Every finding on record at Cedars of Lebanon Care Center

Based on observation, staff interviews and policy review, the facility failed to ensure food items and kitchen equipment were maintained in a manner to prevent foodborne illness. This had the potential to affect all 45 residents who receive food from the kitchen.Findings include:1. Observation of the facility's kitchen on 07/13/26 at 10:10 A.M. revealed there was a dirty pair of gloves that were turned inside out sitting on the ledge underneath the steam table, and there was gray debris resembling dust on a fan which was located over the knives and pointed towards the steam table, on the hood above the stove, and on the plate cover rack.Interview with Dietary Manager #64 on 07/13/26 at 10:10 A.M. verified there was a dirty pair of gloves that were turned inside out sitting on the ledge underneath the steam table and gray debris resembling dust on a fan which was located over the knives and pointed towards the steam table, on the hood above the stove, and on the plate cover rack.Review of the facility's food receiving and storage policy dated October 2017 revealed food services would maintain clean food storage areas at all times. 2. Observation of the facility's kitchen on 07/14/26 at 4:30 P.M. revealed [NAME] #57 took the temperatures of the food items on the steam table during dinner meal service. The tuna salad was 48.6 degrees Fahrenheit and the pasta salad was 49.3 degrees Fahrenheit. [NAME] #57 continued to serve to the pasta and tuna salad to the residents.Interview with [NAME] #57 on 07/14/26 at 4:30 P.M. verified the tuna salad was being held at 48.6 degrees Fahrenheit and the pasta salad was being held at 49.3 degrees Fahrenheit during food service on 07/14/26. Review of the facility's food preparation and service policy dated October 2018 revealed the danger zone for food temperatures was between 41 degrees Fahrenheit and 135 degrees Fahrenheit.

Based on observations, staff interviews, and policy review, the facility failed to ensure residents had a safe and sanitary environment. This affected 12 (#2, #7, #12, #16, #23, #24, #32, #35, #38, #40, #43, and #45) of 45 residents who resided at the facility. The facility census was 45. Findings include:1. Observation on 07/23/26 at 10:20 A.M. revealed Resident #40 and #45 shared a room. Observations of the bathroom revealed a white sheet on the ground around the toilet, with approximately half the sheet being visibly wet. The bathroom had a strong odor of urine and several gnats were observed. The bathroom floor was painted and was peeling up near the door way. Interview on 07/13/2026 at 10:25 A.M. with Housekeeping Aide (HA) #23 revealed Resident #40 and #45 frequently urinate on the bathroom floor and a sheet was put down to soak up the urine. HA #23 verified that gnats were in the bathroom and there was an odor of urine. HA #23 verified the floor was recently painted and was starting to peel and there was visible liquid pooling underneath the paint layer that he assumed was urine.Interview on 07/13/2026 at 10:29 A.M. with Director of Nursing (DON) #54 verified Resident #40 and #45's flooring was recently redone. DON #45 verified the bathroom had an odor of urine, gnats and a liquid on the floor. Interview on 07/16/2026 at 9:33 A.M. with Maintenance Director #23 stated the removed the tile flooring and painted the floor in Resident #40 and #45's room due to urine causing the tiles to keep peeling up. He verified the paint was peeling due to urine on the floor. 2. Observation of Resident #23, #24 and #35's bathroom on 07/16/26 at 9:59 A.M. revealed the baseboard in the bathroom was falling off the wall and the wall behind the baseboard was exposed. There were chunks of the wall that had broken apart and were laying behind the baseboard.Observation of Resident #2 and #7's room on 07/16/26 at 10:01 A.M. revealed there was a brown round stain on the ceiling tile above the sink in the bathroom and gray debris on the ceiling vent in the bathroom. There was gray debris on the ceiling vent in Resident #2 and Resident #7's room near the door to their room. Observation of Resident #32 and #38's room on 07/16/26 at 10:02 A.M. revealed the floor throughout Resident #32 and #38's room was sticky. There was also a brown build up around the edges of Resident #32 and #38's floor throughout their room. Observation of Resident #12, #16 and #43's room on 07/16/26 at 10:04 A.M. revealed the baseboard in Resident #12, #16 and #43's bathroom was falling off the wall exposing the dry wall underneath and there was a brown build up around the edges of Resident #12, #16 and #43's floor throughout their room. Interview with Regional Director of Clinical Operations (RDCO) #77 on 07/16/26 at 9:59 A.M verified the baseboard in Resident #23, #24 and #35's bathroom was falling off the wall; there was a brown round stain on the ceiling tile above the sink in Resident #2 and Resident #7's bathroom; there was gray debris on the ceiling vent in Resident #2 and Resident #7's bathroom; there was gray debris on the ceiling vent in Resident #2 and Resident #7's room near the door to their room; the floor throughout Resident #32 and #38's room was sticky; there was a brown build up around the edges of Resident #32 and #38's floor throughout their room; the baseboard in Resident #12, #16 and #43's bathroom was falling off the wall exposing the dry wall underneath; and there was a brown build up around the edges of Resident #12, #16 and #43's floor throughout their room. Review of the facility's Homelike Environment policy dated May 2017 revealed residents were provided with a safe, clean, comfortable and homelike environment.This deficiency represents non-compliance investigated under Complaint Number 2992063 and Complaint Number 3022583.

Based on observation, interview and policy review, the facility failed to ensure resident's received food portions based on the men spreadsheet. This had the potential to affect 41 residents who the facility identified who were on a regular or mechanical soft diet. The facility census was 45. Findings include:Review of the facility's therapeutic spreadsheet dated 07/14/26 revealed the regular diet included tuna salad served on a tortilla and four ounces of coleslaw. The mechanical soft diet included tuna salad on bread and one soft baked cookie.Observation of tray line in the kitchen on 07/14/26 at 4:30 P.M. revealed [NAME] #57 was serving residents who were ordered regular diets sere served tuna salad with no tortilla or bread and a three ounce scoop of coleslaw. [NAME] #57 was serving residents who were ordered mechanical soft diets a tuna salad without any bread and two cookies.Interview with [NAME] #57 on 07/14/26 at 4:30 P.M. verified residents on a regular diet were served a three ounce scoop of coleslaw and no tortilla/bread. Residents on a mechanical soft diet were served two cookies and no bread. [NAME] #57 verified the therapeutic spreadsheet stated to serve the tuna salad on a tortilla or bread and one cookie for residents on a mechanical soft diet.Review of the facility's menus policy dated October 2018 revealed menus for regular and therapeutic diets were written at least two weeks in advance. The dietitian reviewed and approved all menus.

Based on record review, interview, and policy review, the facility failed to complete a discharge summary after Resident #74 was discharged to another facility and failed to ensure the appropriate information was communicated when Resident #3 was transferred to the hospital. This affected two (#3 and #49) of six residents reviewed for discharges and transfers. The facility census was 45.Findings include:1. Review of the medical record revealed Resident #49 had an admissions date of 11/10/25 and a discharge date of 06/03/26. Diagnoses included schizoaffective disorder, bipolar disorder, drug induced subacute dyskinesia, dementia, borderline personality disorder and post-traumatic stress disorder (PTSD). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was cognitively impaired. Review of the medical record revealed a discharge summary was not completed for Resident #49. Interview on 07/14/2026 at 3:13 P.M. with Social Services #74 verified the discharge summary for Resident #49 was not completed. Review of the undated facility policy titled Discharge Summary and Plan revealed when a discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. 2.Review of the medical record revealed Resident #3 had an admissions date of 02/20/25 with diagnoses including type II diabetes mellitus, chronic obstructive pulmonary disease, and obstructive sleep apnea. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively intact. Review of the progress notes revealed on 05/21/26 at 3:00 P.M., Resident #3 called 911 and was being transported to the hospital. Review of the progress note dated 05/21/26 at 4:43 P.M. revealed the registered nurse from the hospital contacted the facility to request Resident #3's paperwork. Facility nurse stated Resident #3 did not have paperwork because he called 911 independently. The hospital nurse was given report and paperwork was faxed to the hospital. Interview on 07/15/26 at 12:43 with the Director of Nursing (DON) verified the nurse should send paperwork anytime a resident is transferred to the hospital. The DON verified the nurse should have sent paperwork when Resident #3 was transferred to the hospital. Review of the facility policy titled Transfer or Discharge, Information for Receiving Provider dated 07/30/25 revealed when a resident is transferred (return anticipated) specific information about the resident is conveyed to the receiving provider.

Based on record review, and staff interview, the facility failed to notify the state mental health authority with a significant change pre-admission screening and resident review (PASARR) for residents with a change in their mental health or physical conditions. This affected two (#2 and #37) of four residents reviewed for significant change PASARR. The facility census was 45. Findings include: 1. Review of Resident #2's medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder bipolar type. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was moderately cognitively impaired. Review of the PASARR dated 01/23/26 revealed Resident #2 had indications of serious mental illness. Resident #2's diagnosis of schizoaffective disorder was marked on the PASARR. Review of Resident #2's progress notes revealed on 01/27/26 at 3:23 P.M., a referral was made for an inpatient psychiatric evaluation due to a recent escalation in behaviors and physical aggression. Resident #2 was accepted for inpatient psychiatric treatment for assessment and stabilization. On 02/10/26, Resident #2 returned from the psychiatric hospitalization. Review of Resident #2's medical record from 01/27/26 to 07/14/26 revealed no documentation that the facility completed a significant change PASARR or notified the state mental health authority of Resident #2's psychiatric hospitalization or change in mental health condition on 01/27/26. Interview with Regional Director of Operations (RDO) #75 on 07/14/26 at 2:56 P.M. verified the facility did not complete a significant change PASARR or notified the state mental health authority of Resident #2's psychiatric hospitalization or change in mental health condition on 01/27/26. 2. Review of Resident #37's medical record revealed Resident #37 admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia and anxiety disorder. Review of the discharge return anticipated Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was moderately cognitively impaired. Review of the PASARR dated 10/22/25 revealed Resident #37 had indications of serious mental illness. Resident #37's diagnoses of schizophrenia and panic or other severe anxiety disorders were marked on the PASARR. Review of Resident #37's progress note dated 03/02/26 revealed a call was placed to Resident #37's mental health provider related to increased delusions and aggression. Resident #37 was being verbally aggressive with peers and staff and were yelling, cursing and making threats to harm others. Resident #37 was picked up at 11:00 P.M. by the transportation provider and Resident #37 was transferred to the psychiatric hospital for evaluation. The local police were called to assist with Resident #37's transfer to the hospital. On 03/16/26, Resident #37 returned from the psychiatric hospital. Review of Resident #37's medical record from 03/02/26 to 07/14/26 revealed no documentation the facility completed a significant change PASARR or notified the state mental health authority of Resident #37's psychiatric hospitalization or change in mental health condition on 03/02/26. Interview with Regional Director of Operations (RDO) #75 on 07/14/26 at 2:56 P.M. verified the facility did not complete a significant change PASARR or notified the state mental health authority of Resident #37's psychiatric hospitalization or change in mental health condition on 03/02/26.

Based on record review and staff interview, the facility failed to monitor residents' blood sugars and notify the physician of a resident's blood sugar that was outside of parameters according to physician's order. This affected one (#38) of twelve residents reviewed for quality of care. The facility census was 45. Findings include: Review of Resident #38's medical record revealed Resident #38 was admitted to the facility 10/13/16. Diagnoses included type two diabetes mellitus with hypoglycemia without coma. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was cognitively intact. Review of the physician order dated 05/22/26 revealed Resident #38 was ordered insulin Lisprol one unit dial subcutaneous solution pen injector 100 units per millimeter (ml) inject as per sliding scale. Blood sugar readings greater than 400 milligrams (mg) per deciliter (dl) should be given five units and then rechecked in two hours. Call the physician if the blood sugar reading was still greater than 400 mg/dl. Review of Resident #38's blood sugar readings dated 05/31/26 revealed Resident #38's blood sugar level was 539 mg/dl on 05/31/26 at 9:58 A.M. and 444 mg/dl on 05/31/26 at 4:58 P.M. There were no additional blood sugars taken between 05/31/26 at 9:58 A.M. and 05/31/26 at 4:58 P.M. There was no documentation the physician was notified of Resident #38's blood sugar levels being above 400 mg/dl on 05/31/26. Review of Resident #38's blood sugar readings dated 06/07/26 revealed Resident #38's blood sugar level was 429 mg/dl on 06/07/26 at 12:47 P.M. and 429 mg/dl on 06/07/26 at 5:18 P.M. Resident #38's blood sugar readings dated 06/07/26 revealed there were no additional blood sugars taken between 06/07/26 at 12:47 P.M. and 06/07/26 at 5:18 P.M. There was no documentation the physician was notified of Resident #38's blood sugar levels being above 400 mg/dl on 06/07/26. Interview with the Director of Nursing (DON) on 7/15/26 at 11:34 A.M. verified Resident #38's blood sugar reading was 539 mg/dl on 05/31/26 at 9:58 A.M. and 444 mg/dl on 05/31/26 at 4:58 P.M. The DON also verified Resident #38's blood sugar reading was 429 mg/dl on 06/07/26 at 12:47 P.M. and 429 mg/dl on 06/07/26 at 5:18 P.M. The DON confirmed there was no documentation that any additional blood sugars were taken on 05/31/26 or on 06/07/26 or that the physician was notified of Resident #38's blood sugar levels being above 400 mg/dl on 05/31/26 or on 06/07/26 for more than two hours.

