Every finding on record at Bridgeport Health Care Center

Based on resident record review, review of the of the facility Self-Reported Incident (SRI) form, interviews, and review of facility policy, the facility failed to ensure an incident of resident elopement was appropriately identified and addressed according to the policy implemented by the facility. This affected one resident (#90) out of the three residents reviewed for elopement. The facility census was 88. Findings include:Closed record review for Resident #90 revealed the resident was admitted to the facility on [DATE] with diagnoses including intracranial injury with loss of consciousness, epilepsy, repeated falls, and need for assistance with personal care.Review of the facility Nursing admission Assessment, dated 05/20/26, revealed Resident #90 was assessed to not be at risk for elopement. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 05/25/26, revealed Resident #90 was assessed to have impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 12/15. The resident was assessed to have had two or more falls with no injury since admission or the prior assessment, whichever was more recent. Review of the progress notes, dated 05/20/26 through 06/01/26, revealed no documentation of Resident #90 leaving the facility without staff knowledge or supervision. On 06/01/26, the resident was documented to be discharged to the group home.Review of the facility SRI form, dated 06/05/26 and timed 12:21 P.M., revealed on 06/04/26 Ombudsman #900 entered the building and alleged the discharge of Resident #90 on 06/01/26 may be considered an elopement. On 06/01/26 at approximately 6:45 P.M., Resident #90 left the facility with the intent to return to his group home, less than a mile from the facility. Resident #90, when interviewed by the Director of Nursing (DON), stated his intent was to return to living at the group home and once he arrived at the group home, he was readmitted under their care. Resident #90 was alert and oriented with a BIMS assessment score of 14/15, who was assessed on admission to not be at risk of elopement. Resident #90 arrived at the group home independently without incident and voiced he left the facility because he felt he was ready to return to the group home (his previous living situation). Discharge was coordinated with the group home, and all discharged medications were called in to the local pharmacy and follow-up appointments scheduled. Follow-up call to the group home by Administrator on 06/02/26 made with no concerns voiced.During an interview on 06/26/26 at 8:15 A.M., the Administrator and DON confirmed no residents had eloped from the facility in the past three months. They confirmed Resident #90 had left and went back to the group home, but the resident had a BIMS assessment score of 14 indicating he was cognitively intact and the facility did not have paperwork indicating the resident had a legal guardian. During a telephone interview on 06/26/26 at 9:35 A.M., Resident Representative (RR) #888 confirmed she had been appointed guardian for Resident #90 approximately nine years prior and had paperwork for the guardianship which had never been requested by the facility. RR #888 confirmed Resident #90 had a traumatic brain injury, became confused at times, and was not always able to make safe decisions. RR #888 confirmed on 06/01/26, at approximately 8:00 P.M., she received a telephone call from Group Home Supervisor (GHS) #655 informing her Resident #90 was sitting on the couch of the group home. RR #888 confirmed she had not been made aware Resident #90 was returning to the group home, so she called the facility. RR #888 confirmed the DON called her back and stated she would drive to the group home to check on the resident. RR #888 confirmed she was concerned regarding how the resident was able to leave without staff knowledge. RR #888 confirmed Resident #90 had to walk across active railroad tracks and busy streets to return to the group home located over a mile from the facility and had fallen several times in the past with injuries that had resulted in hospitalization. RR #888 confirmed she had agreed to allow Resident #90 to be admitted back to the group home on [DATE] since he wanted to stay there. During a telephone interview on 06/26/26 at 9:50 A.M., GHS #655 confirmed she lived across the street from the group home Resident #90 lived in prior to going to the facility. GHS #655 confirmed Resident #90 had fallen several times and had to be admitted to the facility for therapy services. GHS #655 confirmed sometime during the evening of 06/01/26, she received a telephone from an employee at the group home stating Resident #90 was sitting on the couch inside the home. GHS #655 confirmed she was surprised because she had no idea he was coming. GHS #655 confirmed she called RR #888 who was the residents guardian to see if she knew he was coming back to the group home, and she was also not aware. GHS #655 confirmed the DON of the facility came to the group home to check on Resident #90, and the resident wanted to remain at the facility, so it was agreed by all the resident would remain there. GHS #655 confirmed there were busy roads between the facility and the group home Resident #90 would have had to cross which were not safe for him to walk alone. GHS #655 confirmed she had a copy of the guardianship paperwork indicating RR #888 was Resident #90's court appointed guardian but had never been asked to provide a copy to the facility. During a telephone interview on 06/26/26 at 9:55 A.M., Ombudsman #900 confirmed RR #888 was the guardian of Resident #90. Ombudsman #900 confirmed Resident #90 exited the facility alone and unbeknownst to staff on 06/01/26 and walked across railroad tracks and busy streets to get to the group home located approximately one mile from the facility. Ombudsman #900 confirmed facility staff were not aware Resident #90 had left the facility until they were contacted by RR #888. Ombudsman #900 confirmed the facility was denying Resident #90 had eloped from the facility, but per their policy he did elope. During an interview on 06/26/26 at 11:24 A.M., Social Service Designee (SSD) #200 confirmed she had requested documentation of guardianship for Resident #90 from RR #888, but it was never produced. SSD #200 confirmed the request for guardianship paperwork and failure to provide it had not been documented in the resident's medical record. SSD #200 confirmed RR #888 was listed as Resident #90's guardian in the resident's electronic health record maintained by the facility. SSD #200 confirmed Resident #90 exited the facility sometime after dinner on 06/01/26 without staff knowledge and returned to the group home he had resided in prior to being admitted to the facility. SSD #200 confirmed the DON went to the group home after being notified Resident #90 was there and it was agreed the resident would be discharged from the facility to the group home at that time.During an interview on 06/26/26 at 12:04 P.M., the DON confirmed the facility was unaware Resident #90 had left the facility until RR #888 called in stating he was at the group home. The DON confirmed she went to the group home upon learning he was there and assessed him with no injuries assessed or reported by the resident. The DON confirmed she and other administrative staff returned to the facility following Resident #90 leaving and interviewed all staff present. The DON confirmed the last time staff reported observing the resident was at approximately 6:30 P.M. on 06/01/26 when picking up his dinner meal tray and confirmed she had received the telephone call from facility staff at approximately 8:00 P.M. on 06/01/26 reporting the resident had left the facility and was at the group home. The DON confirmed Resident #90 leaving the facility without staff knowledge and staff not having knowledge of his whereabouts until they were notified by RR #888 was determined to not be an elopement, despite the incident matching the definition of elopement contained in the facilities policy. During an interview on 06/26/26 at 12:28 P.M., the Administrator confirmed Resident #90 had left the faciity on [DATE] at approximately 6:45 P.M. unbeknownst to staff and returned to the group home. The Administrator confirmed staff were not aware of the resident's whereabouts until notified by RR #888 at approximately 8:00 P.M. on 06/01/26. The Administrator confirmed Resident #90 leaving the facility without staff knowledge and staff not having knowledge of his whereabouts until they were notified by RR #888 was determined to not be an elopement, despite the incident matching the definition of elopement contained in the facilities policy.Review of the facility policy titled Elopement Prevention and Management Overview, printed on 06/11/26, revealed elopement is defined as when a resident/patient leaves the premises or a safe area without authorization and/or any necessary supervision and places the resident at risk for harm or injury. A situation in which a resident with decision-making capacity leaves the facility intentionally would generally not be considered an elopement unless the facility is unaware of the resident's departure and/or whereabouts. This deficiency represents non-compliance investigated under Complaint Number 3032299.

Based on observations, interviews, and record reviews, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately completed. This affected four residents (#9, #11,#27, and #86) out of the 26 residents whose MDS assessments were reviewed during the annual survey. The facility census was 85. Findings include:1. Record review for Resident #9 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included major depressive disorder, schizophrenia, and morbid obesity. Review of Section K of the quarterly Minimum Data Set (MDS) assessment, dated 08/05/25, revealed the resident was assessed to weight 208 pounds and to not have had a weight loss of over five percent in the past month or ten percent or more in the last six month. Review of the documented weights for the resident revealed the resident weighed 228.4 pounds on 07/01/25 and 207.6 pounds on 08/01/25 resulting in a loss of 20.8 pounds or 9.11 percent of the residents body weight. Interview with Registered Dietitian #233 on 08/27/25 at 1:45 P.M. confirmed Resident #9 had experienced a weight loss of 20.8 pounds from 07/01/25 to 08/01/25 which was equal to a 9.11 percent body weight loss in one month. Registered Dietitian #233 confirmed the quarterly MDS assessment for Resident #9 was dated 08/05/25 and the resident had experienced a weight loss of more than five percent in the 30 days prior to the assessment. 2. Record review for Resident #86 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included heart disease, Chronic Obstructive Pulmonary Disorder (COPD), and chronic respiratory failure. Review of Section O of the quarterly MDS assessment, dated 08/08/25, revealed the resident was assessed to have not received oxygen while a resident of the facility during the 14-day lookback period. Review of the physicians order, dated 05/30/25, revealed the resident was to be administered oxygen at a rate of three liters per minute by nasal cannula continuously. Interview with MDS Licensed Practical Nurse (LPN) #63 on 08/26/25 at 2:03 P.M. confirmed Resident #86 was documented to have been administered oxygen as ordered during the 14-day lookback period for the MDS assessment dated [DATE]. MDS LPN #63 confirmed Section O of the MDS assessment had been completed inaccurately. 3.Review of the medical record for Resident #27 revealed an admission date of 04/23/25 with diagnoses including hemiplegia, hemiparesis, dementia, hyperlipidemia, depression and anxiety. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #27 was cognitively intact and had impaired range of motion to one side upper extremities and lower extremities. Resident #27 needed supervision of staff to complete oral hygiene and partial to moderate assistance with personal hygiene. Resident #27 had no weight loss and no broken or loosely fitting dentures or partials. Review of the dental consult form completed by on site dentist dated 03/31/25 (prior admission) revealed Resident #27 had heavy plaque, moderate calculus, and missing teeth. Resident #27 had a upper and lower partial that did not fit. No follow up visit scheduled. Review of the nursing admission assessment dated [DATE] revealed Resident #27 had no natural teeth or tooth fragments and was edentulous. The assessment did not include Resident #27 had upper and lower partial. Observation on 08/26/25 at 10:16 A.M. of Resident #27 revealed he had approximately six or seven teeth that had heavy plaque. He was not wearing a partial. Interview on 08/27/25 at 3:01 P.M. with Resident #27 revealed he had an upper and lower partial that did not fit. Resident #27 stated he did not wear them because they were loose in his mouth. The resident denied any pain at this time or chewing problems with his teeth. Interview on 08/28/25 at 11:00 A.M. with Minimum Data Set (MDS) Registered Nurse (RN) #65 confirmed Resident #27 had few teeth remaining and per Resident #27 record he had an upper and lower partial. MDS RN #65 also confirmed the MDS quarterly assessment dated [DATE] was incorrectly marked that Resident #27 was edentulous and did not have broken or loosely fitting partial. 4.Review of the medical record for Resident #11 revealed an admission date of 04/15/25 with diagnosis including hypertensive heart failure, hemiplegia, hemiparesis, diabetes mellitus type two, ischemic cardiomyopathy, anxiety, depression and mood disorder. Review of the physician orders dated 08/25 revealed Resident #27 did not have any active orders for insulin. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #27 was cognitively impaired and required assistance to complete activities of daily living. Review of the medication section of the MDS revealed Resident #27 received seven injections of insulin during the look back period of the assessment. Interview on 08/28/25 at 12:15 P.M. with MDS RN #65 confirmed Resident #11 was coded on the MDS dated [DATE] that he received seven injections of insulin during the look back period.

Based on record review,observation, and interview the facility failed to ensure the dental status care plan was completed accurately. This affected two residents (#27 and #35) of three residents reviewed for dental care. The facility census was 85. Findings include:1.Review of the medical record for Resident #27 revealed an admission date of 04/23/25 with diagnoses including hemiplegia, hemiparesis, dementia, hyperlipidemia, depression and anxiety. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #27 was cognitively intact and had impaired range of motion to one side upper extremities and lower extremities. Resident #27 needed supervision of staff to complete oral hygiene and partial to moderate assistance with personal hygiene. Resident #27 had no weight loss and no broken or loosely fitting dentures or partials. Review of the dental consult form completed by on site dentist dated 03/31/25 (prior admission) revealed Resident #27 had heavy plaque, moderate calculus, and missing teeth. Resident #27 had a upper and lower partial that did not fit. No follow up visit scheduled. Review of the nursing admission assessment dated [DATE] revealed Resident #27 had no natural teeth or tooth fragments and was edentulous. The assessment did not include Resident #27 had upper and lower partial. Review of the plan of care initiated on 06/18/25 and revised on 08/28/25 (after surveyor confirmed plan was incomplete) revealed Resident #27 had oral/dental problems. The goal stated Resident #27 would be free of infection, pain, or bleeding in the oral cavity through the target date of 09/16/25. The interventions included to observe for signs and symptoms of infection such as abscess, swelling, fever, pain or redness. Observation on 08/26/25 at 10:16 A.M. of Resident #27 revealed he had approximately six or seven teeth that had heavy plaque. He was not wearing a partial. Interview on 08/27/25 at 3:01 P.M. with Resident #27 revealed he had an upper and lower partial that did not fit. Resident #27 stated he did not wear them because they were loose in his mouth. The resident denied any pain at this time or chewing problems with his teeth. Interview on 08/27/25 at 3:20 P.M. with Social Services Designee #33 revealed she scheduled ancillary services/appointments. The dental service and vision service was random however she did receive an email from the dentist about making a schedule for next visit. Social Service Designee #33 stated she made an appointment with an outside provide for Resident #27 to see about getting new upper and lower partial plates, however, the resident did not quality. The facility failed to provide evidence of the visit. Interview on 08/28/25 at 11:00 A.M. with Minimum Data Set (MDS) Registered Nurse (RN) #65 confirmed Resident #27 had few teeth remaining and per Resident #27 record he had an upper and lower partial. MDS RN #65 also confirmed the dental plan of care was not completed accurately. 2. Record review for Resident #35 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included heart failure, dementia, and need for assistance with personal care. Review of the state optional Minimum Data Set (MDS) assessment, dated 07/09/25, revealed the resident was assessed to have mildly impaired cognition. Review of the care plan, dated 08/08/25, revealed the resident had oral/dental problems-dentures. Interventions included complete oral assessment upon admission and as needed, dental consult as needed, and provide oral care as needed. Observation and interview with the Director of Nursing (DON) on 08/28/25 at 9:00 A.M. confirmed Resident #35 had her own teeth present in her mouth and did not have dentures. Interview on 08/28/25 at 11:00 A.M. with Minimum Data Set (MDS) Registered Nurse (RN) #65 confirmed the care plan for Resident #35 was inaccurate as it had been completed as though the resident had dentures and not her own natural teeth.

Based on observations, interviews, and record reviews, the facility failed to ensure resident medications were not left at the bedside unattended. This affected one resident (#13) out of the 24 residents observed during the initial pool process. The facility census was 85.Findings include:Record review for Resident #13 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included epilepsy, hemiplegia and hemiparalysis affecting the left non-dominant side, and contracture of the left hand.Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/18/25, revealed the resident was assessed to have impaired cognition.Observation on 08/25/25 at 10:27 A.M. revealed Resident #13 was lying in bed with a tray table placed over the residents abdomen. The resident had a clear plastic medicine cup which was empty sitting on top of the tray table. Several pills were lying on top of the tray table and the resident was pushing them around with his fingers. No facility staff were present in the room. Interview with Resident #13 at the time of the observation confirmed the pills were his and he was going to take them. At 10:32 A.M. Licensed Practical Nurse (LPN) #143 was walking down the hallway pushing a medication cart and was asked to come into Resident #13's room. LPN #143 entered the room and observed the pills lying on top of Resident #13's tray table. LPN #143 confirmed they were the residents morning medications and assisted the resident to take the medications. LPN #143 confirmed it was difficult to get Resident #13 to take his medications, and they had been left in his room without staff supervision. LPN #143 confirmed nurses were to remain with residents until they had taken all medications.

