Every finding on record at Canton Christian Home

Based on review of the medical record, self-reported incident (SRI) review, review of the police incident report, personnel file review, interviews facility policy review, the facility failed to ensure Resident #43 was treated with dignity while care was being provided. This affected one (Resident #43) of one resident reviewed for dignity. The facility census was 49.Findings include:Review of the medical record for Resident #43 revealed an admission date of 07/16/25. Diagnoses included hypo-osmolality and hyponatremia, adult failure to thrive, hypertensive chronic kidney disease and personal history of urinary tract infections.Review of the 10/01/25 quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #43 revealed intact cognition. The resident required maximum assistance from staff for transfers and was dependent upon staff for toileting.Review of Resident #43's care plan with a revision date of 10/09/25 revealed an activity of daily living (ADL) self-care performance and mobility deficits related to weakness, hypertension, and atrial fibrillation. Interventions included transfers and walks with one assist with wheeled walker and gait belt during the day. Use the sit-to-stand lift with one assist for transfers and toileting in the evening. Review of the 10/10/25 physician order for Resident #43 revealed an order for sit-to-stand lift with one assist for transfers and toileting at night. Review of the 10/11/25 skin incident report for Resident #43 revealed the resident was leaning to the right in the wheelchair. The certified nursing assistant (CNA) moved the call light from the resident before positioning. After repositioning, there was a skin tear to the resident's right elbow which was at wheelchair level.Review of the 10/13/25 skin incident report for Resident #43 revealed the resident reported to her son via phone call that a staff member was entering her room and not doing what the resident wanted her to do. The resident stated the staff member pinched the skin of her left forearm, and she was fearful of the staff member. Resident #43's son reviewed the video surveillance from her room camera and reported no indication of pinching or harm to Resident #43. Skin was assessed with no new bruising or redness noted. The incident report noted a previously documented skin tear to bilateral elbow, and upper arm areas.Review of the certified nurse practitioner (CNP) note dated 10/13/25 for Resident #43 revealed she was having increased urinary symptoms and reporting urinary frequently which was worse at night. Resident #43 stated she had to go to the bathroom multiple times throughout the night. Medications for overactive bladder were offered but Resident #43 declined. Resident #43 had an unwitnessed fall on 10/09/25, was found on the floor with her back against the bed frame. Vitals signs were stable. New onset of a skin tear to the left upper extremity. Evaluated today and there is bruising to the site. Likely sarcopenia due to advanced age and 93. Resident #43 has a skin tear from a wheelchair to the right extremity. There was also concern regarding an incident regarding the left forearm being pinched by staff. No noted bruising or new onset skin tear to the left upper or lower extremity. Resident #43 is denying any pain to the left forearm region today.Review of the 10/15/25 wound nurse note revealed bilateral skin tears to arms and was thought to be from arms rubbing against doorway leading into her bathroom. Geri (protective) sleeves were initiated.Review of the facility SRI tracking #266581 dated 10/20/25 timed at 1:44 P.M. revealed an allegation of abuse from Resident #42 towards CNA #220. The summary of the incident revealed Resident #43 called her son in the middle of the night (time unknown) of 10/19/25 into 10/20/25 and stated she was afraid. Resident #43's son came to the facility to report this concern to the Director of Nursing (DON) on 10/20/25. The DON reported the concerns to the Administrator, physician and police department. Review of the first video provided by Resident #43's from the room camera dated 10/20/25 timed at 1:57 A.M. revealed CNA #220 entering Resident #43's room and speaking with Resident #43 who was lying in bed. CNA #220 was observed leaning in and over the resident, shaking her hands up and down and spread her arms out in an intimidating and aggressive manner. Mannerisms appear to show signs of frustration by CNA #220.Review of the second video provided by Resident #43's from the room camera dated 10/20/25 timed at 1:58 A.M. revealed CNA #220 applying the vest for the sit-to-stand machine quickly, pulling Resident #43 toward her without giving Resident #43 an opportunity to sit up on her own. When the sit-to-stand machine was brought to the bedside, it appeared CNA #220 hit the bed and shifted the bed backwards. When CNA #220 applied the lift strap, the video showed the resident was jerked forward towards the machine. CNA #220 lifted and moved Resident #43 by yanking the straps on the sling forward forcefully to attach them to the sit to stand machine.Review of the third video provided by Resident #43's from the room camera dated 10/20/25 timed at 1:59 A.M. revealed as soon as Resident #43 was standing, CNA #220 quickly turned the sit-to-stand machine to the right and swung it around swiftly and pushed it toward the bathroom.Review of the skin assessment dated [DATE] for Resident #43 revealed a skin tear on the back of the upper left and right arms, a yellow area with a purple line on the left lower back, a purple nickel sized area on the left lower leg, a two nickel sized purple areas on the left lower right leg, and a purple, red and yellow area on the front lower leg.Review of the undated statement from Resident #43 revealed she (CNA #220) got very upset saying Resident #43 goes to the bathroom too much and because upset with her. Resident #43 stated she was throwing her arms around like she was very angry. Resident #43 stated she was scared but was not scared anymore.Review of police incident report #25-10866 dated 10/20/25 timed at 3:43 P.M. revealed the reporter (Administrator) reported one of her employees was seen on the camera being physically rough with the elderly victim causing the victim to fear for her safety. Interview on 12/09/25 at 2:53 P.M. with the Director of Nursing (DON) revealed following review of the videos, she felt CNA #220 did not treat Resident #43 with respect during care. Counseling was attempted with CNA #220, but the employee was not receptive. CNA #220 stood up as if to leave and was told her employment was terminated. Interview on 12/10/25 at 11:10 A.M. with Resident #43's son revealed his mother called him during the night and stated an aide was rough with her when assisting her to the bathroom and she was afraid. After reviewing the video footage from the early hours of the morning of 10/20/25, he took the videos to the DON. Resident #43's son stated the CNA appeared to be frustrated and did not feel his mother was treated respectfully.Interview on 12/11/25 at 11:20 A.M. with the DON revealed Resident #43 uses the sit-to-stand machine at night. On 10/20/25, Resident #43's son reported his mother had called him during the night. After reviewing the videos, he brought them in for the DON to review. Resident #43's son stated he felt the aide was rough with her and appeared to be frustrated.Review of the employee file for CNA #220 revealed a date of hire of 05/30/24 and a termination date of 10/21/25 following the incident.Review of the 03/22/2022 revised facility policy called; Quality of Life-Dignity revealed each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. Residents are treated with dignity and respect at all times. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs. Staff are expected to treat cognitively impaired residents with dignity and sensitivity; for example: addressing the underlying motives or root causes for behavior and not challenging or contradicting the resident's beliefs or statements.

Based on medical record review, interview and facility policy review, the facility failed to ensure a baseline care plan was completed as required for Resident #52. This affected one (Resident# 52) of nine residents reviewed for baseline care plans. The facility census was 49.Findings include: Review of the medical record for Resident #52 revealed an admission date of 10/01/25 and a discharge date of 10/17/25. Diagnoses included but were not limited to sepsis, morbid obesity, stage IV chronic kidney disease and liver cell carcinoma.Review of the 10/07/25 admission Minimum Data Set (MDS) 3.0 assessment for Resident #52 revealed intact cognition. Resident #52 was noted to require moderate assistance to being fully dependent upon staff for activities of daily living (ADL).Interview on 12/10/25 at 3:00 P.M. with the Director of Nursing (DON) confirmed she was unable to provide evidence of a baseline care plan for Resident #52. Review of the 11/22/16 facility policy titled: Resident Directed Care Planning Policy and Procedure revealed the interdisciplinary team (IDT) shall develop a baseline care plan for each resident that includes the instructions needed to provide effective and resident-directed care of the resident that meets professional standards of care. The baseline care plan shall be developed within 48 hours of a resident's admission.

Based on the review of the medical record, interviews and facility policy review, the facility failed to ensure bathing was provided and documented as requested and required for Resident #29. This affected one (Resident #29) of one resident reviewed for bathing. The facility census was 49. Findings include:Review of the medical record for Resident #29 revealed an admission on [DATE]. Diagnoses included but were not limited to Parkinson's disease, obesity, dementia and generalized anxiety disorder.Review of the 11/04/25 quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #29 revealed intact cognition. Resident #29 was noted to require moderate staff assistance with bathing and shower transfer.Review of the 11/15/25 bathing assessment for Resident #29 revealed she preferred a tub bath twice a week on day shift.Review of the care plan for Resident #29 revealed it was last reviewed on 11/17/25. Resident #29 was noted to have activities of daily living (ADL) performance and mobility deficits related to muscle weakness, debility and difficulty walking. Interventions listed were staff assistance with bathing or showering weekly and as needed.Review of the facility shower schedule for Resident #29 revealed bathing was scheduled on Sundays and Thursdays on day shift. Review of the Resident #29's Minimum Data Set (MDS) 3.0 Bathing Documentation Survey Report for September 2025 revealed one refusal on 09/25/25. Review of the bathing documentation for October 2025 revealed a refusal on 10/05/25, and bathing was provided on 10/23/25. Review of the bathing documentation for November 2025 revealed a refusal on 11/02/25, a bath was provided on 11/06/25 and 11/27/25.Review of the shower task for Resident #29 for the past 30 days revealed bathing was indicated as not applicable on 11/17/25 and 11/20/25, bath on 11/23/25, not applicable on 11/24/25, bath on 11/27/25, refused on 12/01/25, and a bath on 12/04/25. Review of the documentation from the MDS Bathing Survey Report and the bathing task revealed out of 28 opportunities for bathing between 09/01/25 and 12/07/25 for Resident #29, evidence was provided for five baths and four refusals.Interview on 12/09/25 at 1:42 P.M. with the Director of Nursing (DON) revealed the facility does not use shower sheets. The nurse is supposed to complete a progress note in the medical record and indicate bathing was completed on the Medication Administration Record (MAR). Staff follow the bathing preferences assessment as to the frequency and times for bathing. The DON confirmed Resident #29's bathing preference was two days a week on day shift, and bathing was not completed as requested per resident preference for Resident #29.Interview on 12/10/25 at 12:18 P.M. with Shower Aide #276 revealed there was a shower book which lists the days and shifts for resident bathing. Shower Aide #276 stated Resident #29 was able to make her needs known, required one assist for bathing, got bathed twice a week, and does not usually refuse bathing. Shower Aide #276 confirmed the bathing schedule recently changed due to some of the floor aides thought the shower aide was doing all of the showers and were not completing their scheduled showers.Review of the 10/2022 revised facility policy titled Policy and Procedure for Bathing revealed each resident and/or family will be questioned upon admission as to their choices for bathing. Quarterly, each resident will be questioned if there are any changes to preferences.

Based on observation, record review and interview, the facility failed to ensure the treatment to Resident #8's right heel was completed as ordered. This affected one (Resident #8) out of one resident reviewed for wound care. The facility census was 49.Findings include:Review of the medical record revealed Resident #8 was admitted on [DATE] with diagnoses that included but not limited to chronic pain, protein calorie malnutrition, and anxiety. A plan of care dated 08/29/25 revealed Resident #8 had a pressure ulcer to right heel. Interventions included but not limited to treatments to be administered as ordered and to monitor for effectiveness. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of eight out of 15 which indicated cognitive impairment. The MDS also revealed Resident #8 had an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) that was not present upon admission. A physician order dated 11/26/25 at 12:43 P.M. revealed Resident #8's right heel wound was to be cleansed with Vashe (wound cleanser used to gently clean, debride, and remove microorganisms from wounds), patted dry, Skin Prep (protective barrier) applied to the peri wound, Medihoney (wound gel that promotes healing by creating a moist environment, fights bacteria, reduces inflammation, and helps lift dead tissue) applied to the wound bed, and a Vashe moistened gauze applied to the wound bed only, an abdominal pad (ABD) applied, and then wrapped with rolled gauze daily and as needed if soiled and dislodged. An observation on 12/09/25 at 2:11 P.M. of treatment to Resident #8's right heel by Registered Nurse (RN) #283 revealed the dressing was dated 12/05/25. RN #283 verified the dressing was to be completed daily on the 7:00 P.M. to 7:00 A.M. shift. RN #283 verified the dated dressing revealed the treatment was not completed on 12/06/25, 12/07/25, and 12/08/25.

Based on record review, review of self-reported incident (SRI) tracking #264837, interviews, observations and facility policy review, the facility failed to ensure Resident #61 was not outside the facility without adequate supervision. This affected one (Resident #61) out of one resident reviewed for accidents. The facility census was 49. Findings include: Review of the medical record revealed Resident #61 was admitted on [DATE] and discharged on 09/16/25 with diagnoses that included chronic atrial fibrillation, dementia, major depressive disorder, generalized anxiety, insomnia, restlessness and agitation, and chronic pain.A care plan dated 01/01/23 revealed Resident #61 was at risk for injury related to dementia. Resident #61 wanders looking for wife, has impaired safety awareness, and short attention span. Interventions included wander management system to wrist or leg and checked every shift, attempt to redirect when focused on leaving the facility unassisted or without supervision, if the resident attempts to exit, the staff should try to move the resident to a safe area away from the mode of exiting the facility, and notify the charge nurse or supervisor immediately if an attempt to leave the facility should occur out the doors or elevator unassisted or unsupervised. A WanderGuard (wander management system) and Exit Seeking evaluation dated 03/04/25 revealed Resident #61 was a candidate for the wander management system. Resident #61 was at risk for unintentional exiting from the building due to visits to wife on and off the unit. An order dated 04/24/25 at 4:05 P.M. revealed a wander management bracelet (Roam Alert) was in place on Resident #61. The placement was to be checked by the nurse every shift to ensure function to maintain surveillance on a 24-hour basis.The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #61 had a Brief Interview for Mental Status (BIMS) score of seven out of 15 which indicated cognitive impairment. The MDS also revealed Resident #61 had wandering behavior for one to three days during the seven-day assessment period. A health status note dated 09/03/25 at 7:00 P.M. by Licensed Practical Nurse (LPN) #200 revealed Resident #61 was observed by staff on the patio at the east entrance. Resident #61 stated he was going home. One-on-one supervision was started, and the Director of Nursing (DON) was notified. Review of SRI tracking #264837 revealed on 09/03/25 at 6:54 P.M. Resident #61 was found by staff sitting unsupervised outside of the entrance in his wheelchair. Resident #61 was brought to the nurse and received an assessment with no injury noted. Resident #61 was at baseline and had no complaints of pain. During the investigation, it was noted that the monitoring system was operational, and the doors were operating properly. Staff reported that the resident appeared agitated the night of the incident and was re-directed multiple times.Review of the facility investigation revealed a typed statement by LPN #222 revealed on 09/03/25 at 7:00 P.M. LPN #222 responded to an alarm at the east entrance (located at assisted living). LPN #222 was unaware a resident had exited the facility without an escort. This nurse silenced the alarm and continued with shift duties. A handwritten note (no date) by LPN #200 revealed Resident #61 stated he was going home. Resident #61 was offered fluids and food, which he refused and redirection was not effective. A handwritten statement (no date) by Certified Nursing Assistant (CNA) #201 revealed Resident #61 was agitated. CNA #201 offered Resident #61 food and drinks, but the resident refused. CNA #201 found Resident #61 sitting outside on the patio at the east entrance. Resident #61 was brought back into the facility, and the nurse was notified the resident had been found outside the facility. A handwritten statement dated 09/03/25 by CNA #203 revealed Resident #61 was leaving the dining room. Resident #61 stated his wife yelled at him and he was going home. Resident #61 proceeded to get his clothes and bible and tried to find the exit. CNA #203 notified the nurse of Resident #61's behavior. A handwritten statement dated 09/03/25 by Registered Nurse (RN) #205 revealed after giving report they saw Resident #61 moving towards the exit door. RN #205 closed the door (fire doors between the nursing facility and assisted living facility) and turned the resident back towards his room. RN #205 sat near the entrance until it was time to clock out at 7:00 P.M. A handwritten statement dated 09/03/25 by Resident Assistant (working at the assisted living facility) #206 revealed he was busy when the door alarm when off. Resident Assistant #206 shut the alarm off when he was able and did not see anyone (residents) in the hallway. A handwritten statement dated 09/04/25 by CNA #202 revealed they saw Resident #61 in his wheelchair with his clothes on his lap. Resident #61 stated he was leaving. CNA #202 and CNA #201 attempted to redirect Resident #61 away from the doors. A handwritten statement dated 09/05/25 by CNA #204 revealed Resident #61's wife expressed concerns about Resident #61's behavior. CNA #204 found Resident #61 on the elevator with his clothes. Resident #61 stated he was going home. CNA #204 turned Resident #61 and the resident continued down the hallway. An educational opportunity dated 09/05/25 was written for LPN #222 for failure to follow safety procedures. An interview on 12/09/25 at 10:53 A.M. with Resident #61's daughter revealed the resident was wearing a wander management bracelet, but a visitor was coming in, and the door did not lock. The daughter verified Resident #61 was found sitting on the patio with his clothes. Observation on 12/09/25 at 12:21 P.M. of the video footage revealed on 09/03/25 at 6:53 P.M. Resident #61 exited the assisted living dining room in his wheelchair. At 6:55 P.M. as Resident #61 headed towards the exit door, a visitor can be seen entering the facility and the sliding exit door opened. The visitor looked towards the alarm, and Resident #61 continued out the door. At 6:58 P.M. LPN #222 administered medications to an assisted living resident sitting near the nurse's station. LPN #222 can be seen looking towards the alarm mounted on the wall near the exit door. The video ended at this time. An interview on 12/09/25 at 2:46 P.M, CNA #201 revealed Resident #61 and his wife had a disagreement, and Resident #61 grabbed some belongings and said he was leaving. The staff kept trying to redirect Resident #61 when he said he was leaving. CNA #201 verified there were no alarms sounding when she went on break and found Resident #61 sitting outside on the patio. An interview on 12/10/25 at 8:38 A.M. the DON verified the wander management alarm was turned off by LPN #222 and Resident Assistant #206 that were working at the assisted living facility. The fire doors in the hallway were closed but Resident #61 went through a room to the right at the end of the hallway on the long-term care part of the facility and then into the dining room of the assisted living facility. This did not set off the alarms that were placed near the fire doors on the assisted living part of the facility. CNA #201 went on break and found Resident #61 sitting outside on the patio. CNA #201 and LPN #261 went out the doors around 7:00 P.M. The DON verified she only had part of the video footage saved but stated Resident #61 was only out of the building for about six minutes. The DON verified a staff member was assigned to stay with Resident #61 after the resident was brought back into the facility. An interview on 12/10/25 at 2:35 P.M. LPN #261 verified CNA #201 brought Resident #61 back into the facility as LPN #261 was leaving at 7:00 P.M. The elopement and Exit Seeking Policy, dated 07/11/24, revealed if exit seeking behavior or an elopement is attempted or successfully achieved, ensure the resident is safe and unharmed, attempt to prevent the departure in a courteous manner, enlist help from other staff members in the immediate vicinity, if necessary, and assign a staff member to stay with the resident if appropriate. This deficiency represents non-compliance investigated under Incident Number 2627180.