Based on staff interview and medical record review, the facility failed to ensure a resident's pharmacy recommendation was timely addressed and implemented according to the physician's response to the pharmacy recommendation. This affected one (#35) of five residents reviewed for unnecessary medications. The facility census was 45. Findings include:Review of Resident #35's medical record revealed Resident #35 admitted to the facility on [DATE]. Diagnoses including schizoaffective disorder bipolar type and major depressive disorder.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively intact. Review of the physician order dated 10/27/22 revealed Resident #35 was ordered divalproex sodium tablet delayed release 500 milligrams (mg) give 500 mg by mouth two times a day related to schizoaffective disorder depressive type. Review of Resident #35's pharmacy recommendation dated 11/17/25 revealed Resident #500's divalproex sodium tablet delayed release 500 mg give 500 mg by mouth two times a day was recommended to be reduced. Psychiatrist #80 addressed the pharmacy recommendation on 12/08/25 and wrote to decrease Resident #35's divalproex sodium tablet delayed release to 375 mg two times a day if it was okay with Physician #78.Review of Resident #35's medical record from 11/17/25 to 07/14/26 revealed no documentation that Physician #78 was contacted regarding the 11/17/25 pharmacy recommendation or the recommended gradual dose reduction of Resident #35's divalproex sodium tablet delayed release 500 mg two times a day to divalproex sodium tablet delayed release 375 mg two times a day. Resident #35's divalproex sodium tablet delayed release 500 mg two times a day was not reduced to 375 mg two times a day. Resident #35's divalproex sodium tablet delayed release 500 mg two times a day order remained in place from 11/17/25 to 07/14/26.Interview with the Regional Clinical Director (RCD) #76 on 07/15/26 at 1:51 P.M. verified Resident #35's divalproex sodium tablet delayed release 500 mg two times a day was not reduced to 375 mg two times a day and Resident #35's divalproex sodium tablet delayed release 500 mg two times a day order remained in place from 11/17/25 to 07/14/26. RCD #76 confirmed Psychiatrist #80 addressed the pharmacy recommendation on 12/08/25 and wrote to decrease Resident #35's divalproex sodium tablet delayed release to 375 mg two times a day if it was okay with Physician #78. RCD #76 confirmed the facility did not have any documentation that Physician #78 was contacted regarding the 11/17/25 pharmacy recommendation or the recommended gradual dose reduction of Resident #35's divalproex sodium tablet delayed release 500 mg by mouth two times a day to divalproex sodium tablet delayed release 375 mg two times a day as recommended by Psychiatrist #80.

Based on review of personnel file, staff interviews, and policy review, the facility failed to have a qualified director of food and nutritional services, a full time qualified dietician or other full time clinically qualified nutrition professional. This had the potential to affect all 45 residents who received food from the kitchen. Findings include:Review of Dietary Manager (DM) #64's personnel file revealed DM #64 was hired at the facility on 08/30/23 as the facility's Housekeeping Director. DM #64 was not a certified dietary manager, a certified food service manager, had any national certification for food service management, had an associate's or higher degree in food service management or in hospitality or had two or more years of experience in the position of director of food and nutrition services in a nursing facility setting and had completed a course of study in food safety and management. Interview with Regional Director of Clinical Operations (RDCO) #77 on 07/15/26 at 3:31 P.M. verified DM #64 was the facility's DM and Housekeeping Director. RDCO #77 verified DM #64 was not a certified dietary manager, a certified food service manager, had any national certification for food service management, had an associate's or higher degree in food service management or in hospitality or had two or more years of experience in the position of director of food and nutrition services in a nursing facility setting and had completed a course of study in food safety and management.Interview with DM #64 on 07/15/26 at 3:35 P.M. verified DM #64 recently became the DM in addition to being the Housekeeping Director. DM #64 verified she was not a certified dietary manager, a certified food service manager, had any national certification for food service management, had an associate's or higher degree in food service management or in hospitality or had two or more years of experience in the position of director of food and nutrition services in a nursing facility setting and had completed a course of study in food safety and management. DM #64 reported she was supposed to complete her certifications but did not have time to complete them. Telephone interview with Registered Dietitian (RD) #79 on 07/16/26 at 8:33 A.M. verified RD #79 did not work full time at the facility. RD #79 reported she visited the facility quarterly and she did not go in the kitchen during her visits. RD #79 stated that the facility also had a dietary technician that was at the facility weekly but did not work full time at the facility. Review of the facility's dietician policy dated October 2017 revealed the director of food service management would be designated if the dietitian was not employed at the facility full time. The director of food service management would be a certified dietary manager, a certified food service manager, be nationally certified in food service management and safety, have an associate's degree or higher in food service manager or hospitality, or meet any state requirements for food service and dietary.

Based on resident interview, observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure medications were not left at the bedside. This affected one (#18) of three residents reviewed for medication storage. The facility census was 45.Findings include:Review of the medical revealed Resident #18 was admitted to the facility on [DATE]. Diagnoses included diabetes, chronic non pressure ulcer of the right heel, lymphedema, congestive heart failure, atherosclerotic heart disease, benign prostatic hyperplasia, chronic kidney disease, atrial fibrillation, chronic pain syndrome, neuroleptic induced Parkinsonism, chronic obstructive pulmonary disease (COPD), insomnia, cellulitis of the right lower limb, mood disorder, personality disorder, cardiomyopathy, obstructive sleep apnea, major depressive disorder, anxiety disorder, and hypothyroidism.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had intact cognition, had no behaviors, and received an opioid (pain medication).Review of September 2025 physician ' s orders revealed Resident #18 had an order for oxycodone-acetaminophen 5-325 milligrams (mg) one tablet every six hours for pain and Tylenol Cold and Flu 500 mg four times daily for 14 days for respiratory and body aches. Further review revealed Resident #18 did not have a physician order to leave medications at the bedside. Interview on 09/19/25 at 10:10 A.M. with Resident #18 revealed staff always left medications on his bedside table. Concurrent observation revealed the resident had two yellow tablets and a blue tablet in a medication cup in his bedside table. Resident #18 stated the agency nurse left it in his room a couple days ago and he kept it because he was going to take them later if he needed them.Interview on 09/19/25 at 12:50 P.M. with Licensed Practical Nurse (LPN) #225 verified Resident #18 had three tablets in a medication cup in his room. LPN #225 confirmed the medications were two yellow Tylenol Cold and Flu 500 mg tablets and one blue oxycodone with acetaminophen 5-325 mg, which was a narcotic.Review of the facility policy titled, Administering Oral Medications, dated October 2010, revealed the purpose of the policy was to provide guidelines for the safe administration of oral medication. Further review revealed staff were to remain with the resident until all medication had been taken.This deficiency represents non-compliance investigated under Complaint Number 2577683.

Based on observations, staff interviews, temperature log review, and policy review, the facility failed to store, prepare and serve food under sanitary conditions. This affected all 44 residents receiving food from the facility. The facility total census was 44. Finding include: 1. Observations on 10/15/24 at 8:50 A.M., revealed the following: In the reach in refrigerator there were packages of grated cheese and sliced cheese with no date. The stove had an a black substance built up of the appearance of grease on the stove surface ad in the heating elements. There as a built up of wet substance with the appearance of grease on the hood louvers above the stove cooking surface. There was one large food storage bin label sugar with the food scoop stored on top of the sugar. Two large food storage bins containing foods were not labeled. There three opened hamburger bun packages without open dates. The ice machine had a pink substance constant with mold on the inside were ice was stored. In the reach in freezer, there were three open packages of food with no open dates and were not sufficiently sealed. In the dry storage area, three was a bottle of open golden liquid with no label, no open date and no sufficient lid. There was an open bag of rice with no open date. In the reach in refrigerator, there was milk spillage on thawing chicken and on the adjacent shelves and bottom of the refrigerator. Interview on 10/15/24 at 8:50 A.M., with Diet Manager, (DM) #800 verified the kitchen observations including opened undated foods, unlabeled foods, food scoops stored in the food bins and the need for cleaning of the ice machine, stove, stove louvers, and refrigerator. 2. Observation on 10/16/24 at 10:40 A.M., of the resident food storage refrigerator in the nurse station, revealed the following: The October 2024 temperature log dated 10/01/24 through 10/16/24 had six days of no documentation of day shift refrigerator temperatures. There were two large bags of multiple foods which were unlabeled and undated. There were two liters of opened soda, an open bottle of salad dressing and opened vegetables undated and unlabeled. Interview on 10/16/24 at 10:40 A.M., with Licensed Practical Nurse (LPN) #401 verified the resident food storage refrigerator in the nurse station had an incomplete refrigerator temperature log in October 2024, and unlabeled and undated open food items. 3. Observation on 10/16/24 at 3:36 P.M., of [NAME] #810 pre-washing the blender used for puree foods. The [NAME] #810 was observed to reassemble the washed blender blade into the blender with the same gloved hands used to operate the dishwasher. The blender blade came into contact with the puree foods. Observation on 10/16/24 at 4:28 P.M., revealed [NAME] #810 served the supper meal consisting of a pork sausage on a bun. [NAME] #810 was observed to wear gloves touching the food cart, the food lids, the serving counter and utensils and then opened a bun with the same gloved hand. [NAME] #810 continued touching items and returning to open subsequent buns without changing gloves. [NAME] #810 touched and spun the inside of a resident plate with the same gloved hands. Interview on 10/16/24 at 4:45 P.M., with [NAME] #810 verified she should have changed gloves or used a utensil to open the inside of the bun and should not have touched the inside of a resident plate with the same gloved hands. [NAME] #810 verified she should have changed gloves prior to reassembling the blender blade. Review of the policy titled, Food Receiving and Storage, dated October 2017, revealed foods shall be stored in a manner that complies with safe food handling practices, including foods will be covered, labeled and dated, refrigerated food temperatures will be monitored, foods belonging to residents will be labeled with the resident's name and dated, and food areas kept clean. Review of the policy tilted, Sanitation, dated October 2008, revealed all equipment will be kept clean and ice machines will be cleaned and sanitized per manufacturer instructions. Review of the policy titled, Food Preparation and Service, dated October 2017, revealed gloves must be worn when handling food directly, however gloves can be contaminated and must be changed between tasks.

Based on employee file review, interview, and review of the facility assessment, the facility failed to ensure all staff received education on mental and behavioral health. This affected three State tested Nursing Assistants (STNAs)(#505, #504 and #503) of five STNAs reviewed for mental and behavioral health training. This had the potential to affect all 44 residents residing in the facility. The faciliy census was 44. Findings include: Review of the facility Assessment updated 07/29/24 revealed the facility is a 45-bed secured facility specializing in behaviors and mental health. The facility has a majority of long-term residents with the entire facility specializing in mental and behavioral health. There is no specific unit or area designated for the behavioral or mental health residents. The facility provides staff training/education and competencies that are necessary to provide care and support needed for our resident population. The facility provides the following training topics and competencies that include but is not limited to care/management for persons with dementia and behavioral health training. 1. Review of the employee file of STNA #505 revealed a hire date of 01/04/15. Review of STNA #505's file revealed STNA #505 had no documented evidence of receiving education on mental and behavioral health. 2. Review of the employee file of STNA #504 revealed a hire date of 05/24/23. Review of STNA #504's file revealed STNA #504 had no documented evidence of receiving education on mental and behavioral health. 3. Review of the employee file of STNA #503 revealed a hire date of 08/23/23. Review of STNA #503's file revealed STNA #503 had no documented evidence of receiving education on mental and behavioral health. Interview on 10/17/24 at 2:24 P.M., with Human Resources #105 verified STNA's #505, #504 and #503 did not have documented evidence of receiving education on mental and behavioral health from the facility.

