order for Resident #6 to be monitored for behaviors such as wandering, sexually aggressive, refusals of care, and agitation every shift. Review of the physician orders dated 11/10/22 revealed an order for Resident #6 to be on secured unit due to dementia. Review of the physician orders dated 01/30/23 revealed an order for Resident #6 to be one-on-one supervision every shift. 2. Review of the medical record for Resident #48 revealed an admitted [DATE]. Diagnoses included memory deficit following cerebral infarction, type II diabetes mellitus without complications, and cerebral infarction. Review of the admission, MDS 3.0 assessment dated [DATE] revealed Resident #48 had a BIMS score of 14 indicating he was alert and oriented to person, place, and time. Review of the MDS 3.0 assessment revealed Resident #48 required set-up help only to one-staff physical limited assist from staff for ADL. Review of the care plan dated 01/07/23 revealed Resident #48 required a secured unit for poor cognition, wandered aimlessly form place to place, and had a behavior problem related to being sexually inappropriate with staff members. Interventions included intervene as necessary to protect the rights and safety of others, offer task to divert attention, apply secured device (Wanderguard), administer medications as ordered, monitor, observe, and report to physician. Review of the progress note located in the electronic medical record (EMR) dated 01/12/23 at 7:29 P.M. revealed Resident #48 was being sexually inappropriate with staff members. Resident #48 was redirected to his room. Resident #48 was to be monitored for his behavior and any signs of inappropriate behavior. Review of the progress note dated 01/16/23 at 5:40 A.M. revealed Resident #48 was sexually inappropriate with staff and redirected. Review of the progress note dated 01/17/23 at 4:11 P.M. revealed Resident #48 was making inappropriate sexual comments and actions towards staff. Resident #48 was easily redirected and apologetic. Review of the progress note located in the EMR for Resident #6 dated 01/29/23 at 5:20 P.M. revealed Resident #6 was witnessed being sexually inappropriate with a male resident (Resident #48). Review of the progress note dated 01/29/23 at 6:09 P.M. revealed Resident #48 and another resident, Resident #6, were separated due to inappropriate sexual activity. Head-to-toe skin checks were completed with no issues noted. Resident #48 was assisted to the dining room. The Director of Nursing (DON), local police department, and family were notified. Review of the progress note dated 01/29/23 at 6:17 P.M. for Resident #48 revealed, at approximately 5:00 P.M., Resident #6 and Resident #48 were separated due to inappropriate sexual activity. Review of the progress note revealed head-to-toe skin checks were done with no issues noted. Resident #6 was assisted to the dining room and the DON, local police department, and family were notified. Review of the progress note dated 01/31/21 at 6:30 A.M. revealed Resident #6 had no behaviors and continued one-on-one supervision. Review of the incident log dated 11/03/22 to 02/01/23 revealed an incident of alleged sexual abuse was listed on 01/29/23 at 5:00 P.M. for Residents #6 and #48. Review of the incident log revealed no other reported incidents regarding Residents #6 and #48. Review of the Ohio Department of Health's Gateway system revealed an SRI related to the allegation of abuse initiated as of 01/29/23 for Residents #6 and #48. Further review of the Gateway system revealed other sexual abuse allegations dated 12/30/21 and 04/14/22 for Resident #6. Review returned a history of sexually inappropriate behaviors displayed by Resident #6. Review of the facility SRI tracking number (#) 231552 dated 01/29/23 revealed Resident #6 was in Resident #48's room standing next to the bed with her hands down Resident #48's pants. Residents #6 and #48 were immediately separated and assessed. Assessment returned no injuries noted. Resident #6 was placed on one-on-one supervision. Both residents were then escorted to the dining room for the dinner meal and seated at separate tables. The local police department were notified, and a report was filed. Review of Certified Nurse Aide (CAN) #812's witness statement revealed she found Resident #6's hands down Resident #48's pants as she was making rounds checking resident rooms. CNA #812 revealed she notified staff in charge and separated Residents #6 and #48 from each other. 3. Review of medical record for Resident #47 revealed an admitted [DATE]. Diagnoses included early onset Alzheimer's disease, unspecified severity with other behavioral disturbance, and unspecified dementia, unspecified severity with anxiety. Review of the physician orders dated 09/28/22 revealed an order to check Wanderguard placement on left ankle every shift. Review of the physician orders dated 10/04/22 revealed an order to monitor behaviors for wandering, exit seeking, and being withdrawn every shift. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #47 had a BIMS score of 3 indicating cognitive impairment. Review of the MDS 3.0 assessment revealed Resident #47 required one-staff physical extensive assist for ADL. Review of the care plan dated 01/06/23 revealed Resident #47 required a secured unit due to poor cognition and wandering. Interventions included offer task to divert attention, administer medications as ordered, monitor, observe, and report to physician. 4. Review of medical record for Former Resident (FR) #50 revealed an admitted [DATE]. Diagnoses included dementia, unspecified severity, with other behavioral disturbance, atherosclerotic heart disease of native coronary artery without angina pectoris, and major depressive disorder, recurrent, unspecified. Review of the care plan dated 08/11/22 revealed FR #50 had a behavior problem related to being sexually inappropriate with staff members and female residents. Interventions included offer task to divert attention, administer medications as ordered, monitor, observe, and report to physician. Review of the quarterly, MDS 3.0 assessment dated [DATE] revealed FR #50 had a BIMS score of 3 indicating cognitive impairment. Review of the MDS 3.0 assessment revealed FR #50 required one-staff physical extensive assist from staff for ADL. Review of the progress note, located in the EMR for Resident #47 dated 12/01/22 at 9:15 P.M. revealed Resident #47 was observed in another resident (FR #50) room, sitting on the bed, and being touched inappropriately. Resident #47 and FR #50 were separated immediately; the local police department was notified. Review of the progress note, located in the EMR for FR #50 dated 12/01/22 at 9:27 P.M. revealed he was touching another resident (Resident #47) inappropriately. The Administrator and DON were notified, and the local police were contacted and enroute. Review of the progress note dated 12/01/22 at 10:14 P.M. revealed police arrived at the facility at 9:30 P.M. and obtained report. Review of the incident log dated 11/03/22 to 02/01/23 revealed an incident of alleged sexual abuse was listed on 12/01/22 for Resident #47 and FR #50. Review of the incident log revealed no other