Every finding on record at Candlewood Healthcare and Rehabilitation

Based on record review and interview, the facility failed to ensure Resident #96's resident fund account was dispersed timely following the resident's discharge from the facility. This affected one resident (Resident #96) of five residents reviewed for funds. The facility census was 88. Findings include:Review of Resident #96's medical record revealed the resident was readmitted on [DATE] and discharged on 06/06/25 with diagnoses including unspecified dementia, paranoid schizophrenia and major depressive disorder. Review of resident fund accounts revealed $767.94 (seven hundred sixty-seven dollars and ninety-four cents) was dispersed on 07/29/25 from Resident #96's resident fund account following the resident's discharge from the facility on 06/06/25. Interview on 07/30/25 at 12:18 P.M. with Regional Director of Operations #920 confirmed Resident #96's resident fund account monies were not dispersed within thirty days as required.

Based on record review, interview and observation, the facility failed to ensure staff followed infection control standards to prevent cross contamination during tracheostomy (a tube in the opening of the trachea for breathing) care. This affected one (Resident #76) of one resident reviewed for tracheostomy care. The facility census was 88. Findings include: Review of the medical record for Resident #76 revealed an admission date of 07/31/20 with diagnoses including brain damage, tracheostomy status and chronic respiratory failure. Review of the physician's orders for Resident #76 for July 2025 revealed staff were to change her inner cannula every day and as needed dated 02/28/25 and to change the tracheostomy ties every night shift and as needed dated 06/29/22. An observation was conducted on 07/29/25 at 12:12 P.M. of tracheostomy care to Resident #76 by Registered Nurse (RN) #868 with Assistant Director of Nursing/Licensed Practical Nurse (LPN) #805 present during the observation. RN #868 washed her hands, put on a surgical mask, gown and gloves. Resident #76's tray table was covered with a barrier and supplies were in packages and placed on the table. RN #868 placed a barrier on Resident #76's chest, loosened Resident #76's oxygen mask ties and positioned her for tracheostomy care. RN #868 removed her gloves and washed her hands. She then placed on sterile gloves and began to remove Resident #76's tracheostomy ties and cleaned on both sides of the residents neck. She dried the areas and placed new tracheostomy ties on the resident. RN #868 then removed the split tracheostomy gauze sponge and inner cannula and placed them on the barrier on Resident #76's chest. Next, without removing the soiled gloves nor washing her hands and applying clean gloves, she went to the tray table, removed a new sterile cannula from the package and inserted it into Resident #76's outer cannula. RN #868 opened a new split tracheostomy sponge and placed it around her tracheostomy. She reapplied Resident #76's oxygen mask all while wearing the same soiled gloves worn during the treatment. Interview on 07/29/25 at 12:30 P.M. with RN #868 verified she did not follow proper steps during tracheostomy care. She verified her gloves were not sterile during insertion of the new inner cannula causing cross contamination between clean and dirty areas. Interview on 07/29/25 at 12:31 P.M. with LPN #805 also verified RN #868 did not follow the facility's policy and procedure as well as not maintaining infection control practices to prevent cross contamination. Review of the facility policy titled, Trach Care Policy, revised January 2021, revealed changing the inner cannula, trach dressing and collar should be under sterile technique. The nursing staff were to use non-sterile gloved hands, remove oxygen source, remove site dressing, assess, replace the oxygen source and remove gloves. Staff were to put on sterile gloves and remove the inner cannula with their non-dominant hand. With their dominant hand, nursing staff were to gently insert the clean (new) inner cannula into the outer cannula and replace oxygen. After replacing the inner cannula, staff were to clean under the ties and apply the new dressing and ties.

Based on observation, medical record review, Self-Reported Incident (SRI) review, witness statement review, policy review and interview, the facility failed to ensure Resident #64 and Resident #93 were free from incidents of physical abuse by Resident #50. This affected two residents (Resident #64 and #93) of six residents reviewed for abuse. Actual harm occurred on 09/24/24 when Resident #93 was physically abused/assaulted by Resident #50 resulting in an injury. At the time of the incident, Resident #50 punched, with a closed fist, Resident #93, unprovoked, resulting in Resident #93 experiencing pain rated a seven out of 10 (on a pain scale with 10 being the most severe pain), headache, distress with crying resulting in a transfer to the hospital emergency department where the resident was admitted to a trauma center for further evaluation and treatment and diagnosed with a nondisplaced right occipital bone fracture. As of 10/01/24 Resident #93 had not returned to the facility. Prior to this incident of physical abuse, Resident #50 was noted to have a history of abuse towards other residents. Findings include: 1. Review of the closed medical record for Resident #93 revealed the resident was admitted to the facility on [DATE] from the hospital and discharged to the hospital on 09/24/24. The resident had diagnoses including epilepsy, major depressive disorder, symptoms and signs involving cognitive functions and awareness, suicidal ideation and personal history of transient ischemic attack. Review of a Brief Interview for Mental Status (BIMS) evaluation assessment revealed Resident #93 was cognitively intact. Review of a Social Service History and assessment dated [DATE] revealed Resident #93 used a walker or cane, and rehabilitation was needed to move on to a more normal life. Review of the admission assessment dated [DATE] revealed Resident #93 was alert to person, place, time and situation and was independent with bed mobility, transferring and eating and did not have any pain. Record review revealed Resident #93 and Resident #50 were roommates from 09/17/24 to 09/24/24. Resident #93's daughter was identified to be his Power of Attorney (POA). Review of the medical record for Resident #50 revealed an admitted [DATE] with diagnoses of schizophrenia, dementia with psychotic disturbance, schizoaffective disorder, mood disorder, obsessive compulsive disorder, psychosis, alcohol dependence with alcohol-induced persisting dementia, generalized anxiety disorder and bilateral macular degeneration. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #50 was cognitively intact, had hallucinations and delusions, had other behavioral symptoms and wandering behaviors that occurred one to three days during the assessment, and was independent with transferring and walking 150 feet. Resident #50 had legally appointed guardian. Review of a general note dated 09/24/24 timed 7:08 P.M. authored by Registered Nurse (RN) #7 revealed Resident #93 was hit by another resident (Resident #50) on the side of his head while sitting in the hallway in his wheelchair. The residents were separated from each other. Resident #93 was assessed with no apparent injuries noted. The doctor ordered Resident #93 to be sent to hospital for evaluation. Review of a facility SRI dated 09/24/24 revealed at approximately 7:20 P.M., it was reported to the Administrator that Residents #50 and #93 were involved in altercation. Resident #93 was observed sitting in his wheelchair in the hallway, and without provocation, Resident #50 smacked him on the side of his face/ear. Review of the hospital emergency department nursing note dated 09/24/24 timed 8:10 P.M. revealed Resident #93 was brought in by emergency medical services from nursing home for an altercation with his roommate. Resident #93 stated his roommate hit him in the back of his head with his fist for no reason. Resident #93 reported a seven out of 10 headache. It was noted Resident #93 took baby aspirin and was alert and oriented times four spheres (person, place, time and situation). Review of the hospital emergency department physician assistant note dated 09/24/24 timed 8:10 P.M. revealed Resident #93 presented to the emergency department after an assault. Resident #93 was punched once in the back of the head by his roommate at the nursing home around 7:00 P.M. Resident #93 did not fall to the floor. Resident #93 reported a headache now localized to the site of the punch located at the left-side of the head to neck. Resident #93 had some sensations of feeling the room was spinning which he did feel before the punch but the sensation was now consistent. Tenderness was noted over area depicted in photo [left side to middle of neck underneath the skull]. Resident #93 had full range of motion in his neck, some tenderness associated with looking to the right. Resident #93 had pain with movement and muscular tenderness was present. Review of the weight/vitals tab in the electronic medical record revealed Resident #93 had not had any pain from the time of his admission until staff documented pain on 09/24/24 at 9:35 P.M. as the resident complained of pain rated a seven out of 10. Review of the hospital emergency department physician note dated 09/25/24 timed 12:21 A.M. revealed the physician was notified by radiology of a critical finding of nondisplaced right occipital bone fracture. The note indicated neurosurgery would be consulted. Review of the CT scan of head dated 09/25/24 timed 12:32 A.M. revealed Resident #93 had a questionable nondisplaced fracture of the right occipital bone. Review of the orders-administration note dated 09/25/24 timed 7:42 A.M. revealed Resident #93 was admitted to the trauma center with a diagnosis of a hairline fracture. Review of the repeat CT scan of head dated 09/25/24 timed 8:30 A.M. revealed Resident #93 had a stable nondisplaced right occipital bone fracture. Interview on 09/30/24 at 8:30 A.M. and 10:30 A.M. with Resident #93's daughter/POA revealed on 09/24/24, the nurse called her and had informed her she had observed an incident (resident to resident altercation) and reported that Resident #93 did not provoke Resident #50 in any way. The resident's daughter/POA reported Resident #93 sustained a hairline fracture of the skull as result of the hit from Resident #50. Resident #93 had CT scans of the head prior to being admitted to the facility which did not show a fracture of the skull. When Resident #93's daughter/POA spoke to Resident #93 after the incident, Resident #93 stated, oh my god, I was attacked, my head hurts so bad, my head hurts so bad. Resident #93's daughter/POA confirmed Resident #50 was Resident #93's roommate. Resident #93's daughter/POA also revealed Resident #93 was still at the hospital but was getting ready to discharge to a different long-term acute care hospital for acute rehabilitation. Observation on 09/30/24 at 9:15 A.M. revealed Resident #50 was sitting on the edge of his bed, feeding himself breakfast. Interview, during the observation, with Resident #50 revealed when asked to describe the altercation between himself and Resident #93 last week, Resident #50 responded, that did not happen, nothing happened. Interview on 09/30/24 at 9:20 A.M. with Licensed Practical Nurse (LPN) #4 revealed he received the phone call from the hospital that reported Resident #93 had sustained a hairline fracture of the skull. Interview on 09/30/24 at 11:40 A.M. with RN #7, with the DON present, revealed RN #7 was at the nurses' medication cart, passing medications when Resident #93 self-propelled out of his room and was sitting in his wheelchair in front of the elevator when Resident #50 was walking from the opposite direction then turned around and hit Resident #93 with a closed fist on the left side of Resident #93's head. RN #7 was unable to describe the exact location of the point of contact on Resident #93. RN #7 revealed there had not been any words spoken between the residents at the time of the assault; the assault was unprovoked. Resident #93 reported his head was hurting so the physician ordered to send Resident #93 to the hospital. The RN stated staff had been monitoring Resident #50 every 15 minutes. RN #7 believed she was the only staff member to witness the altercation between Residents #50 and #93. Interview on 10/01/24 at 11:30 A.M. with Physician #14 (who specialized in internal medicine and was Residents #50 and #93's physician) revealed Physician #14 reviewed Resident #93's chart at the hospital and felt Resident #93's occipital bone fracture was still questionable as the resident had prior surgery and the imaging could be unclear. When asked if it was possible that Resident #93 sustained the right occipital bone fracture from Resident #50's hit/punch, Physician #14 stated that it could go either way. Review of a hospital CT scan of the head dated 08/24/24 revealed there was no evidence of Resident #93 having a nondisplaced right occipital bone fracture at the time of this testing. Review of a hospital CT scan of the head dated 09/01/24 revealed there was no evidence of Resident #93 having a nondisplaced right occipital bone fracture at the time of this testing. 2. Review of the closed medical record for Resident #64 revealed an admitted [DATE] with diagnoses of aphasia following cerebral infarction, mild cognitive impairment and unsteadiness on feet. Review of the Minimum Data (MDS) Set 3.0 quarterly assessment dated [DATE] revealed Resident #64 had short and long-term memory problems, was unable to recall the current season and staff names and faces, was moderately impaired with daily decision making and had continuous inattention and disorganized thinking. Resident #64 did not utilize a mobility device and was independent with transferring and walking 150 feet. Resident #64 had a legally appointed guardian. Review of the medical record for Resident #50 revealed an admitted [DATE] with diagnoses of schizophrenia, dementia with psychotic disturbance, schizoaffective disorder, mood disorder, obsessive compulsive disorder, psychosis, alcohol dependence with alcohol-induced persisting dementia, generalized anxiety disorder and bilateral macular degeneration. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #50 was cognitively intact, had hallucinations and delusions, had other behavioral symptoms and wandering behaviors that occurred one to three days during the assessment, and was independent with transferring and walking 150 feet. Resident #50 had legally appointed guardian. Review of the general note dated 09/12/24 timed 6:59 P.M. revealed Resident #64 was unable to communicate if he was in pain. Acetaminophen 650 milligrams was given for pain and an ice pack was applied to the right side of his mouth which was swollen. Review of the general note dated 09/12/24 timed 7:54 P.M. revealed around 6:45 P.M., Resident #64 had just finished his dinner, got up and was walking down the hall when another resident [Resident #50] struck him on the right side of his face, knocking him to the floor. Both residents were immediately separated by staff and assessed for injuries. Resident #64 had a swollen lip. A call was placed to the Medical Director with new orders for vital signs for seven days every shift and apply ice pack to right side of face. The other resident [Resident #50] was sent out to hospital for a psychiatric evaluation and a room change would be completed on a different floor. Resident #50 would remain on one-to-one supervision until the ambulance arrived. Review of the Situation Background Assessment Recommendation or Request (SBAR) Summary for Providers assessment dated [DATE] revealed Resident #64's physician ordered a facial x-ray. Review of the general note dated 09/13/24 revealed Physician #14 was in to see Resident #64 with no new orders. Resident #64 had an x-ray of the right side of this face which was negative. Review of the general note dated 09/13/24 timed 2:10 A.M. revealed Resident #64 returned from emergency department. Review of a facility SRI dated 09/12/24 revealed on 09/12/24 at approximately 6:45 P.M., it was reported that Resident #64 and Resident #50 were involved in a physical altercation. Review of the Individual Aggression Program for Resident #50 updated 09/12/24 (within the Self-Report Incident investigation) revealed to determine the reason for aggression, attempt to identify why the resident was showing such behavior as: behaviors related to reality of declining cognitive status and fear of the future and responded impulsively to other residents/staff being in their space by hitting/kicking out without harm intent. Possible situations: separate residents who were having negative interaction, do not take resident behavior personally, offer/assist with food, use of bathroom or other activities of daily living (ADLs) and encourage/assist to change location. The possible situations chosen for Resident #50 were generalized and not individualized to Resident #50. Review of the witness statement dated 09/12/24 (within the SRI investigation) authored by Licensed Practical Nurse (LPN) #12 revealed at approximately 6:30 P.M., LPN #12 was at the nurses' station in front of the medication cart when LPN #12 witnessed Resident #50 in the hallway close to the nurses' station. Resident #64 came walking by from the dining room and as he was walking by, Resident #50 struck him in the face, and he fell on the floor. LPN #13 immediately went to the area and removed Resident #50 from the scene while other staff assisted Resident #64. Interview on 09/30/24 at 10:55 A.M. and 11:20 A.M. with the Administrator and Director of Nursing (DON) revealed after Resident #50 hit Resident #64, Resident #50 was sent to the hospital and returned with no new orders, then Resident #50 was seen by psychiatry services and a medication review was completed by psychiatry service. Resident #50 was also moved to the third floor and had increased supervision. The DON was unable to specify the expectation for increased supervision. Upon review of Resident #50's medical record as it pertained to the incidents of physical abuse involving Resident #93 and Resident #64 it was noted the resident had a physical behaviors care plan dated 09/13/24 which indicated Resident #50 had potential to demonstrate physical behaviors hitting or attacking because he had poor impulse control. The care planned interventions were generalized and were not individualized to Resident #50. Review of Resident #50's physical behaviors care plan dated 09/25/24 revealed Resident #50 had potential to demonstrate physical behaviors of hitting other residents related to dementia. History of harm to others and intrusive wandering/exit seeking. Resident #50 was demonstrating physical behaviors (hitting other residents related to dementia, history of harm to others, poor impulse control). The care planned interventions were generalized and not individualized to Resident #50. Interview on 09/30/24 at 9:00 A.M. with Registered Nurse (RN) #1 revealed Resident #50 repeated what was spoken to him and invaded personal space. RN #1 was not aware of interventions being in place to protect other residents from Resident #50's impulsive behaviors other than every 15-minute checks. Interview on 09/30/24 at 9:12 A.M. and 10:40 A.M. with State tested Nurse Aide (STNA) #3 revealed Resident #50 had been getting more aggressive. Resident #50 had resided on the third floor, was moved to the second floor then back on the third floor which was his current location. STNA #3 was not aware of any interventions for Resident #50 other than every 15-minute checks. Observation on 09/30/24 at 9:50 A.M. revealed Resident #50 was lying in his bed, asleep. Interview on 09/30/24 at 10:50 A.M. with STNA #5 revealed Resident #50 was on every 15-minute checks. STNA #5 was not aware of any other interventions being in place to protect the safety of other residents. Observation on 09/30/24 at 10:51 A.M. and 12:45 P.M. revealed Resident #50 was lying in his bed, asleep. Observation on 09/30/24 at 12:50 P.M. revealed STNA #9 sitting at the nurses' station with several papers including one paper dated 09/30/24 with Resident's #50 name on it which indicated Resident #50 was on 15-minute checks with increments of 15-minutes from 12:00 A.M. to 11:59 P.M. with staff initials next to each 15-minute increment. There was no documentation of what Resident #50 was doing when the 15-minute checks were completed. Interview, during the observation, with STNA #9 revealed Resident #50 had a recent increase in physical behaviors that were totally unprovoked. On 09/30/24 at 12:52 P.M. the every 15 minute check log for Resident #50 was requested from the the DON. Interview on 09/30/24 at 4:00 P.M. with the Administrator and Regional Director of Clinical Operations (RDCO) #12 confirmed Resident #50 hit Resident #64 and Resident #93 within less than two-week span, unprovoked. Evidence of Resident #50's every 15-minute checks was requested again. Interview on 09/30/24 at 4:20 P.M. with LPN #12 verified she witnessed Resident #64 walking along and Resident #50 hitting Resident #64, unprovoked. LPN #12 was unable to describe if Resident #50 hit Resident #64 with an open hand or closed fist. On 10/01/24 at 9:50 A.M. evidence every 15- minute checks for Resident #50 were completed was requested from Regional Director of Operations (RDO) #13. Review of the facility's Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property dated October 2022 revealed if a resident was accused or suspected, the facility would ensure other residents were protected as determined by the circumstances, which could include but were not limited to, increased supervision of the alleged perpetrator and/or other residents, room or staffing changes, and immediate transfer or discharge, if indicated. Whether the incident/allegation was substantiated or unsubstantiated, the Administrator and/or DON or designee would: ensure involved resident's plan of care was reviewed and revised, as appropriate, consistent with the results of the investigation. At the completion of the complaint investigation on 10/01/24, the facility provided no evidence that every 15 minute checks were completed on Resident #50. This deficiency represents non-compliance investigated under Complaint Number OH00158288 and OH00158285.