Based on medical record review, census review, resident interview, staff interview, and policy review, the facility failed to ensure residents or resident's representatives were notified of room changes. This affected four residents, (#4, #11, #19 and #146) of four residents reviewed for room change notification. The facility total census was 44. Findings include: Review of the faciliy census dated 10/03/24 revealed Resident #4, #11 and #146 resided in the same room. 1. Review of Resident #4's medical record revealed an admitted [DATE]. Diagnoses for Resident #4 included: Schizophrenia, bipolar disease, diabetes, and Parkinsonism. Review of the Minimum Data Set, (MDS) comprehensive assessment, dated 07/9/24, revealed the resident had moderately impaired cognition and required supervision with ambulation. The resident received antipsychotic medication due to delusion and aggression due to schizophrenia. Review of notes dated 10/03/24 at 6:23 P.M., revealed Resident #4 and Resident #146 had a physical altercation. Review of Room Changed Notification Assessment documentation dated 10/07/24 revealed Resident #4's reason for room change made on 10/07/24 was to promote resident safety. There was no documentation the resident or representative were offered an explanation of the reason for the move and opportunity to see the new location and ask questions regarding the move. Interview on 10/17/24 at 10:33 A.M., with Resident #4 stated she did not have anyone explain to her why she was moved. 2. Review of Resident #11's medical record revealed an admitted [DATE]. Diagnoses for Resident #11 include chronic kidney disease, dementia, depression, anxiety, and Parkinson disease. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition. Review of Room Changed Notification Assessment documentation dated 10/07/24 revealed Resident #11's reason for room change made on 10/07/24 was to promote resident safety. There was no documentation the resident or representative were offered an explanation of the reason for the move and opportunity to see the new location and ask questions regarding the move. Interview on 10/1/24 at 9:20 A.M., with Resident #11 stated she did not have anyone talk to her as to why she was moved. 3. Review of Resident #146s medical record revealed an admitted [DATE]. Diagnoses for Resident #146 included: schizoaffective disorder, and schizophrenia bipolar type. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition. The resident had a court appointed guardian. Review of notes dated 10/03/24 at 6:23 P.M., revealed Resident #4 and Resident #146 had a physical altercation. Review of Room Changed Notification Assessment documentation dated 10/07/24 revealed Resident #146 reason for room change made on 10/07/24 was to promote resident safety. There was no documentation the resident or representative were offered an explanation of the reason for the move and opportunity to see the new location and ask questions regarding the move. Interview on 10/16/24 at 2:05 P.M., with Social Service Designee (SSD) #175 verified Residents #4 and #146 had a physical altercation on 10/03/24. Resident #146 was hospitalized on [DATE] and returned to the facility on [DATE]. SSD #175 verified the documentation and room change notices were dated 10/07/24. There was no documentation the residents or the residents' representative were notified of the reason of the room moves, and provided an opportunity to ask questions regarding the room moves for Residents #4, #11 and #146. 43062 4. Review of Resident #19's medical record revealed an admitted [DATE]. Her diagnoses included, chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), hypothyroidism, schizoaffective disorder, bipolar type, congestive heart failure (CHF), and insomnia, Review of the Minimum Data Set (MDS) assessment for Resident #19, dated 07/22/24, revealed Resident #09 was cognitively impaired. Further review of the MDS assessment revealed Resident #19 was dependent on staff for medication administration. Resident #19 required supervision from staff with eating, oral hygiene, toilet use, dressing, and personal hygiene. Review of Resident #19's progress notes dated, 10/06/24, revealed Resident #19 has done well with a recent room change. Review of the facility report titled, Room move notification, dated 10/06/24, was opened and not completed. It was left blank. Interview on 10/16/24 at 2:59 P.M., with State tested Nurse Aide (STNA) #500, verified Resident #19 was moved with several other residents related to the need to move residents for new admissions to the facility. STNA #500 verified Resident #19's move was for about twelve hours because she had to move her back. Interview on 10/16/24 at 4:05 P.M., with the Social Service Director (SSD) #175, verified Resident #19 had a room move on 10/06/24 for about twelve hours and then returned to her original room. SSD #175 verified she has no documentation to confirm the resident, resident roommates, or family were notified of the room change. Review of the undated policy titled Room Change / Roommate Assignment revealed prior to the changing a roommate or roommate assignment , all parties involved the change, including resident and their representative, will be given a 24 hours advance notice unless medically necessary for the safety of the resident. The notice will include why the change is being made and information that will assist the roommate with the room and/or roommate change.

Based on observation, medical record reviews, menu spread sheet review, policy review and staff interviews, the facility failed to prepare foods as planned by the Registered Dietitian. This affected four (#6, #15, #16 and #39) of four residents reviewed for pureed diets. The facility total census was 44. Finding include: Review of Residents #6, #15, #16 and #39's physician orders verified the residents were to receive a puree consistency diet. Review of the menu spreadsheet of the lunch meal revealed the puree residents were to receive four ounces of puree green beans and puree honey mustard chicken tenders. According to the recipe, the chicken tenders were to be prepared with the honey mustard sauce. Observation on 10/16/24 at 12:18 P.M., of the lunch meal revealed [NAME] #810 served Residents #6, #15, #16 and #39, pureed coleslaw instead of puree green beans as listed on the spreadsheet. The [NAME] #810 pureed the chicken with a gravy mix and water. Interview on 10/16/24 at 12:20 P.M., with [NAME] #810 verified Residents #6, #15, #16 and #39 should have received puree green beans. [NAME] #810 stated she had not read the spreadsheet and had not followed the recipe instructions to prepare the puree green beans and the chicken tenders. Interview on 10/16/24 at 12:20 P.M with Diet Manager #800 verified Residents #6, #15, #16 and #39 should have received puree green beans. DM #800 also verified the [NAME] #810 did not have access to the puree green beans and chicken tenders recipe instructions. The puree recipe instructions for puree food preparation were not available for any of the pureed meals served to the residents. Review of the policy titled, Puree Diet dated 2023, revealed the puree diet is to improve or maintain foods that are safe to swallow.

Based on record review, observation, resident interview, staff interview, and policy reviews, the facility failed to ensure residents were treated with dignity and respect. This affected three (#08, #38, and #29) of four residents reviewed for dignity and respect. The facility census was 44. Findings include, 1. Review of Resident #38's medical record an admitted [DATE], with diagnoses including: chronic kidney disease, diabetes mellitus (DM), chronic obstructive sleep apnea (COPD), history of tuberculosis, insomnia, anemia, and heart failure, and major depressive order. Review of the Minimum Data Set (MDS) assessment dated , 09/12/24, revealed Resident #38 was cognitively impaired. Further review of the MDS assessment revealed Resident #38 was dependent on staff for medication administration, eating, oral hygiene, toileting, bathing, and dressing. Observation and interview on 10/15/24 at 10:52 A.M., revealed State tested Nurse Aide (STNA) #900 verified Resident #38 was seated in his chair. STNA #900 verified Resident #38's sweatshirt had dried food substance and crumbs all over it. Resident #39's fingernails were soiled with unknown black substance under his nails. STNA #900 also verified Resident #38's hands and fingers were stained with an unknown brown substance all over them. STNA #900 stated the morning shift did not provide Resident #38 with a clothing protector at breakfast and that was why Resident #38 had crumbs and food stains all over his shirt. Review of the policy titled, Quality of Life-Dignity, dated August 2009, verified each Resident shall be cared for in a manner that promote and enhanced quality of life, dignity, respect, and individuality. Further review of the policy revealed residents will be treated with dignity and respect at at all times. 44083 2. Review of Resident #8's medical record revealed an admitted [DATE]. Diagnoses for Resident #8 included: schizophrenia, depressive disorder and alcoholic induced cirrhosis. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and required supervision with dining and meal service. The resident received a No Added Salt regular consistency diet. Observation on 10/16/24 at 7:50 A.M., of the breakfast meal in the dining room revealed Resident #8 sitting at a table with Resident#15. Resident #15 was feeding himself the breakfast meal. Resident #8 was observed to become increasing agitated with vocalizations and asking State tested Nurse Aide (STNA) #500 why he was not being served. STNA #500 repeatedly notified the kitchen staff of the need to provide Resident #8 the meal. After Resident #8 waited from 7:50 A.M. to 8:02 A.M., and several other residents at other tables being served, Resident #8 received his meal tray. Resident #8 received a plastic spoon and threw the spoon across the table, stating he would not eat with the plastic spoon. STNA #500 requested metal silverware spoon from the kitchen. Observation on 10/16/24 at 8:10 A.M., revealed Diet Manager, (DM) #800 requested metal silverware instead of plastic ware from [NAME] #810. [NAME] #810 stated the kitchen had run out of silverware spoons to provide for residents at the end of the meal service. Interview on 10/16/24 at 8:15 A.M., with STNA #500 verified Resident #8 waited for over 10 minutes to receive his meal tray while Resident #15 consumed the meal at the same table, which resulted in increased agitation form Resident #8. STNA #500 verified she had attempted to request the meal tray sooner, but the kitchen staff had not prepared the tray. STNA #500 verified Resident #8 received a plastic ware spoon which further increased his agitation. STNA #500 stated many residents, during many meals, receive plastic ware near the end of meal service, which results in agitation. 3. Review of Resident #29's medical record revealed an admitted [DATE]. Diagnoses for Resident #29 included: protein calorie malnutrition, and anxiety. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had moderately impaired cognition and received low concentrated sugar and no added salt diet and required supervision for meal service. Interview on 10/15/24 at 1:53 P.M., with Resident #29 stated he often received plastic ware at meals and resulted in increased anxiety. He preferred silverware for meal service and stated he asked for silverware and did not receive it. Interview on 10/16/24 at 8:20 A.M., with DM #800 verified the kitchen had no silverware spoons at the end of meal service and plastic ware has been used. The DM #800 verified residents sitting at a table together should be served at the same time. Review of the policy titled, Dining Room Audits, dated October 2017, revealed residents at each table will be served together. Foods will be served in a homelike setting.

Based on medical record review, Self-Reported Incident report review, resident interviews, staff interviews, and policy review, the facility failed to report allegations of resident to resident physical abuse and allegation of sexual abuse by unknown person, to the state agency. This affected two (#06 and #19) of four residents reviewed for potential abuse. The facility census was 44. Findings include: 1. Review for Resident #06's medical record revealed an admitted [DATE]. Her diagnoses included, cerebral palsy, major depressive disorder, schizoaffective disorder, personality disorder, essential hypertension, hyperlipidemia, hypothyroidism, hallucinations, hypothyroidism, diabetes mellitus (DM), schizophrenia, anxiety disorder, anemia, and insomnia. Review of Resident #06's most recent Minimum Data Set (MDS) assessment, dated 10/04/24, revealed she had impaired cognition. Further review of the MDS assessment revealed Resident #06 was dependent on staff for medication administration, lower body dressing, and bathing. Resident #06 required maximum assistance from staff with oral hygiene and toilet use. She required supervision from staff with eating. Review of Resident #06's care plans, dated 04/17/23 revealed Resident #06 has potential for disturbance of mood/behavior, altered concept of reality, delusions and/or hallucinations related to diagnosis of schizophrenia. Resident #06's behavior care plan revealed she was care planned for being accusatory, and can be sexually inappropriate at times. Review of Resident #06's progress notes revealed on 10/10/24, Resident #06 was noted to have a bruised on her right knee. Resident #06 stated one of the kids pushed her and she hit her knee. No other documentation related to the incident was identified. Review of the facility interdisciplinary team (IDT) investigation, dated 10/10/24, revealed Resident #06 had a noted discoloration area to her right knee. Resident #06 stated she had been pushed into a door from the little kids and then she stated that it was one of her roommates that had pushed her in the chair out of the way. The intervention was listed as: Resident #06 was reminded to not stop in center of the room. The IDT post summary stated: Resident #06 was noted to have a discoloration on her knee. At initial time, she had stated she had been pushed by the kids. Resident #06 stated she wanted to lay down and told the staff she was pushed by her roommate and ran into something. Two nurses assessed Resident #06. An interview was attached from Resident #19 who stated she did not know she pushed Resident #06 into the door. Interview on 10/15/24 at 9:28 A.M., with Resident #06 revealed Resident #06 she was raped by three men while on an outing. Resident #06 stated the men that raped her lived at the facility, however, the incident of rape occurred during the outing on the bus. Resident #06 became tearful and stated she told her guardian about alleged rape. Interview and observation on 10/15/24 at 9:30 A.M., reveled Resident #06 was sitting on the side of her bed with her legs hanging off the edge of the bed. Resident #06 had a large black and purple bruise on her right knee with various colors of green, and brown. Resident #06 stated her roommate (identified as Resident #19) pushed her into the bathroom door and it resulted with a large bruise on her right knee. Resident #06 verified she reported the incident to the night nurse. Interview on 10/15/24 at 9:57 A. M., with the Director of Nursing revealed she had no knowledge of Resident #06's allegation of sexual abuse. The DON stated Resident #06 can be delusional and stated Resident #06 has not been on an outing. The DON reported it was not unusual for Resident #06 to make statements that were not accurate and is care planned for her delusional behavior. Interview on 10/16/24 at 2:59 P.M., with State tested Nurse Aide (STNA) #500 verified she assisted Resident #06 to bed on 10/10/24 after dinner. STNA #500 stated Resident #06 reported to STNA #500 that her roommate (Resident #19) pushed her into the door and caused her to hit her knee and if left a bruise. STNA #500 stated she reported to the two nurses on duty and STNA #500 observed the two nurses question Resident #06 about the incident. STNA #500 verified Resident #06's roommate Resident #19 remain in the same room together. Interview on 10/16/24 at 4:11 P.M. ,with Resident #19 (Resident #06's roommate) verified she pushed Resident #06 into the door and caused the bruise on her right knee. Resident #19 explained that Resident #06 continued to roll Resident #06's wheelchair into Resident #19's area of the room. Resident #19 snarled her face and stated Resident #19 pushed Resident #06's wheelchair into the bathroom door. Interview on 10/16/24 at 5:00 P.M., with the Director of Nursing (DON) stated she interviewed Resident #19 and Resident #19 was unable to state what happened. The DON stated Resident #06 told the staff on 10/10/24 that a child pushed her in her wheelchair and this resulted in bruise on her knee. The DON stated Resident #06 told her that a lady tried to move her out of the room and her leg got bumped. The DON verified the facility failed to complete a thorough investigation and is unable to state what truly happened including if Resident #06's bruised knee is a bruise of unknown origin or an abuse situation. Review of the report titled, Weekly Skin Assessment, dated 10/16/24 and signed on 10/17/24, revealed Resident #06 had a bruise to her right front knee that measured 7.0 centimeters (CM) in length, and 6.0 cm in width, and zero depth. The medical record contained no evidence of the bruise being assessed from 10/10/24 to 10/17/24. Review of the Self Reported Incidents on 10/16/24 at 10:00 A.M., revealed the facility failed to report an allegation of unknown origin/physical abuse for the bruise identified on 10/10/24 or an allegation of sexual abuse related to Resident #06's allegation of abuse on 10/16/24 at 9:28 A.M. Interview on 10/17/24 at 7:55 A.M., with the Administrator verified she investigated the incident on of the unknown bruise 10/16/24 (even though it was documented on 10/10/24) and it revealed Resident #19 reported to her that she pushed Resident #06 into the door. The Administrator reported Resident #19 told her that she pushed Resident #06 into the door because Resident #06 continued to go into Resident #19's side of the room. The Administrator stated Resident #19 stated she would not do it again and that is why she remains in the same room with Resident #06. The Administrator revealed she did not investigate and report the incidents because she would be investigating and reporting incidents up to ten times per day. The Administrator revealed she discussed Resident #06's allegation of sexual abuse with the Director of Nursing (DON) and the DON decided she did not feel the sexual abuse allegation was an allegation that required a complete investigation or required the facility to complete a Self Reported Incident (SRI) investigation. The Administrator stated the DON determined this by the boxes that she checked on the facility abuse form. Interview on 10/17/24 at 1:56 P.M., interview with the Assistant Director of Nursing (ADON) #308 verified the facility did not complete a head to toe assessment following the sexual abuse allegation on 10/15/24. ADON #308 verified the only assessment of the knee injury identified on 10/10/24 was the skin assessment completed on 10/16/24. ADON #308 stated the doctor was notified on 10/10/24, however, ADON #308 was unable to provide documentation verification. Review of the policy titled, Abuse and Neglect Protocol, dated 06/13/21, revealed it was the responsibility of the employees, facility consultants, family members, and visitors to promptly report any incident or suspected incident of neglect or resident abuse, including origins of unknown injuries. The facility policy stated the facility residents have the right to be free from abuse. The facility policy stated, All reports of resident abuse, neglect, and injuries of unknown source shall be promptly and thoroughly investigated by facility management,

