Every finding on record at Birchwood Care Center

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interview, personnel file review, and policy review, the facility failed to ensure a resident was safely transferred to a wheelchair. This resulted in Actual Harm on 04/15/26 when Certified Nurse Aide (CNA) #174 transferred Resident #70 to a wheelchair without utilizing a mechanical lift and additional staff assistance. Resident #70 was sent to the hospital and received treatment for a displaced comminuted right femur fracture (happens when a severe impact breaks a bone into three or more pieces) and a left tibia and fibula fracture. This affected one (Resident #70) of three residents reviewed for accidents. The facility census was 67. Findings include: Review of the medical record for Resident #70 revealed an admission date of 11/30/18 and a discharge date of 05/04/26. Diagnoses included a displaced comminuted fracture of shaft of right femur subsequent encounter for closed fracture with routine healing and an unspecified fracture of upper end of left tibia subsequent encounter for closed fracture without routine healing. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/20/26, revealed Resident #70 was severely cognitively impaired. Resident #70 required was dependent on staff for transfers. Resident #70 had a physician order dated 07/24/24 to use a Sit to Stand lift for transfers as tolerated. Review of the Kardex Report (summary of resident needs) for Resident #70, dated 04/15/26, revealed the resident required the use of a Sit to Stand lift with two staff assistance for transfers.Review of the progress note dated 04/15/26 revealed CNA #174 exited Resident #70's room and reported to the nurse that the resident had pain in the right knee. Resident #70 was assessed and had a deformed right knee and an internally rotated right foot. CNA #174 stated that the Sit to Stand accidentally hit Resident #70's right knee and the resident began complaining of pain, so CNA #174 quickly transferred the resident to a wheelchair to bring Resident #70 to the nurse for evaluation. Resident #70 was transferred to the emergency room for further evaluation. Review of the hospital paperwork dated 04/15/26 revealed Resident #70 presented to the hospital with complaints of pain in both knees following a mechanical fall sustained while transferring from the bed to the bathroom. Per the imagining reports, Resident #70 sustained a highly displaced comminuted fracture of the distal femoral metadiaphysis (severe break of the lower thigh bone above the knee that causes the bone to shatter into multiple pieces and become displaced), a proximal left tibial fracture involving the lateral tibial plateau and tibial metadiaphysis (break in the upper part of the shinbone that damages the outer surface of the knee joint and extends into the upper shaft area of the bone), and a comminuted mildly displaced fracture of the fibular head (the top part of the outer calf bone near the knee that is broken into multiple pieces and slightly out of alignment). Resident #70 was assessed by an orthopedic surgeon and trauma surgeon and had intramedullary nailing surgery for the femur fracture (procedure to fix longer broken bones such as the femur or tibia by inserting a metal rod down the center of the bone). Surgery was not performed for the left proximal tibial fracture, and an immobilizer was placed on Resident #70's left leg. Review of the Interdisciplinary Team (IDT) follow-up note dated 04/22/26 revealed Resident #70 was admitted to the hospital with a displaced comminuted fracture of shaft of right femur and a fracture of the upper end of left tibia and fibula. Resident #70 had reported to her family that she had fallen. Review of the personnel file for CNA #174 revealed the aide was terminated on 04/17/26 by telephone for failure to perform work assignment and carelessness in performance of duties for the incident that occurred on 04/15/26. During an interview on 08/26/26 at 9:20 A.M., the Director of Nursing (DON) stated Resident #70 was in bed and CNA #174 hit the resident's right knee with the Sit to Stand while positioning the lift and continued to get Resident #70 up when the resident's legs locked. The DON verified CNA #174 was the only staff present during the transfer and did not transfer Resident #70 appropriately. Resident #70 had an abrasion to the right knee and began reporting pain in the other leg as the resident was being transferred out of the facility. The hospital called the facility and stated Resident #70's injuries were consistent with a fall. An investigation was completed and it was determined Resident #70 must have fallen during the transfer. During an interview on 08/26/26 at 2:55 P.M., CNA #174 stated she was terminated from the facility because she had not transferred Resident #70 appropriately. She stated there were several occasions where she had not used the Sit to Stand to transfer Resident #70. CNA #174 reported on the day of the incident that the Sit to Stand hit Resident #70's right knee and this led to CNA #174 transferring Resident #70 to the wheelchair alone without using the lift. Review of the facility policy titled Fall and Accident Management, revised June 2019, revealed the facility would identify residents at risk of falls and other accidents and interventions would be implemented to reduce the risk of injuries, falls, or other accidents. The deficient practice was corrected on 04/17/26 when the facility implemented the following corrective actions:On 04/15/26, the DON reviewed Resident #70's medical record and ensured accuracy of care plan for transfer assistance. On 04/15/26, the DON or designee completed an audit to review current residents' care plans to ensure transfer assistance and toileting assistance was accurate. On 04/15/26 or before next scheduled shift, the DON or designee provided education to nurses and aides that included following care plan/Kardex during resident care.On 04/15/26, CNA #174 was immediately provided education regarding transfer assistance and reporting falls and was placed on suspension pending investigation. On 04/16/26, the DON or designee interviewed current alert and oriented residents to determine if there were any falls or incidents that occurred that were not documented in the medical record with no issues noted. On 04/16/26, the DON or designee completed head-to-toe assessments on current cognitively impaired residents to determine if there were any concerns for bruising, abrasions, swelling, or complaints of pain that could be the result of an undocumented fall with no issues noted. On 04/16/26, the DON or designee reviewed current residents' progress notes from the last 14 days to review for any possible injuries that may be related to an undocumented fall. On 04/16/26, the DON or designee reviewed fall documentation from current residents experiencing a fall in the last 14 days to ensure an adequate assessment and documentation was completed, an intervention was implemented post fall, and notifications to responsible party and physician were timely after a fall. On 04/16/26 or before next scheduled shift, the DON or designee provided education to nurses and aides that included residents experiencing a fall, reports a fall, or have been lowered to the floor are reported to the nurse, are adequately assessed by the nurse, and the fall is documented in the medical record, and that the physician and responsible party is notified timely of a resident fall. On 04/16/26 or before next scheduled shift, the DON provided education to nurses and aides that included to ensure residents are provided with transfer assistance according to the care plan. On 04/16/26 or before next scheduled shift, the DON provided education to nurses and aides that included review of pain assessments, pharmacological and non-pharmacological interventions. On 04/16/26 or before next scheduled shift, the DON provided education to nurses and aides that included review of change in condition, reporting, and documenting. The DON or designee completed audits to ensure residents who have experienced a fall are reported to the nurse, assessed by a nurse, the fall is documented in the medical record, the physician and responsible party are notified timely, transfer assistance is provided according to the care plan, and a review of pain or change in condition, which were conducted daily for seven days, twice weekly for two weeks, weekly for two weeks, and then monthly. Any issues were to be addressed by the DON and reported to the Quality Assurance committee for further monitoring. During interviews on 08/26/26, various nurses and CNAs verified they had received training on transfers and following the plan of care for each resident. This deficiency represents non-compliance investigated under Complaint Number 3015755.

Based on observations, review of personnel files, and staff interview, the facility failed to properly handle food items while passing lunch trays to residents. The facility identified 67 residents that received food from the kitchen. The facility census was 69. Findings included: Observation on 02/07/22 at 12:50 P.M. of Housekeeper #74 revealed she was passing the lunch tray to Resident #15. Housekeeper #74 was noted opening the lid of the lunch tray and grabbing the sandwich from the tray with her bare hands. The housekeeper proceeded to cut the sandwich in half and put it back on the tray of Resident #15. Interview on 02/07/22 at 12:52 P.M. with Housekeeper #74 confirmed that she did grab the sandwich of Resident #15 with her bare hands and cut it in half. Housekeeper #74 stated that she washed her hands before passing trays. Observation on 02/08/22 at 12:08 P.M. of Housekeeper #69 revealed she was passing the lunch tray to Resident #37. Housekeeper #69 was noted opening the lid of the lunch tray and grabbing a piece of bread from the plate with her bare hands. The housekeeper then placed the piece of bread back on the tray of Resident #37. Interview on 02/08/22 at 12:11 P.M. with Housekeeper #69 confirmed that she did grab the piece of bread from the plate with her bare hands and set it back on the plate. Housekeeper #69 stated that she was never fully trained to pass trays to the residents. Review of the personnel files for Housekeepers #69 and #74 revealed no training related to the passing of trays to residents.

Based on observation, record review, resident and staff interviews, review of the facility's policy, and review of the guidance from www.medlineplus.gov, the facility failed to provide routine catheter care. This affected one (Resident #39) of three residents reviewed for catheter care. The facility identified five residents with an indwelling or external catheter. The facility census was 69. Findings include: Review of the medical record for Resident #39 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care dated 12/06/21 revealed Resident #39 had an indwelling catheter related to the history of hydronephrosis due to obstruction. Interventions included evaluating for urinary complaints, monitoring for signs/symptoms of a urinary tract infection ([CONDITION(S)]), and providing catheter care per policy. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #39, dated 12/22/21, revealed the resident had intact cognition. Resident #39 required total dependence for toileting. Resident #39 was identified to be continent of bladder and had an indwelling catheter. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's task documentation for Resident #39 for toileting dated 02/01/22 through 02/09/22 revealed no toileting was completed on 02/03/22 and 02/04/22. Interview on 02/09/22 at 9:17 A.M. with Resident #39 stated the staff has never done catheter care and I have been at the facility for over two years. Interview on 02/10/22 at 8:05 A.M. with Registered Nurse (RN) #63 stated that catheter care was defined as cleaning the perineal area from inside to the outside around the catheter at least every shift and as needed. RN #63 confirmed there was no order in the chart of Resident #39 for any type of catheter care. The nurse also confirmed no documentation was being completed on the output of Resident #39. RN #63 would expect the nurse aide staff to provide routine catheter care. Interviews on 02/10/22 from 8:13 A.M. to 8:25 A.M. with State tested Nursing Aides (STNA) #12 and #38 revealed that catheter care was emptying the catheter bag. There was no mention by either staff member regarding cleaning the tubing or around the perineal area. The aides confirmed they do not document catheter care and outputs for Resident #39. Observation on 02/10/22 at 11:09 A.M. of catheter care for Resident #39 performed by STNA #12 cleaned the tubing with soap and water appropriately but cleansed the tube in an outward to inward motion towards the body. Interview on 02/10/22 at 11:29 A.M. with STNA #12 confirmed she incorrectly cleansed the catheter of Resident #39 while completing catheter care. STNA #12 stated she knows she was supposed to clean the tube starting at the body and going away from the body, but instead started away from the body going towards the body. STNA #12 also stated that she never completed catheter care before. Review of the guidance from the website www.medlineplus.gov revealed routine catheter care should be once a day, every day, or more often if needed. Review of the facility's undated policy titled Urinary Catheter Care revealed urinary catheters should be evaluated every day for need and removed promptly when no longer necessary. Patients with urinary catheters will have intake and output recorded.