reported incidents regarding Resident #47 and FR #50. Review of the Ohio Department of Health's Gateway system revealed an SRI related to the allegation of abuse initiated as of 12/01/22 for Resident #47 and FR #50. Further review of the Gateway system revealed another sexual abuse allegation entry dated 09/18/22 for FR #50. Review returned a history of sexually inappropriate behaviors displayed by FR #50. Review of the facility SRI tracking #229701 dated 12/01/22 revealed FR #50 was observed with his hand down Resident #47's pants in his room. Resident #47 and FR #50 were immediately separated and assessed for injury. Resident #47 was escorted out of room and assisted to the common area. FR #50 remained in his room and placed on one-on-one supervision. Review of the facility policy titled OHIO Abuse, Neglect, and Misappropriation, revised 10/27/21, revealed the facility had a policy in place to prevent abuse, mistreatment, or neglect of residents or the misappropriation of their property, corporal punishment and/or voluntary seclusion and to provide guidance to direct staff to manage any concerns or allegations of abuse, neglect, or misappropriation of their property. Review of the policy revealed staff would be established based on census, acuity level, and needs. Review of the facility document revealed the facility did not implement the policy in regard to the allegation of abuse. The above findings were verified during an interview on 02/01/23 at 3:26 P.M. with the DON. This deficiency represents noncompliance investigated under Self-Reported Incident Control Number OH00139805.

Based on record review, staff interview, review of facility Self-Reported Incidents (SRIs) and review of the facility policy titled OHIO Abuse, Neglect, and Misappropriation the facility failed to ensure residents were free from abuse. This affected one resident (#46) of two residents reviewed for physical abuse. The facility census was 48. Findings include: 1. Review of the medical record for Former Resident (FR) #49 revealed an admitted [DATE]. FR #49 was discharged on [DATE]. Diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, paranoid schizophrenia, and other specified mental disorders due to known physiological condition. Review of the 01/03/23, return-not-anticipated, Minimum Data Set (MDS) 3.0 assessment for FR #49 revealed the resident had a memory problem and was severely impaired for tasks of daily life. FR #49 also had a history of physical and verbal symptoms directed towards others. Review of the MDS 3.0 assessment revealed FR #49 required supervision to limited assist from staff for activities of daily living (ADL). Review of the care plan, dated 12/13/22, revealed FR #49 had a behavior problem related to post-traumatic stress disorder, schizophrenia, hallucinations, pain, and psychosocial issues that included physical aggression towards others, exit seeking behaviors, verbal aggression towards others, and placing self on floor. Interventions included intervene as necessary to protect the rights and safety of others, administer medications as ordered, monitor, observe, and report to physician. Review of the physician orders dated 12/14/22 revealed an order for lorazepam oral tablet 0.5 milligrams (antianxiety) to be given one tablet by mouth every eight hours as needed for agitation for 14 days. Review of the physician orders dated 12/19/22 revealed an order for Seroquel oral tablet 100 milligrams (antipsychotic) to be given one tablet by mouth at bedtime for schizophrenia. Review of the physician orders dated 12/27/22 revealed an order for olanzapine oral tablet 2.5 milligrams (antipsychotic) to be given one tablet by mouth at bedtime for schizophrenia. Review of the physician orders dated 12/27/22 revealed an order for one-on-one supervision until further notice every shift for safety. 2. Review of the medical record for Resident #46 revealed an admitted [DATE]. Diagnoses included encephalopathy, difficulty in walking, and dementia unspecified severity, with other behavioral disturbance. Review of the 01/09/23, quarterly, MDS 3.0 assessment for Resident #46 revealed the resident had cognitive impairment. Review of the MDS 3.0 assessment revealed Resident #46 required one-staff physical extensive assist for ADL. Review of the care plan, dated 01/09/23, revealed Resident #46 had a mood problem related to impulse disorder, psychotic disorder, and insomnia, required a secured unit related to poor cognition, dementia, elopement risk, depression, and anxiety. Interventions included offer task to divert attention, apply secured device, administer medications as ordered, monitor, observe, and report to physician. Review of the progress note, located in the electronic medical record (EMR) for FR #49, dated 12/16/22 at 12:50 P.M., revealed he was agitated, swearing, and swinging his cane at staff. Review of the progress note dated 12/26/22 at 10:18 P.M. FR #49 hit another resident (#46) in the face with his cane. FR #49 was separated from Resident #46. FR #49 cane was confiscated as a weapon. FR #49's gait was steady without the use of the cane. FR #49 was placed on one-on-one supervision. Review of the progress note, located in the EMR for Resident #46, dated 12/26/22 at 10:26 P.M., revealed he was hit in the face with a cane by another resident (FR #49). Resident #46 had a 0.5 centimeter (cm) length by 0.5 cm width by 0.5 cm depth laceration under his left eye. Resident #46's eye was cleansed, patted dried, triple antibiotic ointment was applied and open to air. Residents #46 and FR #49 were separated, neurological checks initiated, one-on-one interventions and monitoring were put into place. Review of the incident log dated 11/03/22 to 02/01/23 revealed an incident of alleged resident-to-resident physical abuse was listed on 12/26/22 for Resident #46 and FR #49. Review of the Ohio Department of Health's Gateway system revealed a facility SRI related to the allegation of physical abuse initiated as of 12/26/22 for Resident #46 and FR #49. Review of the facility SRI tracking number (#) 230500 dated 12/26/22 revealed Resident #46 and FR #49 were sitting in the dining room. FR #49 was overheard asking Resident #46 for money. Resident #46 did not answer and attempted to pick up something from the floor. FR #49 thought Resident #46 was trying to take his shoes and took his cane and hit Resident #46 in the face, causing a laceration to his left eye. Review of the facility policy titled OHIO Abuse, Neglect, and Misappropriation, revised 10/27/21, revealed the facility had a policy in place to prevent abuse, mistreatment, or neglect of residents or the misappropriation of their property, corporal punishment and/or voluntary seclusion and to provide guidance to direct staff to manage any concerns or allegations of abuse, neglect, or misappropriation of their property. Review of the policy revealed staff would be established based on census, acuity level, and needs. Review of the facility document revealed the facility did not implement the policy regarding the allegation of abuse. The above findings were verified during an interview on 02/01/23 at 3:26 P.M. with the Director of Nursing (DON).