Based on medical record review, Self-Reported Incident report review, resident interviews, staff interviews, and policy review, the facility failed to thoroughly investigate allegations of resident to resident physical abuse and allegation of sexual abuse by unknown person. This affected two (#06 and #19) of four residents reviewed for potential abuse. The facility census was 44. Findings include: 1. Review for Resident #06's medical record revealed an admitted [DATE]. Her diagnoses included, cerebral palsy, major depressive disorder, schizoaffective disorder, personality disorder, essential hypertension, hyperlipidemia, hypothyroidism, hallucinations, hypothyroidism, diabetes mellitus (DM), schizophrenia, anxiety disorder, anemia, and insomnia. Review of Resident #06's most recent Minimum Data Set (MDS) assessment, dated 10/04/24, revealed she had impaired cognition. Further review of the MDS assessment revealed Resident #06 was dependent on staff for medication administration, lower body dressing, and bathing. Resident #06 required maximum assistance from staff with oral hygiene and toilet use. She required supervision from staff with eating. Review of Resident #06's care plans, dated 04/17/23 revealed Resident #06 has potential for disturbance of mood/behavior, altered concept of reality, delusions and/or hallucinations related to diagnosis of schizophrenia. Resident #06's behavior care plan revealed she was care planned for being accusatory, and can be sexually inappropriate at times. Review of Resident #06's progress notes revealed on 10/10/24, Resident #06 was noted to have a bruised on her right knee. Resident #06 stated one of the kids pushed her and she hit her knee. No other documentation related to the incident was identified. Review of the facility interdisciplinary team (IDT) investigation, dated 10/10/24, revealed Resident #06 had a noted discoloration area to her right knee. Resident #06 stated she had been pushed into a door from the little kids and then she stated that it was one of her roommates that had pushed her in the chair out of the way. The intervention was listed as: Resident #06 was reminded to not stop in center of the room. The IDT post summary stated: Resident #06 was noted to have a discoloration on her knee. At initial time, she had stated she had been pushed by the kids. Resident #06 stated she wanted to lay down and told the staff she was pushed by her roommate and ran into something. Two nurses assessed Resident #06. An interview was attached from Resident #19 who stated she did not know she pushed Resident #06 into the door. Interview on 10/15/24 at 9:28 A.M., with Resident #06 revealed Resident #06 she was raped by three men while on an outing. Resident #06 stated the men that raped her lived at the facility, however, the incident of rape occurred during the outing on the bus. Resident #06 became tearful and stated she told her guardian about alleged rape. Interview and observation on 10/15/24 at 9:30 A.M., reveled Resident #06 was sitting on the side of her bed with her legs hanging off the edge of the bed. Resident #06 had a large black and purple bruise on her right knee with various colors of green, and brown. Resident #06 stated her roommate (identified as Resident #19) pushed her into the bathroom door and it resulted with a large bruise on her right knee. Resident #06 verified she reported the incident to the night nurse. Interview on 10/15/24 at 9:57 A. M., with the Director of Nursing revealed she had no knowledge of Resident #06's allegation of sexual abuse. The DON stated Resident #06 can be delusional and stated Resident #06 has not been on an outing. The DON reported it was not unusual for Resident #06 to make statements that were not accurate and is care planned for her delusional behavior. Interview on 10/16/24 at 2:59 P.M., with State tested Nurse Aide (STNA) #500 verified she assisted Resident #06 to bed on 10/10/24 after dinner. STNA #500 stated Resident #06 reported to STNA #500 that her roommate (Resident #19) pushed her into the door and caused her to hit her knee and if left a bruise. STNA #500 stated she reported to the two nurses on duty and STNA #500 observed the two nurses question Resident #06 about the incident. STNA #500 verified Resident #06's roommate Resident #19 remain in the same room together. Interview on 10/16/24 at 4:11 P.M. ,with Resident #19 (Resident #06's roommate) verified she pushed Resident #06 into the door and caused the bruise on her right knee. Resident #19 explained that Resident #06 continued to roll Resident #06's wheelchair into Resident #19's area of the room. Resident #19 snarled her face and stated Resident #19 pushed Resident #06's wheelchair into the bathroom door. Interview on 10/16/24 at 5:00 P.M., with the Director of Nursing (DON) stated she interviewed Resident #19 and Resident #19 was unable to state what happened. The DON stated Resident #06 told the staff on 10/10/24 that a child pushed her in her wheelchair and this resulted in bruise on her knee. The DON stated Resident #06 told her that a lady tried to move her out of the room and her leg got bumped. The DON verified the facility failed to complete a thorough investigation and is unable to state what truly happened including if Resident #06's bruised knee is a bruise of unknown origin or an abuse situation. Review of the report titled, Weekly Skin Assessment, dated 10/16/24 and signed on 10/17/24, revealed Resident #06 had a bruise to her right front knee that measured 7.0 centimeters (CM) in length, and 6.0 cm in width, and zero depth. The medical record contained no evidence of the bruise being assessed from 10/10/24 to 10/17/24. Review of the Self Reported Incidents on 10/16/24 at 10:00 A.M., revealed the facility failed to report an allegation of unknown origin/physical abuse for the bruise identified on 10/10/24 or an allegation of sexual abuse related to Resident #06's allegation of abuse on 10/16/24 at 9:28 A.M. Interview on 10/17/24 at 7:55 A.M., with the Administrator verified she investigated the incident on of the unknown bruise 10/16/24 (even though it was documented on 10/10/24) and it revealed Resident #19 reported to her that she pushed Resident #06 into the door. The Administrator reported Resident #19 told her that she pushed Resident #06 into the door because Resident #06 continued to go into Resident #19's side of the room. The Administrator stated Resident #19 stated she would not do it again and that is why she remains in the same room with Resident #06. The Administrator revealed she did not investigate and report the incidents because she would be investigating and reporting incidents up to ten times per day. The Administrator revealed she discussed Resident #06's allegation of sexual abuse with the Director of Nursing (DON) and the DON decided she did not feel the sexual abuse allegation was an allegation that required a complete investigation or required the facility to complete a Self Reported Incident (SRI) investigation. The Administrator stated the DON determined this by the boxes that she checked on the facility abuse form. Interview on 10/17/24 at 1:56 P.M., interview with the Assistant Director of Nursing (ADON) #308 verified the facility did not complete a head to toe assessment following the sexual abuse allegation on 10/15/24. ADON #308 verified the only assessment of the knee injury identified on 10/10/24 was the skin assessment completed on 10/16/24. ADON #308 stated the doctor was notified on 10/10/24, however, ADON #308 was unable to provide documentation verification. Review of the policy titled, Abuse and Neglect Protocol, dated 06/13/21, revealed it was the responsibility of the employees, facility consultants, family members, and visitors to promptly report any incident or suspected incident of neglect or resident abuse, including origins of unknown injuries. The facility policy stated the facility residents have the right to be free from abuse. The facility policy stated, All reports of resident abuse, neglect, and injuries of unknown source shall be promptly and thoroughly investigated by facility management,

Based on observation, resident interview, staff interview, and record review, the facility failed to maintain a clean and safe environment. This affected three (#06, #19, #35) of four residents reviewed for environment The facility census was 44. Findings include: 1, Record review for Resident #19 revealed she as admitted to the facility on [DATE]. Her diagnoses included, chronic obstructive pulmonary disease, diabetes mellitus (DM), hypothyroidism, schizoaffective disorder, bipolar disorder, insomnia, and congestive heart failure (CHF). Review of the Minimum Data Set (MDS) assessment for Resident#19 revealed she was cognitively impaired. Further review of the MDS assessment revealed she required supervision from staff with eating, oral hygiene, toilet use, dressing and personal hygiene. Interview and observation on 10/15/24 at 9:41 A.M., with State tested Nurse Aide (STNA) #900 verified the wall behind Resident #19's bed was soiled with dirt and debris. STNA #900 verified various circles of white drywall repair that had not been painted beside Resident 19's bed. STNA #900 verified the toilet seat in Resident #19's bathroom was too small for the toilet and did not feel properly. STNA #900 verified the toilet had no seat cover and that it was broken off. STNA #900 verified the toilet was soiled with dried brown substance, the bathroom had no asperities, and there was dirt and splatter around the walls. 2. Record review for Resident #35 revealed he admitted to the facility on [DATE]. His diagnoses included, schizoaffective disorder, diabetes mellitus, hyperlipidemia, essential primary hypertension, and dementia, chronic pain syndrome. Review of the most recent Minimum Data Set (MDS) assessment, dated 08/30/24, revealed Resident #06 was cognitively intact. Further review of the MDS assessment revealed he was dependent on staff for medication administration, toilet use, bathing, and lower body dressing. He required supervision from staff with eating. Resident #06 required maximum assistance from staff with oral hygiene, upper body dressing, and personal hygiene. Interview and observation on 10/15/24 at 11:11 A.M. with Licensed Practical Nurse (LPN) #401 verified Resident #35's bathroom had black stain around the toilet with water around the base of th toilet. LPN #401 verified there was active flying gnats around Resident #35's toilet. LPN #401 stated she is not sure if the soiled black ring all around the base of the toilet was dirt or urine. LPN #401 verified Resident #35's bathroom had a very strong odor. LPN #401 verified the wall behind Resident #35's bed was soiled and contained a hole in the wall . LPN #401 verified the wall across from Resident #35's bed had dirt and splatter running from the ceiling to the floor along the wall. LPN #401 verified the walls had a black substance on the floor at the base of the walls and the floor. 3. Review of Resident #06's medical record revealed an admitted [DATE]. Resident #06's diagnoses included: cerebral palsy, major depressive disorder, schizoaffective disorder, personality disorder, essential hypertension, hyperlipidemia, hypothyroidism, hallucinations, hypothyroidism, diabetes mellitus (DM), schizophrenia, anxiety disorder, anemia, and insomnia. Review of Resident #06's most recent Minimum Data Set (MDS) assessment, dated 10/04/24, revealed she had impaired cognition. Further review of the MDS assessment revealed Resident #06 was dependent on staff for lower body dressing and bathing. Resident #06 required maximum assistance from staff with oral hygiene and toilet use. She required supervision from staff with eating. Interview and observation on 10/15/24 at 9:28 A.M., revealed Resident #06 was in her bed with her wheelchair next to the bed. Resident #06's wheelchair arms were cracking, and torn. Resident #06 stated her physician told her she had to use the wheelchair for safety. The seat to the wheelchair had a tear on the side where it attaches to the frame of the wheelchair. Interview and observation on 10/15/24 at 9:30 A.M., with State tested Nurse Aide (STNA) #900 verified the arms of Resident #06's wheelchair were cracked and torn. STNA #900 verified the rip on the side of the seat of Resident #06's wheelchair where it connects to the frame.