Based on record review, observation, interview and facility policy review, the facility failed to ensure staff followed standard infection control precautions during medication administration. This affected one (Resident #16) of four residents observed during medication administration. The facility also failed to maintain proper infection control practices while providing wound care for Resident #8. This affected one (Resident #8) of one resident observed for wound care. The facility census was 49.Findings include:1. Review of the medical record for Resident #16 revealed an admission date of 10/16/25 with diagnoses including dementia, chronic kidney disease and diabetes mellitus. Review of the physician's orders for Resident #16 for December 2026 revealed she had an orders for Buspirone 10 milligrams (mg) three times a day for anxiety dated 10/16/25, Gabapentin 300 mg twice daily for nerve pain dated 10/16/25, Memantine 10 mg twice daily for dementia dated 10/16/25, Senna Plus 8.6-50 mg two tablets twice daily for constipation dated 10/16/25, Amlodipine 5 mg once daily for hypertension dated 10/17/25, Glipizide 5 mg in the morning for diabetes mellitus dated 10/17/25, Januvia in the morning for diabetes mellitus dated 10/17/25, Vistaril 25 mg twice daily for anxiety dated 11/05/25, Depakote 125 mg twice daily for anxiety dated 11/11/25, Cholecalciferol 2,000 units in the morning for supplement dated 11/29/25, Oxybutynin Chloride Extended Release 10 mg in the morning for overactive bladder dated 11/29/25, Pioglitazone 45 mg in the morning for diabetic neuropathy dated 11/29/25 and Sertraline 100 mg in the morning for depression dated 12/01/25. Observation on 12/09/25 at 7:48 A.M. of Licensed Practical Nurse (LPN) #233 at the medication cart on hallway B revealed she was popping the medications out of medication cards into her hand and then placing the medications in the medication cup. She had placed all of Resident #16's morning medications into the medication cup. LPN #233 was questioned as to why she was popping the pills into her bare hand and then placing them in the medication cup. She stated she had not realized she had touched the pills. She stated she was afraid of dropping the medications on the floor. LPN #233 verified she should not have touched Resident #16's medications with her bare hands and this was an infection control concern. 2. Review of the medical record revealed Resident #8 was admitted on [DATE] with diagnoses that included but not limited to chronic pain, protein calorie malnutrition, and anxiety. A health status note dated 08/22/25 at 4:00 P.M. revealed therapy notified the nurse Resident #8 had a blister on the back of the (right) heel. A plan of care dated 08/29/25 revealed Resident #8 had a pressure ulcer to right heel. Interventions included but not limited to treatments to be administered as ordered and to monitor for effectiveness. A physician order dated 10/15/25 at 9:02 A.M. revealed Resident #8 was ordered enhanced barrier precautions (EBP) related to a chronic wound. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of eight out of 15 which indicated cognitive impairment. The MDS also revealed Resident #8 had an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) that was not present upon admission. An observation on 12/09/25 at 2:11 P.M. revealed a laminated sign on the outside of Resident #8's door that revealed Resident #8 had EBP in place. An observation of Registered Nurse (RN) #283 completing the treatment to Resident #8's heel revealed RN #283 wore gloves during the dressing change but did not wear a gown. RN #283 verified she had a gown in the treatment cart but forgot to put it on. The policy and procedure updated 02/25/25 revealed the use of EBP for wounds or indwelling medical devices help prevent the spread of multidrug-resistant organisms (MDRO) in accordance with the centers for disease control (CDC). EBP will be implemented with any elder in the nursing home with an indwelling medical device or wound as an intervention to reduce transmission of MDRO's through gown and glove use. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds that require a dressing and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for EBP included wound care (any skin opening requiring a dressing).

Based on observation, record review, review of a facility investigation, review of a facility Self-Reported Incident, review of hospital records, interviews with staff, and review of facility policy, the facility failed to develop and implement a comprehensive and individualized fall prevention program to ensure Resident #45's safety and supervisory needs were addressed timely resulting in a fall with major injury. In addition, the facility failed to ensure appropriate interventions were implemented to prevent additional falls/injury. Actual harm occurred on 01/17/25 when Resident #45, who required a mechanical lift for transfers, was at high risk for falls, and had moderately impaired cognition, was hospitalized after sustaining right and left tibial fractures following an unwitnessed fall. Prior to the unwitnessed fall, a nursing assistant observed the resident yelling for help with her legs hanging out of bed and walked past her room without responding to the resident's calls for help. This affected one resident (#45) of three residents reviewed for falls. The facility census was 56. Findings included: Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including generalized anxiety disorder, major depressive disorder, vascular dementia, hypertension, transient ischemic attack, cerebral infarction, allergic rhinitis, left hemiplegia, diabetes, hypothyroidism, overactive bladder, peripheral vascular disease, Vitamin D deficiency, acute pain due to trauma, edema, obstructive and reflux uropathy, kidney disease, fracture of the right and left tibia, motion sickness, dermatophytosis, insomnia, anorexia, and adult failure to thrive. Review of the plan of care initiated on 08/30/22 revealed Resident #45 was at risk for falls related to left arm pain, hemiplegia, muscle weakness, decreased mobility, and incontinence. Interventions included to be sure the call light was within reach and encourage its use for assistance when needed, anticipate and meet needs as able, attempt to provide a safe environment, the resident liked to put the height of her bed up on her own so ensure education on this unsafe behavior, staff to ensure her bed locks were in place to help provide for her safety due to poor decision making (initiated 01/20/25), Dycem (rubber nonslip mat) to the recliner and check the placement, and place a red dot by the resident's name on the door name tag by the room. Review of Resident #45's physician's orders revealed the resident had orders for gripper socks every shift (initiated 08/26/22), Dycem to the recliner (initiated 01/03/23), and a fall mat to the left side of the bed (initiated 01/17/25). Review of the Fall Risk assessment dated [DATE] revealed Resident #45 was at a high risk for falls. The assessment indicated the resident was alert, she had no falls in three months, she was taking three to four medications that could increase the risk for falls, and the resident was chair bound and unable to perform gait/balance. The assessment stated the resident transferred with a mechanical (Hoyer) lift and two staff assistance, that she wanted to remain in bed all the time but would get up for showers at times and the fall prevention measures remained in place. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #45 had moderately impaired cognition. The assessment revealed the resident required substantial (staff) assistance with rolling side to side and was dependent on staff for transfers. The assessment indicated the resident had not had any falls. Review of the progress note dated 01/17/25 at 3:34 A.M. revealed the nurse had entered the room for Resident #45 and she was lying on the floor on the right side with her feet towards the head of the bed. The resident's bed was up in the air when staff entered the room. Resident #45 denied any pain at the time of the assessment. She had range of motion without resistance to her upper and lower extremities. The resident denied hitting her head and no bumps or lumps were present. She was assisted off the floor with the Hoyer lift with three staff. Review of the progress note dated 01/17/25 at 1:12 P.M. revealed the Certified Nursing Assistant (CNA) was performing morning care and Resident #45 began yelling out in pain. She stated her left knee hurt. The nurse evaluated the resident and the resident's left knee was swollen. Resident #45 began to complain of pain and the Nurse Practitioner (NP) was called and ordered an x-ray and Tylenol every eight hours for three days. Review of the portable x-ray report dated 01/17/25 revealed Resident #45 had right and left tibial fractures. Review of the progress note dated 01/17/25 at 2:46 P.M. revealed x-ray results were obtained and the results were reported to the NP and Resident #45's family. There was a discussion pertaining to what treatment to seek, and a decision was made for the resident to be taken to the Ortho United Clinic; the family did not want the resident to be sent to the emergency room . The note indicated the resident's family would be updated once the facility staff knew anything. Review of the progress note dated 01/17/25 at 4:10 P.M. revealed staff called Resident #45's family to explain that they were unable to find non-emergent ambulance services to transport the resident to the outpatient orthopedics as previously discussed. They explained the resident would be transferred via emergency medical services (EMS) to the emergency room . Review of the progress note dated 01/17/25 at 4:31 P.M. revealed Resident #45's family was notified the resident was being transported to the hospital. Review of the progress note dated 01/18/25 at 2:15 A.M. revealed Resident #45 was admitted to the hospital with acute pain in the knees, hyperglycemia, a pancreatic lesion, closed fracture of the tibia, and a urinary tract infection. Review of the hospital history and physical dated 01/18/25 revealed Resident #45 presented to the emergency room from the nursing facility with knee pain after an unwitnessed fall. She was typically non-ambulatory and used a Hoyer lift. The resident stated everything hurt. An x-ray revealed Resident #45 had proximal bilateral tibial fractures. The hospital recommended the resident be non-weightbearing, to utilize bilateral knee braces and an orthopedic consult. Review of an undated hand-written signed witness statement from CNA #102 revealed another aide [CNA #104] walked past the room of Resident #45 and heard her call out. That aide [CNA #104] let CNA #102 and Licensed Practical Nurse (LPN) #103 know. They walked to the resident's room within minutes of the other aide telling them, and Resident #45 was on the floor on her right side and the bed was in a high position. After the nurse assessed the resident, they placed Resident #45 into bed with the Hoyer lift with no complaints from the resident. Resident #45 stated she was trying to sit up to lean on her table and as she attempted to do that, the table slid and so did she. She stated she had to vomit. Resident #45 expressed no pain during care or turning. Review of a hand-written signed witness statement from CNA #104 dated 01/17/25 revealed on 01/17/25 at 3:00 A.M. she was walking back from break and she saw and heard Resident #45. She saw that the resident was laying down with her feet hanging off the side. She stated it did not look like the resident was trying to get out of bed, so she went to her aide [CNA #102] who was just a few feet away and alerted her to Resident #45's behavior. Review of a hand-written signed witness statement for LPN #103 revealed an aide came to let Resident #45's aide know that her legs were hanging out of the side of the bed. The nurse and the aide entered the room and Resident #45 was on the ground with the bed up in the air. The nurse assessed the resident and notified the Director of Nursing (DON). The resident had no noticeable injuries, and she did not complain of pain. Review of a facility Self-Reported Incident report dated 01/17/25 revealed an aide [CNA #104] was returning to the floor from a break at approximately 3:00 A.M., when she approached Resident #45's room. She stated she saw the resident with her leg sticking out of the covers and reported hearing the resident state, Help me get me out of here. The CNA stated she told the CNA assigned to the resident (CNA #102) Your girl is yelling for you. She stated she proceeded down the hall and returned to her assignment. CNA #102 stated she completed her task she was working on and went to Resident #45's room. LPN #103 and CNA #102 entered the room and found Resident #45 on the floor on her side with her head at the foot of the bed. LPN #103 completed an assessment, vital signs and range of motion. Three staff used a Hoyer lift to return Resident #45 to bed. The Executive Director interviewed staff involved with the incident. CNA #104 stated, The bed was a normal height for [Resident #45], she plays with that controller all the time. The Executive Director verified how high, and CNA #104 stated About regular height of a normal bed. The Executive Director clarified that it was not in the lowest position, CNA #104 said, Correct like where you could stand up from the bed normally. CNA #104 reiterated that the resident was always putting the bed up and down in height, as well as adjusting the head of the bed. The Executive Director again asked for clarification and CNA #104 stated Just below hip height. CNA #104 stated the height of the bed seemed normal to her as the resident kept bed higher than most others. The Executive Director interviewed CNA #102 who stated CNA #104 told her the resident was asking for help. She stated before she finished what she was doing, the resident was on the floor. CNA #102 retrieved a nurse to inform her of Resident #45 on the floor. CNA #102 stated she asked the resident what she was trying to do, the resident responded Nothing, just turn in the bed. Resident #45 stated she put her hand on the overbed table and leaned on the table, then she was on the floor. CNA #102 stated the overbed table was near her legs and lower torso and that the residents' head was pointed to the right, which was at the foot of the bed, looking out to the hallway. CNA #102 stated the nurse asked resident about pain and resident stated she had no pain, but she did wince at a bit and the resident stated she wanted to be in bed. Three staff returned her to bed. CNA #102 stated when the resident was returned to bed, the aide changed the resident thinking the reason she attempted to get up was because her brief was soiled, but the aide stated the diaper was even hardly wet, I expected that maybe it would be soaking and that is why she tried to get up. She stated she rolled the resident through her hips to change her, and she never complained of pain and the staff cleaned her up. CNA #102 did state that she took the bed controls away from the resident, because she would put the bed height up and that the bed was fully extended in height. As part of the facility investigation, the Executive Director interviewed CNA #200 who stated that an LPN informed her that Resident #45 was on the floor. The aide confirmed the resident's location on floor, on her right side with her head to the foot of bed and facing the door. CNA #200 stated the nurse completed vital signs and range of motion on the residents' legs. She stated the resident did have some pain, but also stated she was ok. CNA #200 stated The bed was kind of high, but she plays with the remote. She raises the whole thing up and the head all the way up. When the Executive Director asked for clarification on how high, she stated All the way up to about my hips. As part of the investigation, the Executive Director interviewed LPN #103 who stated when she and CNA #102 entered the room, they found Resident #45 on her right side, with her head facing the door on the floor. She stated she assessed the resident, and she really did not complain of pain. Resident #45 was placed back in bed via three staff and a mechanical lift. LPN #103 stated she notified the physician, left a message for the resident's family and called and notified the DON. The facility SRI included on day shift the same day, the day shift aide [CNA #202] was providing care to Resident #45 and the resident reported pain in her left knee. Upon visualizing the knee, CNA #202 observed swelling and bruising and reported it to the day shift nurse, who assessed and phoned the nurse practitioner and received orders for an x-ray. X-rays were obtained and confirmed bilateral tibia fractures. The family was notified and preferred the resident was not sent to the emergency room if possible and to utilize Ortho United STAT Care. The facility was unsuccessful in obtaining non-emergent cot transport. The squad was called, and Resident #45 was transferred to the emergency room for treatment. She was admitted on [DATE] at 2:30 A.M. inpatient and returned to the facility's care on 01/21/25. As a result of the incident, staff were educated on the high/low lock out on beds. Review of the facility's summary of the fall investigation dated 01/22/25 revealed on 01/17/25 at approximately 5:56 A.M. the DON was notified by LPN #103 that Resident #45 had an unwitnessed fall out of her bed while attempting to get up. Resident #45 had reported to the staff she had been sitting on the edge of her bed and was leaning on a bedside tray table and when she attempted to stand, the tray table she was leaning on moved and she fell . Per the nurse, Resident #45 was assessed, and no injury was noted. She had full range of motion to all her extremities, and she did not verbalize any pain with assessment. The nurse and two nursing assistants used a Hoyer lift to assist Resident #45 back into bed. The facility investigation revealed on 01/17/25 at approximately 11:26 A.M. the DON was called to the bedside of Resident #45 by a staff nurse because Resident #45 was complaining of pain in her left leg at the knee. Resident #45 was resting in bed with an emesis basin by her head when the DON entered the room. Resident #45 responded to voice and was able to verbalize to the DON that her leg hurt. When Resident #45 was asked what leg hurt, she pointed to her right leg. The DON proceeded to assess both of her legs. Her bilateral legs were warm to touch with slight bruising and mild swelling was noted to both legs, just below the knee. Her pedal pulses were strong to the tops of both feet. Resident #45 was able to move both legs and feet. She was able to wiggle her toes on both feet and all toes had good capillary refill. Resident #45 was able to press down her with toes and pull back with her toes on the nurse's hands. There were no signs or symptoms of pain noted when the resident moved her lower extremities independently. When the nurse put pressure on either leg near the knee, Resident #45 cried out, and when the staff rolled her to provide care, she cried out. Resident #45 was able to verbalize she fell early that morning because she was trying to get out of bed. She was not able to say what time the fall happened or why she was trying to get out of bed. At approximately 11:57 A.M. the Nurse Practitioner was updated and had given orders for an X-ray on both legs and Tylenol for pain. The x-rays were completed and the results indicated bilateral fractures to the tibias. Resident #45 was sent to the hospital. Observation with the Director of Nursing on 02/14/25 at 10:15 A.M. revealed Resident #45 was up in the tilt-in-space wheelchair, on a lift pad, her call light was within reach, she had braces to both her lower extremities with an abductor pillow between her legs, and her feet were bare. At the time of the observation, interview with the Director of Nursing (DON) verified Resident #45 should have had shoes on her feet or gripper socks per the physician orders. On 02/14/25 at 1:45 P.M. an interview with the DON revealed it would be her expectation for the staff member to go into the room and assist a resident if they were yelling for help and had their legs out of the bed. She stated the staff were educated to not walk past the room if a resident was yelling for help. She stated CNA #104 was interviewed as to why she walked past the room and did not go into the room of Resident #45 and CNA #104 stated she wished she would have now, but her aide was standing right outside her room when she told her, and she thought she would go right in to check on her. On 02/14/25 at 1:50 P.M. an interview with the Executive Director indicated she expected the staff to go into the room when a resident was yelling out and had their legs out of the bed. During the interview the Executive Director stated when CNA #104 was walking past the room she just told CNA #102 that Resident #45 needed her. Review of the facility policy titled, Falls Prevention, dated 01/24/23 revealed the facility would ensure a fall interdisciplinary prevention and management program would be maintained to reduce the incident of falls and the risk of injury to the residents and promote resident independence. The policy indicated that CNA's would follow the interventions as outlined in the care plan and they would assist and report any resident who appeared unsteady. It also stated the fall prevention interventions would be reviewed and the care plan would be modified in collaboration with the interdisciplinary team. This deficiency represents non-compliance investigated under Complaint Number OH00161945.

