Every finding on record at Bethany Village

Based on record review, staff interviews, and policy review, the facility failed to treat a resident with dignity and respect by violating their privacy. This affected one (#249) out of four residents reviewed for resident rights. The facility census was 248. Findings include: Review of the closed medical record for Resident #249 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included viral pneumonia, depression, psoriasis, hypertension, atrial fibrillation, vitamin d deficiency, localized edema, anxiety disorder, and hyperlipidemia. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #249 had moderately impaired cognition. Resident #249 was assessed to require setup assistance for eating, and oral hygiene, substantial/maximal assistance for bathing, dressing, personal hygiene, and bed mobility, and was dependent on staff for toileting. Review of the facility's counseling/education forms for State tested Nursing Assistants (STNA) #12 and #14 dated 01/20/25 revealed they were educated for taking pictures of a resident that was soiled and showing the pictures to other staff at the facility. The form indicated they were advised not to take pictures of residents with their personal phones or share pictures of residents with other staff. Interviews on 03/02/25 from 1:19 P.M. to 1:49 P.M. via telephone with Registered Nurse (RN) Unit Manager (UM) #100 revealed there was an incident where a picture was taken of a resident, and the staff involved were STNAs #12 and #14. RN UM #100 stated the picture did not show the resident's face and only showed their hands and abdominal area that were soiled. RN UM #100 reported she completed a counseling form with both employees involved. Interview on 03/02/25 at 1:45 P.M. with the Director of Nursing (DON) revealed the picture was alleged to be of Resident #249 and showed feces on their hands and abdominal area. Interview on 03/02/25 at 1:52 P.M. via telephone with STNA #14 revealed she delivered a breakfast tray to Resident #249 and discovered her hands were dirty. STNA #14 stated she informed Resident #249's aide, STNA #12, and both staff pulled back the blankets on Resident #249 where it was revealed the resident was soiled with feces. STNA #14 verified she took a picture of Resident #249's legs that had feces on them and sent the picture to STNA #12 who then shared the picture with RN UM #100. Interview on 03/02/25 at 2:12 P.M. via telephone with STNA #16 revealed STNA #12 showed her the picture and said it was of Resident #249. STNA #16 stated she reported the incident to RN UM #100. Review of the policy titled, Residents' Rights, reviewed 10/22/19, revealed residents had the right to be treated with respect and dignity. This deficiency represents non-compliance investigated under Master Complaint Number OH00161794.

Based on medical record review, staff interview, and review of facility policy, the facility failed ensure a resident was free from unnecessary [CONDITION(S)] medications by ensuring staff documented justification for an increase in a resident's antipsychotic medication. This affected one (#117) of five reviewed for unnecessary medications. The census was 239. Findings include: Review of Resident #117's medical record revealed an admitted [DATE]. Diagnoses listed included cerebral atherosclerosis, heart failure, restlessness and agitation, depression, and dementia with agitation. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #117's brief interview for mental status (BIMS) score was 12, indicating the resident had moderate cognitive impairment. Resident #117 was assessed as not having any psychotic disorders. Review of physician orders revealed an order to increase the antipsychotic medication [MEDICATION(S)] from 25 milligrams (mg) twice a day to 50 mg twice a day (BID) by mouth (PO) dated 04/15/22 for unspecified dementia with behavioral disturbance. Resident #117 remained on [MEDICATION(S)] 50 mg PO BID with an order dated 09/10/22. Review of social services progress notes dated 03/14/22 revealed Licensed Social Worker (LSW) met with Resident #117's daughter via telephone. Resident #117 was adjusting favorably to new living environment with no changes in mood or behavior. Review of physician assistant (PA) progress notes dated 04/15/22 revealed Resident #117 had cerebral atherosclerosis with behaviors and was evaluated for delusions. Resident #117's daughter stated her mother had increased delusions, distressed, and tearful. Resident #117's daughter said many things her mother is saying are not based on reality, such as her spouse is cheating, etc. Resident #117 is currently on [MEDICATION(S)] 25 mg PO BID. Review of an facility internal email dated 04/14/22 from Licensed Social Worker (LSW) #9 to members of the Interdisciplinary Team (IDT) members revealed LSW #9 spoke with Resident #117's daughter who expressed concerns regarding her mother's demeanor, citing that Resident #117 had become increasingly delusional, distressed, and tearful. Resident #117's daughter reported Resident #117 says many things that are not based in reality (such as spouse is cheating on her) and wanted the physician to be consulted regarding whether or not an increase in [MEDICATION(S)] was warranted. Nursing staff was to make the physician aware of Resident #117's daughter's request and provide supporting documentation in the clinical record of Resident #117's mood for physician reference. Further review of Resident #117's medical record from admission from 03/09/22 (date of admission to dementia care unit) through 04/15/22 revealed no documentation of any increase in behaviors such as delusions, distress, or tearfulness. Interview with the Director of Nursing (DON) on 10/27/22 at 1:40 P.M. confirmed there was not documentation in the medical record of any increase of Resident #117's behaviors that would justify an increase in the antipsychotic [MEDICATION(S)] on 04/15/22. The DON confirmed nursing staff should monitor and document any increase in behaviors in a resident's medical record. Review of the facility's policy titled Use pf [CONDITION(S)] Drugs dated effective 04/16/91 and last revised 05/13/22 revealed the IDT will monitor to verify that residents who receive [CONDITION(S)] drugs either are currently exhibiting identified symptoms, behaviors or have a history of said behaviors. Behaviors include but are not limited to the following: a. Sundowning; b. Severe anger; c. Aggression; d. Agitation related to sundowning; e. Agitation due to pain (i.e. [CONDITION(S)]); and f. Anxiety. The IDT is responsible for the following: a. Reviewing the resident's behaviors as indicated; b. Monitoring to ensure behaviors are tracked; c. Providing direction to unit nurse regarding consulting with and discussing with the physician any recommended [CONDITION(S)] drug changes; and d. The MDS nurse will verify that the AIMS (abnormal involuntary movement score) test is done initially and every six months thereafter for antipsychotic drugs.