Based on record review, staff interview, review of facility Self-Reported Incidents (SRIs) and review of the facility policy titled OHIO Abuse, Neglect, and Misappropriation the facility failed to implement a policy to prevent resident-to-resident physical abuse. This affected one resident (#46) of two residents reviewed for physical abuse. The facility census was 48. Findings Include: 1. Review of the medical record for Former Resident (FR) #49 revealed an admitted [DATE]. FR #49 was discharged on [DATE]. Diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, paranoid schizophrenia, and other specified mental disorders due to known physiological condition. Review of the 01/03/23, return-not-anticipated, Minimum Data Set (MDS) 3.0 assessment for FR #49 revealed the resident had a memory problem and was severely impaired for tasks of daily life. FR #49 also had a history of physical and verbal symptoms directed towards others. Review of the MDS 3.0 assessment revealed FR #49 required supervision to limited assist from staff for activities of daily living (ADL). Review of the care plan, dated 12/13/22, revealed FR #49 had a behavior problem related to post-traumatic stress disorder, schizophrenia, hallucinations, pain, and psychosocial issues that included physical aggression towards others, exit seeking behaviors, verbal aggression towards others, and placing self on floor. Interventions included intervene as necessary to protect the rights and safety of others, administer medications as ordered, monitor, observe, and report to physician. Review of the physician orders dated 12/14/22 revealed an order for lorazepam oral tablet 0.5 milligrams (antianxiety) to be given one tablet by mouth every eight hours as needed for agitation for 14 days. Review of the physician orders dated 12/19/22 revealed an order for Seroquel oral tablet 100 milligrams (antipsychotic) to be given one tablet by mouth at bedtime for schizophrenia. Review of the physician orders dated 12/27/22 revealed an order for olanzapine oral tablet 2.5 milligrams (antipsychotic) to be given one tablet by mouth at bedtime for schizophrenia. Review of the physician orders dated 12/27/22 revealed an order for one-on-one supervision until further notice every shift for safety. 2. Review of the medical record for Resident #46 revealed an admitted [DATE]. Diagnoses included encephalopathy, difficulty in walking, and dementia unspecified severity, with other behavioral disturbance. Review of the 01/09/23, quarterly, MDS 3.0 assessment for Resident #46 revealed the resident had cognitive impairment. Review of the MDS 3.0 assessment revealed Resident #46 required one-staff physical extensive assist for ADL. Review of the care plan, dated 01/09/23, revealed Resident #46 had a mood problem related to impulse disorder, psychotic disorder, and insomnia, required a secured unit related to poor cognition, dementia, elopement risk, depression, and anxiety. Interventions included offer task to divert attention, apply secured device, administer medications as ordered, monitor, observe, and report to physician. Review of the progress note, located in the electronic medical record (EMR) for FR #49, dated 12/16/22 at 12:50 P.M., revealed he was agitated, swearing, and swinging his cane at staff. Review of the progress note dated 12/26/22 at 10:18 P.M. FR #49 hit another resident (#46) in the face with his cane. FR #49 was separated from Resident #46. FR #49 cane was confiscated as a weapon. FR #49's gait was steady without the use of the cane. FR #49 was placed on one-on-one supervision. Review of the progress note, located in the EMR for Resident #46, dated 12/26/22 at 10:26 P.M., revealed he was hit in the face with a cane by another resident (FR #49). Resident #46 had a 0.5 centimeter (cm) length by 0.5 cm width by 0.5 cm depth laceration under his left eye. Resident #46's eye was cleansed, patted dried, triple antibiotic ointment was applied and open to air. Residents #46 and FR #49 were separated, neurological checks initiated, one-on-one interventions and monitoring were put into place. Review of the incident log dated 11/03/22 to 02/01/23 revealed an incident of alleged resident-to-resident physical abuse was listed on 12/26/22 for Resident #46 and FR #49. Review of the Ohio Department of Health's Gateway system revealed a facility SRI related to the allegation of physical abuse initiated as of 12/26/22 for Resident #46 and FR #49. Review of the facility SRI tracking number (#) 230500 dated 12/26/22 revealed Resident #46 and FR #49 were sitting in the dining room. FR #49 was overheard asking Resident #46 for money. Resident #46 did not answer and attempted to pick up something from the floor. FR #49 thought Resident #46 was trying to take his shoes and took his cane and hit Resident #46 in the face, causing a laceration to his left eye. Review of the facility policy titled OHIO Abuse, Neglect, and Misappropriation, revised 10/27/21, revealed the facility had a policy in place to prevent abuse, mistreatment, or neglect of residents or the misappropriation of their property, corporal punishment and/or voluntary seclusion and to provide guidance to direct staff to manage any concerns or allegations of abuse, neglect, or misappropriation of their property. Review of the policy revealed staff would be established based on census, acuity level, and needs. Review of the facility document revealed the facility did not implement the policy regarding the allegation of abuse. The above findings were verified during an interview on 02/01/23 at 3:26 P.M. with the Director of Nursing (DON).