Based on record review, interview, observation, review of a facility investigation, and facility policy review, the facility failed to ensure residents were properly transferred by mechanical lift. This affected two residents (#22 and #44) of three residents reviewed for transfers. The facility census was 53. Actual Harm occurred on 05/05/24 when two State tested Nursing Assistants (STNA's) were transferring Resident #22, who had severely impaired cognition and was dependent on staff for transfers, via mechanical lift to her wheelchair and failed to operate the mechanical lift properly, resulting in Resident #22 falling and sustaining a spiral femur fracture requiring surgery and hospitalization . The resident was assessed to exhibit severe pain with leg movement following the incident and signs/symptoms of pain/distress throughout the morning of 05/06/24 before being transferred to the hospital. Findings included: 1. Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including localized edema, anxiety disorder, Alzheimer's Disease, and polyosteoarthritis. Additional diagnoses added in May 2024 included fracture of unspecified part of neck of left femur, history of falling, altered mental status, pain in left hip, fall from other furniture initial encounter, other acute post-procedural pain, and anemia. Review of a care plan revised on 06/23/21 revealed Resident #22 had an activity of daily living (ADL) self-care performance and mobility deficit related to weakness, right artificial hip, anxiety, lower back pain, and severe cognitive impairment with a goal of participating in self-care to optimum level as evidenced by clean, odor free and dressed daily. Interventions included transfers with a hoyer lift and two staff to get out of bed in the morning and a sit to stand with two person assist for all other transfers. Review of a nursing note dated 05/05/24 at 4:56 P.M. by Licensed Practical Nurse (LPN) #201 revealed at 4:00 P.M. a State tested Nurse Aide (STNA) came to this nurse to report the hoyer lift had started to tip while transferring resident, STNAs were able to lower resident to the floor slowly while securing the lift. Resident was given a head-to-toe assessment with no injuries noted, then placed into wheelchair, STNAs were given an in-service on hoyer lift safety during transfers for the fall intervention. Review of a nursing note dated 05/06/24 at 6:19 A.M. by Registered Nurse (RN) #221 revealed Resident #22 was showing signs of severe pain when her left leg was moved, with the on-call providers paged twice and no response. After 6:00 A.M. the facility nurse practitioner was notified with orders for x-ray of left hip, left femur, left knee, and left lower leg. Review of a nursing note dated 05/06/24 at 10:35 A.M. by LPN #215 revealed Resident #22 was awake in bed with signs and symptoms of pain/distress this morning, nurse instructed STNAs not to move resident and leave her in bed, an x-ray was ordered, results were received and report to the provider and the Director of Nursing (DON). Transportation was arranged and Resident #22 was sent to the emergency department for evaluation and treatment. DON called Resident #22's representative to notify them. Review of a discharge Minimum Data Set (MDS) assessment completed on 05/06/24 revealed Resident #22 had severely impaired cognition, required maximum assistance for upper body dressing, lower body dressing, putting on footwear, personal hygiene, and bed mobility, was dependent on staff for transfers, always incontinent of bladder, and frequently incontinent of bowel. Review of a nursing note dated 05/06/24 at 2:54 P.M. by LPN #215 revealed she spoke with the hospital emergency department nurse and received an update, Resident #22 would be admitted for the femur fracture and was waiting on a trauma consult. Review of a nursing note dated 05/06/24 at 2:57 P.M. by DON revealed she made contact with Resident #22's responsible party after playing phone tag all morning to inform her Resident #22 was sent to the hospital with a fracture for evaluation and treatment. Review of a nursing note dated 05/07/24 at 6:44 P.M. revealed an unspecified RN spoke with Resident #22's responsible party and the surgeon stated the surgery went well, Resident #22 had a rod placed to support fractured left femur, would likely be in the hospital for two to three more days, and would be non-weight-bearing for eight weeks. Review of a nursing note dated 05/10/24 at 7:55 P.M. revealed Resident #22 readmitted to the facility. Review of a written statement from STNA #237 dated 05/05/24 revealed while transferring Resident #22, the hoyer lift fell over and they made sure she didn't get hurt. Review of a written statement dated 05/05/24 by STNA #230 revealed while moving Resident #22 from the bed to the chair with a lift, the legs came apart and flipped. STNA #230 stated she caught Resident #22 while STNA #237 lowered the hoyer to the floor. Review of an additional statement from STNA #237 dated 05/05/24 revealed she was guiding the hoyer pad with Resident #22 in it while getting the wheelchair ready while STNA #230 was operating the hoyer lift, when they turned the lift around, it started to tip, both STNAs grabbed Resident #22 and lowered her to the floor. The legs of the hoyer lift were open. Review of an additional statement from STNA #230 dated 05/05/24 revealed she was operating the hoyer lift and when she pulled it away from the bed and started to turn it, the hoyer started tipping over. The other STNA grabbed Resident #22 to catch her from falling to the floor, the legs of the hoyer were open and they were careful with the transfer. Review of an interview from STNA #237 dated 05/06/24 revealed she and STNA #230 tried to transfer Resident #22 from the bed to her wheelchair when the hoyer lift began to tip. STNA #237 and #230 caught Resident #22 and lowered her to the floor before she fell . STNA #237 stated she felt as though STNA #230 was always in too much of a hurry and rushed the residents. Review of an interview from STNA #230 dated 05/06/24 revealed she and STNA #237 were trying to transfer Resident #22 from the bed to the wheelchair when the hoyer lift started to tip over. STNA #230 stated she and STNA #237 grabbed Resident #22, caught her, then lowered her to the floor so she would not fall. STNA #230 stated Resident #22 did not cry out in pain but did appear to be scared. Review of an interview from LPN #201 dated 05/06/24 revealed STNAs reported to him at 4:00 P.M. Resident #22 was in the hoyer lift when it tipped, STNAs told him they caught Resident #22 and lowered her to the floor. A head-to-toe assessment was completed including vital signs and range of motion with no signs or symptoms of injury or distress. LPN #201 stated he gave the STNAs an in-service on hoyer safety usage as the intervention because he felt they used the hoyer improperly. Review of a hospital note dated 05/07/24 revealed Resident #22 presented from the facility after an incident in the hoyer lift where she ended up on the ground and was found to have a distal left femur spiral fracture. Resident #22 was admitted under trauma service, with an orthopedic consult for surgery to complete an open reduction total fixation of left femur on 05/07/24. Review of a care plan dated 05/14/24 revealed Resident #22 had a hip fracture related to fall, non-ambulatory status, fall 05/06/24 with spiral fracture during transfer and underwent surgical intervention of left retrograde femoral rodding on 05/07/24. Review of a MDS assessment completed on 05/17/24 revealed Resident #22 had severely impaired cognition, was dependent on staff for upper body dressing, lower body dressing, putting on footwear, personal hygiene, bed mobility, and transfers, and was always incontinent of bowel and bladder. Interview on 05/23/24 at 3:00 P.M. with STNA #230 revealed she was not actually using the hoyer, but guiding Resident #22 in the hoyer sling to her wheelchair. STNA #230 stated while transferring Resident #22, STNA #237 was operating the hoyer lift when she turned it around and it started to tip. STNA #230 stated she did not know why the lift had started to tip because she was focused on Resident #22 but when she noticed the hoyer began to tip, she attempted to get the wheelchair closer, but was not able to, so she went to the ground on her knees to catch Resident #22. Resident #22's back landed on STNA #230's chest, but Resident #22's coccyx and legs hit the floor. STNA #230 stated it was hard to tell how hard the impact to the ground was because it happened so quick and there was no way to ease the hoyer lift when it tips over. STNA #230 stated Resident #22 fell , and was not lowered to the ground. Interview on 05/23/24 at 4:07 P.M. with STNA #250 and STNA #257 revealed the legs of hoyer lifts do not open unless the remote was used to open the legs. Interview on 05/23/24 at 4:43 P.M. with the Maintenance Director revealed the hoyer lifts were electric and operated by a remote. The Maintenance Director stated if everything on the inspection checklist was operating correctly, there was no way the hoyer lift legs could open up without someone pressing the button. Interview on 05/23/24 at 5:12 P.M. with DON confirmed the conflicting statements as noted above in the facility fall investigation and interviews. 2. Record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, Alzheimer's disease, and osteoporosis. Review of a care plan dated 09/26/22 revealed Resident #44 had an ADL self-care performance and mobility deficit related to anxiety, chronic pain, cognitive impairment, hypertension, osteoporosis, atrial fibrillation, spinal stenosis, non-ambulatory, needs assistance with ADL's, and muscle weakness. Interventions included use a hoyer lift for all transfers and the assistance of two staff members. Review of a MDS assessment dated [DATE] revealed Resident #44 had severely impaired cognition and was dependent on staff for transfers. Review of an order dated 01/06/22 revealed Resident #44 required a hoyer lift with assistance of two staff for all transfers. Observation on 05/23/24 at 3:59 P.M. revealed STNA #250 and #257 assisting Resident #44 with a hoyer lift transfer from her bed to her standard wheelchair. Resident #44 was resting in bed with a hoyer pad under her. STNA #250 and STNA #257 began connecting the hoyer lift to the sling using the red loops, instructed Resident #44 to cross her arms, then STNA #257 began lifting Resident #44 by operating the hoyer lift. Once Resident #44 was lifted from the bed, the hoyer legs were closed then the staff began to move the hoyer lift. While STNA #257 operated the lift, STNA #250 helped to guide Resident #44 towards her wheelchair. Once Resident #44 was hovering over the wheelchair, STNA grabbed the wheelchair and tilted it backwards onto its back wheels with the front wheels completely off the ground and held the wheelchair in place until Resident #44 was lowered into the seat. STNA #250 then lowered the front wheels of the wheelchair down then began to disconnect Resident #44 from the lift. Interview on 05/23/24 at 4:54 P.M. with STNA #250 revealed she positioned Resident #44's wheelchair by tilting it back on the back wheels. STNA #250 stated Resident #44 is the only resident who transfers by hoyer into a standard wheelchair and an agency aide taught her to tilt the wheelchair back to make it easier to position Resident #44 in the chair. STNA #250 stated she had not considered the risks of the wheelchair slipping and falling. Review of hoyer lift bi-monthly inspections dated 12/11/23, 02/13/24, 04/18/24, and 05/08/24 revealed all lifts in the facility were in proper working condition. Review of Resident Council Minutes from 04/11/24 revealed a resident had concerns related to a young, female staff member attempting to transfer him to his bedside commode with a front-wheeled walker. The resident stated he had to educate the staff member on what a bedside commode was, what a sit-to-stand lift was, and how to operate it. Resident stated other aides eventually came to help with the situation so he was able to transfers safely but he was concerned about training because the interaction made him uncomfortable. Review of a Fall policy dated 01/24/23 revealed a fall was any unintentional change in position where the resident ended up on the floor, ground, or other lower level. Review of a policy titled Lifting Machine, Using a Mechanical dated 09/2022 revealed lift design and operation vary across manufacturers, staff must demonstrate competency using the specific machines or devices utilized in the facility. This deficiency represents non-compliance investigated under Complaint Number OH00153814.

Based on review of list of COVID positive staff, review of robo call report, interview, and policy review, the facility failed to ensure residents, their representatives, and families were notified timely after confirmation of staff testing positive for COVID-19. This had the potential to affect all 53 residents in the facility. Findings included: Review of list of COVID positive staff undated revealed State tested Nurse Aide (STNA) #319 tested positive for COVID-19 on 03/13/23 and STNA #337 on 03/16/23. Review of robo call report dated 03/20/23 revealed residents, their representatives, and families were not notified until 03/20/23 at 10:36 A.M., of the positive staff member from 03/15/23 and 03/16/23. The message reported the facility had two staff member test positive for COVID in the last week. Review on facilities policy titled Confirmed COVID-19 cases Notification revised 09/2022 revealed all families, residents, and staff would be notified by utilizing the robo-calling, skype, 1:11 phone calls, letters, memos, and direct communication within 72 hours of the known infections. There was no evidence family, residents, or staff would be notified by 5:00 P.M., the following day after one single case of COVID was identified. Interview on 03/23/23 at 10:58 A.M, with Licensed Practical Nurse (LPN)/Infection Preventionist (IP) #310 confirmed families, residents, and staff were not notified timely of the two positive COVID cases on 03/15/23 or 03/16/23. The LPN verified the policy did not include the notification would be by 5:00 P.M. the following day after confirmation of a positive COVID resident/staff. The LPN reported the facility had misinterpreted the guidelines and thought they had 72 hours, however the notification was still not within 72 hours of the positive confirmation on 03/15/23. The LPN reported families, residents, and staff were all notified by the robo system.

Based on self reported incident review, medical record review and staff interview the facility failed to ensure residents were treated with respect and dignity by staff members. This affected one (Resident #7) of three residents reviewed for respect and dignity. The facility census was 53. Findings include: Review of the facility self reported incident (SRI) #213229 revealed on 10/21/21 State tested Nurse Aide (STNA) #359 was witnessed by staff members speaking to Resident #7 forcefully and pointing her finger at the resident telling Resident #7 to not bother her for assistance when she is with a different resident. Further review of the facility SRI investigation revealed statements obtained by staff witnesses STNA #327, STNA #361 and STNA #322. All STNAs indicated they witnessed STNA #359 talking disrespectfully to Resident #7 when Resident #7 was asking for assistance. Staff indicated STNA #359 pointed her finger and told Resident to not bother her when she is working with another resident. A statement obtained from Resident #7 indicated she was waiting for ambulation assistance from STNA #359. When she asked STNA #359 for assistance, STNA #359 yelled at her and told her no. Further review of the facility investigation revealed STNA #359 was immediately suspended pending investigation and eventually terminated. Review of the medical record for Resident #7 revealed an admitted [DATE] with diagnoses that included chronic kidney disease, atherosclerotic heard disease and peripheral vascular disease. Review of Resident #7's Minimum Data Set (MDS) 3.0 quarterly assessment with a reference date of 01/18/23 revealed Resident #7 has an independent cognition level. Interview with Director of Nursing and Registered Nurse (RN)/Consultant/Advisor #414 on 03/21/23 at 1:35 P.M. verified STNA #359 failed to treat Resident with respect and dignity. This deficiency represents non-compliance investigated under Master Complaint Number OH00135930.

Based on record review, review of the facility self-reported incidents, staff interview, and review of the facility policy on abuse, the facility failed to ensure the results of all abuse allegation investigations were reported in a timely manner. This affected three (#3, #15, and #25) of seven residents reviewed for abuse. The census was 53. Findings include: 1. Review of the open medical record for Resident #25 revealed an admitted [DATE]. Diagnoses included cerebrovascular disease, anxiety disorder, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had severely impaired cognition. Review of the progress note dated 02/11/22 at 6:34 A.M. revealed Resident #25 was brought to the nurse's station with a report that she had left the building. Review of the facility self-reported incident (SRI) #217752 revealed it was created on 02/10/22 and completed on 03/31/22. On 03/23/23 at 10:25 A.M., interview with the Director of Nursing (DON) verified the investigation for SRI #217752 was not completed within five days of the incident. Review of the facility policy titled Abuse Prohibition, not dated, revealed allegations of abuse would be reported to the Ohio Department of Health no later than two hours after the allegation and the results of the thorough investigation would be reported within five working days of the incident. 2. Review of the open medical record for Resident #3 revealed an admitted [DATE]. Diagnoses included vascular dementia with agitation, anxiety disorder, history of falling, history of transient ischemic attack, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 01/18/23, revealed Resident #3 had no cognitive impairment and required extensive assistance of one staff for activities of daily living (ADL). Review of the facility self-reported incident (SRI) #203299 revealed it was created on 03/09/21, there was no completion date, and there was no conclusion indicated. On 03/20/23 at 4:38 P.M., interview with the Director of Nursing (DON) verified SRI #203299 did not have a completion date or a conclusion. She stated she could not locate anything in their records regarding the incident and did not have any documentation of the investigation for the incident. Review of the facility policy titled Abuse Prohibition, not dated, revealed allegations of abuse would be reported to the Ohio Department of Health no later than two hours after the allegation and the results of the thorough investigation would be reported within five working days of the incident. 3. Review of the open medical record for Resident #15 revealed an admitted [DATE]. Diagnoses included anxiety disorder, dementia, and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had severe cognitive impairment. Review of the facility self-reported incident (SRI) #232901 revealed it was created on 03/11/23 and completed on 03/22/22. On 03/23/23 at 10:25 A.M., interview with the Director of Nursing (DON) verified the investigation for SRI #232901 was not completed within five days of the incident. On 03/23/23 at 10:53 A.M., interview with Facility Advisor #414 stated the investigation conclusion was not reported timely and the completion date of 03/22/23 reflected the date that the conclusion of the investigation was reported. Review of the facility policy titled Abuse Prohibition, not dated, revealed allegations of abuse would be reported to the Ohio Department of Health no later than two hours after the allegation and the results of the thorough investigation would be reported within five working days of the incident.