Based on record review, form instruction review, staff interview, and policy review, the facility failed to ensure a Pre-Admission Screening and Resident Review (PASARR) was completed as required. This affected two (#15 and #01) of four residents reviewed for PASARR's. The facility census was 44. Findings include: 1. Review of the medical record revealed Resident #15 was admitted on [DATE], with current diagnoses of schizophrenia, malignant neoplasm base of tongue and dementia. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #15 had moderate cognitive impairment and was frequently incontinent of bowel and bladder. The resident required supervision with eating, moderate assistance with oral hygiene, bed mobility and transfers and maximal assistance with toileting, bathing, dressing and personal hygiene. Review of Resident #15's Level of Care Determination completed by the Council on Aging of Southwestern Ohio, dated 07/12/12, revealed Resident #15 had no indications of serious mental illness nor a developmental disability. Review of Resident #15's medical record diagnoses revealed Resident #15 was assigned the diagnoses of paranoid schizophrenia on 05/03/13. Review of Resident #15's medical record revealed the PASARR designated as being for Resident #15 was a PASARR for another resident. Interview on 10/17/24 at 10:40 A.M., with Social Services Designee #175 verified the facility does not have a PASARR or Level II determination for Resident #15. 44083 2. Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #1 included schizophrenia, urogenital implants, overactive bladder, and dysfunction of bladder. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition. Review of the Pre-Admission Screening and Resident Review, (PASRR), dated 07/23/18 revealed Resident #1 was approved for admission at a nursing facility. There were no further PASRR documents provided. Review of Resident #1's medical diagnoses documentation revealed the new diagnosis of paranoid schizophrenia was added on 01/25/19. Interview on 10/16/24 at 2:05 P.M., Social Service Designee, (SSD) # 175 verified Resident #1 had a new diagnosis of paranoid schizophrenia on 01/25/19. SSD #175 stated there should have been a new PASRR completed for Resident #1 due to a new addition of a mental health diagnosis. Review of Ohio Department of Medicaid PASRR instructions, listed on the PASRR form, dated September 2019, revealed a new PASRR is to be completed for nursing facility residents who experience a significant change in condition. Review of the undated policy titled Admissions revealed a PASARR will be provided, as appropriate, to the facility prior to or upon the resident's admission to the facility.

Based on medical record review, staff interview, resident interview, review of Emergency Medical Services (EMS) report, review of hospital records, review of witness statements, review of a facility Self-Reported Incident (SRI), and review of a facility policy, the facility failed to ensure a resident was free from staff-to-resident physical abuse. This resulted in Actual Harm when Resident #10 was physically abused by Stated tested Nursing Assistant (STNA) #101 who restrained the resident's arms against his chest causing numerous skin tears and contusions to the resident's arms and hands. Subsequently, Resident #10 was transferred to a local hospital where he was assessed and treated for injuries including, multiple skin tears, and contusions of the elbow and forearm. This affected one (#10) out of three Residents (#10, #12, and #25) reviewed for abuse. The facility census was 42. Findings include: Review of the medical record for Resident #10 revealed the resident was admitted to the facility on [DATE]. Diagnoses included acute respiratory failure, chronic kidney disease, diabetes mellitus, history of tuberculosis (TB), quadriplegia, insomnia, muscle weakness, encephalopathy, and major depressive episode. Review of a facility document titled Annual State tested Nursing Assistant (STNA) Competency Checks dated 06/02/24, revealed STNA #101 was proficient/expert/highly skilled in abuse and neglect which included making sure the resident was safe and immediately reporting abuse. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #10 was mildly cognitively impaired. Resident #10 was dependent on staff for all activities of daily living (ADLs). Review of the SRI dated 07/28/24 at 11:54 A.M., revealed an allegation of physical abuse. Resident #10 reported STNAs were rough with him while getting the resident up from the bed to the chair. Resident #10 alleged STNAs #63 and #101 were rough while performing care on the resident when Resident #10 became agitated and attempted to hit and bite the staff members. The staff attempted to protect Resident #10 and themselves. The staff alerted the nurse to the situation after the incident occurred. Both aides were interviewed and suspended pending the results of the investigation. STNA #101 was agency, and the facility requested for her not to return to the facility. The facility completed their investigation and unsubstantiated the allegation of abuse. Review of the After Visit Summary (AVS) emergency room (ER) record dated 07/28/24, revealed Resident #10 arrived in the ER at 2:38 P.M. via the local Fire Department with a complaint of an alleged assault from the Skilled Nursing Facility (SNF) where the resident resides at. Resident #10 reported the aide who provided care for him lost her mind and held him down by his arms and scratched him. Resident #10 voiced complaints of pain to his bilateral forearms and was noted with open skin tears to the back of the resident's hand. Resident #10 stated the aides at the nursing home attacked him and squeezed his arms tight and used their fingernails on his arms. The assessment indicated both of the resident's hands and forearms were discolored and seeping blood. Resident #10 had x-rays performed with no abnormalities. Resident #10 was diagnosed with multiple skin tears, and contusion of the elbow and forearm and discharged back to the facility. Review of a nurse's progress note for Resident #10 dated 07/28/24 at 3:29 P.M. and authored by Licensed Practical Nurse (LPN) #58, revealed she heard Resident #10 yelling he was abused. LPN #58 observed seven skin tears on both arms and the right elbow. Resident #10 stated they grabbed his arms and held them. When questioned, the aides reported Resident #10 tried to grab them, hit them, and bite them. LPN #58 questioned why the aides did not stop providing care and get help. Resident #10 has seven skin tears on both arms and right elbows and the aides were sent home pending an investigation. Review of a nurse's progress note dated 07/28/24 at 3:30 P.M. (recorded as a late entry) and authored by the Director of Nursing (DON), revealed on 07/28/24 at 11:31 A.M., the charge nurse indicated Resident #10 had reported his arms were held down by a STNA. The management staff advised the charge nurse to follow the facility's protocol. The Guardian was notified at 1:48 P.M. of the resident's complaints of bruising to bilateral arms with skin tears and the accusations of the STNA. The DON indicated she had consulted the physician, and he ordered for the resident to be seen by the wound Nurse Practitioner (NP) the next day. The DON indicated the resident wanted to go the hospital; however, the guardian requested for the resident to remain in the facility and be followed by the wound nurse on Monday. The DON indicated the physician had not given an order, but they would have to follow protocol. Review of the EMS report dated 07/28/24 at 4:27 P.M., revealed Resident #10 had injuries to his upper extremities due to an assault. Resident #10 told the EMS crew that he was assaulted by his nursing home aides. Resident #10 stated the staff grabbed him and shook him around in his bed. Resident #10 stated the aides used their fingernails to dig into his skin and cut him. Resident #10 was found lying in his bed and was alert, oriented to person, place, time, and event. Resident #10 had bilateral bruising and abrasions on his forearms and hands. Resident #10 complained of neck and back pain. Resident #10 was transported to the hospital. Review of the Interdisciplinary Team (IDT) Post Investigation Summary dated 07/28/24 and authored by the DON, revealed the DON received a phone call from LPN #58 on 07/28/24 indicating Resident #10 made allegations against the aides who were caring for him. Resident #10 had multiple skin tears on bilateral arms and bruising. The STNAs were removed from resident care and statements were obtained. Resident #10 was being assisted up when his Foley catheter fell and as the aide reached to grab it, the resident's head hit the wall. Resident #10 became upset, cussing and started fighting with the staff by swinging, hitting and trying to bite. The charge nurse provided first-aid to the resident and the resident was sent to the ER. Resident #10 returned back to the facility on [DATE]. Review of a witness statement by Resident #10 dated 07/28/24 and narrated by Social Services Director #61, revealed the agency aide (identified as STNA #101) grabbed the resident and dug her fingernails into his arms. The STNA crossed the resident's arms and pulled them until it felt like they were coming out of socket. Resident #10 was yelling for STNA #63 to help him and STNA #63 said there was nothing wrong. The STNA ripped his shirt off and got blood on the resident's clothes. Resident #10 indicated the aides tried to clean his arms with wipes which was burning and caused unbearable pains. Review of a witness statement from STNA #101 dated 07/28/24, revealed her and an aide (identified as STNA #63) were getting ready to get Resident #10 up and as they were turning him on his side, the resident said they were pulling on his catheter too hard, so she picked it up and put it on the bed. Resident #10 started cussing at them and tried to bite her several times and the resident broke his skin open with the Hoyer lift. STNA #101 indicated they let him calm down then STNA #63 took the resident out to smoke. STNA #63 noted the nurse was notified and they did not hold, hit or restrain the resident. Review of a witness statement from STNA #63 dated 07/28/24, revealed she asked STNA #101 to help get Resident #10 up. STNA #63 noted as they rolled the resident over to put him on the Hoyer pad, the resident hit his head on the wall and got aggravated and immediately accused STNA #101 of abusing him. Resident #10 attempted to bite STNA #101 then STNA #101 held his arms down in order for him to not hurt the STNAs or himself. STNA #63 indicated she left the room to get gloves and when she returned, STNA #101 was still holding the resident's arms down. STNA #63 indicated she observed blood on the resident's arm but did not see any abuse, only the resident being restrained. Review of a witness statement from Housekeeping Manager #91 dated 07/28/24, revealed she was bringing a resident inside from a smoke break, when STNAs #101 and #63 were bringing Resident #10 out of his room. Resident #10 was yelling and crying for help and said he was abused and asked for her to get the nurse. Resident #10 was taken outside for a smoke break around 11:30 A.M. and LPN #58 was outside on the porch. Housekeeping Manager #91 indicated she came back in from a smoke break and called the Administrator and the DON. There was blood and skin tears visible. Review of an undated witness statement from LPN #58, revealed when Resident #10 came out to smoke, he was yelling that they abused him. Resident #10 was asking LPN #58 to look at him. LPN #58 observed skin tears, and the resident stated a STNA was holding him down and abused him. Resident #10 identified STNA #101 along with STNA #63. LPN #58 noted she questioned STNAs #101 and #63 on what happened. Both STNAs were saying the resident was trying to bite STNA #101 and he was swinging his arms around and cussing at them. LPN #58 removed STNAs #101 and #63, got their statements and called the DON. Review of a physician's progress note for Resident #10 dated 07/29/24, revealed the resident was seen for ongoing management of medical conditions including his arms. There was an alleged altercation between the aides and Resident #10 with an active investigation. Resident #10 had bilateral arm skin tears and monitor for signs of infection. Review of a wound NP progress note for Resident #10 dated 07/29/24, revealed the resident was seen for new skin tears to bilateral arms and right hand. Resident #10 was noted with skin tears and bruising to right hand, right forearm and left forearm. Interview with STNA #63 on 08/26/24 at 11:30 A.M., revealed she was assigned to care for Resident #10 on 07/28/24 when she asked STNA #101 for assistance with transferring Resident #10 from his bed to his geriatric (geri) chair (large reclining, padded chairs with wheeled bases, and are designed to assist persons with limited mobility) so he could go on a smoke break. STNA #63 stated Resident #10 became resistant to care and was swinging his arms and tried to bite STNA #101. STNA #63 stated STNA #101 had long fingernails and held Resident #10's arms down around the lower arms and wrist against the bed. STNA #63 stated she was shocked at what she saw and did not know what to do. STNA #63 stated Resident #10 was bleeding from his arms due to multiple open areas. STNA #63 stated they finished transferring Resident #10 to the geri-chair then took Resident #10 outside for a smoke break. STNA #63 stated the resident had blood covering both arms. STNA #63 reported she did not stop the incident when it occurred because at the time of the incident, she did not know what to do; however, she wishes she had just stopped and got a nurse. STNA #63 stated she took Resident #10 outside to the porch to smoke and did not report to the incident to anyone. STNA #63 stated when she got Resident #10 outside, STNA #69 who was assisting residents with the smoke break, noticed the blood all over the resident's arms and called for a nurse. STNA #63 confirmed she received training related to resident abuse and reporting abuse upon being hired in May 2024. Interview with the DON on 08/26/24 at 12:53 P.M., revealed she was contacted by the facility staff on 07/28/24 at 11:31 A.M. and was made aware of the allegations of abuse by Resident #10. The DON stated she did not feel the incident was an abuse situation due her thoughts of the STNAs were only attempting to keep the resident and themselves safe. The DON stated the facility staff did not call 911 immediately because they were waiting on a call back from the Guardian to determine if the resident needed to go the ER. The DON stated Resident #10 called 911 at 2:08 P.M. because he insisted on going to the ER. The DON stated the facility suspended STNA #63 and asked the agency for STNA #101 to be placed on the do not return list. The DON stated there was no abuse and she felt STNAs #63 and #101 were trying to keep Resident #10 safe by preventing Resident #10 from swinging his arms and hitting items. The DON confirmed the facility does not allow residents to be restrained even for safety reasons. Interview with STNA #69 on 08/26/24 at 2:52 P.M., revealed she worked on 07/28/24 on another unit. STNA #69 stated she was on the porch by the exit door on 07/28/24 during the 11:00 A.M. smoke break when she observed STNA #63 transporting Resident #10 to the porch for his smoke break. STNA #69 stated Resident #10 was bleeding from both arms and yelling the aides abused him. STNA #69 instructed STNA #63 to go straight to the break room and not to provide care to anyone because she needed to report this allegation as soon as possible. STNA #69 stated she called for the nurse who was also on the porch to report the abuse allegations and the bleeding on Resident #10's arms. Interview with Resident #10 on 08/26/24 at 3:23 P.M., revealed he was abused and the facility refused to call 911, so he called 911 on 07/28/24. Resident #10 stated a STNA (identified as STNA #101) crossed his arms and pushed his arms down against his chest making it hard to breath. Resident #10 stated the STNA held his arms and caused bruises and scratches on his arms. Interview with LPN #58 on 08/26/24 at 4:12 P.M., revealed she was the nurse assigned to care for Resident #10 on 07/28/24. LPN #58 stated STNAs #63 and #101 were not gentle when they repositioned Resident #10 in bed or when moving the resident's legs. LPN #58 stated she was not in the room at the time when the alleged abuse occurred; however, LPN #58 stated she was in the resident's room prior to the incident because STNAs #63 and #101 were bickering with Resident #10. LPN #58 stated she instructed STNAs #63 and #101 to do their jobs and stop bickering with Resident #10. LPN #58 stated at that time, she did not observe any blood or bruising on Resident #10's arms. LPN #58 stated she went from Resident #10's room to the porch outside to assist with the 11:00 A.M. smoke break. LPN #58 stated she observed STNA #63 assisting Resident #10 to the porch and then left him. LPN #58 stated Resident #10 was yelling that he was abused and when she looked up from the other end of the porch, she observed the blood on Resident #10's arms. LPN #58 stated the blood was smeared and appeared as though someone tried to clean it up. LPN #58 stated she was amazed at the amount of skin tears that Resident #10 had. LPN #58 stated witness statements were obtained from both STNA #63 and STNA #101. LPN #58 stated she contacted the DON, and she did not want Resident #10 sent out to the hospital or the police called. LPN #58 stated she was instructed to write in her report that Resident #10 was swinging his arms, which caused the injuries. LPN #58 stated she advised Resident #10 to contact the police if he wanted to go to the hospital and the resident called 911 himself. Review of electronic mail (e-mail) correspondence from the Administrator dated 08/29/24 at 10:30 A.M., revealed the facility notified the local Police Department, and the Police Department closed the case. The Administrator stated the facility did not press any charges against STNAs #63 or #101. The Administrator stated the facility identified an opportunity for education; however, does not feel that abuse occurred. Review of the personnel file for STNA #63, revealed she was hired on 05/29/24 and received training on resident abuse. STNA #63 had an active STNA license with no restrictions. There were no disciplinary actions or coachable moments identified in her record. Review of the facility policy titled, Abuse and Neglect Protocol, dated 09/24/18, revealed the residents have the right to be free from any form of abuse and this included, physical abuse, verbal abuse, and physical restraints. The policy indicated any individual who observed abuse or suspects abuse must immediately report such incident to the Director of Nursing (DON). This deficiency represents non-compliance investigated under Complaint Number OH00156392.