Based on observation, medical record review, Self-Reported Incident (SRI) review, and interview, the facility failed to develop a care plan with individualized interventions to support the behavioral health care needs of Resident #50, who had diagnoses of major depressive disorder, schizophrenia, generalized anxiety disorder, schizoaffective disorder, mood disorder, obsessive compulsive disorder and psychosis. This affected one (Resident #50) of six residents reviewed for behavioral health care needs. Findings include: Review of the medical record for Resident #50 revealed an admitted [DATE] with diagnoses of schizophrenia, dementia with psychotic disturbance, schizoaffective disorder, mood disorder, obsessive compulsive disorder, psychosis, alcohol dependence with alcohol-induced persisting dementia, generalized anxiety disorder and bilateral macular degeneration. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #50 was cognitively intact, had hallucinations and delusions, had other behavioral symptoms and wandering behaviors that occurred one to three days during the assessment period, and was independent with transferring and walking 150 feet. Resident #50 had legal guardian. Review of the physician orders from September 2024 revealed Resident #50 was ordered: Aripiprazole (an antipsychotic medication) oral tablet 15 milligrams (mg) once a day by mouth at bed time, Clonazepam (medication used to treat anxiety) oral tablet 1 mg by mouth two times a day, and Fluvoxamine Maleate (used to treat obsessed compulsive disorder) oral tablet 50 mg one tablet by mouth in the morning. Review of the psychiatric nurse practitioner progress note dated 09/10/24 revealed Resident #50 appeared to be at baseline for his medication regimen. Resident #50's son was involved in his care, and staff reported no behavioral issues with the resident at this time. Review of the general note dated 09/12/24 timed 8:02 P.M. revealed around 6:45 P.M., Resident #50 was standing out in the hallway when Resident #64 was passing by. Resident #50 struck Resident #64 on the right side of the face, knocking him to the ground. Both residents were separated and assessed for injuries. This resident appeared to have no injuries however the other resident (Resident #64) had a right swollen lip. Resident #50 was immediately placed on one-to-one supervision. Call to medical director with new orders to send to emergency department for psychiatric evaluation and move Resident #50 to the third floor. Review of the general note dated 09/13/24 timed 2:10 A.M. revealed Resident #50 returned from emergency department. Review of the physical behaviors care plan dated 09/13/24 revealed Resident #50 had potential to demonstrate physical behaviors hitting or attacking because he had poor impulse control. The care planned interventions were generalized and were not individualized to Resident #50. Review of the Statement of Expert Evaluation dated 09/17/24 revealed Resident #50 had thought process, affect, memory, concentration and comprehension and judgment impairment. Resident #50 did not know the current president and was unable to count numbers. Resident #50 was recommended to have continued guardianship. Review of the general note dated 09/24/24 timed 8:32 P.M. revealed Resident #50 hit another resident on the side of his head while other resident [Resident #93] was sitting in the hallway in his wheelchair. The residents were separated from each other. The physician ordered Resident #50 to be sent to hospital for evaluation. Ambulance transported the resident to the emergency room via stretcher. Review of the physical behaviors care plan dated 09/25/24 revealed Resident #50 had potential to demonstrate physical behaviors of hitting other residents related to dementia. History of harm to others and intrusive wandering/exit seeking. The care planned interventions were generalized and were not individualized to Resident #50. Review of the physical behaviors care plan dated 09/25/24 revealed Resident #50 was demonstrating physical behaviors (hitting other residents related to dementia, history of harm to others, poor impulse control). The care planned interventions were generalized and not individualized to Resident #50. Review of the SRI dated 09/12/24 revealed on 09/12/24 at approximately 6:45 P.M., it was reported that Resident #64 and Resident #50 were involved in a physical altercation. Review of the Individual Aggression Program for Resident #50 updated 09/12/24 (within the Self-Report Incident investigation) revealed to determine the reason for aggression, attempt to identify why the resident was showing such behavior as: behaviors related to reality of declining cognitive status and fear of the future and responded impulsively to other residents/staff being in their space by hitting/kicking out without harm intent. Possible situations: separate residents who were having negative interaction, don't take resident behavior personally, offer/assist with food, use of bathroom or other activities of daily living (ADLs) and encourage/assist to change location. The possible situations for Resident #50 were generalized and were not individualized to Resident #50. Review of the SRI dated 09/24/24 revealed at approximately 7:20 P.M., it was reported to the Administrator that Residents #50 and #93 were involved in altercation. Resident #93 was observed sitting in his wheelchair in the hallway, and without provocation, Resident #50 smacked him on the side of his face/ear. Interview on 09/30/24 at 9:00 A.M. with Registered Nurse (RN) #1 revealed Resident #50 repeated what was spoken to him and invaded personal space. RN #1 was not aware of additional interventions for Resident #50 other than every 15-minute checks. Interview on 09/30/24 at 9:12 A.M. and 10:40 A.M. with State tested Nurse Aide (STNA) #3 revealed Resident #50 had been getting more aggressive. Resident #50 had resided on the third floor, then was moved to the second floor then currently back on the third floor. STNA #3 was not aware of additional interventions for Resident #50 other than every 15-minute checks. Observation on 09/30/24 at 9:15 A.M. revealed Resident #50 was sitting on the edge of his bed, feeding himself breakfast. Interview, during the observation, with Resident #50 revealed when asked to describe the altercation between himself and Resident #93 last week, Resident #50 responded, that did not happen, nothing happened. Observation on 09/30/24 at 9:50 A.M. revealed Resident #50 was lying in his bed, asleep. Interview on 09/30/24 at 10:50 A.M. with STNA #5 revealed she was not aware of additional interventions for Resident #50 other than every 15-minute checks. Observation on 09/30/24 at 10:51 A.M. revealed Resident #50 was lying in his bed, asleep. Interview on 09/30/24 at 10:55 A.M., 11:20 A.M. with the Administrator and Director of Nursing (DON) revealed after Resident #50 hit Resident #64, Resident #50 was sent to the hospital and returned with no new orders then Resident #50 was seen by psychiatry services and a medication review was completed by psychiatry service. Resident #50 was also moved to the third floor and had increased supervision. The DON was unable to specify the expectation for increased supervision. Interview on 09/30/24 at 11:40 A.M. with RN #7, with the DON present, revealed RN #7 was at the nurses' medication cart, passing medications when Resident #93 self-propelled out of his room and was sitting in his wheelchair in front of the elevator when Resident #50 was walking from the opposite direction then turned around and hit Resident #93 with a closed fist on the left side of Resident #93's head. RN #7 revealed there hadn't been any words spoken to each other at the time of the assault and the assault was unprovoked. The staff had been monitoring Resident #50 every 15-minutes. Observation on 09/30/24 at 12:45 P.M. revealed Resident #50 was lying in his bed, asleep. Interview on 09/30/24 at 12:50 P.M. with STNA #9 revealed Resident #50 had a recent increase in physical behaviors that were totally unprovoked. Interview on 09/30/24 at 4:00 P.M. with the Administrator and Regional Director of Clinical Operations (RDCO) #12 verified Resident #50 hit Resident #64 and Resident #93 within less than two-week span, unprovoked. During an interview on 10/01/24 at 11:25 A.M. with the Administrator and RDCO #12 they refused to verify that individualized care plan interventions were not in place for Resident #50 after the altercation on 09/12/24. This deficiency represents non-compliance investigated under Complaint Number OH00158288 and OH00158285.

Based on observation, medical record review, policy review and interview, the facility failed to ensure a staff-to-resident physical abuse allegation involving Resident #2 was reported to the Administrator. This affected one resident (#2) of five residents reviewed for abuse. The census was 99. Findings include: Review of the medical record for Resident #2 revealed an admitted [DATE] with diagnoses of cerebral infarction, hemiplegia and hemiparesis affecting left non-dominant side, vascular dementia with mood disturbance, diabetes, gastrostomy, chronic heart failure, anxiety disorder, depression, psychosis and suicidal ideations. Review of the general note dated 04/15/24 revealed Resident #2 was alert and oriented times two and pleasant. He was able to make his needs known to staff. He utilized a Hoyer (mechanical lift) for transfers and two-person maximum assistance with all other activities of daily living. He was incontinent of bowel and bladder. He was NPO (nothing by mouth) and was tolerating continuous tube feedings. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #2 was cognitively intact, had hallucinations and delusions, was dependent on staff for oral and personal hygiene, toileting, bathing, upper and lower body dressing, and bed mobility. Observation on 06/17/24 at 9:15 A.M. revealed Resident #2 was lying in bed, in a hospital gown, on his back, asleep, with a feeding tube. Interview, during the observation, with Resident #2 revealed he had a complaint that one of the workers bent his right arm back and cut his fingernails when he told her not to do it. The incident occurred approximately four months ago, and he told a nurse or someone about it but he couldn't remember the name of the person he reported the incident to. Resident #2 stated my arm hurts as he held up and bent his right arm at the elbow. Interview on 06/17/24 at 10:00 A.M. with State-tested Nurse Aide (STNA) #4 revealed Resident #2 did make an allegation of abuse towards STNA #3 saying, she abused him by pulling his arm, and he asked STNA #3 to stop but she didn't. The incident occurred approximately a couple of weeks ago/a month ago. STNA #4 notified former Registered Nurse (RN) #7 of the allegation. Interview on 06/17/24 at 10:28 A.M. with the Administrator and the Director of Nursing (DON) revealed RN #7 hadn't worked at the facility since 02/10/24. The Administrator and the DON were unaware of Resident #2's physical abuse allegation towards STNA #3. Interview on 06/17/24 with Resident #2's Power of Attorney (POA) revealed STNA #3 was rough with Resident #2 and would hold him down and talk smack to him. Resident #2's POA reported the incident to the Scheduler and Case Manager; however, Resident #2's POA was unable to remember the staff names. Interview on 06/17/24 wat 11:25 A.M. with Regional Clinical Support Nurse (RCSN) #9 with the Administrator and DON present, revealed former Administrator/Regional Administrator #10 was also unaware of a physical abuse allegation involving Resident #2 and STNA #3. RCSN #9, the Administrator and the DON all verified it was the expectation and facility policy for the Administrator to be immediately notified a resident abuse allegation. Review of the facility's Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property policy dated October 2022 revealed staff should report all incidents/allegations immediately to the Administrator or designee. If a staff member is accused or suspected, the facility should immediately remove that staff member from the facility and the schedule pending the outcome of the investigation. All incidents and allegations of Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of resident property and all injuries of Unknown Source must be reported immediately to the Administrator or designee. The Administrator/designee should be notified by informing him/her in person, calling via telephone, or sending an email or text message. This deficiency represents non-compliance investigated under Master Complaint Number OH00154585 and Complaint Number OH00154530.