Based on medical record review, staff interview, and policy review, the facility failed to ensure residents were provided with a bed hold notice upon transferring to the hospital. This affected two (#13 and #52) of two residents reviewed for hospitalization . The facility census was 69. Findings include: 1. Review of Resident #52's medical record revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/07/22, revealed Resident #52 was severely cognitively impaired. Review of Resident #52's progress note dated 12/23/21 revealed Resident #52 had complaints of sharp sudden chest pains. Emergency medical services were called. There was no documentation in the medical record that Resident #52 or representative received a bed hold notice. On 12/25/21, Resident #52 returned to the facility from the hospital after treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 02/08/22 at 1:21 P.M. with Chief Operating Officer (COO) #100 verified Resident #52 or representative did not receive a bed hold notice for her hospitalization on [DATE]. 2. Review of the medical record of Resident #13 revealed an admitted [DATE]. The resident transferred to the hospital on 02/05/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive MDS assessment dated [DATE] revealed Resident #13 had intact cognition. Review of a nursing progress note dated 02/05/22 revealed Resident #13's daughter called the nurse on duty to say Resident #13 was not making any sense. The nurse on duty informed the daughter she had been trying to get Resident #13 to agree to go to the hospital. The nurse on duty went to the resident's room again to ask that she go to the hospital and the resident agreed. Emergency medical services were called. Further review of the medical record revealed no evidence of Resident #13 nor resident representative being provided with a bed hold notice for her hospitalization on [DATE]. Interview on 02/09/22 at 8:31 A.M. with COO #100 verified Resident #13 or representative did not receive a bed hold notice for her hospitalization on [DATE]. Review of the facility's policy titled Bed-Holds and Returns, dated 03/2017, revealed prior to a transfer, the resident or resident representative will be informed in writing of the bed-hold and return policy.

Based on medical record review and staff interview, the facility failed to ensure the resident's blood pressure was obtained per physician orders and related to use of a as needed blood pressure medication. This affected two (#12 and #32) of five residents reviewed for unnecessary medications. The facility census was 69. Findings include: 1. Review of the medical record for Resident #12 revealed an admitted [DATE]. Diagnoses included essential (primary) hypertension, [CONDITION(S)], acute on chronic systolic heart failure. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 11/12/21, revealed Resident #12 had intact cognition. Review of the physician orders for February 2022 revealed an order dated 11/01/21 for Labeltalol HCl tablet (antihypertensive) give one tablet by mouth every 12 hours related to essential (primary) hypertension. The medication was to be for a systolic blood pressure (SBP) of less than 110 or a heart rate (HR) of less than 60. Review of the medication administration record (MAR) for January 2022 revealed the medication was administered without a blood pressure nor pulse reading for the 9:00 A.M. administrations on 01/01/22, 01/04/22, 01/07/22, 01/18/22, and 01/25/22. Review of the blood pressure and pulse readings for January 2022 revealed no evidence of either being checked on 01/01/22, 01/04/22, 01/07/22, 01/18/22, and 01/25/22. Interview on 02/09/22 at 12:26 P.M. with Licensed Practical Nurse (LPN) #50 stated, when administering a medication that has parameters, the required information (ie blood pressure (BP) and pulse) was entered directly on the MAR prior to administering the medication. LPN #50 further confirmed there was no BP nor pulse documented on the MAR when the medication was administered and stated entering NA (not applicable) was an option when administering the medication. Interview on 02/09/22 at 3:37 P.M. with the Director of Nursing (DON) verified there were no additional vitals documented at the time of administration for Resident #12 on 01/01/22, 01/04/22, 01/07/22, 01/18/22, and 01/25/22. 2. Review of medical record for Resident #32 revealed an admitted [DATE]. Diagnoses included stroke and [CONDITION(S)] affecting both left and right side. Resident#32 was admitted to hospice on 08/31/21 for [CONDITION(S)] disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/07/21, revealed Resident #32 had short and long term memory problems with severely impaired cognition. Review of the care plan dated 07/16/21 revealed Resident #32 was at risk for an alteration in cardiac output related to hypertension. An intervention included to obtain vital signs every shift and as needed. Review of the physician orders, dated 02/05/22, revealed an order for [MEDICATION(S)] (blood pressure) 0.1 milligram every 24 hours as needed for hypertension for systolic blood pressure over 170 millimeters of mercury (mmHg). Review of the electronic medical record for Resident#32 revealed blood pressures were documented on 02/04/22. There were no other blood pressures documented in Resident #32's medical record from 02/05/22 to 02/08/22. Interview on 02/09/22 at 2:31 P.M. with the Director of Nursing (DON) revealed Resident #32 was on [MEDICATION(S)] as needed. Subsequent interview on 02/09/22 at 3:08 P.M. with the DON verified the facility had not been taking daily blood pressure for Resident#32 to monitor for the parameters on the as needed blood pressure ([MEDICATION(S)]) medication.

Based on observation, staff interview, and review of facility policy, the facility failed to label, date, cover and discard outdated food items from the walk-in refrigerator and freezer. The facility also failed to keep the utensil bins cleaned. This had the potential to affect 84 of the 87 residents residing in the facility. The facility identified three residents (#41, #56 and #68) who did not receive food by mouth. Findings include: On 09/30/19 at 8:30 [NAME]M., an initial tour of the kitchen was conducted with Registered Dietitian (RD) #36. During the observation the following concerns were verified by RD #36: In the refrigerator, there was an opened bag of turkey breast and a container of tuna fish with no date of opened or a use by date. There was a bag of shredded cheese, dated 06/14/19, and there was no date of opened or use by date. There was a bag of roast beef with a date of 09/05/19 and there was no date of opened or use by date. The utensil bin stored in the kitchen was dirty and filled with old food particles, dust and dirt-like particles on the edges and inside the bin, where the clean utensils were kept. Cook (CK) #9 verified findings of utensil storage filled with food crumbs, dust and dirt-like substances. Review of the facility's list of residents whose diet order was nothing by mouth revealed Resident #41, #56 and #68 had diet orders of nothing by mouth. Review of the facility policy titled, Food Receiving and Storage, revised (MONTH) 2008, revealed food services, or other designated staff, will maintain clean food storage areas at all times. All food stored in the refrigerator or freezer will be covered, labeled and dated (use by date).

Based on observation and staff interview, the facility failed to ensure expired medications and laboratory supplies were discarded appropriately. This had the potential to affect all 73 residents residing in the facility. Findings include: Observation of the medication room on level one on 10/03/19 at 9:11 [NAME]M. revealed the following three vials of laboratory specimen medium for stool culture and sensitivity testing with expiration dates of 02/2019 and two vials of Remel transport for mycoplasma and ureaplasma ([MEDICAL CONDITION] test) with an expiration date of 08/2019. All other laboratory supplies being stored were not expired. One unopened stock bottle of certerizine tablets ([MEDICATION NAME]) with an expiration date of 07/2019 was observed being stored in the medication room. Observation of medication being stored in the medication room's refrigerator revealed 10 [MEDICATION NAME] suppository's (controls nausea and vomiting) for Resident #31 that were expired on 07/2019. Interview with the Director of Nursing on 10/03/19 at 9:30 [NAME]M. verified there were expired medication, and laboratory supplies stored in the level one medication room. Observation of the medication room on level two on 10/03/19 at 8:37 [NAME]M. revealed the following four vials of laboratory specimen medium for stool culture and sensitivity testing with expiration dates of 02/2019 and one vial of Remel transport for mycoplasma and ureaplasma with an expiration date of 08/2019. All other laboratory supplies being stored were not expired. Interview with the Licensed Practical Nurse #22 on 10/03/19 immediately following the observation verified there were expired laboratory supplies stored in the level two medication room during the survey.

Based on observation, staff interview and review of facility policy, the facility failed to ensure meals were served in a safe and appetizing temperature. This affected three (Resident #38, #116 and #122) of 12 residents observed on the second floor dining room. This had the potential to affect all 12 residents in the second floor dining room. The facility census was 87. Findings include: 1. Observation on 09/30/19 at 10:02 [NAME]M. to 10:09 [NAME]M., revealed Resident #116's meal was sitting next her and the tray was left covered. Resident #116 was yelling requesting for a cup of water and some milk. Observation on 09/3/10 at 10:21 [NAME]M., revealed State tested Nursing Aide (STNA) #88 started to assist Resident #116 with her meal. Interview on 09/30/19 at 10:22 [NAME]M. Assistant Director of Nursing (ADON) reported food trays comes on the floor for Resident #116 at 9:00 [NAME]M. Interview and observation on 09/30/19 at 10:23 [NAME]M. with Registered Dietitian (RD) #36 revealed the RD took the temperature of Resident #116's food. RD #36 took the temperature of Resident #116's food and the scrambled eggs were 85 degrees Fahrenheit (F) and fat free milk at 48.2 degrees F. RD #36 verified the temperatures of the food served to Resident #116 were not at the appropriate temperatures. RD #36 reported she was a new employee and will investigate the matter. 2. Observation on 09/30/19 at 12:10 [NAME]M. revealed Resident #122's food was placed on the counter top in the dining room away from the resident. At 12:36 P.M., Resident #42 received her meal. Interviews on 09/30/19 at 12:43 P.M. with Resident #38 and #122 revealed they both complained that their meals were not warm, and their bread was hard. Interview and observation on 09/30/19 at 12:44 P.M., revealed RD #36, took the temperatures of Resident #38's food. RD #36 took the temperature of Resident #38's food and the goulash ham was 124 degrees F., the au gratin potatoes were 85 degrees F., and the baby carrots were 74 degrees F. RD #36 reported food should be at a holding temperature of 135 degrees F and reported the garlic bread was overcooked. Review of the facility's policy titled, Food Preparation and Service, revealed temperatures at the point of service should be at least 135 degrees F for hot foods and for cold foods below 40 degrees F.

Based on observation, staff interview, and review of facility policy, the facility failed to maintain water temperatures within the required 105 minimum to 120 degree Fahrenheit maximum temperatures. This affected resident room [ROOM NUMBER], and the shared resident bathrooms located on the 100 and 200 hallways. This had the potential to affect 19 residents the facility identified as cognitively impaired and independently mobile. The facility census was 73. Findings include: Observation of the water temperature was conducted on 09/30/19 at 3:30 P.M. A test of a resident's shared bathroom revealed the water was extremely hot to touch, with steam noted coming from the faucet. The water temperature was conducted with temperature noted at 128 degrees Fahrenheit (F). Observation and interview conducted on 09/30/19 at 3:41 P.M. with Maintenance Director (MD) #10 revealed resident room [ROOM NUMBER]'s water temperature was at 128.1 degrees F. on the MD #10's thermometer. Observation the bathroom shared by the residents on the 100 hall revealed the water temperature was 129.5 degrees F on the MD #10's thermometer. Observation of the bathroom shared by the residents on the 200 hall revealed the water temperature was at 128.8 F degrees. MD #10 verified the water temperatures were too high/hot during the time of observation. Review of the facility's policy titled, Safety of Water Temperatures, dated 12/2009 revealed the facility would keep tap water temperatures no more they 120 degrees F to prevent scalding of residents.