Based on interview and record review, the facility failed to provide documentation to show that residents and/or their resident representative had been afforded education about the risks and benefits of influenza vaccine prior to vaccine administration to ensure they were able to make informed choices related to their decision to receive the influenza vaccine. Specifically, there was no evidence of education provided for three of five sampled residents (Resident (R) R4, R7 and R8) reviewed for immunizations. Findings include: Review of the facility policy titled, Immunization and Vaccination, revised 11/16/19, revealed residents are provided the current Centers for Disease Control (CDC) Vaccine Information Sheet (VIS) prior to vaccinations. The VIS provides information regarding CDC's recommendations, and associated risks and benefits of the influenza vaccine. 1. Review of the hard copy undated Face Sheet revealed R4 was admitted to the facility on [DATE]. Review of R4's electronic medical record (EMR) revealed a scanned Influenza Consent with the box checked indicating, I would like to receive the facility chosen and CDC recommended influenza vaccine annually while at (NAME)any Village. The Influenza Consent was signed and dated 10/2/19. Review of the facility Flu Vaccine Consent Form, revealed the most up to date VIS for the seasonal flu vaccine will be provided annually. Review of the EMR for R4 in the section for Administration History for the Medication Administration Record [REDACTED]. Review of the section for Preventive Health Care, under Influenza vaccine 2020 in R4's EMR, revealed the box for Education provided had not been checked when the influenza vaccine was administered to R4 on 9/30/20. Review of the Progress Notes section revealed an absence of documentation to show that education about the risks and benefits of vaccination had been provided to R4 or R4's representative 2. Review of the hard copy undated Face Sheet revealed R7 was admitted to the facility on [DATE]. Review of R7's EMR revealed a scanned copy of the Influenza Consent with the box checked that indicated, I would like to receive the facility chosen and CDC recommended influenza vaccine annually while at (NAME)any Village. This form was signed and dated 10/16/19. Review of the facility Flu Vaccine Consent Form, revealed the most up to date VIS for the seasonal flu vaccine will be provided annually. Review of the EMR for R7 under the Progress Notes tab, revealed the time and location of the influenza vaccination on 10/05/20, however, there was an absence of documentation to show that education about risks and benefits had been provided prior to the vaccine being administered to R7. Documentation in the Preventative Health Care section of R7's EMR revealed a document that confirmed the influenza vaccine had been administered to R7 on 10/5/20, but the box for Education provided to show that R7 or R7's representative had been afforded information about the risks and benefits associated with the influenza vaccine had not been checked. 3. Review of the hard copy undated Face Sheet revealed R8 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of R8's EMR revealed a scanned copy of the Influenza Consent located in the Resident Documents tab. The Influenza Consent revealed the box was checked that indicated, I would like to receive the facility chosen and CDC recommended influenza vaccine annually while at (NAME)any Village. The consent was signed and dated 9/30/19. Review of the facility form Flu Vaccine Consent Form, revealed the most up to date VIS for the seasonal flu vaccine will be provided annually. Review of the section Administration History for the MAR indicated [REDACTED]. Review of documentation contained in the section Preventative Health Care, Influenza Vaccine 2020, revealed the box for Education provided had not been checked on the influenza document dated 9/20/20 to indicate that R8 or R8's representative had been afforded education regarding the risks and benefits associated with the influenza vaccine. On 03/04/21 at 2:15 PM, the Interim DON confirmed the box on the Preventative Health Care screen form that indicated education about the risks and benefits for the influenza vaccine should be checked for R4, R7 and R8, but was not checked to indicate education had been provided prior to R4, R7 and R8 being vaccinated. On 03/04/21 at 2:38 PM the Administrator and the Assistant Administrator verbalized the influenza vaccination consent was an annual consent and the education about risks and benefits of the influenza vaccine should be given each time the vaccine was administered. The Administrator and Assistant Administrator confirmed documentation about providing the education about risks and benefits was met by checking the Preventative Health Care selection for the influenza vaccination each year and verified that R4, R7 and R8 did not have the box checked for the 2020-2021 influenza vaccinations provided.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed record review, review of the facility's investigation report, and interviews with the physician and facility staff, the facility failed to ensure Resident #01 was free from accident hazards when she [MEDICAL CONDITION] her bilateral feet caused by the heating system in her room. Actual harm occurred to Resident #01 when her bed was against the heating unit, and the resident's feet laid on the heating unit for an extended period of time resulting in second [MEDICAL CONDITION](involves the first two layers of skin and may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin) to her bilateral feet. This affected one (#01) of three residents reviewed for accidents. The facility census was 243. Findings include: Review of the medical record for Resident #01 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/23/18, revealed the resident had impaired cognition. She required extensive assistance of two staff members for bed mobility. She had a ceiling lift (an electric lift mounted in the ceiling of the resident's room) and was totally dependent of two staff members for transfers and was frequently incontinent of bladder and bowel. Review of the nursing progress notes, dated 12/24/18 at 7:39 A.M., revealed at approximately 4:30 A.M., the stated tested nurse aide (STNA) reported to the nurse that Resident #01's skin was very warm to touch, and her bilateral lower extremities were found resting on the heater which was turned on at that time. Upon nursing assessment, the resident's skin was warm, dry to touch and flushed in color. Her temperature was 102.8 degrees Fahrenheit (F). Her bilateral feet were observed with large fluid filled blisters and a small amount of clear drainage seeping from the left foot. Her bilateral feet were very tender to touch. Cool compresses applied to back of neck and beneath bilateral arms. Resident observed turning and repositioning self toward her left side, which was the side of the bed the heater was on. Her bed was moved away from the wall and heater at that time. Bilateral lower extremities were left open to the air. At 6:00 A.M., Resident #01's temperature was decreased to 98.8 F. degrees. Review of the wound assessment form, dated 12/24/18 at 9:32 A.M., revealed the wounds were assessed. The left foot dorsal (top) was identified as being 10 centimeters (cm.) circular wound bed to the left foot extending into the second, third and fourth toes, related to second degree burns. The burn was documented as being seven cm. wide. Blistered area had peeling epidermis revealing 100 percent (%) granulation with serous drainage and the surrounding skin was red and blanchable. The right foot dorsal was identified as having 13 cm. in length by seven cm. wide peeling epidermis with 100% granulation, serous drainage, related to second [MEDICAL CONDITION] dorsally and wrapping around to the ball and arch of her right foot, and her second, third and fourth toes appeared with fluid filled blistering. The right ball of the foot was assessed to be 13 cm. long by seven cm. wide. It was noted to be peeling epidermis with 100% granulation and serous drainage due to second degree burn. Review of physician orders [REDACTED].M. revealed a new order to wash wounds to bilateral feet, apply silverdene ointment, cover with vasogauze, wrap with Kerlix two times a day until condition was resolved. On 12/24/18 at 10:41 A.M., another new order was for [MEDICATION NAME] (nerve pain medication) 200 milligrams (mg.) and [MEDICATION NAME] (narcotic for moderate to serve pain) by mouth twice a day prior to dressing change. On 12/24/18 at 6:42 P.M., a new order was for a bed cradle to the resident's bed to elevate the blanket off of her feet. Review of the Certified Nurse Practitioner (CNP) progress note, dated 12/26/18, revealed she assessed Resident #01. The CNP stated the resident had second [MEDICAL CONDITION]. The resident has [MEDICAL CONDITION] and she placed her feet on top of the room's heater in the middle of the night. She was found in the morning with blisters. The resident has Alzheimer's dementia and was unable to recall the events. She has a large open blister on the top of her left foot from the midfoot to the toes. She also has now new appearing blisters to her fifth toe and midfoot that were intact. She has a large blister to her bottom foot as well. Her toes on the right have purple discoloration, her skin was warm to touch and she has a palpable pedal pulse. The resident's daughter was at bedside discussed at length about burn pathophysiology, [MEDICAL CONDITION] and [MEDICAL CONDITION]. The CNP ordered the current treatment to continue, elevate legs as tolerated and added Keflex (antibiotic) 500 milligrams (mg.) three times a day as [MEDICATION NAME]. Wound physician to assess and treat wounds and ultrasound to bilateral legs to better assess arteries. Also, ordered blood work for basic metabolic panel and complete blood count. Review of the dietitian progress note dated 12/27/18 11:44 A.M., revealed the resident had sustained injuries to bilateral feet and would need extra fluids and protein to aid in healing. The plan was to add additional juice on each meal tray to increase fluids and ask nursing to order a protein supplement named pro-med 30 milliliters (ml.) three times a day to increase protein. Review of the physician progress notes [REDACTED]. He noted her right foot had a blister around the entire circumference of the foot going into the toes. Her great toe, second and third toes were discolored. The left foot was starting to look better. It had blisters on a couple of the toes and the anterior surface of the foot. There was some discoloration of the second and third toe as well. The physician ordered for the resident to be transferred to the hospital for