Based on observation and interviews, the facility failed to ensure kitchen employees were wearing beard guards while preparing and serving food, and failed to ensure drinks on resident meal trays were covered while carrying the trays through the hallways for delivery to the residents. This had the potential to affect all 94 residents receiving meals from the kitchen. The facility identified four residents (#2, #32, #65, and #74) as receiving nothing by mouth. The facility census was 98. Findings include: 1. Observation on 02/01/24 from 12:20 P.M. to 12:25 P.M. revealed State tested Nursing Assistant (STNA) #336 poured lemonade and fruit punch into plastic cups in an area around the nurse's station and then placed the cups of liquid back onto the meal trays in the covered food cart. STNA #336 then closed the door to the covered food cart and pushed it down the hall and placed the cart in the middle of the hall between room [ROOM NUMBER] and 111. STNA #336 then took Resident #95's meal tray out of the covered food cart and walked it down to the end of the hallway with the lemonade uncovered, and STNA #358 was observed taking Resident #89's out of the covered food cart and walked it down to the end of the hallway with the lemonade uncovered. Interview with Resident #89 on 02/01/24 at 12:26 P.M. with Resident #89 confirmed her lemonade didn't have a lid on it and stated sometimes the beverages comes with lids and sometimes they don't. Interview with Resident #95 on 02/01/24 at 12:28 P.M. confirmed his lemonade did not have a lid on it and stated, that is how it is served. Interview on 02/01/24 at 12:31 P.M. with STNAs #336 and #358 confirmed they walked down the hall with the beverages uncovered. Interview with Dietitian #45 on 02/01/24 at 3:12 P.M. confirmed the beverages should have been covered if the meal trays were being walked down the hallway. 2. Observations of the kitchen on 02/06/24 from 11:40 A.M. to 12:41 P.M. revealed from 11:40 A.M. to 11:47 A.M., Dietary Cook (DC) #401, who had a beard, was not wearing a beard guard while he prepared the puree chili, puree wax beans, and took the temperatures of the food items on the steam table. Observation at 12:00 P.M. revealed Regional Culinary #450 asked DC #401 to put on a beard guard. Observation of tray line from 12:07 P.M. to 12:41 P.M. revealed Dietary Aide (DA) #322, who had a beard, was not wearing a beard guard as he placed a domed lids on the plates of food then placed the food items in food carts. Observation of kitchen area on 02/06/24 from 11:40 A.M. to 12:41 P.M. revealed DA #330 who had a beard, was wearing a paper blue surgical mask under chin with parts of the beard on the side of the face sticking out between the ear loops of the surgical mask and was walking in and out of the kitchen and putting stock away. Interview on 02/06/24 at 12:41 P.M. with Regional Culinary #450 confirmed DC #450 had not been wearing a beard guard as he should have been until she asked him to put a beard guard on. Interview on 02/06/24 at 12:45 P.M. with Dietary Manager #374 confirmed DA #330 had a beard and a surgical mask under the chin was not an appropriate beard guard and DA #322 had a beard and was not wearing a beard guard. Dietary Manager #374 stated anyone working in the kitchen with a beard should wear a beard guard. This deficiency represents non-compliance investigated under Complaint Number OH00150593.

Based on observations, interviews, review of facility food production sheets and diet type report, the facility failed to ensure Resident #18, #28, #38, #63, #85 and #94 received the pureed main entree in the proper portion size, failed to ensure Residents #19, #44, #49, #50, #60, #76, #77, #86 and #89 received the appropriate main entree for their low sodium diets as ordered, and failed to ensure Residents #13, #17, #21, #23, #25, #26, #30, #34, #41, #87, #91, #53, #54, #67, #69, #72, #73 and #79 received fortified foods as ordered. This affected a total of 33 residents of 94 residents receiving meals from the kitchen. The facility identified four residents (#2, #32, #65 and #74) as receiving nothing by mouth. The facility census was 98. Findings include: 1. Review of the facility food production sheet for lunch on 02/06/24 revealed residents on a puree diet were to receive two number eight scoops of pureed chili. Observation of the lunch tray line on 02/06/24 from 12:07 P.M. to 12:41 P.M. revealed residents who were on a puree diet received one number eight scoop of pureed chili from Dietary Cook (DC) #450 who was observed serving the pureed chili on the tray line. Interview on 02/06/24 at 12:34 P.M. with DC #450 confirmed he gave one number eight scoop of pureed chili to the residents on a puree diet. Review of the 02/06/24 lunch production sheet and interview with Dietary Manager on 02/06/24 at 12:57 P.M. confirmed the production sheet had not been followed and all residents on a puree consistency should have received two number eight scoops of pureed chili instead of one number eight scoop of puree chili. Review of the facility document titled Diet Type Report identified Residents #18, #28, #38, #63, #85 and #94 as having either pureed meat or pureed diet. 2. Review of facility food production sheet for lunch on 02/06/24 revealed residents on a low sodium diet were to receive one three-ounce hamburger on a bun with lettuce and onion instead of the chili. Observation of the lunch tray line on 02/06/24 from 12:07 P.M. to 12:41 P.M. revealed residents on a low sodium diet received one eight-ounce scoop of chili from DC #450. Interview on 02/06/24 at 12:34 P.M. with DC #450 confirmed he gave one eight-ounce scoop of chili for the residents on a low sodium diet. Review of the 02/06/24 lunch production sheet and interview with Dietary Manager on 02/06/24 at 12:57 P.M. confirmed the production sheet had not been followed and residents on a low sodium diet should have received one three-ounce hamburger on a bun with lettuce and onion instead of the one eight-ounce scoop of chili. Review of the facility document titled Diet Type Report identified Residents #19, #44, #49, #50, #60, #76, #77, #86 and #89 as having a low sodium diet. 3. Observation of the lunch tray line on 02/06/24 from 12:07 P.M. to 12:41 P.M. revealed residents who were identified on their meal tickets as needing fortified mashed potatoes for lunch did not receive them. Observation of the items in the steam table revealed no fortified mashed potatoes had been prepared for the meal. Interview on 02/06/24 at 12:08 P.M. with DC #450 confirmed there were no fortified mashed potatoes made, and stated he only gave fortified mashed potatoes when mashed potatoes were on the menu. Interview on 02/06/24 at 12:45 P.M. with Dietary Manager #374 confirmed those residents who have fortified mashed potatoes identified on their meal ticket should receive them daily not when they are on the menu. Interview on 02/08/24 at 11:11 A.M. with Dietitian #451 confirmed residents who have fortified food identified on their meal ticket should be receiving the fortified food daily, not when they are on the menu. Dietitian #451 then stated the cooks down there know that. Review of the facility document titled Diet Type Report identified Residents #13, #17, #21, #23, #25, #26, #30, #34, #41, #87, #91, #53, #54, #67, #69, #72, #73 and #79 as having fortified foods diet. This deficiency resulted from incidental findings during the investigation of Complaint Number OH00150593.

Based on record review, review of the facility Self-Reported Incident (SRI) investigation, review of policy, observations and interviews, the facility failed to ensure Resident #7 and Resident #8 were free from physical abuse. This affected two residents (Resident #7 and #8) out of three residents reviewed for abuse. The facility census was 92. Findings include: 1. Review of the medical record for Resident #8 revealed an admitted [DATE] with diagnoses including schizoaffective disorder, drug-induced subacute dyskinesia, chronic obstructive pulmonary disease, insomnia, vascular dementia without behavior disturbance, psychotic disturbance or mood disturbance, schizophrenia, major depressive disorder, muscle weakness and abnormal gait. Review of Resident #8's Minimum Data Set (MDS) 3.0 assessment, dated 09/12/23 , revealed moderate cognitive deficit with a Brief Interview for Mental Status ( BIMS) score of 10 out of 15. Resident #8 had no physical or verbal behavior exhibited toward others, was a one-person physical assistance for bed mobility, one-person physical assist for walking in the room, needed supervision for dressing, eating and toilet use. Resident #8 had no broken teeth, or mouth or facial pain noted. Resident #8 had no surgical wounds or skin tears. Review of the comprehensive care plan, start date 06/14/23, documented Resident #8 was at risk for sexually oriented behavior related to dementia with behaviors and altered mental status. The goal was for Resident #8 to comply with staff directions and behave in a safe and respectful manner through next review date. Interventions included conduct an evaluation of sexually oriented behavioral symptoms to determine what Resident #8 is communicating through behavior, use creative refocusing to alter behavior patterns, redirection, and referral for a psychiatric evaluation and utilize psychoactive medication as warranted. 2. Review of Resident #7's medical record revealed an admitted [DATE] with medical diagnoses including type two diabetes mellitus, schizophrenia, anxiety disorder, insomnia, unspecified intellectual disabilities, major depressive disorder and generalized anxiety disorder, Review of Resident #7's annual MDS 3.0 assessment, dated 07/06/23, revealed cognition was intact with a BIMS score of 15 out of 15. Resident #7 did not hallucinate or had delusions and had no physical or verbal behaviors exhibited toward others. Resident #7 needed one-person physical assist for bed mobility and was independent to walk. Resident #7 needed set up for dressing, eating and toilet use. Review of comprehensive care plan , completion date 08/08/23, revealed Resident #7 was at risk for potential verbal aggression when frustrated. Goal for Resident #7 was to verbalize understanding of need to control verbally abusive behavior through the review date. Interventions included staff to remain calm and not raise voice, encourage Resident #7 to vent feelings, staff not to take resident's behavior personally, encourage resident to participate in individual or group activities, and notify physician related to medication. Review of a nursing note dated 10/10/23 written by Licensed Practical Nurse ( LPN) #424 revealed loud voices with cursing and yelling in the room of Resident #7 and Resident #8. LPN #424 observed Resident #7 in Resident #8's bed. Resident #8 was on top of Resident #7 hitting him with his fist. Resident #7 was choking Resident #8 and hitting his face. Resident #8 was bleeding from the mouth and under right eye and his neck was very red. SR #8 had a laceration under his right eye. The medical director and family were informed. Review of the facility document titled Skin Grid Non-Pressure V5, dated 10/09/23, written by LPN #424 revealed Resident #8 had red marks on his neck and a skin tear on face measuring 0.5 centimeters (cm) in length by 0.5 cm in width and 0.1 cm depth. The wound had sanguineous bloody drainage. Review of a nursing note dated 10/10/23 written by LPN #325 revealed Resident #8 returned from the hospital that morning with no new orders and vital signs within normal limits. Resident #8 was moved to another room. A message was left for the guardian to call back regarding the update on the room change. Review of Resident #8's hospital emergency visit summary on 10/09/23 revealed an admission diagnosis of assault. Imaging tests were ordered of the cervical spine, head and maxillofacial bones and a chest x ray. All results were negative and Resident #8 was discharged back to the facility on [DATE] Review of the facility SRI investigation, dated 10/10/23 , revealed at 10:30 P.M. the administrator received a call from the second-floor charge nurse to report Resident #7 and Resident #8 were in an altercation. The preliminary investigation revealed Resident #7 stated the roommate (Resident #8) was masturbating in bed, and Resident #7 wanted him to stop. Resident #8 reported Resident #7 came over to his side of the room and began making derogatory remarks about his family. Both residents were immediately separated. Resident #8 had a laceration under his eye and was bleeding from the mouth. Police were called. Resident #7 was placed on every 15-minute checks and Resident #8 was transported to the emergency room . Both of the resident's representatives and physicians were notified. The facility unsubstantiated the allegation of abuse indicating the resident's indicated they had a disagreement, hit each other but denied feeling abused. Review of the witness statement dated 10/09/23 authored by State tested Nursing Assistant (STNA) #379 revealed she heard the nurse responding to a resident altercation and followed the nurse down the hall. Resident #8 was on top of Resident #7 pounding him in the face with his fist. The staff worked together to deescalate the situation. Review of the witness statement dated 10/09/23 authored by Licensed Practical Nurse (LPN) #424 revealed she heard cursing and yelling and went to the room of Resident #7 and Resident #8 to find Resident #8 on top of Resident #7 hitting him in the face and Resident #7 was choking Resident #8. Review of the witness statement dated 10/09/23 authored by STNA #302 revealed she heard the nurse scream for help, went to the room of Resident #8 and Resident #7 and saw Resident #8 on top of Resident #7 punching him in the face. STNA #302 and the other staff broke up the fight. Review of the witness statement dated 10/09/23 authored by STNA #311 revealed she witnessed Resident #7 and #8 fighting with each other. Interview on 10/12/23 at 9:46 A.M. with the Executive Director( ED) revealed as of 09/01/23 Resident #7 and SR #8 were roommates. The ED verified the altercation with Resident #7 and #8. The ED verified SR #8 had a laceration under the eye and blood from the mouth and needed to go to the hospital emergency room . Resident #7 did not have any injuries and refused to go the hospital. Interview on 10/12/23 at 2:45 P.M. with Resident #8 revealed he felt Resident #7 did not like him because he masturbated. Resident #8 stated Resident #7 scratched him and he was not missing any teeth. Resident #8 stated he did not feel safe because his roommate would start fights with him. Resident #8 also stated he did not feel scared now that he was away from Resident #7. Observation during this interview revealed Resident #8 had a pink laceration under the right eye and a pink laceration on the neck. Interview on 10/10/23 at 3:00 P.M. with Resident #7 revealed Resident #8 did not have his curtain closed when he was masturbating and that bothered him. Resident #7 stated he was upset because nobody should have to see that. Interview on 10/12/23 with STNA #379 who witnessed the event stated Resident #7 would get upset easily. STNA #379 said Resident #8 had blood under his eye and blood in his mouth from the fight with Resident #7. Interview on 10/12/23 at 1:29 P.M. with LPN #332 stated Resident #8 had a cut under eye and welts around his neck from being choked during the fight with Resident #8. Resident #8 was nervous because of what happened but presently not scared. The ambulance took Resident #8 to the hospital emergency room for evaluation of his injuries. Interview on 10/12/23 at 1:32 P.M. with STNA #311 revealed she was in the linen room on the night of 10/09/23 and heard screaming. Resident #8 was on top of Resident #7 fighting. STNA #311 verified Resident #8 had a cut under his eye and a scratch on the resident's neck. Interview on 10/12/23 at 1:42 P.M. with STNA #329 revealed she was called to help with the altercation. Both residents were separated and kept safe that night. Interview on 10/12/23 at 5:30 P.M. with LPN #424 revealed she was sitting behind the nurse station and heard yelling down the hall. When LPN #424 entered the room Resident #8 was on top of Resident #7 and Resident #8 had a bloody mouth and a cut eye. LPN #424 called for help immediately and the staff separated the two residents to keep them safe. LPN #424 called 911 and stayed with Resident #8 until the ambulance arrived and transported the resident to the hospital. Interview on 10/12/23 at 12:49 P.M. with Social Worker Designee (SWD) #301 revealed both Resident #7 and #8 had no history of not getting along, but Resident#7 was uncomfortable with Resident #8 masturbating in their room. SWD #310 met with both residents on 10/12/23 and Resident #8 was educated to pull the curtain for privacy during masturbation. SWD #301 stated Resident #8 had a right to privacy and freedom from abuse. Interview on 10/16/23 at 9:12 A.M. with the Director of Nursing (DON) revealed neither resident had ever shown signs of aggression. The DON stated the hospital stated no major injuries were sustained, only a laceration on Resident #8. Interview on 10/16/23 at 11:09 A.M. with the Director of Behavioral Health Psychologist #459 revealed Resident #8 was a quiet resident and never had problems with other roommates and Resident #7 was opinionated and religiously fixated, therefore, the masturbation bothered Resident #7 and provoked him against Resident #8 contributing to the fight. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation, dated October 2022, documented the definition of abuse as the willful infliction of injury resulting in physical harm. The documented definition of willful as the means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. This deficiency represents non-compliance investigated under Complaint Number OH00147293. .

