Every finding on record at Brentwood Health Care Center

Based on observation, interview, record review, and facility policy review, the facility failed to ensure personal protective equipment (PPE) was worn for Enhanced Barrier Precaution (EBP) during medication administration via percutaneous endoscopic gastrostomy (PEG) tube for Resident #83. This affected one (Resident #83) five residents reviewed for medication administration had the potential to affect all residents on Registered Nurse (RN) #509's assignment, who had EBP's to include (Residents #3, #12, #35, and #36). The facility failed to ensure infection control was maintained during perineal care for Resident #94. This affected one resident (Resident #94) of three residents observed for perineal care and had the potential to affect all residents on Certified Nursing Assistant (CNA) #377's assignment to include (Residents #1, #13, #19, #38, #42, #43, #60, #62 and #68) and CNA #508's assignment to include (Residents #5, #29, #39, 44, #45, #73, #80, and #89). The facility census was 80.Findings include: 1. Review of the medical record for Resident #83 revealed an admission date of 07/31/24. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, dysphagia, and encounter for attention to gastrostomy. Review of the care plan dated 05/10/25 revealed Resident #83 was at risk for dehydration related to use of tube feeding. Interventions included administer medications per physician orders, EBP due to tube feed, and head of bed at 30 degrees at all times. Review of the physician orders dated July 2025 revealed an order for Baclofen 5 milligram (mg) (muscle relaxer) via PEG-tube three times a day (TID) for muscle spasms and EBP due to tube feed every shift. Observation on 07/22/25 at 1:00 P.M. revealed RN #509 entered Resident #83's room, who was on EBP's for tube feeding, to administer medications via the PEG-tube site. RN #509 performed hand hygiene and donned gloves. RN #509 opened Resident #83's PEG-tube and flushed with 15 milliliter (ml) of water, followed by medication of Baclofen 5 mg mixed with 15 ml of water, followed by a 15 ml water flush. RN #509 closed the PEG-tube site, removed his gloves and performed hand hygiene before exiting Resident #509's room. RN #509 did not don a gown as required for EBP. Interview on 07/22/25 at 1:16 P.M. with RN #509 confirmed he did not wear the correct PPE to administer medications via PEG-tube. RN #509 reported he wasn't aware he had to wear PPE for tube feeding medication administration. RN #509 reported he did not know where the bin with PPE was located in Resident #83's room. Interview on 07/22/25 at 1:20 P.M. with the Director of Nursing (DON) confirmed EBP was to be in place and PPE worn for medications via PEG-tube feeding to include a gown. Observation on 07/22/25 at 1:20 P.M. with the DON in Resident #83's room revealed a plastic bin with PPE located in the corner of the room behind a Broda chair, with PRAFO boots (a foot and ankle orthotic) on top of it, and an oxygen tank in front of the bin drawers. Review of the facility policy, Enhanced Barrier Precautions, revised 03/29/24, revealed implement EBP's for the prevention of transmission of multidrug-resistant organisms (MRDO). The policy further stated make gowns and gloves available immediately near or outside of the resident's room. High-contact resident care activities include feeding tubes. 2. Review of the medical record for Resident #94 revealed an admission date of 05/12/25. Diagnoses included Alzheimer's Disease, dementia, and congestive heart failure. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #94 had severely impaired cognition and was dependent on staff for all needs. Observation on 07/23/25 at 8:17 A.M. of incontinence care for Resident #94 revealed CNAs #337 and #508 gathered supplies, explained the procedure, provided privacy, and donned gloves without performing hand hygiene first. CNA #508 placed two clean washcloths in the bottom of the sink and began to run water over them. CNA #508 then picked up one of the washcloths and added soap to it and then picked up the other washcloth and placed it on the counter and then placed the soap washcloth on top of it. CNA #508 then took a basin and placed water in it and then placed the two washcloths from the counter in the basin. CNA #508 began to perform perineal care. During perineal care when cleaning the buttocks, the washcloth had stool on it and CNA #508 got stool on her right gloved hand. CNA #508 continued to provide perineal care without removing the stool soiled glove, performing hand hygiene and donning new gloves. CNA #508 then grabbed a tube of barrier cream with the soiled glove and applied barrier cream to Interview on 07/23/25 at 8:39 A.M. with CNA #337 confirmed she did not perform hand hygiene before and after removing gloves. CNA #337 reported she did not know she had to wash hands before applying gloves and taking off gloves. Interview on 07/23/25 at 8:40 A.M. with CNA #508 confirmed she didn't wash hands before glove usage, placed two washcloths in bottom of sink, the placed the same two washcloths on the side of the sink, then got basin and placed the same two washcloths into the basin with water. CAN #508 didn't change her gloves when she got stool on the right one, applied barrier cream with the glove with stool on it, and didn't perform hygiene when she removed her gloves. Interview on 07/23/25 at 8:45 A.M. with the DON confirmed hand hygiene was to be performed before and after glove usage, for perineal care you were to use the basin and not place washcloths in bottom of sink, remove gloves when soiled with stool, and remove gloves when soiled with stool before applying barrier cream. Review of the facility policy, Perineal Care, revised 02/15/24, revealed it is to promote cleanliness and comfort and prevent infection to the extent possible and to prevent and assess for skin breakdown. The policy further stated, perform hand hygiene and put on gloves and remove gloves and perform hand hygiene.

Based on record review and staff interview, the facility failed to accurately code the preadmission screen and resident review (PASRR) status on the Minimum Data Set (MDS) 3.0 assessment for Residents #43 and #82. This affected two (Residents #43 and #82) of three residents identified by the facility as having a level two mental illness and/or an intellectual disability. The facility census was 80.Findings include:1. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, schizophrenia and depression. Review of the level two PASRR assessment from the Ohio Department of Mental Health and Addiction Services (ODMHAS) (the state contracted PASRR agency for level two serious mental illness PASRR evaluations), dated 03/06/24, revealed Resident #43 had a level two mental illness.Review of section A of the most recent comprehensive MDS 3.0 assessment dated [DATE] revealed the facility answered no to the question Is the resident currently considered by the state level II pre admission screen and resident review (PASRR) process to have serious mental illness and/or intellectual disability (mental retardation in federal regulation) or a related condition?.2. Review of the medical record revealed Resident #82 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy, epilepsy and anxiety disorder. Review of the level two PASRR assessment from the Ohio Department of Developmental Disabilities ([NAME]) (the state contracted PASRR agency for level two developmental disability PASRR assessments), dated 05/17/23, revealed Resident #82 had a level two developmental disability.Review of section A of the most recent comprehensive MDS 3.0 assessment dated [DATE] revealed the facility answered no to the question of Is the resident currently considered by the state level II pre admission screen and resident review (PASRR) process to have serious mental illness and/or intellectual disability (mental retardation in federal regulation) or a related condition?.Social Worker #461 verified the PASRR coding inaccuracies for Residents #43 and #82 in an interview on 07/23/25 at 3:00 P.M.

Based on interview, review of a self-reported incident (SRI), record review and review of the facility policies, the facility failed to ensure residents were free from unauthorized video recordings by staff. This affected one resident (#4) of three residents reviewed for abuse. The facility census was 88. Findings include: Review of Resident #4's medical record revealed an admitted [DATE] and diagnoses including Alzheimer's disease, type II diabetes, dementia with other behavioral disturbance, depression, anxiety, and adult failure to thrive. Review of Resident #4's quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 had short and long term memory problems and severe cognitive impairment with continuous inattention and disorganized thinking. Resident #4 rejected care one to three days in the seven-day look-back period. Resident #4 required substantial to maximum assistance with toileting, set up to dress her upper body, supervision to dress her lower body and supervision for sitting to standing and to complete toileting transfers. Resident #4 was frequently incontinent of bowel and bladder. Review of a facility self-reported incident dated 10/23/24 revealed on the morning of 10/23/24, Housekeeper #344 reported to the Director of Nursing (DON) that a friend of hers (Community Person #350) called her to let her know he saw a live feed on a web-based application called Tagged where a facility staff member was at work in the resident ' s room with the resident in the background of the video. He reported he was not able to record the video but did take several screenshots (still photos) during the live feed. The DON reported this to the Administrator and an investigation was immediately started. Certified Nursing Assistant (CNA) #349 and Resident #4 were identified in the video. CNA #349 was suspended immediately pending outcome of the investigation. Interviews were completed with staff; CNA #349 denied the allegation and reported Licensed Practical Nurse (LPN) #244 was in the room while she got Resident #4 dressed as she tended to be combative. LPN #244 denied the allegation and denied seeing CNA #349's phone or a camera while in the room. Interview with Community Person (CP) #350 confirmed he saw the live video and reported the recording device was across the room from where Resident #4 was being provided care. He stated it appeared as though the employee was changing the residents' brief but at no time was Resident #4 observed to be naked or with private areas exposed to the viewer and the staff member did not make fun of the resident or disparage her in any way. Residents on the 300 hall (where Resident #4 resided) were interviewed by Social Service Designee (SSD) #325 with no additional concerns reported; Resident #4 was not able to provide coherent information when interviewed due to her advanced dementia. The facility determined the allegation to be unsubstantiated for abuse as Resident #4 was in the background of the video but the content of the video was not demeaning or humiliating to the resident. The facility disciplined CNA #349 for violation of resident privacy policies as a result of their investigation. Continued review of the facility investigation revealed a photo timed 10/23/24 at 6:59 A.M. with Resident #4 in a blouse and pants putting socks on. A second photo with the same time-stamp revealed a blurry photo of CNA #349 with Resident #4's blurry face noted in the background and the rest of Resident #4's body was not visible as CNA #349 was in the foreground. Review of a photo timed 10/23/24 at 7:02 A.M. with Resident #4 laying across her bed with her heels resting on the edge of the bed. Resident #4 had on blue socks and her top was covered but her legs including her thighs were bare. Resident #4's buttocks or private areas were not observable from the photo. Review of a photo timed 10/23/24 at 7:16 A.M. revealed CNA #349 in the facility hallway, with tubing in her hands and the room [ROOM NUMBER] is visible in the background. Interview on 11/12/24 at 10:49 A.M. with the Administrator regarding the SRI on 10/23/24 revealed Housekeeper #344 said her friend, CP #350 said an employee [CNA #349] was live in the facility in a resident's room on social media between 6:30 A.M. and 7:00 A.M. The social media application, called Tagged, was used for dating and involved users taking videos of themselves. The Administrator indicated he interviewed CP #350 by phone for the facility investigation and learned CNA #349's phone was propped up in the resident's room as she completed resident care and he did not observe Resident #4 naked. The Administrator stated as far as he was aware, no one at the facility had seen the video except CP #350. Interview on 11/12/24 at 11:37 A.M. with CNA #349 revealed she worked a 16-hour shift from 10/22/24 into 10/23/24. CNA #349 stated Resident #4 was combative so did not provide care at that time and continued to care for her other residents. CNA #349 stated LPN #244 told her on her way out of the facility she needed to care for Resident #4 and they could do it together. CNA #349 stated she was on her phone watching videos on Tagged (dating application) and was unaware a user had requested to livestream. CNA #349 could not deny the livestream request and thus her phone started to record while she was in Resident #4's room. CNA #349 denied making disparaging comments to Resident #4 and indicated she was very polite. CNA #349 verified she provided personal care to Resident #4 but her breasts and perineal areas were not exposed at any time. CNA #349 explained on Tagged, a video would be live and once it was over it would not be saved anywhere as it was not posted to an account but was live content. CNA #349 was unaware if any one at the facility had seen the video and called it a lesson learned. Interview was attempted with CP #350 on 11/12/24 at 11:50 A.M. but was not successful. Interview on 11/12/24 at 11:54 A.M. with Housekeeper #344 revealed her children's father, CP #350, was on Tagged and had sent photos of Individual #4 to the DON from the livestream as he saw she was being changed, recognized the facility and was 'bothered by the situation.' Housekeeper #344 indicated she had seen the photos but not the video and indicated Resident #4's private areas were not visible in the photos. Interview was attempted with LPN #244 on 11/12/24 at 12:08 P.M. but was not successful. Interview on 11/12/24 at 12:10 P.M. with the DON revealed she helped with the SRI investigation on 10/23/23 and indicated the photos in the file were what they received from CP #350. The DON stated the only staff members aside from herself and the Administrator that had viewed the photos was Housekeeper #344 and she was unaware of anyone at the facility that had viewed the video as of the time of the interview. The DON also verified Resident #4 was not interviewable due to cognitive status. Interview was attempted with Resident #4's responsible party on 11/12/24 at 1:52 P.M. but was not successful. Follow-up interview on 11/12/24 at 2:25 P.M. with the DON verified the identified privacy concerns with Resident #4 as a result of CNA #349's phone recording the resident without her consent or knowledge. The DON confirmed CNA #349 was terminated as a result of the facility's investigation due to not meeting privacy and facility policy expectations as they could not determine abuse had occurred. Review of the policy, Personal Cell Phones, reviewed/revised 04/01/24 revealed the facility would provide quality care to its residents without interruption. The facility prohibits employees from using personal cell phones for any reason on the nursing units or in working areas of the facility. This includes calls, texts, social media or any other use of cell phones. Under no circumstances should employees take pictures, videos or any other personal representations of any resident, family member, visitor, or staff member for the purpose of personal use, social media or any other reason. Review of the policy, Resident Rights, dated 2024 revealed the resident had the right to personal privacy including medical treatment and personal care. This deficiency represents non-compliance investigated under Master Complaint Number OH00159552 and Complaint Number OH00159466.