Based on medical record review and staff and resident interviews, the facility failed to provide assessments for routine dental care. This affected one (Resident #9) of one resident reviewed for dental services in the investigation stage of the annual survey. The facility census was 73. Findings include: Review of the medical record revealed Resident #9 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Further review of the medical record revealed Resident #9's payer source was Medicaid, effective in 06/2018. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/21/19, revealed the resident was cognitively intact, with no noted behaviors and/or refusal of care noted. Review of Section L Oral/Dental status revealed the resident had no broken teeth and/or dental concerns noted. Interview on 09/30/19 at 11:06 [NAME]M. with Resident #9 stated she had not seen the dentist since being admitted to the facility. Resident #9 stated it had been about three years since she had been seen, and her top plate needed some work and she had some cavities in the bottom teeth that needed looked at. Interview on 10/02/19 at 2:36 P.M. and again on 10/03/19 at 12:08 P.M. with Social Services (SS) #53 stated residents were assessed on admission if they would like to be seen by ancillary services, and then they were added as needed and yearly to the visit list. SS #53 stated residents were reminded throughout the year at resident council when services were coming in, so they can be added if they would like to be seen. SS #53 verified she was aware Resident #9 doesn't get of bed to go to resident council. SS #53 was unable to voice how residents that do not attend resident council are aware of services. SS #53 stated she was not working in the facility when Resident #9 initially signed for services but she should have been reassessed when she changed payer source from Medicare to Medicaid. SS #53 verified the resident was not reassessed when payer sources changed.

Based on record review, staff interview, hospice staff interview and facility-hospice contract, the facility failed to collaborate on a comprehensive plan of care and failed to designate a staff member who was responsible for working with hospice to coordinate care to the resident by both providers. This affected one (Resident #26) of two residents reviewed for hospice services. The facility identified 13 residents who receive hospice services. The facility census was 73. Findings include: Medical record review for Resident #26 revealed an admission of 04/10/14. [DIAGNOSES REDACTED]. Review of the physician order, dated 04/28/18, revealed an order to admit the resident to hospice services. Review of the quarterly assessment, dated 07/05/19, revealed the resident had impaired cognition and was receiving hospice services. Review of the plan of care revealed the resident was receiving hospice services related to late stage [MEDICAL CONDITION]. Interventions included to contact dietary to provide a courtesy cart as needed, encourage the resident to verbalize feelings and concerns about end of life issues, provide validation, notify the social worker, clergy as needed, encourage my family to verbalize feelings and concerns about end of life issues. Notify social worker/clergy as needed, receives supplemental services through Hospice Provider #1 with a telephone number listed. The resident will be visited by a State tested Nursing Assistant (STNA) two to three times weekly, a Registered Nurse (RN) weekly, a Social Worker and Clergy weekly and as needed. The resident desired comfort care, comfort foods as desired, no tube feeding, notify hospice agency for any changes in condition or unmet needs of the resident or family/friends. Staff were to observe for changes in condition, pain, level of consciousness, etc, notify Case Manager Nurse and hospice agency. There was no designated staff member listed for communication with hospice services. Review of the hospice contract with the facility, dated 10/21/09, revealed hospice and facility will jointly develop and agree upon a coordinated plan of care which was consistent with the hospice philosophy and was responsive to the unique needs of the hospice patient and his or her expressed desire for hospice. Additionally, the contract stated that the plan of care will identify which provider was responsible for performing the respective functions that have been agreed upon and included in the plan of care. Under the coordination of care section, the contract states the hospice and the facility shall communicate with one another regularly and as needed for each patient, each party was responsible for documentation such communications in its respective clinical record to ensure the needs of the hospice patient are met. Review of the social services notes for Resident #26, dated 08/19/19 at 2:50 P.M., revealed a care conference was held social services, nursing, activities, and the resident's family. Resident did not attend secondary to decreased cognitive functioning and inability to provide meaningful participation. The attending physician involved in the patient's plan of care via review and revision of physician orders [REDACTED]. There was no mention any hospice staff involvement. Interview with Hospice Registered Nurse (RN) #201 at 1:45 P.M. on 10/01/19 verified there was no meeting to develop a comprehensive care plan between the hospice agency and the designated facility staff member. Hospice RN #201 stated she will talk with the nurse that was caring for the residents that she visited and give them any updates or changes but it was not the same nurse all the time. Additionally, the Hospice RN stated that she was invited to the care conferences but could not attend all of them due to time constraints related to resident care. Interview with the Director of Nursing and Licensed Social Worker (LSW) #53 on 10/02/19 at 2:30 P.M. revealed the LSW stated there was not a designated staff member identified to communicate with hospice on an ongoing basis. LSW further stated that she does invite hospice to the care conference but they do not always attend. The LSW denied any other documents that she maintained to document the collaboration between the facility and the hospice provider. Review of the facility's policy titled Hospice Program, with a revision date of 04/2014, stated when a resident participated in the hospice program, a coordinated plan of care between the facility, hospice agency, and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. The care plan shall be revised and updated as necessary to reflect the resident's current status.

Based on medical record review, staff interview, and review of facility policy, the facility failed to monitor for the continued need for [MEDICAL CONDITION] medication. This affected one (Resident #35) of five residents reviewed for unnecessary medications. The facility census was 73. Findings include: Medical record review for Resident #35 revealed an admission on 12/03/18. [DIAGNOSES REDACTED]. Review of the Minimum Data Set assessment, dated 07/31/19, revealed the resident had impaired cognition and the resident was taking an antidepressant and antipsychotics medication all seven days during the look back period. Review of the plan of care revealed an initiation date of 01/22/19 with a revision date of 06/18/19. The resident was at risk for complications related to the use of [MEDICAL CONDITION] medication. Interventions included to document any adverse effect to routine or as needed medication (PRN), staff was to monitor for tremors or changes in mental status, notify physician with any problems and complete a quarterly abnormal involuntary movement scale (AIMS). Review of the physicians orders, dated 10/2019, revealed an order for [REDACTED]. Further review of the medical record for Resident #35 revealed there was no AIMS assessments available for review. The medical record was silent for any other monitoring for abnormal movement related to antipsychotic medication. Interview on 10/02/19 at 2:07 P.M. with Registered Nurse #217 verified the AIMS tests was not completed as it should have been. Review of the facility's policy titled [MEDICAL CONDITION]/psychopharmacological Policy, dated (YEAR), revealed the facility did not implement the policy in regards to the allegation. Number 13 states the facility will conduct AIMS testing at least every six months and as needed to monitor for movement disorders.

Based on medical record review, review of facility policy and staff interview, the facility failed to effectively provide a restorative program to Resident #14. This affected one (Resident #14) of one resident reviewed for restorative therapy. The facility identified 42 resident receiving rehabilitation services. Findings include: Medical record review for Resident #14 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 06/28/19, revealed the resident had intact cognition. The resident required extensive assistance for bed mobility and transfers. Ambulation occurred only once or twice in the look back period and no set up help or physical assistance from staff was provided. The resident was coded as having a restorative ambulation program during the look back period and participated one day. Review of the plan of care revealed the resident was on a restorative nursing program for ambulation to improve ambulation related to balance problems, unsteady gait, weakness and limited endurance. The goals included for the resident to remain full weight bearing, free of decline in mobility status and ambulate daily. Interventions included to assess for dizziness, unsteady gait, impaired balance or fatigue, assess walker for correct height (top of walker should match crease in wrist when standing straight up), assist in putting on socks and well-fitting nonskid shoes, provide caution to take small steps when turning, not step all the way to the front bar of the walker, not take a step until all four legs of the walker were level on the ground, not place walker too far ahead, not lean forward over walker, encourage participation in ambulation program, provide rest periods as needed, physical therapy or occupational therapy as indicated, and encourage to complete ambulation program 7.5 minutes per day six to seven days per week. Interview with Physical Therapy Assistant #111 on 10/04/19 at 3:20 P.M. stated the facility used to have a state tested nursing assistant (STNA) to complete the restorative program but now they have a nurse that does it. Interview with State tested Nursing Assistant (STNA) #100 on 10/04/19 at 3:18 P.M. verified that she was assigned to Resident #14 and did not do any restorative programs for Resident #14 as they have a nurse that does that now. Interview with Licensed Practical Nurse #22 on 10/04/19 at 3:25 P.M., verified the resident had a restorative program for ambulation to be done six to seven days a week. LPN verified restorative treatments for the last 30 days were documented as provided only on thirteen days, 09/04/19, 09/09/19, 09/10/19, 09/11/19, 09/14/19, 09/18/19, 09/20/19, 09/22/19, 09/23/19, 09/24/19, 09/27/19, 09/29/19 and 09/30/19. Review of the facility's policy titled Restorative Nursing Care, dated 07/2013, revealed rehabilitative nursing care is provided for each resident admitted to the program.