Based on record review, review of a facility self-reported incident, facility policy review and interview the facility failed ensure a smoking privilege was not withheld as a punishment for Resident #71 and failed to ensure the resident was free from an incident of staff to resident abuse. Actual Harm occurred on 02/17/23 when facility staff withheld smoking as a punishment for Resident #71 which then escalated to an altercation between State tested Nurse Aide (STNA) #563 Resident #71. STNA #563 was observed to pin Resident #71 against the wall causing the resident to be fearful of the aide and upset/crying resulting in psychosocial harm. This affected one resident (#71) of three residents reviewed for abuse. The facility census was 93. Findings include: Review of the medical record for Resident #71 revealed an admitted [DATE] with diagnoses including bipolar disorder, anxiety disorder, chronic obstructive pulmonary disease, and post-traumatic stress disorder. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #71 had intact cognition. Resident #71 required extensive one-staff physical assistance for bed mobility; and supervision with set-up help only for transfers, dressing, eating, toileting, and hygiene. Resident #71 was always continent of urine and bowel. Review of the care plan dated 01/18/23 revealed Resident #71 had chronic obstructive pulmonary disease related to smoking. Interventions included to increase supervision while smoking and monitor for signs and symptoms of acute respiratory insufficiency. The care plan also included a focus that Resident #71 had behavior problems related to sexually provocative behaviors. Interventions included to administer medications as ordered and to approach and speak to the resident in a calm manner and divert attention as to remove her from the situation and take to an alternative location. Review of the smoking safety screen dated 01/28/23 revealed Resident #71 was safe to smoke with supervision. Review of the elopement evaluation completed 02/07/23 revealed Resident #71 was not at risk for elopement. Review of a facility SRI, tracking number 232237 initiated 02/18/23 revealed Resident #71 alleged on 02/17/2023 around 7:45 P.M. (during resident smoke time) she entered the sitting area leading to the outside area. The resident indicated she was stopped by STNA #563 and advised she needed to wait due to requiring increased supervision while smoking. While the resident attempted to proceed to go outside, STNA #563 attempted to redirect the resident and stood in front of the door with her back facing the resident. Resident #71 placed her arm around STNA #563's neck trying to pull her to the ground. Resident #71 then grabbed STNA #563's face causing her to have scratch that bled. STNA #563 turned her body around to face Resident #71, while still in a hold, and pushed the resident back breaking loose from the resident's grip. STNA #601 intervened. The receptionist, who heard the commotion came to assist and escorted Resident #71 back to her unit. At approximately 10:00 P.M., East Cleveland Police came to the facility to report Resident #71 had contacted them to make a report; however, upon attempts to interview the resident, she declined to say anything regarding the incident. On 02/18/2023 STNA #601 contacted ADON #610 to report that at the time of the incident she witnessed STNA #563 punch Resident #71 in the face after pushing the resident off her. STNA #563 was immediately suspended pending investigation but had not worked since the time of the incident. Resident #71 was assessed with no visible signs of being punched in the face. Upon further investigation, it's noted that other witnesses who were there at the time of this incident did not see STNA #563 punch Resident #71 in the face. Interview with Resident #71 revealed she denied being punch in the face. Review of the nursing progress note dated 02/22/23 revealed Resident #71 had a skin assessment performed with no skin impairments noted. Interview on 02/22/23 at 2:31 P.M. with Resident #12 revealed she witnessed the commotion of a fight with a staff member and a resident on 02/17/23 during the evening smoke break. Resident #12 reported when she heard their voices raise, she went and stood in a opposite corner on the smoking patio because she was scared and did not remember a lot of details. Interview on 02/22/23 at 3:47 P.M. with Resident #71 revealed the night of 02/17/23 at the 7:00 smoke break, she was told by an aide that she was not allowed to go outside to smoke. She reported the staff were mad at her because around 2:30 P.M. she attempted to assist a wheelchair resident outside causing the alarm to go off. She reported after the incident staff told her she could not have her evening smoke break, another aide stood in the doorway blocking her from exiting to the smoking patio. She reported that aide broke her cigarette in half and turned around facing outside blocking the doorway. Resident #71 reported she then attempted to physically get around the aide by grabbing onto her back and attempting to slip underneath her arm to get outside. The aide then turned around and pinned her up against the wall restraining her with her right hand on the right side of her chest and neck. She confirmed many staff members then came to the area and she was taken back to her room. She reported she denied seeking any medical treatment and did not file a police report because she did not want to be an enemy to anyone. Resident #71 stated she used to work in a nursing home and would never treat her residents that way and reported she just went to her room to cry. Resident #71 became tearful during the interview. Telephone interview on 2/23/23 at 11:21 A.M. with STNA #563 revealed Resident #71 was at the door around smoke break time on 02/17/23 around 7:35 P.M. Resident #71 was told by a co-worker that she could not go out and smoke because she was caught attempting to elope with a wheelchair resident earlier in the day setting the alarms off. STNA #601 informed Resident #71 that she did not follow the rules; therefore, she could not smoke. STNA #563 stated she asked Resident #71 to give her the cigarette she was holding, and Resident #71 gave it to her. She was then standing in the doorway to the smoking patio facing the outside when Resident #71 jumped on her back attempting to take her to the ground. STNA #563 reported Resident #71 got her almost on her knees when she regained her footing and stood up and turned around now face to face with Resident #71 when she pushed her with her right hand on Resident #71's chest and neck pinning her up against the wall by the vending machines to restrain her. She reported two other aides attempted to separate them when Resident #71 scratched her face drawing blood. Telephone interview on 02/23/23 at 11:27 A.M. with STNA #601 revealed when she was coming to work on 02/17/23 she saw Resident #71 pushing a wheelchair resident outside the front doors setting off the alarms. She reported because Resident #71 was attempting to elope she was denied her smoking privileges for that evening, and Resident #71 was instructed not to go to the first floor without supervision. While she was taking residents to the 7:00 P.M. smoke break she found Resident #71 on the first floor unsupervised. STNA #601 said she told Resident #71 to return to her room because she could not go out for smoke break because she was caught taking a resident outside earlier setting off the alarms and was asked to not come on the floor unsupervised. She reported STNA #563 was standing at the doorway and took Resident #71's cigarette and broke it in half and then turned to look outside while taunting Resident #71 saying you can't smoke. Resident #71 then charged behind STNA #563 and attempted to take her down. STNA #563 regained her footing turned around, so she was face to face with Resident #71 and pushed her back into the building pinning her against the wall with her right-hand holding Resident #71 against the wall by her right neck and chest area. STNAs #600 and #601 attempted to break them up when Resident #71 slipped her arms underneath STNAs #600 and #601 scratching STNA #563 in the face causing her to bleed and let go of her grip on Resident #71. STNA #601 reported after Resident #71 scratched STNA #563 in the face, STNA #563 punched Resident #71 in the head. (Resident #71 denied being punched in the head by STNA #563). Telephone interview on 02/23/23 at 11:43 A.M. with STNA #600 revealed she was in the smoking patio door area on 02/17/23 around 7:00 P.M. using the vending machines. She reported she heard STNA #601 tell Resident #71 she could not go smoke. STNA #563 then began blocking the door and informing Resident #71 she could not go smoke when Resident #71 charged her back attempting to remove her from the doorway. STNA #563 then regained her footing turned around and pushed Resident #71 back into the building pinning Resident #71 against the wall with her right hand holding her by her right neck and chest area. STNA #600 reported her, and STNA #601 attempted to separate them when Resident #71 reached underneath their hands and scratched STNA #563 in the face causing her to bleed. STNA #600 reported sometimes STNA #563 could get very heated, and she was pleading with her to let Resident #71 go when she had her pinned to the wall and the only thing that made her let Resident #71 go was when Resident #71 scratched her in the face. Interview on 02/23/23 at 1:30 P.M. with the Interim Administrator reported her staff should never tell a resident they cannot smoke as a form of punishment. Following the incident on 02/17/23, the Administrator reported Resident #71 was examined, had no physical injuries, reported no physical harm and denied filing a police report or seeking emergency medical attention. Interview on 02/23/23 at 2:00 P.M. with the Interim Administrator, the Director of Nursing (DON), and Resident #71 revealed Resident #71 confirmed STNA #563 did pin her up against the wall with her right-hand holding her by her right neck and chest area. She confirmed she had no physical markings, but reported she was afraid to say anything because she does not want enemies in the facility. Resident #71 repeated she used to work in a nursing home and would never treat her residents that way. During the interview, Resident #71 denied being punched in the head by STNA #563. Review of the facility policy Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property, dated October 2022, revealed residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. This includes but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint that is not required to treat the resident's medical condition. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This deficiency represents noncompliance investigated under Master Complaint Number OH00140497. This deficiency is an example of continued noncompliance from the survey completed on 01/31/23.

Based on interview and record review the facility failed to provide clothing purchased by Resident #1 that was purchased on 11/28/22. This affected one Resident #1 of five residents reviewed for clothing purchases. The facility census was 93. Findings include: Review of the medical record for Resident #1 revealed an admitted [DATE] with diagnoses including multiple sclerosis, acquired absence of right and left leg above the knee, and paranoid schizophrenia. Review of Resident #1's contact list revealed Resident #1 was not her own responsible party. Resident #1's sister was listed as her power of attorney. Review of the witness authorization statement dated 1/03/14 revealed Resident #1 and her power of attorney gave the facility permission to manage a personal account for Resident #1 while in the facility. Review of the care plan dated 10/17/22 revealed Resident #1 had impaired cognitive function related to dementia with behaviors and cognitive communication deficit. Interventions included to identify yourself at each interaction with her and keep consistent routines and try to provide consistent care givers as much as possible. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 had moderate cognitive impairment. Resident #1 required total dependence of two-staff for transfers and toileting; extensive one-staff physical assistance for eating; and extensive two-staff physical assistance for bed mobility, dressing, and personal hygiene. Resident #1 was frequently incontinent of urine and always incontinent of bowel. Review of clothing vendor invoice dated 11/28/22 revealed Resident #1 purchased 12 pants sets at 50 dollars a piece with 48 dollars tax equaling 648 dollars. No signature was noted. Review of account statement for Resident #1 from 10/01/22 to 12/31/22 revealed a charge on 12/09/22 for 648 dollars for clothing. Interview on 02/22/23 at 11:18 A.M. with Resident #1 and her power of attorney revealed Resident #1 was charged for 12 clothing outfits on 11/28/22 for 648 dollars and they do not know where the items are. Resident #1 reported she never received the clothing. Observation during the interview of Resident #1's closet revealed four clothing outfits hanging up. Interview on 02/28/23 at 11:00 A.M. with Clothing Vendor #618 revealed Resident #1 did purchase 12 clothing outfits which includes pants and a top for a total of 648 dollars on 11/28/22 when they were in the facility. Clothing Vendor #618 reported the items were delivered immediately to the staff after purchase and they provided a receipt. He reported they do not handle any financial concerns or notifying of families that the activities directors handle that. Interview on 02/28/23 at 11:27 A.M. with Activities Director #543 revealed she did notify all the families that the clothing vendor would be in the facility on 11/28/22. She reported she did not document the notification and did not inform any families of the residents' purchases. She reported Resident #1 did receive her clothing and it was labeled before it was taken to her room. Interview on 02/28/23 at 11:48 A.M. with the Interim Administrator revealed Resident #1 did receive her clothing and reported they must be in the dirty laundry, but she didn't want to have staff rummage through to find them. She confirmed there was no documentation that Resident #1's family was notified of her purchases or that there was proof of delivery of the items. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property, dated October 2022, revealed residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. This includes but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint that is not required to treat the resident's medical condition. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This deficiency represents non-compliance investigated under Complaint Numbers OH00140056 and OH00140068.