Based on record review and interview, the facility failed to ensure Resident #6 and Resident #50 were free from resident to resident sexual abuse. This affected two residents (#6 and #50) of three residents reviewed for abuse. Actual physical and/or psychosocial harm, applying the reasonable person concept, occurred on 06/05/24 to Resident #50, a resident with impaired cognition, when Resident #101 who had a history of sexually inappropriate behaviors without care planned interventions in place, placed his hand down Resident #50's incontinence brief (an incident of sexual abuse). Following the incident, Resident #6 was visibly crying and shaking with a noted change by family on 06/06/24. Findings include: 1. Review of Resident #50's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's disease with dyskinesia, unspecified dementia and anxiety disorder. Review of Resident #50's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of a police report for Resident #50 dated 06/06/24 authored by Police #359 revealed they were called to the facility by Resident #50's family regarding an incident that occurred with Resident #101. Resident #50's family member was told by staff members a male (resident) tried to inappropriately touch her mother (Resident #50) under her gown during the evening of 06/05/24. Review of an undated Police Department Witness Statement form authored by Licensed Practical Nurse (LPN) #223 indicated she was informed Resident #101 attempted to reach inside Resident #50's brief. She did not witness the activity. A full assessment was completed of Resident #50 for physical trauma or injury. Review of an undated Police Department Witness Statement form authored by State tested Nursing Assistant (STNA) #284 indicated on 06/05/24 she observed Resident #101 attempting to touch Resident #50 inappropriately. The residents were separated. Review of an undated Police Department Witness Statement form authored by STNA #340 indicated on 06/05/24, the employee overheard a commotion and observed another STNA removing Resident #101 away from Resident #50 because his hands were on the wheelchair and he would not let go. Resident #101 was taken back to his room. Resident #50's incontinence brief was intact. Review of Resident #50's medical record did not reveal entries in the progress notes concerning physical or sexual abuse by Resident #101 on 06/05/24 per the police report. There was no evidence of the resident's assessment when the incident occurred or of any follow-up with the resident after the incident. Interview on 07/01/24 at 7:50 A.M. with Resident #50's daughter indicated she called the local police department related to this incident because she felt the resident had increased agitation (as a result of the incident) and related to possible abuse concerns. An attempt to interview Resident #50 on 07/01/24 at 10:01 A.M. was unsuccessful as the resident only knew her name and was not interviewable. Interview on 07/01/24 at 2:58 P.M. with STNA #227 revealed she was told by STNA #340 that another resident had reached over and fondled Resident #50 in the lady parts down below. She stated staff intervened when Resident #50 screamed and the residents were separated. Interview on 07/01/24 at 4:37 P.M. with STNA #340 revealed she did not witness this sexual abuse and denied telling another STNA about the abuse. The STNA further stated, the resident (#50) did not have pants on at the time of the incident. STNA #340 indicated she was the staff member who got Resident #50 out of bed from a nap prior to dinner on 06/05/24 because the resident's husband came in to visit. STNA #340 confirmed she dressed the resident in a top and incontinence brief with no pants or bottoms and only placed a sheet over her legs. STNA #340 stated she placed Resident #50 back in bed following the incident with Resident #101 and the resident still had a top on and a incontinence brief with a sheet over her legs. Interview on 07/02/24 at 7:27 A.M. with STNA #284 revealed Resident #101 was sitting next to Resident #50 on 06/05/24 at the nursing station. Resident #101 had his hand (unknown which hand) in Resident #50's brief. Resident #50 was observed to be crying and Resident #101 was removed from the area. Another STNA (unknown who the employee was) was observed hugging Resident #50 and asked her if she was ok. Resident #50 reported she was not ok. Interview on 07/02/24 at 10:49 A.M. with LPN #223 revealed she did not witness the incident between Resident #50 and #101. She confirmed she wrote a statement, and she said an STNA told her about the sexual abuse incident. Interview on 07/02/24 at 11:26 A.M. with the Director of Nursing (DON) confirmed she was informed of this incident between Resident #50 and #101 on 06/06/24 by staff members. The DON confirmed she was aware the local police department came into the facility on [DATE] to investigate a concern with Resident #50 but stated she did not feel it was abuse so she did not conduct a thorough investigation and did not report the incident to State agency. The DON confirmed the facility could not provide evidence of any type of assessment of Resident #50 after the incident on 06/05/24. Interview on 07/02/24 at 12:20 P.M. with LPN #290 revealed she worked on a different hall on 06/05/24 and was coming up to the nurse's station and remembered Resident #50 was upset, crying, and shaking after the incident with Resident #101. Review of Resident #101's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged on [DATE] (to an assisted living) with diagnoses including hemiplegia, malignant neoplasm of the bladder and anxiety disorder. Review of Resident #101's comprehensive care plan dated 01/19/24 revealed the care plan did not include interventions to address sexual abuse or inappropriate sexual behavior. Interview on 07/02/24 at 3:09 P.M. with Licensed Social Worker (LSW) #287, who does care plans for resident behaviors, confirmed Resident #101's did not have a comprehensive and individualized plan of care in place to prevent sexual abuse/address sexually inappropriate behavior(s). 2. Review of Resident #6's medical record revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses including unspecified dementia, anxiety disorder and anemia. Review of Resident #6's quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem. Interview on 07/02/24 at 11:26 A.M. with the DON revealed she had been informed of an incident involving Resident #6 and she stated she felt what was reported to her was not sexual abuse. She stated a nurse had told her Resident #101 had attempted to grab Resident #6 by his pants. She denied reporting this incident of sexual abuse to the State agency and denied doing a thorough investigation because she stated she did not feel it was abuse. An attempt to interview Resident #6 on 07/08/24 at 12:50 P.M. was unsuccessful as the resident was cognitively impaired and was only able to state his name. Review of Resident #6's medical record revealed no evidence the incident between Resident #101 and Resident #6 was documented in his record. The record did not include an assessment after the incident. Review of Resident #101's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged on [DATE] (to an assisted living) with diagnoses including hemiplegia, malignant neoplasm of the bladder and anxiety disorder. Review of Resident #101's comprehensive care plan dated 01/19/24 revealed the care plan did not include interventions to address sexual abuse or inappropriate sexual behavior. Review of Resident #101's progress note dated 04/25/24 at 6:39 A.M. authored by Registered Nurse (RN) #299 revealed the resident was up at the nursing station sitting next to Resident #6 and attempting to grab at Resident #6's penis. The resident was pulling at his pants and trying to put his hand down the resident's pants. Resident #6 yelled and stated, you are hurting me. The resident was moved into the television room and kept coming up to the other residents to touch them inappropriately. The note indicated nursing would continue to monitor. Review of Resident #101's progress note dated 04/28/24 at 11:08 A.M. authored by LPN #290 indicated the resident was wheeling himself up to female and male residents and placing his hand under their clothes and attempting to touch them. The staff removed him away from the residents and observed him by taking him to his room. The physician was notified. The note did not identify which residents were involved. Interview on 07/02/24 at 12:20 P.M. with LPN #290 revealed on 04/28/24, Resident #101 was wheeling himself up and placing his hands under both male and female resident's clothing. She confirmed Resident #101 had behaviors of touching other residents' underneath of their clothes and stated she had witnessed him placing his hands under a female resident's clothing but she could not recall the resident's name or date of the incident. She stated of course it was sexual abuse however, she could not state who she had reported the incident too. Interview on 07/02/24 at 3:09 P.M. with Licensed Social Worker (LSW) #287, who does care plans for resident behaviors, confirmed Resident #101's did not have a comprehensive and individualized plan of care in place to prevent sexual abuse/address sexually inappropriate behavior(s). Review of the facility policy, Abuse, Neglect, and Exploitation, revised 12/04/23 revealed the facility defined sexual abuse as non-consensual sexual contact of any type with a resident. In addition, the policy revealed the facility would provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. This deficiency represents non-compliance investigated under Master Complaint Number OH00154836 and Complaint Number OH00154684.