Based on medical record review, review of the hospital record, staff interview, and review of the facility policy, the facility failed to provide timely care for a resident following a fall. This affected one (#63) of one resident reviewed for accidents during the investigation stage of the annual survey. The facility census was 73. Findings include: Review of the medical record for Resident #63 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/02/19, revealed Resident #63 was severely cognitively impaired with verbal behaviors directed toward other one to three days during the look-back period. The resident required extensive one-person assistance with dressing, personal hygiene, extensive two-person assistance with bed mobility and total two-person assistance with transfers. Review of the MDS assessment, dated 08/20/19 revealed the resident received non-medication interventions along with scheduled and as needed medications for pain. Resident #63 was noted during that time with a fall with major injury since admission/prior assessment. Review of the nursing progress notes, dated 07/23/19 at 3:20 P.M., revealed Resident #63 was found laying on the floor in her room, next to the bed and the physician was notified of the fall with no injury. Resident #63 was noted with a complaint of right knee pain but had chronic pain and voiced no new complaints of pain. Subsequent review of the resident's progress notes, revealed on 07/23/19 at 3:39 P.M., the resident was administered her as needed [MEDICATION NAME]-[MEDICATION NAME] (a narcotic pain medication, also known as [MEDICATION NAME]) 5-325 milligram (mg.) tablet for her complaint of right knee pain. The progress note, dated 07/24/19 at 5:45 [NAME]M., revealed the resident was provided as needed Tylenol 650 mg. for complaint of bilateral knee pain with her pain rated at a five, on a pain scale of zero (no pain) to ten (most severe pain). On 07/24/19 at 1:43 P.M., Resident #63 was provided her as needed [MEDICATION NAME] for pain. On 07/25/19 at 3:58 [NAME]M., Resident #63 was provided her as needed [MEDICATION NAME] for complaint of right knee pain. There was no notification noted where the physician was notified of the increased pain in the right knee. Review of the MAR, dated 07/01/19 through 07/31/19, revealed Resident #63 received scheduled [MEDICATION NAME] 5-325 mg., two times daily at 9:00 [NAME]M. and 9:00 P.M. for pain. The resident ' s pain was noted to be zero from 07/01/19 through 07/23/19, except for three occasions, the pain was rated at a three on 07/07/19, 07/09/19 and 07/23/19. The pain level increased on 07/24/19, the day after the resident fell . On 07/24/19 at 9:00 P.M., Resident #63 was noted with a pain scale of seven. On 07/25/19 at 9:00 P.M., the resident was noted with a pain scale of eight. On 07/26/19 at 9:00 [NAME]M., the resident was noted with a pain scale of 10 and at 9:00 P.M. the resident was noted with a pain scale of eight. Further review of the MAR revealed the resident had as needed (PRN) medications Tylenol 650 mg. every six hours, and [MEDICATION NAME] 5-325 mg. every four hours as needed. There were no doses of either medication administered to the resident from 07/01/19 through 07/22/19. Resident #63 was noted on the MAR as provided the [MEDICATION NAME] for pain on 07/23/19 at 3:39 P.M. rated at three, on 07/24/19 at 1:43 P.M. for pain rated at nine, and again on 07/25/19 at 3:58 [NAME]M. for pain rated at four. Further review of the MAR revealed the resident was also provided the PRN Tylenol 650 mg. on 07/24/19 at 5:45 [NAME]M. for pain rated at a five. Subsequent review of the progress note, dated 07/27/19 at 10:10 [NAME]M., revealed the physician was called regarding Resident #63's complaint of right and left knee pain with swelling noted. A new order was received for x-rays of both knees. On 07/27/19 at 2:15 P.M., the physician was notified of the right knee non displaced [MEDICAL CONDITION] femur and the left knee non displaced [MEDICAL CONDITION] lateral femur. The physician ordered for the resident to be sent out to the local hospital. Review of the local hospital after visit summary, dated 07/27/19, revealed Resident #63 was seen in the emergency department and [DIAGNOSES REDACTED]. The resident fitted with a large knee immobilizer placed on the right knee and medium knee immobilizer placed on the left knee and consulted for local orthopedic physician outpatient. Interview conducted on 10/03/19 at 10:35 AM. with the Assistant Director of Nursing (ADON) #28 reviewed the fall for Resident #63. ADON #28 stated the staff notified they doctor on the date of the fall, on 07/23/19, and there was a noted increase of pain and swelling on the 27th and that was what triggered them to call the physician a second time and get an order. ADON #28 stated between 07/23/19 to 07/27/19, the resident was at her baseline and did not require physician notification/intervention. At that time, the surveyor reviewed Resident #63's MAR and progress notes dated 07/01/19 through 07/31/19 with ADON #28 who verified resident was documented with increased pain scale requiring the use of PRN pain medication from 7/23/19 through 7/27/19. ADON #28 verified Resident #63 did not use any PRN pain medication the entire month prior and was noted with the highest complaint of pain at a three out of 10 pain scale, and following the fall was noted with a pain scale from a seven to nine out of 10. ADON #28 verified there was no other physician notification between the fall on 07/23/19 to 07/27/19, of the residents increased complaints of pain. ADON #28 stated he would have to review the incident further, however was never able to provide additional information during the survey. Review of the facility policy titled, Change in a Resident's Condition or Status, with a revision date of 04/2014, revealed the facility would notify the attending physician in changes in the resident physical/emotional/mental condition.

Based on medical record review, review of the Resident Assessment Instrument (RAI) manual and staff interview, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for residents. This affected two (Resident #35 and #63) of 18 residents reviewed for accuracy in MDS assessments in the investigation stage of the annual survey. The facility census was 73. Findings include: 1. Review of the medical record revealed Resident #63 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the wound care notes, dated 08/30/19, revealed Resident #63 had an unstageable pressure area (full thickness or skin tissue loss with depth unknown) noted to her coccyx, with new orders to apply [MEDICATION NAME] cream every shift and as needed. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/02/19, revealed Resident #63 had no pressure injury noted with no ulcers, wounds, and/or skin problems noted. Interview on 10/02/19 at 8:28 P.M. with MDS Coordinator Registered Nurse (RN) # 155 verified Resident #63's MDS assessment dated [DATE] was incorrect, with no documentation of the pressure area to the coccyx. RN #63 state it was completely missed. 2. Medical record review for Resident #35 revealed an admission on 12/03/18 with [DIAGNOSES REDACTED]. Review of quarterly Minimum Data Set (MDS) assessment, dated 01/14/19, revealed the resident required extensive assistance from staff for bed mobility, transfers and dressing. The resident was frequently incontinent and bladder. Resident #35 required supervision and physical assistance from one staff member for walking. The pain interview revealed the resident's pain had occurred occasionally in the last five days and was rated at a two, from a scale of one to ten (zero was no pain and ten was severest, unbearable pain). Review of the subsequent quarterly MDS assessment, dated 04/16/19, revealed the resident had an improvement and required supervision for bed mobility, transfer and dressing. The resident's urinary incontinence improved as well as the resident was now occasionally incontinent for bladder Resident #35 remained supervised with walking but no longer required physical assistance from a staff member. This was an improvement from the previous assessment. The pain interview revealed the resident's pain had occurred frequently and was rated at a five. This indicated the pain had increased and was more severe than the previous quarterly MDS assessment. Interview on 10/02/19 at 12:46 P.M. with Registered Nurse (RN) #217 verified the quarterly MDS assessment, dated 04/16/19, should have been changed to a significant change assessment due to her improvements in two care areas. The RN stated the facility does not have a policy for MDS completion but follows the RAI manual. Review of the Resident Assessment Instrument (RAI) manual version 1.17.1, (MONTH) 2019, chapter two states a significant change assessment must be completed when there is a major decline or improvement in a resident status impacting more than one area of the residents health.

Based on medical record review, staff interview, and review of facility policy, the facility failed to provide rationale and duration for continued use of an as needed (PRN) [MEDICAL CONDITION] medication. This affected one (Resident #21) of five residents reviewed for unnecessary medications during the investigation stage of the annual survey. The facility census was 73. Findings include: Review of the medical record revealed Resident #21 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/10/19, revealed Resident #21 was severely cognitively impaired with [MEDICAL CONDITION] behaviors of disorganized thinking continuously present. The resident received antianxiety medication three days of the seven day look back period. Review of the physician orders [REDACTED]. Review of the Medication Administrator Record revealed Resident #21 was provided the PRN [MEDICATION NAME] 27 times from 05/01/19 through 09/30/19. The resident received the PRN [MEDICATION NAME] on the following dates: on 05/03/19, 05/04/19, 05/07/19, 05/22/19, 05/24/19, 05/29/19, 05/31/19, 06/05/19, 06/07/19, 06/12/19, 06/14/19, 06/21/19, 06/26/19, 06/28/19, 07/03/19, 07/05/19, 07/09/19, 07/10/19, 07/14/19, 07/17/19, 07/18/19, 07/19/19, 07/24/19, 07/26/19, 08/02/19, 09/04/19 and 09/06/19. Further review of the medical record was silent of continued monitoring for behaviors, side effects, and/or effectiveness for the continued use of the [MEDICAL CONDITION] medications. Interview on 10/03/19 at 12:31 P.M. with the Director of Nursing (DON) #4 stated her understanding was that residents wee able to have orders for PRN [MEDICATION NAME] for greater than 14 days without a physician's documentation. DON #4 then verified she was misinformed regarding the use of PRN [MEDICATION NAME], and verified Resident #21 had continued receiving the medication PRN without the required documentation of rationale and verified the duration.

Based on medical record review, staff interview and policy review, the facility failed to timely address a gradual dose reduction (GDR) recommendation and physicians orders for medication changes. This affected one (Resident #35) of five residents reviewed for unnecessary medications. The facility census was 73. Findings include: Medical record review for Resident #35 revealed an admission on 12/03/18. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/31/19, revealed the resident had impaired cognition and the resident was taking an antidepressant medications all seven days during the look back period. Review of the pharmacy recommendations, dated 08/07/19, revealed the resident was currently receiving an antidepressant [MEDICATION NAME] (antidepressant) extended release (ER) 150 milligrams (mg.) daily since 12/03/18. The physician wrote an order to decrease [MEDICATION NAME] to 100 mg. daily on 09/13/19. Review of the physician's orders [REDACTED]. on 09/17/19 and to start [MEDICATION NAME] 100 mg. daily on 09/18/19. This was four days after the physician wrote to decrease [MEDICATION NAME] to 100 mg. daily. Interview with Director of Nursing (DON) on 10/03/19 at 4:30 P.M. stated the pharmacy will send the GDR in a folder with the medication delivery about ten days after the review of the resident's medical record. If there were any recommendations, they were placed in the physician's box at the facility. He will pick them up and take them with him. After the physicians reviews them, he will bring them back to the facility and any new orders will be addressed. The DON stated this particular physician does not come in very often. The DON stated the facility's time line for addressing the GDR's was between 30 and 60 days to complete the recommendations. She verified the orders were written on 09/13/19 by the physician and not put in to the electronic health record until 09/17/19. Resident #35 received a higher dose for four additional days. Review of the facility's [MEDICAL CONDITION]/psychopharmacological medication policy, dated (YEAR), revealed the facility's pharmacist will monitor psychoactive drug use in the facility to ensure medications are not used in excessive dosages for excessive durations as well as for potential adverse interactions, notify the physician and nursing administration when a [MEDICAL CONDITION] medication is past due for review, ensure proper timelines are followed per regulatory guidance for dosage reduction attempts.

Based on facility record review and staff interview, the facility failed to maintain the minimum required committee members for the Quality Assessment and Assurance (QAA) quarterly meetings. This had the potential all 73 residents residing in the facility. Findings include: Facility record review and staff interview was conducted on 10/03/19 at 7:12 P.M. with Corporate Administrator (CA) #189. Review of the QAA quarterly meetings revealed there were four noted meetings conducted, as required. However an Administrator did not attend two of the four meetings held on 01/18/19 and 07/19/19. CA #189 verified the Administrator was not signed in for attending the meetings. CA #189 stated the Administrator did not attend due to he was a single father and may have had something with his daughter at the time of the meetings and was unable to attend. CA #189 verified she was aware an Administrator was required to attend and there was no Administrator present during those two quarterly meetings, as required.