Based on record review, resident and staff interview the facility failed to complete an accurate comprehensive assessment for Resident #28, #47 and #74. This affected three residents (Resident #28, #47 and #74) of thirteen reviewed for comprehensive assessments. The facility census was 86 in house. Findings include: 1. Review of the medical record for Resident #28 revealed an admitted [DATE] with diagnoses including hypertension, diabetes mellitus type two, hyperlipidemia, muscle weakness and difficulty walking. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #28 had clear speech and was rarely understood therefore the Brief Interview Mental Status (BIMS) was not completed. Resident #28 was coded as modified independence with decision making. Resident #28 required staff assistance to complete activities of daily living. An interview on 01/14/25 at 4:02 P.M. with Resident #28 confirmed the resident was alert and oriented with clear speech. An interview on 01/15/25 at 3:50 P.M. with the Director of Nursing (DON) confirmed Resident #28 had clear speech and would be able to complete the BIMS interview. The DON confirmed the MDS dated [DATE] revealed Resident #28 had unclear speech and was unable to be assessed for BIMS. The DON stated Resident #28 refused to participate in the interview. Review of the Resident Assessment Instrument Manual revealed if the resident was at least sometimes understood the interview should be attempted. If a resident refused to answer a particular item, accept the refusal and move on to the next question. The interviewer may stop the interview and code the answer 0 if there had been no verbal or written response to any of the question up to section C0300C-the day of the week and the resident chooses to not answer (refusal). 2. Review of the medical record for Resident #47 revealed an admitted [DATE] with diagnoses including cerebral infarction, hemiplegia/hemiparesis affecting the right side, dysphagia, and diabetes mellitus type two. Review of the admission MDS dated [DATE] revealed Resident #47 range of motion was not assessed. Resident #47 required assistance from the staff to complete activities of daily living. Review of the quarterly MDS dated [DATE] revealed Resident #47 was independent with decision making with no behaviors. Resident #47 had no impaired range of motion to his bilateral upper extremities or bilateral lower extremities. Resident #47 was coded as not using any device for mobility. An observation on 01/14/25 at 1:45 P.M. of Resident #47 revealed the resident's right hand was closed in a fist. The resident was unable to open his hand upon request. An interview on 01/15/25 at 3:50 P.M. with the Director of Nursing (DON) revealed the DON was not aware Resident #47 had a contracture to his right hand. The DON also confirmed the MDS dated [DATE] and 10/31/24 were not coded correctly. An observation of Resident #47 along with Occupational Therapist (OT) #143 on 01/16/25 at 10:30 A.M. confirmed Resident #47 had a contracture to his right hand. 3. Review of the medical record for Resident #74 revealed an admitted [DATE] with diagnoses including epilepsy, cerebral infarction, traumatic subdural hemorrhage and bipolar disorder. Review of annual MDS dated [DATE] revealed Resident #74 had clear speech but was coded as rarely understood. Resident #74 required staff assistance to complete activities of daily living. Interview on 01/14/25 at 4:07 P.M. with Resident #74 revealed the resident had clear speech and was oriented to person and place. An interview on 01/15/25 at 3:50 P.M. with the Director of Nursing (DON) confirmed Resident #74 had clear speech and would be able to complete the BIMS interview. The DON confirmed the MDS dated [DATE] revealed Resident #74 had unclear speech and was unable to be assessed for BIMS. The DON stated Resident #74 refused to participate in the interview. Review of the Resident Assessment Instrument Manual revealed if the resident was at least sometimes understood the interview should be attempted. If a resident refused to answer a particular item, accept the refusal and move on to the next question. The interviewer may stop the interview and code the answer 0 if there had been no verbal or written response to any of the question up to section C0300C-the day of the week and the resident chooses to not answer (refusal).

Based on observation, record review and interview the facility failed to develop and implement a comprehensive and individualized range of motion program to timely identify and implement therapy recommendations to treat and prevent potential worsening of a right-hand contracture for Resident #47, a resident admitted to the facility with diagnosis of cerebral infarction, hemiplegia/hemiparesis affecting the right side. This affected one resident (#47) of one resident reviewed for range of motion. The facility census was 86. Findings include: Review of the medical record for Resident #47 revealed an initial admitted [DATE] with diagnoses including cerebral infarction, hemiplegia/hemiparesis affecting the right side, dysphagia, chronic obstructive pulmonary disease and diabetes mellitus type two. Review of the admission nursing assessment dated [DATE] revealed Resident #47 did not have any contractures to the bilateral upper extremities. Review of an Occupational Therapy (OT) evaluation dated 06/27/24 revealed it did not assess Resident #47's range of motion to right upper extremity. The evaluation noted Resident #47 had hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. Review of Resident #47's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had unclear speech and was rarely understood with no memory problem. Review of the mood and behaviors section of the assessment revealed Resident #47 had little interest or pleasure in doing things, feeling tired, trouble with sleep, trouble with concentrating but did not have any behaviors. Resident #47 was totally dependent on staff for activities of daily living per section G. The assessment did not address range of motion. Review of an OT treatment note dated 08/05/24 revealed OT was providing joint mobilization and assisted active range of motion to right upper extremity. The recertification also noted to add a splint to the right hand as it was becoming contracted. Review of the physician's orders for August and September 2024 revealed no orders for a hand splint device or range of motion to the resident's upper extremities. Review of an OT treatment note dated 10/01/24 revealed Resident #47 received orthotic training on use of palm guard for three hours to right hand with no signs and symptoms of decreased skin integrity. Review of an OT treatment note dated 10/03/24 revealed Resident #47 was noted with increased tone throughout his right upper extremity. Resident #47 had decreased tolerance with ranging of right hand. Resident #47 was at risk for skin breakdown in palm of right hand. Review of an OT treatment note dated 10/21/24 revealed Resident #47 was seen for completing staff education as appropriate related to the palm guard. OT placed folded soft device in hand. Per facility policy, nursing to write the order and complete the plan of care for palm guard (to right hand). Resident discharged from OT services this date. Review of Resident #47's quarterly MDS assessment dated [DATE] revealed the resident was rarely understood, was independent in decision making, had no behaviors, had no impaired range of motion to bilateral upper and lower extremities, and was dependent on staff for activities of daily living. Review of Resident #47's medical record in October 2024, including occupational therapy notes, revealed no evidence the facility assessed the severity of Resident #47's right upper extremity impairment at this time. Review of the physician's orders from October through December 2024 revealed no orders for a hand splint device and range of motion to upper extremities to Resident #47 right hand were written. Review of the physician's orders for January 2025 revealed no orders for a hand splint device, range of motion to upper extremities, or specific skin treatment to Resident #47 right hand. Review of Resident #47's plan of care revealed no care plan addressing the resident's contracture to his right hand. An observation on 01/14/25 at 1:45 P.M. of Resident #47 revealed the resident's right hand was closed in a fist. The resident was unable to open his hand upon request. An observation on 01/15/25 at 9:05 A.M. of Resident #47 revealed the resident's right hand remained closed in a fist. An interview with Resident #47 at the time of the observation revealed the resident responded no when asked if he had a device to put on his right hand, and that no one stretched his hand. An interview on 01/15/25 at 9:29 A.M. with Licensed Practical Nurse (LPN) # 203 confirmed Resident #47 did not have any orders for a splint, carrot or any device for his right hand (to address the identified contracture). In addition, LPN #203 stated the facility did not currently have a restorative program. An interview on 01/15/25 at 1:45 P.M. with Certified Nursing Assistant (CNA) # 124 revealed the CNA provided care for Resident #47. CNA #47 stated she did not provide range of motion or a device to the right hand of Resident #47 as part of the resident's routine care. An interview on 01/15/25 at 3:50 P.M. with the Director of Nursing (DON) revealed the DON was not aware Resident #47 had a contracture to his right hand. The DON confirmed there were no orders to care for the contracture or skin of Resident #47's right hand. The DON stated she would call the physician for orders for skin care and a therapy evaluation at this time. An observation of Resident #47 along with Occupational Therapist (OT) #143 on 01/16/25 at 10:30 A.M. confirmed Resident #47 had a contracture to his right hand. At the time of the observation, Resident #47 refused to permit OT #143 to stretch out his hand. OT #143 stated Resident #47 had been on therapy case load and was discharged in October 2024 (with recommendations for contracture management). OT #143 also confirmed Resident #47 did not currently have any kind of device for his right hand to keep it stretched out, prevent decline in range of motion or worsening of the contracture. OT #143 stated Resident #47 initial/admission therapy evaluation did not indicate the resident had a contracture of his right hand and it was possible that Resident #47 range of motion to right hand would become worse without treatment and care. A telephone interview on 01/23/25 at 12:10 P.M. with OT #143 revealed OT #143 did not complete the admission therapy evaluation for Resident #47. OT #143 did complete an evaluation for the contracture of Resident #47's right hand on 01/16/25. OT #143 stated the contracture did not visibly appear worse than it was when she saw it in 10/2024. OT #143 also verified there were no measurements taken of the resident's range of motion of the right hand in 10/2024 to compare to the measurements she did on 01/16/25. OT #143 stated the admission evaluation did not include range of motion and it was not required to. An interview on 01/23/25 at 3:15 P.M. with the Administrator revealed Resident #47's October 2024 MDS was incorrect, and it should have been coded the resident had impairment to his upper extremity. The facility did not have a policy on prevention of decline in range of motion per the Administrator.

Based on review of the Self Reporting Incident (SRI), record review, and interview the facility failed to implement individualized interventions and revise the care plan to address the Resident #69's dementia care needs related to sexual behaviors. This affected one resident (Resident #69) of one reviewed for dementia care. The facility census was 86. Findings include: Review of the medical record of Resident #69 revealed an admitted [DATE] with diagnoses including unspecified dementia, anxiety, hypertension and hyperlipidemia. Resident #69 had a durable power of attorney (DPOA) listed in the medical record. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #69 had severe cognitive impairment with a Brief Interview of Mental Status (BIMS) score of three with no behaviors. Resident #69 required supervision of staff to complete activities of daily living. Review of SRI #256217 dated 01/17/25 revealed Resident #69 was observed by staff in a sexual act with Resident #64. The facility was completing the investigation. However, the investigation revealed both residents were interviewed, assessed and monitored for psychosocial adverse effects. The staff were interviewed along with other residents with no concerns. The Social Worker had provided education to both Resident #64 and Resident #69 about safe sexual relationships. The Social Worker also spoke to both residents about a plan for future sexual encounters. Resident #64 and #69 agreed that if they wanted to have a sexual encounter they would inform the staff so that privacy would be provided. Review of Resident #69's medical record revealed no evidence the facility discussed Resident #69's plan to provide privacy for sexual contact with the resident's DPOA or physician. The plan of care had not been revised with interventions to address the sexual contact as well. Interview on 01/22/25 at 1:10 P.M. with Resident #69 DPOA revealed the facility had notified her of the sexual encounter. However, the facility had not informed her or discussed with her the plan to provide privacy for the residents to have a sexual relationship. The DPOA stated Resident #69 was not able to make safe, right or wrong decisions. Interview on 01/22/25 at 1:55 P.M. with Resident #69 revealed the resident was alert and oriented to person and place. Resident #69 denied any knowledge of the event or the discussion with Social Worker about the plan for privacy. A phone interview on 01/22/25 at 2:18 P.M. with Resident #69's nurse practitioner, who provided services to Resident #69, confirmed Resident #69 had dementia, confusion and was not cognitively able to make safe decisions on his own. Interview on 01/22/25 at 3:09 P.M. with the Director of Nursing (DON) confirmed the facility did not inform or discuss the plan for privacy for Resident #64 and #69 with the DPOA of Resident #69. DON revealed the licensed social worker (LSW) completed a sexual consent form provided by corporate and completed it on both residents. Both residents were assessed to be able to consent to a sexual relationship. Review of the facility policy titled Dementia Care revealed it is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Safety is a primary concern for the residents, staff and visitors. Residents with dementia and/or dementia-related diagnoses will be treated with the same respect and dignity and afforded the same resident rights regardless of diagnoses, severity of condition or payment source . The policy continued with resident representatives will be communicated with for resident needs, updated, and notification as required by law. This deficiency represents non-compliance investigated under Complaint Number OH00161778.

Based on medical record review, staff interview, observation, and facility policy review, this facility failed to ensure enhanced barrier protection including gloves were in place during wound care. This affected one (Resident #126) of the three residents reviewed for wound care. The facility census was 91. Findings include: Review of the medical record for Resident #126 revealed and admitted [DATE]. Diagnoses included type two diabetes mellitus, foot ulcers, and peripheral vascular disease. Review of Resident #126's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating a moderately impaired cognition for daily decision making abilities. Resident #126 was noted to have one venous and arterial ulcer, and a diabetic foot ulcer. Review of the care plan dated 03/20/24 and revised 04/13/24 revealed Resident #126 had impaired skin integrity, or was at risk for altered skin integrity due to right lateral foot ulcer, left skin skin tear, right knee skin tear, right top foot skin tear, left lateral foot arterial ulcer, left groin surgical, and left forearm skin tear. Interventions include to complete daily skin checks, and complete treatments as ordered. Review of treatment orders for Resident #126 revealed the following: -Cleanse with house wound cleanser, apply Calcium Alginate to areas on right lateral foot, cover with gauze and Kerlix. -Cleanse wound to dorsal right foot with normal saline solution, pat dry and apply Betadine to wound bed, and leave open to air daily. -Cleanse wound to left lateral foot with normal saline solution, pat dry apply Betadine to wound bed and leave open to air daily. -Cleanse wound to left lateral heel with normal saline solution or wound cleanser, apply Medihoney to wound bed and cover with gauze and wrap with Kerlix every day shift. -Cleanse wound to left shin with normal saline solution, pat dry apply skin prep to wound bed and leave open to air daily. -Cleanse wound to right foot 5th digit with normal saline solution, apply skin prep to wound bed and leave open to air daily. -Cleanse wound to right knee with normal saline solution, pat dry apply skin prep to wound bed and leave open to air daily. -Cleanse wound to top of left foot with normal saline solution, pat dry apply Betadine to wound bed and leave open to air daily. Observation on 05/07/24 at 11:22 A.M. revealed during general observations Resident #126's room door was open and Licensed Practical Nurse (LPN) #135 could be seen completing a dressing change for Resident #126. Continued observation revealed LPN #135 did not have a gown or gloves on and was observed using a split gauze to spray house wound cleanser on and then cleanse the resident wound which appeared to be on the right lower leg. LPN #135 continued to opened a bandage package, applied ointment to the bandage and then placed the bandage directly on the wound followed by opening another bandage package, applied ointment to the bandage and placed it on the residents other wound. LPN #135 was then observed leaving the residents room without washing her hands. Interview on 05/07/2024 at 11:24 A.M. with LPN #135 revealed when starting the dressing change, she had gloves on but removed them due to getting Betadine on the gloves. LPN #135 confirmed she did not have gloves or a gown on during dressing change for Resident #126. LPN # 135 also confirmed she did not wash her hands prior to exiting the resident room. Interview on 05/07/2024 at 11:38 A.M. with the Administrator confirmed residents with chronic wounds, including Resident #126 should be in enhanced barrier precaution isolation which included the use of gloves and gown when completing care such as wound care. Review of the facility policy titled Standard Precautions, dated 06/24/2021 revealed under section II. When to perform Hand Hygiene, B. Before and after direct contact with a resident's intact skin. C. After contact with blood, body fluids or exertions, mucous membranes, non-intact skin or wound dressing. This deficiency was an incidental finding during investigation for Master Complaint Number OH00153465.