Based on record review and interview, the facility failed to implement there abuse prohibition policy after an allegation of abuse was made to protect the residents, thoroughly investigation the allegation, and report the allegations and findings to the State agency. This finding affected two residents (Residents #6 and Resident #50) of three residents reviewed for abuse. Findings include: 1. Review of Resident #50's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's disease with dyskinesia, unspecified dementia and anxiety disorder. Review of Resident #50's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of a police report for Resident #50 dated 06/06/24 authored by Police #359 revealed they were called to the facility by Resident #50's family regarding an incident that occurred with Resident #101. Resident #50's family member was told by staff members a male (resident) tried to inappropriately touch her mother (Resident #50) under her gown during the evening of 06/05/24. Review of an undated Police Department Witness Statement form authored by Licensed Practical Nurse (LPN) #223 indicated she was informed Resident #101 attempted to reach inside Resident #50's brief. She did not witness the activity. A full assessment was completed of Resident #50 for physical trauma or injury. Review of an undated Police Department Witness Statement form authored by State tested Nursing Assistant (STNA) #284 indicated on 06/05/24 she observed Resident #101 attempting to touch Resident #50 inappropriately. The residents were separated. Review of an undated Police Department Witness Statement form authored by STNA #340 indicated on 06/05/24, the employee overheard a commotion and observed another STNA removing Resident #101 away from Resident #50 because his hands were on the wheelchair and he would not let go. Resident #101 was taken back to his room. Resident #50's incontinence brief was intact. Review of Resident #50's medical record did not reveal entries in the progress notes concerning physical or sexual abuse by Resident #101 on 06/05/24 per the police report. There was no evidence of the resident's assessment when the incident occurred or of any follow-up with the resident after the incident. Interview on 07/01/24 at 7:50 A.M. with Resident #50's daughter indicated she called the local police department related to this incident because she felt the resident had increased agitation (as a result of the incident) and related to possible abuse concerns. An attempt to interview Resident #50 on 07/01/24 at 10:01 A.M. was unsuccessful as the resident only knew her name and was not interviewable. Interview on 07/01/24 at 2:58 P.M. with STNA #227 revealed she was told by STNA #340 that another resident had reached over and fondled Resident #50 in the lady parts down below. She stated staff intervened when Resident #50 screamed and the residents were separated. Interview on 07/01/24 at 4:37 P.M. with STNA #340 revealed she did not witness this sexual abuse and denied telling another STNA about the abuse. The STNA further stated, the resident (#50) did not have pants on at the time of the incident. STNA #340 indicated she was the staff member who got Resident #50 out of bed from a nap prior to dinner on 06/05/24 because the resident's husband came in to visit. STNA #340 confirmed she dressed the resident in a top and incontinence brief with no pants or bottoms and only placed a sheet over her legs. STNA #340 stated she placed Resident #50 back in bed following the incident with Resident #101 and the resident still had a top on and a incontinence brief with a sheet over her legs. Interview on 07/02/24 at 7:27 A.M. with STNA #284 revealed Resident #101 was sitting next to Resident #50 on 06/05/24 at the nursing station. Resident #101 had his hand (unknown which hand) in Resident #50's brief. Resident #50 was observed to be crying and Resident #101 was removed from the area. Another STNA (unknown who the employee was) was observed hugging Resident #50 and asked her if she was ok. Resident #50 reported she was not ok. Interview on 07/02/24 at 10:49 A.M. with LPN #223 revealed she did not witness the incident between Resident #50 and #101. She confirmed she wrote a statement, and she said an STNA told her about the sexual abuse incident. Interview on 07/02/24 at 11:26 A.M. with the Director of Nursing (DON) confirmed she was informed of this incident between Resident #50 and #101 on 06/06/24 by staff members. The DON confirmed she was aware the local police department came into the facility on [DATE] to investigate a concern with Resident #50 but stated she did not feel it was abuse so she did not conduct a thorough investigation and did not report the incident to State agency. The DON confirmed the facility could not provide evidence of any type of assessment of Resident #50 after the incident on 06/05/24. Interview on 07/02/24 at 12:20 P.M. with LPN #290 revealed she worked on a different hall on 06/05/24 and was coming up to the nurse's station and remembered Resident #50 was upset, crying, and shaking after the incident with Resident #101. Review of Resident #101's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged on [DATE] (to an assisted living) with diagnoses including hemiplegia, malignant neoplasm of the bladder and anxiety disorder. Review of Resident #101's comprehensive care plan dated 01/19/24 revealed the care plan did not include interventions to address sexual abuse or inappropriate sexual behavior. Interview on 07/02/24 at 3:09 P.M. with Licensed Social Worker (LSW) #287, who does care plans for resident behaviors, confirmed Resident #101's did not have a comprehensive and individualized plan of care in place to prevent sexual abuse/address sexually inappropriate behavior(s). 2. Review of Resident #6's medical record revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses including unspecified dementia, anxiety disorder and anemia. Review of Resident #6's quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem. Interview on 07/02/24 at 11:26 A.M. with the DON revealed she had been informed of an incident involving Resident #6 and she stated she felt what was reported to her was not sexual abuse. She stated a nurse had told her Resident #101 had attempted to grab Resident #6 by his pants. She denied reporting this incident of sexual abuse to the State agency and denied doing a thorough investigation because she stated she did not feel it was abuse. An attempt to interview Resident #6 on 07/08/24 at 12:50 P.M. was unsuccessful as the resident was cognitively impaired and was only able to state his name. Review of Resident #6's medical record revealed no evidence the incident between Resident #101 and Resident #6 was documented in his record. The record did not include an assessment after the incident. Review of Resident #101's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged on [DATE] (to an assisted living) with diagnoses including hemiplegia, malignant neoplasm of the bladder and anxiety disorder. Review of Resident #101's comprehensive care plan dated 01/19/24 revealed the care plan did not include interventions to address sexual abuse or inappropriate sexual behavior. Review of Resident #101's progress note dated 04/25/24 at 6:39 A.M. authored by Registered Nurse (RN) #299 revealed the resident was up at the nursing station sitting next to Resident #6 and attempting to grab at Resident #6's penis. The resident was pulling at his pants and trying to put his hand down the resident's pants. Resident #6 yelled and stated, you are hurting me. The resident was moved into the television room and kept coming up to the other residents to touch them inappropriately. The note indicated nursing would continue to monitor. Review of Resident #101's progress note dated 04/28/24 at 11:08 A.M. authored by LPN #290 indicated the resident was wheeling himself up to female and male residents and placing his hand under their clothes and attempting to touch them. The staff removed him away from the residents and observed him by taking him to his room. The physician was notified. The note did not identify which residents were involved. Interview on 07/02/24 at 12:20 P.M. with LPN #290 revealed on 04/28/24, Resident #101 was wheeling himself up and placing his hands under both male and female resident's clothing. She confirmed Resident #101 had behaviors of touching other residents' underneath of their clothes and stated she had witnessed him placing his hands under a female resident's clothing but she could not recall the resident's name or date of the incident. She stated of course it was sexual abuse however, she could not state who she had reported the incident too. Interview on 07/02/24 at 3:09 P.M. with Licensed Social Worker (LSW) #287, who does care plans for resident behaviors, confirmed Resident #101's did not have a comprehensive and individualized plan of care in place to prevent sexual abuse/address sexually inappropriate behavior(s). Review of the facility policy, Abuse, Neglect, and Exploitation, revised 12/04/23 revealed the facility defined sexual abuse as non-consensual sexual contact of any type with a resident. The policy revealed the facility would provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Investigation of Alleged, Neglect and Exploitation included an immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigation include: identifying staff responsible for the investigation; exercising caution in handing evidence that could be used in a criminal investigation, investigating different types of alleged violations, identifying and interviewing all persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; focusing the investigation on determining is abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause, and provide complete and thorough documentation of the investigation. Protection of Resident included the facility will make efforts to ensure all residents are protected from physical and psychosocial harm as well as additional abuse, during and after the investigation. Examples include but are not limited to: Responding immediately to protect the alleged victim and integrity of the investigation; examining the victim for any sign of injury, including a physician examination or psychosocial assessment if needed; increased supervision of the alleged victim and residents; room or staffing changes, if necessary, to protect the resident from the alleged perpetrator; protection from retaliation; providing emotional support and counseling to the resident during and after the investigation, as needed; revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. Reporting Response included the facility will have written procedures that include but are not limited to: reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes which are immediately, but not later than two hours after the allegation is made if that even that causes the allegation involve abuse or result in seriously body injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury; assuring that reporters are free fro retaliation or reprisal; promoting a culture of safety and open communication in the work environment prohibiting retaliation against any employee who reports suspicion of a crime; taking all necessary actions as a result if the investigation, which may include, but are not limited to the following: analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident occurred, and what changes are needed to prevent further occurrences; defining how care provision will be changed and/or improved to protect residents receiving services; training of staff on changes made and demonstration of staff competency after training is implemented; the expected date for implementation; and identification of staff responsible for monitoring the implementation of the plan. Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within five working days of the incident, as required by state agencies. This deficiency represents non-compliance investigated under Master Complaint Number OH00154836 and Complaint Number OH00154684.

Based on record review and interviews, the facility failed to report a change in condition to Resident #50's responsible party and physician, when the resident was sexually abused and was agitated and crying. This affected one resident (Resident #50) of three residents reviewed for notification of change in condition. Findings include: Review of Resident #50's open medical record revealed the resident was admitted on [DATE] with diagnoses including Parkinson's disease with dyskinesia, unspecified dementia and anxiety disorder. Review of Resident #50's Admission MDS 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #50's police report dated 06/06/24 authored by Police #359 indicated they were called to facility by Resident #50's family regarding an incident that occurred with Resident #50. Resident #50's family was told by staff members a male tried to inappropriately touch her mother under her gown during the evening of 06/05/24. Review of Resident #50's undated Police Department Witness Statement form authored by Licensed Practical Nurse (LPN) #223 indicated she was informed Resident #101 attempted to reach inside Resident #50's brief. She did not witness the activity. A full assessment was completed of Resident #50 for physical trauma or injury. Review of Resident #50's undated Police Department Witness Statement form authored by State tested Nursing Assistant (STNA) #284 indicated on 06/05/24 she observed Resident #101 attempting to touch Resident #50 inappropriately. The residents were separated. Review of Resident #50's undated Police Department Witness Statement form authored by STNA #340 indicated on 06/05/24, the employee overheard a commotion and observed another STNA removing Resident #101 away from Resident #50 because his hands was on the wheelchair and he would not let go. Resident #101 was taken back to his room. Resident #50's incontinence brief was intact. Review of Resident #50's medical record did not reveal entries in the progress notes concerning physical or sexual abuse by Resident #101 on 06/05/24 per the police report. There was no evidence of the resident's assessment when the incident occurred or following up with the resident after the incident. There was no evidence Resident #50's physician or representative was notified of the incident. Interview on 07/01/24 at 7:50 A.M. with Resident #50's daughter indicated she called the local police department because she felt the resident had increased agitation and possible abuse concerns. She reported not being notified of the incident with Resident #101 or that her mother was upset in any way. Interview on 07/01/24 at 9:53 A.M. with Director of Nursing (DON) confirmed the nursing staff should have contacted the physician and family regarding the change in condition of Resident #50. DON reported she became aware of an incident with Resident #50 on 06/06/24, the next day, when Resident #50's daughter was at the facility and upset that her mom didn't seem right. Resident #50's daughter called the police that day. DON reported Resident #50 had a change in condition on 06/05/24 when she was upset. DON reported the family should have been notified right away of the change in her condition. Interview on 07/01/24 at 10:15 A.M. with LPN #220 revealed Resident #50's daughter asked her on 06/06/24 if something happened to her mom, daughter had tears in her eyes, and LPN #220 did not know anything happened. LPN #220 went and got their supervisor and DON. Interview on 07/01/24 at 2:58 P.M. with STNA #227 indicated she was told by STNA #340 that another resident had reached over and fondled Resident #50 in the lady parts down below. She stated staff intervened when Resident #50 screamed and the residents were separated. Interview on 07/01/24 at 4:37 P.M. with STNA #340 reported she did not witness sexual abuse and denied telling another STNA about the abuse. The resident did not have pants on at the time of the incident. STNA #340 indicated she was the staff member who got the resident out of bed from a nap prior to dinner on 06/05/24 because the husband came in to visit. STNA #340 confirmed she dressed the resident in a top and incontinence brief with no pants or bottoms. She only placed sheet over her legs. STNA #340 stated she placed Resident #50 back in bed following the incident with Resident #101 and the resident still had a top on and a incontinence brief with a sheet over her legs. Interview on 07/02/24 at 7:27 A.M. with STNA #284 revealed Resident #101 was sitting next to Resident #50 on 06/05/24 at the nursing station. Resident #101 had his hand (unknown which hand) in Resident #50's brief. Resident #50 was observed to be crying and Resident #101 was removed from the area. Another STNA (unknown who the employee was) was observed hugging Resident #50) and asked her if she was ok. Resident #50 reported she was not ok. Interview on 07/02/24 at 10:49 A.M. with LPN #223 stated she did not witness the incident between Resident #50 and #101. She confirmed she wrote a statement, and she said a State tested Nursing Assistant (STNA) told her about the sexual abuse incident. Interview on 07/02/24 at 12:20 P.M. with LPN #290 revealed she worked on a different hall on 06/05/24 and was coming up to the nurse's station and remembers Resident #50 was upset, crying, and shaking after the incident with Resident #101. Review of facility policy, Notification of Changes, revised 12/15/23, revealed the purpose of this policy is to ensure the facility promptly inform the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. This deficiency represents non-compliance investigated under Complaint Number OH00154684.