Based on record review, review of facility staff statements, review of the facility Abuse policy and procedure and staff interview the facility failed to ensure an allegation of staff to resident abuse was reported to the State agency as required. This affected one resident (#31) of three residents reviewed for abuse. Findings Include: Review of the medical record for Resident #31 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/24/21 revealed the resident had impaired cognition. The assessment revealed the resident was also dependent on two staff for bed mobility, transfers and toileting. On 04/30/21 at 10:55 A.M. interview with State tested Nursing Assistant (STNA) #102 revealed she was aware of an incident involving STNA #103 and Resident #31. STNA #102 revealed the activities person came to her (date not provided) and said STNA #103 pulled Resident #31's hair at dinner time (date not provided). The facility provided staff statements related to the above incident. A statement from Activities Assistant (AA) #444, dated 04/16/21 at 5:45 P.M. revealed STNA #103 brought Resident #103 into the dining area. She (the resident) was vocalizing and bending over in her chair. STNA #103 told Resident #31 to sit back pushing her from the front. Then went behind her chair grabbed a large portion of her hair and pulled her back. An undated/untimed statement from STNA #103 revealed the STNA was in the dining room at the time when she noticed Resident #31 falling forward. To prevent the fall, I grabbed the clothing protector which had the end of her hair wrapped around it accidentally pulling her hair. The STNA's statement documented she was just preventing her fall. A statement from the Director of Nursing (DON) dated 04/16/21 revealed she received a phone call from the nurse (Registered Nurse (RN) #400) around 6:00 P.M. The nurse stated the activities assistant informed her she witnessed an STNA pull a resident's hair. The DON revealed the incident had not been witnessed by the nurse. The DON proceeded to speak to STNA #103, who stated she noticed said resident leaning forward in her wheelchair and went over to assist the resident back into the wheelchair to prevent a fall. STNA #103 indicated she had attempted to grab the resident's shoulder and instead grabbed the resident's clothing protector and a portion of the resident's hair by accident. The DON then spoke to AA #444. AA #444 stated she had witnessed STNA #103 pull a portion of the resident's hair trying to get the resident to sit back in her wheelchair. The DON directed RN #400 to assess Resident #31 and notified the Administrator. The DON's statement revealed after speaking with all involved parties (AA #444 and STNA #103) there were no findings of abuse suspected. STNA #103 was educated on the importance of proper positioning of residents. Review of the DON's statement revealed no evidence STNA #103 was removed from the facility/schedule pending an investigation (the STNA continued to work the remainder of her shift on this date and on subsequent dates following the incident), no evidence additional information was obtained from AA #444 following the DON's interview with STNA #103, no evidence a statement was obtained or attempted from Resident #31 regarding the incident, no evidence the facility identified any other residents who had been in the area at the time of the incident for possible interview, no evidence other staff who might have had knowledge of the incident were interviewed to ensure a complete and thorough investigation was completed and no evidence with only conflicting statements from two facility employees with involvement in the incident, the facility attempted to have the employees demonstrate/re-enact what had occurred to allow for a more thorough investigation. A statement from the Administrator, dated 04/16/21 revealed RN #400 called her to report STNA #103 may have pulled a resident's (Resident #31's) hair. The Administrator asked RN #400 if she saw what happened but RN #400 stated she did not. RN #400 indicated it occurred in the dining room and AA #444 was in the room. There was no indication in the statement the incident was identified to be a potential incident of abuse. In addition, there was no evidence RN #400 was directed to remove STNA #103 from the facility or directed to initiate an investigation. There was no evidence the incident was reported to the State agency as an allegation of staff to resident physical abuse. Review of the facility self-reported incidents revealed no evidence the facility reported this incident to the State agency as required. On 04/30/21 at 12:19 P.M. interview with Registered Nurse (RN) #400 revealed an incident had occurred and Activities Aide (AA) #444 reported State tested Nursing Assistant (STNA) #103 pulled Resident #31 back into her chair by her hair. RN #400 revealed she spoke to the STNA who stated she had pulled the resident's hair on accident when the resident's hair was caught in a Velcro clothing protector the resident was wearing when the resident was pulled up in a chair. RN #400 revealed she immediately notified the Director of Nursing (DON) and the Administrator. During the interview, RN #400 verified STNA #103 was not removed from the facility immediately at the time of the incident and indicated she was not aware of an investigation being completed. On 04/30/21 at 12:10 P.M. interview with the Administrator revealed staff were to report abuse immediately, separate those involved, call the police, notify the family and physician and implement interventions for all incidents of abuse with all the residents and staff. A head to toe assessment should be completed on the resident. During the interview, the Administrator denied any incidents of staff to resident abuse being reported to her. The Administrator also failed to provide any evidence the incident involving STNA #103 and Resident #31 was reported to the State agency. On 04/30/21 at 12:57 P.M. interview with the DON, the DON revealed she had received a call from RN #400 (on 04/16/21) that STNA #103 had pulled Resident #31's hair. The DON stated she talked with STNA #103 over the phone and the STNA revealed she accidentally pulled Resident #31's hair when pulling the resident up in her chair as it got caught in her clothing protector. The DON revealed after she spoke to STNA #103, she didn't feel it was meant to be malicious. The DON failed to provide any evidence the incident had been reported to the State agency at the time it occurred as a potential staff to resident physical abuse incident. On 04/30/21 at 2:50 P.M. a telephone interview with Activities Aide (AA) #444 regarding the incident involving STNA #103 and Resident #31 revealed the resident had been verbal and was trying to get up out of her chair. AA #444 revealed she witnessed STNA #103 place both hands on Resident #31's shoulders and push the resident back in her chair. STNA #103 then walked behind the chair and placed one hand on the chair for leverage and with the other hand grasped a large section of Resident #31's hair and pulled her back in the chair. AA #444 revealed she immediately went to STNA #103 and told her, I saw what you did. AA #444 revealed she then reported the incident to RN #400. Review of facility policy titled Ohio Abuse, Neglect & Misappropriation, revised date 04/01/19 revealed it was the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. It was the intent of this facility to prevent the abuse, mistreatment, or neglect of residents or the misappropriation of their property, corporal punishment and/or involuntary seclusion and to provide guidance to direct staff to manage any concerns of allegations of abuse, neglect or misappropriation of their property. The policy also indicated the results of the facility investigation must be reported to the survey agency, the Executive Director (ED) or designee and other officials in accordance with State law, within five working days of the incident. This deficiency substantiates Complaint Number OH 999.