an evaluation of [MEDICAL CONDITION] the hospital's burn team. Review of the hospital documentation, dated 12/27/18, revealed the burn team assessed the resident's second [MEDICAL CONDITION] her bilateral feet. The resident was assessed to be a poor surgical candidate due to her multiple medical comorbidities. Blisters were ruptured at bedside. The wound bed blanched on her feet bilaterally. There was some concern regarding the right great toe, however, it blanched slowly as well. Given the size of the great toe wound, there was a chance that it would heal on its own without surgical debridement. The burn team felt the resident could return to the facility with follow up visits weekly at the burn clinic. The resident's daughter requested she be admitted to hospital for treatment. The resident was admitted and remained in the hospital until 12/31/18 when she returned to the facility. Upon discharge, the resident was to be scheduled to be seen in the wound clinic weekly. Subsequently, the resident went back to the hospital on [DATE] and did not return to the facility. Review of the State tested Nurse Aide (STNA) #7 statement dated 12/23/18 revealed she took care of Resident #01 from 3:00 P.M. until 12:37 A.M. Around 8:00 P.M., STNA #7 took Resident #01 to her room and placed her into the bed. A bed bath was given and Resident #01 was dressed in her pajamas. STNA #7 denied Resident #01 had any complaints of being cold or wanting the temperature turned up in her room. At 8:30 P.M., Licensed Practical Nurse (LPN) #010, came into the room and did a skin check on Resident #01 without any concerns. Resident #01 then remained in bed with the head of the bed elevated, laying on her left side as was her preference. STNA #7 said she had checked on Resident #01 around 10:00 P.M. and noted that Resident #01's feet were off the pillow so she elevated them back on the pillow. Her bed was in the low position that was level with the heater, she was on her left side and the head of the bed was elevated Review of STNA #5's undated statement revealed on 12/23/18 assumed care of Resident #01 for the third shift. She received report from the second shift STNA at approximately 12:00 A.M. STNA #5 checked on Resident #01 again at 2:30 A.M. Resident #01 was still resting on her left side, as she preferred. At that time when checked, her brief appeared to be dry, so incontinence care was not needed. Resident #01 was also noted to have her head and feet close to the edge of the bed, so STNA #5 repositioned her more into the center of the bed. Resident #01 was lightly sleeping during this care and did not make any verbal communication with STNA #5. STNA #5 did not note the room temperature was any warmer than usual for this resident. STNA #5 did report that Resident #01 does have a tendency to be colder, but she had not stated that during this shift. STNA #5 did not move the bed but she did elevate the foot of Resident #01's bed to make it a more comfortable position with her bent legs. At 3:45 A.M., STNA #5 was stocking resident rooms. Upon entering Resident #01's room, STNA #5 noted the temperature was very hot. STNA #01 walked closer to the heater and noted Resident #01's feet were propped on top of the heater with the sheet and blanket covering them. STNA #5 moved Resident #01's lower extremities off the heater and looked at the control panel on the heater. The temperature was set at 85 degrees F. STNA #5 turned the temperature down to 70 degrees F. STNA #5 did not think Resident #01 looked well. She Review of LPN #010 statement dated 12/28/18 revealed at approximately 4:30 A.M., an STNA reported Resident #01's lower legs were found on the heater. LPN #010 assessed Resident #01 upper extremities and face were flushed in color and hot to touch. Bilateral feet had scattered intact blisters. Resident #01's temperature was 102.8 degrees F. Cool compresses were applied and Resident #01 temperature came down to 98.2 degrees F at 6:15 A.M. Blisters on bilateral feet and ankles were increased in size and opening. Skin appeared to be peeling. Telephone interview on 01/08/19 at 10:30 A.M. with Facility Physician #01 revealed that normally it takes more than an hour for a burn of this type to occur. However, due to the resident's [DIAGNOSES REDACTED]. The physician verified [MEDICAL CONDITION] second [MEDICAL CONDITION] to the blisters. Telephone interview on 01/08/19 at 4:10 P.M. with LPN #010 revealed she has taken care of Resident #01 many times before. She stated Resident #01 always laid in her bed on her left side. Many times, on different dates, she has had to come into the room and put her legs back in the bed due to her laying so close to the edge of the bed. When she was on her left side, Resident #01 will throw her legs over the side of the bed. On the night of 12/24/18, LPN #010 revealed she had not been in Resident #01's room until STNA #5 called her to the room. At that time, she observed the bed was pushed up against the heater instead of having room along the side of the bed to stand. When she assessed Resident #01, she was hot and her skin was red. They moved the bed away from the heater, turned down the heat, and started to apply cool compresses on her skin. When she first saw her there was only a few scattered blisters on her lower extremities, but by 6:00 A.M. more blisters appeared and her skin started to peel. Interview on 01/08/19 at 2:00 P.M. with the Director of Nursing (DON) revealed that through their investigation, they felt when Resident #01 put her feet on top of the heating unit, she must have pushed on the temperature control, increasing the room temperature to 85 degrees F. The facility was unable to determine when the resident's bed was placed against the heating unit. This deficiency substantiates Complaint Number OH 1958. As a result of the incident, the facility implemented the following corrective actions to correct the deficient practice by 01/07/19: · Resident #1's was assessed and provided treatment. The bed was moved into a different location in the room. On 12/26/18, a digital temperature control was added to her room. · The night supervisors checked all resident rooms on 12/24/18 to ensure that beds were not positioned in close proximity to the heaters. · The maintenance department completed quality checks and audits on the functioning of the heating systems along with alert system for out of range temperatures. No temperatures were noted to be out of range through the date checked on 12/26/18. · On 12/24/18, the Director of Nursing (DON)/designee began educating staff on the spacing of beds in relation to the in-room heating units. In-services were completed on 12/31/18. · Staff were educated by the DON and nurse supervisors from 12/26/18 through 12/31/18 on policies addressing resident comfort, homelike environment, and standards for monitoring residents' comfort. · On 12/27/18, education was provided by social workers on each unit to each of the residents and written communication to families regarding safety measures with heating units. · The DON or designee have been conducting audits of room temperatures, thermostat settings, position of resident beds and to ensure no items are placed on heaters, every night for two (2) weeks and then twice a week for six (6) weeks. The Quality Assurance Committee met on 01/03/19 to review the event and interventions. Quality Assurance Committee will monitor the results of the audits and follow-up as needed.

Based on medical record review, observation, review of the facility's Gait Belts/Transfer Belts policy and staff interview, the facility failed to prevent a resident from sustaining injuries from a fall. This resulted in actual harm when a state tested nursing assistant (STNA) did not use a gait belt during transfer of Resident #62 who subsequently fell and sustained head injuries. This affected one (Resident #62) of five residents reviewed for falls. The facility identified 132 residents that required assistance with ambulation or use of an assistive device. The facility census was 250. Findings include: Review of Resident #62's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #62's care plan and resident care guide dated 09/29/16 revealed that Resident #62 had potential for falls related to weakness, impaired cognition with decreased safety and was to be physically assisted by one person, using a gait belt and walker for transfers and with ambulation/mobility. Review of Resident #62's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was a four indicating severe cognitive impairment. Resident #62 was assessed as requiring one person physical assistance with transfers Review of Resident #62's interdisciplinary note dated 07/08/18 revealed STNA #200 was assisting Resident #62 with a transfer from bed to a standing position. STNA #200 was documented as stating Resident #62 stood up and held onto a walker, but as Resident #62 started to take a step she lost her balance, leaned over towards her left side and fell on to the floor, hitting the back of her head on the bed rail. Resident #62's fall was witnessed by STNA #200 and Resident #62 did not lose consciousness. A laceration was noted to the back of Resident #62's head with a heavy amount of bleeding. Resident #62 did not have a gait belt on during the transfer. Resident #62 was transferred to a local hospital emergency department (ED). Review of Resident #62's hospital records dated 07/08/18 through 07/09/18 revealed Resident #62 sustained a mechanical fall with a scalp laceration, small frontal subdural hematoma without pressure effect and limited right frontal subarachnoid hemorrhage. Review of an interdisciplinary note dated 07/10/18 revealed Resident #62 returned to the facility from the hospital with a [DIAGNOSES REDACTED]. Interview on 09/12/18 at 1:04 P.M. with Licensed practical nurse (LPN) #300 verified STNA #200 was documented as not using a gait belt while assisting Resident #62 with a transfer on 07/08/18 and the resident fell and sustained a subdural hematoma and a laceration to her head as a result of the fall. LPN #300 verified staff should use gait belts with residents, including Resident #62, who required one person physical assistance. Resident #62 was observed on 09/12/18 at 12:41 P.M. ambulating with a walker with the assistance of an STNA. Resident #62 had a gait belt around her waist that the STNA was holding on to. Review of the Gait Belts/Transfer Belts policy, (revised 06/28/18), revealed gait belts are to be used to promote safe transferring for all weight bearing residents who require hands-on assistance for residents to go to the standing position (whether or not partial of full weight bearing) and to protect residents and/or staff from accidental trauma and/or injury to skin or joints.