Based on record review, interview, and policy review, the facility failed to timely report allegations of sexual abuse to the Administrator and State agency. This finding affected two residents (Residents #6 and Resident #50) of three residents reviewed for abuse. Findings include: 1. Review of Resident #50's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's disease with dyskinesia, unspecified dementia and anxiety disorder. Review of Resident #50's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of a police report for Resident #50 dated 06/06/24 authored by Police #359 revealed they were called to the facility by Resident #50's family regarding an incident that occurred with Resident #101. Resident #50's family member was told by staff members a male (resident) tried to inappropriately touch her mother (Resident #50) under her gown during the evening of 06/05/24. Review of an undated Police Department Witness Statement form authored by Licensed Practical Nurse (LPN) #223 indicated she was informed Resident #101 attempted to reach inside Resident #50's brief. She did not witness the activity. A full assessment was completed of Resident #50 for physical trauma or injury. Review of an undated Police Department Witness Statement form authored by State tested Nursing Assistant (STNA) #284 indicated on 06/05/24 she observed Resident #101 attempting to touch Resident #50 inappropriately. The residents were separated. Review of an undated Police Department Witness Statement form authored by STNA #340 indicated on 06/05/24, the employee overheard a commotion and observed another STNA removing Resident #101 away from Resident #50 because his hands were on the wheelchair and he would not let go. Resident #101 was taken back to his room. Resident #50's incontinence brief was intact. Review of Resident #50's medical record did not reveal entries in the progress notes concerning physical or sexual abuse by Resident #101 on 06/05/24 per the police report. There was no evidence of the resident's assessment when the incident occurred or of any follow-up with the resident after the incident. Interview on 07/01/24 at 7:50 A.M. with Resident #50's daughter indicated she called the local police department related to this incident because she felt the resident had increased agitation (as a result of the incident) and related to possible abuse concerns. An attempt to interview Resident #50 on 07/01/24 at 10:01 A.M. was unsuccessful as the resident only knew her name and was not interviewable. Interview on 07/01/24 at 2:58 P.M. with STNA #227 revealed she was told by STNA #340 that another resident had reached over and fondled Resident #50 in the lady parts down below. She stated staff intervened when Resident #50 screamed and the residents were separated. Interview on 07/01/24 at 4:37 P.M. with STNA #340 revealed she did not witness this sexual abuse and denied telling another STNA about the abuse. The STNA further stated, the resident (#50) did not have pants on at the time of the incident. STNA #340 indicated she was the staff member who got Resident #50 out of bed from a nap prior to dinner on 06/05/24 because the resident's husband came in to visit. STNA #340 confirmed she dressed the resident in a top and incontinence brief with no pants or bottoms and only placed a sheet over her legs. STNA #340 stated she placed Resident #50 back in bed following the incident with Resident #101 and the resident still had a top on and a incontinence brief with a sheet over her legs. Interview on 07/02/24 at 7:27 A.M. with STNA #284 revealed Resident #101 was sitting next to Resident #50 on 06/05/24 at the nursing station. Resident #101 had his hand (unknown which hand) in Resident #50's brief. Resident #50 was observed to be crying and Resident #101 was removed from the area. Another STNA (unknown who the employee was) was observed hugging Resident #50 and asked her if she was ok. Resident #50 reported she was not ok. Interview on 07/02/24 at 10:49 A.M. with LPN #223 revealed she did not witness the incident between Resident #50 and #101. She confirmed she wrote a statement, and she said an STNA told her about the sexual abuse incident. Interview on 07/02/24 at 11:26 A.M. with the Director of Nursing (DON) confirmed she was informed of this incident between Resident #50 and #101 on 06/06/24 by staff members. The DON confirmed she was aware the local police department came into the facility on [DATE] to investigate a concern with Resident #50 but stated she did not feel it was abuse so she did not conduct a thorough investigation and did not report the incident to State agency. The DON confirmed the facility could not provide evidence of any type of assessment of Resident #50 after the incident on 06/05/24. Interview on 07/02/24 at 12:20 P.M. with LPN #290 revealed she worked on a different hall on 06/05/24 and was coming up to the nurse's station and remembered Resident #50 was upset, crying, and shaking after the incident with Resident #101. Review of Resident #101's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged on [DATE] (to an assisted living) with diagnoses including hemiplegia, malignant neoplasm of the bladder and anxiety disorder. Review of Resident #101's comprehensive care plan dated 01/19/24 revealed the care plan did not include interventions to address sexual abuse or inappropriate sexual behavior. Interview on 07/02/24 at 3:09 P.M. with Licensed Social Worker (LSW) #287, who does care plans for resident behaviors, confirmed Resident #101's did not have a comprehensive and individualized plan of care in place to prevent sexual abuse/address sexually inappropriate behavior(s). 2. Review of Resident #6's medical record revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses including unspecified dementia, anxiety disorder and anemia. Review of Resident #6's quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem. Interview on 07/02/24 at 11:26 A.M. with the DON revealed she had been informed of an incident involving Resident #6 and she stated she felt what was reported to her was not sexual abuse. She stated a nurse had told her Resident #101 had attempted to grab Resident #6 by his pants. She denied reporting this incident of sexual abuse to the State agency and denied doing a thorough investigation because she stated she did not feel it was abuse. An attempt to interview Resident #6 on 07/08/24 at 12:50 P.M. was unsuccessful as the resident was cognitively impaired and was only able to state his name. Review of Resident #6's medical record revealed no evidence the incident between Resident #101 and Resident #6 was documented in his record. The record did not include an assessment after the incident. Review of Resident #101's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged on [DATE] (to an assisted living) with diagnoses including hemiplegia, malignant neoplasm of the bladder and anxiety disorder. Review of Resident #101's comprehensive care plan dated 01/19/24 revealed the care plan did not include interventions to address sexual abuse or inappropriate sexual behavior. Review of Resident #101's progress note dated 04/25/24 at 6:39 A.M. authored by Registered Nurse (RN) #299 revealed the resident was up at the nursing station sitting next to Resident #6 and attempting to grab at Resident #6's penis. The resident was pulling at his pants and trying to put his hand down the resident's pants. Resident #6 yelled and stated, you are hurting me. The resident was moved into the television room and kept coming up to the other residents to touch them inappropriately. The note indicated nursing would continue to monitor. Review of Resident #101's progress note dated 04/28/24 at 11:08 A.M. authored by LPN #290 indicated the resident was wheeling himself up to female and male residents and placing his hand under their clothes and attempting to touch them. The staff removed him away from the residents and observed him by taking him to his room. The physician was notified. The note did not identify which residents were involved. Interview on 07/02/24 at 12:20 P.M. with LPN #290 revealed on 04/28/24, Resident #101 was wheeling himself up and placing his hands under both male and female resident's clothing. She confirmed Resident #101 had behaviors of touching other residents' underneath of their clothes and stated she had witnessed him placing his hands under a female resident's clothing but she could not recall the resident's name or date of the incident. She stated of course it was sexual abuse however, she could not state who she had reported the incident too. Interview on 07/02/24 at 3:09 P.M. with Licensed Social Worker (LSW) #287, who does care plans for resident behaviors, confirmed Resident #101's did not have a comprehensive and individualized plan of care in place to prevent sexual abuse/address sexually inappropriate behavior(s). Review of the facility policy, Abuse, Neglect, and Exploitation, revised 12/04/23 revealed the facility defined sexual abuse as non-consensual sexual contact of any type with a resident. The policy revealed the facility would provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Reporting Response included the facility will have written procedures that include but are not limited to: reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes which are immediately, but not later than two hours after the allegation is made if that even that causes the allegation involve abuse or result in seriously body injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury; assuring that reporters are free fro retaliation or reprisal; promoting a culture of safety and open communication in the work environment prohibiting retaliation against any employee who reports suspicion of a crime; taking all necessary actions as a result if the investigation, which may include, but are not limited to the following: analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident occurred, and what changes are needed to prevent further occurrences; defining how care provision will be changed and/or improved to protect residents receiving services; training of staff on changes made and demonstration of staff competency after training is implemented; the expected date for implementation; and identification of staff responsible for monitoring the implementation of the plan. Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within five working days of the incident, as required by state agencies. This deficiency represents non-compliance investigated under Master Complaint Number OH00154836 and Complaint Number OH00154684.

Based on record review, interview, and policy review, the facility failed to thoroughly investigate allegations of resident to resident sexual abuse for Resident #6 and Resident #50. This affected two residents (Resident 6 and Resident #50) of three residents reviewed for abuse. Findings include: 1. Review of Resident #50's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's disease with dyskinesia, unspecified dementia and anxiety disorder. Review of Resident #50's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of a police report for Resident #50 dated 06/06/24 authored by Police #359 revealed they were called to the facility by Resident #50's family regarding an incident that occurred with Resident #101. Resident #50's family member was told by staff members a male (resident) tried to inappropriately touch her mother (Resident #50) under her gown during the evening of 06/05/24. Review of an undated Police Department Witness Statement form authored by Licensed Practical Nurse (LPN) #223 indicated she was informed Resident #101 attempted to reach inside Resident #50's brief. She did not witness the activity. A full assessment was completed of Resident #50 for physical trauma or injury. Review of an undated Police Department Witness Statement form authored by State tested Nursing Assistant (STNA) #284 indicated on 06/05/24 she observed Resident #101 attempting to touch Resident #50 inappropriately. The residents were separated. Review of an undated Police Department Witness Statement form authored by STNA #340 indicated on 06/05/24, the employee overheard a commotion and observed another STNA removing Resident #101 away from Resident #50 because his hands were on the wheelchair and he would not let go. Resident #101 was taken back to his room. Resident #50's incontinence brief was intact. Review of Resident #50's medical record did not reveal entries in the progress notes concerning physical or sexual abuse by Resident #101 on 06/05/24 per the police report. There was no evidence of the resident's assessment when the incident occurred or of any follow-up with the resident after the incident. Interview on 07/01/24 at 7:50 A.M. with Resident #50's daughter indicated she called the local police department related to this incident because she felt the resident had increased agitation (as a result of the incident) and related to possible abuse concerns. An attempt to interview Resident #50 on 07/01/24 at 10:01 A.M. was unsuccessful as the resident only knew her name and was not interviewable. Interview on 07/01/24 at 2:58 P.M. with STNA #227 revealed she was told by STNA #340 that another resident had reached over and fondled Resident #50 in the lady parts down below. She stated staff intervened when Resident #50 screamed and the residents were separated. Interview on 07/01/24 at 4:37 P.M. with STNA #340 revealed she did not witness this sexual abuse and denied telling another STNA about the abuse. The STNA further stated, the resident (#50) did not have pants on at the time of the incident. STNA #340 indicated she was the staff member who got Resident #50 out of bed from a nap prior to dinner on 06/05/24 because the resident's husband came in to visit. STNA #340 confirmed she dressed the resident in a top and incontinence brief with no pants or bottoms and only placed a sheet over her legs. STNA #340 stated she placed Resident #50 back in bed following the incident with Resident #101 and the resident still had a top on and a incontinence brief with a sheet over her legs. Interview on 07/02/24 at 7:27 A.M. with STNA #284 revealed Resident #101 was sitting next to Resident #50 on 06/05/24 at the nursing station. Resident #101 had his hand (unknown which hand) in Resident #50's brief. Resident #50 was observed to be crying and Resident #101 was removed from the area. Another STNA (unknown who the employee was) was observed hugging Resident #50 and asked her if she was ok. Resident #50 reported she was not ok. Interview on 07/02/24 at 10:49 A.M. with LPN #223 revealed she did not witness the incident between Resident #50 and #101. She confirmed she wrote a statement, and she said an STNA told her about the sexual abuse incident. Interview on 07/02/24 at 11:26 A.M. with the Director of Nursing (DON) confirmed she was informed of this incident between Resident #50 and #101 on 06/06/24 by staff members. The DON confirmed she was aware the local police department came into the facility on [DATE] to investigate a concern with Resident #50 but stated she did not feel it was abuse so she did not conduct a thorough investigation and did not report the incident to State agency. The DON confirmed the facility could not provide evidence of any type of assessment of Resident #50 after the incident on 06/05/24. Interview on 07/02/24 at 12:20 P.M. with LPN #290 revealed she worked on a different hall on 06/05/24 and was coming up to the nurse's station and remembered Resident #50 was upset, crying, and shaking after the incident with Resident #101. Review of Resident #101's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged on [DATE] (to an assisted living) with diagnoses including hemiplegia, malignant neoplasm of the bladder and anxiety disorder. Review of Resident #101's comprehensive care plan dated 01/19/24 revealed the care plan did not include interventions to address sexual abuse or inappropriate sexual behavior. Interview on 07/02/24 at 3:09 P.M. with Licensed Social Worker (LSW) #287, who does care plans for resident behaviors, confirmed Resident #101's did not have a comprehensive and individualized plan of care in place to prevent sexual abuse/address sexually inappropriate behavior(s). 2. Review of Resident #6's medical record revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses including unspecified dementia, anxiety disorder and anemia. Review of Resident #6's quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem. Interview on 07/02/24 at 11:26 A.M. with the DON revealed she had been informed of an incident involving Resident #6 and she stated she felt what was reported to her was not sexual abuse. She stated a nurse had told her Resident #101 had attempted to grab Resident #6 by his pants. She denied reporting this incident of sexual abuse to the State agency and denied doing a thorough investigation because she stated she did not feel it was abuse. An attempt to interview Resident #6 on 07/08/24 at 12:50 P.M. was unsuccessful as the resident was cognitively impaired and was only able to state his name. Review of Resident #6's medical record revealed no evidence the incident between Resident #101 and Resident #6 was documented in his record. The record did not include an assessment after the incident. Review of Resident #101's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged on [DATE] (to an assisted living) with diagnoses including hemiplegia, malignant neoplasm of the bladder and anxiety disorder. Review of Resident #101's comprehensive care plan dated 01/19/24 revealed the care plan did not include interventions to address sexual abuse or inappropriate sexual behavior. Review of Resident #101's progress note dated 04/25/24 at 6:39 A.M. authored by Registered Nurse (RN) #299 revealed the resident was up at the nursing station sitting next to Resident #6 and attempting to grab at Resident #6's penis. The resident was pulling at his pants and trying to put his hand down the resident's pants. Resident #6 yelled and stated, you are hurting me. The resident was moved into the television room and kept coming up to the other residents to touch them inappropriately. The note indicated nursing would continue to monitor. Review of Resident #101's progress note dated 04/28/24 at 11:08 A.M. authored by LPN #290 indicated the resident was wheeling himself up to female and male residents and placing his hand under their clothes and attempting to touch them. The staff removed him away from the residents and observed him by taking him to his room. The physician was notified. The note did not identify which residents were involved. Interview on 07/02/24 at 12:20 P.M. with LPN #290 revealed on 04/28/24, Resident #101 was wheeling himself up and placing his hands under both male and female resident's clothing. She confirmed Resident #101 had behaviors of touching other residents' underneath of their clothes and stated she had witnessed him placing his hands under a female resident's clothing but she could not recall the resident's name or date of the incident. She stated of course it was sexual abuse however, she could not state who she had reported the incident too. Interview on 07/02/24 at 3:09 P.M. with Licensed Social Worker (LSW) #287, who does care plans for resident behaviors, confirmed Resident #101's did not have a comprehensive and individualized plan of care in place to prevent sexual abuse/address sexually inappropriate behavior(s). Review of the facility policy, Abuse, Neglect, and Exploitation, revised 12/04/23 revealed the facility defined sexual abuse as non-consensual sexual contact of any type with a resident. The policy revealed the facility would provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Investigation of Alleged, Neglect and Exploitation included an immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigation include: identifying staff responsible for the investigation; exercising caution in handing evidence that could be used in a criminal investigation, investigating different types of alleged violations, identifying and interviewing all persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; focusing the investigation on determining is abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause, and provide complete and thorough documentation of the investigation. This deficiency represents non-compliance investigated under Master Complaint Number OH00154836 and Complaint Number OH00154684.