Based on record review, review of facility staff statements, review of the facility Abuse policy and procedure and staff interview the facility failed to timely identify a situation of potential staff to resident abuse involving Resident #31, failed to ensure a complete and thorough investigation was completed following the allegation, failed to protect Resident #31 from further potential abuse following the incident and failed to report the allegation of abuse to the State agency as required. This affected one resident (#31) of three residents reviewed for abuse. Findings Include: Review of the medical record for Resident #31 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/24/21 revealed the resident had impaired cognition. The assessment revealed the resident was also dependent on two staff for bed mobility, transfers and toileting. On 04/30/21 at 10:55 A.M. interview with State tested Nursing Assistant (STNA) #102 revealed she was aware of an incident involving STNA #103 and Resident #31. STNA #102 revealed the activities person came to her (date not provided) and said STNA #103 pulled Resident #31's hair at dinner time (date not provided). The facility provided staff statements related to the above incident. A statement from Activities Assistant (AA) #444, dated 04/16/21 at 5:45 P.M. revealed STNA #103 brought Resident #103 into the dining area. She (the resident) was vocalizing and bending over in her chair. STNA #103 told Resident #31 to sit back pushing her from the front. Then went behind her chair grabbed a large portion of her hair and pulled her back. An undated/untimed statement from STNA #103 revealed the STNA was in the dining room at the time when she noticed Resident #31 falling forward. To prevent the fall, I grabbed the clothing protector which had the end of her hair wrapped around it accidentally pulling her hair. The STNA's statement documented she was just preventing her fall. A statement from the Director of Nursing (DON) dated 04/16/21 revealed she received a phone call from the nurse (Registered Nurse (RN) #400) around 6:00 P.M. The nurse stated the activities assistant informed her she witnessed an STNA pull a resident's hair. The DON revealed the incident had not been witnessed by the nurse. The DON proceeded to speak to STNA #103, who stated she noticed said resident leaning forward in her wheelchair and went over to assist the resident back into the wheelchair to prevent a fall. STNA #103 indicated she had attempted to grab the resident's shoulder and instead grabbed the resident's clothing protector and a portion of the resident's hair by accident. The DON then spoke to AA #444. AA #444 stated she had witnessed STNA #103 pull a portion of the resident's hair trying to get the resident to sit back in her wheelchair. The DON directed RN #400 to assess Resident #31 and notified the Administrator. The DON's statement revealed after speaking with all involved parties (AA #444 and STNA #103) there were no findings of abuse suspected. STNA #103 was educated on the importance of proper positioning of residents. Review of the DON's statement revealed no evidence STNA #103 was removed from the facility/schedule pending an investigation (the STNA continued to work the remainder of her shift on this date and on subsequent dates following the incident), no evidence additional information was obtained from AA #444 following the DON's interview with STNA #103, no evidence a statement was obtained or attempted from Resident #31 regarding the incident, no evidence the facility identified any other residents who had been in the area at the time of the incident for possible interview, no evidence other staff who might have had knowledge of the incident were interviewed to ensure a complete and thorough investigation was completed and no evidence with only conflicting statements from two facility employees with involvement in the incident, the facility attempted to have the employees demonstrate/re-enact what had occurred to allow for a more thorough investigation. In addition, the DON's statement did not indicate the incident was reported to the State agency. A statement from the Administrator, dated 04/16/21 revealed RN #400 called her to report STNA #103 may have pulled a resident's (Resident #31's) hair. The Administrator asked RN #400 if she saw what happened but RN #400 stated she did not. RN #400 indicated it occurred in the dining room and AA #444 was in the room. There was no indication in the statement the incident was identified to be a potential incident of abuse. In addition, there was no evidence RN #400 was directed to remove STNA #103 from the facility or directed to initiate an investigation. There was no evidence the incident was reported to the State agency as an allegation of staff to resident physical abuse. Review of the facility self-reported incidents revealed no evidence the facility reported this incident to the State agency as required. On 04/30/21 at 12:19 P.M. interview with Registered Nurse (RN) #400 revealed an incident had occurred and Activities Aide (AA) #444 reported State tested Nursing Assistant (STNA) #103 pulled Resident #31 back into her chair by her hair. RN #400 revealed she spoke to the STNA who stated she had pulled the resident's hair on accident when the resident's hair was caught in a Velcro clothing protector the resident was wearing when the resident was pulled up in a chair. RN #400 revealed she immediately notified the Director of Nursing (DON) and the Administrator. During the interview, RN #400 verified STNA #103 was not removed from the facility immediately at the time of the incident and indicated she was not aware of an investigation being completed. On 04/30/21 at 11:01 A.M. interview with the DON revealed following any allegation of abuse she gathers information and reports it. She stated the facility completes skin sweeps on residents, obtains statements from everyone in the facility, talks to everybody staff and residents and then investigates and determines if there was actual abuse to report. The DON revealed the staff member would be removed from the facility with an allegation of abuse. At the time of the interview, the DON indicated no one had reported abuse to her and she was not aware of any incidents of staff to resident abuse. On 04/30/21 at 12:10 P.M. interview with the Administrator revealed staff were to report abuse immediately, separate those involved, call the police, notify the family and physician and implement interventions for all incidents of abuse with all the residents and staff. A head to toe assessment should be completed on the resident. During the interview, the Administrator denied any incidents of staff to resident abuse being