Based on observation, medical record review, staff interview, and policy review, the facility failed to monitor Resident #36's skin under a splint/boot on the left foot to prevent the development of a pressure ulcer. Actual harm occurred on 12/26/23 when Resident #36, who was cognitively impaired was identified to have a deep tissue injury (DTI) pressure ulcer (described as intact skin with a localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) to the left foot caused by a splint. The splinting device had been implemented following a fracture on 12/18/23. However, staff failed to monitor/assess the resident's skin integrity under the splint resulting in the DTI pressure ulcer development. On 01/2224 the pressure ulcer was assessed to be unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar). This affected one resident (#36) of three residents reviewed for pressure ulcers. The facility census was 92. Findings include: Review of the medical record for Resident #36 revealed an admitted [DATE] and diagnoses including cerebrovascular disease, dementia, and diabetes. The resident resided on the secured dementia unit. Review of a quarterly Minimum Data Set assessment dated [DATE] revealed the resident had a brief interview for mental status score of five (5), indicating severe cognitive impairment. The assessment also reflected the resident required substantial/maximal assistance with bed to chair transfers and walking was not attempted (during the assessment period) due to medical condition/safety. Review of a nursing progress note revealed on 12/18/23 at 4:15 P.M. (documented as a late entry on 12/20/23 at 8:46 P.M. by Licensed Practical Nurse (LPN) #139) the nurse was called to Resident #36's room by aide. The resident had sustained a fall. The resident was subsequently transported to the hospital for an evaluation and treatment. Review of hospital records from 12/20/23 revealed the resident arrived (to the hospital) with a left leg fracture after a fall. The record noted the resident had a fracture of tibia and fibula after a fall at the nursing home. A splint was applied to the left leg and instructions were given to follow up with orthopedics. The hospital instructions further stated to monitor for any swelling or breakdown around the splint. Review of a nursing progress note dated 12/20/23 at 10:20 P.M. revealed Resident #36 returned from the hospital. Review of physician's orders revealed an order dated 12/21/23 for an ace bandage to lower left extremity. The order indicated to leave in place until follow up with orthopedic (the order did not address the splint that was applied at the hospital on 12/20/23). There was no order written to monitor the skin around or under the brace at that time (and as per the hospital instructions). A plan of care dated 12/21/23 revealed the resident had a fractured left tib/fib, had impaired skin integrity or was at risk for altered skin integrity. The care plan did not include monitoring the resident's skin under the splint/boot A nursing progress note dated 12/22/23 at 9:45 A.M. revealed the resident was out of the facility for appointment with orthopedics. On 12/22/23 at 12:00 P.M. the resident returned from the appointment. However, the facility did not have any physician notes from this orthopedic appointment. Review of Resident #36's medical record revealed there was no evidence the skin under the brace was monitored until 12/26/23 when the wound nurse practitioner noted a deep tissue injury (DTI) to the top of the left foot measuring 2.0 centimeters (cm) long by 3.0 cm wide acquired on 12/26/23. On 12/26/23 the wound nurse practitioner recommended to cleanse the top of the left foot DTI with wound cleanser, apply skin prep, and leave open to air. The resident's plan of care was updated on 12/26/23 to monitor for skin breakdown under the splint/boot when check skin every two hours under brace and notify physician of any concerns was added to the plan of care. On 12/26/23 staff also documented on the care plan the resident had acquired an unstageable pressure ulcer of the left foot in the facility from an orthotic boot. An order was written on 12/26/23 to check skin every two hours under brace and notify physician of any concerns (six days after a splint was applied and after a pressure ulcer had already developed). Review of physician's orders and the treatment administration records (TAR) from December 2023 and January 2024 revealed a treatment was not initiated until 01/10/24 (15 days after the wound nurse practitioner made a treatment recommendation) to cleanse top of left foot pressure wound with in house wound cleanser, pat dry, apply Betadine and cover with ABD (padded gauze) for protection from Ortho boot. Review of wound nurse practitioner notes revealed on 01/02/24 the area on the top of the left foot was larger (3.5 cm long by 3.5 cm wide) with the same treatment recommended as on 12/26/23 (not implemented until 01/10/24). Review of a nursing progress note dated 01/02/24 at 12:49 P.M. revealed Resident #36 returned without a follow up summary from an orthopedic appointment. Orthopedic office attempted to be contacted to request details of appointment without success. Review of orthopedic physician consult notes dated 01/02/24 revealed Resident #36 was placed in a short leg walking boot with instructions to remove the boot for hygiene as well as evaluation of the decubitus ulcer. Review of a nurse's progress note dated 01/05/24 at 10:11 A.M. revealed Resident #36 would need to return for another orthopedic appointment in four weeks. Resident #36 was placed in a short leg walking boot with instructions to remove boot for hygiene and wound treatments. Review of the medical record and orders revealed the order for the ace bandage to lower left extremity with instructions to leave in place until follow up with orthopedics originally dated 12/21/23 was not discontinued until 01/05/24 (even though the resident had been wearing either a splint or boot since 12/20/23). There were no physician's orders for a splint/boot of any kind in the medical record until 01/05/24, when an order was written for a short leg walking boot to left leg/foot. An assessment by the wound practitioner on 01/09/24 revealed a the resident was assessed to have a Stage II pressure ulcer (defined as a partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister) on the top of the left foot measuring 3.2 cm long by 2.8 cm wide with the same treatment recommended as on 12/26/23 (not implemented until 01/10/24). Review of the medical record revealed a wound nurse practitioner note dated 01/16/24 revealed the top of the left foot was a Stage II pressure ulcer measuring 4 cm long by 3 cm wide with 75-99 percent epithelial tissue. Review of the wound nurse practitioner note dated 01/22/24 revealed the top of the left foot was assessed to be an an unstageable pressure ulcer (defined as full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) measuring 4.2 cm long by 3.5 cm wide with 75-99 percent eschar. Review of the wound nurse practitioner note dated 02/20/24 revealed the top of the left foot was an unstageable pressure ulcer measuring 4 cm long by 2.2 cm wide with 75-99 percent eschar. Observation on 02/27/24 at 1:08 P.M. revealed Resident #36 was in bed on her back. She was observed to have an approximate 3 cm long by 3 cm wide dry, black scabbed area of eschar on the top of the left foot. Interview with the Director of Nursing (DON) on 02/28/24 at 10:45 A.M. confirmed there were no physician's orders to monitor the skin around or under the splint/boot until 12/26/23. She stated the nurse who wrote the order on 12/21/23 to leave the ace bandage in place did not know there was a splint under it. The DON confirmed the facility did not have any physician notes from the orthopedic visit on 12/22/23. She stated the hospital had applied a fiberglass splint to the left ankle on 12/20/23 and she did not know if the orthopedic physician left that splint on or applied a different type on 12/22/23. She stated at some point, the resident had a short leg walking boot applied. The DON confirmed a treatment to the top of the left foot did not start until 01/10/24 (15 days after a treatment order was received). Review of the undated facility policy titled Daily Skin Care for Skin Care and Wound Management revealed staff were to monitor skin in contact with adaptive equipment for areas of pressure. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, staff interview, and policy review, the facility failed to ensure Resident #36 received adequate staff assistance during a staff assisted transfer from bed to chair to prevent a fall with injury. Actual harm occurred on 12/18/23 when Resident #36, who was cognitively impaired, at risk for falls and required substantial/maximal assistance from staff for transfers sustained a fall during a one-person staff assisted transfer. At the time of the transfer, the nursing assistant, (NA) #170 failed to use a gait belt and the resident fell to the floor with a resulting fracture of the left ankle. This affected one resident (#36) of four residents reviewed for falls. The facility census was 92. Findings include: Review of the medical record for Resident #36 revealed an admitted [DATE] and diagnoses including cerebrovascular disease, dementia, and diabetes. The resident resided on the secured dementia unit. Review of the plan of care revealed on 04/09/22 the resident was noted to be at risk for falls related to impaired cognition, history of stroke, history of falls, safety awareness, and weakness. The plan of care on 04/09/22 and revised on 10/10/23 revealed the resident required substantial/maximal assistance for bed to chair transfers and helper does more that half the effort. It did not specify if the transfer was to be completed by one or two staff. Review of a fall risk assessment dated [DATE] revealed the resident was at risk for falls. Review of a quarterly Minimum Data Set assessment dated [DATE] revealed the resident had a brief interview for mental status score of 5, indicating severe cognitive impairment. The assessment revealed the resident required substantial/maximal assistance with bed to chair transfers and walking was not attempted due to medical condition/safety. Review of nursing progress note revealed on 12/18/23 at 4:15 P.M. (documented as a late entry on 12/20/23 at 8:46 P.M. by Licensed Practical Nurse (LPN) #139) the nurse was called to Resident #36's room by an aide. Resident noted to be sitting on the floor on the fall mat. Back was resting against the bed. Legs extended out in front of resident with arms crossed over her chest when this nurse entered the room. Head to toe assessment completed. No complaints of pain. No bruising or discolorations noted at this time. Vital signs obtained and all within normal limits. Interview with the Director of Nursing on 02/28/24 at 10:45 A.M. revealed that LPN #139 did not document the fall on 12/18/23 as she originally did not consider it a fall. She stated the nurse was later educated that this was considered a fall. Review of a written statement from Nursing Assistant #170 revealed on 12/18/23 at approximately 4:40 P.M. she was transferring Resident #36 from the bed to her wheelchair for dinner. The statement included she (the nursing assistant) sat her (the resident) up in bed before placing her hand on her back and then using her other hand to make sure her wheelchair was locked. As she reached to do so, she (the resident) began to slide off the bed. Her (the resident's)legs were bent and got stuck under her until her bottom hit the ground and she straightened her legs and extended them outward. LPN #139 came in to help her get the resident up. LPN #139 said that since Nursing Assistant #170 saw it happen and she was on her mat, it was not a fall. The resident's bed was in the lowest position when this happened and Nursing Assistant #170 stated she did not recall the resident screaming out in pain or complaining about being hurt. The statement was dated 12/21/23. Review of a nursing progress note revealed on 12/20/23 at 6:33 A.M. Resident #36 was complaining of left ankle pain when staff attempts to move left leg. No redness or swelling noted. Physician contacted and an order for a left ankle x-ray was given. Review of a nursing progress note revealed on 12/20/23 at 4:13 P.M. Resident #36 had x-ray completed today due to complaints of pain in left ankle/leg. Nurse practitioner at bedside and wanted resident to be sent to the hospital due to x-ray results. Resident transported to hospital. Review of the x-ray report of the left ankle from 12/20/23 revealed an acute nondisplaced oblique (at an angle) fracture of the distal tib-fib (the ankle end of the two long bones in the leg). Review of hospital records from 12/20/23 revealed the resident arrived (to the hospital) with a left leg fracture after a fall. The hospital records noted the resident had a fracture of tibia and fibula after a fall at the nursing home. A splint was applied to the left leg and instructions were given to follow up with orthopedics. Review of a nursing progress note revealed on 12/20/23 at 10:20 P.M. Resident #36 returned from the hospital. Resident has a tibia and fibula fracture. It is recommended that an appointment be scheduled for resident to see orthopedics. On 12/21/22 at 9:22 A.M. it was documented that an appointment was scheduled with orthopedics on 12/22/23 at 10:00 A.M. Nursing progress notes on 12/22/23 at 9:45 A.M. stated the resident was out of the facility for appointment with orthopedics. On 12/22/23 at 12:00 P.M. the resident returned from the appointment. However, the facility did not have any physician notes from the orthopedic appointment. Interview with the Director of Nursing on 02/28/24 at 10:45 A.M. confirmed the facility did not have any physician notes from the orthopedic visit on 12/22/23. She stated the hospital had applied a fiberglass splint to the left ankle on 12/20/23 and she did not know if the orthopedic physician left that splint on or applied a different type on 12/22/23. She stated at some point, the resident had a short leg walking boot applied. Resident #36 was seen again by the orthopedic physician on 01/02/24. An x-ray on 01/02/24 showed stable alignment of tibial and fibular fractures without significant interval healing. The physician notes stated evaluation of nondisplaced spiral type fracture to the left distal third of the tibial shaft as well as associated fracture to the left distal fibular shaft. The resident was placed in a short leg walking boot with instructions to remove the boot for hygiene as well as evaluation of the decubitus ulcer. Continue short leg walking boot immobilization. Return in four weeks. Review of a nursing progress note on 01/02/24 at 12:49 P.M. revealed Resident #36 returned without a follow up summary from the orthopedic appointment. Orthopedic office attempted to be contacted to request details of appointment without success. Voicemail left. On 01/05/24 at 10:11 A.M. notes indicated the resident will need to return for another orthopedic appointment in four weeks. Resident was placed in a short leg walking boot with instructions to remove boot for hygiene and wound treatments. There were no physician's orders for a splint/boot of any kind in the medical record until 01/05/24, when an order was written for a short leg walking boot to left leg/foot. Review of a nursing progress note on 01/30/24 at 8:46 A.M. revealed the resident left for an orthopedic appointment. On 01/30/24 at 1:38 P.M. the resident returned with new orders to discontinue the walking boot and encourage to float heels. Next appointment 02/27/24 with x-ray prior. The facility did not have any written notes from the orthopedic physician for the visit on 01/30/24. This was confirmed by the Director of Nursing on 02/28/24 at 10:45 A.M. Review of a nursing progress note on 02/27/24 at 9:17 A.M. revealed the resident left for an orthopedic appointment. On 02/27/24 at 10:43 A.M. the resident returned. It stated a visit summary was unavailable. Office contacted for findings or new orders. Office provided doctor referral to wound care with no other details available. Interview with Nursing Assistant #170 on 02/27/24 at 2:45 P.M. confirmed a couple months ago she was transferring Resident #36 from the bed to the chair by herself. She stated during the transfer, the resident slid to the mat on the floor by the bed. She stated the resident was supposed to be a two person transfer but she did not know that at the time. She stated the resident then had a broken foot a few days later. Interview with the Director of Nursing (DON) and MDS Registered Nurse #197 on 02/28/24 at 8:15 A.M. revealed the fracture diagnosed for Resident #36 on 12/20/23 was attributed to the fall on 12/18/23. The DON stated Nursing Assistant #170 did not use a gait belt to transfer Resident #36 from bed to chair, and should have. She stated that after the fall, she told Nursing Assistant #170 not to transfer the resident by herself. They confirmed the plan of care and kardex used by the nursing assistants (prior to the incident) did not specify if Resident #36 was to be transferred by one staff or two. The DON stated Resident #36 had always been a one staff assist for transfers but that Nursing Assistant #170 couldn't do it by herself. Interview with the DON on 02/28/24 at 10:45 A.M. revealed Nursing Assistant #170 was educated to use a gait belt for transfers after Resident #36's fall on 12/18/23. In addition, during the interview, the DON revealed the facility did not have any written notes from the orthopedic physician for the visit on 02/27/24. Review of the facility undated policy on Using a Gait Belt revealed using a gait belt while transferring or walking a patient would provide you and the patient increased safety and security. You can control a patient's balance and can keep the patient from falling by using a gait belt. This deficiency represents non-compliance investigated under Master Complaint Number OH00150944.

Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan that included the level of staff assistance required for transfers. This affected one of three sampled residents (Resident #36). The facility census was 92. Findings include: Review of the medical record for Resident #36 revealed an admitted [DATE] and diagnoses including cerebrovascular disease, dementia, and diabetes. The resident resided on the secured dementia unit. Review of a fall risk assessment dated [DATE] revealed the resident was at risk for falls. Review of a quarterly Minimum Data Set assessment dated [DATE] revealed the resident had a brief interview for mental status score of 5, indicating severe cognitive impairment. It further stated the resident required substantial/maximal assistance with bed to chair transfers. It stated walking was not attempted due to medical condition/safety. Review of the plan of care revealed on 04/09/22 the resident was noted to be at risk for falls related to impaired cognition, history of stroke, history of falls, safety awareness, and weakness. The plan of care on 04/09/22 and revised on 10/10/23 stated the resident required substantial/maximal assistance for bed to chair transfers and helper does more that half the effort. (It did not specify if the transfer was to be completed by one or two staff). Review of nursing progress notes revealed on 12/18/23 at 4:15 P.M. (documented as a late entry on 12/20/23 at 8:46 P.M. by Licensed Practical Nurse (LPN) #139) the nurse was called to Resident #36's room by aide. Resident noted to be sitting on the floor on the fall mat. Back was resting against the bed. Legs extended out in front of resident with arms crossed over her chest when this nurse entered the room. Head to toe assessment completed. No complaints of pain. No bruising or discolorations noted at this time. Vital signs obtained and all within normal limits. Review of a written statement from Nursing Assistant #170 revealed on 12/18/23 at approximately 4:40 P.M. she was transferring Resident #36 from the bed to her wheelchair for dinner. It stated she sat her up in bed before placing her hand on her back and then using her other hand to make sure her wheelchair was locked. As she reached to do so, the resident began to slide off the bed. Her legs were bent and got stuck under her until her bottom hit the ground and she straightened her legs and extended them outward. LPN #139 came in to help her get the resident up. The statement was dated 12/21/23. Review of a nursing progress note revealed on 12/20/23 at 6:33 A.M. Resident #36 was complaining of left ankle pain when staff attempts to move left leg. No redness or swelling noted. Physician contacted and an order for a left ankle x-ray was given. Review of a nursing progress note revealed on 12/20/23 at 4:13 P.M. Resident #36 had x-ray completed today due to complaints of pain in left ankle/leg. Nurse practitioner at bedside and wanted resident to be sent to the hospital due to x-ray results. Resident transported to hospital. Review of the x-ray report of the left ankle from 12/20/23 revealed an acute nondisplaced oblique (at an angle) fracture of the distal tib-fib (the ankle end of the two long bones in the leg). Review of hospital records from 12/20/23 revealed the resident arrived with a left leg fracture after a fall. It stated the resident had a fracture of tibia and fibula after a fall at the nursing home. A splint was applied to the left leg and instructions were given to follow up with orthopedics. Interview with Nursing Assistant #170 on 02/27/24 at 2:45 P.M. confirmed a couple months ago she was transferring Resident #36 from the bed to the chair by herself. She stated the resident slid to the mat on the floor by the bed. She stated the resident was supposed to be a two person transfer but she did not know that at the time. She stated the resident then had a broken foot a few days later. She stated the resident was now to be a two person transfer. Interview with the Director of Nursing (DON) and MDS Registered Nurse #197 on 02/28/24 at 8:15 A.M. revealed the fracture diagnosed for Resident #36 on 12/20/23 was attributed to the fall on 12/18/23. The DON stated Nursing Assistant #170 did not use a gait belt to transfer Resident #36 from bed to chair, and should have. She stated that after the fall, she told Nursing Assistant #170 not to transfer the resident by herself. They confirmed the plan of care and kardex used by the nursing assistants did not specify if Resident #36 was to be transferred by one staff or two. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on staff interview and record review, the facility failed to include all the mental health diagnoses on the preadmission screening and resident review (PASARR) for Resident #8. This affected one (#8) of three residents reviewed for PASARR. The facility census was 90. Findings include: Review of the medical record for Resident #8 revealed an admitted [DATE]. Diagnoses included paranoid schizophrenia, major depressive disorder, antisocial personality disorder, psychosis, mood disorder. and anxiety disorder. A diagnosis of dementia with agitation was added on 08/15/15. Review of the PASARR completed on 03/13/23, revealed Resident #8 received antipsychotic, antidepressant, antianxiety and mood stabilizer medications. Resident #8 did not have any indication of intellectual and developmental disability. The PASARR revealed Resident #8 had indications of serious mental illness including schizophrenia, mood disorder, delusional disorder and severe anxiety. The PASARR did not include the diagnosis of antisocial personality disorder or psychosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had moderately impaired cognition with no behavior symptoms. Resident #8 exhibited feelings of down/depressed and tired with little energy. Resident #8 received antipsychotic medication, antidepressant and antianxiety medication seven of seven days during the look back period. An interview on 12/14/23 at 9:32 A.M. with Social Services Designee #200 verified she missed the diagnosis of antisocial personality and psychosis listed on Resident #8's medical diagnosis list. Social Service Designee #200 confirmed the PASARR was incomplete.

Based on observations, resident and staff interviews, record reviews, and review of the facility policy, the facility failed to identify and implement treatment for residents with skin alterations. This affected two (#3 and #20) of the two residents reviewed for non-pressure skin alterations during the annual survey. The facility census was 90. Findings include: 1. Record review for Resident #20 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic heart failure, type two diabetes mellitus, weakness, and chronic obstructive pulmonary disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/10/23, revealed Resident #20 had severely impaired cognition and required substantial to maximal assistance from staff for bed mobility, transfers, and toileting. Review of the care plan, most recently revised on 09/15/23, revealed Resident #20 had or was at risk for impaired skin integrity. Interventions included to complete weekly skin checks. Review of the facility's Weekly Skin Check assessment, dated 12/12/23, revealed Resident #20 was documented to not have any skin alterations present. Further record review for Resident #20 revealed no documentation of the presence of any skin alterations on the residents feet or toes. Interview with Resident #20 on 12/11/23 at 2:43 P.M. revealed the resident voiced concerns over needing to see the foot doctor due to being diabetic and having skin alterations on her toes. Observation on 12/11/23 at 2:47 P.M. revealed Resident #20 had small scabs present on the top of the second, third, and fourth toe on the residents right foot and reddened areas present to the tops of the second, third, and fourth toes on the left foot. No treatments were observed to be in place at the time of the observation. Observation and interview with Licensed Practical Nurse (LPN) #90 on 12/14/23 at 11:26 A.M. verified there were scabs and reddened areas present to the tops of the toes of Resident #20's left and right foot. LPN #90 additionally verified there was no treatment orders or documentation of the presence of the skin alterations on Resident #20's toes. 34299 2. Review of the medical record for Resident #3 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus, neuromuscular dysfunction of the bladder, neuropathy, and peripheral vascular disease. Review of the plan of care dated 06/15/23, last revised on 09/28/23, revealed Resident #3 had impaired skin integrity and was at risk for altered skin integrity. Interventions included to complete skin at risk assessment upon admission, quarterly and as needed along with weekly skin assessments, and float heels as tolerated. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had mild to moderate cognitive impairment. Resident #3 required extensive assistance of two persons for personal care/hygiene and bathing. The assessment did not indicate any skin impairments and no treatments to altered skin integrity. Review of the weekly skin assessments dated 12/07/23 and 12/14/23, completed by a licensed nurse, revealed Resident #3 had no skin impairment to the bilateral lower extremities. Review of the physician orders dated 12/2023 revealed no orders to assess Resident #3 bilateral lower extremities or any treatment for the scabbed areas and large white dry scales to bilateral lower extremities. Interview and observation on 12/13/23 at 9:05 A.M. with Licensed Practical Nurse (LPN) #90 revealed she was not aware of any abnormal skin impairment to Resident #3's bilateral lower extremities. Observation of Resident #3's bilateral lower extremities with LPN #90 revealed Resident #3 had dark purple/black lower extremities with dry scaly raised areas and brown scabs. LPN #90 confirmed the areas and stated the State tested Nursing Assistants (STNA) provided lotion to skin after bathing. LPN #90 confirmed there was not any documentation in the medical record regarding the areas to Resident #3's bilateral lower extremities. Review of the facility policy titled Skin Care and Wound Management Overview, dated 12/13/23, revealed facility staff strived to prevent resident/patient skin impairment and to promote the healing of existing wounds. Each resident/patient was assessed upon admission then weekly for any changes in skin condition.

Based on staff interview, record review, and facility policy review, the facility failed to ensure Resident #31 was provided a speech therapy screen or evaluation as recommended by the dietitian on admission. This affected one (Resident #31) of three residents reviewed for nutrition. The facility census was 89. Findings include: Review of the medical record for Resident #31 revealed an admitted [DATE]. Diagnoses included encephalopathy, end stage renal disease, type two diabetes mellitus, and dementia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had impaired cognition and was dependent on staff for assistance with activities of daily living. The assessment indicated Resident #31 had no problems with swallowing or chewing, and no weight loss. Resident #31 had no documentation of therapy services during the look back period. Review of the admission dietary nutritional assessment dated [DATE] revealed Resident #31's meal intakes had been fair and the current nutritional plan of care met the resident's estimated needs. The dietitian recommended a speech therapy screen related to Resident #31 had stated she had difficulty swallowing. Review of the physician orders dated 12/2023 revealed Resident #31 was ordered a renal diet, regular texture with thin liquids. Review of the medical record for Resident #31 revealed no evidence of a speech/swallowing screen or evaluation. An interview on 12/14/23 at 3:26 P.M. with the Administrator verified Resident #31 was not screened or evaluated by speech therapy since admission. Review of the facility policy titled Nutritional Assessment and Recommendations revealed the facility had 14 days to implement a recommendation.

Based on observations, staff interviews, and record review, the facility failed to ensure physicians orders were in place for the administration of oxygen therapy. This affected one (Resident #9) of two residents reviewed for respiratory care during the annual survey. The facility census was 90. Findings include: Record review for Resident #9 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia with other behavioral disturbances, pulmonary fibrosis, and chronic obstructive pulmonary disease (COPD). Review of the five-day Minimum Data Set (MDS) assessment, dated 11/19/23, revealed Resident #9 had mildly impaired cognition. Review of the care plan, dated 11/16/23, revealed Resident #9 had COPD with shortness of breath while lying flat. Interventions included oxygen therapy as ordered. Review of the physicians orders for Resident #9 dated from 11/16/23 to 12/11/23 revealed there was no order for the administration of oxygen. Observations on 12/11/23 at 3:23 P.M. and on 12/12/23 at 9:15 A.M. revealed Resident #9 was sitting up in her recliner and had oxygen being administered by nasal cannula with the oxygen concentrator set to administer two liters per minute. Observation and interview with Licensed Practical Nurse (LPN) #100 on 12/12/23 at 2:11 P.M. verified Resident #9 had oxygen being administered by nasal cannula at a rate of two liters per minute. LPN #100 additional verified Resident #9 did not have physicians orders in place for the administration of oxygen. Interview with LPN #90 on 12/12/23 at 2:39 P.M. revealed physicians orders should be in place for all residents receiving oxygen therapy to determine the amount of oxygen to be administered.

Based on staff interview and record review, the facility failed to ensure there was an appropriate diagnosis for the administration of an antipsychotic medication for Resident #52. This affected one (#52) of five residents reviewed for unnecessary medications. The facility census was 90. Findings include: Review of the medical record for Resident #52 revealed an admitted [DATE]. Diagnoses included anxiety, depression, visual and auditory hallucinations, and dementia with psychotic disturbance. Review of the plan of care dated 07/24/23 revealed Resident #52 used antipsychotic medication related to dementia with psychotic disturbances. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 was cognitively intact and received an antipsychotic medication seven of seven days during the look back period. Review of the progress note dated 11/06/23 revealed the Psychiatric Nurse Practitioner (NP) #22 was in the facility and ordered to increase the olanzapine 2.5 milligrams (mg) by mouth from daily to two tablets by mouth at bedtime for dementia with psychotic disturbance. The nursing progress notes were silent on reason for increase in olanzapine. Review of the physician order dated 11/06/23 revealed Resident #52 had an order for olanzapine (antipsychotic) 2.5 mg two tablets at bedtime for diagnosis of dementia with psychotic disturbance. An interview on 12/14/23 at 10:18 A.M. with the Director of Nursing confirmed Resident #52 received an antipsychotic medication for the diagnosis of dementia with behavioral disturbance and this was not an appropriate diagnosis for the use of the antipsychotic medication.

Based on observations and staff interviews, the facility failed to ensure resident's bathroom tiles remained in good repair. This affected one bathroom that was shared by three residents in two rooms (rooms [ROOM NUMBERS]). The facility identified the three residents in rooms [ROOM NUMBERS] who were ambulatory and used the bathroom. The facility census was 90. Findings include: Observation on 12/11/23 at 9:35 A.M. of the secured memory care unit revealed three floor tiles located in the bathroom shared by rooms [ROOM NUMBERS] were broken creating jagged, uneven edges. Observation and interview on 12/13/23 at 3:30 P.M. with State tested Nursing Assistant (STNA) #990 verified the tiles located in the bathroom shared by rooms [ROOM NUMBERS] were broken and had jagged edges which could cause a resident to trip or cut their feet. STNA #990 verified three residents used the restroom with the broken, jagged tiles. Observation and interview with Maintenance Technician #950 on 12/14/23 at 2:00 P.M. verified the three tiles in the bathroom shared by rooms [ROOM NUMBERS] were broken, jagged and needed replaced. Maintenance Technician #950 denied reports from facility staff of the tiles in the bathroom being broken or in of being replaced.

Based on observation, record review, self-reported incident review and interview, the facility failed to ensure all residents were free from incidents of misappropriation of medication. This affected three residents (#58, #90, and #91) of three residents reviewed for misappropriation. The facility census was 89. Findings include: Record review revealed Resident #58 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus type II, hypertension, anxiety, bipolar disorder, anxiety, suicidal ideations, depression and neuropathy. Record review revealed Resident #58 was alert and oriented to person, place, and time with a current Brief Mental Status (BIMS) score of 15 (out of 15 on the most recent Minimum Data Set (MDS) 3.0 assessment completed on [DATE]. Review of physician's orders revealed the resident received the anti-psychotic medication, Abilify 15 milligrams (mg) by mouth once daily at bedtime. Review of Resident #90's closed medical record review revealed the resident was admitted to the facility on [DATE] and was discharged to the hospital on [DATE] and did not return to the facility. The resident had diagnoses including paranoid schizophrenia, anxiety, hypothyroidism, hypertension, delusional disorders, reduced mobility, and muscle weakness. This resident had a BIMS score of 15 (out of 15) on the last MDS 3.0 assessment completed on [DATE]. Review of physician's orders during the resident's stay revealed the resident had an order for the anti-psychotic medication, Risperdal 1 mg by mouth twice daily in the morning and at bedtime. Review of Resident #91's closed medical record revealed the resident was admitted to the facility on [DATE] and expired in the facility on [DATE]. Resident #91 had diagnoses including myocardial infarction, bipolar disorder, hypertension, Alzheimer's disease, anxiety, dysphagia, schizophrenia, atrial fibrillation, and hyperlipidemia. The resident was alert to person and place with a BIMS score of 9 (out of 15) on the last completed MDS 3.0 assessment completed on [DATE]. Review of physician's orders during the resident's stay revealed the resident had an order for the anti-psychotic medication, Seroquel 25 mg by mouth once daily in the morning. Review of facility self-reported incident (SRI), tracking number 233025 revealed on [DATE] the facility became aware of a situation involving a possible misappropriation of property, which involved a former nurse who worked as a contracted agent. Review of the SRI revealed the incidents involved three residents (one current and two discharged ) and was also being investigated by an Ohio Board of Nursing Special Investigator. The report identified Registered Nurse #40 as the person of interest in the investigation. Medications included Seroquel 25 mg, Abilify 15 mg, and Risperdal 1 mg. Interview with the Administrator and Director of Nursing on [DATE] at 8:45 A.M. revealed the facility was notified of an ongoing investigation involving one current and two former residents. Both stated that a Special Investigator from the Board of Nursing telephoned the facility on [DATE] and informed them of an ongoing investigation involving psychotropic medications for Resident #58, Resident #90, and Resident #91. They stated a medication card for each resident was returned to them on [DATE], with the count for each: Resident #58 had nine pills out of thirty for Aripiprazole (Abilify) 15 mg; Resident #90 had 28 out of thirty for Risperidone 1 mg; and Resident #91 had 16 out of thirty for Seroquel 25 mg. These medications were returned with a suspected misappropriation date between June and [DATE]. Both verified they did not know or suspect these medications had been taken from the facility, and verified they first became aware of the situation on [DATE]. Both indicated they were told by the investigator that the investigation was ongoing and that was the only information they had been provided. Telephone Interview with Enforcement Agent #50 on [DATE] at 10:55 A.M. revealed this agent received a complaint from a former boyfriend of Registered Nurse #40 recently. He stated the boyfriend provided him with the three cards of medications for the three residents involved, while being told the former nurse at the facility had brought them home for the boyfriend to use. He stated he personally brought the medications back to the facility on [DATE], and informed the facility of the investigation that was ongoing. Observation of Medication Rooms with the Director of Nursing on [DATE] at 12:10 P.M. revealed any medications that were due to be returned to the pharmacy were to be placed in sealable plastic bags and kept on the counter to be picked up by pharmacy personnel. The Director of Nursing revealed when a resident was either discharged , a medication was discontinued, or if the resident would expire, all medications were to be placed in the plastic bags and kept in the locked medication room until they were picked up by the pharmacy. The Director of Nursing stated she could not say for sure, but believed Registered Nurse #40 removed the medications from the room on night shift after the three residents had either went to the hospital or expired. This deficiency represents non-compliance investigated under Control Number OH00141175.