Based on record review and interview, the facility failed to develop and implement comprehensive care plans for Resident #100's Intravenous (IV) medication. This affected one residents (Resident #100) out of three residents reviewed for care plans. Findings include: Review of the medical record for Resident #100 revealed an admitted [DATE] and a discharge date of [DATE] with diagnosis including but not limited to displaced intertrochanteric fracture of right femur, rheumatoid arthritis, chronic obstructive pulmonary disease (COPD), paroxysmal atrial fibrillation, chronic diastolic congestive heart failure, anxiety disorder, and depression. Review of the Medicare 5 day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #100 had intact cognition. Review of the physician order dated 04/15/24 revealed an order for Intravenous (IV) for Zosyn (antibiotic medication) reconstitute 3.375 (3-0.375) gram (gm) (piperacillin sodium-tazobactam sodium) administer every 6 hours for atelectasis (complete or parital collapse of lung). Review of the current care plan dated 03/22/24 revealed no care plan to address Resident #100's IV medication. Interview on 07/02/24 at 1:50 P.M. with LPN #285 (MDS Nurse) confirmed there was no care plan for the IV for Resident #100.

Based on observation, interview and record review, the facility failed to update the care plan for Resident #274 to include her missing eye glasses. This affected one resident (Resident #274) of five residents reviewed for comprehensive care plans. Findings include: Record review for Resident #274 revealed an admitted [DATE]. Diagnosis included Parkinson's disease and combined forms of age related cataract, bilateral. Record review of the activity assessment dated [DATE] revealed Resident #274 enjoyed spending most of her time reading the bible, sitting in silence, and visiting with friends. Record review of the quarterly Minimum Data Set, dated dated dated [DATE] revealed resident was able to make herself understood, usually understands others, vision was impaired and wore corrective lenses. Resident #274 required supervision with activities of daily living. Record review of the care plan dated 09/29/22 revealed Resident #274 had a potential for communication problem related to severely impaired cognition, unclear speech and impaired hearing. Resident #274 spoke German so she required a longer period to understand and be understood. Interventions included to face Resident #274 and make eye contact, use alternative communication tools as needed such as the communication book/board. Resident #274 had impaired vision related to cataracts. Interventions included to arrange consultation with eye care practitioner as required and Resident #274 required the following visual aids, glasses. Record review of the progress note for Resident #274 dated 11/21/22 (untimed) completed by Optometrist #619 revealed the examination was completed for a follow up six months for cataracts and dry eyes. Spectacle exam included flat top bifocal which resident was noted to have. Observation on 12/19/22 at 11:00 A.M. of Resident #274 revealed Resident #274 was sitting up in her wheelchair in her room. Resident #274 was not wearing eye glasses. Resident #274 spoke a different language and the surveyor was unable to communicate with Resident #274. On the nightstand near Resident #274 was a a bible (German) and watch magazines. Interview on 12/19/22 at 11:54 A.M. with Resident #274's daughter revealed Resident #274's eye glasses were missing at facility for over six months. Resident #274 wore her glasses daily due to poor vision. Resident #274 enjoyed reading which was difficult for her without the glasses. Resident #274's daughter revealed the staff told her the eye doctor was coming months ago to replace the glasses. Resident #274's daughter revealed she requested the facility let her know when the eye doctor was coming so she could be there due to Resident #274 spoke German and the doctor would not be able to understand her during the assessment. Resident #274's daughter revealed the facility did not let her know when the appointment was so when the eye doctor visited, he was unable to understand her and Resident #274 still had not received her new glasses. Interview on 12/21/22 at 10:16 A.M. with Licensed Social Worker (LSW) #594 revealed Resident #274 and her daughter had a care conference on 08/05/22 at 11:41 A.M. LSW #594 revealed this was the first time she became aware Resident #274 was missing her eye glasses. LSW #594 confirmed she forgot to communicate with Optometrist #619 prior to his visit and also when he visited Resident #274 in November 2022 that Resident #274 needed her eye glasses replaced. LSW #594 confirmed Optometrist #274 was unaware Resident #274's eye glasses were missing at the time of the visit and the eyeglasses have not been reordered. LSW revealed the optometrist visited the facility quarterly to see residents and would also make emergency visits if needed. Interview on 12/21/22 at 2:08 P.M. with State tested Nursing Assistant (STNA) #559 revealed Resident #274's glasses had been missing for a while. STNA #559 revealed prior to Resident #274's glasses missing, Resident #274 would put her glasses on and take them off herself. STNA #559 revealed Resident #274 enjoyed watching television (German channels when available) and reading the bible with her daughter. Interview on 12/21/22 at 2:44 P.M. with Licensed Practical Nurse (LPN)/Care Plan Nurse #531 confirmed Resident #274's care plan was not updated for vision and not having her glasses available. LPN/Care Plan Nurse #531 revealed the care plan should have been updated with the quarterly MDS.

Based on observation, interview and record review, the facility failed to timely report and investigate an injury of unknown origin for Resident #275. This affected one resident (Resident #275) of two residents reviewed for injuries of unknown origin. Findings include: Record review for Resident #275 revealed an admitted [DATE]. Diagnosis included history of congestive heart failure and paroxysmal atrial fibrillation. Record review of the Admission Baseline Care Plan dated 12/15/22 completed by Licensed Practical Nurse (LPN) #582 revealed Resident #275 was alert to person and confused. Resident #275 had an unsteady gait and weakness. Resident #275 was dependent for toileting, required extensive assistance for bed mobility and total dependence for transfers of two person physical assistants. Record review of the Admission Skin assessment dated [DATE] initiated by LPN #544 revealed Resident #275 had bruising to the chest and on both arms. Record review of the physician orders for December 2022 for Resident #275 revealed Resident #275 had orders for coumadin five milligrams (mg) by mouth at bed time for atrial fibrillation. Orders included to monitor for signs and symptoms of bleeding every shift due to anticoagulants. Record review of Resident #275's medical record revealed no documentation of bruising to Resident #275's left side of her neck. Observation on 12/19/22 at 10:03 A.M. revealed Resident #275 was sitting up in a wheelchair in her room. The door to her room had been closed. Resident #275 was sitting in the chair with no shirt on and just a bra. Resident #275 had a large dark blue/ purple bruise covering the entire left side of her neck including a portion of the upper left chest. The bilateral arms had multiple small bruises. Resident #275 rambled and was unable to explain how the large bruise to her neck occurred. Interview on 12/19/22 at 10:08 A.M. with State tested Nursing Assistant (STNA) #559 revealed she assisted Resident #275 with A.M. care and was unsure how the bruising occurred to Resident #275's neck. Interview on 12/19/22 at 10:15 A.M. with Licensed Practical Nurse (LPN) #542 revealed she was Resident #275's charge nurse and was aware Resident #275 had bruising to her neck. LPN #542 revealed she normally did not work with Resident #275 and was unsure how the bruising occurred. Interview and observation on 12/20/22 at 1:36 P.M. with Registered Nurse (RN) #524 confirmed he was Resident #275's charge nurse. Observation of Resident #275's bruising to the left side of her neck with RN #524 confirmed Resident #275 had a large dark blue/ purple bruise covering the entire left side of her neck including a portion of the upper left chest. RN #524 revealed he was unaware Resident #524 had bruising to her neck area. Interview and observation on 12/20/22 at 1:45 P.M. with Wound Care Nurse Licensed Practical Nurse (LPN) #532 revealed she completed a skin assessment for Resident #275 (initiated by LPN #544) on 12/16/22 during the day shift. Wound Care Nurse LPN #532 revealed Resident #275 did not have any bruising to her neck when she assessed her on 12/16/22. Interview on 12/20/22 at 1:53 P. M with Director of Nursing (DON) and Administrator revealed the DON was not made aware of the bruising at the time it occurred on Resident #275's neck. DON confirmed this was bruising that occurred after admission and she should have been updated when it occurred so she could investigate the cause of the injury. Record review of the progress note for Resident #275 dated 12/20/22 at 3:26 P.M. completed by RN #524 revealed Resident #275 had a dark purple in color with light purple bruise from the mid breast to the left ear lobe which measured 26 centimeters (cm) in length by 11 cm in width. Resident #275 also had a dark purple bruise to the left upper arm that measured 13 cm by 12 cm. Interview on 12/20/22 at 3:38 P.M. with LPN #535 revealed she worked with Resident #275 on 12/16/22 during the evening shift, 3:00 P.M. to 11:00 P.M. LPN #535 confirmed Resident #275 had the large bruise to her left neck area at that time. LPN #375 confirmed she did not report the bruise to anyone and revealed she assumed the bruise to Resident #275's neck was present on admission.