Based on record review, review of the facility self-reported incidents, staff interview, and review of the facility policy on abuse, the facility failed to conduct a thorough investigation for an allegation of abuse. This affected two (#3 and #13) of seven residents reviewed for abuse. The census was 53. Findings include: 1. Review of the open medical record for Resident #3 revealed an admitted [DATE]. Diagnoses included vascular dementia with agitation, anxiety disorder, history of falling, history of transient ischemic attack, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 01/18/23, revealed Resident #3 had no cognitive impairment and required extensive assistance of one staff for activities of daily living (ADL). Review of the facility self-reported incident (SRI) #203299, dated 03/09/21, revealed Resident #3 stated she was thrown into bed and this resulted in a skin tear to her left forearm. There were no named witnesses, no named alleged perpetrators, and no supporting documentation. The incident report had no completion date and no conclusion indicated. Review of the progress note dated 03/10/21 at 1:58 P.M. revealed Resident #3 had a skin tear to her left forearm and small bruises to her lower legs. On 03/20/23 at 4:38 P.M., interview with the Director of Nursing (DON) verified SRI #203299 was not completed. She stated she could not locate anything in their records regarding the incident and did not have any documentation of the investigation for the incident. Review of the facility policy titled Abuse Prohibition, not dated, revealed a thorough investigation of all allegations of abuse would be completed and kept in an investigation file. Investigations would include assessing the resident for injury, notify the physician, notify the family or responsible party, interview the resident, implement an interdisciplinary plan of care, and use all information gathered during the investigation to determine whether the allegation was substantiated or not. 2. Review of the open medical record for Resident #13 revealed an admitted [DATE]. Diagnoses included bipolar disorder, major depressive disorder, and schizophrenia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had no cognitive impairment and required total dependence or extensive assistance for activities of daily living (ADLs). Review of the facility self-reported incident (SRI) #215818, dated 12/21/21, revealed Resident #13 stated a staff member placed a urine soaked gown on her face. The investigation file only included witness statements from staff. There was no other investigation information included in the investigation file. On 03/23/23 at 8:37 A.M., interview with the Director of Nursing (DON) verified the investigation for SRI #215818 was not a complete and thorough investigation into the incident. Review of the facility policy titled Abuse Prohibition, not dated, revealed a thorough investigation of all allegations of abuse would be completed and kept in an investigation file. Investigations would include assessing the resident for injury, notify the physician, notify the family or responsible party, interview the resident, implement an interdisciplinary plan of care, and use all information gathered during the investigation to determine whether the allegation was substantiated or not.

Based on record review and interview, the facility failed to ensure all required information was sent to the receiving provider upon Resident #50's transfer to the hospital. This affected one resident (Resident #50) out of one resident reviewed for hospitalization . Findings Include: Resident #50 admitted to facility on 02/03/23 with diagnoses of cerebral vascular accident, anxiety disorder, pneumonia, history of fall with right hip fracture, and cognitive deficits. Review of the Base Line Care Plan dated 02/04/23, revealed Resident #50 required assist of one staff member for activities of daily living (ADL). Resident #50 Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of eleven, indicating moderate cognitive impairment. Review of progress note dated 02/15/23 at 5:50 PM, revealed Resident #50 slid out of the recliner on to the floor. Progress note dated 02/15/23 at 6:17 PM revealed Licensed Practical Nurse (LPN) #334 assessed Resident #50 for injury; noted a purple raised area to left side of forehead, a purple raised area to left shoulder with complaint of left shoulder and left hip pain. LPN #334 notified certified nurse practitioner (CNP), and received orders to send Resident #50 to the hospital for evaluation and treatment as indicated. Emergency Medical Services (EMS) arrived at facility and transported Resident #50 to a local hospital. Resident #50's information sent to the hospital included Resident Demographic sheet, Physician Orders and Advanced Directive status form. Review of progress note dated 02/17/23 at 11:28 AM, revealed Resident #50 was discharged and return to the facility was not anticipated. Review of Resident #50's Transfer or Discharge information revealed the information provided to the receiving hospital did not include Resident #50 special risk factors, comprehensive care plan goals, baseline and current mental, behavioral, and functional status, reason for transfer, and recent vital signs. The information also did not include the required discharge summary reflecting Resident #50 stay while at the facility. Interview with Director of Nursing, on 03/21/23 at 2:04 PM, confirmed Resident #50 discharge information sent to the local hospital included Resident Demographic Sheet, Physician orders and Advanced Directives form. Resident #50's discharge information did not include the above required information.

Based on record review and interview, the facility failed to notify Resident #50's resident representative in writing of the resident's transfer and discharge. This affected one resident (Resident #50) out of one resident reviewed for hospitalization . Findings Include: Resident #50 admitted to facility on 02/03/23 with diagnoses of cerebral vascular accident, anxiety disorder, pneumonia, history of fall with right hip fracture, and cognitive deficits. Review of the Base Line Care Plan dated 02/04/23, revealed Resident #50 required assist of one staff member for activities of daily living (ADL). Resident #50 Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of eleven, indicating moderate cognitive impairment. Review of progress note dated 02/15/23 at 5:50 PM, revealed Resident #50 slid out of the recliner on to the floor. Progress note dated 02/15/23 at 6:17 PM revealed Licensed Practical Nurse (LPN) #334 assessed Resident #50 for injury; noted a purple raised area to left side of forehead, a purple raised area to left shoulder with complaint of left shoulder and left hip pain. LPN #334 notified certified nurse practitioner (CNP), and received orders to send Resident #50 to the hospital for evaluation and treatment as indicated. Emergency Medical Services (EMS) arrived at facility and transported Resident #50 to a local hospital. Review of progress note dated 02/16/23 at 1:40 AM, revealed Resident #50 was admitted to the local hospital intensive care unit for multiple fractures. Review of progress note dated 02/16/23 at 1:51 PM, revealed Resident #50 family members removed personal items from Resident #50 current room in the facility. Review of progress note dated 02/17/23 at 11:28 AM, revealed Resident #50 was discharged and return to the facility was not anticipated. Record review revealed Resident #50 representative was not sent a written transfer or discharge notice of Resident #50's transfer to hospital. Interview on 03/22/23 at 12:54 PM with Licensed Social Worker #412 confirmed there was no written transfer or discharge notice sent to Resident #50 representative.

Based on closed record review, review of hospital records, and interviews the facility failed to ensure a newly admitted resident had routine care and dietary orders to provide immediate care. This affected one (Resident #203) of three closed records reviewed. Findings included: Closed medical record for Resident #203 revealed the resident was admitted on [DATE] with diagnoses including syncope and collapse, chronic kidney disease, nonrheumatic mitral valve, absence of kidney, Barrett's esophagus, chest pain, atrial fibrillation, depression, pain, and hypotension. Review of Resident #203's nursing note dated 09/09/22 at 6:43 P.M., revealed the resident was admitted to the facility from the a local hospital and left against medical advice (AMA) on 09/10/22 at 11:22 A.M. Review of Resident #203's physician orders dated 09/09/23 to 09/10/23 revealed there was only orders for medication and code status. There was no evidence of orders for diet or routine care. Review of Resident #203's nursing note dated 09/10/22 created at 2:56 P.M., by Licensed Practical Nurse (LPN) #300 revealed the LPN entered the resident's room at 9:47 A.M. and observed there was no breakfast tray on the tray table. The LPN inquired if she had breakfast this morning. The resident stated she didn't have breakfast yet. The LPN proceeded to let the resident know she had her medication and after she took her medication a staff member would be in to get her breakfast order. The staff offered the resident everything on the breakfast menu and the resident requested yogurt and cranberry juice. Review of Resident #203's nursing note created on 09/10/22 at 3:48 P.M., revealed at 10:43 A.M. staff reported the resident's daughter wanted to speak to the Administrator and Director of Nursing (DON) regarding the resident not being admitted into the facility due to the hospital packet still in the resident room and the care her mother was currently receiving. The resident had been admitted to the facility under skilled nursing services. Review of Resident #203's nursing note dated 09/10/22 created at 4:02 P.M., by LPN #300 revealed at 11:10 A.M. the resident's daughter came up to the nurse in the hallway and started verbally attacking the nurse over the resident not receiving breakfast. The nurse attempted to tell the daughter she did get breakfast and what she had asked for and received. The daughter stated in a loud angry voice my mom did not get a breakfast and this lady was nice enough to get my mom oatmeal. I don't care what you have to say. The nurse proceeded to explain the resident had asked for yogurt and cranberry juice. The daughter interrupted again and was yelling at the nurse that her mom was forgetful and that her mom's hospital packet was still in her mom's room which meant she wasn't even admitted into the facility. The nurse tried to explain that nurses was looking at her mom's chart and that she was admitted , and that medication were ordered. The daughter proceeded to tell the nurse she wanted to talk with the Administrator or DON and that she wanted a wheelchair she was taking her mother out of the facility and proceeded walking down hallway to elders room. Review of Resident #203's discharged minimum data set (MDS) for not anticipating to return dated 09/10/22 revealed the assessments were not completed for function, cognition, and swallowing/nutritional status. The bowel and bladder section indicated the resident was always continent of urine and bowel was unknown. Review of Resident #203's baseline plan of care revealed the resident was discharged with power of attorney (POA) prior to the completion of the baseline plan. Review of Resident #203's recapitulation of resident stay dated 09/12/22 and locked 12/01/22 revealed the resident was admitted from the hospital after stay for syncope, collapse and orthostatic hypotension. She came in on 09/09/22 skilled through insurance services for physical and occupational therapy services and nursing monitoring due to recent medication changes and hypotension episodes. Further review of Resident #203's electronic medical record revealed the only hospital records scanned into the medical record was the resident medication reconciliation list. There was no evidence of resident's status and care needs (activities of daily living, diet, therapy orders, etc.) Interview on 03/20/23 at 10:12 A.M., with Resident #203's daughter revealed her mom called her confused. When she arrived to the facility on [DATE] her mom was weak and lethargic. No one had helped her to the bathroom, and she had been incontinent and had feces on her. She had tried to toilet herself and had urinated on the floor. Her mom was not provided a dinner on 09/09/22 or a breakfast on 09/10/22 until almost lunch time. Her mom was a fall risk due to she had fallen at home and when she arrived her moms call light was not in reach, nor did she have any bedrails. Interview on 03/21/23 at 4:00 P.M., with LPN #300 revealed the admission nurse was from agency and did not enter all the residents' orders nor did the staff complete a nursing assessment. The daughter was upset and was not able to be reason with. The daughter wanted her mom to have a full coarse breakfast and she was trying to explain the diet orders were entered and she had identified the resident did not receive a breakfast [NAME] this morning and she had the kitchen provide the resident with cranberry juice and yogurt as she requested. Interview on 03/21/23 at 5:06 P.M., with the DON revealed Resident #11 did not have a nursing assessment or diet orders. Interview on 03/22/23 1:23 P.M., with Registered Nurse (RN) #305 revealed she was the DON during that time of the incident with Resident #203. The resident arrived between shift change around 6:30 P.M. on 09/09/22. The ongoing and coming on nurses were agency nurses and they were aware of the admission. The admission nursing assessment was not competed nor was all the orders including the diet orders. Around 10:30 A.M., the next day (09/10/22) she had received a call from LPN #300 regarding that Resident #203's daughter was upset that her mom was not fed and the admission paper work from the hospital was still in the residents room. RN #305 reported she had completed an investigation but the facility cannot find it the investigation including the staff interviews. This deficiency represents non-compliance investigated under Complaint Number OH00135930.

Based on closed record review, review of hospital records, and interviews, the facility failed to ensure a newly admitted resident received quality standard care. This affected one (Resident #203) of three closed records reviewed. Findings included: Closed medical record for Resident #203 revealed the resident was admitted on [DATE] with diagnoses including syncope and collapse, chronic kidney disease, nonrheumatic mitral valve, absence of kidney, Barrett's esophagus, chest pain, atrial fibrillation, depression, pain, and hypotension. Review of Resident #203's nursing note dated 09/09/22 at 6:43 P.M., revealed the resident was admitted to the facility from the a local hospital and left against medical advice (AMA) on 09/10/22 at 11:22 A.M. Review of Resident #203's physician orders dated 09/09/23 to 09/10/23 revealed there was only orders for medication and code status. There was no evidence of orders for diet or routine care. Review of Resident #203's nursing note dated 09/10/22 created at 2:56 P.M., by Licensed Practical Nurse (LPN) #300 revealed the LPN entered the resident's room at 9:47 A.M. and observed there was no breakfast tray on the tray table. The resident was on telephone; and asked person which she was talking on phone with if she could call them back. The resident hung up the phone and the LPN inquired if she had breakfast this morning. The resident stated she didn't have breakfast yet. The LPN proceeded to let the resident know she had her medication and after she took her medication a staff member would be in to get her breakfast order. The resident was sitting on side of bed with call light in reach. Staff offered resident everything on the breakfast menu and the resident refused everything except yogurt and cranberry juice. Review of Resident #203's nursing note created on 09/20/22 at 3:48 P.M., revealed at 10:43 A.M. staff reported the resident's daughter wanted to speak to the Administrator and Director of Nursing (DON) regarding the resident not being admitted into the facility due to the hospital packet still in the resident room and the care her mother was currently receiving. The creator of the note asked the staff member to let the daughter know she was with another resident and would be down shortly. The resident had been admitted to the facility under skilled nursing services. Review of Resident #203's nursing note dated 09/10/22 created at 4:02 P.M., by LPN #300 revealed at 11:10 A.M. she had just left a resident's room when the dietary cook came to her cart to let her know the resident's daughter was upset and wanted to talk with the nurse, Administrator, or DON. The nurse asked the dietary cook to let the daughter know she would be right there. The daughter came up to the nurse in the hallway and started verbally attacking the nurse over the resident not receiving breakfast. The nurse attempted to tell the daughter she did get breakfast and what she had asked for and received. The daughter stated in a loud angry voice my mom did not get a breakfast and this lady was nice enough to get my mom oatmeal. I don't care what you have to say. The nurse proceeded to explain the resident had asked for yogurt and cranberry juice. The daughter interrupted again and was yelling at the nurse that her mom was forgetful and that her mom's hospital packet was still in her mom's room which meant she wasn't even admitted into the facility. The nurse tried to explain that nurses was looking at her mom's chart and that she was admitted , and that medication were ordered. The daughter proceeded to tell the nurse she wanted to talk with the Administrator or DON and that she wanted a wheelchair she was taking her mother out of the facility and proceeded walking down hallway to elders room. Review of Resident #203's discharged minimum data set (MDS) for not anticipating to return dated 09/10/22 revealed the assessments were not completed for function, cognition, and swallowing/nutritional status. The bowel and bladder section indicated the resident was always continent of urine and bowel was unknown. Review of Resident #203's baseline plan of care revealed the resident was discharged with POA prior to the completion of the baseline plan. Review of Resident #203's recapitulation of resident stay dated 09/12/22 and locked 12/01/22 revealed the resident was admitted from the hospital after stay for syncope, collapse and orthostatic hypotension. She came in on 09/09/22 skilled through insurance services for physical and occupational therapy services and nursing monitoring due to recent medication changes and hypotension episodes and discharged out on 09/10/22 when family took her from the facility prior to admission paperwork being completed as an unplanned discharge. No home care paperwork was set up and family would not wait to take her mother home until this could be arranged. Further review of Resident #203's electronic medical record revealed the only hospital records scanned into the medical record was the resident medication reconciliation list. There was no evidence of resident's status and care needs (activities of daily living, diet, therapy orders, etc.) Interview on 03/20/23 at 10:12 A.M., with Resident #203's daughter revealed her mom called her confused. When she arrived, her mom was weak and lethargic. No one had helped her to the bathroom, and she had been incontinent and feces on her. She was not provided a dinner on 09/09/22 or a breakfast on 09/10/22. Her mom was a fall risk because she had fallen at home and her call light was not in reach, nor did she have any bedrails. Interview on 03/21/23 at 4:00 P.M., with LPN #300 revealed the admission nurse was from agency and did not enter all the residents' orders nor completed a nursing assessment. The daughter was upset and was not able to be reason with. The daughter wanted her mom to have a full coarse breakfast and she was trying to explain the diet orders were not entered in the computer and did not receive a breakfast tray and she had the kitchen provide the resident with cranberry juice and yogurt as she requested. Interview on 03/21/23 at 5:06 P.M., with the DON revealed Resident #11 did not have a nursing assessment or diet orders. Interview on 03/22/23 1:23 P.M., with Registered Nurse (RN) #305 revealed she was the DON during that time of the incident with Resident #203. The resident arrived between shift change around 6:30 P.M. on 09/09/22. The ongoing and coming on nurses were agency nurses and they were aware of the admission. The admission nursing assessment was not competed and orders including diet orders were not entered. Around 10:30 A.M., the next day (09/10/22) she received a call from LPN #300 regarding that Resident #203's daughter was upset that her mom was not fed and the admission paper work form the hospital was still in the room. RN #305 reported she had completed an investigation but the facility cannot find the investigation, including staff interviews. This deficiency represents non-compliance investigated under Complaint Number OH00135930.

Based on medical record review and staff interview, the facility failed to ensure residents with pressure ulcer wounds had wound assessments completed at least every seven days. This affected one (Resident #204) of two residents reviewed for wounds. Findings include: Review of Resident #204's medical record revealed an admitted [DATE] with a readmitted [DATE]. Admission diagnoses included pressure ulcer to the heel, Alzheimer's disease with dementia and chronic obstructive pulmonary disease. Further review of the medical record revealed upon readmission to the facility on [DATE], Resident #204 was identified with a pressure ulcer wound to the right heel. Initial pressure ulcer wound assessment was completed on [DATE] which identified the wound as a stage two pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough) measuring 4.0 centimeters (cm) by 5.0 cm and a depth of less than 0.1 cm. Further review of the wound assessments revealed no additional wound assessment completed. Resident #204 remained in the facility until [DATE] when she expired under hospice services. Review of hospice visitation notes revealed on [DATE] Resident #204's pressure ulcer to the right heel remained a stage two. Interview with Registered Nurse (RN) #307 on [DATE] at 11:10 A.M. verified no comprehensive wound assessments completed after the initial assessment on [DATE] for Resident #204's stage two pressure ulcer to the right heel.