Based on record review, facility self-reported incident (SRI) review, staff interview and facility policy review, the facility failed to ensure Resident #51 was free from physical abuse from Resident #88. This affected two residents (#51 and #88) of three residents reviewed for physical abuse. The facility census was 96. Findings include: 1.Review of Resident #51's medical record revealed an admitted [DATE] with diagnoses including schizophrenia, dementia, psychotic disturbance, mood disturbance, anxiety, and major depressive disorder, recurrent. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #51 was alert and oriented with long-term cognition impairment. Review of the MDS assessment revealed Resident #51 required one to two-staff extensive assist to total dependence for activities of daily living (ADL). Review of the plan of care dated 09/28/22 revealed Resident #51 had a mood problem related to schizophrenia, major depressive disorder, anxiety disorder, and dementia with behavioral symptoms that included physical abuse and aggression. Interventions included redirection, intervene when inappropriate behaviors observed, provide one-on-one, administer medications as ordered, monitor, document, record, and report to physician. Review of the physician orders dated 12/20/22 revealed Resident #51 had an order for Seroquel 25 milligram tablet to be given one by mouth one time a day for schizophrenia, Namenda 10 milligram tablet to be given 10 milligrams by mouth two times a day related to dementia, Seroquel 50 milligram tablet to be given one by mouth at bedtime for agitation and aggression, Aricept 10 milligram tablet to be given one by mouth one time a day related to dementia, and clonazepam 1 milligram tablet to be given three times a day related to schizophrenia. 2. Review of Resident #88's medical record revealed an admitted [DATE] with diagnoses including paraplegia, cauda equina syndrome, and spondylosis with myelopathy, cervical region. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #88 was alert and oriented to person, place, and time. Review of the MDS assessment revealed Resident #88 required one to two-staff physical extensive assist for ADL. Review of the plan of care dated 01/18/23 revealed Resident #88 had a history of being verbally abusive related to bipolar disorder, poor impulse control, and physically aggressive towards staff. Interventions included administer medications as ordered, analyze triggers, and deescalate behaviors, document, record, and report to physician. Review of the physician orders dated 12/07/22 revealed Resident #88 had an order to monitor for spitting, cussing, crying, weeping, and yelling every shift. Review of the incident log dated 10/25/22 to 01/25/23 revealed on 11/14/22 there was a reported incident of a resident-to-resident altercation that involved Residents #51 and #88. Review of the SRI #229198 dated 11/15/22 revealed Resident #51 observed Resident #88 knocking on the door of room number #213. Review of the SRI revealed Resident #51 told Resident #88 to get away from the door and Resident #88 started to become verbally aggressive. Resident #51 jumped up, and began swinging at Resident #88 and in return, Resident #88 hit Resident #51 in the face and fell . Review of the progress note, located in Resident #51 electronic medical record (EMR), dated 11/14/22 at 11:22 P.M. revealed Resident #51 sustained an abrasion to the right side of his face. Review of the progress note dated 11/15/22 at 8:43 A.M. revealed Resident #51 had an altercation with another resident with interventions that included redirection and change in scenery. Review of the progress note revealed Resident #51 had a history of being in other residents' business and being very aggressive when being redirected by staff. Review of the progress note dated 11/15/22 at 11:42 A.M. revealed, upon assessment, Resident #51 had a new bruise noted to his right cheek area. Review of the progress note dated 11/15/22 at 11:49 A.M. revealed bruising to Resident #51 cheek was present upon assessment after altercation but now had a brownish-grey bruise present. Review of the progress note dated 11/15/22 at 12:54 P.M. revealed Resident #51 was observed to have two scratches to the left side of his neck. Review of the skin grid non-pressure assessment dated [DATE] revealed Resident #51 had an abrasion to the left side of his face with bruising that measured 2.0 centimeters by 1.5 centimeters. Interview on 01/25/23 at 3:04 P.M. with the Administrator revealed Residents #51 and #88 had an altercation that resulted in Resident #51 having an abrasion to the right side of his face. Interview revealed Resident #51 was the aggressor and Resident #88 was protecting himself. The Administrator revealed both residents were separated, rooms moved, and educated. The Administrator verified findings in SRI #229198. Review of the facility document titled Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property dated October 2022, revealed the facility had a policy in place that residents would be free from abuse, neglect, exploitation, and misappropriation of resident property. Review of the policy, under the section titled Prevention and Identification revealed the facility would intervene in situations in which abuse was more likely to occur.

Based on record review and staff interview the facility failed to implement a policy related to abuse. This affected one of three residents reviewed for abuse (Resident #74). The facility census was 96. Findings Include: Review of medical record for Resident #74 revealed an admitted [DATE]. Diagnoses included schizoaffective disorder, unspecified, muscle weakness (generalized), and essential (primary) hypertension. Review of the 01/02/23, quarterly, Minimum Data Set (MDS) 3.0 assessment for Resident #74 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 that indicated she was alert and oriented to person, place, and time. Review of the MDS assessment revealed Resident #74 was independent with setup help from staff for activities of daily living (ADLs). Review of the care plan, dated 12/16/22, revealed Resident #74 had a mood problem related to admission and schizoaffective disorder. Interventions included administer medications as ordered, monitor, observe, and report to physician. Review of the physician orders dated 01/10/23 revealed an order for a room on the secured unit to promote psychosocial well-being and interaction with peers. Review of the progress note dated 01/17/23 at 8:50 P.M. revealed Resident #74 complained of other residents coming into her room and threatening her. Resident #74 revealed she did not want anyone coming into her room. Review of the progress note dated 01/20/23 at 3:36 P.M. revealed Resident #74 reported allegations of verbal assault and all appropriate parties made aware. Resident #74 was made aware of room change. Review of the incident log dated 10/25/22 to 01/25/23 revealed an allegation of abuse, neglect, and/or misappropriation with no injuries was listed on 01/20/23 at 2:47 P.M. for Resident #74. Review of the incident log revealed no other reported incidents regarding Resident #74. Review of the Ohio Department of Health's Gateway system revealed no Self-Reported Incident (SRI) related to the allegation of abuse was initiated as of 01/25/23. Interview on 01/25/23 at 9:38 A.M. with the Administrator revealed she did not initiate an SRI. The Administrator revealed she did not initiate an SRI due to Resident #74 stated a man asked her when was the last time she had sex and someone asking a question is not considered abuse. The Administrator also revealed Resident #74 reported someone came to her door with a knife, but she could not distinguish if it was a delusion or reality. Interview on 01/25/23 with the State Agency, Administrator and ADON #801 revealed there was no evidence of anything that happened and only an allegation was made. Interview revealed there was no perpetrator identified. Interview revealed due to an internal investigation, there was no need for an SRI to be initiated, and Resident #74 was moved off the secured unit, and staff and residents were interviewed with no findings. Review of the facility document titled Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property dated October 2022, revealed the facility had a policy in place that residents would be free from abuse, neglect, exploitation, and misappropriation of resident property. Review of the policy revealed the facility would investigate all alleged violations and immediately report all such allegations to the Administrator and to the Ohio Department of Health (ODH). Review of the document revealed the facility did not implement the policy in regard to the allegation. This deficiency represents noncompliance investigated under Complaint Number OH00139611.

Based on record review, staff interview, review of the facility self-reported incidents (SRIs) in the Ohio Department of Health's Gateway system, and review of the facility policy the facility failed to ensure an allegation of abuse was reported to the state agency. This affected one resident (#74) of three residents reviewed for abuse. The facility census was 96. Findings include: Review of the medical record for Resident #74 revealed an admitted [DATE]. Diagnoses included schizoaffective disorder, muscle weakness (generalized), and essential (primary) hypertension. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #74 revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 15 indicating she was alert and oriented to person, place, and time. Review of the MDS assessment revealed Resident #74 was independent with set-up help from staff for activities of daily living (ADL). Review of the care plan dated 12/16/22 revealed Resident #74 had a mood problem related to admission and schizoaffective disorder. Interventions included administer medications as ordered, monitor, observe, and report to physician. Review of the physician orders dated 01/10/23 revealed an order for a room on the secured unit to promote psychosocial well-being and interaction with peers. Review of the progress note dated 01/17/23 at 8:50 P.M. revealed Resident #74 complained of other residents coming into her room and threatening her. Resident #74 revealed she did not want anyone coming into her room. Review of the progress note dated 01/20/23 at 3:36 P.M. revealed Resident #74 reported allegations of verbal assault and all appropriate parties were notified. Resident #74 was made aware of room change. Review of the incident log dated 10/25/22 to 01/25/23 revealed an allegation of abuse, neglect, and/or misappropriation with no injuries was listed on 01/20/23 at 2:47 P.M. for Resident #74. Review of the incident log revealed no other reported incidents regarding Resident #74. Review of the Ohio Department of Health's Gateway system revealed no facility SRI related to Resident #74's allegation of abuse was initiated as of 01/25/23. Interview on 01/25/23 at 9:38 A.M. with the Administrator revealed she did not initiate a SRI. The Administrator revealed she did not initiate a SRI due to Resident #74 stated a man asked her when was the last time she had sex and someone asking a question is not considered abuse. The Administrator also revealed Resident #74 reported someone came to her door with a knife, but she could not distinguish if it was a delusion or reality. Interview on 01/25/23 with the Administrator and Assistant Director of Nursing (ADON) #801 revealed there was no evidence of anything that happened and only an allegation was made. Interview revealed there was no perpetrator identified. Interview revealed due to an internal investigation, there was no need for a SRI to be initiated, and Resident #74 was moved off the secured unit, and staff and residents were interviewed with no findings. Review of the facility document titled Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property dated October 2022, revealed the facility had a policy in place that residents would be free from abuse, neglect, exploitation, and misappropriation of resident property. Review of the policy revealed the facility would investigate all alleged violations and immediately report all such allegations to the Administrator and to the state agency. Review of the document revealed the facility did not implement the policy in regard to the allegation. This deficiency represents noncompliance investigated under Complaint Number OH00139611.

Based on observation, interview, and record review the facility failed to serve food at the proper portion size to meet the residents' nutritional needs. This had the potential to affect 80 residents that received meals from the facility kitchen. Two (Resident's #56 and #58) of 82 residents received nothing by mouth. The facility census was 82. Findings include: Observation 09/20/22 at 5:10 P.M. of the dinner tray line revealed diced parsley potatoes were being served with a green #12 scoop which is equivalent to two and two thirds ounces (oz). The spreadsheet for 09/20/22's dinner meal called for four oz. Whole kernel corn was being served with a green #12 scoop which is equivalent to two and two thirds oz. The spreadsheet for 09/20/22's dinner meal called for four oz. Pureed mashed potatoes was being served with a green #12 scoop which is equivalent to two and two thirds oz. The spreadsheet for 09/20/22's dinner meal called for four oz. Cooked vegetables for mechanical soft diets were being served with a blue #16 scoop which is equivalent to two oz. The spreadsheet for 09/20/22's dinner meal called for four oz. Dietary Manager (DM) #207 verified the above findings and switched utensils for proper portion control sizes on 09/20/22 at 5:25 P.M. Interview on 09/21/22 at 11:36 A.M. with Registered Diet Technician (RDT) #215, Registered Dietitian (RD) #209 and DM #207 revealed RDT #215 does not do a full tray line audit. RDT #215 stated that she checked 10 residents' tray tickets to match the doctor's order. Review of the undated facility poster posted on the reach-in refrigerator located behind the steam table titled, Portion Control Chart, revealed colored scoop sizes with portion control sizes.

Based on record review, observation, and interview the facility failed to employ dietary staff who could demonstrate competence in how to properly run a low temperature dish machine. This had the potential to affect all residents receiving meals from the kitchen except for two (Resident's #56 and #58) who did not receive food by mouth. The facility census was 82. Findings include: Observation and interview on 09/19/22 at 11:15 A.M. revealed Dietary Manager (DM) #207 tested the low temperature dish machine. The strips she used did not get a reading, so she checked the chemicals which revealed the sanitizer and rinse aide were emptied. Observation on 09/19/22 at 11:18 A.M. DM #207 and Dietary Aide (DA) #210 went to the storeroom to get sanitizer and returned with rinse aide and three gallons of quat sanitizer. DA #210 stated that there was no sodium hypochlorite solution sanitizer. DM #207 walked away from the dish area. Observation and interview on 09/19/22 at 11:20 A.M. revealed DA #210 was pouring quat sanitizer into the empty five-gallon sodium hypochlorite solution sanitizer bucket. DA #210 stated that DM #207 instructed him to pour quat sanitizer into the empty sodium hypochlorite solution sanitizer bucket. DA #210 stated that the dish machine does not beep or indicate when chemicals are low. DA #210 said he usually checks it at the end of the month but had not checked it today. Interview on 09/19/22 at 11:25 A.M. with DM #207 revealed she believed quat could be used in the dish machine as a ware washing sanitizer but was not sure on the concentration. Interview on 09/19/22 at 1:14 P.M. with Customer Service Representative #230 for the facility's chemical company revealed quat sanitizer was not a suitable sanitizer for a low temperature dish machine. Review of the facility's chemical company's fact sheet titled, [NAME]-Rinse Disinfectant and Sanitizer, dated 05/10/20, revealed for pre-cleaned dishes, flatware, and similar food processing equipment the pre-cleaned equipment must be immersed in a solution of one to two ounces of [NAME]-RINSE to four gallons of water (200-400 parts per million (ppm) active quat or equivalent use dilution) for one minute. Allow sanitized objects to adequately drain and then air dry BEFORE contact with food so little or no residue remains. There was no need for water rinse. Review of the facility's chemical company's fact sheet titled, Alchor; Liquid Sanitizer, dated 10/25/18, revealed the chemical's chlorine release in rinse cycles promotes free rinsing and protects food from surface contamination and bacterial growth on kitchen utensils. This product is ideal for low temperature dish machines final rinse operations.

Based on record review, observation, and interviews the facility did not ensure food was served at palatable temperatures This had the potential to affect 80 residents that received meals from the facility kitchen. Two (Resident's #56 and #58) of 82 residents received nothing by mouth. Finding include: Interviews on 09/19/22 between 11:00 A.M. and 4:31 P.M. with Resident's #7 (second floor), #44 (third floor), and #79 (second floor) during the screening process of the annual survey revealed complaints about food taste and temperatures which lead to a test tray on 09/20/22. Observation on 09/20/22 at 4:31 P.M. with Corporate Food Service Manager (CFM) #208 revealed he calibrated the food thermometer to the best of his knowledge. Observation of the tray line on 09/20/22 at 5:00 P.M. revealed all hot food items on the steam table were over 165 degrees Fahrenheit (F). There was no heat retention system being used in the kitchen to keep the food warm besides the steam table, thermal domes to cover the plates, and enclosed meal delivery carts. The food truck left the kitchen at 6:04 P.M. and arrived on the unit at 6:07 P.M. When the last tray on the truck was delivered, Dietary Manager (DM) #207 went to take the temperature of the food and stated that the temperature for beef, corn, and mashed potatoes did not reach above 100 degrees F and should be hotter. Interview on 09/21/22 at 11:36 A.M. with Registered Diet Technician (RDT) #215, Registered Dietitian (RD) #209, and Dietary Manager (DM) #207 revealed RDT #215 does not do a full tray line audit. RDT #215 stated that she mostly checks the purees for temperature. The facility could not provide this surveyor with a policy of what food temperatures should be during service and did not provide requested food commitee minutes.