Based on observation, record review, facility policy and procedure review, review of the Centers for Disease Control (CDC) guidance and interview the facility failed to maintain acceptable infection control practices, including the proper use of personal protective equipment (PPE) and isolation precautions to prevent the potential spread of COVID-19. This affected two residents (#49 and #185) and had the potential to affect all 84 residents residing in the facility. Findings Include: 1. Review of Resident #49's medical record revealed an initial admitted [DATE] with the latest readmission of 04/01/22 with the admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care, dated 02/15/22 revealed the resident was at risk for COVID-19 related to declination of (COVID-19) vaccine or vaccine administration contraindicated. Interventions included droplet isolation. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 03/20/22 revealed the resident had clear speech, understands others, makes herself understood and had no cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 15. Review of the mood and behavior section of the MDS revealed the resident rejected care. The assessment revealed the resident required extensive assistance from two staff for bed mobility, transfers and ambulation. Review of the monthly physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order indicated the resident was to be on droplet precautions for seven days and may come out of isolation on day eight after a negative COVID-19 test. On 04/04/22 at 10:45 A.M. Registered Nurse (RN) #129 was observed to enter Resident #49's room. The RN failed to apply the proper PPE (i.e. gown, gloves, eye protection and N95 mask) at the time she entered the room. The RN was wearing a surgical mask. At the time the RN entered, the resident was noted to have a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #129 proceeded to check the resident's blood sugar upon entering the room. Interview with RN #129 at the time of the observation verified the resident was in droplet precautions for COVID-19 and she failed to utilize any PPE when in the resident's room. On 04/04/22 at 10:47 A.M. RN #129 attempted to obtain a disposable gown from the plastic PPE cabinet outside Resident #49's room. However, there were no disposable gowns in the cabinet. The RN then obtained a disposable gown from a cabinet down the hallway and applied the gown and a pair of gloves. RN #129 entered Resident #49's room, administered the resident's insulin and exited the room. The RN did not remove/discard or change her surgical mask upon exiting and walked down the hallway. No protective eyewear was worn by the RN while in Resident #49's room. On 04/04/22 at 2:56 P.M. interview with RN #402 verified Resident #49 was on droplet precautions and indicated all staff should be wearing a gown, gloves, eye protection and an N95 mask when entering the resident's room. Review of the facility's policy titled, Standard Precautions and Transmission Based Precautions (TBP), last revised 06/25/21 revealed isolation precautions were the method of preventing the spread of contagious disease and microorganism transfer to others following Center for Disease Control (CDC) recommendations and guidelines. TBP were designed for residents documented or suspected to be infected with highly transmissible or epidemiological important pathogens for which additional precautions beyond Standard Precautions were needed to interrupt transmission of disease causing microorganism. For droplet precautions, staff would utilize the proper PPE upon entering the room or cubical area including gloves, mask and eye protection before contacting the resident or environment. Review of the current CDC guidance related to COVID-19 in nursing homes revealed newly-admitted residents and residents who had left the facility for greater than 24 hours, regardless of vaccination status, should have a series of two [CONDITION(S)] tests for [CONDITION(S)]-COV-2 infection; immediately and, if negative, again 5-7 days after their admission. In general, all residents who are not up to date with all recommended COVID-19 vaccine doses and were new admissions and readmissions should be placed in quarantine, even if they have a negative test upon admission, and should be tested as described in the testing section above; COVID-19 vaccination should also be offered. 2. Record review revealed Resident #185 was admitted to the facility on [DATE] with a latest re-admission of 04/01/22. Resident #185 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS 3.0 assessment, dated 03/04/22 revealed the resident had minimal cognitive impairment and was able to make his needs known at all times. Resident #185 was readmitted to the facility on [DATE] following a hospitalization from [DATE] through 04/01/22. This resident had been vaccinated for COVID-19 with a first dose on 09/24/21 and second dose on 10/12/21. On 04/03/22 a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was discontinued on 04/04/22. On 04/03/22 at 8:05 P.M. observation of Resident #185's room revealed there was no isolation cart or signage near the room indicating the resident was in any type of isolation. On 04/04/22 at 8:00 A.M. observation of Resident #185's room revealed there was an isolation cart and signage posted identifying the resident was on droplet precautions. At the time of the observation, Resident #185 was observed exiting his room via wheelchair. The resident was returned to his room by a facility staff and educated he was on isolation precautions. On 04/04/22 at 8:15 A.M. interview with Social Service Director (SSD) #406 revealed she had spoken with Resident #185 on 04/03/22 at approximately 8:05 A.M. in the main lobby. SSD #406 revealed she was unaware the resident was on any type of isolation precautions at that time as the resident was in the lobby and there were no indications of the resident being on droplet precautions. On 04/04/22 at 8:25 A.M. interview with the Director of Nursing revealed Resident #185 had been placed on droplet precautions on 04/03/22 due to being readmitted following the hospitalization even though the resident returned on 04/01/22. The DON then indicated since the resident had been vaccinated for COVID-19 the precautions weren't necessary and therefore an order had been obtained this morning (on 04/04/22) to discontinue the isolation. The DON was unable to provide any evidence of COVID-19 testing for the resident following the resident's re-admission. In addition, there was no evidence the facility followed the isolation precautions during the time they were ordered. Review of the facility's policy titled, Standard Precautions and Transmission Based Precautions (TBP), last revised 06/25/21 revealed isolation precautions were the method of preventing the spread of contagious disease and microorganism transfer to others following Center for Disease Control (CDC) recommendations and guidelines. TBP were designed for residents documented or suspected to be infected with highly transmissible or epidemiological important pathogens for which additional precautions beyond Standard Precautions were needed to interrupt transmission of disease causing microorganism. For droplet precautions, staff would utilize the proper PPE upon entering the room or cubical area including gloves, mask and eye protection before contacting the resident or environment. Review of the current CDC guidance related to COVID-19 in nursing homes revealed newly-admitted residents and residents who had left the facility for greater than 24 hours, regardless of vaccination status, should have a series of two [CONDITION(S)] tests for [CONDITION(S)]-COV-2 infection; immediately and, if negative, again 5-7 days after their admission.

Based on observation and interview the facility failed to maintain a clean and functional environment for all residents with evidence of poor repair to five rooms that required wall repairs and paint. This affected seven residents who resided in Rooms 38, 32, 28, 157 and 165. The facility census was 84. Findings Include: On 04/06/22 at 4:35 P.M. observation of Room 38 revealed the west wall of the room had paint that was visually bubbled up and peeling away from the wall. Some areas had exposed dry wall and other exposed areas from missing paint. Observation and interview with Maintenance Director #237 and Maintenance Technician #318 at the time of the observation verified the finding. On 04/06/22 at 4:38 P.M. observation of Room 32 revealed the south wall and the west wall of this room had bubbled paint that extended from the ceiling to the floor. Some areas of exposed dry wall were observed as well. Observation and interview with Maintenance Director #237 and Maintenance Technician #318 at the time of the observation verified the finding. On 04/06/22 at 4:42 P.M. observation of Room 28 revealed the south wall of the room had bubbled paint that extended from the ceiling to the floor. Observation and interview with Maintenance Director #237 and Maintenance Technician #318 at the time of the observation verified the finding. On 04/06/22 at 4:46 P.M. observation of Room 165 revealed multiple areas of exposed dry wall, with multiple holes in places along the baseboard of the room. Observation and interview with Maintenance Director #237 and Maintenance Technician #318 at the time of the observation verified the finding. On 04/06/22 at 4:52 P.M. observation of Room 157 revealed the south wall was partially exposed with multiple large cracks in the paint. Dry wall was exposed in multiple areas where the paint was peeling away. Observation and interview with Maintenance Director #237 and Maintenance Technician #318 at the time of the observation verified the finding. In addition, interview with Maintenance Director #237 and Maintenance Assistant #318 on 04/06/22 at 5:00 P.M. again verified the findings made during the above observations.