Based on observations and staff interviews, the facility failed to ensure a safe, functional, and homelike environment for the residents. This affected six resident rooms of 18 resident rooms and one shower room utilized by all residents. The census was 42. Findings include: Observation on 07/10/24, of the main shower room, utilized by all facility residents, revealed damaged drywall and peeling paint on the shower stall ceiling and grout between the ceramic tile that had a black residue. Observation on 07/10/24, revealed resident Rooms 104, 105, 111, 112, 114 and 115 to have ceiling tile with black or brown stains. Observation on 07/10/24 of room [ROOM NUMBER] revealed a hole in the wall behind the main door and room [ROOM NUMBER] revealed a hole in the wall behind the middle bed. Interview on 07/10/24 at 8:05 A.M., with Staff #200 confirmed the condition of the main shower room stall, the discolored ceiling tiles in rooms 104, 105, 111, 112, 114 and 115, and the holes in the wall in room [ROOM NUMBER] and 114. Interview on 07/10/24 at 1:35 P.M., with Staff #300 confirmed all residents as utilizing the main shower room. This deficiency represents non-compliance investigated under Complaint Number OH00154800.

Based on medical record review, staff interviews, review of a facility Self- Reported Incident (SRI), review of a police report and review of the facility abuse policy, the facility staff failed to take action to protect residents from further potential abuse after Resident #15 alleged he was sexually abused by Resident #3. This resulted in Immediate Jeopardy for one (#15) of three residents reviewed for sexual abuse and 34 (#1, #2, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35 and #36) additional cognitively impaired residents who were potentially at risk for abuse. The facility census was 36. On 07/08/13 at 1:00 P.M., the Director of Nursing (DON) was notified that Immediate Jeopardy began on 06/30/13 at 4:30 A.M. when Resident #15 was found by State tested Nursing Assistant (STNA) #10 lying face down on his torso perpendicular across the bed with his head and arms hanging over one side of the bed and his legs from the knees down hanging over the opposite side of the bed. Resident #15's pants were on the floor and he was wearing a pull up incontinence product. When Resident #15 was asked how he got in that position he stated he had been sexually assaulted by his roommate, Resident #3. Resident #15's allegation of sexual abuse was reported to Licensed Practical Nurse (LPN) #5, the charge nurse on duty. LPN #5 failed to take action to ensure protection of the other residents in the facility and initiate direct continuous observation of Resident #3's whereabouts to prevent further abuse. From 07/01/13 to 07/04/13, during the period he was on 15 minute checks, Resident #3 was observed to inappropriately touch other residents four times. The 15 minutes checks were not effective at preventing potential further abuse. The Immediate Jeopardy was removed on 07/05/13 at 10:30 A.M. when Resident #3 was placed on continuous visual supervision by staff. The deficiency remained at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) until it was corrected on 07/29/13 when the facility implemented the following corrective actions: ? On 06/30/13 at 5:00 A.M., Resident #15 was removed from the room and provided one on one monitoring by LPN #5. ? On 06/30/13 at 7:00 A.M., the facility began 15 minute checks on Resident #3. ? On 06/30/13 at 10:10 A.M. Resident #15 was transported to the hospital emergency room for evaluation. The facility was informed the rape test was negative and the Sexual Assault Nurse Examiner (SANE) assessment nurse had nothing to add. The resident returned to the facility the same day. The emergency room report dated 06/30/13 at 11:13 A.M. documented the Resident #15 had no rectal tears or bleeding at the current time. ? On 06/30/13 at 10:21 A.M., the police were notified and dispatched to the facility where they arrived at 10:41 A.M. ? On 07/05/13 at 10:30 A.M., Resident #3 was placed on constant visual supervision by staff. ? Interviews with three residents (#10, #12 and #17) on 07/09/13 at 10:45 A.M. revealed they had never been abused by other residents or staff. They voiced no issues with the care they received by staff and expressed they did not feel afraid in the facility. ? On 07/10/13, the facility revised and implemented their new abuse policy. The new policy stated "if staff is accused abuser, they will be asked for a written statement and be closed out and go home unless arrested, and will remain off the job/suspension until investigation is completed." "Always protect the resident from harm during the investigation by providing room change (if applicable), place suspected perpetrator on one on one (monitoring) indefinitely or until proven innocent, if applicable the suspected perpetrator may also be taken by police." ? On 07/10/13 the facility implemented their newly revised Abuse policy, adding how to protect residents when abuse is alleged. All staff were inserviced on the newly revised policy. ? On 07/29/13, LPN #300, LPN #301, STNA #201, #202, #203 and #204 were interviewed and all were able to articulate the newly revised Abuse policy. Findings include: Review of the medical record of Resident #15 revealed [DIAGNOSES REDACTED]. The most recent comprehensive assessment dated [DATE] identified the resident with severe cognitive impairment, unclear speech, sometimes understood, and usually understands others. He was identified with inattention, disorganized thinking that was present with fluctuations and his behaviors included hallucinations and [MEDICAL CONDITION]. The assessment documented Resident #15's Activities of Daily Living (ADL) as independent with bed mobility, limited assistance of one staff for transfers, extensive assist of one staff for dressing, toileting, and personal hygiene. The resident is incontinent of both bowel and bladder, and is self-ambulatory in a wheelchair. Review of the medical record of Resident #3 revealed [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] from a psychiatric hospital where he had been placed due to grossly impaired judgment, behavior or capacity to recognize reality, inability to meet life demands, risk to self, and benefit from hospital treatment, disabled. Review of the social work assessment from the hospital documented the resident had a history of [REDACTED]. He had a history of [REDACTED]. His legal status was incompetent. Review of the initial facility's Self-Reported Incident Form dated 06/30/13 documented the facility suspected Resident #3 sexually abused his roommate, Resident #15. Resident #15 was moved to another room and taken to the hospital for a rape kit test. Investigation along with the local police department is in progress. The allegation of sexual abuse was substantiated by the facility. Review of nursing notes dated 06/30/13 at 4:30 A.M. revealed LPN #5 documented STNA #10 was doing rounds when she found Resident #15 (victim) lying across his bed the opposite way. He was asked how he got that way and he replied, "The man next door put me this way", (referring to Resident #3). The resident's arms and legs were bending over the sides of the bed. A puddle of water was at the edge of the bed. At the resident's feet, his pants were lying on the floor next to the bed. He was put in the bed the correct way by staff. He was asked why he was placed like that in bed and the resident stated, "The man next door gave me pop to lay like that." The resident was asked if he was touched inappropriately and he stated, "the guy next door put his fingers in my rectum". At this time, Resident #3 awoke and asked staff "what was going on." He was told to remain asleep. Resident #15 was checked, and his body was found to be wet on his abdomen and lower extremities. The resident stated "I want to get out of here." When asked why, the resident stated, "he (Resident #3) is trying to get me to suck his penis." The written statement by STNA #10, dated 06/30/13, documented she was walking down the hall and noticed the door to the room of Resident #3 and Resident #15 was closed. She documented upon entering the room Resident #15 was seen lying face down sideways in the bed with his butt in the air, stomach on the bed, and hands in front of him. His pants were off and on the floor. STNA #10 got LPN #5 and they began to reposition the resident. He was asked how he got in that position and if someone tried to touch him. He said "a man threw me in this position. He told me he needed to see how deep my rectum was and the man said he was a doctor." He stated the man "stuck his finger in my rectum." The resident stated he "poked him twice and tried to put it (penis) in my ear and my eye." It was noted the resident said he was not hurt and a guard was placed at the door. The statement documented Resident #3 tried to close the door but staff opened it right away. Staff got Resident #15 dressed and out of the room. STNA #10 documented she noticed a smear of stool in Resident #15's incontinent brief and he had not had a bowel movement that shift. Review of the written statement by STNA #11 on 06/30/13 documented she was working the second assignment which did not include Resident #3 or Resident #15. Documentation indicated LPN #10 had asked STNA #11 to watch the resident's room while the DON was contacted. STNA #11 was asked to watch Resident #15 to ensure she knew where he was and to make sure nothing happened. STNA #11 stood in the hallway for a while until she had to attend to her residents she was assigned and the nurse gave her permission to go. STNA #11 documented she watched Resident #3 who appeared anxious/nervous and he came out of his room several times. "When I left to do my assignment he was sitting in the TV room and then returned to his room and shut the door. I opened the door and told him they could not have the door shut. I turned on the light and Resident #3 was walking back to his bed and Resident #15 was lying in his bed on his back. I believe it was about 4:30 A.M. when I was asked to watch the room." A written statement by the day shift supervisor, LPN #66, dated 06/30/13 documented Resident #15 made allegations his roommate, Resident #3, had said he was a doctor and gave him a rectal exam with his finger. It was reported the bed sheet was smeared with a small amount of stool. At 8:00 A.M., Resident #15 was re-located to room [ROOM NUMBER], a vacant room. The physician's Nurse Practitioner was called at 8:10 A.M. and Resident #15's family was notified at 9:30 A.M. The police were contacted at 10:10 A.M. LPN #66 ' s statement documented staff were continuing to do 15 minute checks on Resident #3. The police called the squad to transport Resident #15 to the emergency room for testing. The report from the emergency roiagnom on [DATE] at 11:25 A.M. was the resident was negative for any trauma of the anal area. Review of the written statement documented by LPN #5 on 06/30/13 at 4:30 A.M. revealed while interviewing Resident #15, Resident #3 left the room. LPN #5 followed him and asked to see his hands and he refused, putting them into his pockets. She noted on the facility camera she saw Resident #3 re-enter the room and Resident #15 was in his bed. Resident #15 was observed throwing off his covers and trying to get up. While getting him up and dressed she noted two small drops of blood and a smudge of feces a few inches from the blood. See documented she took the resident with her to the nurses' station and kept him with her through her morning medication pass. On 07/01/13 at 10:05 A.M., Resident #15 was interviewed by the DON. The resident did not recall the incident and said he was not aware of anything happening between him and his roommate. On 07/01/13 at 10:15 A.M., Resident #3 was interviewed by the DON and denied telling his roommate he was a doctor and examining him. Review of a nursing note dated 07/01/13 at 12:30 P.M. revealed Resident #3 was observed rubbing the chest of a male resident, Resident #28, rubbing his shoulder, and then shook his hand. On 07/03/13 at 9:05 A.M., an interview was conducted with Resident #3. When he was asked about an incident with his former roommate and if he had touched him inappropriately Resident #3 stood up and said "No, I'm not talking to you anymore" and left the area. On 07/03/13 at 9:15 A.M., an interview was conducted with Resident #15. When the resident was asked if anyone had touched him or made him uncomfortable he said "I'm not really sure. He was rubbing against me and bumping against me." When asked again about sexual advances, he said, "No" and if they did he didn't know about it. The resident was pleasant and smiling during the interview and did not appear uncomfortable. On 07/03/13 at 5:30 P.M., nurses notes documented Resident #3 was observed seated on the side of a female resident, Resident #26, with his hand on her shoulder and holding her other hand which was resting on her knee. He was asked four times by staff to let go and would not. The nurse had to physically pry their hands apart. Nurses notes documented a review of the camera footage showed Resident #3 had kissed the female resident on the forehead during their encounter. On 07/04/13 at 8:43 A.M., nurses' notes documented Resident #3 leaning in for a hug after shaking the hand of a male resident (#13). He was reminded at that time what the police had said. The police were called and spoke with the resident about keeping his hands to himself. At 1:20 P.M., activity staff observed Resident #3 kissing female Resident #4 on the lips. Review of the camera footage showed Resident #3 walked past the female resident stopped, turned towards her and kissed her twice. Nursing notes documented the resident was reminded he was not to touch or kiss anyone and remained on 15 minute checks. On 07/04/13 at 8:43 A.M., the nurse was exiting room [ROOM NUMBER] to the middle lobby when she observed Resident #3 shaking hands with male Resident #13 with another hand on his shoulder leaning in for a hug. The resident was reminded what the police officer had said to him earlier about touching others. The police department, no time indicated, was documented as coming to the facility and speaking with Resident #3 about not touching others. A call to the physician was made at 10:30 A.M. and the physician ordered the resident on a hormone medication, [MEDICATION NAME] 10 milligrams daily. Review of nurses' notes dated 07/04/13 at 1:20 P.M. revealed activity staff alerted the nurse she observed Resident #3 kissing female Resident #4 on the lips. Camera footage reviewed showed Resident #4 was kissed twice by Resident #3. Interview with the DON on 07/05/13 at 10:30 A.M. revealed the physician had been called and continuous one-on-one monitoring was put in place for Resident #3. A staff member was observed on 07/05/13 sitting outside the resident's door and with him in the common areas throughout the day. On 07/08/13 at 8:48 P.M., a detective from the police department interviewed Resident #3 again. After the interview, he informed the DON and the surveyor Resident #3 had admitted lying Resident #15 across the bed and taking off his pants. He told the officer Resident #15 requested to be positioned that way, and he was hot. Review of the facility Policy and Procedure for Abuse, Neglect, and Misappropriation of Property, dated 01/25/12, did not contain any section discussing protection of residents during allegations of abuse. The policy contained one sentence that stated "always protect the resident from harm during the investigation" but the policy did not indicate what specific actions were required by facility staff to ensure the protection of other residents after an allegation of abuse is made. This citation substantiates Complaint Number OH 809.