Based on observation, interview and record review, the facility failed to complete a comprehensive baseline care plan for Resident #275 to include care for bruising and anticoagulant therapy. This affected one resident (Resident #275) of three residents reviewed for baseline care plans. Findings include: Record review for Resident #275 revealed an admitted [DATE]. Diagnosis included history of congestive heart failure and paroxysmal atrial fibrillation. Record review of the Admission Baseline Care Plan dated 12/15/22 completed by Licensed Practical Nurse (LPN) #582 revealed Resident #275 was alert to person and confused. Resident #275 had an unsteady gait and weakness. Resident #275 was dependent for toileting, required extensive assistance for bed mobility and total dependence for transfers of two person physical assistants. Record review of the Admission Skin Assessment initiated by Licensed Practical Nurse #544 dated 12/16/22 revealed Resident #275 had bruising to the chest and on both arms. Record review of the physician orders for December 2022 for Resident #275 revealed Resident #275 had orders for Coumadin (anticoagulant medication) five milligrams (mg) by mouth at bed time for atrial fibrillation. Orders included to monitor for signs and symptoms of bleeding every shift due to anticoagulants. Review of the Admission Baseline Care Plan revealed it was silent of a plan to manage the resident's anticoagulant therapy, bruising or skin impairments. Observation on 12/19/22 at 10:03 A.M. revealed Resident #275 was sitting up in a wheelchair in her room. The door to her room had been closed. Resident #275 was sitting in the chair with no shirt on and just a bra. Resident #275's shirt was lying on the floor next to her. Resident #275 had a large dark blue/ purple bruise covering the entire left side of her neck including a portion of the upper left chest. The bilateral arms had multiple small bruises. Resident #275 rambled and was unable to explain how the large bruise to her neck occurred. Record review of Resident #275's medical record revealed no documentation of the bruising to Resident #275's left side of her neck. Interview and observation on 12/20/22 at 1:36 P.M. with Registered Nurse (RN) #524 confirmed he was Resident #275's charge nurse. Observation of Resident #275's bruising to the left side of her neck with RN #524 confirmed Resident #275 had a large dark blue/ purple bruise covering the entire left side of her neck including a portion of the upper left chest. RN #524 revealed he was unaware Resident #524 had bruising to her neck area. Interview and observation on 12/20/22 at 1:45 P.M. with Wound Care Nurse Licensed Practical Nurse (LPN) #532 revealed she completed a skin assessment for Resident #275 on 12/16/22 (date after admission) during the day shift. Wound Care Nurse LPN #532 revealed Resident #275 did not have any bruising to her neck when she assessed her on 12/16/22. Interview on 12/20/22 at 3:21 P.M. with Director of Nursing (DON) confirmed the baseline care plan did not include the location of Resident #275's bruising on admission, the use of Coumadin and need for continued monitoring for additional bruising. DON confirmed these items should have been added to the baseline care plan. Interview on 12/20/22 at 3:59 P.M. with Certified Nurse Practitioner (CNP) #618 confirmed he was not made aware of the additional bruising which included the bruising to Resident #275's left side of her neck and the new bruise located on Resident #275's left upper arm. CNP #618 revealed due to the additional bruising, his concern for Resident #275 was bleeding. CNP #618 revealed he would hold Resident #275's coumadin and obtain additional lab values.

Based on observation, interview and record review, the facility failed to properly store and secure medications for Resident #30 and Resident #67. This affected two residents (Resident #30 and #67) of two residents reviewed for medication storage. Findings include: 1. Record review for Resident #30 revealed an admitted [DATE]. Diagnosis included hypertensive heart disease, paroxysmal atrial fibrillation, Barrette's esophagus without dysplasia, gastro-esophageal reflux disease (GERD), gout, and need for assistance with personal care. Record review of the Modification of Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #30 was cognitively intact. Resident #30 required supervision with activities of daily living. Record review of the care plan dated 12/04/22 revealed Resident #30 had an alteration in the digestive system related to hiatal hernia, Barret's esophagus, and GERD. Interventions included to administer medication per the physician orders. Record review of the physician orders for 12/19/22 for Resident #30 revealed orders for Metoprolol Succinate extended release (ER) tablet 25 milligrams (mg) by mouth two times a day for hypertension, hold for heart rate below 60 or systolic blood pressure below 110, Omeprazole tablet delayed release 20 mg two times a day for GERD, and Zyloprim tablet 300 mg (Allopurinol) give one tablet by mouth one time a day for gout. Observation on 12/19/22 at 9:38 A.M. revealed Resident #30 was resting quietly in bed with her eyes closed. A medication cup was sitting on the bedside table with three pills in the cup, one white, one brown and one orange. Interview on 12/19/22 at 9:40 A.M. with Licensed Practical Nurse (LPN) #542 verified the medications Allopurinol, Omeprazole, and Metoprolol were left at Resident #30's bedside. Interview on 12/19/22 at 1:23 P.M. with Resident #30 revealed staff always left her medications for her to take when she got up. Interview on 12/22/22 at 10:38 A.M. with Director of Nursing (DON) confirmed Resident #30 did not have orders to self administer medications. DON revealed she would expect the nurse to stay with the residents until the resident either took the medication or refused the medication. 2. Record review for Resident #67 revealed an admitted [DATE]. Diagnosis included hypertensive heart and chronic kidney disease with heart failure. Record review of the Admission Medicare five day Minimum Data Set, dated dated dated [DATE] revealed Resident #67 was cognitively intact. Resident #67 required extensive assistance of two for bed mobility, transfers, dressing and one person physical assist and supervision with eating. Resident #67 received routine pain medication rated a five on the pain scale of one to 10. Record review of the physician orders dated 10/09/22 revealed Resident #67 had an order Chlorhexidine Gluconate solution 0.12% 30 milliliters (ml) mucous membrane two times a day for mouth pain. Medication scheduled to be administered at 9:00 A.M. and 5:00 P.M. Record review of the care plan dated 10/10/22 revealed Resident #67 had an activity of daily living self care performance deficit due to musculoskeletal impairment, decreased mobility. Interventions included to allow time for completion of any task, do not rush, praise/encourage all efforts. Observation on 12/19/22 at 10:14 A.M. revealed Resident #67 was up in his wheelchair and exiting his room. Observation revealed Resident #67 had a liquid medication in a medication cup sitting on his bedside table. Resident #67 revealed he had forgotten to take his medication. Interview on 12/19/22 at 10:15 A.M. with LPN #542 revealed the medication left on Resident #67's bedside table was Chlorhexidine Gluconate solution. LPN #542 revealed if residents were alert and oriented, she would tell them what medications they had then leave it for them and come back later to check on them. Interview on 12/22/22 at 10:38 A.M. with Director of Nursing (DON) confirmed Resident #67 did not have orders to self administer medications. DON revealed she would expect the nurse to stay with the residents until the resident either took the medication or refused the medication.

Based on observation, interview, and record review, the facility failed to ensure Resident #42's chronic pain was addressed in a timely manner. This affected one resident (Resident #42) of five residents reviewed for medications. Findings include: Review of the medical record for Resident #42 revealed admitted [DATE]. Diagnoses included generalized osteoarthritis, fibromyalgia, age related osteoporosis, anxiety disorder, spinal stenosis, history of clavicle and thoracic spinal vertebra #7 fracture, presence of left artificial hip joint, and pain of unspecified joint. Review of Care Plan dated 07/21/22 revealed Resident #42 had alteration in comfort related to fibromyalgia, osteoporosis, spinal stenosis, and history of fractures. Interventions included administer medications as ordered, monitor for side effects and effectiveness, report abnormal findings to physician, monitor and report signs and symptoms of non-verbal pain, report requests of pain treatment, and notify physician of breakthrough pain. Review of Psych Solutions progress note dated 09/27/22 revealed staff reported Resident #42 was seeking medications at times and was noted to watch clock for pain medications. Resident #42 had worsening anxiety and chronic somatic complaints. Psych Nurse Practitioner recommended pain management consult. Review of nursing progress note dated 09/29/22 revealed physician rounded and new order to increase Gabapentin to 200 milligrams (mg) three times per day. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 received scheduled and as needed (PRN) pain medication. Resident #42 reported frequent pain in last five days. Resident #42 reported seven out of 10 pain which made it hard to sleep and limited day to day activities. Review of the current physician's orders for December 2022 revealed Resident #42 had standing orders for 200 mg Gabapentin three times per day for pain, 1 percent (%) Voltaren gel applied to right hip twice daily for pain, and 4% Lidocaine patch applied to right knee once daily for pain. Resident #42 had as needed orders for 650 mg Acetaminophen every eight hours for pain and 325 mg Percocet every four hours as needed for moderate pain. Resident #42 had order to monitor pain level every shift. Review of medication administration record (MAR) for November 2022 revealed Resident #42 used as needed (PRN) Acetaminophen on 11/27/22 for pain with effective results. Resident #42 received PRN Percocet, six doses on 11/29/22, five doses on 11/04/22, 11/06/22, 11/11/22, 11/15/22, 11/17/22, 11/19/22, 11/23/22, 11/25/22, and 11/27/22, and three doses on 11/05/22, 11/07/22, 11/08/22, 11/10/22, 11/13/22, 11/16/22, 11/20/22, 11/24/22, 11/28/22, and 11/30/22 with complaints of four to 10 out of 10 pains. Resident #42 also received scheduled medications as ordered for pain including Gabapentin, Voltaren gel, and Lidocaine patch. Review of Physician's Progress Note dated 11/14/22 revealed Resident #42 was reviewed for general medical care follow up and had medications reviewed. There was no indication of review of frequent reports of moderate to severe pain. Review of MAR for December 2022 revealed Resident #42 used PRN Acetaminophen on 12/11/22 for pain with effective results. Resident #42 received PRN Percocet, six doses on 12/01/22, five doses on 12/02/22, 12/04/22, 12/09/22, and 12/15/22, and four doses on 12/05/22, 12/06/22, 12/07/22, 12/08/22, 12/10/22, 12/11/22/, 12/12/22, 12/13/22, 12/16/22, 12/17/22, 12/18/22. Resident #42 used two doses of PRN Percocet on 12/03/22. Resident #42 was complaining of pain ranging from two to eight out of 10. Resident #42 also received scheduled medications as ordered for pain including Gabapentin, Voltaren gel, and Lidocaine patch. Interview on 12/19/22 at 11:18 A.M. with Resident #42 revealed she had been having a lot more pain in legs, hands, and feet. Resident #42 described the pain was throbbing. Resident #42 indicated she had reported pain to facility staff. During interview Resident #42 was observed to be laying back in bed with legs pulled up. Resident #42 was noted to be restless and squirming in bed with eyes closed throughout most of the interview. Resident #42's legs appeared to be tensed. Resident #42 indicated the facility provided her with a gel for pain however it did not help. Review of phone physician's order form dated 12/21/22 revealed physician placed order for pain management consult for fibromyalgia. Interview on 12/21/22 at 2:01 P.M. with Licensed Practical Nurse (LPN) #542 revealed Resident #42 had been declining. Resident #42 was noted to ask for her PRN Percocet every four hours. LPN #542 noted Resident #42 would count pills in cup and ask for Percocet even if not due. LPN #542 indicated she won't report the pain but watches the clock. Interview on 12/21/22 at 2:06 P.M. with State tested Nursing Assistant (STNA) #562 revealed Resident #42 does most of her care on her own. STNA #562 noted Resident #42 always just wants her pain medications. Interview on 12/21/22 at 3:07 P.M. with Director of Nursing (DON) and Registered Nurse (RN) Supervisor #522 revealed the social worker usually gets the psych notes and files them right away. The psych team usually does not make many recommendations so we must have missed the recommendation for pain management consult. DON indicated Resident #42 was declining in October 2022 and we recommended hospice services however the family was not agreeable. RN Supervisor #522 indicated Resident #42 has good and bad days with pain. DON reported when she works the floor and passes medications Resident #42 knows to the minute when she can get PRN Percocet. DON and RN Supervisor #522 confirmed pain management recommendation was not addressed until 12/21/22.