Based on observations, interview, record review, and facility policy review the facility failed to ensure proper ware washing and a clean and sanitary kitchen. This had the potential to affect 80 residents that received meals from the facility kitchen. Two (Resident's #56 and #58) of 82 residents received nothing by mouth. Findings include: 1. A tour of the kitchen on 09/19/22 from 11:00 A.M. to 11:25 A.M. revealed the following: The walk-in freezer had garlic bread, veal patties, and chicken patties not wrapped properly, labeled, or dated. Bins that had barley, sugar, and rice were not labeled and dated, and the sugar and rice had scoops sitting directly on the food. The walk-in refrigerator brats were not wrapped properly, labeled, or dated. Interview on 09/19/22 at 11:07 A.M. Cook #102 verified the above observations. Review of the facility policy titled, Labeling and Dating, dated 09/08/21, revealed leftovers and opened items shall be clearly labeled with the date the food item was to be discarded. 2. Observation and interview on 09/19/22 at 11:15 A.M. revealed Dietary Manager (DM) #207 tested the low temperature dish machine. The strips she used did not get a reading, so she checked the chemicals which revealed the sanitizer and rinse aide were emptied. Observation on 09/19/22 at 11:18 A.M. DM #207 and Dietary Aide (DA) #210 went to the storeroom to get sanitizer and returned with rinse aide and three gallons of quat sanitizer. DA #210 stated that there was no sodium hypochlorite solution sanitizer. DM #207 walked away from the dish area. Observation and interview on 09/19/22 at 11:20 A.M. revealed DA #210 was pouring quat sanitizer into the empty five-gallon sodium hypochlorite solution sanitizer bucket. DA #210 stated that DM #207 instructed him to pour quat sanitizer into the empty sodium hypochlorite solution sanitizer bucket. DA #210 stated that the dish machine does not beep or indicate when chemicals are low. DA #210 said he usually checks it at the end of the month but had not checked it today. Interview on 09/19/22 at 11:25 A.M. with DM #207 revealed she believed quat could be used in the dish machine as a ware washing sanitizer but was not sure on the concentration. Interview on 09/19/22 at 1:14 P.M. with Customer Service Representative #230 for the facility's chemical company revealed quat sanitizer was not a suitable sanitizer for a low temperature dish machine. Review of the facility's chemical company's fact sheet titled, [NAME]-Rinse Disinfectant and Sanitizer, dated 05/10/20, revealed for pre-cleaned dishes, flatware, and similar food processing equipment the pre-cleaned equipment must be immersed in a solution of one to two ounces of [NAME]-RINSE to four gallons of water (200-400 parts per million (ppm) active quat or equivalent use dilution) for one minute. Allow sanitized objects to adequately drain and then air dry BEFORE contact with food so little or no residue remains. There was no need for water rinse. Review of the facility's chemical company's fact sheet titled, Alchor; Liquid Sanitizer, dated 10/25/18, revealed the chemical's chlorine release in rinse cycles promotes free rinsing and protects food from surface contamination and bacterial growth on kitchen utensils. This product is ideal for low temperature dish machines final rinse operations. Review of the facility policy titled, General cleaning of equipment, dated 10/01/21, revealed basic cleaning equipment will be maintained in a clean and sanitary condition after every use to ensure food safety. 3. Observation on 09/20/22 at 5:20 P.M. revealed Cook #122 was serving breadsticks with his gloved hand then reached for serving utensils to dish food. Dietary Manager (DM) #207 gave Cook #122 a pair of tongs. Cook #122 did wash his hands and change gloves. Cook #122 continued to pick up the breadsticks with his gloved hand. Interview on 09/21/22 at 11:36 A.M. with Registered Diet Technician (RDT) #215, Registered Dietitian (RD) #209 and Dietary Manager (DM) #207 revealed RD #209 does kitchen sanitation audits monthly in the kitchen.

Based on observation, staff interview, and review of facility drug storage policy and manufacturer's instructions the facility failed to ensure [MEDICATION(S)] (PPD) and [MEDICATION(S)] were stored according to manufacture guidelines. This had the potential to effect five (Resident's #8, #14, #20, #57 and #286) who were admitted in the last 30 days and three (Resident's #35, #42, and #62) who received [MEDICATION(S)]. The facility census was 81. Findings include: Observation on 09/21/22 at 2:30 P.M. with Licensed Practical Nurse (LPN) #213 of the second-floor medication room revealed the refrigerator had one opened multi use vial of PPD solution (used to diagnosis [CONDITION(S)]) with an expiration date of 09/26/24. There was no labeled date when the bottle was opened. There was a bottle of [MEDICATION(S)] (an antacid) with an expiration date of September 2020. Interview on 09/21/22 at 2:30 P.M. with LPN #213 revealed once a multi vial of [MEDICATION(S)] solution was opened the nurse was to document the date on the vial. Review of the manufacturer's instructions for [MEDICATION(S)] (PPD) solution revealed the vial should be refrigerated and protected from light. Vials in use more than 30 days should be discarded. Review of the facility policy titled Storage of Medications, dated April 2018, revealed the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All drugs shall be returned to the dispensing pharmacy or destroyed.

Based on observation, interview, record review, and facility policy review the facility failed to ensure medications were not left unattended at the resident's bedside. This affected one (Resident #44) of 82 residents observed for environmental safety. The facility census is 82. Findings included: Review of the medical record for Resident #44 revealed an admitted [DATE] with diagnoses including [CONDITION(S)] ([CONDITION(S)]), asthma, and diabetes. Review of the physician's orders for September 2022 revealed an order for [MEDICATION(S)]-[MEDICATION(S)] solution, a breathing treatment, 0.5-2.5 milligrams (mg) in 3 milliliters (ml) with instructions to inhale orally three times a day for shortness of breath related to [CONDITION(S)]. There was no order to leave medications at the bedside. Observation on 09/21/22 at 8:35 A.M. of medication administration with Registered Nurse (RN) #143 for Resident #44 revealed she prepared the morning medications including the [MEDICATION(S)]-[MEDICATION(S)] breathing treatment. RN #143 entered the room and Resident #143 was self-administering her breathing treatment. There was an empty plastic vial labeled [MEDICATION(S)]-[MEDICATION(S)]. Interview with Resident #44 at the time of the observation revealed the nurse left the treatment which was left over from a day ago. Resident #44 stated she knows how to use the breathing machine. Interview on 09/21/22 at 8:45 A.M. with RN #143 verified Resident #44 did not have an order to self-administer the breathing treatment. RN #143 stated she will hold the morning breathing treatment since Resident #44 self-administered her own. Review of the facility policy titled Administration and Documentation of Medications, dated January 2020, revealed medications must be kept secure at all times. Nurses must give medication directly to each resident and may not leave them at the bedside or other locations.

Based on observation, interview, record review, and facility policy review the facility failed to ensure a medication error rate of less than 5%. Two errors were observed in 33 opportunities resulting in a 6.06% medication error rate. This affected two (Resident's #58 and #81) of six (Resident's #4, #6, #44, #58, #61 and #81) observed for medication administration. The facility census was 82. Findings include: 1. Review of the medical record for Resident #81 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #81 had impaired cognition and required extensive assistance of one staff with bed mobility, transfers, and personal hygiene. Review of the care plan dated [DATE] revealed Resident #81 had a self-care deficit related to cognition and tremors. Intervention included to crush medication and open capsules. Review of the [DATE] physician's order revealed orders for [MEDICATION(S)] 60 milligrams (mg), to reduce blood pressure, every eight hours. Hold medication if heart rate is less than 60 beats per minutes (bpm) and if systolic blood pressure is less than 110. Observation on [DATE] at 8:17 A.M. revealed Licensed Practical Nurse (LPN) #214 preparing Resident #81's morning medications including the [MEDICATION(S)]. LPN #214 walked into the room and poured the whole pills into the resident's mouth and Resident #81 swallowed the pills with a protein shake. LPN #214 was asked to review the instructions on the [MEDICATION(S)] card which included parameters to hold the medication. LPN #214 pulled out the blood pressure machine walked into the room and took the residents blood pressure. The blood pressure was within acceptable parameter of 153 systolic over 94 diastolic and hear rate of 73 bpm. Interview on [DATE] at 8:20 P.M. with LPN #214 stated she read the parameters in the order but did not take the residents blood pressure prior to administering the medication. Review of the facility policy titled Administration and Documentation of Medications, dated [DATE], revealed the individual administering medications must check the label three times to verify the right resident, right medication, right dosage, right time, and right route of administration before giving the medication. The following information must be checked for each resident prior administering medication. a. Allergies to mediations b. Vital signs, if necessary Nurses are responsible for ensuring vital signs, weights, or other required measurements are obtained prior to administering medications. 2. Review of the medical record for Resident #58 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #58 had impaired cognition and required total assistance of two staff with bed mobility, transfers, and personal hygiene. Review of the care plan dated [DATE] revealed Resident #58 had a self-care deficit related to coma, brain injury, and [CONDITION(S)]. Intervention included resident was a tube feed and nothing by mouth (NPO). Review of the [DATE] physician's order revealed orders for [MEDICATION(S)] sulfate solution 300 mg/6.5 milliliter (ml), iron supplement, every morning. Give 300 mg by percutaneous endoscopic gastrostomy (PEG) a feeding tube. Observation of medication administration on [DATE] at 8:44 A.M. revealed LPN #213 preparing the resident's morning medication including the [MEDICATION(S)] sulfate solution with an expiration date of [DATE]. LPN #213 walked into the room and stopped the feeding tube and repositioned the resident for medication administration. The surveyor stopped the medication administration and asked the LPN #213 to verify the medication and expiration date. Interview on [DATE] at 9:04 A.M. with LPN# 213 verified the [MEDICATION(S)] sulfate had expired. LPN #213 stated she missed the expiration date when preparing the medication. Review of the facility policy titled Administration and Documentation of Medications, dated [DATE], revealed the individual administering medications must check the label three times to verify the right resident, right medication, right dosage, right time, and right route of administration before giving the medication. The expiration date on the medication label must be checked prior to administration.