Based on observations, interviews and review of facility policy, the facility failed to ensure opened packages of frozen food items were identified and had the month, day, and year, as well as use by date on them. This had the potential to affect all 69 residents who received meals from the kitchen. Findings include: Observation of the facility's freezer on 08/20/18 at 8:45 A.M. revealed open, clear, frozen plastic bags of corn, breaded fish, breaded chicken, and perogies, which were not in their original packaging and were not dated with the open date. Interview of Dietary Manager #79 on 08/20/18 at 8:45 A.M. verified the packages of frozen corn, breaded fish, breaded chicken, and perogies had no open date on them. DM #79 stated she would date them. Review of the undated facility policy titled, Use by Dates and Food Storage, revealed every item must be identified with the name of the product if taken out of the original package along with the month, day, and year, and use by date. Review of the undated facility policy titled, Refrigerated and Frozen Storage, revealed all foods must be properly covered and dated during storage

Based on record review and staff interviews, the facility delayed disbursing a resident's funds timely after a resident was discharged from the facility and failed to notify a resident to spend down their money when their resources were within two hundred dollars less than the maximum amount permitted for medicaid. This affected two (Resident #62 and #203) of five residents reviewed for resident funds accounts. The facility identified 16 current residents who had funds account with the facility. The facility census was 69. Findings include: 1. Review of the medical record for Resident #203 revealed an admitted [DATE] and a discharge date of [DATE]. Review of a copy of facility check number 1577, dated 01/26/18, indicated an amount of $572.35 was sent to Attorney General's Office for estate recovery, closure of account for Resident #203. Interview on 08/23/18 at 11:10 A.M. with Business Office Manager (BOM) #301 reported she was not aware of what delayed the account closure since she was not in the current position until late (MONTH) (YEAR). BOM #301 indicated accounts should be closed within 30 days of a resident's discharge but was unaware of facility policy. 2. Review of the medical record for Resident #62 revealed an admitted [DATE]. A review of the facility's trust balance for Resident #62 revealed a balance of $1923.67. Interview on 08/23/18 at 11:10 A.M. with BOM #301 reported she had plans to make Resident #62 aware of need to spend down monies from account to prevent reaching maximum allowable of $2000.00. She verified resident had not been informed and was unaware of a policy of when residents were to be warned of possibility of reaching maximum balances.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record reviews, review of hospital documentation, review of the sexual abuse nurse examiner (SANE) documentation, review of the self-reported incident (SRI) investigation documentation, review of a police report, review of the facility's abuse policy and staff interview, the facility failed to ensure a resident was free from being sexually assaulted. This resulted in actual harm to Resident #7 when she was sexually assaulted and received tears to her labia and vagina. This affected one (#7) of three residents reviewed for abuse. The facility census was 69. Findings include: Review of Resident #7's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #7's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was rarely able to be understood and had been assessed by staff as severely cognitively impaired. Resident #7 was assessed as being totally dependent on staff for activities of daily living (ADL). Review of Resident #70's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #70 had wandering behaviors which occurred daily and was assessed with [REDACTED].#70 required supervision with transfers, walking in his room and in the corridor. Review of an SRI filed by the facility on 09/12/17 and completed on 09/18/17 revealed the investigation documented, during a phone interview completed with State tested Nursing Assistant (STNA) #50 on 09/11/17 at 11:00 P.M., she checked on Resident #7 on 09/11/17 at approximately 7:30 P.M. to 7:45 P.M. Resident #7's adult incontinence brief was dry, Resident #7 was covered up and sleeping. STNA #50 left Resident #7's door open because she had a bed alarm on. At approximately 10:00 P.M. on 09/11/17, STNA #50 notices Resident #7's door is closed. STNA #50 opens Resident #7's door and finds Resident #70's wheelchair in the room in front of Resident #7's recliner, but Resident #70 was not in the room. Resident #7's bed sheet was folded back diagonally on one corner and her flannel night gown was pulled up to her navel. Both sides of her incontinence brief were unfastened and the front of the incontinence brief was pulled down. The back of the incontinence brief was still under Resident #7. STNA #50 immediately notified the nurse and did not touch anything. Resident #70 was found in the common lounge area by staff and placed on one to one supervision until the investigation was completed. Resident #7 was assessed by a facility nurse then sent to a local emergency department (ED) on 09/12/17 at 2:45 A.M. for assessment. The conclusion of the SRI investigation revealed the facility substantiated Resident #7 was sexually abused. Review of the hospital ED records dated 09/12/17 revealed Resident #7 had signs of injury in the vagina and evidence of vaginal penetration. A tear of the right vaginal wall with pooled fluid did not appear to be semen and no active bleeding was documented. The [DIAGNOSES REDACTED]. Review of a SANE report dated 09/12/17 at 3:00 A.M. revealed Resident #7 had small right vaginal tears and two right labial wall small tears. Anatomical drawings with location of tears were included in this report. Review of a police report dated 09/12/17 revealed a local police officer responded to the local ED on 09/12/17 at 4:40 A.M. on a suspected sexual abuse. Resident #7 was documented as being found by staff with her incontinence brief down and with the wheelchair of Resident #70 in her room. Resident #70 was documented as being found by the nurse's station and was not acting normal. Resident #70 did not want nurses to touch him and seemed uncomfortable around them. No attempt to interview Resident #70 was documented. Resident #7 did not respond to the police officer attempting to interview her at the ED. Interview with the Administrator and Chief Operating Officer (COO) #40 on 10/16/17 at 1:15 P.M. both stated they had viewed surveillance camera video footage of the hallway in which Resident #7 resided on 09/11/17. Both the Administrator and COO #40 stated Resident #70 was the only person seen entering and exiting the room of Resident #7 on 09/11/17 between the times when STNA #50 left the room around 7:45 P.M. and reentered the room at approximately 10:00 P.M. COO #40 again confirmed during interviews on 10/16/17 at 1:15 P.M. and 3:03 P.M. Resident #70 was the only person she observed on surveillance camera video footage entering and exiting the room of Resident #7 on 09/11/17 between the times when STNA #50 left the room around 7:45 P.M. and reentered the room at approximately 10:00 P.M. COO #40 could not remember if Resident #70 ambulated in his wheelchair or walked behind his wheelchair to enter Resident #7's room. COO #40 stated video footage was unable to be viewed by the surveyor due to the recording only saving for a period of two weeks. Observation of Resident #7 on 10/16/17 at 2:33 P.M. revealed she was lying in her bed covered up with covers. Resident #7's eyes were closed and her arms were drawn up on her chest and resting comfortably. A stop sign banner was cross the doorway and an exit/enter door way alarm was is in place at the entrance way. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated 2016, revealed the facility will not tolerate Abuse Neglect and Exploitation of its residents or Misappropriation of personal property. The policy defined Sexual Abuse as non-consensual sexual contact of any type with a resident. As a result of the incident the facility implemented the following corrective actions to correct the deficient practice by 09/15/17: · On 09/12/17, upon discovery of the incident Resident #7 was assessed by staff and sent to the ED for evaluation. · On 09/12/17, both Resident #7 and Resident #70 were assessed by the physician. · On 09/12/17, Resident #70 was placed on continuous one to one staff supervision and was discharged from the facility on 09/15/17. · On 09/12/17, the DON/designee reviewed all care plans for behaviors and wandering for residents of the facility to ensure they were appropriate. · On 09/12/17, the DON/designee performed skin assessments of all female residents residing in the same unit of the facility as Resident #70. · · On 09/12/17, the DON/designee interviewed all residents capable of being interviewed that also resided in the same unit of the facility as Resident #70. · On 09/12/17 and 09/13/17, all facility staff members of various departments and shifts were in-serviced by the DON/designee about abuse policy and procedures. · On 09/15/17, Resident #7 was moved to a room closer to the nurse's station and a stop entry sign and doorway alarm were put in place. · On 10/01/17 and 10/16/17, interviews over various times with various disciplines of staff all revealed knowledge of facility abuse policy and procedures. · On 10/16/17, two additional resident's (#41 and #55) medical records were reviewed for potential abuse and no concerns were identified. This deficiency substantiates Complaint Number OH 564.

Based on record review and staff interviews, the facility failed to notify the physician of excessive weight gain and a high laboratory test result delaying a resident's treatment. This resulted in actual harm when Resident #80 was displaying signs of excessive weight gain, increased confusion and shortness of breath while sitting, difficulty speaking, bilateral upper extremity of three plus pitting (significant swelling) [MEDICAL CONDITION], abnormal breath sounds and abnormal laboratory test requiring the resident to being sent to the emergency room for treatment of [REDACTED]. This affected two (#80 and #96) of five residents reviewed for change in condition. The facility identified eight current residents with the [DIAGNOSES REDACTED]. The facility census was 69. Findings include: 1. Review of Resident # 80's medical record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had moderate cognitive impairment and required extensive assistance with activities of daily living (ADL) including transferring, dressing, toileting and personal hygiene. Review of the admission physician orders [REDACTED]. The resident's weight on 04/14/17 was 153.6 pounds and on 04/15/17 was 153.1 pounds. No weight was obtained on 04/16/17, 04/20/17, 04/21/17, 04/26/17, 04/27/17 and 05/01/17. From 05/02/17 through 05/17/17 the resident's weight ranged between 151-154 pounds. On 05/18/17, the resident weight was not obtained. Review of the medical record revealed there was no documented evidence of the physician being notified of the weight continue increase from 04/11/17 to 05/18/17. Review of nurse's progress note dated 05/18/17 at 4:52 P.M. revealed Resident #80 was noted with increased confusion and shortness of breath while sitting. The resident had difficulty with speaking. The nurse's assessment found he was positive for bilateral upper extremity [MEDICAL CONDITION] of three plus pitting (significant swelling) and bilateral breath sounds were with equal expansion, decreased throughout all fields; crackle sounds on the left stronger than the right with decreased bases. The resident had activity intolerance. The physician was called and new orders were received for Stat (meaning immediate) chest x-ray, CBC (complete blood count), and BNP (B-type natriuretic peptide) due to the resident's history of [MEDICAL CONDITION]. Review of physician orders [REDACTED].M. a stat chest X-ray was ordered and at 4:55 P.M. a stat CBC and BNP were ordered. The CBC and BNP were completed and neither were within normal limits. The resident's BNP was critically high at 1045 pg/ml (pictogram per milliliter) (normal range 0-77 pg/ml). There was no evidence in the medical record of notification to the physician of the abnormal laboratory results and no evidence the stat chest X-ray had ever been completed. Review of the nurse's progress note dated on 05/19/17 at 6:15 A.M. Resident #80 was washed, dressed and transferred to his wheelchair by staff. The resident seemed to have immediately fallen asleep. He slumped down in his chair and was unresponsive. Resident #80's blood pressure was 142/117, his pulse was 76 beats per minutes and his respiratory rate was 22-24 respirations per minute with an oxygen saturation of 85 percent on room air. Minimal intercostal retractions were noted without nasal flaring. Crackles were heard on auscultation of the upper right and left lung fields and breath sounds were diminished at bases. No circumolar pallor was noted or general cyanosis. The physician was notified who ordered the resident be sent out to the hospital. The 911 squad was called and upon arrival the resident became alert and oriented to person and place only. The resident was transported to the hospital via the 911 squad and admitted to the hospital with [REDACTED]. Further review of the medical record indicated the resident remained in the hospital until 05/24/17 when he was discharged back to the facility. Interviewed on 06/08/17 at 8:55 A.M. with the Director of Nursing (DON) revealed her expectation was that stat ordered X-rays would be completed immediately or as soon as possible and at least within four hours. Interview on 06/08/2017 at 12:45 P.M. with Registered Nurse (RN) #20 revealed stat diagnostic tests, such as X-rays should be completed a soon as possible or within four to five hours. RN #20 verified the facility had not notified the physician of the resident's weight gain or of the resident's abnormal labs. RN #20 further verified the facility had not obtained the physician ordered stat X-ray prior to the resident being sent to the hospital via the 911 squad. 2. Review of Resident #96's medical record revealed the resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Review of Resident #96's physician's orders [REDACTED]. Review of Resident 96's weight log revealed there were no documented weights on 05/22, 05/23, 05/24, 05/30, and 06/04. Resident #96 additionally had a weight gain of 3 pounds on 05/31/17 (121 pounds) to 06/01/17 (124 pounds), and a documented weight gain of 7 pounds from 06/03/17 (123 pounds) to 06/05/17 (130 pounds). Review of progress notes revealed there was no documentation present that the facility informed the physician of the resident's weight gain from 05/31/17 to 06/01/17 and 06/03/17 to 06/05/17 as per the physician order. Interview with the Director of Nursing on 06/08/17 at 12:43 P.M. verified the facility did not weight Resident #96 daily as ordered and the physician was not notified of the weight change.