Based on medical record review, staff interviews, review of a facility Self-Reported Incident (SRI), review of a police report and review of the abuse policy, the facility failed to develop an abuse policy and procedure that included protection of residents from harm during an abuse investigation. Failure to have a comprehensive abuse policy and procedure that staff could operationalize resulted in Immediate Jeopardy for one (#15) of three residents reviewed for actual sexual abuse and put all 36 residents residing in the facility at risk for abuse due to the systemic failure. On 07/08/13 at 1:00 P.M. the Director of Nursing (DON) was notified that Immediate Jeopardy began on 06/30/13 at 4:30 A.M. when Resident #15 was found by State tested Nursing Assistant (STNA) #10 lying face down on his torso perpendicular across the bed with his head and arms hanging over one side of the bed and his legs from the knees down hanging over the opposite side of the bed. Resident #15's pants were on the floor and he was wearing a pull up incontinence product. When Resident #15 was asked how he got in that position he stated he had been sexually assaulted by his roommate, Resident #3. Resident #15's allegation of sexual abuse was reported to Licensed Practical Nurse (LPN) #5, the charge nurse on duty. LPN #5 failed to take action to ensure protection of the other residents in the facility and initiate direct continuous observation of Resident #3's whereabouts to prevent further abuse. From 07/01/13 to 07/04/13, during the period he was on 15 minute checks, Resident #3 was observed to inappropriately touch other residents four times. The 15 minutes checks were not effective at preventing potential further abuse. The Immediate Jeopardy was removed on 07/05/13 at 10:30 A.M. when Resident #3 was placed on continuous visual supervision by staff. The deficiency remained at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) until it was corrected on 07/29/13 when the facility implemented the following corrective actions: ? On 06/30/13 at 5:00 A.M., Resident #15 was removed from the room and provided one-on-one monitoring by LPN #5. ? On 06/30/13 at 7:00 A.M., the facility began 15 minute checks on Resident #3. ? On 06/30/13 at 10:10 A.M., Resident #15 was transported to the hospital emergency room for evaluation. The facility was informed the rape test was negative and the Sexual Assault Nurse Examiner (SANE) assessment nurse had nothing to add. The resident returned to the facility the same day. The emergency room report dated 06/30/13 at 11:13 A.M. documented the Resident #15 had no rectal tears or bleeding at the current time. ? On 06/30/13 at 10:21 A.M., the police were notified and dispatched to the facility where they arrived at 10:41 A.M. ? On 07/05/13 at 10:30 A.M., Resident #3 was placed on constant visual supervision by staff. ? Interview with three residents (#10, #12 and #17) on 07/09/13 at 10:45 A.M. revealed they had never been abused by other residents or staff. They voiced no issues with the care they received by staff, and they did not feel afraid in the facility. ? On 07/10/13, the facility revised and implemented the new abuse policy. The new policy stated "if staff is accused/abuser, they will be asked for a written statement and be closed out and go home unless arrested and will remain off the job/suspension until investigation is completed." "Always protect the resident from harm during the investigation by providing room change (if applicable), place suspected perpetrator on one-on-one (monitoring) indefinitely or until proven innocent, if applicable the suspected perpetrator may also be taken by police." ? On 07/10/13 the facility implemented their newly revised Abuse policy, adding how to protect residents when abuse is alleged. All staff were inserviced on the newly revised policy. ? On 07/29/13, LPN #300, LPN #301, STNA #201, #202, #203 and #204 were interviewed and all were able to articulate the newly revised Abuse policy. Findings include: Review of the medical record of Resident #15 revealed [DIAGNOSES REDACTED]. The most recent comprehensive assessment dated [DATE] identified the resident with severe cognitive impairment, unclear speech, sometimes understood and usually understands others. He was identified with inattention, disorganized thinking that is present with fluctuations and his behaviors included hallucinations and [MEDICAL CONDITION]. The assessment documented Resident #15's Activities of Daily Living (ADL) as independent with bed mobility, limited assistance of one staff for transfers, extensive assist of one staff for dressing, toileting, and personal hygiene. The resident is incontinent of both bowel and bladder, and is self-ambulatory in a wheelchair. Review of the medical record of Resident #3 revealed [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] from a psychiatric hospital where he had been placed due to grossly impaired judgment, behavior or capacity to recognize reality, inability to meet life demands, risk to self, and benefit from hospital treatment, disabled. Review of the social work assessment from the hospital documented the resident had a history of [REDACTED]. He had a history of [REDACTED]. His legal status was incompetent. Review of the initial facility's Self-Reported Incident Form dated 06/30/13 documented the facility suspected Resident #3 sexually abused his roommate, Resident #15. Resident #15 was moved to another room and taken to the hospital for a rape kit test. Investigation along with the local police department is in progress. The allegation of sexual abuse was substantiated by the facility. Review of nursing notes dated 06/30/13 at 4:30 A.M. revealed LPN #5 documented STNA #10 was doing rounds when she found Resident #15 (victim) lying across his bed the opposite way. He was asked how he got that way and he replied "The man next door put me this way" (referring to Resident #3). The resident's arms and legs were bending over the sides of the bed. A puddle of water was at the edge of the bed. At the resident's feet, his pants were lying on the floor next to the bed. He was put in the bed the correct way by staff. He was asked why he was placed like that in bed and the resident stated, "The man next door gave me pop to lay like that." The resident was asked if he was touched inappropriately and he stated, "the guy next door put his fingers in my rectum". At this time, Resident #3 awoke and asked staff "what was going on." He was told to remain asleep. Resident #15 was checked, and his body was found to be wet on his abdomen and lower extremities. The resident stated "I want to get out of here." When asked why, the resident stated "he (Resident #3) is trying to get me to suck his penis." The written statement by STNA #10, dated 06/30/13, documented she was walking down the hall and noticed the door to the room of Resident #3 and Resident #15 was closed. She documented upon entering the room Resident #15 was seen lying face down sideways in the bed with his butt in the air, stomach on the bed, and hands in front of him. His pants were off and on the floor. STNA #10 got LPN #5 and they began to reposition the resident. He was asked how he got in that position and if someone tried to touch him. He said "a man threw me in this position. He told me he needed to see how deep my rectum was and the man said he was a doctor. He stated the man stuck his finger in my rectum. The resident stated he "poked him twice and tried to put it (penis) in my ear and my eye." It was noted the resident said he was not hurt and a guard was placed at the door. The statement documented Resident #3 tried to close the door but staff opened it right away. Staff got Resident #15 dressed and out of the room. STNA #10 documented she noticed a smear of stool in Resident #15's incontinent brief and he had not had a bowel movement that shift. Review of the written statement by STNA #11 on 06/30/13 documented she was working the second assignment which did not include Resident #3 or Resident #15. Documentation indicated LPN #10 had asked STNA #11 to watch the resident's room while the DON was contacted. STNA #11 was asked to watch Resident #15 to ensure she knew where he was and to make sure nothing happened. STNA #11 stood in the hallway for a while until she had to attend to her residents she was assigned and the nurse gave her permission to go. STNA #11 documented she watched Resident #3 who appeared anxious/nervous and he came out of his room several times. "When I left to do my assignment he was sitting in the TV room and then returned to his room and shut the door. I opened the door and told him they could not have the door shut. I turned on the light and Resident #3 was walking back to his bed and Resident #15 was lying in his bed on his back. I believe it was about 4:30 A.M. when I was asked to watch the room." A written statement by the day shift supervisor, LPN #66, dated 06/30/13 documented Resident #15 made allegations his roommate, Resident #3, had said he was a doctor and gave him a rectal exam with his finger. It was reported the bed sheet was smeared with a small amount of stool. At 8:00 A.M., Resident #15 was re-located to room [ROOM NUMBER], a vacant room. The physician's Nurse Practitioner was called at 8:10 A.M. and Resident #15's family was notified at 9:30 A.M. The police were contacted at 10:10 A.M. LPN #66's statement documented staff were continuing to do 15 minute checks on Resident #3. The police called the squad to transport Resident #15 to the emergency room for testing. The report from the emergency roiagnom on [DATE] at 11:25 A.M. was the resident was negative for any trauma of the anal area. Review of the written statement documented by LPN #5 on 06/30/13 at 4:30 A.M. revealed while interviewing Resident #15, Resident #3 left the room. LPN #5 followed him and asked to see his hands and he refused, putting them into his pockets. She noted on the facility camera she saw Resident #3 re-enter the room and Resident #15 was in his bed. Resident #15 was observed throwing off his covers and trying to get up. While getting him up and dressed she noted two small drops of blood and a smudge of feces a few inches from the blood. See documented she took the resident with her to the nurses' station and kept him with her through her morning medication pass. On 07/01/13 at 10:05 A.M., Resident #15 was interviewed by the DON. The resident did not recall the incident and said he was not aware of anything happening between him and his roommate. On 07/01/13 at 10:15 A.M., Resident #3 was interviewed by the DON and denied telling his roommate he was a doctor and examining him. Review of a nursing note dated 07/01/13 at 12:30 P.M. revealed Resident #3 was observed rubbing the chest of a male resident, Resident #28, rubbing his shoulder, and then shook his hand. On 07/03/13 at 9:05 A.M., an interview was conducted with Resident #3. When he was asked about an incident with his former roommate and if he had touched him inappropriately Resident #3 stood up and said "No, I'm not talking to you anymore" and left the area. On 07/03/13 at 9:15 A.M., an interview was conducted with Resident #15. When the resident was asked if anyone had touched him or made him uncomfortable he said "I'm not really sure. He was rubbing against me and bumping against me." When asked again about sexual advances, he said, "No" and if they did he didn't know about it. The resident was pleasant and smiling during the interview and did not appear uncomfortable. On 07/03/13 at 5:30 P.M., nurses notes documented Resident #3 was observed seated on the side of a female resident, Resident #26, with his hand on her shoulder and holding her other hand which was resting on her knee. He was asked four times by staff to let go and would not. The nurse had to physically pry their hands apart. Nurses notes documented a review of the camera footage showed Resident #3 had kissed the female resident on the forehead during their encounter. On 07/04/13 at 8:43 A.M., nurses' notes documented Resident #3 leaning in for a hug after shaking the hand of a male resident (#13). He was reminded at that time what the police had said. The police were called and spoke with the resident about keeping his hands to himself. At 1:20 P.M., activity staff observed Resident #3 kissing female Resident #4 on the lips. Review of the camera footage showed Resident #3 walked past the female resident stopped, turned towards her and kissed her twice. Nursing notes documented the resident was reminded he was not to touch or kiss anyone and remained on 15 minute checks. On 07/04/13 at 8:43 A.M., the nurse was exiting room [ROOM NUMBER] to the middle lobby when she observed Resident #3 shaking hands with male Resident #13 with another hand on his shoulder leaning in for a hug. The resident was reminded what the police officer had said to him earlier about touching others. The police department, no time indicated, was documented as coming to the facility and speaking with Resident #3 about not touching others. A call to the physician was made at 10:30 A.M. and the physician ordered the resident on a hormone medication, [MEDICATION NAME] 10 milligrams daily. Review of nurses' notes dated 07/04/13 at 1:20 P.M. revealed activity staff alerted the nurse she observed Resident #3 kissing female Resident #4 on the lips. Camera footage reviewed showed Resident #4 was kissed twice by Resident #3. Interview with the DON on 07/05/13 at 10:30 A.M. revealed the physician had been called and continuous one-on-one monitoring was put in place for Resident #3. A staff member was observed on 07/05/13 sitting outside the resident's door and with him in the common areas throughout the day. On 07/08/13 at 8:48 P.M., a detective from the police department interviewed Resident #3 again. After the interview, he informed the DON and the surveyor Resident #3 had admitted lying Resident #15 across the bed and taking off his pants. He told the officer Resident #15 requested to be positioned that way, and he was hot. Review of the facility Policy and Procedure for Abuse, Neglect, and Misappropriation of Property, dated 01/25/12, did not contain any section discussing protection of residents during allegations of abuse. The policy contained one sentence that stated "always protect the resident from harm during the investigation" but the policy did not indicate what specific actions were required by facility staff to ensure the protection of other residents after an allegation of abuse is made. This citation substantiates Complaint Number OH 809.