Based on observation, medical record review, review of facility witness statements, review of the facility Abuse policy and procedure, review of a facility self-reported incident (SRI) report, and resident and staff interviews, the facility failed to ensure an allegation of sexual abuse was reported immediately, but no later than two hours after the allegation was made, to the Administrator and State agency as required. This resulted in Immediate Jeopardy on 03/03/21 between 8:00 P.M. and 9:00 P.M. when Resident #24 alleged to Certified Nursing Assistant (CNA) #200 and State tested Nursing Assistant (STNA) #201 that she had been sexually abused (touched in her vaginal area) by Resident #100. CNA #200 and STNA #201 stated they immediately reported the allegation to Licensed Practical Nurse (LPN) #202. However, LPN #202 failed to immediately report the allegation to the Administrator. The allegation of resident to resident sexual abuse was not reported to the Administrator until 03/08/21 (five days after Resident #24 reported it to facility staff). This resulted in the likelihood of serious harm or injury to residents with the potential for continued abuse of residents. This affected one resident (Resident #6), and had the potential to affect all 88 residents residing in the facility who were at risk for potential harm or injury related to incidents of resident to resident sexual abuse not being reported . On 03/09/21 at 3:20 P.M. the Administrator was notified Immediate Jeopardy began on 03/03/21 between 8:00 P.M. and 9:00 P.M. when Resident #24 reported she was sexually abused by Resident #100 to CNA #200 and STNA #201. CNA #200 and STNA #201 reported the allegation to LPN #202. However, LPN #202 did not report the allegation to anyone allowing the potential for continued abuse of residents. The Immediate Jeopardy continued until 03/08/21 when the Administrator was made aware of the resident to resident sexual abuse allegation. The Immediate Jeopardy was removed on 03/08/21 when the facility implemented the following corrective action: · On 03/08/21 at 4:30 P.M. the Administrator and Director of Nursing (DON) spoke to Resident #24 while conducting facility rounds. Resident #24 stated that she spoke to the state surveyor earlier that day and told her that a male resident entered her room at a previous time, and she thinks he touched her inappropriately. · On 03/08/21 at 4:40 P.M. the Administrator spoke to Regional Director of Operations for guidance and steps to proceed with reporting and start of investigation. · On 03/08/21 at 4:45 P.M. the Administrator submitted the SRI report via the EIDC system. · On 03/08/21 at 5:00 P.M. Unit Manager RN #208 notified the Medical Director of the incident. The Medical Director ordered a psychiatric consult to be initiated due to change of cognition status for Resident #24. · On 03/08/21 at 5:00 P.M. the Administrator notified the Local Police Department of the alleged incident. · On 03/08/21 at 5:00 P.M. the Social Services Director called the daughter and mother of Resident #24 to notify them of the alleged incident. · On 03/08/21 at 5:00 P.M. Unit Manager RN #207 completed a head to toe assessment on Resident #24. No negative findings or distress were noted during this assessment. A pain assessment was completed with no pain noted. · On 03/08/21 at 5:30 P.M. a Local Police Officer arrived at the facility to obtain a report and speak to Resident #24. Resident #24 informed the Officer that the alleged perpetuator of the incident was a male resident (Resident #100) but could not recall a last name or a time that the incident occurred. · On 03/08/21 at 5:45 P.M. the Social Services Director and Unit Manager RN #207 completed a psychosocial well-being assessment on Resident #24 with no concern noted. Resident #24 had not had any negative side effects. The Social Services Director completed a Brief Interview for Mental Status (BIMS) assessment for Resident #24 and the resident scored a 0 during this assessment. · On 03/08/21 at 6:00 P.M. the Social Services Director attempted to obtain a statement from Resident #24's roommate but was unsuccessful due to cognition status. · On 03/08/21 at 6:00 P.M. the Administrator, Director of Nursing, Social Services Director, and both Unit Manager RN's #207 and #208 began obtaining staff statements regarding any incident that had occurred previously with Resident #24. · On 03/08/21 at 6:15 P.M. CNA #200 and STNA #201 stated to Administrator and DON that Resident #24 reported on 03/03/21 that Resident #100 wandered into her room. This was believed to have occurred on the night of 03/02/21. When CNA #200 asked Resident #24 why Resident #100 was in her room she pointed to her private area. CNA #200 stated she informed Resident #24 that she would report to the nurse on duty. CNA #200 and STNA #201 stated they informed LPN #202. (Resident #100 was discharged from the facility on 03/05/21). · On 03/08/21 at 6:40 P.M. the DON spoke to LPN #202 to obtain a statement regarding the report CNA #200 and STNA #201 made to her regarding Resident #24. LPN #202 stated that CNA #200 and STNA #201 informed her that Resident #24 reported to them that Resident #100 wandered into her room and made her feel uncomfortable. LPN #202 stated she immediately went to speak to Resident #24 to ask her if she had any issues or concerns. Resident #24 stated to LPN #202 that No, everything is fine. Can I have my tums tonight and again in the morning with my coffee? LPN #202 stated the resident appeared at her baseline, no signs of distress noted, or signs of psychosocial impairment noted during her assessment. · On 03/08/21 at 7:00 P.M. the DON completed 1:1 education and discipline with LPN #202 regarding the facility policy for Abuse, Neglect and Misappropriation including reporting and investigating. · On 03/08/21 at 7:00 P.M. Unit Manager RN #208 completed 30 like resident interviews with residents that were interviewable and residing on B and D Hall. Like residents were asked Have there been any other concerns or problems with a roommate or any other resident? and Has the staff addressed the concern(s) to your satisfaction? There were no other issues noted during the questionnaires. · On 03/08/21 at 7:00 P.M. Unit Manager RN #207 completed 12 head to toe assessments on like residents that were not interviewable and resided on B and D Hall. There were no other issues noted during the head to toe assessments. · On 03/08/21 at 7:15 P.M. the Administrator and Social Services Director completed 100% of staff education on the facility policy for Abuse, Neglect and Misappropriation including reporting and investigating. Staff must report any allegation of abuse, neglect, and misappropriation to the Executive Director immediately. Staff educated included 57 Nursing, 15 Administration, 12 Dietary, 8 Housekeeping/Laundry, 13 Therapy, 4 Activities and 2 Maintenance personnel. Education was completed via in person and phone for all facility staff. · On 03/08/21 at 7:45 P.M. the facility team initiated employee questionnaires on 3 employees, 3 times per week for 4 weeks then random thereafter asking employees if they have witnessed/heard of any abuse/neglect/misappropriation of a resident/employee and if Yes did they report to administration. Facility team also initiated employee questionnaires on 3 employees, 3 times per week for 4 weeks then random thereafter asking employees if they are aware of the facility policy on reporting abuse, neglect or misappropriation, what does immediate mean to you(A. Now, B. 2 hrs., C. 24 hrs.) and who do you notify of any suspected abuse, neglect or misappropriation (A. Supervisor, B. Administrator(ED), C. Director of Nursing(DON), D. All of the above). The Administrator and DON will ensure compliance with completing the questionnaires. · On 03/08/21 at 7:45 P.M. the facility team initiated resident questionnaires on 3 residents, 3 times per week for 4 weeks then random thereafter asking residents if they have witnessed/heard of any abuse/neglect/misappropriation of a resident/employee and if Yes did they report to administration. The Administrator and DON will ensure compliance with completing the questionnaires. · On 003/8/21 at 8:30 P.M. An Ad-Hoc QAPI meeting was held to review incident and investigation process. · On 03/09/21 at 8:30 A.M. the facility team continued employee and resident audits on Abuse, Neglect and Misappropriation. · On 03/10/21 between 1:00 P.M. and 1:10 P.M. Interview with STNA #204, LPN #205, and LPN #206 revealed they had recent education and in-servicing of the facility abuse policy and reporting by facility and all were aware of proper reporting procedures. Although the Immediate Jeopardy was removed on 03/08/21, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure continued compliance. Findings include: Interview with the Administrator on 03/08/21 at 11:50 A.M. revealed there had been no allegations or reports of sexual abuse in the past year. He stated the last incident reported to the State Survey Agency was on 02/27/21. He stated this involved an argument over food between two residents (did not include Resident #24). Review of the medical record for Resident #24 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment completed 01/02/21 revealed the resident had a Brief Interview for Mental Status score of ten, indicating moderately impaired cognitive status. It also indicated the resident required extensive assistance from one staff for bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene. The resident was not identified on the MDS to have any behaviors. Review of the closed medical record for Resident #100 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a MDS Assessment completed 02/02/21 revealed the resident had a BIMS score of 15 indicating intact cognition. The MDS indicated the resident required supervision only for walking in room and corridor and had wandering behaviors. The plan of care stated the resident was manipulative, told untruths, wandered, and was sexually inappropriate with staff. Review of nurses' notes revealed on 02/12/21 at 3:31 A.M. Resident #100 approached an aide in a sexual manner and attempted to reach out and touch her private area. She stepped back and told the resident to stop. The resident stated yum, that's good. The resident then laid back into bed and started winking at another aide telling her to come get into bed with him. A nurse note on 02/12/21 at 3:42 A.M. revealed a nursing assistant reported that Resident #100 unfastened his pants and shook his penis at her. Resident #100 was transferred to a psychiatric facility on 02/12/21 at 7:00 P.M. Review of hospital records revealed on 02/12/21 the physician documented the resident had been grabbing at female staff's private areas, yelling, and aggressive at times. He admitted to the physician that he hears voices telling him to grab women. Observations on 03/08/21 at 1:15 P.M. revealed Resident #24 sitting in a wheelchair in her room. The resident was playing a game on her cell phone. Interview with Resident #24 on 03/08/21 at 1:15 P.M. revealed Resident #100 came into her room one night and laid in bed with her. Resident #24 stated Resident #100 took off her disposable brief and put his fingers up her vagina. Resident #24 stated this caused her pain. She stated he finally got up and went back to his room. Resident #24 stated she reported this the next morning to a female staff person that she thought was a nursing assistant. She stated she did not know the name of the person she reported this to or the date she reported it, but it happened a few nights ago. Interview with LPN #202 on 03/08/21 at 2:00 P.M. revealed she was not aware of any reports of sexual abuse. She specifically stated she was not aware of any allegations of sexual abuse of Resident #24, either from staff or resident. Interview with LPN #203 on 03/08/21 at 2:15 P.M. revealed STNA #201 had told her sometime last week Resident #100 had gone into Resident #24's room and either touched her or tried to touch her. STNA #201 told LPN #203 that she had reported this to LPN #202. LPN #203 stated she did not report this to anyone else since LPN #202 was aware. Interview with STNA #201 on 03/08/21 at 2:30 P.M. revealed she had gone to Resident #24's room last week (she thought 03/01/21) at around 9:00 P.M. She stated CNA #200 was already in Resident #24's room. She stated Resident #24 was telling CNA #200 that Resident #100 had put his fingers inside her vagina. STNA #201 stated Resident #24 stated Resident #100 had dropped his pants and Resident #24 was afraid he was going to put his penis inside of her. The resident stated it had happened a day or two prior but she was afraid to tell someone. STNA #201 stated she and CNA #200 both went immediately and reported what Resident #24 had told them to LPN #202. STNA #201 stated LPN #202 was notified that Resident #24 alleged that Resident #100 put his fingers inside her vagina. STNA #201 stated that LPN #202 then got on the telephone and called someone, but she did not know who. STNA #201 stated she was not aware of anything done by the facility as a result of the allegation. She stated she had not been asked by administrative staff to give a statement regarding the allegation. However, she stated Resident #100 was transferred from the facility a few days after the allegation. STNA #201 stated this was not the first time Resident #100 had been accused of touching a female resident. She stated approximately nine months ago, Resident #6 accused him of touching her inappropriately. Interview with CNA #200 on 03/08/21 at 2:50 P.M. revealed sometime last week Resident #24 had reported to her and STNA #201 that Resident #100 came into her room the night before and touched her vagina. She stated that she and STNA #201 then immediately went and reported this to LPN #202. She stated LPN #202 was notified that Resident #24 had reported that Resident #100 touched her private parts. She stated she did not know if LPN #202 took any action on the allegation. She stated she had not been asked by any administrative staff to give a statement regarding the allegation. Interview with the Administrator on 03/09/21 at 8:05 A.M. revealed Resident #24 had reported an allegation of sexual abuse to him on the evening of 03/08/21. He stated an investigation was then started and the incident reported to the State Survey Agency. Review of the facility's investigation including staff statements revealed the following. Review of a witness statement from CNA #200 dated 03/08/21 revealed on 03/03/21 between 8:00 P.M. and 9:00 P.M. Resident #24 reported to her that a male resident believed to be Resident #100 came into her room and touched her on 03/02/21. She pointed to her private area. She then reported this to LPN #202. Review of a witness statement from STNA #201 dated 03/08/21 revealed on 03/03/21 between 8:00 P.M. and 9:00 P.M. she went into Resident #24's room and overheard her tell CNA #200 that a male resident, believed to be Resident #100, came into her room and touched her. STNA #201 and CNA #200 reported this to LPN #202. Review of a witness statement from LPN #202 dated 03/08/21 revealed Resident #24 never made a report of abuse to her. Her statement did not state anything about what STNA #201 and CNA #200 reported to her in regard to allegations made by Resident #24. Review of a statement written by the DON dated 03/08/21 revealed she spoke with LPN #202 via telephone regarding the complaint of alleged abuse from Resident #24. On the night in question, the STNAs came to LPN #202 indicating that Resident #24 had told them a male resident was in her room and it had made her feel uncomfortable. LPN #202 stated she immediately went to speak to Resident #24 asking her if she was having any issues or concerns about anything or anyone and the resident said, no everything is fine. Interview with the Administrator and DON on 03/09/21 at 8:30 A.M. revealed that through their investigation on 03/08/21, it was determined Resident #24 alleged Resident #100 had touched her inappropriately on the night of 03/02/21 and the allegation was reported to CNA #200 on 03/03/21. They stated CNA #200 then reported this to LPN #202. They stated STNA #201 had overheard Resident #24 tell CNA #200 about the incident. The DON stated she interviewed LPN #202 who stated the nursing assistants had reported that Resident #24 stated a male resident had made her feel uncomfortable. LPN #202 told the DON she went and talked with Resident #24 who told her everything was fine. The Administrator and DON confirmed the allegation by Resident #24 was not reported to either of them until 03/08/21, when Resident #24 reported it to the Administrator. The Administrator confirmed the allegation of sexual abuse by Resident #24 on 03/03/21 should have been reported immediately to the Director of Nursing and Administrator and was not. Review of the facility policy titled Abuse, Neglect, and Misappropriation effective 10/07/14 and revised 02/01/17 and 04/01/19 revealed sexual abuse was defined as non-consensual sexual contact of any type with a resident. The policy stated it was the intent of the facility to prevent the abuse, mistreatment, or neglect of residents and to provide guidance to direct staff to manage any concerns or allegations of abuse, neglect, or misappropriation of their property. In the event an allegation is made, the facility will take measures to protect residents from harm during an investigation. The accurate and timely identification of any event which would place our residents at risk is a primary concern of the facility. Each report of alleged abuse, neglect, or misappropriation of funds will be identified and reported to the supervisor and investigated timely. The supervisor of designee will notify the Director of Nursing and Executive Director of the incident or allegation immediately and no later than twenty-four hours after being notified of incident or allegation and direct required notification of agencies, physician, family, and resident representative. The Executive Director will direct the investigation. In the event a situation is identified as abuse, neglect, or misappropriation, an investigation by the executive leadership will immediately follow up. The resident's safety is the first consideration. The following steps will be followed as appropriate: A physical examination (head to toe) will be performed by the Director of Nursing or designee nurse and documented in the resident's chart. Statements will be obtained from the resident or from the reporter of the incident, in writing whenever possible by the Executive Director or designee. In the event the alleged abuse involves a resident to resident altercation, the residents will be placed in separate areas and the appropriate physical assessments will be completed on each resident. Documentation of the facts and findings will be completed in each resident medical record. Notify the physicians of each resident. Notify the resident representative. Update care plans. Complete any appropriate referrals from the physician that may include mental health assessments. The policy stated statements from staff should include a first-hand knowledge of the incident and a description of what was witnessed, seen, or heard. The policy stated all alleged violations involving abuse are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. The self-report will be made to the Executive Director and State Survey Agency and other local authorities including but not limited to local police, if appropriate. If the events that cause the allegations do not result in serious bodily injury, reporting to the administrator (executive director) and to other reporting regulatory bodies must occur within 24 hours. The results of the facility's investigation must be reported to the survey agency, the executive director/designee, and other officials in accordance with state law, within five working days of the incident. This deficiency substantiated Complaint Number OH 621.