Based on record review and staff interviews, the facility failed to obtain physician ordered daily weights, obtain a stat chest X-ray, and notify the physician of excessive weight gain and a high laboratory test result. This resulted in actual harm when Resident #80 was displaying signs of excessive weight gain, increased confusion and shortness of breath while sitting, difficulty speaking, bilateral upper extremity of three plus pitting (significant swelling) [MEDICAL CONDITION], abnormal breath sounds and abnormal laboratory test requiring the resident to being sent to the emergency room for treatment of [REDACTED]. This affected two (#80 and #96) of five residents reviewed for change in condition. The facility identified eight current residents with the [DIAGNOSES REDACTED]. The facility census was 69. Findings include: 1. Review of Resident # 80's medical record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had moderate cognitive impairment and required extensive assistance with activities of daily living (ADL) including transferring, dressing, toileting and personal hygiene. Review of the admission physician orders [REDACTED]. The resident's weight on 04/14/17 was 153.6 pounds and on 04/15/17 was 153.1 pounds. No weight was obtained on 04/16/17, 04/20/17, 04/21/17, 04/26/17, 04/27/17 and 05/01/17. From 05/02/17 through 05/17/17 the resident's weight ranged between 151-154 pounds. On 05/18/17, the resident weight was not obtained. Review of the medical record revealed there was no documented evidence of the physician being notified of the weight continue increase from 04/11/17 to 05/18/17. Review of nurse's progress note dated 05/18/17 at 4:52 P.M. revealed Resident #80 was noted with increased confusion and shortness of breath while sitting. The resident had difficulty with speaking. The nurse's assessment found he was positive for bilateral upper extremity [MEDICAL CONDITION] of 3 plus pitting (significant swelling) and bilateral breath sounds were with equal expansion, decreased throughout all fields; crackle sounds on the left stronger than the right with decreased bases. The resident had activity intolerance. The physician was called and new orders were received for Stat (meaning immediate) chest x-ray, CBC (complete blood count), and BNP (B-type natriuretic peptide) due to the resident's history of [MEDICAL CONDITION]. Review of physician orders [REDACTED].M. a stat chest X-ray was ordered and at 4:55 P.M. a stat CBC and BNP were ordered. The CBC and BNP were completed and neither were within normal limits. The resident's BNP was critically high at 1045 pg/ml (pictogram per milliliter) (normal range 0-77 pg/ml). There was no evidence in the medical record of notification to the physician of the abnormal laboratory results and no evidence the stat chest X-ray had ever been completed. Review of a nurse's progress note dated 05/20/17 at 2:10 A.M. (late entry) documented: Yesterday the resident began using his call light regularly about every 10-15 minutes while yelling out hey, hey, come here from about 0300 (meaning 3:00 A.M.) on. This behavior was neither isolated nor unusual for this resident in my brief experience with him. When staff would enter his room resident would ask for his shoes stating it's time for breakfast and or do you want to go to lunch with my friend? The resident would be reoriented to the correct time and informed breakfast was still several hours away. The resident is clearly confused secondary to Alzheimer's dementia and would frequently reply no, no really. It's only 3 AM so what should I do now? Staff suggested he try and sleep some more before breakfast and things would quiet down for a while. This cycle of events would repeat some 10 or 15 minutes later. The note further stated on the morning of 05/19/17 at 6:15 A.M. Resident #80 was washed, dressed and transferred to his wheelchair by staff. The resident seemed to have immediately fallen asleep. He slumped down in his chair and was unresponsive. Resident #80's blood pressure was 142/117, his pulse was 76 beats per minutes and his respiratory rate was 22-24 respirations per minute with an oxygen saturation of 85 percent on room air. Minimal intercostal retractions were noted without nasal flaring. Crackles were heard on auscultation of the upper right and left lung fields and breath sounds were diminished at bases. No circumolar pallor was noted or general cyanosis. The physician was notified who ordered the resident be sent out to the hospital. The 911 squad was called and upon arrival the resident became alert and oriented to person and place only. The resident was transported to the hospital via the 911 squad and admitted to the hospital with [REDACTED]. Further review of the medical record indicated the resident remained in the hospital until 05/24/17 when he was discharged back to the facility. Interviewed on 06/08/17 at 8:55 A.M. with the Director of Nursing (DON) revealed her expectation was that stat ordered X-rays would be completed immediately or as soon as possible and at least within four hours. Interview on 06/08/2017 at 12:45 P.M. with Registered Nurse (RN) #20 revealed stat diagnostic tests, such as X-rays should be completed a soon as possible or within four to five hours. RN #20 verified the facility had not notified the physician of the resident's weight gain or of the resident's abnormal labs. RN #20 further verified the facility had not obtained the physician ordered stat X-ray prior to the resident being sent to the hospital via the 911 squad. 2. Review of Resident #96's medical record revealed the resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Review of Resident #96's physician's orders [REDACTED]. Review of Resident 96's weight log revealed there were no documented weights on 05/22, 05/23, 05/24, 05/30, and 06/04. Resident #96 additionally had a weight gain of 3 pounds on 05/31/17 (121 pounds) to 06/01/17 (124 pounds), and a documented weight gain of 7 pounds from 06/03/17 (123 pounds) to 06/05/17 (130 pounds). Review of progress notes revealed there was no documentation present that the facility informed the physician of the resident's weight gain from 05/31/17 to 06/01/17 and 06/03/17 to 06/05/17 as per the physician order. Interview with the Director of Nursing on 06/08/17 at 12:43 P.M. verified the facility did not weight Resident #96 daily as ordered and not notified of the weight change.

Based on medical record review, observations, interviews, and review of a facility Self-Reported Incident (SRI), the facility failed to ensure incidents of suspected physical and verbal abuse toward residents were immediately reported to the administrator of the facility and subsequently failed to ensure residents were protected from potential further abuse. This resulted in Immediate Jeopardy for two (#1 and #2) of three residents reviewed for abuse who were physically and verbally abused by a Hospice agency staff member. This had the potential to affect all 73 residents currently residing in the facility, including nine residents (#5, #57, #34, #23, #53, #49, #28, #63 and #48) directly assigned to the care of the Hospice agency staff member. On 09/03/15 at 1:15 P.M., the Director of Nursing (DON), Assistant Director of Nursing (ADON) and Quality Assurance Nurse were notified Immediate Jeopardy began on 08/13/15 when Hospice State tested Nursing Assistant (STNA) #100 was witnessed by facility staff, STNA #1, putting a soapy washcloth onto Resident #2's face and mouth and verbally abuse her by calling her a [***] and a whore when she became agitated and resisted care during a shower. Hospice STNA #100 was then witnessed by facility staff STNA #1 and STNA #2 to physically and verbally abuse Resident #1 by saying if you don't quit fighting, I will cut you up during a shower on 08/16/15 when he tightly held the resident's head and roughly shaved him after the resident had refused to be shaved. As a result, Resident #1 sustained nicks and was bleeding after the incident. Hospice STNA #100 provided services in the facility on 08/13/15, 08/15/15, 08/16/15 and 08/17/15. On 08/19/15, facility staff STNA #1 and STNA #2 reported the incidents of abuse to the DON, which had occurred on 08/13/15 and 08/16/15. The Immediate Jeopardy was removed on 08/19/15 when the facility implemented the following corrective actions: · On 08/19/15, the facility DON notified the Hospice agency of the allegations of abuse, and that the Hospice STNA (#100) was no longer to provide care in the facility. · On 08/19/15, facility STNA #1 and STNA #2 were counseled on the abuse policy and procedure, and specifically that any mistreatment/abuse is to be reported immediately. · On 08/19/15, nine other residents, #5, #57, #34, #23, #53, #49, #28, #63 and #48, identified as under the care of Hospice STNA #100 between 08/13/15 and 08/19/15, were assessed for abuse. · On 09/03/15 and 09/04/15, all staff in the building on day shift and all nursing staff on night shift were in-serviced regarding abuse reporting and what constitutes abuse. All facility STNA's were scheduled to be in-serviced on 09/11/15. · The DON, Administrator, and ADON will conduct weekly monitoring of random staff and residents for four weeks, and then two staff members will be randomly questioned every month for monitoring through December 2015. This will continue to be monitored on an on-going basis through the Quality Assurance Committee. Although the Immediate Jeopardy was removed on 08/19/15, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility started conducting staff in-services on abuse and abuse reporting and was in the process of monitoring and verifying the corrective action taken was effective. Findings include: Review of the medical record for Resident #2 revealed she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. She was documented as receiving Hospice services. The comprehensive assessment, dated 07/28/15, assessed the resident as being moderately cognitively impaired and had physically and verbally aggressive behaviors which significantly interfered with resident ' s care. She was either dependent on staff or required extensive assistance for care. Review of the medical record for Resident #1 revealed he was admitted on [DATE]. Resident #1 had [DIAGNOSES REDACTED]. He was not receiving Hospice services. The comprehensive assessment, dated 08/19/15, assessed the resident as being severely cognitively impaired, rejected care and was totally dependent on staff for bathing, and required extensive assist for personal hygiene and toileting. Review of a facility SRI dated 08/19/15 documented facility STNA #1 reported a concern with Hospice STNA #100. STNA #1 reported when she and STNA #2 were showering Resident #1 last week Hospice STNA #100 came into the shower room. Hospice STNA #100 had overheard Resident #1 was refusing to be shaved. Hospice STNA #100 said he would help them. STNA #1 stated she was uncomfortable with the way he shaved Resident #1, stating he wrapped his arm around the resident's neck and pulled his head back and roughly shaved him. STNA #1 also stated Hospice STNA #100 said to Resident #1, If you don't quit fighting, I'll cut you up. STNA #1 also reported that last week she was in the bathroom with Hospice STNA #100 showering Resident #2. Resident #2 attempted to bite STNA #1, and Hospice STNA #100 took a washcloth full of soapy water and shoved it in her face, eyes, and mouth and stated to the resident every time you try to bite her, this is what I am going to do to you. STNA #1 stated the resident continued to curse at Hospice STNA #100 and he began to call Resident #2 derogatory names such as whore and [***] . After the shower was completed, Hospice STNA #100 sprayed Resident #2 with body spray and stated There, [***] , now you smell like a whore. The facility's SRI, dated 08/19/15, documented STNA #2 was interviewed by the DON and Administrator by phone regarding the incident with Resident #1. STNA #2 stated Hospice STNA #100 restrained Resident #1 by holding his head to shave him. She stated she was uncomfortable with the incident. The DON and Administrator interviewed Resident #2 on 08/19/15. When asked if she had any issues with any of the Hospice staff, Resident #2 stated yes and identified Hospice STNA #100. Resident #2 stated he put a soapy cloth in my face, in my mouth and he pulled my hair. I don't want him near me. Resident #2 was assessed and no injuries were found. Resident #1 was assessed immediately following the report on 08/19/15, and no injuries were found. Documentation indicated STNA #1 had reported that she noted several bleeding spots on Resident #1's face following the incident the previous week. The resident was cognitively impaired and unable to provide any information regarding the incident. The facility's conclusion was there is reasonable suspicion that abuse may have taken place, but we are unable to say with certainty that any abuse has occurred. The allegation was reported to (Hospice STNA #100's) employer for investigation, and the local authorities were also notified. During an interview with the DON and Quality Assurance Nurse #3 on 09/03/15 at 9:50 A.M., the above SRI was reviewed. They stated it was determined the incident with Resident #2 occurred on 08/13/15, and the incident with Resident #1 occurred on 08/16/15. They confirmed STNA #1 reported the incidents on 08/19/15, six days after the first incident occurred and three days after the second incident. The DON stated Hospice STNA #100 was also in the facility providing Hospice services on 08/15/15 and 08/17/15. The DON stated STNA #1 was working in the facility at this time, and STNA #2 was on medical leave. Interview with STNA #1 on 09/03/15 at 10:20 A.M. revealed she was assisting Hospice STNA #100 with showering the resident. She was assigned to the care of Resident #2 that day, and Hospice STNA #100 was also assigned to Resident #2 by the Hospice agency. The resident began to try to bite STNA #1, at which time Hospice STNA #100 put a very soapy washcloth in the resident's face and mouth. The resident was calling Hospice STNA #100 names. Hospice STNA #100 then called Resident #2 a [***] and told her you smell like a whore. At the end of the shower, he sprayed the resident with perfume and said there, [***] , now you smell like a whore. Regarding the incident with Resident #1, STNA #1 stated she and STNA #2 were giving Resident #1 a shower, and he had refused to be shaved. During this time, Hospice STNA #100 walked into the shower room and put his bags down, and said what, you can't shave him? I'll do it. STNA #1 indicated they did not ask Hospice STNA #100 to help them, and Resident #1 was not receiving Hospice services. Hospice STNA #100 came in and said to STNA #1 and STNA #2 you and you, hold his arms. He got behind the resident and put his arm around the residents neck and held the resident up against him, as in a head lock. STNA #1 said Hospice STNA #100 told the resident to hold still or I'll cut you up, or some words close to that. STNA #1 said Hospice STNA #100 shaved him roughly, and the resident was bleeding in several different spots on his face. She said after the incident with Resident #1, she decided to report the incidents involving Hospice STNA #100 the next time she saw the DON. She thinks it was the day after or two days after the incident with Resident #1. She stated she didn't report the incidents immediately, because she was not sure if it was abuse. She also stated others in the facility seemed to think highly of Hospice STNA #100. During the interview, STNA #1 also stated Hospice STNA #100 had made her feel uncomfortable in the past because he talked loudly and sternly to residents while getting in their faces. She didn't give an example identifying any specific resident, but gave an example of Hospice STNA #100 leaning in a resident's face and yelling Don't do that! Resident #1 was observed on 09/03/15 at 11:00 A.M. He was in a common area on the first floor with three other residents and an unidentified STNA. He did not respond appropriately when spoken to. He kept saying Amen. He was observed to have a few days growth of beard. No cuts or bruises were observed. Observation on 09/03/15 at 4:25 P.M. revealed Resident #2 was lying in bed awake. When greeted the resident did not respond appropriately and became verbally abusive. Review of the facility policy, titled Resident Abuse, undated, indicated The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, and misappropriation. Our facility will not condone resident abuse by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies serving the resident, family members, legal guardians, sponsors, friends, or other individuals. All personnel must promptly report any incident or suspected incident of resident abuse, including injuries of unknown source and misappropriation of resident property The policy also included, .The person(s) observing an incident of resident abuse or suspecting resident abuse must immediately report such an incident to the charge nurse. The charge nurse must immediately notify the director of nursing and/or administrator This deficiency substantiates Complaint Number OH 531.