Based on staff interview, facility policy, and record review, the facility failed to ensure all medications were stored securely. This affected two residents (#1 and#2) out of four residents reviewed for medications. The facility census was 250. Findings include: 1. Record review of Resident #1 revealed the resident was admitted to the facility on [DATE] and was discharged on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #1's physician orders [REDACTED]. Further review of the medications active at discharge revealed Donepezil (treats [MEDICAL CONDITION], [MEDICATION NAME] (treats lupus and arthritis), and [MEDICATION NAME] (muscle relaxant) were not medications listed for Resident #1. 2. Record review of Resident #2 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #2's physician orders, dated 04/05/18, revealed the physician discontinued to use of three medications: [REDACTED] Review of the discharge documentation for Resident #1 revealed Resident #1 was discharged from the facility with Resident #2 medication cards for three medications: [REDACTED] Interview on 04/18/18 at 1:30 P.M. with the Director of Nursing (DON) verified Resident #1 was discharged from the facility with three medication cards, which were for Resident #2 and were medications provided to the facility from the pharmacy. The DON verified Resident #2 medication cards were discontinued medications from 04/05/18. Review of facility policy titled Medication storage, dated 05/2006, revealed any discontinued drug will be returned to the pharmacy for credit and destruction. Per the policy, only authorized personnel will have access to the medications. This deficiency substantiated Complaint Number OH 255.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE CORRECTED PRIOR TO THIS SURVEY. Based of medical record review, review of facility self-reported incidents (SRIs), resident interview, staff interview, review of personnel file, review of police evidence and the facility's abuse policy the facility failed to implement the facility's policy on abuse to prevent the theft of jewelry from two Residents (#1 and #3) by housekeeper (HK) #10. This affected two of six residents reviewed for misappropriation and two of seven SRIs reviewed. The facility census was 252. Findings include: 1. Review of Resident #3's medical record revealed and admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #3's brief interview for mental status score (BIMS) was a 15 indicating the resident was cognitively impaired. Review of SRI # 0 revealed on 11/08/17, Resident #3 reported several jewelry items missing. Residents and staff were interviewed and SRI # 0 was unsubstantiated due to inconclusive evidence. Review of SRI # 4 revealed Resident #3 reported witnessing HK #10 take items from a drawer in her room. Nursing staff was notified and the police were called. A pearl necklace belonging to Resident #3 and a watch of unknown origin were found on HK #10. She was arrested by the police. During an interview on 12/04/17 at 9:43 A.M. Resident #3 stated she reported missing two gold necklaces in August 2017 and again more items in November 2017. Resident #3 stated on 11/11/17, HK #10 came in her room and kneeled down by a small chest of drawers. Resident #3 stated she asked HK #10 what she was doing and HK #10 said she was getting the trash. Resident #3 stated HK #10 exited the room and Resident #3 yelled at HK #10 to come back to her room. Resident #3 asked HK #10 what she had taken. HK #10 denied taking anything and stated the resident could look in HK #10's pockets. Resident #3 reported putting on her call light and telling nursing staff, she believed HK #10 had taken something from her room. 2. Review of Resident #1's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #1's brief interview for mental status score (BIMS) was 5 indicating severe cognitive impairment. Review of SRI # 4 and SRI# 6 revealed family of Resident #1 reported a wedding ring missing from a drawer in Resident #1's room on 11/07/17. A police report was filed and staff and residents were interviewed. SRI # 6 was unsubstantiated. SRI # 4 was substantiated on 11/21/17 after police located items HK #10 had sold to a local pawn shop. Resident #1's wedding ring was found along with an earring belonging to Resident. The family did not know the earring was missing. Review of police evidence 17- revealed photographs of seven items located at a local pawn shop identified as belonging to Resident #1 and Resident #3. These items included a pearl necklace, four gold rings and a gold button. Review of HK #10's personnel file revealed a hire date of 05/02/16. Further review revealed all pre-employment screening and necessary educations were completed. HK #10 was placed on unpaid administrative leave and was arrested on 11/11/17. HK #10 was given a do not trespass order by the police. HK #10 was terminated on 11/16/17. The Administrator stated in an interview on 12/104/17 at 10:12 A.M., items from Resident #1 and Resident #3 were confirmed stolen from HK #10. The Administrator stated staff called the police after Resident #3 reported seeing HK #10 take something from her room. The Administrator confirmed when police searched HK #10 at the facility a pearl necklace belonging to Resident #3 was found in HK #10's purse. The Administrator stated police had located items HK #10 had sold to a local pawn shop and these items were identified as belonging to Resident #1 and Resident #3. The Administrator stated the pawn shop was holding these items. The facility was buying the items back and returning them to Resident #1 and Resident #3. The Administrator stated all residents had been interviewed and educated on missing items, and all staff had been educated on misappropriation. Review of the facility's Licensed Area Abuse, Neglect, Exploitation, Mistreatment and Misappropriation policy revealed the facility will not tolerate any form of abuse, neglect, mistreatment or misappropriation of resident's property by anyone. Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings without the resident's consent. As a result of the incident the facility took the following actions to correct the deficient practice by 11/18/17 · On 11/14/17, a locked drawer was installed in Resident #3's bedside stand. · By 11/15/17, the facility educated all staff on resident misappropriation. · On 11/16/17, the facility terminated HK #10's employment. · By 11/18/17, the facility educated and screened all residents for misappropriation. · The facility placed Residents #1 and #3 stolen items on hold at the local pawn shop for repurchase and return to Residents #1 and #3. This deficiency substantiates Complaint Number OH 747.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE CORRECTED PRIOR TO THIS SURVEY. Based of medical record review, review of facility self-reported incidents (SRIs), resident interview, staff interview, review of personnel file, review of police evidence and the facility's abuse policy the facility failed to prevent the theft of jewelry from two Residents (#1 and #3) by housekeeper (HK) #10. This affected two of six residents reviewed for misappropriation and two of seven SRIs reviewed. The facility census was 252. Findings include: 1. Review of Resident #3's medical record revealed and admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #3's brief interview for mental status score (BIMS) was a 15 indicating the resident was cognitively impaired. Review of SRI # 0 revealed on 11/08/17, Resident #3 reported several jewelry items missing. Residents and staff were interviewed and SRI # 0 was unsubstantiated due to inconclusive evidence. Review of SRI # 4 revealed Resident #3 reported witnessing HK #10 take items from a drawer in her room. Nursing staff was notified and the police were called. A pearl necklace belonging to Resident #3 and a watch of unknown origin were found on HK #10. She was arrested by the police. During an interview on 12/04/17 at 9:43 A.M. Resident #3 stated she reported missing two gold necklaces in August 2017 and again more items in November 2017. Resident #3 stated on 11/11/17, HK #10 came in her room and kneeled down by a small chest of drawers. Resident #3 stated she asked HK #10 what she was doing and HK #10 said she was getting the trash. Resident #3 stated HK #10 exited the room and Resident #3 yelled at HK #10 to come back to her room. Resident #3 asked HK #10 what she had taken. HK #10 denied taking anything and stated the resident could look in HK #10's pockets. Resident #3 reported putting on her call light and telling nursing staff, she believed