reported to her. The Administrator also failed to provide any evidence the incident involving STNA #103 and Resident #31 was reported to the State agency. On 04/30/21 at 12:57 P.M. during a follow up interview with the DON, the DON revealed she had received a call from RN #400 (on 04/16/21) that STNA #103 had pulled Resident #31's hair. The DON stated she talked with STNA #103 over the phone and the STNA revealed she accidentally pulled Resident #31's hair when pulling the resident up in her chair as it got caught in her clothing protector. The DON revealed after she spoke to STNA #103, she didn't feel it was meant to be malicious. However, the DON denied conducting any additional investigation into the incident. The DON failed to provide any evidence the incident had been reported to the State agency at the time it occurred as a potential staff to resident physical abuse incident or evidence STNA #103 was suspended pending an investigation. On 04/30/21 at 2:50 P.M. a telephone interview with Activities Aide (AA) #444 regarding the incident involving STNA #103 and Resident #31 revealed the resident had been verbal and was trying to get up out of her chair. AA #444 revealed she witnessed STNA #103 place both hands on Resident #31's shoulders and push the resident back in her chair. STNA #103 then walked behind the chair and placed one hand on the chair for leverage and with the other hand grasped a large section of Resident #31's hair and pulled her back in the chair. AA #444 revealed she immediately went to STNA #103 and told her, I saw what you did. AA #444 revealed she then reported the incident to RN #400. Review of facility policy titled Ohio Abuse, Neglect & Misappropriation, revised date 04/01/19, revealed it was the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. It was the intent of this facility to prevent the abuse, mistreatment, or neglect of residents or the misappropriation of their property, corporal punishment and/or involuntary seclusion and to provide guidance to direct staff to manage any concerns of allegations of abuse, neglect or misappropriation of their property. The policy also indicated an employee who was alleged or accused of being a party to abuse, neglect, misappropriation of property would be immediately removed from the area of resident care, interviewed by facility leadership for a written statement and not left alone. After completing the statement the employee would be asked to vacate the facility until further investigation of the incident was completed. The results of the facility investigation must be reported to the survey agency, the Executive Director (ED) or designee and other officials in accordance with State law, within five working days of the incident. This deficiency substantiates Complaint Number OH 999.

Based on observation, record review, and interview, the facility failed to ensure ordered fall-prevention interventions were in place for Resident #25. This affected one of three residents (Resident #25, #27, and #10) reviewed for falls. The total census was 46. Findings include: Observation on 03/26/19 at 8:47 A.M. revealed Resident #25 to be in the facility dining room in his wheelchair, which had no anti-rollback or anti-tipping devices in place. An attempt to interview him at this time revealed he was not interviewable. Interview with Rehab Clinical Coordinator #210 on 03/26/19 at 10:55 A.M. confirmed Resident #25 did not have anti-tipping or anti-rollback devices in place on his wheelchair. Record review of Resident #25 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He had orders in place for anti-rollback and anti-tipping devices to be applied to the wheelchair, with a start date of 05/23/18. He had fall events on 03/09/19, 03/11/19, and 03/16/19 with no evidence of severe harm. The above findings were verified with the Administrator at 2:30 P.M. on 03/26/19. This deficiency substantiated complaint #OH 230.

Based on observation and staff interview the facility failed to serve the lunch meal at a palatable temperature to three residents (Resident #27, #41, and #33) of 40 residents eating in the dining room. The facility census was 45. Findings Include: 1. The lunch service was observed on 01/22/19 from 12:35 P.M. through 1:10 P.M. The lunch trays were given to the three residents at approximately 12:35 P.M. At 1:05 P.M. an aide sat down next to Resident #27 and started to feed him. The meal was stopped and Dietary Manager (DM) 202 was asked to check the temperature of the resident's food. Resident #27's food temperatures were pureed pork 141 degrees Fahrenheit (F), pureed rice was 132 degrees F, and pureed carrots were 122 degrees F. Review of the Kardex (contains instructions for resident care) for Resident #27 revealed he required extensive assistance of one staff member at meals and at times may require total dependence on staff to eat his meals. The resident could not be interviewed due to cognition. 2. Resident # 41's food temperatures were checked and the pureed pork was 133 degrees F, pureed rice was 130 degrees F, and the pureed carrots were 110 degrees F. DM #202 informed the aides not to feed the residents until the meals were reheated. Review of the Kardex for Resident #41 revealed he required extensive assistance of one staff member at meals and at times may require total dependence on staff to eat his meals.The resident could not be interviewed due to cognition. Interview with DM #202 at 1:10 P.M. confirmed the food should be served at no less than 135 degrees F. 3. Review of Resident #33's medical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively impaired and required the extensive assist of one person at meals. Review of physician's orders [REDACTED]. Review of Resident #33's Kardex (document detailing care needs of a resident) revealed she required extensive to dependent assistance and staff participation for eating. The resident could not be interviewed due to cognition. Observation of the lunch meal on 01/22/19 starting at 12:30 P.M. revealed Resident #33 was served her plate consisting of mechanically altered pork, rice and cauliflower at 12:35 P.M. Her plate remained uncovered to air and untouched until staff came by to assist her at 12:55 P.M. Per surveyor intervention, temperature readings of the food on Resident #33's plate were obtained by Food Service Director (FSD) #202 at 12:58 P.M. and were as follows: pork 111 degrees Fahrenheit (F); cauliflower 96 degrees F and rice 115 degrees F. Interview with FSD #202 at the time of the above observation revealed foods should be at least 135 degrees F at the time of presentation to the table and verified food should not have been sitting out uncovered before Resident #33 was assisted at the meal.