Based on medical record review, observations, interviews, and review of a facility Self-Reported Incident (SRI), the facility failed to ensure staff followed the facility ' s abuse policy and procedure when two incidents of suspected physical and verbal abuse toward residents were not reported immediately to the administrator of the facility and subsequently failed to ensure residents were protected from potential further abuse. This resulted in Immediate Jeopardy for two (#1 and #2) of three residents reviewed for abuse who were physically and verbally abused by a Hospice agency staff member. This had the potential to affect all 73 residents who resided in the facility, including nine residents (#5, #57, #34, #23, #53, #49, #28, #63 and #48) directly assigned to the care of the Hospice agency staff member. On 09/03/15 at 1:15 P.M., the Director of Nursing (DON), Assistant Director of Nursing (ADON) and Quality Assurance Nurse were notified Immediate Jeopardy began on 08/13/15 when Hospice State tested Nursing Assistant (STNA) #100 was witnessed by facility staff, STNA #1, putting a soapy washcloth onto Resident #2's face and mouth and verbally abuse her by calling her a [***] and a whore when she became agitated and resisted care during a shower. Hospice STNA #100 was then witnessed by facility staff STNA #1 and STNA #2 to physically and verbally abuse Resident #1 by saying if you don't quit fighting, I will cut you up during a shower on 08/16/15 when he tightly held the resident's head and roughly shaved him after the resident had refused to be shaved. As a result, Resident #1 sustained nicks and was bleeding after the incident. Hospice STNA #100 provided services in the facility on 08/13/15, 08/15/15, 08/16/15 and 08/17/15. On 08/19/15, facility staff STNA #1 and STNA #2 reported the incidents of abuse to the DON, which had occurred on 08/13/15 and 08/16/15. The Immediate Jeopardy was removed on 08/19/15 when the facility implemented the following corrective actions: · On 08/19/15, the facility DON notified the Hospice agency of the allegations of abuse, and that the Hospice STNA (#100) was no longer to provide care in the facility. · On 08/19/15, facility STNA #1 and STNA #2 were counseled on the abuse policy and procedure, and specifically that any mistreatment/abuse is to be reported immediately. · On 08/19/15, nine other residents, #5, #57, #34, #23, #53, #49, #28, #63 and #48, identified as under the care of Hospice STNA #100 between 08/13/15 and 08/19/15, were assessed for abuse. · On 09/03/15 and 09/04/15, all staff in the building on day shift and all nursing staff on night shift were in-serviced regarding abuse reporting and what constitutes abuse. All facility STNA's were scheduled to be in-serviced on 09/11/15. · The DON, Administrator, and ADON will conduct weekly monitoring of random staff and residents for four weeks, and then two staff members will be randomly questioned every month for monitoring through December 2015. This will continue to be monitored on an on-going basis through the Quality Assurance Committee. Although the Immediate Jeopardy was removed on 08/19/15, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility started conducting staff in-services on abuse and abuse reporting and was in the process of monitoring and verifying the corrective action taken was effective. Findings include: Review of the medical record for Resident #2 revealed she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. She was documented as receiving Hospice services. The comprehensive assessment, dated 07/28/15, assessed the resident as being moderately cognitively impaired and had physically and verbally aggressive behaviors which significantly interfered with resident ' s care. She was either dependent on staff or required extensive assistance for care. Review of the medical record for Resident #1 revealed he was admitted on [DATE]. Resident #1 had [DIAGNOSES REDACTED]. He was not receiving Hospice services. The comprehensive assessment, dated 08/19/15, assessed the resident as being severely cognitively impaired, rejected care and was totally dependent on staff for bathing, and required extensive assist for personal hygiene and toileting. Review of a facility SRI dated 08/19/15 documented facility STNA #1 reported a concern with Hospice STNA #100. STNA #1 reported when she and STNA #2 were showering Resident #1 last week Hospice STNA #100 came into the shower room. Hospice STNA #100 had overheard Resident #1 was refusing to be shaved. Hospice STNA #100 said he would help them. STNA #1 stated she was uncomfortable with the way he shaved Resident #1, stating he wrapped his arm around the resident's neck and pulled his head back and roughly shaved him. STNA #1 also stated Hospice STNA #100 said to Resident #1, If you don't quit fighting, I'll cut you up. STNA #1 also reported that last week she was in the bathroom with Hospice STNA #100 showering Resident #2. Resident #2 attempted to bite STNA #1, and Hospice STNA #100 took a washcloth full of soapy water and shoved it in her face, eyes, and mouth and stated to the resident every time you try to bite her, this is what I am going to do to you. STNA #1 stated the resident continued to curse at Hospice STNA #100 and he began to call Resident #2 derogatory names such as whore and [***] . After the shower was completed, Hospice STNA #100 sprayed Resident #2 with body spray and stated There, [***] , now you smell like a whore. The facility's SRI, dated 08/19/15, documented STNA #2 was interviewed by the DON and Administrator by phone regarding the incident with Resident #1. STNA #2 stated Hospice STNA #100 restrained Resident #1 by holding his head to shave him. She stated she was uncomfortable with the incident. The DON and Administrator interviewed Resident #2 on 08/19/15. When asked if she had any issues with any of the Hospice staff, Resident #2 stated yes and identified Hospice STNA #100. Resident #2 stated he put a soapy cloth in my face, in my mouth and he pulled my hair. I don't want him near me. Resident #2 was assessed and no injuries were found. Resident #1 was assessed immediately following the report on 08/19/15, and no injuries were found. Documentation indicated STNA #1 had reported that she noted several bleeding spots on Resident #1's face following the incident the previous week. The resident was cognitively impaired and unable to provide any information regarding the incident. The facility's conclusion was there is reasonable suspicion that abuse may have taken place, but we are unable to say with certainty that any abuse has occurred. The allegation was reported to (Hospice STNA #100's) employer for investigation, and the local authorities were also notified. During an interview with the DON and Quality Assurance Nurse #3 on 09/03/15 at 9:50 A.M., the above SRI was reviewed. They stated it was determined the incident with Resident #2 occurred on 08/13/15, and the incident with Resident #1 occurred on 08/16/15. They confirmed STNA #1 reported the incidents on 08/19/15, six days after the first incident occurred and three days after the second incident. The DON stated Hospice STNA #100 was also in the facility providing Hospice services on 08/15/15 and 08/17/15. The DON stated STNA #1 was working in the facility at this time, and STNA #2 was on medical leave. Interview with STNA #1 on 09/03/15 at 10:20 A.M. revealed she was assisting Hospice STNA #100 with showering the resident. She was assigned to the care of Resident #2 that day, and Hospice STNA #100 was also assigned to Resident #2 by the Hospice agency. The resident began to try to bite STNA #1, at which time Hospice STNA #100 put a very soapy washcloth in the resident's face and mouth. The resident was calling Hospice STNA #100 names. Hospice STNA #100 then called Resident #2 a [***] and told her you smell like a whore. At the end of the shower, he sprayed the resident with perfume and said there, [***] , now you smell like a whore. Regarding the incident with Resident #1, STNA #1 stated she and STNA #2 were giving Resident #1 a shower, and he had refused to be shaved. During this time, Hospice STNA #100 walked into the shower room and put his bags down, and said what, you can't shave him? I'll do it. STNA #1 indicated they did not ask Hospice STNA #100 to help them, and Resident #1 was not receiving Hospice services. Hospice STNA #100 came in and said to STNA #1 and STNA #2 you and you, hold his arms. He got behind the resident and put his arm around the residents neck and held the resident up against him, as in a head lock. STNA #1 said Hospice STNA #100 told the resident to hold still or I'll cut you up, or some words close to that. STNA #1 said Hospice STNA #100 shaved him roughly, and the resident was bleeding in several different spots on his face. She said after the incident with Resident #1, she decided to report the incidents involving Hospice STNA #100 the next time she saw the DON. She thinks it was the day after or two days after the incident with Resident #1. She stated she didn't report the incidents immediately, because she was not sure if it was abuse. She also stated others in the facility seemed to think highly of Hospice STNA #100. During the interview, STNA #1 also stated Hospice STNA #100 had made her feel uncomfortable in the past because he talked loudly and sternly to residents while getting in their faces. She didn't give an example identifying any specific resident, but gave an example of Hospice STNA #100 leaning in a resident's face and yelling Don't do that! Resident #1 was observed on 09/03/15 at 11:00 A.M. He was in a common area on the first floor with three other residents and an unidentified STNA. He did not respond appropriately when spoken to. He kept saying Amen. He was observed to have a few days growth of beard. No cuts or bruises were observed. Observation on 09/03/15 at 4:25 P.M. revealed Resident #2 was lying in bed awake. When greeted the resident did not respond appropriately and became verbally abusive. Review of the facility policy, titled Resident Abuse, undated, indicated The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, and misappropriation. Our facility will not condone resident abuse by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies serving the resident, family members, legal guardians, sponsors, friends, or other individuals. All personnel must promptly report any incident or suspected incident of resident abuse, including injuries of unknown source and misappropriation of resident property The policy also included, .The person(s) observing an incident of resident abuse or suspecting resident abuse must immediately report such an incident to the charge nurse. The charge nurse must immediately notify the director of nursing and/or administrator This deficiency substantiates Complaint Number OH 531.