HK #10 had taken something from her room. 2. Review of Resident #1's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #1's brief interview for mental status score (BIMS) was 5 indicating severe cognitive impairment. Review of SRI # 4 and SRI# 6 revealed family of Resident #1 reported a wedding ring missing from a drawer in Resident #1's room on 11/07/17. A police report was filed and staff and residents were interviewed. SRI # 6 was unsubstantiated. SRI # 4 was substantiated on 11/21/17 after police located items HK #10 had sold to a local pawn shop. Resident #1's wedding ring was found along with an earring belonging to Resident. The family did not know the earring was missing. Review of police evidence 17- revealed photographs of seven items located at a local pawn shop identified as belonging to Resident #1 and Resident #3. These items included a pearl necklace, four gold rings and a gold button. Review of HK #10's personnel file revealed a hire date of 05/02/16. Further review revealed all pre-employment screening and necessary educations were completed. HK #10 was placed on unpaid administrative leave and was arrested on 11/11/17. HK #10 was given a do not trespass order by the police. HK #10 was terminated on 11/16/17. The Administrator stated in an interview on 12/104/17 at 10:12 A.M., items from Resident #1 and Resident #3 were confirmed stolen from HK #10. The Administrator stated staff called the police after Resident #3 reported seeing HK #10 take something from her room. The Administrator confirmed when police searched HK #10 at the facility a pearl necklace belonging to Resident #3 was found in HK #10's purse. The Administrator stated police had located items HK #10 had sold to a local pawn shop and these items were identified as belonging to Resident #1 and Resident #3. The Administrator stated the pawn shop was holding these items. The facility was buying the items back and returning them to Resident #1 and Resident #3. The Administrator stated all residents had been interviewed and educated on missing items, and all staff had been educated on misappropriation. Review of the facility's Licensed Area Abuse, Neglect, Exploitation, Mistreatment and Misappropriation policy revealed the facility will not tolerate any form of abuse, neglect, mistreatment or misappropriation of resident's property by anyone. Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings without the resident's consent. As a result of the incident the facility took the following actions to correct the deficient practice by 11/18/17 · On 11/14/17, a locked drawer was installed in Resident #3's bedside stand. · By 11/15/17, the facility educated all staff on resident misappropriation. · On 11/16/17, the facility terminated HK #10's employment. · By 11/18/17, the facility educated and screened all residents for misappropriation. · The facility placed Residents #1 and #3 stolen items on hold at the local pawn shop for repurchase and return to Residents #1 and #3. This deficiency substantiates Complaint Number OH 747.

Based on record review, staff interview and physician interview, the facility failed to ensure a resident received the proper foot treatment and care after it was determined the resident required specialized foot care. This affected one (Resident #243) of six residents sampled for special services/treatment. The facility census was 242. Findings include: Clinical record review revealed Resident #243 was admitted to the facility on [DATE] and discharged to the hospital on [DATE] due to vascular occlusion of the left foot. Review of his cumulative [DIAGNOSES REDACTED]. Review of the admission assessment revealed the resident was alert and oriented. Review of Resident #243's plan of care related to signs and symptoms of hypo/[MEDICAL CONDITION] due to diabetes revealed the resident's blood sugar levels were not believed to be in good control. The plan of care did not have any approaches in regards to foot care until he developed a blister and cracked areas on the left foot due to vascular occlusion and [MEDICAL CONDITION]. Review of admission skin assessment form dated 09/10/13 revealed the resident had a black toenail on the second toe of his left foot and the third toe had a toenail missing with a scab. The treatment was to apply skin prep and monitor. Review of physician's orders [REDACTED]. Review of the Certified Nurse Practitioner's (CNP) progress note dated 11/02/13 revealed the resident had a vascular ulcer to the right foot with [MEDICAL CONDITION]. An order was written for an antibiotic and to follow up with podiatry. On 11/25/13 an order was received for a podiatry consult for thick, long nail care. On 11/29/13 a physician order [REDACTED]. Review of the CNP progress note dated 12/06/13 revealed an order for [REDACTED].#243 was ever seen by podiatry services after being referred five times. Interview with the Director of Nursing (DON) on 01/18/14 at 9:00 A.M. confirmed Resident #243 was never seen by a podiatrist. She further revealed the podiatrist was in the facility four times during Resident #243's stay on 09/11/13, 10/07/13, 11/11/3 and 12/02/13. Interview with the Medical Director, who was also Resident #243's physician, on 01/18/14 at 2:00 P.M. revealed Resident #243 was referred to podiatry due to the [DIAGNOSES REDACTED]. This deficiency substantiates Complaint Number OH 310.

2. During observation of the Pyxis System on 11/07/2013 at 10:00 A.M. on the Bethany Rehabilitation Center (BRC) unit revealed one 1,000 ML (milliliter) bag of 0.5% Dextrose intravenous solution with an expiration date of June 2013. There was two small bottles of Piperacillin and Tazobactam (antibiotics) both with an expiration date of July 1, 2013. Interview with Registered Nurse (RN) #4 on 11/07/13 at 10:10 A.M. that the aforementioned medications were expired. Interview with Pharmacist on 11/07/2013 at 12:15 P.M. verified that the Pyxis system is maintained by the pharmacy and is available for emergency use by the facility for the residents. Interview with DON on 11/07/13 at 2:17 P.M. verified there was no documentation found when the last time the Pyxis system had been audited by pharmacy. Review of an undated facility policy titled "Drug Storage" revealed discontinued and expired medications should be removed from medication carts, refrigerators, and cupboards promptly. Review of a facility policy dated 01/2012 titled "Drug Storage Audits-Facilities" revealed drug storage audits for dispensed as well as emergency supply medications are performed by the pharmacy every six months. Further review of a policy revealed all expired, discontinued, damaged and/or contaminated medications are removed from resident care areas by facility personnel and stored separately from medications available for administration. Based on observation, staff interview and policy review the facility failed to appropriately label medications and failed to ensure medications stored in the emergency supply was not expired for one Pyxis (medication storage managed by a contracted pharmacy) out of one Pyxis system within the facility. This affected one of 13 medication carts reviewed. This had the potential to affect 24 residents who receive medications from the Gardenview med cart, front and had the potential to affect 47 residents the facility identified who reside on the unit the for who the Pyxis system supplied emergency medications. The facility census is 246. 1. Observation on 11/07/13 at 9:45 A.M. on Woodview Unit revealed the medication cart for the front hall contained a medication cup with two unidentified pills in the section for Resident #24. In the section for Resident #49, there was a second medication cup containing six unidentified pills. The two medication cups were not labeled in any way. The medication cups did not identify the medication's name, strength, expiration date, or the name of the resident they were for. During an interview with Licensed Practical Nurse (LPN) #1 on 11/7/13 at 9:45 A.M. she verified that there was an unlabeled medication cup in the section for Resident #24 containing two pills. LPN #1 stated that Resident #24 was in the beauty shop and did not receive the pills. LPN #1 verified there were six unidentified pills in a medication cup in the section for Resident #49. LPN #1 stated that Resident #49 was sleeping and did not receive the pills. Review of the facility policy entitled Drug Storage, updated 10/2010, revealed "Medications are to remain in the container in which they are dispensed. Only pharmacy personnel may transfer medications from one container to another."