Based on observation, record review, staff and resident interviews, review of the facility ' s Safety of Residents/Smoking Policy (revised 08/15/15), and review of leave of absence logs, the facility staff failed to provide adequate supervision to ensure residents followed the facility smoking policy rules and prevent residents from smoking in resident rooms, which are unapproved smoking areas in the facility. This resulted in Immediate Jeopardy for four of thirteen sampled residents reviewed who were smokers and observed smoking in their rooms or with cigarettes and/or lighters in their rooms. This included Resident #60, Resident #75, Resident #125, and Resident #132. This presented a potential for fire in the facility which could cause serious injury, harm, impairment, or death to the residents living in the facility. There were 63 identified smokers in the facility. The facility census was 120 residents. On 01/20/16 at 3:33 P.M. the administrator, director of nursing, maintenance director, activities director, director of rehabilitation, Unit Manager #400, Unit Manager #401, human resource manager, business manager, and regional director of clinical services were notified that Immediate Jeopardy began on 12/12/15 when Resident #60 and Resident #125 were observed smoking in Resident #60 ' s room. Resident #60 has a [DIAGNOSES REDACTED].#125 has [DIAGNOSES REDACTED]. The Immediate Jeopardy continued when Resident #60 was observed smoking in his room on 12/13/15, 01/05/16, and 01/06/16. The Immediate Jeopardy continued when Resident #75, who had [DIAGNOSES REDACTED]. The Immediate Jeopardy continued when Resident #75 was observed by the surveyor on 01/14/16 at 5:11 P.M. exiting his room with a green disposable lighter. State tested Nursing Assistant (STNA) #200 indicated Resident #75 was not supposed to have a disposable lighter and he would not give the lighter to the STNA. Resident #75 was allowed to move about the facility unsupervised with the lighter. The Immediate Jeopardy continued when Licensed Practical Nurse (LPN) #301 documented on 01/19/16 at 5:03 P.M. that Resident #60 was smoking marijuana in his room and was counseled by LPN #306. The Immediate Jeopardy continued on 01/19/16 when Resident #60 returned to the facility from a leave of absence (LOA) and was observed by the surveyor at 5:25 P.M. with a pack of cigarettes in his room and Resident #132 handing Resident #60 a cigarette. When notified of the observation, LPN #301 did not attempt to look in Resident #60 ' s room for any smoking items or cigarette lighters. At 5:50 P.M., Resident #132 gave the pack of cigarettes to the administrator, unit manager, and director of nursing (DON) upon their request. The Immediate Jeopardy was removed on 01/21/16 when the facility implemented the following corrective actions: · On 01/14/16 Resident #75 returned from a leave of absence and Case Manager (CM) #500 confiscated the cigarette lighter from the resident. · On 01/14/16 and continuing through 01/20/16, the facility conducted searches for smoking materials on a daily basis and documented the results on monitoring sheets. All residents who smoked were included in these searches. · On 01/19/16, Resident #60 was counseled and re-educated by the director of nursing and administrator on the facility ' s smoking policy. · On 01/20/16, STNA #200 received counseling and re-education by the director of nursing on reporting and documenting smoking paraphernalia observed in resident possession. · On 01/20/16, Resident #60 consented to be transferred to the secured unit of the facility. On 01/21/16 at 11:15 A.M. the surveyor observed Resident #60 on the secured unit with no smoking materials in his room or visible on his person. · On 01/20/16, the administrator educated four receptionists and two security guards on a new systematic change implemented on 01/20/16 for tracking residents who leave the facility and on their return giving their smoking materials to the receptionist and/or security guard. · On 01/20/16 and 01/21/16, the administrator, director of nursing (DON), and department managers re-educated facility staff regarding the smoking policy. This included two Registered Nurses (RN), 23 LPNs, 49 STNAs, 12 Housekeeping/Laundry Staff, 11 dietary staff, the maintenance supervisor, the maintenance technician, two physical therapy assistants, one physical therapist, one occupational therapist, the rehabilitation manager, the business office manager, the director of nursing, the activity director, the case manager, four receptionists, and two security guards. The facility plans include continuing this training with their remaining staff. · On 01/21/16, 57 of the 63 identified smokers in the facility were re-educated by the administrator, director of nursing, and department managers regarding the facility smoking policy. · On 01/21/16, 34 staff were asked to complete questionnaires to ascertain their knowledge of the facility smoking policy. This included four registered nurses, six LPNs, 16 STNAs, one social worker, one occupational therapist, one physical therapist, the housekeeping/laundry supervisor, and one laundry staff. The facility plans include continuing this assessment of staff knowledge with the remaining staff. Although the Immediate Jeopardy was removed when the facility established systems to ensure monitoring of residents' smoking activity, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) because the facility is continuing with educating staff and residents. As of 01/21/16, 19 of 107 facility staff and 6 residents had not received the smoking policy training. In addition the facility is continuing their assessment of the remaining 73 staff members regarding their post training knowledge of the current facility smoking policy and procedures. Findings include: 1. Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 3 of 15 indicating the resident was cognitively impaired. The MDS revealed Resident #60 required supervision for most activities of daily living. A smoking assessment dated [DATE] indicated the resident was safe while smoking but the facility would store his lighter and cigarettes. On 12/12/15 at 10:50 P.M., Licensed Practical Nurse (LPN) #301 documented in a progress note that Resident #60 was observed with Resident #125 smoking marijuana in his room. Resident #125 had [DIAGNOSES REDACTED].#304, this resident required one-to-one supervision while smoking. On 12/13/15 at 2:04 A.M., LPN #303 documented in the progress notes Resident #60 was observed smoking in the bathroom of his room, with a distinctive odor coming from the room. On 01/05/16 at 4:20 P.M., LPN #301 documented Resident #60 was observed smoking marijuana in his room. He was redirected to not smoke in his room. LPN #301 notified Psychologist #501 who was in the building at the time of this observation. On 01/06/16 at 3:00 P.M. Case Manager (CM) #500 documented Resident #60 was observed smoking in his room. On 01/14/16 at 8:43 A.M., a progress note written by CM #500 indicated Resident #60 was observed smoking in his room, at which time the resident signed a contract to follow all smoking rules and policies or he may be discharged from the facility. A nurses progress note written by LPN #301 dated 01/19/16 at 5:03 P.M. revealed Resident #60 was smoking marijuana in his room and was counseled at 5:08 P.M. by LPN #306. On 01/19/16 at 5:23 P.M, the surveyor observed Resident #60 return to the facility from a leave of absence (LOA) and sign in at the front desk. At 5:25 P.M., the surveyor observed Resident #60 in his room with his roommate, Resident #132, and Resident #114 who also smoked cigarettes. A pack of cigarettes was observed on an over the bed table and Resident #132 was handing Resident #60 a single cigarette. Resident #132 had [DIAGNOSES REDACTED]. A loose brown shredded substance was observed on Resident #60 ' s night stand and when asked Resident #60 indicated it was for smoking. The surveyor immediately reported the observation to the charge nurse (LPN #301) who had no knowledge that the resident had been on a LOA, and indicated it was not legal for her to search the resident. When the surveyor left the unit at 5:35 P.M., LPN #301 had not attempted to look in Resident #60 ' s room for any smoking items or cigarette lighters. A behavior progress note written by the DON on 01/20/16 at 10:37 P.M. as a late entry revealed on 01/19/16 at 5:50 P.M. the administrator, unit manager, and DON went to Resident #132 ' s room to ask for his smoking items. The resident gave them a pack of cigarettes, and was re-educated on the facility smoking policy. 2. Medical record review revealed Resident #75 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the smoking assessments dated 12/16/14, 02/13/15, 03/16/15, 05/19/15, 08/06/15, 09/08/15, and 12/14/15 revealed Resident #75 needed the facility to store his cigarettes and lighters or matches. In addition, the smoking assessments dated 12/16/14, 05/19/15, 08/06/15, 09/08/15, and 12/14/15 indicated the resident needed supervision during smoking. Review of the MDS assessment dated [DATE] revealed a BIMS score of 12 and signs of delirium. The resident had a court appointed guardian related to his inability to care for himself in the community. Review of the progress note dated 01/06/16 written by CM #500 revealed the resident was found smoking in his room, and was educated on the rules of the facility along with the smoking policy. The resident expressed not caring about the rules in the facility and stated he would smoke when he wanted to smoke. On 01/14/16 at 5:11 P.M. the surveyor observed Resident #75 exiting his room with a green disposable lighter, part of an extinguished cigarette, and a cell phone. When the surveyor asked Resident #75 if he was supposed to have a lighter, the resident put the lighter in the pocket of his shirt. State tested Nursing Assistant (STNA) #200 was sitting across the hall, and said Resident #75 was not supposed to have a lighter, but he would not give it to me. STNA #200 then followed Resident #75 down the hall toward the elevator. At 5:13 P.M, interview with STNA #200 revealed Resident #75 had gone down the elevator, and she did not obtain the cigarette lighter from Resident #75. At 5:18 P.M., the surveyor then observed Resident #75 in the courtyard where the residents smoke. Interview with the resident revealed he had given the cigarette lighter to STNA #201. Resident #75 then went back into the building. At 5:20 P.M., interview with STNA #201, revealed Resident #75 did not give her the cigarette lighter, and the resident had returned into the building with the cigarette lighter. STNA #201 said staff were supposed to light the residents ' cigarettes. STNA #201 then went into the building and returned to the courtyard stating Resident #175 said he threw the lighter in the trash. However, at 5:25 P.M. the surveyor and STNA #201 could not find the cigarette lighter in the trash. The administrator was notified of these observations on 01/14/16 at 5:35 P.M. At 5:46 P.M., the administrator revealed inservices had begun to educate staff regarding smoking materials, and room sweeps were being conducted. On 01/21/16 at 4:01 P.M. the surveyor observed Resident #75 returning to the facility from a leave of absence. The resident signed back in at the front desk. There were no smoking materials visible on the resident. STNA #204 picked up the smoke box from the receptionist in order to go outside to the patio for the smoke break for the residents. At 4:14 P.M., Resident #75 was observed at the doorway of his room with LPN #307, who was asking him to open his coat. LPN #307 checked for smoking materials with none found. No smoking materials visible in Resident #75 ' s room. On 01/20/16, the administrator educated four receptionists and two security guards on a new systematic change implemented on 01/20/16 for tracking residents who leave the facility and on their return giving their smoking materials to the receptionist and/or security guard. According to the new procedures, the staff at the front desk were required to track all residents leaving the facility, indicating if they issued any resident smoking materials when leaving the facility, and if they obtained any smoking materials when the resident returned. The front desk staff were required to report to the administrator immediately any resident who refused to turn over smoking materials upon return. The resident would then be placed on 1:1 supervision until resolved. On 01/20/16 and 01/21/16, the administrator, DON, and department managers re-educated all facility staff regarding the smoking policy. As of 01/21/16, the facility had inserviced 88 of 107 staff, and had a plan in place to inservice the remaining 19 staff members. On 01/21/16, 34 staff were asked to complete questionnaires to ascertain their knowledge of the facility smoking policy. The facility plans to continue their smoking policy and procedure knowledge assessment for the remaining 73 facility staff members. In addition, as of 01/21/16, 57 of the 63 identified residents who smoked were re-educated by the administrator, DON, and department managers regarding the facility smoking policy. The facility has plans to re-educate the remaining six residents who smoke cigarettes at the facility. This deficiency is an incidental finding discovered during the course of this complaint investigation.

Based on medical record review, interview with staff, review of a facility Self-Reported Incident report, review of the facility Abuse/Neglect/Misappropriation of Property Policy, review of the facility One to One Supervision policy, and review of a police report, the facility failed to ensure Resident #3 was free from physical abuse by Housekeeper #29. This resulted in Immediate Jeopardy for one resident (#3), who was hit in the face by the housekeeper, causing harm to the resident which resulted in a bloodied face. This affected one of three residents reviewed for abuse out of a current facility census of 117. On [DATE] at 3:55 P.M., the Administrator Director of Nursing (DON) and Corporate Registered Nurse (RN) #41 were notified Immediate Jeopardy began on [DATE] at 3:05 P.M. when Resident #3 was observed by Licensed Practical Nurse (LPN) #30, at the third floor nurses' station with blood on her nose and mouth. The resident was unable to state what had happened. At that same time, LPN #30 heard Resident #18 state that Resident #3 was bleeding because she and Housekeeper #29 were fighting. Facility staff failed to investigate or report the abuse to administrative staff which resulted in Housekeeper #29 working the remainder of her shift on this date and returning to work on [DATE]. LPN #30 did not report the abuse to the administrator until the next day, [DATE] at 7:30 A.M. The Immediate Jeopardy was removed on [DATE] when the facility initiated the following corrective actions: · On [DATE] at approximately 8:00 A.M., the Administrator notified Housekeeper #29 her employment was suspended pending an abuse investigation. Housekeeper #29 was escorted from the building and as of [DATE], has not returned to the facility. · On [DATE] at 9:43 A.M., LPN #30 and LPN #31 were suspended pending investigation for failing to report the incident to administrative staff in a timely manner following the incident. · Beginning on [DATE] and continuing through [DATE], in-service training was conducted by the Administrator, DON, RN #32, RN #48 and RN #29 for all staff, which included five RNs, 21 LPNs, 45 State-tested Nurse Aides (STNA), 9 Housekeeping staff, 38 Ancillary staff and 13 'on call' (as needed) staff related to the facility's current abuse policy including the immediate reporting of all instances and allegations of abuse. All staff, except for an STNA on medical leave and three on-call employees were trained as of [DATE]. A plan was in place to ensure these four staff received training prior to returning to work. · On [DATE], all 117 current residents were interviewed and assessed for possible abuse by the Administrator, DON, RN #32, RN #48, RN #29 (unit managers). Two residents (Residents #2 and #20) expressed concerns of possible staff abuse at that time. These allegations were reported to the State agency and thoroughly investigated with the investigations completed on [DATE] with no evidence of abuse occurring. · Beginning on [DATE] and continuing through [DATE], all STNAs and licensed nursing staff were provided in-service training on the revised one to one supervision. An addendum was made to the undated facility policy, 'One to One Supervision' to include that continuous supervision was to be made even if the resident was sleeping. As part of the investigation of the incident involving Resident #3, the facility determined the resident, who had a nursing intervention for one to one supervision by nursing staff, was not being provided the supervision at the time she was abused by Housekeeper #29. · On [DATE], STNA #40 was suspended for failing to provide the one to one supervision for Resident #3 as required on [DATE]. · Beginning on [DATE], the facility initiated a new Ambassador program. All residents by room numbers were assigned to a management team member who will conduct daily (Monday through Friday) individual interviews with their assigned residents to assess concerns they may have with care. Random residents would be interviewed on the weekend by the weekend supervisor. The daily interviews were to continue for a month with weekly interviews to be conducted after that time. · On [DATE], [DATE] and [DATE], interviews with RN #32, LPNs #31, #33, #41 and #43, STNAs #40, #42, #44 and #45 and Housekeepers #46 and #47, revealed all staff interviewed were knowledgeable of the facility abuse policy and procedure, aware of the reporting processes in place related to suspected abuse and also knowledgeable of the expectation of one on one supervision requirements. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for than minimal harm that is not Immediate Jeopardy) as not all staff had been re-educated regarding the facility abuse policy, on-going random audits and interviews and monitoring by the facility to ensure the continued resident safety and provision of residents with an opportunity to express concerns could not be evaluated. Findings include: Review of Resident #3's closed medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's plan of care, dated [DATE] revealed the resident was placed on the secured unit due to the resident's [DIAGNOSES REDACTED]. An initial/entry Minimum Data Set (MDS) 3.0 Assessment had not been completed, but review of the resident ' s five day MDS 3.0 Assessment, dated [DATE], revealed the resident was severely cognitively impaired, with memory problems and had behaviors including physical, verbal and other behaviors. Review of nursing progress notes revealed the resident had two falls, documented on [DATE] at 1:34 P.M. and 6:28 P.M. and had struck other residents on [DATE] at 3:21 P.M. and 6:23 P.M. Her physically aggressive and verbally abusive behavior continued, leading to a nursing intervention and order dated [DATE] at 7:21 A.M. for one to one staff supervision due to physical aggression. This intervention was referenced in the nursing progress notes and was to be provided at all times. Review of the current undated facility policy entitled One to One Supervision, revealed one to one supervision would be continuous. Review of a nursing note written by LPN #31, dated [DATE] at 3:15 P.M. revealed Resident #3 was observed standing at the glass window of the locked dementia unit, with a moderate amount of blood on her mouth and nose. The note indicated LPN #31 cleansed the area with soap and water, assessed the resident to have no injury observed, and indicated the resident stated she did not know what had happened. The next nursing note, dated [DATE] at 11:10 P.M. revealed the resident was very physically aggressive, trying to attack staff, throwing items out of room and towards staff. A nurse's note written by RN #32 and dated [DATE] at 9:11 A.M. revealed a summary of the events beginning on [DATE] at 3:05 P.M. The note revealed another unidentified resident alleged Resident #3 was hit by another unidentified staff member in the face the previous day. The resident was without any bruising to the facial area. On [DATE] at 9:45 A.M., interview with RN #32, revealed she was the nurse who wrote the above note as a summary of the incident involving Resident #3. RN #32 also verified Resident #18 had made the actual allegation of abuse on [DATE]. The note written on [DATE] at 9:11 A.M. further revealed Resident #3 had walked up to the desk with bleeding around her mouth and nose at approximately 3:05 P.M. on [DATE] and, after escorting the resident to her room, the note indicated it was assumed the bleeding came from biting the inside of her mouth, as a deep crevice was noted to the right inner cheek and the resident had broken teeth both upper and lower which had been previously assessed at the time of the resident's admission. The note indicated the slow, moderate bleeding ceased without difficulty, the resident was without any emotional distress and was unable to verbalize what had happened. The note indicated the resident was at baseline, combative and pacing from room to nursing station window. The note indicated the resident's physician and power of attorney (POA) for the resident were made aware of the situation. Record review revealed Resident #3 was transferred to the hospital on [DATE] for continued behaviors and change in mental and physical status. The resident had not returned to the facility as of the time of the on-site investigation. On [DATE] at 9:45 A.M. interview with RN #32 revealed she observed Resident #3 on [DATE] after the incident, and noted the resident was bleeding, but attributed the bleeding something like a nose bleed or related to her [DIAGNOSES REDACTED]. She was unaware of an actual injury that had occurred, but told LPN #31 to notify the physician of the bleeding. She stated she was not sure the physician was notified on [DATE] and she did not assess the resident until [DATE] when she was made aware by the administrator the resident had been hit in the face. She stated she called the physician and POA at that time and verified the note she wrote dated [DATE] at 9:15 A.M. was a summary of the entire incident. The summary of the Self-Reported Incident, submitted to the State agency, dated [DATE] revealed physical abuse by a staff member (Housekeeper #29), involving Resident #3 was substantiated. Review of a police report form, titled Police Department In Station General Offense Report Form, dated [DATE] (no time noted), revealed Housekeeper #29 admitted she hit Resident #3 in the face on [DATE]. Housekeeper #29 stated Resident #3 had called her a nigger and struck her twice prior to the housekeeper hitting the resident back, making her bleed from her mouth. On [DATE] at 2:06 P.M. interview with the Administrator revealed the Regional Manager for Health Care Services Group, who oversees the facility housekeeping, laundry and dietary departments filed an in person police report of the incident with the local police department on behalf of the facility on [DATE] at approximately 1:15 P.M. The Administrator revealed as of [DATE] the police department had not been onsite in the facility, but the incident currently had a case number and detective assigned to it. Review of a statement by the Administrator, dated [DATE] at 7:30 A.M., revealed Housekeeper #29 was interviewed by the Administrator. She stated Resident #3 had hit her earlier in the day and when she was at the janitor's closet at the end of her shift, the resident again approached and hit her. Housekeeper #29 stated she hit Resident #3, then left and went home. Review of a statement, dated [DATE] by STNA #40 revealed she was the staff member who was assigned the one to one supervision for Resident #3 on [DATE]. The statement provided revealed STNA #40 left the unit at 3:03 P.M. and the resident was laying down sleeping. On [DATE] at 3:20 P.M. interview with STNA #40 verified the above information contained in her statement. The STNA stated she left the unit because her shift was over, and that she told LPN #31 she was leaving. She stated that she was in-serviced on [DATE] regarding the one to one policy, with the emphasis placed on continuous supervision even when the resident was sleeping. Review of a statement, completed by LPN #33, dated [DATE] revealed she had just come on to the unit on [DATE] to start her 3:00 P.M. to 11:00 P.M. shift and noticed Resident #3 bleeding at approximately 3:15 P.M. She stated she took the resident to her room to help stop the bleeding. An second interview with LPN #33 on [DATE] at 1:30 P.M. revealed she saw LPN #30 talking with Housekeeper #29 when she took Resident #3 to her room at 3:15 P.M. Review of a statement, completed by LPN #30, dated [DATE] revealed Resident #18 approached the nurse's station window and stated that Resident #3 and Housekeeper #29 were fighting and the resident was bleeding everywhere. An interview with LPN #30 on [DATE] at 11:00 A.M. revealed she heard Resident #18 make the above statement, and approached LPN #31, the nurse working the secured unit, and told her your resident has been punched. A follow up interview with LPN #30, dated [DATE] at 2:00 P.M. revealed she approached Housekeeper #29 after hearing Resident #18's statement and Housekeeper #29 told her Resident #3 was [***] ing with me. She again stated she went to the nurse's station and told LPN #31. LPN #30 was asked why she did not remove Housekeeper #29 from working and the LPN stated the housekeeper had left the floor. Review of a statement dated [DATE] and completed by LPN #31, revealed she was at the nurse's station on the phone on [DATE] at 3:00 P.M. when she saw Resident #3 at the window with blood around her nose and mouth. After she completed the phone call, she stated she helped clean up the resident and after assessing her, could not find an injury. She stated she asked the staff working on the unit if they knew what happened but no one knew. LPN #31 stated she did not know the resident was hit until [DATE] when the Administrator approached her for an interview. Review of a statement contained in the an undated summary of the investigation written by the Administrator, revealed LPN #30 saw Housekeeper #29 at work on [DATE] and reported the incident to the Administrator at that time. Review of the investigation revealed RN #50 interviewed Resident #18 on [DATE]. There was no time given for the interview. Resident #18 resided on the secured memory care unit with Resident #3. The interview revealed Resident #18 said she was in her room and the hallway and she saw Resident #3 going in and out of rooms. She was asked what specifically had happened concerning Resident #3, but stated she didn't say anything happened and that she hadn't told anyone anything. On [DATE] at 10:30 A.M. during an interview with the Administrator, the timeline of events involving Resident #3 which occurred on [DATE] and [DATE] were discussed. The Administrator verified Housekeeper #29 admitted she hit Resident #3 in the mouth on [DATE] around 3:00 P.M. and then left for the day because her shift had ended. Review of the time clock punch detail revealed Housekeeper #29 clocked out at 3:07 P.M., returning the next day, clocking in for her shift at 6:53 A.M. The Administrator further verified Resident #3 was observed by LPN #33 and LPN #30 on [DATE] at 3:05 P.M. with blood on her nose and mouth. The Administrator also verified Resident #18 told LPN #30 that Resident #3 and Housekeeper #29 had been fighting, causing the resident's bleeding. The Administrator revealed although LPN #30 stated she told LPN #31that Resident #3 had been punched, this information was not reported to administrative staff or investigated in a timely manner. The Administrator also verified Housekeeper #29 worked her shift on [DATE] and returned to work as scheduled on [DATE]. The Administrator verified on [DATE] at 10:30 A.M. that STNA #40 was assigned to one to one supervision of Resident #3 on [DATE] from 7:00 A.M. until 3:00 P.M but had left the unit at the end of her shift, leaving Resident #3 asleep in her room. She verified the resident should have been supervised continuously according to the policy. The Administrator verified the investigation concluded that Resident #3 came out of her room, two doors down the hall from the housekeeping closet, where Housekeeper #29 was putting away her housekeeping cart and Housekeeper #29 hit Resident #3 in the face after Resident #3 hit her. She verified LPN #30 heard Resident #18 state Housekeeper #29 and Resident #3 were fighting. The Administrator stated an investigation was initiated with the local police department on [DATE] and Housekeeper #29, LPN #30 and LPN #31 had all been suspended as of that date related to their knowledge and/or involvement in the incident with Resident #3. On [DATE] at 9:50 A.M. interview with the Administrator verified Housekeeper #29 had been suspended and had not worked since [DATE] at 7:30 A.M. when she was removed from the unit. She stated Housekeeper #29's employment would be terminated but that had not officially occurred, as it was difficult to reach the employee by phone. The time punch detail for Housekeeper #29 indicated she clocked out on [DATE] at 8:00 A.M. after the initial interview with her was completed. Review of the facility Abuse/Neglect/Misappropriation of Property policy, dated [DATE], revealed the residents of the facility would be protected from physical abuse, which was defined as hitting, slapping, pinching or kicking. The policy indicated that an investigation of abuse would be initiated immediately upon identification of possible abuse. This deficiency substantiates Complaint Number OH 038.