Based on review of a medical record, personnel files, a facility self-reported incident (SRI), the facility Resident Imaging policy and local law enforcement interviews, the facility failed to ensure staff did not violate one resident's (Resident #71) right to privacy and confidentiality. This resulted in Immediate Jeopardy and psychosocial harm for Resident #71 when Certified Nursing Assistant (CNA) #111 pulled the resident's pants down to his ankles, exposing his genital area while State tested Nursing Assistant (STNA) #120 video recorded the incident without the resident's consent. This video was posted on a social media website, resulting in outcomes which one would expect a reasonable person in a similar situation to sustain humiliation and feelings of degradation. This affected one of three residents reviewed for privacy and confidentiality. On 04/15/20 at 9:32 A.M., the Administrator and the Director of Nursing (DON) were notified that Immediate Jeopardy began on 04/07/20 at approximately 7:00 P.M. when CNA #111 violated Resident #71's privacy and confidentiality and pulled his pants down around his ankles, in the hallway, exposing his genital area while STNA #120 recorded the actions of CNA #111. The video was later posted on social media by an individual who was not an employee at the facility and viewed an undetermined number of times. Review of the video revealed CNA #111 was observed with her mask down below her mouth and could be seen smiling and laughing after she pulled down Resident #71's pants. Resident #71 was observed agitated and upset during the incident. STNA #120 could be heard laughing during the incident. The Immediate Jeopardy was removed on 04/09/20 when the facility implemented the following corrective actions: · On 04/09/20 at approximately 5:30 A.M., the DON received notification from Licensed Practical Nurse (LPN) #118 of a video involving a resident being posted on social media. The DON initiated an internal investigation involving the video and notified the Administrator of the posting on social media. The DON and Unit Manager LPN #117 attempted to contact CNA #111 and STNA #120 to obtain statements, however, they were unable to reach employees at this time. LPN #118 identified STNA #120 by voice recognition. · On 04/09/20 at 5:45 A.M., the Regional Director of Operations educated the Administrator on the facility Abuse, Neglect, Exploitation, Misappropriation policy and facility policy for Resident Images. · On 04/09/20 at 6:10 A.M. the Administrator notified local law enforcement of the incident and a report was filed. · On 04/09/20 at 6:00 A.M. a head to toe assessment was completed on Resident #71 by LPN #117 with no abnormal findings. The DON and LPN #117 initiated like resident assessments with no abnormal findings. · On 04/09/20 at 6:20 A.M. the Medical Director and Resident #71's attending physician were notified of the incident. A message was left for Resident #71's guardian to return a phone call to the facility. · On 04/09/20 at 7:00 A.M. Unit Managers LPN #117, and Registered Nurse (RN) #106, Activity Director (AD) #133, Social Service Director (SSD) #126, and the Administrator began interviews for all residents regarding abuse, neglect or misappropriation and inquired if any resident had knowledge of an employee taking videos while providing care. Interviews were completed on 04/09/20 (no time identified). No negative responses were obtained. · On 04/09/20 at 7:15 A.M. the Administrator submitted notification in the form of a SRI to the State Agency. · On 04/09/20 at 7:30 A.M. the facility team, consisting of the Administrator, DON, LPN #117, RN #106, SSD #126, Human Resources staff (HR) #129 and AD #133 initiated the collection of statements from staff members regarding the incident on 04/07/20. · On 04/09/20 at 7:45 A.M. the Interdisciplinary Team (IDT) consisting of the Administrator, DON, Unit Managers LPN #117 and RN#106, SSD #126, HR #129 and AD #133 met to review the SRI and develop the plan to investigate. · On 04/09/20 at 9:00 A.M. HR #129 completed an audit of all employee files, background information and licensure status with no concerns identified. · On 04/09/20 at 9:00 A.M., SSD #126 completed a psychosocial evaluation of Resident #71 which indicated no negative effects from the incident. · On 04/09/20 at 9:15 A.M., the Administrator educated department managers including the DON, AD #133, Unit Managers LPN #117 and RN #106, SSD #126, HR #129 on the facility Abuse, Neglect, Exploitation, Misappropriation policy and facility policy for Resident Images. · On 04/09/20 from approximately 9:20 A.M. through 8:00 P.M., the DON, AD #133, Unit Managers LPN #117 and RN #106, SSD #126, HR #129 educated 10 RNs, 16 LPNs, 42 CNAs/STNAs/Hospitality Aides, 16 Office Staff, 15 Therapy Staff, 10 Housekeeping Staff and 12 Dietary staff on facility Abuse, Neglect, Exploitation, Misappropriation policy and facility policy for Resident Images. All staff were in serviced except for CNA #111 and STNA #120 who were suspended. Inservice education occurred at the facility and per telephone for staff who were not scheduled to work on 04/09/20. · On 04/09/20 at approximately 9:30 A.M., the Administrator completed notification to the State Agency Nurse Aide Registry of the incident with Resident #71 involving STNA #120 and CNA #111. · On 04/09/20 at approximately 10:00 A.M. HR #129 and the DON notified CNA #111 and STNA #120 of suspension effective immediately pending investigation. · On 04/09/20 at 11:05 A.M. SSD #126 spoke with Resident #71's guardian and informed him of the incident. · On 04/09/20 at 11:30 A.M. an Ad-Hoc QAPI meeting with the Administrator, DON, RN #106, Medical Director, HR #129, SSD #126 and MDS RN #132 and #135, and RN #136 was held to review the incident regarding CNA #111 pulling Resident #71's pants down and STNA #120 recording the incident and the investigation process. · On 04/13/20, STNA #120 and CNA #111 were terminated from employment at the facility for taking a video of a resident and posting it on social media and sharing it with other individuals. Neither employee had been in the building after 04/09/20. Termination notification was mailed via certified mail. · On 04/13/20 between 1:23 P.M. to 2:30 P.M. and on 04/14/20 interview between 11:52 A.M. to 1:01 P.M. with Registered Nurse (RN) #106, LPN #117, #119, STNA #109, #110 #124, and SSD #126 reported they had been in-serviced on 04/09/20 regarding abuse prevention, resident privacy, and use of social media. Although the Immediate Jeopardy was removed, the deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure continued compliance. Findings Include: Record review revealed Resident #71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #71 was discharged from the facility to the local emergency room for evaluation on 11/13/19 for becoming physically aggressive with another resident. Resident #71 was then transferred for an inpatient psychiatric hospital stay and on 12/12/19 was readmitted to the facility. Review of the Medicare five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #71 had a Brief Interview for Mental Status score of 2, indicating severe cognitive impairment and the resident was able to make himself understood. Resident #71 required extensive assistance with activities of daily living including toileting, dressing and personal hygiene. No behaviors were identified. A review of Resident #71's medical record revealed on 04/09/20 at 8:22 A.M. a weekly skin assessment was completed by LPN #117 which indicated no bruises, scratches or skin alterations were noted. A progress note by the DON on 04/09/20 at 8:30 A.M. indicated she was notified that an STNA had recorded a video of Resident #71 and the video had been posted on social media. Resident #71 was questioned regarding the incident and had no recollection voiced of any incidents of any kind. An investigation was initiated, SRI started, and local law enforcement was notified by the Administrator. The physician was notified, and the DON attempted to notify the guardian. Review of SSD #126's progress note on 04/09/20 at 9:27 A.M. indicated she met with Resident #71 and there were no signs or symptoms of distress noted. On 04/09/20 at 11:05 A.M., SSD #126 indicated she spoke with the resident's guardian and details of the incident were explained. Review of an undated social media video provided by the local police department revealed Resident #71 standing in a hallway when CNA #111 approached the resident and pulled his pants down to his ankles, exposing his genital area. STNA #120 was viewed video recording the incident. Resident #71 was observed stating I said not to (expletive) do these things now. Now who was it, you? The staff members were viewed laughing at the resident. Review of facility SRI # 1 dated 04/09/20 at 7:43 A.M. revealed around 6:00 A.M. on 04/09/20 the Administrator was notified of a video that was placed on social media regarding Resident #71 and CNA #111. The video appeared to have CNA #111 pulling Resident #71's pants down and STNA #120 recording the incident. The SRI indicated CNA #111 and STNA #120 were immediately placed on leave during pending investigation of the matter. Review of STNA #120's telephone statement dated 04/09/20 provided to the facility stated she was at the facility on 04/07/20, however, was not around when the video was taken. Review of a telephone statement dated 04/09/20 by CNA #111 indicated she played around with Resident #71 like that all the time. I was not expecting for his pants to fall because they were big on him. After the video was taken, I pulled his pants up, gave him a hug and said I was sorry. CNA #111 stated she was not sure who recorded the incident and was not sure how it was given to the individual who placed it on social media. Review of a statement from LPN #122 dated 04/13/20 indicated she was present when the incident between CNA #111 and Resident #71 occurred. LPN #122 stated she had her phone out to take a picture of STNA #113 when she walked through the door, however, she noted CNA #111 was pulling down Resident #71's pants so she immediately erased the video from her phone. LPN #122 indicated STNA #120 was observed with her phone out and pointed towards Resident #71. LPN #122 stated was not aware STNA #120 was recording when CNA #111 was pulling Resident #71's pants down until 04/09/20 when she saw the video on social media. LPN #122 stated she did not report the incident when it originally happened because she was intimidated by coworkers. An attempt to contact STNA #120 via telephone was made on 04/13/20 at 2:32 P.M. and 4:20 P.M. The phone call went straight to voice mail and indicated voice mail had not been set up. An attempt to contact CNA #111 was made on 04/13/20 at 2:34 P.M., however, a message was received the phone number had been discontinued. During a telephone interview with the Administrator on 04/14/20 at 10:31 A.M. he stated he was first made aware of the situation when the DON called him on 04/09/20 after 6:00 A.M. The Administrator reported the DON informed him of a video on social media and the DON forwarded the video to him. The Administrator reported he immediately notified the regional consultant for the facility and local law enforcement. He initiated a SRI when he arrived at the facility. The Administrator reported he instructed the DON to immediately contact the employees, obtain a telephone statement of what occurred and inform STNA #120 and CNA #111 of immediate suspension pending investigation. The Administrator reported no cameras were available on the secured unit to review the incident. The Administrator stated STNA #120 was not scheduled to work on 04/07/20, however, she came to the building and brought STNA #113 birthday gifts. A telephone interview on 04/14/20 at 11:00 AM with the DON revealed she was notified by LPN #118 on 04/09/20 around 6:00 A.M. of a video posted on social media regarding Resident #71 and CNA #111. The DON stated LPN #118 had received an anonymous call earlier that morning informing her of the video. The DON stated she immediately notified the Administrator and started the investigation. During a telephone interview with Unit Manager, LPN #117, on 04/14/20 at 12:20 P.M. revealed he had been notified by the DON on 04/09/20 of a video on social media with CNA #111 and Resident #71. LPN #117 reported he immediately came to work and completed the assessment on Resident #71. LPN #117 stated the resident was confused, however, had no increased behaviors and was cooperative. A telephone interview on 04/14/20 at 1:04 P.M. with LPN #118 revealed she had received an anonymous phone call at work on 04/09/20, somewhere around 6:00 A.M. informing her of a video posting on social media regarding a resident at the facility and CNA #111 and STNA #120. She stated she asked the caller where the video was found, and she gave the name of the individual who had posted the video. LPN #118 stated she immediately found the video and alerted the DON of the phone call and findings. A telephone interview with LPN#122 on 04/16/20 at 4:00 P.M. revealed she was present at the facility when CNA #111 pulled Resident #71's pants down, exposing his genital area. LPN #122 stated Resident #71 became upset when this happened. LPN #122 stated she did not report this incident. LPN #122 stated she was not aware of a video until 04/09/20 when she viewed the social media video. LPN #122 reported she was not aware of anyone 'taking' a video, however, STNA #120 was holding a phone out, pointed towards Resident #71 when the incident occurred. A review of Detective #130's investigative report dated 04/09/20 indicated the police department contacted STNA #120 who was then taken to the police department for an interview. During the interview, STNA #120 stated she was not aware of the video until 5:30 A.M. on 04/09/20 when CNA #111 informed her Citizen #146 had posted a video of her (CNA #111) pulling Resident #71's pants down at work. STNA #120 told Detective #130 she was not working when the incident occurred and was not present at the facility. STNA #120 told Detective #130 that Resident #71 had poor vision and explained staff would sometimes 'bark' and Resident #71 would call for the dog, asking where the dog was. STNA #120 again told the detective she had nothing to do with the video and was not present when the video was taken. STNA #120 informed Detective #130 it appeared the video was taken when Resident #71 was in the hallway. STNA #120 stated the video had been in CNA #111 photo gallery and Citizen #146 hacked her phone and uploaded the video. Review of Detective #130's investigative report revealed during an interview with CNA #111 on 04/09/20 she stated she was working on 04/07/20 on the secured unit and informed Resident #71 he needed to be changed and went to 'tug' on his pants when they just dropped. CNA #111 stated she did pull his pants back up. CNA #111 stated Citizen #146 got on her 'Snap Chat' and then posted the video on social media. CNA #111 stated she did not know who took the video. CNA #111 confirmed STNA #120 was present in the facility when the incident occurred, however, STNA #120 was not working. Telephone interview on 04/14/20 at 1:51 P.M. with Detective #130 revealed the department had received a call from a citizen the morning of 04/09/20 and later the Administrator called the department to inform them of a video on social media which included Resident #71 and staff members. Detective #130 stated he had interviewed CNA #111 and STNA #120 and was continuing to investigate the incident. Review of CNA #111's personnel file revealed she was hired on 09/05/19 as a hospitality aide and completed a Nurse Aide Training and Competency Evaluation Program on 02/20/20 but had not taken her state test. CNA #111 signed acknowledgement of the facility Abuse, Neglect and Exploitation policy on 09/05/19. The personnel file contained an Employee Corrective Action Form dated 04/09/20 which indicated CNA #111 was suspended pending investigation related to an incident with a resident on 04/07/20. CNA #111 was notified of her suspension by telephone. No previous disciplinary actions were noted for CNA #111. Review of STNA #120's personnel file revealed a hire date of 09/05/19 and had a current STNA certification through 12/02/21. STNA #120 had a most recent signed acknowledgement of the facility Abuse, Neglect and Exploitation policy on 01/06/20. The personnel file contained an Employee Corrective Action Form dated 04/09/20 which indicated STNA #120 was suspended during investigation of an incident with a resident on 04/07/20. Review of the facility policy Resident Images, dated 08/12/16 revealed the facility prohibits employees from taking photos in any fashion including posting on social media sites or videos that demean or humiliate a resident. This deficiency substantiates Complaint Number OH 783, OH 656, and OH 27.