Based on review of a facility self-reported incident (SRI) report, review of facility investigation documentation, clinical record review, staff interviews, review of the facility's abuse policy, review of an employee personnel file and review of facility training records and monitoring documentation, the facility failed to ensure staff immediately notified the Administrator and failed to immediately protect residents when Resident #459 reported she was sexually abused by Visitor #1. This resulted in Immediate Jeopardy for one (#459) of four sampled residents and 48 additional residents who resided on the Bethany Rehabilitation Center (BRC). These residents were placed at risk for Immediate Jeopardy from abuse because Visitor #1 remained unsupervised in the facility after a staff member was informed of the sexual abuse allegation. The total resident census was 239. On 03/22/11 at 12:20 P.M., the Administrator, Director of Nursing (DON) and the Vice President of Residential Care were notified Immediate Jeopardy began on 03/13/11 from 3:00 A.M. when Residential Care Technician (RCT) #91 failed to take any action after Resident #459 stated she was sexually abused by Visitor #1. Visitor #1 remained in the facility until 03/13/11 at 7:38 A.M. when he left after spending the night in the facility. Visitor #1 had unrestricted assess to Resident #459 and the other 48 residents on the BRC unit until 03/13/11 at 6:30 P.M. when licensed practical nurse (LPN) #118 became aware of the sexual abuse allegation and reported it to her supervisor. The Immediate Jeopardy was removed on 03/13/11 at 6:30 P.M. when the facility banned Visitor #1 from the building; thereby, protecting residents from potential abuse. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 03/22/11 when the facility implemented the following corrective actions: ? On 03/13/11 at 6:30 P.M., the facility banned Spouse #1 from the building. Resident #459 was assessed for signs and symptoms of abuse and provided support and comfort by the nursing staff, physicians, certified nurse practitioner and social worker. The facility initiated an investigation to include notification of the local police. ? On 03/15/11 at 3:30 P.M., all residents residing on the BRC unit were interviewed and it was determined Visitor #1 had not been in their rooms. ? On 03/17/11, the facility developed and implemented a new Employee Visitor Policy. As of 03/22/11, all staff had been educated on the new employee visitor policy and reviewed the facility's abuse policy, with the exception of 14 staff members on leave of absence. Those 14 staff members will not be permitted to return to work until they have received education on the new employee visitor policy and review the abuse policy. ? 03/17/11, the facility arranged to have a security guard posted at the entrance of the building from 10:00 P.M. to 8:15 A.M. to control access to the building until all staff is educated on the newly implemented employee visitor policy. ? Observations on 03/22/11 at 12:15 A.M. through 1:30 A.M. revealed no employees had family visitors in the facility. Interviews with random staff throughout the facility revealed 20 staff members were trained and knowledgeable of the facility's new policy. ? On 03/22/11, safety and security audits were initiated to ensure staff was knowledgeable about the facility's new employee visitor policy. The Administrator stated safety audits would be conducted weekly for four weeks and then monthly for three months to evaluate staff compliance of the policy. Findings include: Review of the clinical record of Resident #459 revealed the resident was admitted to the facility's rehabilitation center (BRC) from the hospital on [DATE]. The resident was admitted with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #459 was alert and oriented with moderate cognitive impairment. Review of the facility's self reported incident (SRI) dated 03/17/11 revealed Resident #459 reported she was in bed in her room on the morning of 03/13/11 when at approximately 3:00 A.M. a "male" touched her breast. The SRI stated the description of the male matched that of an employee's spouse who had accompanied the employee to the facility for a going away celebration for that employee. According to the facility investigation documentation, RCT #91 was interviewed via telephone on 03/13/11 at 7:00 P.M. and verified she answered Resident #459's call light and the resident told her a "male touched her breast." RCT #91 stated the resident asked the time and she told her it was 3:05 A.M. RCT #91 stated she didn't report the allegation and that she forgot. RCT #91 stated there had been no male caregivers in the resident's room that night. She also stated her husband (Visitor #1) had spent the night on the BRC unit. Review of a witness statement dated 3/16/11 provided by registered nurse (RN) #82 revealed he saw Visitor #1 in the dining room during the night shift on 3/12 to 03/13/11. RN #82 stated he asked Visitor #1 if he was planning to stay all night until RCT #91's shift ended and Visitor #1 said yes. RN #82 reported he saw Visitor #1 on the BRC unit but there were long stretches of time when he did not observe Visitor #1 at all because he was busy with his job. Review of a witness statement dated 3/16/11 from registered nurse (RN) #77 revealed RCT #91 entered the facility on 03/12/11 around 10:50 P.M. to 10:55 P.M. accompanied by Visitor #1. RN #77 stated he saw Visitor #1 in the dining room between approximately 12:40 A.M. and until 3:00 A.M. RN #77 was in the nurse's station and did not see Visitor #1 between 3:00 A.M. and 5:00 A.M. Interview with the Administrator and Director of Nursing (DON) on 03/21/11 at 2:43 P.M. revealed the facility was unaware of the incident until 03/13/11 at 6:30 P.M. when the resident's daughter reported to licensed practical nurse (LPN) #118 that Resident #459 told her she had been touched inappropriately by a male in her room. The Administrator stated upon learning of the incident the facility immediately started an investigation to include notification of the police. During interview on 03/22/11 at 9:45 A.M., the Administrator stated Visitor #1 entered the facility with RCT #91 on 03/12/11 at 10:57 P.M. when she clocked in for duty. Visitor #1 remained on the facility premises throughout her shift until 03/13/11 at 7:38 A.M. when RCT #91 clocked out. During interview on 03/22/11 at 2:05 P.M., Centerville Police Sergeant (CPS) #110 confirmed Visitor #1 was arrested and he confessed to entering the room of Resident #459, to touching her breast and inserting his fingers into her vagina without her permission. CPS #110 stated Visitor #1 said he had not had contact with Resident #459 prior to the incident the morning of 03/13/11. During interview on 03/23/11 at 3:20 P.M., LPN # 118 stated Resident #459's daughter approached her on 03/13/11 and asked her if she had heard about the resident's "crazy dream." She stated she then questioned the resident and the resident told her a large man, bald, wearing a blue shirt had come into her room in the night. LPN #118 stated she then notified the supervisor and the facility began their investigation. Review of the facility's policy and procedures titled "Licensed Area Abuse, Neglect, Mistreatment, Misappropriation" dated 12/18/10 and last revised 07/28/08, revealed the policy stated sexual abuse included but was not limited to sexual harassment, sexual coercion, or sexual assault. The policy stated anyone suspecting resident abuse had occurred was to immediately report the suspicions or allegations to his/her supervisor and/or Nursing Supervisor/Manager. The policy further stated when the suspected person of the abuse was a visitor or other, and where the abuse was potentially criminal (e.g. sexual abuse), the abuse will be reported to the appropriate authorities and all other appropriate measures would be taken to protect the resident in question. Review of RCT #91's personnel file revealed she was last trained on the facility's abuse policy on 11/30/10. This certification deficiency substantiates facility self reported incident number OH 059.