Based on medical record review, observation, review of a facility Self-Reported Incident (SRI), and staff interview, the facility failed to ensure a resident was protected from physical and verbal abuse by an outside Hospice agency staff member. This resulted in Immediate Jeopardy for two residents (Residents #1 and #2) who were physically and verbally abused by a Hospice agency staff member. This affected two of three residents reviewed for abuse. The facility census was 73. On 09/03/15 at 1:15 P.M., the Director of Nursing (DON), Assistant Director of Nursing (ADON) and Quality Assurance Nurse were notified Immediate Jeopardy began on 08/13/15 when Hospice State tested Nursing Assistant (STNA) #100 was witnessed by facility staff, STNA #1, putting a soapy washcloth onto Resident #2's face and mouth and verbally abuse her by calling her a [***] and a whore when she became agitated and resisted care during a shower. Hospice STNA #100 was then witnessed by facility staff STNA #1 and STNA #2 to physically and verbally abuse Resident #1 by saying if you don't quit fighting, I will cut you up during a shower on 08/16/15 when he tightly held the resident's head and roughly shaved him after the resident had refused to be shaved. As a result, Resident #1 sustained nicks and was bleeding after the incident. Hospice STNA #100 provided services in the facility on 08/13/15, 08/15/15, 08/16/15 and 08/17/15. On 08/19/15, facility staff STNA #1 and STNA #2 reported the incidents of abuse to the DON, which had occurred on 08/13/15 and 08/16/15. The Immediate Jeopardy was removed on 08/19/15 when the facility implemented the following corrective actions: · On 08/19/15, the facility DON notified the Hospice agency of the allegations of abuse, and that the Hospice STNA (#100) was no longer to provide care in the facility. · On 08/19/15, facility STNA #1 and STNA #2 were counseled on the abuse policy and procedure, and specifically that any mistreatment/abuse is to be reported immediately. · On 08/19/15, nine other residents, #5, #57, #34, #23, #53, #49, #28, #63 and #48, identified as under the care of Hospice STNA #100 between 08/13/15 and 08/19/15, were assessed for abuse. · On 09/03/15 and 09/04/15, all staff in the building on day shift and all nursing staff on night shift were in-serviced regarding abuse reporting and what constitutes abuse. All facility STNA's were scheduled to be in-serviced on 09/11/15. · The DON, Administrator, and ADON will conduct weekly monitoring of random staff and residents for four weeks, and then two staff members will be randomly questioned every month for monitoring through December 2015. This will continue to be monitored on an on-going basis through the Quality Assurance Committee. Although the Immediate Jeopardy was removed on 08/19/15, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility started conducting staff in-services on abuse and abuse reporting and was in the process of monitoring and verifying the corrective action taken was effective. Findings include: Review of the medical record for Resident #2 revealed she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. She was documented as receiving Hospice services. The comprehensive assessment, dated 07/28/15, assessed the resident as being moderately cognitively impaired and had physically and verbally aggressive behaviors which significantly interfered with resident ' s care. She was either dependent on staff or required extensive assistance for care. Review of the medical record for Resident #1 revealed he was admitted on [DATE]. Resident #1 had [DIAGNOSES REDACTED]. He was not receiving Hospice services. The comprehensive assessment, dated 08/19/15, assessed the resident as being severely cognitively impaired, rejected care and was totally dependent on staff for bathing, and required extensive assist for personal hygiene and toileting. Review of a facility SRI dated 08/19/15 documented facility STNA #1 reported a concern with Hospice STNA #100. STNA #1 reported when she and STNA #2 were showering Resident #1 last week, Hospice STNA #100 came into the shower room. Hospice STNA #100 had overheard Resident #1 was refusing to be shaved. Hospice STNA #100 said he would help them. STNA #1 stated she was uncomfortable with the way he shaved Resident #1, stating he wrapped his arm around the resident's neck and pulled his head back and roughly shaved him. STNA #1 also stated Hospice STNA #100 said to Resident #1, If you don't quit fighting, I'll cut you up. STNA #1 also reported that last week she was in the bathroom with Hospice STNA #100 showering Resident #2. Resident #2 attempted to bite STNA #1, and Hospice STNA #100 took a washcloth full of soapy water and shoved it in her face, eyes, and mouth and stated to the resident every time you try to bite her, this is what I am going to do to you. STNA #1 stated the resident continued to curse at Hospice STNA #100 and he began to call Resident #2 derogatory names such as whore and [***] . After the shower was completed, Hospice STNA #100 sprayed Resident #2 with body spray and stated There, [***] , now you smell like a whore. The facility's SRI, dated 08/19/15, documented STNA #2 was interviewed by the DON and Administrator by phone regarding the incident with Resident #1. STNA #2 stated Hospice STNA #100 restrained Resident #1 by holding his head to shave him. She stated she was uncomfortable with the incident. The DON and Administrator interviewed Resident #2 on 08/19/15. When asked if she had any issues with any of the Hospice staff, Resident #2 stated yes and identified Hospice STNA #100. Resident #2 stated he put a soapy cloth in my face, in my mouth and he pulled my hair. I don't want him near me. Resident #2 was assessed and no injuries were found. Resident #1 was assessed immediately following the report on 08/19/15, and no injuries were found. Documentation indicated STNA #1 had reported that she noted several bleeding spots on Resident #1's face following the incident the previous week. The resident was cognitively impaired and unable to provide any information regarding the incident. The facility's conclusion was there is reasonable suspicion that abuse may have taken place, but we are unable to say with certainty that any abuse has occurred. The allegation was reported to (Hospice STNA #100's) employer for investigation, and the local authorities were also notified. During an interview with the DON and Quality Assurance Nurse #3 on 09/03/15 at 9:50 A.M., the above SRI was reviewed. They stated it was determined the incident with Resident #2 occurred on 08/13/15, and the incident with Resident #1 occurred on 08/16/15. They confirmed STNA #1 reported the incidents on 08/19/15, six days after the first incident occurred and three days after the second incident. The DON stated Hospice STNA #100 was also in the facility providing Hospice services on 08/15/15 and 08/17/15. The DON stated STNA #1 was working in the facility at this time, and STNA #2 was on medical leave. Interview with STNA #1 on 09/03/15 at 10:20 A.M. revealed she was assisting Hospice STNA #100 with showering the resident. She was assigned to the care of Resident #2 that day, and Hospice STNA #100 was also assigned to Resident #2 by the Hospice agency. The resident began to try to bite STNA #1, at which time Hospice STNA #100 put a very soapy washcloth in the resident's face and mouth. The resident was calling Hospice STNA #100 names. Hospice STNA #100 then called Resident #2 a [***] and told her you smell like a whore. At the end of the shower, he sprayed the resident with perfume and said there, [***] , now you smell like a whore. Regarding the incident with Resident #1, STNA #1 stated she and STNA #2 were giving Resident #1 a shower, and he had refused to be shaved. During this time, Hospice STNA #100 walked into the shower room and put his bags down, and said what, you can't shave him? I'll do it. STNA #1 indicated they did not ask Hospice STNA #100 to help them, and Resident #1 was not receiving Hospice services. Hospice STNA #100 came in and said to STNA #1 and STNA #2 you and you, hold his arms. He got behind the resident and put his arm around the residents neck and held the resident up against him, as in a head lock. STNA #1 said Hospice STNA #100 told the resident to hold still or I'll cut you up, or some words close to that. STNA #1 said Hospice STNA #100 shaved him roughly, and the resident was bleeding in several different spots on his face. She said after the incident with Resident #1, she decided to report the incidents involving Hospice STNA #100 the next time she saw the DON. She thinks it was the day after or two days after the incident with Resident #1. She stated she didn't report the incidents immediately, because she was not sure if it was abuse. She also stated others in the facility seemed to think highly of Hospice STNA #100. During the interview, STNA #1 also stated Hospice STNA #100 had made her feel uncomfortable in the past because he talked loudly and sternly to residents while getting in their faces. She didn't give an example identifying any specific resident, but gave an example of Hospice STNA #100 leaning in a resident's face and yelling Don't do that! Resident #1 was observed on 09/03/15 at 11:00 A.M. He was in a common area on the first floor with three other residents and an unidentified STNA. He did not respond appropriately when spoken to. He kept saying Amen. He was observed to have a few days growth of beard. No cuts or bruises were observed. Observation on 09/03/15 at 4:25 P.M. revealed Resident #2 was lying in bed awake. When greeted, the resident did not respond appropriately and became verbally abusive. Review of the facility policy, titled Resident Abuse, undated, indicated The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, and misappropriation. Our facility will not condone resident abuse by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies serving the resident, family members, legal guardians, sponsors, friends, or other individuals. All personnel must promptly report any incident or suspected incident of resident abuse, including injuries of unknown source and misappropriation of resident property The policy also included, .The person(s) observing an incident of resident abuse or suspecting resident abuse must immediately report such an incident to the charge nurse. The charge nurse must immediately notify the director of nursing and/or administrator This deficiency substantiates Complaint Number OH 531.