Based on review of the medical record, personnel files, a facility self-reported incident (SRI), facility video tape, facility Resident Images policy, facility Abuse, Neglect and Exploitation policy and interviews with staff and local law enforcement, the facility failed to ensure one cognitively impaired resident (Resident #71) was free from mental and emotional abuse by facility staff. This resulted in Immediate Jeopardy and psychosocial harm for one resident (Resident #71) when Certified Nursing Assistant (CNA) #111 pulled Resident #71's pants down to his ankles, exposing his genital area while State tested Nursing Assistant (STNA) #120 video recorded the incident without consent. This video was then posted on a social media website. Applying the reasonable person concept to the incident would result in the person feeling humiliated, demeaned and exploited. This affected one of three residents reviewed for abuse. On 04/15/20 at 9:32 A.M., the Administrator and the Director of Nursing (DON) were notified that Immediate Jeopardy began on 04/07/20 at approximately 7:00 P.M. when CNA #111 pulled Resident #71's pants down around his ankles exposing his genital area while STNA #120 recorded the incident. The video was later posted on social media and viewed an undetermined number of times. Review of the video revealed CNA #111 was observed with her mask down below her mouth and could be seen smiling and laughing after she pulled down Resident #71's pants in the hallway. Resident #71 was observed to be agitated and upset during the incident and was cursing at the staff. STNA #120 could be heard laughing as Resident #71's pants were pulled down and he became upset. The Immediate Jeopardy was removed on 04/09/20 when the facility implemented the following corrective actions: · On 04/09/20 at approximately 5:30 A.M., the DON received notification from Licensed Practical Nurse (LPN) #118 of a video involving a resident being posted on social media. The DON initiated an internal investigation involving the video and notified the Administrator of the posting on social media. The DON and Unit Manager, LPN #117, attempted to contact CNA #111 and STNA #120 to obtain statements, however, they were unable to reach employees at that time. LPN #118 identified STNA #120 by voice recognition. · On 04/09/20 at 5:45 A.M., the Regional Director of Operations educated the Administrator on the facility Abuse, Neglect, Exploitation, Misappropriation policy and facility policy for Resident Images. · On 04/09/20 at 6:10 A.M. the Administrator notified the Portsmouth Police Department of the incident and a report was filed. · On 04/09/20 at 6:00 A.M. a head to toe assessment was completed on Resident #71 by LPN #117. There were no abnormal findings from Resident #71's assessment. The DON and LPN #117 initiated like resident assessments with no abnormal findings. · On 04/09/20 at 6:20 A.M. the Medical Director and Resident #71's attending physician were notified of the incident. A message was left for Resident #71's guardian to return a phone call to the facility. · On 04/09/20 at 7:00 A.M. Unit Manager, LPN #117, Registered Nurse (RN) #106, Activity Director (AD) #133, Social Service Director (SSD) #126, and the Administrator began interviews for all residents regarding abuse, neglect or misappropriation and inquired if any resident had knowledge of an employee taking videos while providing care. Interviews were completed on 04/09/20 (no time identified). No negative responses were obtained. · On 04/09/20 at 7:15 A.M. the Administrator submitted notification in the form of an SRI to the State Agency. · On 04/09/20 at 7:30 A.M. the facility team consisting of the Administrator, DON, LPN #117, RN #106, SSD #126, Human Resources staff (HR) #129 and AD #133 initiated the collection of statements from staff members regarding the incident on 04/07/20. · On 04/09/20 at 7:45 A.M. the Interdisciplinary Team (IDT) consisting of the Administrator, DON, Unit Managers LPN #117 and RN#106, SSD #126, HR #129 and AD #133 met to review the SRI and develop the plan to investigate. · On 04/09/20 at 9:00 A.M. HR #129 completed an audit of all employee files, background information and licensure status with no concerns identified. · On 04/09/20 at 9:00 A.M., SSD #126 completed a psychosocial evaluation of Resident #71 which showed no negative effects from the incident. · On 04/09/20 at 9:15 A.M., the Administrator educated department managers including the DON, AD #133, Unit Managers LPN #117 and RN #106, SSD #126, HR #129 on the facility Abuse, Neglect, Exploitation, Misappropriation policy and facility policy for Resident Images. · On 04/09/20 from approximately 9:20 A.M. through 8:00 P.M., the DON, AD #133, Unit Managers LPN #117 and RN #106, SSD #126, HR #129 educated 10 RNs, 16 LPNs, 42 CNAs/STNAs/Hospitality Aides, 16 Office Staff, 15 Therapy Staff, 10 Housekeeping Staff and 12 Dietary staff on facility Abuse, Neglect, Exploitation, Misappropriation policy and facility policy for Resident Images. All staff were in serviced except for CNA #111 and STNA #120 who were suspended. Inservice education occurred at the facility and per telephone for staff who were not scheduled to work on 04/09/20. · On 04/09/20 at approximately 9:30 A.M., the Administrator completed notification to the State Agency Nurse Aide Registry of the incident with Resident #71 involving STNA #120 and CNA #111. · On 04/09/20 at approximately 10:00 A.M. HR #129 and the DON notified CNA #111 and STNA #120 of suspension effective immediately pending investigation. · On 04/09/20 at 11:05 A.M. SSD #126 spoke with Resident #71's guardian and informed him of the incident. · On 04/09/20 at 11:30 A.M. an Ad-Hoc QAPI meeting with the Administrator, DON, RN #106, Medical Director, HR #129, SSD #126 and Minimum Data Set (MDS) 3.0 RNs #132 and #135, and RN #136 was held to review the incident regarding CNA #111 pulling Resident #71's pants down and STNA #120 recording the incident and investigation process. · On 04/13/20, STNA #120 and CNA #111 were terminated from employment at the facility for taking a video of a resident and posting it on social media and sharing it with other individuals. Neither employee had been in the building after 04/09/20. Termination notification was mailed via certified mail. · On 04/13/20 between 1:23 P.M. to 2:30 P.M. and on 04/14/20 interview between 11:52 A.M. to 1:01 P.M. with Registered Nurse (RN) #106, LPN #117, #119, STNA #109, #110 #124, and SSD #126 reported they had been in-serviced on 04/09/20 regarding abuse prevention, resident privacy, and use of social media. Although the Immediate Jeopardy was removed, the deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure continued compliance. Findings Include: Record review revealed Resident #71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #71 was discharged from the facility to the local emergency room for evaluation on 11/13/19 for becoming physically aggressive with another resident. Resident #71 was then transferred for an inpatient psychiatric hospital stay and on 12/12/19 was readmitted to the facility. Review of the Medicare five-day MDS assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 2, indicating severe cognitive impairment and the resident was able to make himself understood. Resident #71 required extensive assistance with activities of daily living including toileting, dressing and personal hygiene. No behaviors were identified. A review of Resident #71's medical record revealed on 04/09/20 at 8:22 A.M. a weekly skin assessment was completed by LPN #117 which indicated no bruises, scratches or skin alterations were noted. A progress note by the DON on 04/09/20 at 8:30 A.M. indicated she was notified that an STNA had previously recorded a video of Resident #71 and the video had been posted on social media. Resident #71 was questioned regarding the incident and had no recollection of any incidents of any kind. An investigation was initiated, SRI started, and local law enforcement was notified by the Administrator. The physician was notified, and the DON attempted to notify the guardian. Review of SSD #126's progress note on 04/09/20 at 9:27 A.M. indicated she met with Resident #71 and there were no signs or symptoms of distress noted. On 04/09/20 at 11:05 A.M., SSD #126 indicated she spoke with the resident's guardian and details of the incident were explained. Review of a social media video (video was not dated) provided by the local police department revealed Resident #71 standing in a hallway when CNA #111 approached the resident and pulled his pants down to his ankles, exposing his private area while STNA #120 video recorded the incident. Resident #71 was observed to turn to STNA #120 and state I said not to (expletive) do these things now. Now who was it, you? Review of the facility SRI # 1 dated 04/09/20 at 7:43 A.M. revealed around 6:00 A.M. on 04/09/20 the Administrator was notified of a video that was placed on social media regarding Resident #71 and CNA #111. The video appeared to have CNA #111 pulling Resident #71's pants down and STNA #120 recording the incident. The SRI indicated CNA #111 and STNA #120 were immediately placed on leave pending investigation of the matter. Review of STNA #120's telephone interview statement dated 04/09/20 provided to the facility indicated she was at the facility on 04/07/20, however, was not around when the video was taken. Review of a telephone interview statement dated 04/09/20 by CNA #111 indicated she played around with Resident #71 like that all the time. I was not expecting for his pants to fall because they were big on him. After the video was taken, I pulled his pants up, gave him a hug and said I was sorry. CNA #111 stated she was not sure who recorded the incident and was not sure how it was given to the individual who placed it on social media. Review of a statement from LPN #122 dated 04/13/20 indicated she was present when the incident between CNA #111 and Resident #71 occurred. LPN #122 stated she had her phone out to take a picture of STNA #113 when she walked through the door, however, noted CNA #111 was pulling down Resident #71's pants so she immediately erased the video from her phone. LPN #122 indicated STNA #120 was observed having her phone out and pointed towards Resident #71. LPN #122 stated was not aware STNA #120 was recording when CNA #111 was pulling Resident #71's pants down until 04/09/20 when she saw the video on social media. LPN #122 stated she did not report the incident when it originally happened because she was intimidated by coworkers. An attempt to contact STNA #120 via telephone was made on 04/13/20 at 2:32 P.M. and 4:20 P.M. The phone call went straight to voice mail and indicated voice mail had not been set up. An attempt to contact CNA #111 was made on 04/13/20 at 2:34 P.M., however, a message was received the phone number had been discontinued. During a telephone interview with the Administrator on 04/14/20 at 10:31 A.M. he stated he was first made aware of the situation when the DON called him on 04/09/20 after 6:00 A.M. The Administrator reported the DON informed him of a video on social media and the DON forwarded the video to him. The Administrator reported he immediately notified the regional consultant for the facility, the police department and initiated an SRI when he arrived at the facility. The Administrator reported he instructed the DON to immediately contact the employees, obtain a telephone statement of what occurred and inform STNA #120 and CNA #111 of immediate suspension pending investigation. The Administrator reported no cameras were available on the secured unit to review any footage. The Administrator stated STNA #120 was not scheduled to work on 04/07/20, however, she came to the building and brought STNA #113 birthday gifts, entered through the designated employee entrance, recorded her temperature and completed the facility COVID 19 health questionnaire. The Administrator revealed LPN #122's statement was obtained on 04/13/20 and when she indicated she was aware of the incident, however, did not immediately report due to intimidation by peers, she was immediately placed on suspension pending investigation. A telephone interview on 04/14/20 at 11:00 AM with the DON revealed she was notified by LPN #118 on 04/09/20 around 6:00 A.M. of a video posted on social media regarding Resident #71 and CNA #111. The DON stated LPN #118 had received an anonymous call earlier that morning informing her of the video. The DON stated she immediately notified the Administrator and started the investigation. A telephone interview with Unit Manager, LPN #117 on 04/14/20 at 12:20 P.M. revealed he had been notified by the DON on 04/09/20 of a video on social media with CNA #111 and Resident #71. LPN #117 reported he immediately came to work and completed the assessment on Resident #71. LPN #117 stated the resident was confused, however, had no increased behaviors and was cooperative. A telephone interview on 04/14/20 at 1:04 P.M. with LPN #118 revealed she had received an anonymous phone call at work on 04/09/20, somewhere around 6:00 A.M. of a video posted regarding a resident at the facility and CNA #111 and STNA #120. She stated she asked the caller where the video was found, and she gave the name of the individual who had posted the video. LPN #118 stated she immediately found the video and alerted the DON of the phone call and findings. A telephone interview with LPN#122 on 04/16/20 at 4:00 P.M. revealed she was present at the facility when CNA #111 pulled Resident #71's pants down, exposing his private areas. LPN #122 stated Resident #71 became upset when this happened. LPN #122 stated she did not report this incident. LPN #122 stated she was not aware of a video until 04/09/20 when she viewed the social media video. LPN #122 reported she was not aware of anyone 'taking' a video, however, STNA #120 was holding a phone out, pointed towards Resident #71 when the incident occurred. A review of Detective #130's investigative report dated 04/09/20 indicated the police department contacted STNA #120 who was then taken to the police department for an interview. During the interview, STNA #120 stated she was not aware of the video until 5:30 A.M. on 04/09/20 when CNA #111 informed her Citizen #146 had posted a video of her (CNA #111) pulling Resident #71's pants down at work. STNA #120 told Detective #130 she was not working when the incident occurred and was not present at the facility. STNA #120 told Detective #130 that Resident #71 had poor vision and explained staff would sometimes 'bark' and Resident #71 would call for the dog, asking where the dog was. STNA #120 again stated she had nothing to do with the video and was not present when the video was taken. STNA #120 informed Detective #130 it appeared the video was taken when Resident #71 was in the hallway. STNA #120 stated the video had been in CNA #111's photo gallery and Citizen #146 hacked her phone and uploaded the video. Review of Detective #130's investigative report revealed during an interview with CNA #111 on 04/09/20, she stated she was working on 04/07/20 on the secured unit and informed Resident #71 he needed to be changed and went to 'tug' on his pants when they just dropped. CNA #111 stated she did pull his pants back up. CNA #111 stated Citizen #146 got on her 'Snap Chat' and then posted the video on social media. CNA #111 stated she did not know who took the video. CNA #111 confirmed STNA #120 was present in the facility when the incident occurred, however, STNA #120 was not working. Interview on 04/14/20 at 1:51 P.M. via telephone with Detective #130 of the police department revealed the department had received a call from a citizen the morning of 04/09/20 and later the Administrator called the department to inform them of a video on social media which included Resident #71 and staff members. Detective #130 stated he had interviewed CNA #111 and STNA #120 and was continuing to investigate the incident. Review of CNA #111's personnel file revealed she was hired on 09/05/19 as a hospitality aide and completed a Nurse Aide Training and Competency Evaluation Program on 02/20/20 but had not taken her state test. CNA #111 signed acknowledgement of the facility Abuse, Neglect and Exploitation policy on 09/05/19. The personnel file contained an Employee Corrective Action Form dated 04/09/20 which indicated CNA #111 was suspended pending investigation related to an incident with a resident on 04/07/20. CNA #111 was notified of her suspension by telephone. No previous discipline actions were noted for CNA #111. Review of STNA #120's personnel file revealed a hire date of 09/05/19 and had a current STNA certification through 12/02/21. STNA #120 had a most recent signed acknowledgement of the facility Abuse, Neglect and Exploitation policy on 01/06/20. The personnel file contained an Employee Corrective Action Form dated 04/09/20 which indicated STNA #120 was suspended during investigation of an incident with a resident on 04/07/20. Review of the facility policy Abuse, Neglect, and Exploitation, dated 01/19/17, revealed the facility would provide resident centered care to meet the psychosocial, physical needs of the resident. Abuse was defined as the willful infliction of mental anguish and included the deprivation of a caretaker to attain or maintain psychosocial well-being. Mental abuse was defined as including humiliation. Review of the facility policy Resident Images, dated 08/12/16 revealed the facility prohibits employees from taking photos in any fashion including posting on social media sites or videos that demean or humiliate a resident. This deficiency substantiates Complaint Number OH 783, OH 656, and OH 627.

Based on observation, record review, staff interview and review of facility abuse and neglect policy, the facility failed to prevent the physical abuse of Resident #43 by Resident #4. This resulted in actual harm when Resident #4 pushed Resident #43 causing a fractured humerus and clavicle and compression fractures of the [MEDICATION NAME] vertebrae. This affected one (Resident #43) of three residents reviewed for abuse. The facility census was 96. Findings include: Resident #43 was admitted to the facility on [DATE] from a local hospital with [DIAGNOSES REDACTED]. Review of the Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #43 had severe cognitive impairment, wandering behaviors and required assistance of one staff person to complete most activities of daily living. The resident had a current care plan to address behaviors of being combative with direct care, defecating and urinating in inappropriate places, throwing soiled attends on floor, cursing and throwing items at staff. Resident #43 was out of the facility at the time of the investigation receiving treatment at a local hospital and was unable to be observed or interviewed. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the current MDS assessment revealed Resident #4 had cognitive impairment, no hallucinations or delusions, and required limited assistance with most activities of daily living. Resident #4 had a current care plan to address behavioral problem related to hitting walls/closet doors, pacing, making false accusations regarding money and hoarding food in his room. Resident #4 also had a potential to demonstrate physical behaviors of grabbing and spitting at staff and aggressiveness with others. Resident #4 was out of the facility at the time of the investigation receiving treatment at a behavioral health facility and unable to be observed or interviewed. Resident #43 and #4 were roommates in the facility's secured unit for residents with dementia and cognitive impairment. They had been roommates since Resident #4's transfer to the secured unit in (MONTH) of (YEAR). Review of Resident #4's progress notes dated 11/05/18 revealed Licensed Practical Nurse (LPN) #75 documented Resident #4 was pacing the hallway and becoming agitated with his roommate. Non- pharmacy interventions were not effective and Resident #4 was mediated with an as needed [MEDICATION NAME] 25 milligrams (mg). Review of a progress note dated 12/13/18 revealed LPN #75 documented Resident #4 came out into hall, was cussing at staff and claiming his roommate stole his dentures. Staff attempted to explain to the resident the dentist had his dentures for repair however, Resident #4 continued to state his roommate had stolen his dentures in the middle of the night. He wanted him (roommate) out of room stating, this is my room. Review of Resident #43's progress not dated 01/21/19 revealed LPN #3 documented she was alerted by State tested Nurse Assistants (STNAs) # 8 and #44 that while they were charting they heard Resident #4 yelling at Resident #43, so they went to check on the residents. LPN #3 further documented the STNA's reported when they entered the room Resident #43 was lying supine on his bed with his right arm behind him and Resident #4 was standing by the bed yelling at Resident #43 to get the (expletive) out of my room. When asked, Resident #43 stated Resident #4 had pushed him down. Resident #43 was complaining of pain to his arm and the upper arm appeared abnormal. LPN #3 documented Resident #43 was sent out to the emergency room . The physician and resident representative were both notified as well as facility administration and local police. Review of hospital imaging records for Resident #43 dated 01/22/19 revealed the resident had Computerized Tomography (CT) of abdomen/pelvis/thorax and cervical spine and bone scan of the whole body which documented findings of fracture of humerus and clavicle and acute compression fractures involving [MEDICATION NAME] vertebrae one and two. Review of the hospital orthopedic consult for evaluation of right humeral shaft fracture dated 01/22/19 revealed the orthopedic doctor documented Resident #43 presented to the emergency room with a right arm deformity and a fractured humerus following an altercation at his nursing facility. An interview was conducted with STNA #8 on 01/23/19 at 11:09 A.M. regarding the 01/21/19 physical altercation between Residents #43 and #4. She reported she was working the night shift on 01/21/19 in the secured unit of the facility. STNA #8 stated she had just finished rounds, was sitting down to chart when she heard Resident #4 screaming get out of my room and went to see what was going on. STNA #8 said that upon entering the residents' room Resident #4 was standing over Resident #43 who was laying supine on his bed with his right arm underneath him. She reported she asked what was going on and Resident #4 said he pushed Resident #43. STNA #8 said took Resident #4 outside the room and informed him that both he and Resident #43 shared the room and showed him their names displayed next to the door. STNA#8 communicated that Resident #43 complained of his arm hurting and she informed the nurse of the incident. The nurse assessed Resident #43. STNA #8 communicated that she had not received any reports from previous shifts of any behaviors or aggressiveness by either resident. She reported she was familiar with both residents and Resident #4 at times required redirecting regarding having a roommate due to him thinking the room was to be occupied only by him. STNA #8 reported Resident #43 was then sent out to the hospital, and Resident #4 stayed in his room with one-on-one supervision. An interview was conducted with STNA #44 on 01/23/19 at 2:50 P.M. regarding the 01/21/19 physical altercation between Residents #43 and #4. STNA #44 reported she was working the night shift on 01/21/19 in the secured unit of the facility. STNA #44 stated she had just finished rounds, was sitting down to chart when she heard Resident #4 screaming get out of my room and went to see what was going on along with STNA #8. She said she found Resident #4 standing on Resident #43's side of the room screaming, telling Resident #43 to get out of his room and Resident #43 was laying on his bed. She stated STNA #8 took Resident #4 out in the hallway and showed him both names telling him he shared a room with another resident. STNA #44 stated she got the nurse and showed her Resident #43. The LPN assessed Resident #43 and called the director of nursing (DON) and sent Resident #43 out to the hospital. STNA #44 stated that from the time she and the other STNA came on shift at 10:00 P.M. the residents were sleeping, everything was quiet, and both residents were in bed. She stated when the residents were asked what happened both stated Resident #4 had shoved Resident #43. An interview was conducted with LPN #3 on 01/23/19 at 3:26 P.M. regarding the 01/21/19 physical altercation between Residents #43 and #4. She reported she was working the night shift (7:00 P.M. to 7:30 A.M.) on 01/21/19 in the secured unit of the facility. She shared that prior to that Sunday night shift she had not had any concerns regarding either resident's behavior with each other. LPN #3 stated she was called to the room by STNA #8 who was reporting an incident between Resident #43 and Resident #4. LPN #3 stated upon arrival to the room STNA #44 was talking with Resident #4, she noticed Resident #43's arm and began to assess him for further injuries. She reports she alerted the other nurses in the facility of the incident, called nursing administration staff and planned for Resident #43 to be transported to the emergency room . One-on-one supervision of Resident #4 was beginning. LPN #3 stated that prior to the incident everyone had been sleeping and it had been quiet. She reported Resident #4 in the past had been at times aggressive with staff regarding his ensure, but displayed no physical aggressiveness. He had asked why he was paying rent and the other resident was staying in his room at times telling his roommate (Resident #43) he had to leave his room. She stated Resident #43 mostly stayed to himself, sat in the dining room or wandered around in his wheelchair with occasional behaviors. An interview was conducted with Licensed Social Worker (LSW) #70 on 01/23/19 at 2:04 P.M. regarding the 01/21/19 incident between Residents #43 and #4. LSW#70 reported she was not aware of any issues between Resident #43 and Resident #4. She further stated she had thought they would be good roommates because Resident #43 was usually out of the room most of the day wandering and Resident #4 stayed in the room most of the day. She denied receiving any request for room change for Resident #43. LSW #70 stated a room change had been made following the incident. An interview was conducted with DON #28 on 01/23/19 at 4:50 P.M. regarding the 01/21/19 incident between Residents #43 and #4. She reported she was informed of the incident by phone. The DON stated she told the nurse to notify the physician, resident representative and law enforcement. DON #28 stated that per the abuse policy following the incident all residents were assessed, Resident #4 was put under one-on-one supervision and a behavioral health referral was made. DON #28 reported that she was not aware of any issues between Resident #43 and Resident #4 prior to the incident. The facility's policy titled Abuse, Neglect & Misappropriation last revised on 02/01/17 was reviewed. The policy specified it was the policy of the facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. It is the intent of this facility to prevent the abuse, mistreatment, or neglect of a resident or the misappropriation of their property, corporal punishment and/or involuntary seclusion and to provide guidance to direct staff to manage any concerns or allegation of abuse, neglect or misappropriation of their property. This deficiency substantiates Complaint Number OH 262.