Based on observation, interview and record review the facility failed to ensure consistent use of adaptive equipment for one resident (Resident #17) of 43 residents observed for dining (Resident #36 and Resident #38 were identified by the facility as receiving nothing by mouth). The facility census was 45 residents. Findings include: Review of Resident #17's medical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of an annual minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #17 was cognitively impaired, had a mechanically altered diet and had no weight loss or weight gain. Review of physician's orders [REDACTED].#17 was on a puree diet with honey thick liquids and required a small bolus spoon (adaptive device used for those with decreased oral motor strength to ensure food is entirely consumed). Review of a nutrition assessment dated [DATE] revealed Resident #17 received a pureed diet with honey thick liquids and required a small bolus spoon. Review of a nutrition care plan revealed Resident #17 was at risk for choking at meals and pocketed food (held it in his cheeks) and required feeding assistance at meals. Interventions included to assist with feeding Resident #17 including alternating small bites and sips, following any safe feeding strategies per speech-language pathologist guidelines and use of the small bolus spoon. Observation of the lunch meal on 01/23/19 starting at 12:45 P.M. revealed State tested Nurse Aide (STNA) #200 feeding Resident #17 soup as well as thickened water with a plastic spoon. A bolus spoon was available and used for the pureed items on the resident's plate. STNA #200 continued to use the plastic spoon to provide water to Resident #17 at 12:53 P.M. Resident #17 coughed several times throughout the observation. Observation of the lunch meal on 01/24/19 starting at 12:26 P.M. revealed STNA #200 seated to the right of Resident #17. STNA #200 brought Resident #17's tray to the table at 12:34 P.M. which consisted of two small bolus spoons, a glass of thickened milk, a glass of thickened water, a plate with pureed entrees and sides, soup and pudding. STNA #200 then went over to the medication cart to grab several plastic spoons off the cart. STNA #200 was noted to use these plastic spoons to provide Resident #17 thickened water at 12:37 P.M., 12:44 P.M. and 12:51 P.M. and soup at 12:48 P.M. Resident #17 coughed several times throughout the observation. Interview on 01/24/19 at 12:58 P.M. with STNA #200 revealed she had fed Resident #17 on 01/23/19 and on 01/24/19. STNA #200 did not tell the surveyor why she used a plastic spoon to feed Resident #17 soup instead of the bolus spoon and stated she used the plastic spoon on the thickened water to ensure he had enough to drink. Interview on 01/24/19 at 1:03 P.M. with Occupational Therapist #201 verified Resident #17 was to have the bolus spoon for all items during the meal and showed the surveyor the physician's orders [REDACTED].

Based on medical record review and staff interview the facility failed ensure accuracy of a periodic assessment for Resident #39. This affected one resident (Resident #39) of four residents reviewed for assessments. Findings include: Review of Resident #39's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE], section J-1800, revealed Resident #39 had no falls since her previous assessment and no major injuries from falls. The record indicated Resident #39's previous quarterly assessment was completed on 04/01/18. Review of Resident #39's progress notes dated 05/26/18 at 10:20 P.M. revealed Resident fell face-down on the floor in the dinning room at 8:30 P.M. The nurse witnessed the resident walking in the dinning room. The resident bent down to look for something, lost her balance and fell , face down. Resident #39 was checked for injuries and treated for [REDACTED]. The progress notes dated 05/27/18 at 2:17 P.M. revealed Resident #39 had a closed non-displaced spiral [MEDICAL CONDITION] of the right humerus (arm). On 07/18/18 at 10:03 A.M. Registered Nurse (RN) #800 verified the quarterly MDS dated [DATE] was not accurately coded to capture Resident #39's fall with a fracture that occurred on 05/26/18.

Based on observation, review of self reported incidents, medical record review and staff interview the facility failed to ensure proper assistive devices were in place for Resident #34 to prevent potential accidents. This affected one resident (Resident #34) of four reviewed for accidents. The facility census was 48. Findings include: Review of a facility self report incident (SRI) dated 05/28/18, identified Resident #34 was found with a bruise to left side of his mouth. The facility initiated an investigation into the injury of unknown origin. The facilities investigation identified Resident #34 was believed to use his call button and cord like a fishing pole (throwing for casting). The facility identified following this incident they would place a soft pad call light for Resident #34. On 07/18/18 at 10:30 A.M. observation of Resident #34 revealed him seated in his wheelchair with a hard call light attached. Interview with State tested Nursing Assistant (STNA) #700 on 07/18/18 at 10:30 A.M. confirmed Resident #34 presently had a hard push button type call light attached to his wheel chair. STNA #700 revealed there was a soft pad call light in the resident's room. However, she was not aware Resident #34 should be using a soft call light. The interview confirmed Resident #34's Kardex (used by STNAs to identify specific resident care needs) did not include the type of call light Resident #34 needed.