Based on record review and interview, the facility failed to ensure residents received restorative therapy per plan of care. This affected one (Resident #12) of one reviewed for limited range of motion. Findings included: Record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including need for assistance with personal care, senile ectropion of eyelid, ganglion, pain left and right leg, anorexia, dysphagia, constipation, hyponatremia, abdominal pain, neuropathy, abnormal weight loss, neoplasm of skin of scalp and neck, pain in toes, edema, gout, restless leg syndrome, polyneuropathy, heart failure, rheumatoid arthritis, osteoarthritis of left wrist, presbyopia, pain, dementia, chronic kidney disease, Alzheimer's, gastro-esophageal reflux disease, hyperlipidemia, joint pain unspecified, vitiligo, urge incontinence, and effusion of ankle and foot. Review of Resident #12's range of motion plan of care revealed the resident was at risk for impaired mobility due to activity of daily living decline, decrease in strength, and weakness. The resident's interventions were to receive restorative active range of motion to bilateral upper and lower extremities time 10 reps, wheelchair mobility in halls using legs for propulsion for 25-30 feet for fifteen minutes six to seven times a week. Review of the aides task documentation dated 02/20/23 to 03/21/23 revealed the resident was to receive restorative active range of motion to bilateral upper and lower extremities time 10 reps, wheelchair mobility in halls using legs for propulsion for 25-30 feet for fifteen minutes six to seven times a week. The week of 02/20/23 to 02/25/23 the resident only received restorative four times. The week of the 02/26/23 to 03/04/23 the resident had received restorative four time that week. The week of 03/05/23 to 03/11/23 the resident received restorative five times. The week of 03/12/23 to 03/18/23 the resident had received restorative three times and was not available one day of the seven days. Review of Resident #12's quarterly minimum date set (MDS) dated [DATE] revealed the resident had limited range of motion on upper and lower extremities on both sides and required extensive assistance with the majority of her activities of daily living. Interview on 03/21/23 at 2:09 PM with Registered Nurse (RN)/Restorative Nurse #309 confirmed Resident #12 did not receive restorative services per her plan of care (5-6 times a week) from 02/20/23 to 03/21/23. RN #309 reported the resident was ordered therapy for leg strengthening on 03/07/23 to 04/06/23, however the restorative program would continue due to the resident was not receiving upper ROM exercises from therapy. RN #309 reported restorative services had over 40 programs with 37 residents and only have two restorative aides. The restorative aides attempt to do as many programs during the week the can but they don't have the manpower to complete all the programs as care planned. The goal was to do as many programs as possible. Interview on 03/22/23 at 7:45 A.M., with restorative aide (RA)/State tested Nurse's Aide (STNA) #322 revealed on Tuesday, Wednesday, and Thursday there was two restorative aides and only one on the other days. The floor staff did not have time to perform restorative therapy and occasionally the restorative aides get pulled to the floor to help. They had two substitute restorative aides but with the staffing shortage the two substitute aides have not been able to help. The RA reported there was over 40 programs and with each program 15 minutes there was not enough time in one day for one person to complete all the programs. RA #322 verified resident in restorative were not receiving restorative therapy 6-7 days a week because there was not enough time or staff to complete all the programs. She tried to alterative floors to ensure the resident are at least receiving restorative 3-4 times a week. RA #332 confirmed Resident #12 should still be receiving restorative for upper extremities even though therapy was providing strength training for her lower extremities. RA #332 verified when she was short of time she would skip the residents that were receiving therapy services even though therapy may not be treating the area the resident was ordered for restorative services. Interview on 03/22/23 at 2:06 P.M., with Therapy Manger (TM) #410 revealed Resident #12 was receiving therapy for leg strengthening and restorative should continue to provided services to the upper extremities. TM #410 reported if a resident was in a restorative program and was picked up by therapy, restorative would still continue to provided services for areas not treated by therapy.

Based on record review and interview the facility failed to complete a comprehensive fall investigation to include root cause and ensure the safety of the resident after a fall with injury. This affected one resident (Resident #50) out of two residents reviewed for falls. Findings Include: Record review on 03/20/23 revealed Resident #50 admitted to facility on 02/03/23 with diagnoses of cerebral vascular accident, anxiety disorder, pneumonia, history of fall with right hip fracture, COVID 19 and cognitive deficits. Resident #50 Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of eleven, indicating moderate cognitive impairment. Review of the Base Line Care Plan dated 02/04/23, revealed Resident #50 required assist of one staff member for Activities of Daily Living (ADL) including transfers and toileting. Review of Resident #50's Fall Care Plan dated 02/06/23 revealed interventions to prevent falls included call light with in reach, appropriate footwear, and red dot on doorframe to indicate high fall risk. Review of progress note dated 02/15/23 at 5:50 PM, revealed Resident #50 slid out of the recliner on to the floor. Progress note dated 02/15/23 at 6:17 PM revealed Licensed Practical Nurse (LPN) #334 assessed Resident #50 for injury; noted a purple raised area to left side of forehead, a purple raised area to left shoulder with complaint of left shoulder and left hip pain. LPN #334 notified certified nurse practitioner (CNP), and received orders to send Resident #50 to the hospital for evaluation and treatment as indicated. Emergency Medical Services (EMS) arrived at facility and transported Resident #50 to a local hospital. Review of progress note dated 02/16/23 at 1:40 AM, revealed Resident #50 was admitted to the local hospital intensive care unit for multiple fractures. Resident #50 did not return to the facility. Review of a fall witness statement in reference to Resident #50's fall 02/15/23, by LPN #334 dated 02/16/23, revealed Resident #50 was eating dinner in room due to being in droplet isolation following new diagnoses of COVID 19. At 5:50 P.M. Resident #50 was observed on the floor by recliner by State tested Nursing Assistant (STNA) #412; LPN #334 was notified and assessed Resident #50 for injury; LPN #334 observed a purple raised area on left forehead, a purple raised area on left shoulder and complaint of pain to left shoulder and left hip. LPN #334 and STNA #412 assisted Resident #50 up from the floor and placed her in bed for further assessment, rather than assessing the resident prior to moving her. LPN #334 left Resident #50's room to notify the resident's representative of the fall. STNA #412 also left the room. Resident #50's daughter called facility to report she was observing Resident #50 after the fall, via video camera located in room, standing beside her bed. LPN #334 stated STNA #412 took Resident #50 to the restroom following notification by daughter of Resident #50 standing up from bed. Review of Resident #50's 02/15/23 fall investigation completed by Director of Nursing (DON) revealed Resident #50 had increased anxiety due to being in droplet isolation precautions. Resident #50 typically ate meals in the dining room. DON indicated LPN #334 did not complete a thorough fall event assessment on Resident #50 when she fell on [DATE]. On 02/20/23, individual education on safety procedures was given to LPN #334 and staff education for safety procedures was performed by DON. The fall investigation did not identify a root cause for Resident #50 fall on 02/15/23. Interview with DON on 03/22/23 at 12:42 P.M. confirmed Resident #50 had been moved following LPN #334 initial assessment of Resident #50 with complaint of pain and possible injuries. DON revealed the resident should not have been moved off the floor without a thorough assessment. DON also confirmed there was no root cause identified for Resident #50 fall on 02/15/23. This deficiency represents non-compliance investigated under Master Complaint Number OH00135930.

Based on record review, observation, interview, and policy review, the facility failed to ensure Resident #11's pharmacy review was acted upon timely, as needed psychotropic medication had stop dates, and resident received appropriate dose of anti-anxiety medication. This affected one (Resident #11) of five reviewed for medications. Findings included: Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including dementia with mood disorder, anxiety, depression, restlessness, insomnia, impulsiveness, and Alzheimer's. 1. Review of Resident #11's pharmacy recommendation dated 03/08/23 recommended to discontinue Remeron 7.5 milligrams (mg). The physician agreed to discontinue the Remeron on 03/15/23. Review of Resident #11's physiatrist note dated 03/15/23 revealed to discontinue Remeron. Review of Resident #11's orders and Medication Administration Records dated 03/2023 revealed no evidence the Remeron 7.5 mg had been discontinued. Interview on 03/22/23 at 1:23 P.M., with the Director of Nursing (DON) verified the Remeron should have discontinued on 03/15/23, however it was not discontinued. 2. Review of Resident #11 physician orders dated 03/2023 revealed the resident had been ordered Ativan (anti-anxiety) 0.5 mg, Benadryl (antihistamine) 25 mg and Haldol (antipsychotic) 1 mg (ABH) GEL, apply as need three times daily (every eight hours as needed) for agitation/restlessness since 08/15/22. There was no evidence of a stop date. Interview on 03/22/23 at 1:23 P.M., with the DON verified the there was no stop date the ABH gel. The DON reported she had spoken to hospice to remind them to indicate stop dates as needed medication. 3. Review of Resident #11's orders dated 03/20/23 revealed the resident was ordered Ativan (anti-anxiety) 0.5 mg, Benadryl (antihistamine) 25 mg and Haldol (antipsychotic) 1 mg (ABH) GEL, apply as needed three times daily (every eight hours as needed) for agitation/restlessness since 08/15/22, ABH gel apply once in the morning for agitation/restlessness. Apply to back of neck or lower back in the morning for agitation/restlessness since 09/20/22, Remeron 7.5 mg po daily, Ativan 0.5 mg four times daily for agitation/anxiety, Zoloft 50 mg at bedtime for depression, and Melatonin 3 mg at night for insomnia. Review of hospice recert dated 02/12/23 and medication list dated 03/15/23 revealed the resident was ordered Ativan 0.25 mg every six hours. There was a discrepancy noted from the facilities orders of Ativan 0.5 mg compared to Hospice orders of 0.25 mg. Review of Resident #11's psychiatrist noted dated 03/15/23 indicated the resident was only receiving the ABH gel three times daily as needed and Ativan 0.5 mg four times daily. The plan indicated the resident used the ABH gel and Ativan as needed for behaviors. A second note indicated the Ativan was used for comfort measures. There was no reference to the resident receiving scheduled ABH gel per the orders. Review of Resident #11's Nurse Practitioner (NP) dated 03/16/23 revealed the resident was only receiving the ABH gel as needed and Ativan 0.5 mg four times a day. The plan indicated the resident was only receiving as needed medication from hospice. There was no reference to the resident receiving scheduled ABH gel per the orders. Observation on 03/20/23 at 10:32 A.M., of Resident #11 revealed the resident would not respond when attempting to talk with him. Observation on 03/21/23 at 8:24 A.M. of Resident #11 revealed the resident was sitting in the dining room asleep. His breakfast tray was setting on the table untouched and uncovered. Observation on 03/21/23 at 9:11 A.M., Resident #11 was still in the dining room asleep as an activity was in progress. Observation on 03/22/23 at 7:35 A.M., Resident #11 was asleep in the hallway. Observation and interview with Resident #11 on 03/23/23 at 9:10 A.M., with Registered Nurse (RN) #307 revealed the resident answered two question and stopped responding. The resident could not keep eyes open. RN #307 reported the resident was more active in the evening. Interview on 03/22/23 at 1:23 P.M., with the DON verified psychiatrist notes and NP notes were not accurate to reflect the resident current medications. The DON reported she would have to reach out to hospice to verify the Ativan order. Interview on 03/23/23 at 9:46 A.M., with Hospice RN #416 and Hospice Clinical Director #417 revealed they understood the concerns with the Ativan order due to the physician had signed scripts for Ativan 0.5 mg, however on the hospice recertification forms and the hospice medication list indicated the resident was only on Ativan 0.25 mg. The Hospice Clinical Director reported they would talk to the physician and get the Ativan discrepancy clarified and assess the resident. Review of the facilities policy titled, Psychotropic Drug Use undated revealed the use of psychotropic drug therapy would be used when appropriate to enhance the resident's quality of life, while maximizing functional potential and well-being of the residents. As needed anti-psychotic medication are limited to 14 days and will not be renewed unless the attending physician or prescribing practitioner evaluates the resident in person, for the appropriateness of that medication. A psychotropic drug is considered a chemical restraint when it was used as the first intervention to control behaviors, mood, or mental status. The consulting pharmacist would perform a chart review of each resident each month to assess for unnecessary drug therapies and potential reduction. This deficiency represents non-compliance investigated under Complaint Number OH00131654.