Based on observation, interview and record review, the facility failed to assist Resident #274 in replacing lost eye glasses to help maintain vision. This affected one resident (Resident #274) of one resident reviewed for vision. Findings include: Record review for Resident #274 revealed an admitted [DATE]. Diagnosis included Parkinson's disease and combined forms of age related cataract, bilateral. Record review of the activity assessment dated [DATE] revealed Resident #274 enjoyed spending most of her time reading the bible, sitting in silence, and visiting with friends. Record review of the quarterly Minimum Data Set, dated dated dated [DATE] revealed resident was able to make herself understood, usually understands others, vision was impaired and wore corrective lenses. Resident required supervision with activities of daily living. Record review of the care plan dated 09/29/22 revealed Resident #274 had a potential for communication problem related to severely impaired cognition, unclear speech and impaired hearing. Resident #274 spoke German so she required a longer period to understand and be understood. Interventions included to face Resident #274 and make eye contact, use alternative communication tools as needed such as the communication book/board. Resident #274 had impaired vision related to cataracts. Interventions included to arrange consultation with eye care practitioner as required and Resident #274 required the following visual aids, glasses. Record review of the progress note for Resident #274 dated 11/21/22 (untimed) completed by Optometrist #619 revealed the examination was completed for a follow up six months for cataracts and dry eyes. Spectacle exam included flat top bifocal which resident was noted to have. Observation on 12/19/22 at 11:00 A.M. of Resident #274 revealed Resident #274 was sitting up in her wheelchair in her room. Resident #274 was not wearing eye glasses. Resident #274 spoke a different language and the surveyor was unable to communicate with Resident #274. On the nightstand near Resident #274 was a a bible (German) and watch magazines. Interview on 12/19/22 at 11:54 A.M. with Resident #274's daughter revealed Resident #274's eye glasses were missing at facility for over six months. Resident #274 wore her glasses daily due to poor vision. Resident #274 enjoyed reading which was difficult for her without the glasses. Resident #274's daughter revealed the staff told her the eye doctor was coming months ago to replace the glasses. Resident #274's daughter revealed she requested the facility let her know when the eye doctor was coming so she could be there due to Resident #274 spoke German and the doctor would not be able to understand her during the assessment. Resident #274's daughter revealed the facility did not let her know when the appointment was so when the eye doctor visited, he was unable to understand her and Resident #274 still had not received her new glasses. Interview on 12/21/22 at 10:16 A.M. with Licensed Social Worker (LSW) #594 revealed Resident #274 and her daughter had a care conference on 08/05/22 at 11:41 A.M. LSW #594 revealed this was the first time she became aware Resident #274 was missing her eye glasses. LSW #594 confirmed she forgot to communicate with Optometrist #619 prior to his visit and also when he visited Resident #274 in November 2022 that Resident #274 needed her eye glasses replaced. LSW #594 confirmed Optometrist #274 was unaware Resident #274's eye glasses were missing at the time of the visit and the eyeglasses have not been reordered. LSW #594 revealed the optometrist visited the facility quarterly to see residents and would also make emergency visits if needed. Interview on 12/21/22 at 2:08 P.M. with State tested Nursing Assistant (STNA) #559 revealed Resident #274's glasses had been missing for a while. STNA #559 revealed prior to Resident #274's glasses missing, Resident #274 would put her glasses on and take them off herself. STNA #559 revealed Resident #274 enjoyed watching television (German channels when available) and reading the bible with her daughter.

Based on observation, interview and record review, the facility failed to monitor Resident #275's change in condition related to bruising. This affected one resident (Resident #275) of three residents reviewed for quality of care. Findings include: Record review for Resident #275 revealed an admitted [DATE]. Diagnosis included history of congestive heart failure and paroxysmal atrial fibrillation. Record review of the Admission Baseline Care Plan dated 12/15/22 completed by Licensed Practical Nurse (LPN) #582 revealed Resident #275 was alert to person and confused. Resident #275 had an unsteady gait and weakness. Resident #275 was dependent for toileting, required extensive assistance for bed mobility and total dependence for transfers of two person physical assistants. Record review of the Admission Skin Assessment initiated by Licensed Practical Nurse #544 dated 12/16/22 revealed Resident #275 had bruising to the chest and on both arms. Record review of the physician orders for December 2022 for Resident #275 revealed Resident #275 had orders for Coumadin five milligrams (mg) by mouth at bed time for atrial fibrillation. Orders included to monitor for signs and symptoms of bleeding every shift due to anticoagulants. Record review of Resident #275's medical record revealed no documentation of bruising to Resident #275's left side of her neck. Observation on 12/19/22 at 10:03 A.M. revealed Resident #275 was sitting up in a wheelchair in her room. The door to her room had been closed. Resident #275 was sitting in the chair with no shirt on and just a bra. Resident #275's shirt was lying on the floor next to her. Resident #275 had a large dark blue/ purple bruise covering the entire left side of her neck including a portion of the upper left chest. The bilateral arms had multiple small bruises. Resident #275 rambled and was unable to explain how the large bruise to her neck occurred. Interview on 12/19/22 at 10:08 A.M. with State tested Nursing Assistant (STNA) #559 revealed she assisted Resident #275 with A.M. care and was unsure how the bruising occurred to Resident #275's neck. STNA #559 revealed Resident #275 often removed her own clothing. Interview on 12/19/22 at 10:15 A.M. with Licensed Practical Nurse (LPN) #542 revealed she was Resident #275's charge nurse and was aware Resident #275 had bruising to her neck. LPN #542 revealed she normally did not work with Resident #275 and was unsure how the bruising occurred. Interview and observation on 12/20/22 at 1:36 P.M. with Registered Nurse (RN) #524 confirmed he was Resident #275's charge nurse. Observation of Resident #275's bruising to the left side of her neck with RN #524 confirmed Resident #275 had a large dark blue/ purple bruise covering the entire left side of her neck including a portion of the upper left chest. RN #524 revealed he was unaware Resident #524 had bruising to her neck area. Interview and observation on 12/20/22 at 1:45 P.M. with Wound Care Nurse LPN #532 revealed she completed a skin assessment for Resident #275 on 12/16/22 (date after admission) during the day shift. Wound Care Nurse LPN #532 revealed Resident #275 did not have any bruising to her neck when she assessed her on 12/16/22. Record review of the progress note for Resident #275 dated 12/20/22 at 3:26 P.M. completed by RN #524 revealed Resident #275 had a dark purple in color with light purple bruise from the mid breast to the left ear lobe which measured 26 centimeters (cm) in length by 11 cm in width. Resident #275 also had a dark purple bruise to the left upper arm that measured 13 cm by 12 cm. Interview on 12/20/22 at 3:21 P.M. with Director of Nursing confirmed the physician nor Certified Nurse Practitioner (CNP) #618 had been made aware of Resident #275's bruise to the left side of the neck. Interview on 12/20/22 at 3:38 P.M. with LPN #535 revealed she worked with Resident #275 on 12/16/22 during the evening shift, 3:00 P.M. to 11:00 P.M. LPN #535 confirmed Resident #275 had the large bruise to her left neck area at that time. LPN #375 confirmed she did not report the bruise to anyone and revealed she assumed the bruise to Resident #275's neck was present on admission. Interview on 12/20/22 at 3:59 P.M. with CNP #618 confirmed he was not made aware of the additional bruising which included the bruising to Resident #275's left side of her neck and the new bruise located on Resident #275's left upper arm. CNP #618 revealed due to the additional bruising, his concern for Resident #275 was bleeding. CNP #618 revealed he would hold Resident #275's coumadin and obtain additional lab values.

Based on observation, interview and record review, the facility failed to report a change in condition to Resident #275's responsible party and physician, who had bruising to the left side of her neck. This affected one resident (Resident #275) of two residents reviewed for notification of change in condition. Findings include: Record review for Resident #275 revealed an admitted [DATE]. Diagnosis included history of congestive heart failure and paroxysmal atrial fibrillation. Record review of the Admission Baseline Care Plan dated 12/15/22 completed by Licensed Practical Nurse (LPN) #582 revealed Resident #275 was alert to person and confused. Resident #275 had an unsteady gait and weakness. Resident #275 was dependent for toileting, required extensive assistance for bed mobility and total dependence for transfers of two person physical assistants. Record review of the Admission Skin Assessment initiated by Licensed Practical Nurse #544 dated 12/16/22 revealed Resident #275 had bruising to the chest and on both arms. Record review of the physician orders for December 2022 for Resident #275 revealed Resident #275 had orders for coumadin five milligrams (mg) by mouth at bed time for atrial fibrillation. Orders included to monitor for signs and symptoms of bleeding every shift due to anticoagulants. Record review of Resident #275's medical record revealed no documentation of the bruising to Resident #275's left side of her neck. Observation on 12/19/22 at 10:03 A.M. revealed Resident #275 was sitting up in a wheelchair in her room. The door to her room had been closed. Resident #275 was sitting in the chair with no shirt on and just a bra. Resident #275's shirt was lying on the floor next to her. Resident #275 had a large dark blue/ purple bruise covering the entire left side of her neck including a portion of the upper left chest. The bilateral arms had multiple small bruises. Resident #275 rambled and was unable to explain how the large bruise to her neck occurred. Interview on 12/19/22 at 10:08 A.M. with State tested Nursing Assistant (STNA) #559 revealed she assisted Resident #275 with A.M. care and was unsure how the bruising occurred to Resident #275's neck. STNA #559 revealed Resident #275 often removed her own clothing. Interview on 12/19/22 at 10:15 A.M. with LPN #542 revealed she was Resident #275's charge nurse and was aware Resident #275 had bruising to her neck. LPN #542 revealed she normally did not work with Resident #275 and was unsure how the bruising occurred. Interview on 12/19/22 at 12:24 P.M. with Resident #275's daughter confirmed she was also Resident #275 Power of Attorney (POA)/Responsible Party. Resident #275's daughter revealed she last visited Resident #275 on 12/15/22 when she was admitted to the facility. Resident #275's daughter revealed she had not been contacted of any changes in condition by the facility regarding Resident #275 and was unaware of any bruising to Resident #275's left side of her neck. Interview and observation on 12/20/22 at 1:36 P.M. with Registered Nurse (RN) #524 confirmed he was Resident #275's charge nurse. Observation of Resident #275's bruising to the left side of her neck with RN #524 confirmed Resident #275 had a large dark blue/ purple bruise covering the entire left side of her neck including a portion of the upper left chest. RN #524 revealed he was unaware Resident #524 had bruising to her neck area. Interview and observation on 12/20/22 at 1:45 P.M. with Wound Care Nurse Licensed Practical Nurse (LPN) #532 revealed she completed a skin assessment for Resident #275 on 12/16/22 (date after admission) during the day shift. Wound Care Nurse LPN #532 revealed Resident #275 did not have any bruising to her neck when she assessed her on 12/16/22. Record review of the progress note for Resident #275 dated 12/20/22 at 3:26 P.M. completed by RN #524 revealed Resident #275 had a dark purple in color with light purple bruise from the mid breast to the left ear lobe which measured 26 centimeters (cm) in length by 11 cm in width. Resident #275 also had a dark purple bruise to the left upper arm that measured 13 cm by 12 cm. Interview on 12/20/22 at 3:21 P.M. with Director of Nursing confirmed the physician nor certified nurse practitioner (CNP) had been made aware of Resident #275's bruise to the left side of the neck. Interview on 12/20/22 at 3:38 P.M. with LPN #535 revealed she worked with Resident #275 on 12/16/22 during the evening shift, 3:00 P.M. to 11:00 P.M. LPN #535 confirmed Resident #275 had the large bruise to her left neck area at that time. LPN #375 confirmed she did not report the bruise to anyone and revealed she assumed the bruise to Resident #275's neck was present on admission.

Based on record review and interview, the facility failed to develop and implement comprehensive care plans for Resident #67's pain and Resident #66's pain and infection. This affected one resident (Resident #66) of three residents reviewed for infections and two residents (Resident #66 and #67) of five reviewed for pain. Findings include: 1. Review of the medical record for Resident #66 revealed an admitted [DATE]. Diagnoses included dementia without behavioral disturbance, fibromyalgia, muscle weakness, difficulty walking, and depression. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/24/22, revealed Resident #66 had impaired cognition. The assessment indicated Resident #66 had one fall with no injuries and Resident #66 received as needed pain medications. Review of physician order dated 08/18/22 revealed Resident #66 had order for 325 milligram (mg) tablet of Tramadol twice daily for pain, 1 drop of Gentamicin Sulfate in left eye four times per day for infection, and 250 mg Keflex once daily for infection prophylactic. Review of current care plan for 12/22/22 revealed no care plan to address Resident #66's pain or infections. Interview on 12/22/22 at 10:14 A.M. with Licensed Practical Nurse (LPN) #534 confirmed there was no care plans for pain or infection control in the current care plan for Resident #66. 42011 2. Record review for Resident #67 revealed an admitted [DATE]. Diagnosis included hypertensive heart and chronic kidney disease with heart failure. Record review of the Admission Medicare five day Minimum Data Set, dated dated dated [DATE] revealed Resident #67 was cognitively intact. Resident #67 received routine pain medication rated a five on the pain scale of one to 10. Record review of the physician orders dated 10/09/22 revealed Resident #67 had an order Chlorhexidine Gluconate solution 0.12% 30 milliliters (ml) mucous membrane two times a day for mouth pain. Record review of the current care plan for 12/22/22 revealed Resident #67 had no care plan to address pain. Interview on 12/22/22 at 10:34 A.M. with LPN #531 confirmed there was pain care plan in the current comprehensive care plan for Resident #67.