Based on observation, interview and record review, the facility failed to ensure nutritional interventions were put in place for Resident #16 and failed to consistently monitor and assess meal consumption for Resident #17. Resident #16 experienced actual harm with a continued significant weight loss with no interventions. This affected two of three residents reviewed for nutrition. The facility census was 93. Findings include: 1. Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the undated care plan for alteration in nutritional status revealed Resident #16 had a history of [REDACTED]. Interventions included monitor weight and provide diet and supplements as ordered. On admission to the facility Resident #16 weighed 161.7 pounds. Review of the quarterly Minimum Data Set (MDS) assessment dated 08/19/13 revealed Resident #16 was moderately cognitively impaired and needed the extensive assistance of one staff member to eat. Review of the admission nutritional assessment dated [DATE] revealed Resident #16 was on a therapeutic no added salt, restricted carbohydrate diet and was usually fed by the staff. Record review revealed Resident #16 weighed 148.1 pounds on 06/16/13. Review of the Registered Dietician (RD) note dated 06/24/13 timed 11:24 A.M. indicated the resident was tolerating the diet well, and acknowledged the weight of 148.1 pounds obtained on 06/16/13. The note indicated that the resident had sustained a significant weight loss of 8.4 percent over 30 days, and indicated "while beneficial, this weight loss is too fast." The note indicated a recommendation for a dietary supplement (Med Pass) to be given twice a day to help maintain weight. Review of the medical record revealed no evidence the dietary supplement, Med Pass was received by Resident #16 from the initial order of 06/24/13 through the RD's review of the resident on 07/11/13. Review of the RD note dated 07/11/13 indicated Resident #16 "does not have an appetite" and had been eating less than 25 percent of meals for several days. The note indicted Resident #16 had an eight pound weight loss over the last week and a half and the recommendation was for the continued use of the Med Pass supplement, as well as an additional nutritional supplement at bedtime. There was no acknowledgement that the resident had received the previous ordered twice a day supplement. Review of the treatment administration record (TAR) revealed between July 11, 2013 and July 31, 2013 Resident #16 should have received the twice a day supplement 41 times and it was documented as being received 26 times. During the same time frame Resident #16 should have received the bedtime supplement 21 times and it was documented as being received 13 times. Resident #16 weighed 151 pounds on 08/05/13. Review of the treatment administration record revealed an order to weigh the resident weekly, but no weekly weights were marked on the record. Review of the meal intake record for the first 10 days of September, 2013 revealed only 16 of a possible 30 meals were marked with an intake percentage. Review of the weights for September, 2013 revealed Resident #16 weighed 143.7 pounds on either 09/04/13 or 09/05/13, as the date was unclear. This represented a weight loss of 7.3 pounds. There was no evidence the RD had addressed the weight loss with the resident review on 09/11/13. Interview with the RD on 09/11/13 at 4:45 PM verified Resident #16 had experienced a significant weight loss from admission on 05/25/13 and the weight of 06/16/13. The RD verified the significant weight loss was not addressed until 06/24/13, 8 days later, and the supplement recommended on that date was not given as ordered. The RD verified Resident #16 again lost weight when she was weighed on 07/03/13 and this weight loss was not addressed until 07/11/13, eight days later. The RD verified Resident #16 did not receive all of the ordered doses of the recommended supplements. The RD further verified Resident #16 had lost weight when weighed on 09/04/13 or 09/05/13 and the 7.3 pound weight loss had not been addressed prior to the interview with the surveyor on 09/11/13. The RD verified that she should be notified of any weight loss and that interventions should be evaluated on a prompt basis and administered as ordered. 2. Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to interview with the RD on 09/11/13 at 12:30 P.M., Resident #17 had received enteral nutrition for three years through a gastrostomy tube ([DEVICE]). Although the [DEVICE] was still used for fluid flushes and medications, after further tests and speech therapy the previous year, Resident #17 has been receiving oral intake for meals. Review of Resident #17's weight history revealed on 03/04/13 his weight was 152.8 pounds and by 08/05/13 his weight was 139 pounds. Review of the RD notes on 09/11/13 revealed the latest documentation was dated 03/20/13 which indicated Resident #17 has been losing weight and had a 4.4 percent weight loss over the previous 30 days. The RD note indicated Resident #17's oral meal intake records kept by nursing indicated he was eating 77 percent at meals. The RD recommended a meal supplement for lunch and dinner. On 09/11/12 at 12:40 P.M. Resident #17 was observed being fed his pureed lunch. He was only eating his pudding, and upon interview stated he didn't like ham and only liked mashed potatoes if it had gravy. Very little of his meal was observed eaten. On 09/11/13 at 12:30 P.M. the RD stated that she was aware of Resident #17's weight loss, had ordered supplements and stated "but he continues to lose weight and it's perplexing to me." The RD was unaware of the resident's preferences of not liking ham and wanting mashed potatoes with gravy. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].

The following finding pertains to an incident of past non-compliance that was subsequently corrected prior to this survey. Based on record review and interview, the facility failed to provide the appropriate treatment and cleaning of a gastrostomy tube for Resident #89 resulting in a hospital admission for a fever and [MEDICAL CONDITION] tube malfunction. This affected one of three residents reviewed with gastrostomy tubes. The facility census was 88. Findings include: Review of the facility's undated policy and procedure for tube feeding and care of a gastrostomy site revealed no direction or instruction to tie a [MEDICAL CONDITION] tube in a knot. The policy for care of the gastrostomy site revealed the insertion site should be cleaned with soap and water at least once a day or as ordered by the physician. Review of the medical record for Resident #89 revealed [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the treatment administration record (TAR) for September 2011, revealed Resident #89's [MEDICAL CONDITION] tube insertion site was scheduled to be cleaned daily on the night shift. Further observation of the TAR revealed the cleaning of the [MEDICAL CONDITION] tube site was not signed off as completed from 09/01/11 through the resident's discharge to the hospital on [DATE]. The medical record did not contain evidence of daily cleaning of the resident's [MEDICAL CONDITION] tube site. Review of the medical record revealed it did not contain documentation of the condition of the [MEDICAL CONDITION] tube or it's insertion site. Review of a nurse's note dated 09/09/11 at 5:30 A.M. revealed Resident #89 sounded "congested" and his oxygen level was 88% (normal is 92-100%). The nurse put oxygen on Resident #89, called the physician and continued to monitor the resident. The note did not contain documentation of the [MEDICAL CONDITION] tube or it's insertion site. Review of a nurse's note dated 09/09/11 at 9:00 A.M. revealed Resident #89 had a "dark brown" [MEDICAL CONDITION] residual, his lung sounds were improved but he was using accessory muscles to breath. The resident's temperature was 99.4 degrees axillary. The physician was called and the resident was sent to the hospital for an evaluation. The note did not contain documentation of the [MEDICAL CONDITION] tube or it's insertion site. Review of the hospital [MEDICATION NAME] consultation dated 09/11/11 revealed Resident #89 was admitted to the hospital on [DATE] with respiratory distress, fever and [MEDICAL CONDITION] tube malfunction. The consultation revealed the resident had a temperature "spike" on 09/10/11 and her [MEDICAL CONDITION] tube was found to be clogged and "foul smelling." Review of page two of the consultation report revealed Resident #89's [MEDICAL CONDITION] tube was found to have a knot in the tubing. The resident's [MEDICAL CONDITION] tube was cut, the knot was removed from the tubing and the [MEDICAL CONDITION] tube was reattached. The physician documented an x-ray was ordered to "rule out abscess." Results of the x-ray were not provided. On 09/26/11 at 2:12 P.M., an interview with Resident #21 (a resident with a gastrostomy tube) revealed the nurses used to tie her [MEDICAL CONDITION] tube in a knot to keep it from leaking. On 09/26/11 at 2:20 P.M., an interview with the DON verified the nurses were tying resident's [MEDICAL CONDITION] tubes in knots. The DON revealed tying the [MEDICAL CONDITION] tube in a knot was "common practice" at the facility and he was not aware of this until the hospital called and informed him about Resident #89's admission due to a knot in his tube. The DON revealed he had inserviced the staff and the specific nurse who admitted to tying Resident #89's tube in a knot, he ordered caps for the feeding tubes and the nurses are now aware that tying a knot in a [MEDICAL CONDITION] tube was unacceptable. The DON verified Resident #89 was admitted to the hospital with [REDACTED]. On 09/27/11 at 9:05 A.M., an interview with the DON verified Resident #89's medical record, including TAR's, did not provide evidence indicating the resident's [MEDICAL CONDITION] tube insertion site was cleansed with soap and water every day. The DON verified Resident #89 was still in the hospital. Review of the facility's corrective action revealed the following were implemented prior to this complaint survey. a. On 9/15/11, the nurse who cared for Resident #89 on 09/09/11, Registered Nurse (RN) #12, was provided a one-on-one training by the DON on [MEDICAL CONDITION] tube care. b. On 09/15/11, the DON inserviced 12 nurses, including RN #12, on [MEDICAL CONDITION] tube care and facility policies on Tube Feeding: Gastrostomy Feedings Gravity, Tube Feeding: Gastrostomy Tube Drug Administration, Tube Feeding: Gastrostomy Tube Irrigation, Tube Feeding: Gastrostomy Tube Removal and Tube Feeding: Gastrostomy Tube Re-Insertion. c. On 09/26/11 while onsite, surveyors observed Resident #8 and #21's gastrostomy tube sites and found them clean and dry. The tubing was capped and had no knots in them. This deficiency substantiated allegations contained in Complaint Number OH 395.