Based on record review, review of two facility Self-Reported Incidents (SRIs), associated investigations and the facility abuse policy and procedure, interviews with staff, Medical Director #535, Certified Nurse Practitioner (CNP) #506 and #611, the facility failed to ensure Resident #12 and Resident #123, assessed as cognitively impaired, were free from sexual abuse by Resident #13. This resulted in Immediate Jeopardy and the potential for serious harm on [DATE] at 6:30 A.M. when Resident #13 was observed in Resident #123's room with his hands inside Resident #123's underwear. The Immediate Jeopardy remained ongoing, on [DATE] at 8:15 P.M. when Resident #13 was observed with his arm/hand down the front of Resident #12's blouse. There was no evidence, following either incident, the facility immediately assessed Resident #123 or Resident #12 and no evidence the facility implemented interventions to prevent further incidents of sexual abuse by Resident #13. This affected two residents and had the potential to affect 21 additional cognitively impaired female residents (Residents #1, #4, #8, #9, #15, #19, #22, #26, #28, #32, #33, #34, #37, #38, #41, #45, #46, #50, #56, #59 and #60) identified by the facility to be at risk. The facility census was 70. On [DATE] at 4:24 P.M. the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] when Resident #13 was observed with his hands inside Resident #123's underwear making sexual motions. The Immediate Jeopardy continued on [DATE] when Resident #13 was observed with his arm down the front of Resident #12's blouse. The facility failed to thoroughly investigate either incident of sexual abuse and failed to timely develop and implement an individualized plan for Resident #13 to address sexually inappropriate behaviors and prevent additional incidents of sexual abuse. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE], the DON initiated education for all staff members on sexual abuse, safety of residents during a potentially abusive situation, resident rights, how to report suspected abuse and who to report it to. The training was overseen by the Administrator. As of [DATE] at 8:40 A.M., 174 of 179 staff members were in-serviced. The five staff members who had not received the education were on leave and a plan for these employees to receive the education prior to returning to work was in place. · On [DATE], the facility implemented a plan for behavior monitoring to be completed each shift per the charge nurse for Resident #13. The charge nurse would audit for verbal or physical sexual advances, initiate interventions including redirection to supervised activities or to his room, one-to-one supervision or medication administration to deter or stop behavior and determine the effectiveness. This would remain ongoing until Resident #13 had a significant change in condition which the facility had defined as a functional decline related to [MEDICAL CONDITION]. This will be overseen by the Quality Assurance (QA) committee quarterly. · On [DATE] Resident #13's plan of care was updated to reflect the addition of [MEDICATION NAME] for sexually inappropriate behaviors and to reflect his past incidents of sexual abuse with female residents. · On [DATE] the facility Abuse policy and procedure was updated to include definitions of potential sources of abuse including resident to resident, staff to resident, family member to resident, and visitor to resident. · On [DATE] a physician's orders [REDACTED].#13's behaviors, including sexual behaviors. Behavior task monitoring was scheduled for once a shift and identified behaviors including walking slowly down the corridors, looking into other resident's rooms, lingering around female residents, and attempts at being sexually inappropriate. This monitoring documentation was to be completed through the Point of Care system (PCC) electronic medical record by the nurse assigned to care for the resident on the Medication Administration Record [REDACTED]. · On [DATE] at 4:00 P.M., one-to-one monitoring of Resident #13's assigned direct care staff was initiated. The one-to-one included that Resident #13 was to have direct supervision 24- hours a day, seven days a week until further notice. A log sheet was implemented for staff to document when there was a change and what staff member was completing the one-to-one. Staff documented to have completed the one on one from [DATE] through [DATE] included STNA staff, the activity director and resident assistants (non-state tested care staff). · On [DATE] the facility-initiated auditing by the Interdisciplinary Team (IDT) to identify patterns or changes in behaviors of Resident #13. A plan for any identified patterns or behaviors would be addressed according to the findings. The facility Minimum Data Set 3.0 (MDS) nurses would update the plan of care accordingly and Unit Managers would be responsible for providing education to staff as changes are made. This audit was planned to remain in place until Resident #13 sustained a significant change and the threat to other residents was no longer valid. All oversight would be done by the Quality Assurance (QA) committee quarterly. · On [DATE] the facility adapted a new format to streamline investigations for more thorough, consistent investigations for each allegation of abuse. All 14 Registered Nurses (RNs) and 11 Licensed Practical Nurses (LPNs) were educated on the new policy/ procedure and paperwork by [DATE] by the DON or her designee. Oversight for ongoing training needs would be completed annually for skills training and as needed. All new employees would receive education on completing investigations by the DON or her designee upon hire. · On [DATE], Resident #13 was evaluated by Psychiatric Certified Nurse Practitioner (PCNP) #610 who documented Resident #13 had a history of [REDACTED]. PCNP #610 further documented the medication would take four to six weeks to determine effectiveness. · Beginning on [DATE], Resident #13's seating arrangements at meals and activities would be changed so that Resident #13 sat with only male residents. If the event was unavoidable, a staff member would be seated within reach of Resident #13 to prevent any physical touching of female residents. This was to be overseen by the DON or designee. · On [DATE] Resident #13 was started on the [MEDICATION NAME] medication, [MEDICATION NAME] ([MEDICATION NAME]) as a medication used to decrease libido. · On [DATE] RN #544, RN #503 and RN #523 conducted observations of all residents with a Brief Interview for Mental Status score of 7 or less (indicative of cognitive impairment) including the 22 cognitively impaired female residents (Resident #1, #4, #8, #9, #12, #15, #19, #22, #26, #28, #32, #33, #34, #37, #38, #41, #45, #46, #50, #56, #59 and #60) for physical signs/symptoms of sexual abuse with no negative findings identified. · On [DATE] Assistant Director of Nursing (ADON) #519 conducted an audit of MDS data entries to determine if any facility residents had exhibited sexually inappropriate behavior in the past 30 days. Resident #13 was the only identified resident. · From [DATE] through [DATE] staff interviews completed with the following employees revealed they had received sexual abuse training and were aware of what to look for regarding resident to resident behaviors, how to complete thorough investigations, and Resident #13's specific behaviors: LPNs #505 and #513; RNs #514, #515 and #523; Dietary Aide (DA) #516 and #526; State tested Nursing Assistants (STNAs) #507, #517, #518, #511 #524, #528, #530 and #542; Resident Assistant (RA) #520; Activities Director (AD) #521; Activities Assistant (AA) #522; Housekeepers (HSKP) #525, #527 and #532; Social Service (SS) #529; Therapy Manager (TM) #531 and Laundry Aide (LA) #533,. Although the Immediate Jeopardy was removed on [DATE] the facility remains out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Record review revealed Resident #13 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed a plan of care, dated [DATE] which indicated Resident #13 had a history of [REDACTED]. The care plan was updated on [DATE] to reflect an incident in which Resident #13 tried to put the hand of a female resident down his pants. Interventions included to analyze key times of behaviors, staff members, places, circumstances, triggers, and what would de-escalate the behavior and document, assess and anticipate Resident #13's needs. The care plan indicated to complete a review of Resident #13's behaviors quarterly, inform Resident #13 his behaviors and/or comments were inappropriate and to stop. If the behaviors continued; make sure Resident #13 was safe and leave and return later with additional help. Additional interventions included monitor Resident #13's interactions daily, and notify the CNP or Physician of Resident #13's behaviors and ask them to reassess medications if the behaviors persisted. Review of Resident #13's quarterly MDS assessment, dated [DATE], revealed Resident #13 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. The assessment revealed he exhibited physical behaviors directed towards others one to three days a week. Resident #13 was assessed to require limited assistance from one person for locomotion off the unit. On [DATE] record review revealed no documentation of a quarterly review of Resident #13's behaviors had been completed in (YEAR). Review of a facility self-reported incident (SRI), tracking number 3, dated [DATE] revealed on [DATE] at 8:30 A.M. Laundry Supervisor (LS) #500 entered the room of female Resident #123 and saw Resident #13 at Resident #123's bedside. The SRI documented Resident #123's blanket was pulled down and Resident #13 had his hands close to the pelvic region of Resident #123. The SRI stated staff immediately intervened and removed Resident #13 from the room. The SRI documented the facility concluded the allegation of sexual abuse was unsubstantiated. Review of the facility incident investigation revealed a handwritten statement by LS #500 which stated on [DATE] around 8:30 A.M. LS #500 entered the room of Resident #123 and observed Resident #13 at the bedside of Resident #123. LS #500's written statement indicated Resident #123's blanket was removed, and Resident #13 had his hands between Resident #123's legs. LS #500 documented she left the room and told STNA #501 who immediately entered the room and removed Resident #13 from the room. Review of Resident #123's medical record revealed a lack of documentation including progress notes, assessments, or notification of the physician or family regarding the incident with Resident #13 on [DATE]. Review of Resident #13's medical record revealed a nursing progress note dated [DATE] at 12:59 P.M. written by RN #519 which indicated Resident #13 was spoken to regarding the inappropriateness of visiting female residents in their room unaccompanied. RN #519 further documented Resident #13 appeared uncomfortable, however stated understanding. RN #519 also documented the family was notified of the conversation as well. However, Resident #13's medical record contained no new assessments or behavioral referrals and the plan of care was not updated regarding the [DATE] incident or any new interventions to prevent further incidents of sexual abuse. Review of a facility incident report dated [DATE] at 7:45 A.M. and completed by RN #508 revealed STNA #501 had reported Resident #13 was observed in Resident #123's room with his hands in the vicinity of Resident #123's groin. The incident report did not include any documentation that a physical assessment of Resident #123 was completed. There was no documentation that Resident #123's responsible party or physician were notified of the incident or that any new interventions were implemented for Resident #13 at this time. Interview with LS #500 on [DATE] at 9:08 A.M. revealed on [DATE] at approximately 6:30 A.M. she was delivering laundry to residents' rooms. LS #500 reported she had initially seen Resident #13 go into Resident #123's room however she was not concerned. LS #500 then went into Resident #123's room to hang up clothing and heard a mumbling sound and turned around and saw Resident #13 with both hands, up to the wrist, under Resident #123's underwear making an up and down motion. LS #500 further stated she called out Resident #13's name and he jerked his hands back to where his hands were still under Resident #123's underwear. LS #500 said she ran into the hall and yelled for assistance. STNA #501 came to the room and told Resident #13 to stop and escorted Resident #13 from the room. LS #500 reported she had to write a statement regarding what she had observed but was told by the DON not to discuss the incident with anyone and it would be taken care of. LS #500 reported having been trained on abuse within the past month, however she said she was not trained on what to do in situations regarding resident to resident sexual abuse. LS #500 also repeatedly stated as a non-nursing employee, she had been told not to have physical contact with residents and to get assistance (from nursing staff) for any situations regarding residents. On [DATE] at 9:46 A.M. interview with STNA #501 revealed on [DATE] LS #500 had come into the hall asking for assistance. Upon entering the room of Resident #123, STNA #501 saw Resident #13 with his hands hovering approximately three to four inches above Resident #123's vaginal area. STNA #501 stated Resident #123's blanket was moved and did not cover the pelvic area. STNA #501 also stated she informed RN #508 of the incident, after escorting Resident #13 out of Resident #123's room. STNA #501 said she wrote a witness statement, however she had been interviewed by the DON before writing the statement. STNA #501 said the facility staff were trained at least yearly regarding abuse, however she had not received training specifically regarding what to do with residents with sexually inappropriate behaviors. STNA #501 stated Resident #13 was constantly touching his genitals. STNA #501 said there was no information in the kiosks, where the STNA staff find information on residents and resident tasks, directing staff to watch or monitor Resident #13 for any sexually oriented behaviors. STNA #501 said since she knew his history, she did watch Resident #13 more closely. Interview with the DON on [DATE] at 3:30 P.M. revealed the DON completed the facility investigation of the [DATE] incident. The DON confirmed a staff member witnessed Resident #13 touching Resident #123 inappropriately and went for help. The DON confirmed Resident #13 was no longer touching the resident when a second staff person, STNA #501, arrived. The DON also confirmed the SRI documented sexual abuse was unsubstantiated, but the DON was unable to remember why it was unsubstantiated. The DON confirmed the investigation did not include evidence Resident #123 was assessed for evidence of a sexual assault, was not sent to the hospital for evaluation and there was no evidence Resident #123's family or physician were notified of the incident. The DON confirmed the facility investigation lacked evidence that interviews were conducted with any other staff working at the time of the incident and there was insufficient evidence any facility residents in the area were interviewed as potential witnesses to this incident or had possibly experienced a similar incident. In addition, the investigation did not include a statement from Resident #13. The DON confirmed four facility residents were asked a general question about any concerns in the facility. The DON confirmed a thorough investigation was not completed. During a follow up interview on [DATE] at 7:30 A.M. the DON asked if an addendum could be added to the SRI. She said after review of the information again she said the allegation of sexual abuse involving Resident #13 and Resident #123 should have been substantiated. Review of Resident #123's closed medical record revealed Resident #123 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS, dated [DATE], revealed Resident #123 had severe cognitive impairment and required extensive assist of two staff for bed mobility, transfers, toileting, and personal hygiene. Review of an admission health status progress note, dated [DATE] at 3:00 P.M. by RN #508 revealed the resident was alert to self with confusion. There were no nursing progress notes documented between [DATE] and [DATE], the time of the sexual abuse. Resident #123 expired in the facility on [DATE]. Telephone interview with CNP #506 on [DATE] at 3:52 P.M. revealed she was not made aware of the incident of sexual abuse between Resident #13 and Resident #123. CNP #506 indicated she saw Resident #13 the day after the incident on [DATE]. CNP #506 indicated information for visits was gathered from the computer documentation system and stated at the time of her visit, no documentation regarding sexual abuse or sexually inappropriate behavior was noted. Review of a facility SRI revealed on [DATE] an incident of sexual abuse occurred between Resident #13 and another female resident, Resident #12. Review of Resident #12's medical record revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #12's quarterly MDS assessment, dated [DATE], revealed the resident was assessed to be severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of three. The assessment revealed the resident required an extensive assist of two persons for bed mobility and transfers and required extensive assist of one person for dressing, toilet use and personal hygiene. Review of Resident #12's plan of care dated [DATE] revealed the resident was at risk for injury related to several issues including dementia, impaired safety awareness, and impaired decision-making ability. Review of a facility SRI, tracking number 3, dated [DATE] revealed Resident #12 had wandered into the doorway of Resident #13's room in her wheelchair. STNA #504 walked by the room and noted Resident #12 was sitting in the doorway. When STNA #504 went to remove Resident #12 from the doorway, Resident #13 was observed with his arm down Resident #12's blouse, up to his elbow. Resident #12 was removed from the location and Resident #13 was informed his behavior was inappropriate. The conclusion of the SRI revealed staff had been on high alert for female residents being around or in Resident #13's room and were to monitor what Resident #13 was doing at all times when he was out of his room. The SRI indicated Resident #13's son was notified, and the family was asked to address the behaviors with Resident #13. The DON spoke with Resident #13 and he did not recall the incident. A consult was made to psychological services. The facility substantiated an incident of sexual abuse with Resident #13 being the perpetrator. Review of Resident #13's medical record revealed no evidence of how or when the family addressed the behaviors with Resident #13. Review of the facility investigation for this incident revealed a written statement by STNA #504 dated [DATE] and signed on [DATE]. The statement verified the above information contained in the SRI. Interview with STNA #504 on [DATE] at 2:30 P.M. revealed on [DATE] between 3:00 P.M. and 4:00 P.M., she saw what she thought was another resident standing in the doorway over an unidentified resident. STNA #504 stated she then discovered Resident #12 in Resident #13's doorway. Resident #12 was in her wheelchair facing the inside of the room with her back to the hallway. Resident #13 was standing over the resident with his hand down the front of her blouse. STNA #504 stated she discovered Resident #13 with his hand all the way down her blouse to his elbow. STNA #504 described the incident in detail including Resident #13's hand and arm moving in an up and down motion under the blouse from the top of the chest to Resident #12's abdomen. STNA #504 stated she told Resident #13 to stop and he huffed at her and pulled his hand from the resident's blouse. STNA #504 described the huff as being upset because he was caught. STNA #504 stated she called for help, removed Resident #12 from Resident #13's room and told her supervisor what had happened. STNA #504 stated she was told to write a statement and give it to her supervisor. STNA #504 stated once she wrote the statement, that was the last she knew about the incident. STNA #504 stated she was not interviewed by the DON or her supervisor on what she had witnessed. STNA #504 said Resident #13 usually targeted residents who were more confused and could not call out for help or tell the resident no. STNA #504 stated she was not in-serviced on how to deal with Resident #13's inappropriate sexual behaviors. STNA #504 stated there was no information on the Kardex (a medical information system to communicate information about a resident) and she was not informed by nursing staff as to what types of behaviors to monitor for or report to the nurse. Review of Resident #12's nurse's notes dated [DATE] to [DATE] revealed no documented evidence the incident of sexual abuse/ inappropriate touch had taken place between Resident #13 and Resident #12. Resident #12's medical record contained no documented evidence she was assessed and evaluated for any type of injury. Review of Resident #13's medical record, following this incident revealed no nursing progress notes regarding the [DATE] incident with Resident #12. Resident #13's medical record revealed a Mini Mental Status Exam completed on [DATE] with a score of ,[DATE] which indicated mild cognitive impairment. Review of a psychiatry progress note, and evaluation completed on [DATE] revealed staff reported Resident #13 had a history of [REDACTED]. The evaluation documented that more recently, at the end of (MONTH) (YEAR), Resident #13 was sexually aggressive towards a confused female patient and had been grabbling at her genitals and breasts. Resident #13 was placed on the anti-depressant medication [MEDICATION NAME] five milligrams (mg) every morning. Resident #13's care plan was updated to include the intervention of the psychiatry referral; however, it was not updated to include the sexual abuse incident from [DATE]. Phone interview with CNP #506 on [DATE] at 3:52 P.M. revealed she was not made aware of the incident of sexual abuse between Resident #12 and Resident #13. CNP #506 revealed she saw Resident #12 on [DATE] and was not informed of the incident on [DATE] prior to the visit. CNP #506 also stated she gathered information from the computer charting and there was no information documented regarding the incident. Interview on [DATE] at 7:15 A.M with LPN #505, the charge nurse on Resident #12's unit revealed she had heard through the rumor mill about an incident between Resident #13 and Resident #12. LPN #505 stated prior to the incident she had observed Resident #13 wandering in the halls and in the dining room. LPN #505 stated she was not told by the DON of any incidents between Resident #12 and Resident #13. LPN #505 verified neither Resident #12 or Resident #13's care plan had been changed to include increased monitoring. Interview with STNA #510 on [DATE] at 3:09 P.M. revealed there had been no training on how to deal with residents who had sexually inappropriate behaviors. STNA #510 stated Resident #13 needed to be observed more closely as he was ornery with women. STNA #510 stated she was made aware of this from another nurse and STNA involved in a prior incident. On [DATE] at 4:24 P.M., interview with the DON and the Administrator verified the above two documented incidents of sexual abuse involving Resident #13. The administrative staff verified there was no evidence the facility had developed and implemented a comprehensive and individualized behavior management plan to prevent Resident #13 from sexually abusing female residents in the facility. Interview with Medical Director (MD) #535 who was Resident #12, Resident #13, and Resident #123's primary care physician, on [DATE] at 8:37 A.M. revealed the facility had not notified him of any sexual abuse allegations or incidents in the facility, including the incidents involving Resident #13 on [DATE] and [DATE]. MD #535 also indicated sexual abuse had not been previously discussed during any of the facility quality assurance meetings held in (YEAR). Record review revealed one-to-one supervision was initiated for Resident #13 on [DATE] at 4:00 P.M. A memo for staff indicated the one-to-one supervision would be direct supervision 24 hours a day, seven days per week until further notice. It included training to ensure staff documented who was completing the one-to-one and indicated no agency staff could do the monitoring. On [DATE], Resident #13 was evaluated by Psychiatric CNP, PCNP #610 who documented Resident #13 had a history of [REDACTED]. PCNP #610 further documented the medication would take four to six weeks to determine effectiveness. On [DATE] at 12:00 P.M. Resident #13 was observed in the dining room sitting at a table with Resident #15 (a female resident identified as being cognitively impaired) and two other residents. The closest staff member to Resident #13 was Resident Assistant, (RA) #520 who was sitting approximately twenty feet away from Resident #13. Interview with RA #520 on [DATE] at 12:18 P.M. revealed she was informed by the DON that she could sit far away from Resident #13 if she could monitor him. When RA #520 was questioned if she could redirect behaviors from twenty feet away and prevent inappropriate touching, RA #520 moved to Resident #13's left side. Review of Resident #13's medical record and behavior monitoring revealed on [DATE] at 10:59 A.M. Resident #13, while walking down the hall, unintentionally brushed his right hand against LPN #513's buttocks. Beginning on [DATE], a plan for Resident #13's seating arrangements at meals and activities would be changed so that Resident #13 sat with only male residents. If the event was unavoidable, a staff member would be seated within reach of Resident #13 to prevent any physical touching of female residents. During a follow up interview with the DON on [DATE] at 11:17 A.M. the DON revealed one-to-one supervision could only be sustained for Resident #13 for approximately six months. In lieu of one-to-one supervision, the DON indicated there were no other behavioral interventions or an individualized and comprehensive behavior management plan to prevent Resident #13 from sexually abusing other residents as of this time. Prior to the one-to-one supervision, Resident #13 had been started on the anti-depressant medication [MEDICATION NAME] (originally started on [DATE] and increased on [DATE]). Review of the medication usage with the DON and review of the MedScapes website indicated the side effect of [MEDICATION NAME] included a libido decrease of three to seven percent. [MEDICATION NAME] did not have an off-label usage for sexual libido decrease. The DON revealed on [DATE] she began a 30-day discharge process for Resident #13. No notice had been issued as of this time. On [DATE] a physician order [REDACTED]. Interview with CNP #611 on [DATE] at 7:26 A.M. revealed she had assessed and spoken to Resident #13 on this date. During the interview, the CNP indicated Resident #13 acknowledged he had been sexually inappropriate with female residents (specific names of residents and dates not provided) which she indicated constituted rape and that he appeared to be remorseful. The CNP had concerns with what the facility should or could do regarding Resident #13's sexually inappropriate behaviors. CNP #611 confirmed adding the medication [MEDICATION NAME] ([MEDICATION NAME]) on [DATE], however stated the medication would take approximately three weeks to be noticeably effective. CNP #611 did confirm knowledge of Resident #13's history of sexually inappropriate behaviors and stated she had previously discussed interventions to be used with staff including telling Resident #13 when masturbating to conduct the act in the privacy of his room and to ask Resident #13 not to touch his penis in the shower. CNP #611 indicated she was unsure if these interventions had been or were being implemented by staff. During the interview the CNP indicated an interdisciplinary team approach with on-going monitoring, including the implementation of on-going psychological services and medication monitoring would be implemented to ensure Resident #13's sexually inappropriate behaviors were managed and to ensure the safety of the other facility residents. On [DATE] at 8:20 A.M. interview with the DON and Administrator revealed the administrative and nursing staff were actively working with Resident #13's physician and nurse practitioners to develop a long-term plan to address Resident #13's sexually inappropriate behaviors and that one-to-one supervision would be provided while evaluating the effectiveness of the new medications ([MEDICATION NAME] and [MEDICATION NAME]) that had been ordered. The DON indicated the need for one-to-one supervision would be re-evaluated as needed and indicated as part of the corrective action, all staff, not only nursing staff, were trained to identify sexually inappropriate behaviors and signs of sexual abuse. The Administrator also indicated the facility was actively evaluating whether Resident #13's needs could be met in this facility or if placement in a different facility would be needed to better meet the resident's needs. Review of facility policy titled, Abuse, Misappropriation Policy and Procedures updated (MONTH) (YEAR), defined sexual abuse as including but not limited to sexual harassment, sexual coercion or sexual assault. Non-consensual sexual contact of any type with a resident was also defined as sexual abuse. The policy stated investigations would include, but were not limited to, interviews of the resident, resident's roommate, interview of staff currently working and those that had worked previously; working backwards until no further information could be obtained or the cause had been revealed. The policy also stated other entities would be notified depending on the situation including local law enforcement. The policy did not address the notification of resident's responsible parties.