Based on review of a facility self-reported incident (SRI) report, review of facility investigation documentation, clinical record review, staff interviews, review of the facility's abuse policy, review of an employee personnel file and review of facility training records and monitoring documentation, the facility failed to implement their abuse policy to ensure staff immediately notified the Administrator and protect residents from further abuse after Resident #459 reported to a staff member she was sexually abused by Visitor #1. Resident #459 stated she was sexually abused by Visitor #1 at approximately 3:00 A.M. Visitor #1 remained in the facility until 03/13/11 at 7:38 A.M. Visitor #1 had unrestricted assess to Resident #459 and the other 48 residents on the BRC unit until 03/13/11 at 6:30 P.M. when licensed practical nurse (LPN) #118 became aware of the sexual abuse allegation and reported it to her supervisor. The facility remained out of compliance at a Severity Level 3 (actual harm that is not immediate jeopardy) until it was corrected on 03/22/11 when the facility implemented the following corrective actions: ? On 03/13/11 at 6:30 P.M., the facility banned Spouse #1 from the building. Resident #459 was assessed for signs and symptoms of abuse and provided support and comfort by the nursing staff, physicians, certified nurse practitioner and social worker. The facility initiated an investigation to include notification of the local police. ? On 03/15/11 at 3:30 P.M., all residents residing on the BRC unit were interviewed and it was determined Visitor #1 had not been in their rooms. ? On 03/17/11, the facility developed and implemented a new Employee Visitor Policy. As of 03/22/11, all staff had been educated on the new employee visitor policy and reviewed the facility ' s abuse policy, with the exception of 14 staff members on leave of absence. Those 14 staff members will not be permitted to return to work until they have received education on the new employee visitor policy and review the abuse policy. ? 03/17/11, the facility arranged to have a security guard posted at the entrance of the building from 10:00 P.M. to 8:15 A.M. to control access to the building until all staff is educated on the newly implemented employee visitor policy. ? Observations on 03/22/11 at 12:15 A.M. through 1:30 A.M. revealed no employees had family visitors in the facility. Interviews with random staff throughout the facility revealed 20 staff members were trained and knowledgeable of the facility ' s new policy. ? On 03/22/11, safety and security audits were initiated to ensure staff was knowledgeable about the facility ' s new employee visitor policy. The Administrator stated safety audits would be conducted weekly for four weeks and then monthly for three months to evaluate staff compliance of the policy. Findings include: Review of the clinical record of Resident #459 revealed the resident was admitted to the facility from the hospital on [DATE]. The resident was admitted with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #459 was alert and oriented with moderate cognitive impairment. Review of the facility ' s self reported incident (SRI) dated 03/17/11 revealed Resident #459 reported she was in bed in her room on the morning of 03/13/11 when at approximately 3:00 A.M. a " male " touched her breast. The SRI stated the description of the male matched that of an employee ' s spouse who had accompanied the employee to the facility for a going away celebration for that employee. According to the facility investigation documentation, RCT #91 was interviewed via telephone on 03/13/11 at 7:00 P.M. and verified she answered Resident #459 ' s call light and the resident told her a " male touched her breast. " RCT #91 stated the resident asked the time and she told her it was 3:05 A.M. RCT #91 stated she didn ' t report the allegation and that she forgot. RCT #91 stated there had been no male caregivers in the resident ' s room that night. She also stated her husband (Visitor #1) had spent the night on the BRC unit. Review of a witness statement dated 3/16/11 provided by registered nurse (RN) #82 revealed he saw Visitor #1 in the dining room during the night shift on 3/12 to 03/13/11. RN #82 stated he asked Visitor #1 if he was planning to stay all night until RCT #91 ' s shift ended and Visitor #1 said yes. RN #82 reported he saw Visitor #1 on the BRC unit but there were long stretches of time when he did not observe Visitor #1 at all because he was busy with his job. Review of a witness statement dated 3/16/11 from registered nurse (RN) #77 revealed RCT #91 entered the facility on 03/12/11 around 10:50 P.M. to 10:55 P.M. accompanied by Visitor #1. RN #77 stated he saw Visitor #1 in the dining room between approximately 12:40 A.M. and until 3:00 A.M. RN #77 was in the nurse ' s station and did not see Visitor #1 between 3:00 A.M. and 5:00 A.M. Interview with the Administrator and Director of Nursing (DON) on 03/21/11 at 2:43 P.M. revealed the facility implemented their abuse policy and procedures on 03/13/11 at 6:30 P.M. when the resident ' s daughter reported to licensed practical nurse (LPN) #118 that Resident #459 told her she had been touched inappropriately by a male in her room. During interview on 03/22/11 at 9:45 A.M., the Administrator stated Visitor #1 entered the facility with RCT #91 on 03/12/11 at 10:57 P.M. when she clocked in for duty. Visitor #1 remained on the facility premises throughout her shift until 03/13/11 at 7:38 A.M. when RCT #91 clocked out. During interview on 03/22/11 at 2:05 P.M., Centerville Police Sergeant (CPS) #110 confirmed Visitor #1 was arrested and he confessed to entering the room of Resident #459, to touching her breast and inserting his fingers into her vagina without her permission. CPS #110 stated Visitor #1 said he had not had contact with Resident #459 prior to the incident the morning of 03/13/11. During interview on 03/23/11 at 3:20 P.M., LPN # 118 stated Resident #459 ' s daughter approached her on 03/13/11 and asked her if she had heard about the resident ' s " crazy dream. " She stated she then questioned the resident and the resident told her a large man, bald, wearing a blue shirt had come into her room in the night. LPN #118 stated she then notified the supervisor and the facility began their investigation. Review of the facility ' s policy and procedures titled " Licensed Area Abuse, Neglect, Mistreatment, Misappropriation " dated 12/18/10 and last revised 07/28/08, revealed the policy stated sexual abuse included but was not limited to sexual harassment, sexual coercion, or sexual assault. The policy stated anyone suspecting resident abuse had occurred was to immediately report the suspicions or allegations to his/her supervisor and/or Nursing Supervisor/Manager. The policy further stated when the suspected person of the abuse was a visitor or other, and where the abuse was potentially criminal (e.g. sexual abuse), the abuse will be reported to the appropriate authorities and all other appropriate measures would be taken to protect the resident in question. On 03/13/11 at approximately 3:05 A.M. Resident #459 reported she was sexually abused to RCT #1 and RCT #1 did not implement the facilities abuse policy and procedures. Review of RCT #91 ' s personnel file revealed she was last trained on the facility's abuse policy on 11/30/10. This certification deficiency substantiates facility self reported incident number OH 059.