Based on observation and staff interview, the facility failed to maintain a clean and sanitary environment in resident rooms and failed to maintain resident care equipment in a clean and sanitary condition. This affected all 24 resident occupied rooms, one (Resident #37) of three residents who receive tube feed, and 13 (Residents #3,#5, #11, #12, #14, #19, #20, #25, #27, #29, #32, #35 and #41) of 14 residents who required a floor mat for a fall intervention. Based on observation and interview, the facility failed to maintain a clean laundry processing area. This has the potential to affect all 45 residents in the facility. Findings include: 1. An environmental tour was conducted with the Administrator on 12/12/17 between 4:14 P.M. and 4:42 P.M. The following was verified at the time of observation by the Administrator. Rooms 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 113, 114, 115, 116, 117, 118, 119, 120, 121, 122, 123, 124, 125 and 126 contained debris, discoloration, scuffing and staining on the floors. Rooms 101, 105 and 120 contained toilets with significant discoloration and grime. rooms [ROOM NUMBERS] contained privacy curtains with multiple stains on them. Rooms 115, 118 and 120 contained water stains or discoloring on the ceiling. room [ROOM NUMBER] contained a cracked and discolored over head light by the window bed. room [ROOM NUMBER] contained no cover on the bathroom light. room [ROOM NUMBER] contained a resident's comforter with multiple stains on it. 2. Observation of resident care equipment with the Director of Nursing (DON) on 12/13/17 between 8:03 A.M. and 8:12 A.M. revealed the following Observations of the floor mats for Residents #3,#5, #11, #12, #14, #19, #20, #25, #27, #29, #32, #35 and #41 revealed various levels of stains on each of the mats. Observation of the tube feed pole attached to Resident #37 revealed the pole had dried tube feed and caked on debris particles on it. These findings were verified at the time of observations by the DON. 3. On 12/14/17 at 10:48 A.M. tour of the clean laundry room was made with Housekeeping/Laundry Manager #2 and Laundry Assistant #2. The exhaust fan system, sprinkler system pipes and gauges located in the clean laundry room were heavily coated with lint and debris generated from the dryer. On 12/14/17 at 10:48 A.M. an interview with Laundry Assistant #2 revealed the clean laundry was removed from the dryer, placed on a cart and folded. The folding area was directly in front of the exhaust and sprinkler system. Laundry Assistant #2 stated, I do not clean the fan or the pipes. I clean the dryer lint trap every hour and my clean laundry area only. On 12/14/17 at 10:48 A.M. an interview with Housekeeping/Laundry Manager #2 verified the exhaust fan and pipes were not cleaned by laundry staff but by maintenance staff. On 12/14/17 at 11:05 A.M. an interview with Maintenance Worker #2 verified the exhaust fan system was cleaned every few months. Maintence Worker #2 stated the sprinkler pipes and gauges were not cleaned by maintenance staff.

Based on observation and resident and staff interview, the facility failed to maintain comfortable temperature levels in the rooms of Residents #13, #30 and #246, and in room [ROOM NUMBER]. This affected four of nine residents whose rooms were observed. Findings include: 1. In an interview on 12/11/17 at 12:59 P.M. Resident #246 stated she was always cold in her room. In an interview on 12/11/17 at 2:37 P.M. Resident #36 stated (in broken English due to primary language being Spanish) very chilly while sitting in her room. In an interview on 12/11/17 at 4:37 P.M. Resident #13 stated her room was always quite drafty and got really cold at night. Observation of the rooms belonging to Residents #13, #36 and #246 on 12/12/17 between 2:55 P.M. and 3:07 P.M. with Maintenance Worker #2 revealed the area surrounding the air conditioning unit in each of the rooms lacked a hard seal and a noticeable very cold draft was coming in from the outside. The observations were verified at the time of discovery with Maintenance Worker #2. Review of the National Weather Service Forecast Office website (w2.weather.gov) revealed an outside air temperature on 12/12/17 of 21 degrees Fahrenheit at the time of observation of the rooms of Residents #13, #36, and #246. 2. An environmental tour was conducted with the Administrator on 12/12/17 between 4:14 P.M. and 4:42 P.M. The following was verified at the time of observation with the Administrator. room [ROOM NUMBER] was noticeably cool and contained a draft from the outdoors coming through the air conditioning unit.

Based on observation and staff interview, the facility failed to maintain the confidentiality of medical information. This affected one (Resident #23) of one residents reviewed for privacy. Findings include: Review of the facility's public survey book for compliance on 12/14/17 at 1:48 P.M. revealed at the end of the most recent annual survey results was a fax confirmation cover sheet dated 07/13/17 that contained sensitive medical information regarding Resident #23. This cover sheet included information about urinary concerns for Resident #23. These findings were verified with Corporate Administrator #3 on 12/14/17 at 1:55 P.M.

Based on record review and interview, the facility failed to implement interventions to prevent a fall. This resulted in actual harm for Resident #52 who fell out of bed and suffered a fracture of the right hip. This deficient practice affected one (Resident #52) of three residents reviewed for falls. The facility census was 47. Findings include: Review of the medical record revealed Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. and dementia. Review of the facility's fall investigations revealed Resident #52 sustained several falls beginning on 09/10/13 when he slipped on the floor. On 01/17/14, the resident fell in the hallway while self- ambulating in therapy. On 01/30/14, Resident #52 was observed on the floor in his room with a skin tear. The facility initiated a new intervention to wear proper footwear. On 02/10/14, the resident was found sitting on the floor in his room with proper footwear andno injuries. The facility initiated anti-slip strips to the floor to prevent a future fall. On 02/11/14, the resident was in his room and found on the floor with a skin tear to the right forearm. The facility implemented a new intervention for an alarming sensor to the bed. On 03/08/14, Resident #52 was found on the floor in the middle of the room with a 2 centimeter skin tear at the corner of his right eyebrow. The fall investigation witness statement revealed the resident removed his nightgown, so the alarm did not sound. There was no indication of a sensor alarm to his bed or if it was in proper use and functioning. Review of Resident#52 ' s care plan for falls revealed an intervention added on 02/11/14 for a pressure sensitive alarm to the bed. Review of the medical record revealed on 03/08/14 the resident complained of right hip pain, an x-ray was completed indicating Resident #52 sustained a right hip fracture and was sent to the hospital for surgical repair. During an interview with the director of nursing on 04/07/14 at 3:15 P.M. it was verified the bed pressure sensitive alarm was not in use at the time of Resident #52's fall on 03/08/14. The DON verified the staff failed to follow the plan of care resulting in a fall and a fracture to the right hip for Resident #52.