Based on record review, review of facility Self-Reported Incidents (SRIs), associated investigations and the facility abuse policy and procedure, interviews with staff, Medical Director #535, Certified Nurse Practitioner (CNP) #506 and #611 the facility failed to effectively implement their abuse policy and procedure to ensure Resident #12 and Resident #123, assessed as cognitively impaired, were free from sexual abuse by Resident #13. The facility also failed to ensure the incidents of sexual abuse were thoroughly investigated. This resulted in Immediate Jeopardy and the potential for serious harm on [DATE] at 6:30 A.M. when Resident #13 was observed in Resident #123's room with his hands inside Resident #123's underwear. The Immediate Jeopardy remained ongoing, on [DATE] at 8:15 P.M. when Resident #13 was observed with his arm/hand down the front of Resident #12's blouse. There was no evidence, following either incident, the facility immediately assessed Resident #123 or Resident #12 and no evidence the facility implemented interventions to prevent further incidents of sexual abuse by Resident #13. In addition, the facility failed to effectively implement their Abuse policy and procedure to ensure incidents of verbal/emotional abuse involving Residents #29, #320 and #321 identified during review of the SRIs dated [DATE], [DATE] and [DATE] were thoroughly investigated. . This affected two residents for sexual abuse (Residents #12 and #123) and three residents for verbal abuse (Resident #29, #320 and #321.). The facility identified 21 additional cognitively impaired female residents (Residents #1, #4, #8, #9, #15, #19, #22, #26, #28, #32, #33, #34, #37, #38, #41, #45, #46, #50, #56, #59 and #60) as at risk for sexual abuse due to a lack of investigation. The facility census was 70. On [DATE] at 4:24 P.M. the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] when Resident #13 was observed with his hands inside Resident #123's underwear making sexual motions. The Immediate Jeopardy continued on [DATE] when Resident #13 was observed with his arm down the front of Resident #12's blouse. The facility failed to thoroughly investigate either incident of sexual abuse and failed to timely develop and implement an individualized plan for Resident #13 to address sexually inappropriate behaviors and prevent additional incidents of sexual abuse. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE], the DON initiated education for all staff members on sexual abuse, safety of residents during a potentially abusive situation, resident rights, how to report suspected abuse and who to report it to. The training was overseen by the Administrator. As of [DATE] at 8:40 A.M., 174 of 179 staff members were in-serviced. The five staff members who had not received the education were on leave and a plan for these employees to receive the education prior to returning to work was in place. · On [DATE], the facility implemented a plan for behavior monitoring to be completed each shift per the charge nurse for Resident #13. The charge nurse would audit for verbal or physical sexual advances, initiate interventions including redirection to supervised activities or to his room, one on one supervision or medication administration to deter or stop behavior and determine the effectiveness. This would remain ongoing until Resident #13 had a significant change in condition which the facility had defined as a functional decline related to [MEDICAL CONDITION]. This will be overseen by the Quality Assurance (QA) committee quarterly. · On [DATE] Resident #13's plan of care was updated to reflect the addition of [MEDICATION NAME] for sexually inappropriate behaviors and to reflect his past incidents of sexual abuse with female the residents. · On [DATE] the facility Abuse policy and procedure was updated to include definitions of potential sources of abuse including resident to resident, staff to resident, family member to resident, and visitor to resident. · On [DATE] a physician's orders [REDACTED].#13's behaviors, including sexual behaviors. Behavior task monitoring was scheduled for once a shift and identified behaviors including walking slowly down the corridors, looking into other resident's rooms, lingering around female residents, and attempts at being sexually inappropriate. This monitoring documentation was to be completed through the Point of Care system (PCC) electronic medical record by the nurse assigned to care for the resident on the Medication Administration Record [REDACTED]. · On [DATE] at 4:00 P.M., one-to-one monitoring of Resident #13 assigned/scheduled direct care staff was initiated. The one-to-one included that Resident #13 was to have direct supervision 24- hours a day, seven days a week until further notice. A log sheet was implemented for staff to document when there was a change and what staff member was completing the one-to-one. Staff documented to have completed the one on one from [DATE] through [DATE] included STNA staff, the activity director and resident assistants (non-State tested care staff). · On [DATE] the facility-initiated auditing by the Interdisciplinary Team (IDT) to identify patterns or changes in behaviors of Resident #13. A plan for any identified patterns or behaviors would be addressed according to the findings. The facility Minimum Data Set 3.0 (MDS) nurses would update the plan of care accordingly and Unit Managers would be responsible for providing education to staff as changes are made. This audit was planned to remain in place until Resident #13 sustained a significant change and the threat to other residents was no longer valid. All oversight would be done by the Quality Assurance (QA) committee quarterly. · On [DATE] the facility adapted a new format to streamline investigations for more thorough, consistent investigations for each allegation of abuse. The new investigation policy now included step by step procedures the investigation should take, including a potential of witnesses, general questions to ask for residents and witnesses, documents checklist, investigation log, and investigation summary form. All 14 Registered Nurses and 11 Licensed Practical Nurses were educated on the new policy/ procedure and paperwork by [DATE] by the DON or her designee. Oversight for ongoing training needs would be completed annually for skills training and as needed. All new employees would receive education on completing investigations by the DON or her designee upon hire. · On [DATE], Resident #13 was evaluated by Psychiatric Certified Nurse Practitioner (PCNP) #610 who documented Resident #13 had a history of [REDACTED]. PCNP #610 further documented the medication would take four to six weeks to determine effectiveness. · Beginning on [DATE], Resident #13's seating arrangements at meals and activities would be changed so that Resident #13 sat with only male residents. If the event was unavoidable, a staff member would be seated within reach of Resident #13 to prevent any physical touching of female residents. This was to be overseen by the DON or designee. · On [DATE] Resident #13 was started on the [MEDICATION NAME] medication, [MEDICATION NAME] ([MEDICATION NAME]) as a medication used to decrease libido. · On [DATE] RN #544, RN #503 and RN #523 conducted observations of all residents with a Brief Interview for Mental Status score of 7 or less (indicative of cognitive impairment) including the 22 cognitively impaired female residents (Resident #1, #4, #8, #9, #12, #15, #19, #22, #26, #28, #32, #33, #34, #37, #38, #41, #45, #46, #50, #56, #59 and #60) for physical signs/symptoms of sexual abuse with no negative findings identified. · On [DATE] Assistant Director of Nursing (ADON) #519 conducted an audit of MDS data entries to determine if any facility residents had exhibited sexually inappropriate behavior in the past 30 days. Resident #13 was the only identified resident. · From [DATE] through [DATE] staff interviews completed with the following employees revealed they had received sexual abuse training and were aware of what to look for regarding resident to resident behaviors, how to complete thorough investigations, and Resident #13's specific behaviors: LPNs #505 and #513, RNs #514, #515 and #523, Dietary Aide (DA) #516 and #526 State tested Nursing Assistants (STNAs) #507, #517, #518, #511 #524, #528, #530 and #542, Resident Assistant (RA) #520, Activities Director (AD) #521, Activities Assistant (AA) #522, Housekeepers (HSKP) #525, #527 and #532, Social Service (SS) #529, Therapy Manager (TM) #531 and Laundry Aide (LA) #533,. Although the Immediate Jeopardy was removed on [DATE] the facility remains out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: 1. Record review revealed Resident #13 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed a plan of care, dated [DATE] which indicated Resident #13 had a history of [REDACTED]. The care plan was updated on [DATE] to reflect an incident in which Resident #13 tried to put the hand of a female resident down his pants. Interventions included to analyze key times, staff members, places, circumstances, triggers, and what would de-escalate the behavior and document, assess and anticipate Resident #13's needs. The care plan indicated to complete a review of Resident #13's behaviors quarterly, inform Resident #13 his behaviors and/or comments were inappropriate and to stop. If the behaviors continued to make sure resident #13 was safe and to leave and return later with additional help. Additional interventions included to monitor Resident #13's interactions daily, and to notify the CNP or Physician of Resident #13's behaviors and ask them to reassess medications if behaviors persist. Record review revealed no documentation of a quarterly review of Resident #13's behaviors had been completed in (YEAR). Review of a facility self-reported incident (SRI), tracking number 3, dated [DATE] revealed on [DATE] at 8:30 A.M. Laundry Supervisor (LS) #500 entered the room of female Resident #123 and saw Resident #13 at Resident #123's bedside. The SRI documented Resident #123's blanket was pulled down and Resident #13 had his hands close to the pelvic region of Resident #123. The SRI stated staff immediately intervened and removed Resident #13 from the room. The SRI documented the facility concluded the allegation of sexual abuse was unsubstantiated. Review of the facility incident investigation revealed a handwritten statement by LS #500 which stated on [DATE] around 8:30 A.M. LS #500 entered the room of Resident #123 and observed Resident #13 at the bedside of Resident #123. LS #500's written statement indicated Resident #123's blanket was removed, and Resident #13 had his hands between Resident #123's legs. LS #500 documented she left the room and told STNA #501 who immediately entered the room and removed Resident #13 from the room. Review of Resident #123's medical record revealed a lack of documentation including progress notes, assessments, or notification of the physician or family regarding the incident with Resident #13 on [DATE]. Review of Resident #13's medical record revealed a nursing progress note dated [DATE] at 12:59 P.M. written by RN #519 which indicated Resident #13 was spoken to regarding the inappropriateness of visiting female residents in their room unaccompanied. RN #519 further documented Resident #13 appeared uncomfortable, however stated understanding. RN #519 also documented the family was notified of the conversation as well. However, Resident #13's medical record contained no new assessments or behavioral referrals and the plan of care was not updated regarding the [DATE] incident or any new interventions to prevent further incidents of sexual abuse. Review of a facility incident report dated [DATE] at 7:45 A.M. and completed by RN #508 revealed STNA #501 had reported Resident #13 was observed in Resident #123's room with his hands in the vicinity of Resident #123's groin. The incident report did not include any documentation that a physical assessment of Resident #123 was completed. There was no documentation that Resident #123's responsible party or physician were notified of the incident or that any new interventions were implemented for Resident #13 at this time. Interview with LS #500 on [DATE] at 9:08 A.M. revealed on [DATE] at approximately 6:30 A.M. she was delivering laundry to residents' rooms. LS #500 reported she had initially seen Resident #13 go into Resident #123's room however she was not concerned. LS #500 then went into Resident #123's room to hang up clothing and heard a mumbling sound and turned around and saw Resident #13 with both hands, up to the wrist, under Resident #123's underwear making an up and down motion. LS #500 further stated she called out Resident #13's name and he jerked his hands back to where his hands were still under Resident #123's underwear. LS #500 said she ran into the hall and yelled for assistance. STNA #501 came to the room and told Resident #13 to stop and escorted Resident #13 from the room. LS #500 reported she had to write a statement regarding what she had observed but was told by the DON not to discuss the incident with anyone and it would be taken care of. LS #500 reported having been trained on abuse within the past month, however she said she was not trained on what to do in situations regarding resident to resident sexual abuse. LS #500 also repeatedly stated as a non-nursing employee, she had been told not to have physical contact with residents and to get assistance (from nursing staff) for any situations regarding residents. On [DATE] at 9:46 A.M. interview with STNA #501 revealed on [DATE] LS #500 had come into the hall asking for assistance. Upon entering the room of Resident #123, STNA #501 saw Resident #13 with his hands hovering approximately three to four inches above Resident #123's vaginal area. STNA #501 stated Resident #123's blanket was moved and did not cover the pelvic area. STNA #501 also stated she informed RN #508 of the incident, after escorting Resident #13 out of Resident #123's room. STNA #501 said she wrote a witness statement, however she had been interviewed by the DON before writing the statement. STNA #501 said the facility staff were trained at least yearly regarding abuse, however she had not received training specifically regarding what to do with residents with sexually inappropriate behaviors. STNA #501 stated Resident #13 was constantly touching his genitals. STNA #501 said there was no information in the kiosks, where the STNA staff find information on residents and resident task, directing staff to watch or monitor Resident #13 for any sexually oriented behaviors. STNA #501 said since she knew his history, she did watch Resident #13 more closely. Interview with the DON on [DATE] at 3:30 P.M. revealed the DON completed the facility investigation of the [DATE] incident. The DON confirmed a staff member witnessed Resident #13 touching Resident #123 inappropriately and went for help. The DON confirmed Resident #13 was no longer touching the resident when a second staff person, STNA #501, arrived. The DON also confirmed the SRI documented sexual abuse was unsubstantiated, but the DON was unable to remember why it was unsubstantiated. The DON confirmed the investigation did not include evidence Resident #123 was assessed for evidence of a sexual assault, was not sent to the hospital for evaluation and there was no evidence Resident #123's family or physician were notified of the incident. The DON confirmed the facility investigation lacked evidence that interviews were conducted with any other staff working at the time of the incident and there was insufficient evidence any facility residents in the area were interviewed as potential witnesses to this incident or who possibly experienced a similar incident. In addition, the investigation did not include a statement from Resident #13. The DON confirmed four facility residents were asked a general question about any concerns in the facility. The DON confirmed a thorough investigation was not completed. During a follow up interview on [DATE] at 7:30 A.M. the DON asked if an addendum could be added to the SRI. She said after review of the information again she said the allegation of sexual abuse involving Resident #13 and Resident #123 should have been substantiated. Review of Resident #123's closed medical record revealed Resident #123 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS, dated [DATE], revealed Resident #123 had severe cognitive impairment and required extensive assist of two staff for bed mobility, transfers, toileting, and personal hygiene. Review of an admission health status progress note, dated [DATE] at 3:00 P.M. by RN #508 revealed the resident was alert to self with confusion. There were no nursing progress notes documented between [DATE] and [DATE], the time of the sexual abuse. Resident #123 expired in the facility on [DATE]. Review of a facility SRI revealed on [DATE] an incident of sexual abuse occurred between Resident #13 and another female resident, Resident #12. Review of Resident #12's medical record revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #12's quarterly MDS assessment, dated [DATE], revealed the resident was assessed to be severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of three. The assessment revealed the resident required an extensive assist of two persons for bed mobility and transfers and required extensive assist of one person for dressing, toilet use and personal hygiene. Review of Resident #12's plan of care dated [DATE] revealed the resident was at risk for injury related to several issues including dementia, impaired safety awareness, and impaired decision-making ability. Review of a facility SRI, tracking number 3, dated [DATE] revealed Resident #12 had wandered into the doorway of Resident #13's room in her wheelchair. STNA #504 walked by the room and noted Resident #12 was sitting in the doorway. When STNA #504 went to remove Resident #12 from the doorway, Resident #13 was observed with his arm down Resident #12's blouse, up to his elbow. Resident #12 was removed from the location and Resident #13 was informed his behavior was inappropriate. The conclusion of the SRI revealed staff had been on high alert for female residents being around or in Resident #13's room and were to monitor what Resident #13 was doing at all times when he was out of his room. The SRI indicated Resident #13's son was notified, and the family was asked to address the behaviors with Resident #13. The DON spoke with Resident #13 and he did not recall the incident. A consult was made to psychological services. The facility substantiated an incident of sexual abuse with Resident #13 being the perpetrator. Review of Resident #13's medical record revealed no evidence of how or when the family addressed the behaviors with Resident #13. Review of the facility investigation for this incident revealed a written statement by STNA #504 dated [DATE] and signed on [DATE]. The statement verified the above information contained in the SRI. Interview with STNA #504 on [DATE] at 2:30 P.M. revealed on [DATE] between 3:00 P.M. and 4:00 P.M., she saw what she thought was another resident standing in the doorway over an unidentified resident. STNA #504 stated she then discovered Resident #12 in Resident #13's doorway. Resident #12 was in her wheelchair facing the inside of the room with her back to the hallway. Resident #13 was standing over the resident with his hand down the front of her blouse. STNA #504 stated she discovered Resident #13 with his hand all the way down her blouse to his elbow. STNA #504 described the incident in detail including Resident #13's hand and arm moving in an up and down motion under the blouse from the top of the chest to Resident #12's abdomen. STNA #504 stated she told Resident #13 to stop and he huffed at her and pulled his hand from the resident's blouse. STNA #504 stated she called for help, removed Resident #12 from Resident #13's room and told her supervisor what had happened. STNA #504 stated she was told to write a statement and give it to her supervisor. STNA #504 stated once she wrote the statement, that was the last she knew about the incident. STNA #504 stated she was not interviewed by the DON or her supervisor on what she had witnessed. STNA #504 stated she was not in-serviced on how to deal with Resident #13's inappropriate sexual behaviors. STNA #504 stated there was no information on the Kardex (a medical information system to communicate information about a resident) and she was not informed by nursing staff as to what types of behaviors to monitor for or report to the nurse. Review of Resident #12's nurse's notes dated [DATE] to [DATE] revealed no documented evidence the incident of sexual abuse/ inappropriate touch had taken place between Resident #13 and Resident #12. Resident #12's medical record contained no documented evidence she was assessed and evaluated for any type of injury. Review of Resident #13's medical record, following this incident revealed no nursing progress notes regarding the [DATE] incident with Resident #12. Resident #13's medical record revealed a Mini Mental Status Exam completed on [DATE] with a score of ,[DATE] which indicated mild cognitive impairment. Review of a psychiatry progress note, and evaluation completed on [DATE] revealed staff reported Resident #13 had a history of [REDACTED]. The evaluation documented that more recently, at the end of (MONTH) (YEAR), Resident #13 was sexually aggressive towards a confused female patient and had been grabbling at her genitals and breasts. Resident #13 was placed on the anti-depressant medication [MEDICATION NAME] five milligrams (mg) every morning. Resident #13's care plan was updated to include the intervention of the psychiatry referral; however, it was not updated to include the sexual abuse incident from [DATE]. Phone interview with CNP #506 on [DATE] at 3:52 P.M. revealed she was not made aware of the incident of sexual abuse between Resident #12 and Resident #13. CNP #506 revealed she saw Resident #12 on [DATE] and was not informed of the incident on [DATE] prior to the visit. CNP #506 also stated she gathered information from the computer charting and there was no information documented regarding the incident. Interview on [DATE] at 7:15 A.M with LPN #505, the charge nurse on Resident #12's unit revealed she had heard through the rumor mill about an incident between Resident #13 and Resident #12. LPN #505 stated prior to the incident she had observed Resident #13 wandering in the halls and in the dining room. LPN #505 stated she was not told by the DON of any incidents between Resident #12 and Resident #13. LPN #505 verified neither Resident #12 or Resident #13's care plan had been changed to include increased monitoring. Interview with STNA #510 on [DATE] at 3:09 P.M. revealed there had been no training on how to deal with residents who had sexually inappropriate behaviors. STNA #510 stated Resident #13 needed to be observed more closely as he was ornery with women. STNA #510 stated she was made aware of this from another nurse and STNA involved in a prior incident. On [DATE] at 4:24 P.M., interview with the DON and the Administrator verified the above two documented incidents of sexual abuse involving Resident #13. The administrative staff verified there was no evidence the facility had developed and implemented a comprehensive and individualized behavior management plan to prevent Resident #13 from sexually abusing female residents in the facility. Interview with Medical Director (MD) #535 who was Resident #12, Resident #13, and Resident #123's primary care physician, on [DATE] at 8:37 A.M. revealed the facility had not notified him of any sexual abuse allegations or incidents in the facility, including the incidents involving Resident #13 on [DATE] and [DATE]. MD #535 also indicated sexual abuse had not been previously discussed during any of the facility quality assurance meetings held in (YEAR). Interview with CNP #611 on [DATE] at 7:26 A.M. revealed she had assessed and spoken to Resident #13 on this date. During the interview, the CNP indicated Resident #13 acknowledged he had been sexually inappropriate with female residents (specific names of residents and dates not provided) which she indicated constituted rape and that he appeared to be remorseful. The CNP had concerns with what the facility should or could do regarding Resident #13's sexually inappropriate behaviors. CNP #611 confirmed adding the medication [MEDICATION NAME] ([MEDICATION NAME]) on [DATE], however stated the medication would take approximately three weeks to be noticeably effective. CNP #611 did confirm knowledge of Resident #13's history of sexually inappropriate behaviors and stated she had previously discussed interventions to be used with staff including telling Resident #13 when masturbating to conduct the act in the privacy of his room and to ask Resident #13 not to touch his penis in the shower. CNP #611 indicated she was unsure if these interventions had been or were being implemented by staff. During the interview the CNP indicated an interdisciplinary team approach with on-going monitoring, including the implementation of on-going psychological services and medication monitoring would be implemented to ensure Resident #13's sexually inappropriate behaviors were managed and to ensure the safety of the other facility residents. On [DATE] at 8:20 A.M. interview with the DON and Administrator revealed the administrative and nursing staff were actively working with Resident #13's physician and nurse practitioners to develop a long-term plan to address Resident #13's sexually inappropriate behaviors and that one-to-one supervision would be provided while evaluating the effectiveness of the new medications ([MEDICATION NAME] and [MEDICATION NAME]) that had been ordered. The DON indicated the need for one-to-one supervision would be re-evaluated as needed and indicated as part of the corrective action, all staff, not only nursing staff, were trained to identify sexually inappropriate behaviors and signs of sexual abuse. The Administrator also indicated the facility was actively evaluating whether Resident #13's needs could be met in this facility or if placement in a different facility would be needed to better meet the resident's needs. Review of facility policy titled, Abuse, Misappropriation Policy and Procedures updated (MONTH) (YEAR), defined sexual abuse as including but not limited to sexual harassment, sexual coercion or sexual assault. Non-consensual sexual contact of any type with a resident was also defined as sexual abuse. The policy stated investigations would include, but were not limited to, interviews of the resident, resident's roommate, interview of staff currently working and those that had worked previously; working backwards until no further information could be obtained or the cause had been revealed. The policy also stated other entities would be notified depending on the situation including local law enforcement. The policy did not address the notification of resident's responsible parties. 2. Review of a facility SRI, tracking number 3 dated [DATE] revealed Resident #320 alleged a facility STNA did not take her to the restroom as requested, instead informed Resident #320 she had already been there. The facility concluded an allegation of verbal/emotional abuse was unsubstantiated. Review of the investigation of the allegation revealed the facility completed an interview with Resident #320, interviewed the STNA involved, received a written statement from the STNA involved and three other staff members, and reviewed the call light log from the 11 - 7 shift on [DATE]. The conclusion of the facility investigation was to do staff education with the STNA involved regarding urinary frequency in the geriatric population and the types of signs and symptoms to report to the nurse. Further review into the facility investigation revealed the facility did not interview any other residents regarding care received or treatment from staff during the investigation. Interview with the DON on [DATE] at 3:30 P.M. confirmed the facility investigation lacked thorough interviews with staff working at the time of the incident and no additional facility residents in the area were interviewed as potential witnesses to this incident or possibly experienced a similar incident. The DON confirmed the lack of evidence did not support a thorough investigation was completed. Review of facility policy titled, Abuse, Misappropriation Policy and Procedures updated (MONTH) (YEAR), defined verbal/emotional abuse as oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families. The policy stated investigations would include, but were not limited to, interviews of the resident, resident's roommate, interview of staff currently working and those that had worked previous working backwards until no further information could be obtained or the cause had been revealed. The policy also stated other entities would be notified depending on the situation including local law enforcement. 3. Review of facility SRI, tracking number 9 dated [DATE] revealed Resident #29 alleged a facility STNA had called her a name. The facility concluded an allegation of verbal/emotional abuse was unsubstantiated. Review of the investigation into the allegation revealed the facility completed an interview with Resident #29, interviewed the STNA involved, and received written statements from two staff members whom Resident #29 had discussed her concerns with. Further review into the facility investigation revealed the facility did not interview any other residents regarding care received or treatment from staff during the investigation. Interview with the DON on [DATE] at 3:30 P.M. confirmed the facility investigation lacked thorough interviews with staff working at the time of the incident and no additional facility residents in the area were interviewed as potential witnesses to this incident or possibly experienced a similar incident. The DON confirmed the lack of evidence did not support a thorough investigation was completed. Review of facility policy titled, Abuse, Misappropriation Policy and Procedures updated (MONTH) (YEAR), defined verbal/emotional abuse as oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families. The policy stated investigations would include, but were not limited to, interviews of the resident, resident's roommate, interview of staff currently working and those that had worked previous working backwards until no further (TRUNCATED)