Based on observation, review of a facility self-reported incident (SRI) report, facility investigation documentation, clinical record, staff interviews, resident interviews, interview of the police Sergeant #110 who investigated the case and review of the facility's abuse policy and new employee visitor policy, the facility failed to ensure Resident #459 was free from sexual abuse by the spouse of an employee (Visitor #1). This had the potential to affect the 48 residents residing on the Bethany Rehabilitation Center (BRC) as Visitor #1 had unrestricted access to the residents. The total census of the facility was 239 residents. Resident #459 reported on 03/13/11 at 3:00 A.M. that a "big man, bald headed" wearing a "navy blue short sleeved t-shirt" entered her room, pulled the door shut, and sat down in a chair next to her bed. The resident stated Visitor #1 reached over and pulled the covers down and then lifted her gown up to her waist. The resident stated the man touched her breast and put his hand down the side of her underpants. Resident #459 reported the allegation of sexual abuse to Resident Care Technician (#91) on 03/13/11 at 3:05 A.M. but the staff member failed to take any action. The facility was out of compliance at a Severity Level 3 (actual harm that is not immediate jeopardy) until it was corrected on 03/22/11 when the facility implemented the following corrective actions: ? On 03/13/11 at 6:30 P.M., the facility banned Visitor #1 from the building after Resident #459 repeated the allegation of sexual abuse to Licensed Practical Nurse (LPN) #118. Resident #459 was assessed for signs and symptoms of sexual abuse and provided support and comfort by the nursing staff, physicians, certified nurse practitioner and social worker. The facility initiated an investigation to include notification of the local police. ? On 03/15/11 at 3:30 P.M., all residents residing on the BRC unit were interviewed and it was determined Visitor #1 had not been in their rooms. ? On 03/17/11, the facility developed and implemented a new Employee Visitor Policy. As of 03/22/11, all staff had been educated on the new employee visitor policy and reviewed the facility's abuse policy, with the exception of 14 staff members on leave of absence. Those 14 staff members will not be permitted to return to work until they have received education on the new employee visitor policy and review the abuse policy. ? 03/17/11, the facility arranged to have a security guard posted at the entrance of the building from 10:00 P.M. to 8:15 A.M. to control access to the building until all staff is educated on the newly implemented employee visitor policy. ? Observations on 03/22/11 at 12:15 A.M. through 1:30 A.M. revealed no employees had family visitors in the facility. Interviews with random staff throughout the facility revealed 20 staff members were trained and knowledgeable of the facility's new policy. ? On 03/22/11, safety and security audits were initiated to ensure staff was knowledgeable about the facility's new employee visitor policy. The Administrator stated safety audits would be conducted weekly for four weeks and then monthly for three months to evaluate staff compliance of the policy. Findings include: Review of the clinical record of Resident #459 revealed the resident was admitted to the facility's rehabilitation center (BRC) from the hospital on [DATE]. The resident was admitted with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #459 was alert and oriented with moderate cognitive impairment. Review of the facility's self reported incident (SRI) dated 03/17/11 revealed Resident #459 reported she was in bed in her room on the morning of 03/13/11 when at approximately 3:00 A.M. a "male" touched her breast. The SRI stated the description of the male matched that of an employee's spouse who had accompanied the employee to the facility for a going away celebration for that employee. Review of facility investigation documentation dated 03/13/11 revealed LPN #118 called registered nurse (RN) #214 to report an allegation of abuse made by Resident #459. LPN #118 also reported she (LPN #118) thought the spouse of Residential Care Technician (RCT) #91 had spent the night on the BRC unit. LPN #118 described RCT #91's spouse as large, overweight, with a shaved head and wearing a dark shirt. The facility investigation documentation by night supervisor/registered nurse (RN) #319 dated 03/13/11, stated during interview at 8:30 P.M. Resident #459 confirmed a man had entered her room and she described him as a "big man, bald headed" wearing a "navy blue short sleeved t-shirt." She stated the man came into her room, pulled the door shut, leaving it open" about 12 inches" and sat down in a chair next to her bed. She stated she asked the man what time it was and he replied 3:00 A.M. Resident #459 stated after the man sat down he reached over and pulled the covers down and then lifted her gown up to her waist. The resident stated the man touched her breast and put his hand down the side of her underpants. Resident #459 stated she told the man how old she was and he got up and left and she put her call light on. Resident #459 stated "the nurse" came right in and she told her everything that happened. Resident #459 stated the person answering the call light asked her why she thought there was a man in her room and that "the nurse" told her "there's no man" and told her it was just her imagination. The resident stated she asked why she would imagine anything like that. She said her gown was still raised when the staff member/"nurse" came in to answer her light. Resident #459 described the "nurse" who entered the room as RCT #91. According to the facility investigation documentation, RCT #91 was interviewed via telephone on 03/13/11 at 7:00 P.M. and verified she answered Resident #459's call light and that the resident told her a "male touched her breast." RCT #91 stated the resident asked the time and she told her it was 3:05 A.M. RCT #91 stated she didn't report the allegation and that she forgot. RCT #91 stated there had been no male caregivers in the resident's room that night. She also stated her husband had spent the night on the BRC unit. Review of a witness statement dated 3/16/11 provided by registered nurse (RN) #82 revealed he saw Visitor #1 in the dining room during the night shift on 3/12 to 03/13/11. RN #82 stated he asked Visitor #1 if he was planning to stay all night until RCT #91's shift ended and Visitor #1 said yes. RN #82 reported he saw Visitor #1 on the BRC unit but there were long stretches of time when he did not observe Visitor #1 at all because he was busy with his job. Review of a witness statement dated 3/16/11 from registered nurse (RN) #77 revealed RCT #91 entered the facility on 03/12/11 around 10:50 P.M. to 10:55 P.M. accompanied by Visitor #1. RN #77 stated he saw Visitor #1 in the dining room between approximately 12:40 A.M. and until 3:00 A.M. RN #77 was in the nurse's station and did not see Visitor #1 between 3:00 A.M. and 5:00 A.M. Social service progress notes dated 03/15/11 (untimed) stated a meeting was held with Resident #459, the resident's daughter #45, LSW #217 and a police officer #110. During the meeting police officer #110 told Resident #459 that Visitor #1 had confessed to entering her room in the middle of the night and inappropriately touching her and that the incident was not a dream but had actually occurred. The resident expressed surprise and anxiety and stated she was okay and did not want to talk about it. Review of physician progress notes [REDACTED]. A psychological evaluation dated 03/16/11 stated the resident was tense and anxious. The evaluation stated the resident reported an increase in anxiety since "a sex offender attacked me"..."I don't want to think about that"..."I don't want to talk about it." Interview with the Administrator and Director of Nursing (DON) on 03/21/11 at 2:43 P.M. revealed the facility was unaware of the incident until 03/13/11 at 6:30 P.M. when the resident's daughter reported to licensed practical nurse (LPN) #118 that Resident #459 told her she had been touched inappropriately by a male in her room. The Administrator stated upon learning of the incident the facility immediately started an investigation to include notification of the police. During interview on 03/21/11 at 5:16 P.M., Resident #459 stated she did not want to talk about the incident and wished to put it out of her mind. She then placed her hand to her mouth and looked away. During interview on 03/22/11 at 9:45 A.M., the Administrator stated Visitor #1 entered the facility with RCT #91 on 03/12/11 at 10:57 P.M. when she clocked in for duty. Visitor #1 remained on the facility premises throughout her shift until 03/13/11 at 7:38 A.M. when RCT #91 clocked out. During interview on 03/22/11 at 2:05 P.M., Centerville Police Sergeant (CPS) #110 stated Visitor #1 was arrested and he confessed to entering the room of Resident #459, to touching her breast and inserting his fingers into her vagina without her permission. CPS #110 stated Visitor #1 stated he had not had contact with Resident #459 prior to the incident the morning of 03/13/11. During interview on 03/23/11 at 3:20 P.M., LPN # 118 stated Resident #459's daughter approached her on 03/13/11 and asked her if she had heard about the resident's "crazy dream." She stated she then questioned the resident and the resident told her a large man, bald, wearing a blue shirt had come into her room in the night. LPN #118 stated she then notified the supervisor and the facility began their investigation. Review of the facility's policy and procedures titled "Licensed Area Abuse, Neglect, Mistreatment, Misappropriation" dated effective 12/18/10 and last revised 07/28/08, revealed the policy stated sexual abuse included but was not limited to sexual harassment, sexual coercion, or sexual assault. The policy stated anyone suspecting resident abuse had occurred was to immediately report the suspicions or allegations to his/her supervisor and/or Nursing Supervisor/Manager. The policy further stated when the suspected person of the abuse was a visitor or other, and where the abuse was potentially criminal (e.g. sexual abuse), the abuse will be reported to the appropriate authorities and all other appropriate measures would be taken to protect the resident in question. Review of the facility's Visitor Policy dated 09/09/10, revealed the policy did not include visitors of employees and only addressed resident's visitors. Review of the facility's new Employee Visitor Policy dated 03/17/11, revealed the policy stated employees were only permitted to have visitors on their scheduled break time and all visitors must register at the reception desk. The policy stated visitors of employees were not permitted in resident areas and that they must be accompanied by the employee at all times. On 03/22/11 and 03/23/11, the survey team reviewed facility audit records and confirmed employees were monitored for compliance of the facility's new employee visitor policy on 03/17/11, 03/18/11, 03/21/11, 03/22/11 and 03/23/11. This certification deficiency substantiates facility self report incident number OH 059.