Based on record review and interview, the facility failed to maintain accurate Minimum Data Set (MDS) assessments for Resident #30 and Resident #66. This affected two residents (Resident #30 and Resident #60) of seven residents reviewed for accuracy of assessments. Findings include: 1. Review of the medical record for Resident #66 revealed an admitted [DATE]. Diagnoses included dementia without behavioral disturbance, fibromyalgia, muscle weakness, difficulty walking, and depression. Review of physician order dated 08/18/22 revealed Resident #66 had order for 325 milligram (mg) tablet of Tramadol twice daily for pain. Review of the discharge Minimum Data Set (MDS) assessment, dated 10/21/22, revealed Resident #66 had impaired cognition. The assessment indicated Resident #66 had no falls with injury. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/24/22, revealed Resident #66 had impaired cognition. The assessment indicated Resident #66 had one fall with no injuries and Resident #66 received as needed pain medications. Review of progress Notes from August 2022 to December 2022 revealed Resident #66 had falls on 09/22/22, 09/23/22, and 11/24/22. Resident #66 was reported to sustain skin tear to right elbow from the 09/22/22 fall, skin tear on bilateral arms and left thigh on 09/23/22, and skin tears to right elbow, right wrist, and right forearm at 11/24/22 fall. Interview on 12/21/22 at 3:00 P.M. with Licensed Practical Nurse (LPN) #534 confirmed she miscoded falls with injury on 09/22/22 and 09/23/22 for 10/21/22 MDS assessment and fall with injury on 11/24/22 for the 11/24/22 MDS assessment. LPN #534 confirmed she miscoded the regimented pain medication. 35768 2. Review of medical record for Resident #30 revealed an admitted [DATE]. Diagnoses included major depressive disorder, anxiety disorder, acute kidney failure and Barrette's esophagus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/02/22, revealed the resident had intact cognition. The MDS dated [DATE], 12/03/22 and current MDS assessment dated for 03/05/23 indicated Resident #30 was ordered a mechanical soft diet and a prescribed weight loss regimen. Interview on 12/20/22 at 315 P.M. with Diet Manager (DM) #501 stated Resident #30 was not on a weight loss program, the manager stated resident received a boost nutritional supplement daily. The manager stated she personally takes the menus down to resident for the resident to choose her meals because she was so picky with meals. Interview on 12/20/22 at 3:20 P.M. with Dietitian #619 stated Resident #30 was not on a weight loss program and the dietitian verified the error in documentation on the MDS. Interview on 12/20/22 at 3:38 P.M. with LPN #534 stated Resident #30 was not on a weight loss program, and verified the error in documentation on the MDS.

Based on record review and interview, the facility failed to ensure Resident #71 and #73's transfer and discharge information was included in the medical record with evidence the receiving provider received information regarding the residents care. This affected two residents (Resident #71 and #73) of five reviewed for discharge. Findings Include: 1. Review of medical record for Resident #71 revealed an initial admitted [DATE], a readmitted [DATE] and discharge date of [DATE]. Resident #71's diagnoses included Alzheimer's disease, dementia, and chronic kidney disease. Review of the discharge Minimum Data Set (MDS) assessment, dated 11/20/22, revealed the resident had impaired cognition. The resident required extensive assistance for bed mobility, transfers, ambulation. Review of the nurse progress notes dated 11/20/22 through 11/21/22 revealed Resident #71 was sent to the hospital with change in condition including heavy breathing, gray in color and gurgling. Further review of progress notes revealed no documentation indicating the resident returned to the facility, passed away in the hospital or was transferred to another facility. The medical record was silent of information provided to a receiving provider regarding Resident #71's needs. Interview on 12/20/22 at 3:49 P.M. with Social Worker (SW) #594 revealed Resident #71's son came to the facility when the resident was still in the hospital and stated he was done with the facility, the resident was now private pay, and he didn't want to pay for the room. The son gathered the residents' personal items and left. SW #594 stated the resident was her own guardian, however the son took care of her when she was at home. SW #594 believed the resident passed away while in the hospital but could not confirm it. SW #594 verified Resident #71's transfer and discharge information was not detailed in the medical record. 2. Review of medical record for Resident #73 revealed an initial admitted [DATE], a readmitted [DATE] and discharge date of [DATE]. Diagnoses included unspecified fracture of right femur, hypertension, and anxiety disorder. Review of the discharge Minimum Data Set (MDS) assessment, dated 11/17/22, revealed the resident had intact cognition. The resident required limited assistance for bed mobility, transfers, ambulation. Review of the nurse progress notes dated 10/17/22 at 7:02 A.M. revealed the nurse practitioner received Resident #73's kidney, ureter, and bladder (KUB) radiology results collected on 10/16/22, and no new orders were written. Review of Resident #73's progress note dated 10/17/22 at 2:27 P.M. revealed Resident #73 was sent to hospital per physician order. Review of Resident #73's progress note dated 10/20/22 at 9:35 A.M. revealed the resident was in the hospital, transfer notice sent to state agency, and the residents bed was not held. Further review of progress notes revealed no documentation indicating the resident returned to the facility, passed away in the hospital or was transferred to another facility. The medical record was silent of information provided to a receiving provider regarding Resident #73's needs. Interview on 12/20/22 at 3:49 P.M. with SW #594 stated Resident #73 was receiving therapy due to sustaining a fracture. SW #594 stated Resident #73 was private pay and didn't want to hold a room. SW #594 verified Resident #73's transfer and discharge information was not detailed in the medical record.

Based on record review and interview the facility failed to ensure Resident #82's diabetic medication, [MEDICATION NAME], was administered in a timely manner as ordered following the discontinuation of insulin and failed to ensure blood sugars were monitored during the delay in administration. Actual harm occurred when the facility failed to administer the [MEDICATION NAME] as ordered, the resident exhibited an acute change in condition with an elevated blood sugar ([MEDICAL CONDITION]) resulting in hospitalization in the intensive care unit. This affected one resident (Resident #82) of four sampled residents. Findings include: Review of Resident #82's closed medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility Nursing Admission Assessment, dated 12/01/17 at 5:00 P.M. revealed Resident #82 was alert and oriented with some short term memory deficit. Vital signs were stable with a slight elevation in blood pressure and pulse. Review of the hospital discharge plan titled My Discharge Plan and Hospital Stay, dated 12/01/17 revealed Resident #82 was hospitalized [DATE] through 12/01/17. Review of the hospital discharge medication management list revealed three titled areas- STOP taking these medications, START taking these medications, and CONTINUE taking these medications. The medication list was reviewed for management of diabetes during the hospitalization and upon admission to the facility. The STOP list included [MEDICATION NAME] 70/30 KwikPen (injectable insulin). The list did not identify the last dose given. The CONTINUE list included, [MEDICATION NAME] (oral hypoglycemic medication), 500 milligrams (mg.) twice daily with meals. Review of the facility admission physician orders [REDACTED]. The review revealed no indication for the use insulin. The hypoglycemic medication, [MEDICATION NAME] 500 mg., was ordered to be given twice daily at 9:00 A.M. and 5:00 P.M. for diabetes. The first dose was scheduled to be given 12/02/17 at 9:00 A.M. Review of the medication administration record (MAR) and corresponding nursing notes revealed [MEDICATION NAME] was not available and not given 12/02/17 at 9:00 A.M. The same review revealed no evidence the resident was assessed, no evidence the blood sugar was monitored and no evidence the physician was notified. Review of the MAR and corresponding nurses notes revealed [MEDICATION NAME] was not available and not given 12/02/17 at 5:00 P.M. The same review revealed no evidence the resident was assessed, no evidence the blood sugar was monitored and no evidence the physician was notified. Review of a nursing progress notes, dated 12/03/17 at 8:21 A.M., revealed Resident #82 was lethargic and short of breath. Oxygen was initiated and the resident's blood sugar level was obtained. The glucometer (device to measure blood sugar level) registered high. The physician was notified and ordered an insulin injection. Ten units of a fast acting insulin was administered. Resident #82 became more alert. Review of the same nursing notes revealed no evidence the resident's blood sugar reading was rechecked until 11:01 A.M., when Resident #82 became non-responsive to verbal and physical stimuli. The blood sugar reading continued to read high. Resident #82 remained on 3 liters of oxygen per nasal cannula but the resident's oxygen level had decreased. Respirations were shallow, labored and rapid at 28 breaths per minute. The resident's skin was cool and clammy. Resident #82 was taken by emergency transport (911) to the hospital. Review of a nurse's note dated 12/03/17 at 2:35 P.M. revealed Resident #82 was admitted to the intensive care unit. An interview was completed with the Director of Nursing (DON) on 12/20/17 at 3:40 P.M. The DON verified the record review but believed the nurse's actions were appropriate because the physician had not ordered blood sugar monitoring. Review of the facility provided Blood Glucose Monitoring In-House policy and procedure revised 03/01/14 revealed the purpose was: A. To monitor residents' blood glucose levels as ordered and as needed. To assist in determining if changes in diet or drug regimen are needed. B. To assist in determining if changes in diet or drug regimen are needed. C. To prevent complications related to abnormal blood glucose levels. The same policy revealed: A. Tests for blood glucose monitoring will be performed and documented by the licensed practical nurses (LPN's) or registered nurses (RN's) B. physician's orders [REDACTED]. C. Nursing judgement may determine need for non-scheduled blood glucose monitoring without a physician's orders [REDACTED].>Review of the manufacturer's information for glucometer blood sugar readings revealed the glucometer will register high if a blood sugar is over 500 mg/deciliter (dl). Review of the official American Diabetic Association Blood Sugar Chart revealed an individual without a diabetic [DIAGNOSES REDACTED]./dl before a meal, and less than 140 mg./dl. two hours after a meal. An individual with a diabetic [DIAGNOSES REDACTED]./dl before a meal, and less than 180 mg./dl. two hours after a meal. This deficiency substantiates Complaint Number OH 130.

Based on record review and interview the facility failed to ensure interventions were implemented to prevent the deterioration of pressure ulcers to Resident #173's bilateral heels. This resulted in harm to the resident, when the pressure ulcers deteriorated from Stage I to unstageable pressure ulcers. This affected one resident (Resident #173) of four residents reviewed for pressure ulcers. Findings Include: Review of Resident #173's closed medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed the resident was discharged from the facility on 09/12/14. Review of the nursing history and assessment, dated 07/26/14 revealed Resident #173 had impairment to the right and left heels described as red and soft. A physician order, dated 07/26/14 was in place to float bilateral heels with pillow when in bed to enhance skin integrity. Review of the Minimum Data Set (MDS) 3.0 assessments, dated 08/02/14 and 08/09/14 revealed the resident had four Stage I (an observable pressure-related alteration of intact skin, whose indicators as compared to adjacent or opposite area on the body may include changes in consistency including firm or boggy appearance) pressure ulcers. The MDS assessment, dated 08/23/14 revealed the resident had two unstageable (due to the presence of slough and/or eschar to the wound bed) pressure ulcers. Review of the treatment flow sheet, dated 08/06/14 revealed Resident #173's bilateral heels were soft and red. On 08/13/14 the treatment flow sheet revealed Resident #173's left and right heels declined to red and boggy. Review of Resident #173's care plan and physician orders [REDACTED]. The treatment flow sheet dated, 08/20/14 revealed Resident #173's bilateral heels were assessed to have declined. The right heel developed a five centimeter by five centimeter area that was described to be 100% eschar (defined as a piece of dead tissue that was cast off from the surface of the skin). The left heel developed a five centimeter by four centimeter area that was also described to be 100% eschar. On 08/20/14 the consultant wound nurse practitioner began assessing the resident's pressure ulcers. A flow sheet, dated 08/20/14 and completed by the nurse practitioner revealed the resident had an area to right heel measuring five centimeters in length by five centimeters width and an area to the left heel measuring five centimeters in length by four centimeters width. Both heels were described as firm, pink and blanchable with 100% eschar. An order was written by the physician on 08/20/14 for skin prep to both heels, to pad and protect and secure with a Kerlix. On 12/17/14 at 10:30 A.M. interview with registered nurse (RN) #20 verified the pressure ulcers to Resident #173's heels had deteriorated from 07/26/14 when they were assessed to be Stage I pressure ulcers to 08/20/14 when they were assessed to be unstageable pressure ulcers with no evidence of any new interventions being implemented for the resident to prevent the deterioration.