Based on record review, review of two facility Self-Reported Incidents (SRIs), associated investigations and the facility abuse policy and procedure, interviews with staff, Medical Director #535 and Certified Nurse Practitioner (CNP) #506 the facility failed to ensure incidents of sexual abuse, involving Resident #12 and Resident #123, assessed as cognitively impaired, were thoroughly investigated. This resulted in Immediate Jeopardy and the potential for serious harm on 05/06/18 at 6:30 A.M. when Resident #13 was observed in Resident #123's room with his hands inside Resident #123's underwear. The Immediate Jeopardy remained ongoing, on 11/27/18 at 8:15 P.M. when Resident #13 was observed with his arm/hand down the front of Resident #12's blouse. There was no evidence, following either incident, the facility conducted thorough investigations of the alleged sexual abuse. In addition, the facility failed to ensure incidents of verbal/emotional abuse involving Residents #29, #320 and #321 identified during review of the SRIs dated 06/01/18, 09/28/18 and 09/30/18 were thoroughly investigated. . This affected two residents for sexual abuse (Residents #12 and #123) and three residents for verbal abuse (Resident #29, #320 and #321.). The facility identified 21 additional cognitively impaired female residents (Residents #1, #4, #8, #9, #15, #19, #22, #26, #28, #32, #33, #34, #37, #38, #41, #45, #46, #50, #56, #59 and #60) as at risk for sexual abuse due to a lack of investigation. The facility census was 70. On 12/11/18 at 4:24 P.M. the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 05/06/18 when Resident #13 was observed with his hands inside Resident #123's underwear making sexual motions. The Immediate Jeopardy continued on 11/27/18 when Resident #13 was observed with his arm down the front of Resident #12's blouse. The facility failed to thoroughly investigate either incident of sexual abuse and failed to timely develop and implement an individualized plan for Resident #13 to address sexually inappropriate behaviors and to prevent additional incidents of sexual abuse. The Immediate Jeopardy was removed on 12/17/18 when the facility implemented the following corrective actions: · On 12/11/18, the DON initiated education for all staff members on sexual abuse, safety of residents during a potentially abusive situation, resident rights, how to report suspected abuse and who to report it to. The training was overseen by the Administrator. As of 12/14/18 at 8:40 A.M., 174 of 179 staff members were in-serviced. The five staff members who had not received the education were on leave and a plan for these employees to receive the education prior to returning to work was in place. · The facility Abuse policy and procedure was updated to include definitions of potential sources of abuse on 12/12/18, these include resident to resident, staff to resident, family member to resident, and visitor to resident. · On 12/13/18 the facility adapted a new format to streamline investigations for more thorough, consistent investigations for each allegation of abuse. The new investigation policy now included step by step procedures the investigation should take, including a potential of witnesses, general questions to ask for residents and witnesses, documents checklist, investigation log, and investigation summary form. All 14 Registered Nurses (RN) and 11 Licensed Practical Nurses (LPN) were educated on the new policy/ procedure and paperwork by 12/14/18 by the DON or her designee. Oversight for ongoing training needs would be completed annually for skills training and as needed. All new employees would receive education on completing investigations by the DON or her designee upon hire. · From 12/12/18 through 12/17/18 staff interviews completed with the following employees revealed they had received sexual abuse training and were aware of what to look for regarding resident to resident behaviors, how to complete thorough investigations, and Resident #13's specific behaviors: LPNs #505 and #513; RNs #514, #515 and #523; Dietary Aide (DA) #516 and #526; State tested Nursing Assistants (STNAs) #507, #517, #518, #511 #524, #528, #530 and #542; Resident Assistant (RA) #520; Activities Director (AD) #521; Activities Assistant (AA) #522; Housekeepers (HSKP) #525, #527 and #532; Social Service (SS) #529; Therapy Manager (TM) #531 and Laundry Aide (LA) #533,. Although the Immediate Jeopardy was removed on 12/17/18 the facility remains out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: 1. Review of a facility self-reported incident (SRI), tracking number 3, dated 05/06/18 revealed on 05/06/18 at 8:30 A.M. Laundry Supervisor (LS) #500 entered the room of female Resident #123 and saw Resident #13 at Resident #123's bedside. The SRI documented Resident #123's blanket was pulled down and Resident #13 had his hands close to the pelvic region of Resident #123. The SRI stated staff immediately intervened and removed Resident #13 from the room. The SRI documented the facility concluded the allegation of sexual abuse was unsubstantiated. Review of the facility incident investigation revealed a handwritten statement by LS #500 which stated on 05/06/18 around 8:30 A.M. LS #500 entered the room of Resident #123 and observed Resident #13 at the bedside of Resident #123. LS #500's written statement indicated Resident #123's blanket was removed, and Resident #13 had his hands between Resident #123's legs. LS #500 documented she left the room and told STNA #501 who immediately entered the room and removed Resident #13 from the room. Review of Resident #123's medical record revealed a lack of documentation including progress notes, assessments, or notification of the physician or family regarding the incident with Resident #13 on 05/06/18. Review of Resident #13's medical record revealed a nursing progress note dated 05/07/18 at 12:59 P.M. written by RN #519 which indicated Resident #13 was spoken to regarding the inappropriateness of visiting female residents in their room unaccompanied. RN #519 further documented Resident #13 appeared uncomfortable, however stated understanding. RN #519 also documented the family was notified of the conversation as well. Review of a facility incident report dated 05/06/18 at 7:45 A.M. and completed by Registered Nurse (RN) #508 revealed STNA #501 had reported Resident #13 was observed in Resident #123's room with his hands in the vicinity of Resident #123's groin. The incident report did not include any documentation that a physical assessment of Resident #123 was completed. There was no documentation that Resident #123's responsible party or physician were notified of the incident or that any new interventions were implemented for Resident #13. Interview with the DON on 12/10/18 at 3:30 P.M. revealed the DON completed the facility investigation of the 05/06/18 incident. The DON confirmed a staff member witnessed Resident #13 touching Resident #123 inappropriately and went for help. The DON confirmed Resident #13 was no longer touching the resident when a second staff person, STNA #501, arrived. The DON also confirmed the SRI documented sexual abuse was unsubstantiated, but the DON was unable to remember why it was unsubstantiated. The DON confirmed the investigation did not include evidence Resident #123 was assessed for evidence of a sexual assault, was not sent to the hospital for evaluation and there was no evidence Resident #123's family or physician were notified of the incident. The DON confirmed the facility investigation lacked evidence that interviews were conducted with any other staff working at the time of the incident and there was insufficient evidence any facility residents in the area were interviewed as potential witnesses to the incident or may have experienced a similar incident. In addition, the investigation did not include a statement from Resident #13. The DON confirmed four facility residents were asked a general question about any concerns in the facility. The DON confirmed a thorough investigation was not completed. During a follow up interview on 12/11/18 at 7:30 A.M. the DON asked if an addendum could be added to the SRI. She said after review of the information again she said the allegation of sexual abuse involving Resident #13 and Resident #123 should have been substantiated. Telephone interview with Certified Nurse Practitioner (CNP) #506 on 12/11/18 at 3:52 P.M. revealed she was not made aware of the incident of sexual abuse between Resident #13 and Resident #123. CNP #506 indicated she saw Resident #13 the day after the incident on 05/07/18. CNP #506 indicated information for visits was gathered from the computer documentation system and stated at the time of her visit, no documentation regarding sexual abuse or sexually inappropriate behavior was noted. On 11/28/18 review of a facility Self-Reported Incident revealed another incident of sexual abuse occurred between Resident #13 and another female resident, Resident #12. Review of a facility SRI, tracking number 3, dated 11/28/18 revealed Resident #12 had wandered into the doorway of Resident #13's room in her wheelchair. STNA #504 walked by the room and noted Resident #12 was sitting in the doorway. When STNA #504 went to remove Resident #12 from the doorway, Resident #13 was observed with his arm down Resident #12's blouse, up to his elbow. Resident #12 was removed from the location and Resident #13 was informed his behavior was inappropriate. The conclusion of the SRI revealed staff had been on high alert for female residents being around or in Resident #13's room and to were to monitor what Resident #13 was doing at all times when he was out of his room. The SRI indicated Resident #13's son was notified, and the family was asked to address the behaviors with Resident #13. The DON spoke with Resident #13 and he did not recall the incident. A consult was made to psychological services. The facility substantiated an incident of sexual abuse with Resident #13 being the perpetrator. Review of Resident #13's medical record revealed no evidence of how or when the family addressed the behaviors with Resident #13. Review of the facility investigation for this incident revealed a written statement by STNA #504 dated 11/27/18 and signed on 11/29/18. This statement verified the above information contained in the SRI. Phone interview with Certified Nurse Practitioner (CNP) #506 on 12/11/18 at 3:52 P.M. revealed she was not made aware of the incident of sexual abuse between Resident #12 and Resident #13. CNP #506 revealed she saw Resident #12 on 12/10/18 and was not informed of the incident on 11/26/18 prior to the visit. CNP #506 also stated she gathered information from the computer charting and there was no information documented regarding the incident. Interview with Medical Director (MD) #535 who was Resident #12, Resident #13, and Resident #123's primary care physician, on 12/13/18 at 8:37 A.M. revealed the facility had not notified him of any sexual abuse allegations or incidents in the facility, including the incidents involving Resident #13 on 05/06/18 and 11/27/18. MD #535 also indicated sexual abuse had not been previously discussed during any of the facility quality assurance meetings held in (YEAR). During a follow up interview with the DON on 12/16/18 at 11:17 A.M. the DON verified the concerns related to the lack of documentation regarding the SRIs completed involving Resident #13, lack of thorough investigation and lack of documentation of family and physician notification. Review of facility policy titled, Abuse, Misappropriation Policy and Procedures updated (MONTH) (YEAR), revealed investigations would include, but were not limited to, interviews of the resident, resident's roommate, interview of staff currently working and those that had worked previously; working backwards until no further information could be obtained or the cause had been revealed. The policy also stated other entities would be notified depending on the situation including local law enforcement. The policy did not address the notification of resident's responsible parties. 2. Review of a facility SRI, tracking number 3 dated 06/01/18 revealed Resident #320 alleged a facility STNA did not take her to the restroom as requested, instead informed Resident #320 she had already been there. The facility concluded an allegation of verbal/emotional abuse was unsubstantiated. Review of the investigation of the allegation revealed the facility completed an interview with Resident #320, interviewed the STNA involved, received a written statement from the STNA involved and three other staff members, and reviewed the call light log from the 11 - 7 shift on 05/31/18. The conclusion of the facility investigation was to do staff education with the STNA involved regarding urinary frequency in the geriatric population and the types of signs and symptoms to report to the nurse. Further review into the facility investigation revealed the facility did not interview any other residents regarding care received or treatment from staff during the investigation. Interview with the DON on 12/10/18 at 3:30 P.M. confirmed the facility investigation lacked thorough interviews with staff working at the time of the incident and no additional facility residents in the area were interviewed as potential witnesses to this incident or possibly experienced a similar incident. The DON confirmed the lack of evidence did not support a thorough investigation was completed. 3. Review of facility SRI, tracking number 9 dated 09/28/18 revealed Resident #29 alleged a facility STNA had called her a name. The facility concluded an allegation of verbal/emotional abuse was unsubstantiated. Review of the investigation into the allegation revealed the facility completed an interview with Resident #29, interviewed the STNA involved, and received written statements from two staff members whom Resident #29 had discussed her concerns with. Further review into the facility investigation revealed the facility did not interview any other residents regarding care received or treatment from staff during the investigation. Interview with the DON on 12/10/18 at 3:30 P.M. confirmed the facility investigation lacked thorough interviews with staff working at the time of the incident and no additional facility residents in the area were interviewed as potential witnesses to this incident or possibly experienced a similar incident. The DON confirmed the lack of evidence did not support a thorough investigation was completed. 4. Review of facility SRI, tracking number 0 dated 09/30/18 revealed Resident #321 alleged an STNA was gruff and rough during personal care. The facility concluded an allegation of verbal/emotional abuse was unsubstantiated. Review of the investigation into the allegation revealed the facility completed an interview with Resident #321 and her daughter, interviewed the STNA involved, and received a written statement from the STNA involved and two other staff members, one of whom was a witness. Further review into the facility investigation revealed the facility did not interview any other residents regarding care received or treatment from staff during the investigation. Interview with the DON on 12/10/18 at 3:30 P.M. confirmed the facility investigation lacked thorough interviews with staff working at the time of the incident and no additional facility residents in the area were interviewed as potential witnesses to this incident or possibly experienced a similar incident. The DON confirmed the lack of evidence did not support a thorough investigation was completed.