Based on review of a facility self-reported incident (SRI), medical record review, resident and staff interview, review of a police report, and review of the facility abuse policy, the facility failed to ensure one cognitively impaired male resident was free from sexual abuse. This resulted in Immediate Jeopardy for one (#15) resident who was found to have been sexually assaulted by Resident #3. The affected one (#15) of three residents reviewed for potential sexual abuse in a total facility census of 36. All 36 residents in the facility are cognitively impaired. On 07/08/13 at 1:00 P.M., the Director of Nursing (DON) was notified that Immediate Jeopardy began on 06/30/13 at 4:30 A.M. when Resident #15 was found by State tested Nursing Assistant (STNA) #10 lying face down on his torso perpendicular across the bed with his head and arms hanging over one side of the bed and his legs from the knees down hanging over the opposite side of the bed. Resident #15's pants were on the floor and he was wearing a pull up incontinence product. When Resident #15 was asked how he got in that position he stated he had been sexually assaulted by his roommate, Resident #3. The Immediate Jeopardy was removed on 07/05/13 at 10:30 A.M. when the facility placed Resident #3 on constant visual supervision by staff. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal that is not Immediate Jeopardy) until it was corrected on 07/29/13 when the facility implemented the following corrective action: ? On 06/30/13 at 5:00 A.M., Resident #15 was removed from the room and provided one-on-one monitoring by Licensed Practical Nurse (LPN) #5. ? On 06/30/13 at 7:00 A.M., the facility began 15 minutes checks on Resident #15. ? On 06/30/13 at 10:10 A.M., Resident #15 was transported to the hospital emergency room for evaluation. The facility was informed the rape test was negative and the Sexual Assault Nurse Examiner (SANE) assessment nurse had nothing to add. The resident was returned to the facility the same day. The emergency room report dated 06/30/13 at 11:13 A.M. documented the resident had no rectal tears or bleeding at the current time. The patient was evaluated by the SANE nurse and would be discharged . ? On 06/30/13 at 4:00 P.M. and continuing on 07/01/13 and 07/02/13, all employees of the facility were in-serviced on abuse and abuse reporting, including suspected criminal abuse. ? On 06/30/13 at 10:21 A.M., the police were notified and dispatched to the facility, arriving at 10:41 A.M. ? On 07/01/13 at 7:00 A.M., Resident #3 was placed on 15 minutes checks. ? On 07/05/13 at 10:30 A.M., Resident #3 was placed on constant visual supervision by staff. ? On 07/05/13 at 11:00 A.M., all departments were in-serviced on the one-on-one policy, abuse policy and procedures for conducting an investigation. ? Interviews with LPN #10 and LPN #12 on 07/09/13 at 10:30 A.M. revealed they had been in-serviced on the new changes to the abuse policy, and the one-on-one policy. ? Interviews with STNA #13 and STNA #14 on 07/09/13 at 10:40 A.M. revealed both had been in-serviced on the new changes to the abuse policy and the one-on-one policy. ? Interviews with three residents (#10, #12 and #17) on 07/09/13 at 10:45 A.M. revealed they had never been abused by other residents or staff. They voiced no issues with the care they received by staff and expressed they did not feel afraid in the facility. ? On 07/10/13 the facility implemented their newly revised Abuse policy, adding how to protect residents when abuse is alleged. All staff were inserviced on the newly revised policy. ? On 07/29/13, LPN #300, LPN #301, STNA #201, #202, #203 and #204 were interviewed and all were able to articulate the newly revised Abuse policy. Findings include: Review of the medical record of Resident #15 revealed [DIAGNOSES REDACTED]. The most recent comprehensive assessment dated [DATE] identified the resident with severe cognitive impairment, unclear speech, sometimes understood, and usually understands others. He was identified with inattention, disorganized thinking that was present with fluctuations and his behaviors included hallucinations and [MEDICAL CONDITION]. The assessment documented Resident #15's Activities of Daily Living (ADL) as independent with bed mobility, limited assistance of one staff for transfers, extensive assist of one staff for dressing, toileting, and personal hygiene. The resident is incontinent of both bowel and bladder, and is self-ambulatory in a wheelchair. Review of the medical record of Resident #3 revealed [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] from a psychiatric hospital where he had been placed due to grossly impaired judgment, behavior or capacity to recognize reality, inability to meet life demands, risk to self, and benefit from hospital treatment, disabled. Review of the social work assessment from the hospital documented the resident had a history of [REDACTED]. He had a history of [REDACTED]. His legal status was incompetent. Review of the initial facility's Self-Reported Incident Form dated 06/30/13 documented the facility suspected Resident #3 sexually abused his roommate, Resident #15. Resident #15 was moved to another room and taken to the hospital for a rape kit test. Investigation along with the local police department is in progress. The allegation of sexual abuse was substantiated by the facility. Review of nursing notes dated 06/30/13 at 4:30 A.M. revealed LPN #5 documented STNA #10 was doing rounds when she found Resident #15 (victim) lying across his bed the opposite way. He was asked how he got that way and he replied, "The man next door put me this way", (referring to Resident #3). The resident's arms and legs were bending over the sides of the bed. A puddle of water was at the edge of the bed. At the resident's feet, his pants were lying on the floor next to the bed. He was put in the bed the correct way by staff. He was asked why he was placed like that in bed and the resident stated, "The man next door gave me pop to lay like that." The resident was asked if he was touched inappropriately and he stated, "the guy next door put his fingers in my rectum". At this time, Resident #3 awoke and asked staff "what was going on." He was told to remain asleep. Resident #15 was checked, and his body was found to be wet on his abdomen and lower extremities. The resident stated "I want to get out of here." When asked why, the resident stated, "he (Resident #3) is trying to get me to suck his penis." The written statement by STNA #10, dated 06/30/13, documented she was walking down the hall and noticed the door to the room of Resident #3 and Resident #15 was closed. She documented upon entering the room Resident #15 was seen lying face down sideways in the bed with his butt in the air, stomach on the bed, and hands in front of him. His pants were off and on the floor. STNA #10 got LPN #5 and they began to reposition the resident. He was asked how he got in that position and if someone tried to touch him. He said "a man threw me in this position. He told me he needed to see how deep my rectum was and the man said he was a doctor." He stated "the man stuck his finger in my rectum". The resident stated he "poked him twice and tried to put it (penis) in my ear and my eye." It was noted the resident said he was not hurt and a guard was placed at the door. The statement documented Resident #3 tried to close the door but staff opened it right away. Staff got Resident #15 dressed and out of the room. STNA #10 documented she noticed a smear of stool in Resident #15's incontinent brief and he had not had a bowel movement that shift. Review of the written statement by STNA #11 on 06/30/13 documented she was working the second assignment which did not include Resident #3 or Resident #15. Documentation indicated LPN #10 had asked STNA #11 to watch the resident's room while the DON was contacted. STNA #11 was asked to watch Resident #15 to ensure she knew where he was and to make sure nothing happened. STNA #11 stood in the hallway for a while until she had to attend to her residents she was assigned and the nurse gave her permission to go. STNA #11 documented she watched Resident #3 who appeared anxious/nervous and he came out of his room several times. "When I left to do my assignment he was sitting in the TV room and then returned to his room and shut the door. I opened the door and told him they could not have the door shut. I turned on the light and Resident #3 was walking back to his bed and Resident #15 was lying in his bed on his back. I believe it was about 4:30 A.M. when I was asked to watch the room." A written statement by the day shift supervisor, LPN #66, dated 06/30/13 documented Resident #15 made allegations his roommate, Resident #3, had said he was a doctor and gave him a rectal exam with his finger. It was reported the bed sheet was smeared with a small amount of stool. At 8:00 A.M., Resident #15 was re-located to room [ROOM NUMBER], a vacant room. The physician's Nurse Practitioner was called at 8:10 A.M. and Resident #15's family was notified at 9:30 A.M. The police were contacted at 10:10 A.M. LPN #66 ' s statement documented staff were continuing to do 15 minute checks on Resident #3. The police called the squad to transport Resident #15 to the emergency room for testing. The report from the emergency roiagnom on [DATE] at 11:25 A.M. was the resident was negative for any trauma of the anal area. Review of the written statement documented by LPN #5 on 06/30/13 at 4:30 A.M. revealed while interviewing Resident #15, Resident #3 left the room. LPN #5 followed him and asked to see his hands and he refused, putting them into his pockets. She noted on the facility camera she saw Resident #3 re-enter the room and Resident #15 was in his bed. Resident #15 was observed throwing off his covers and trying to get up. While getting him up and dressed she noted two small drops of blood and a smudge of feces a few inches from the blood. See documented she took the resident with her to the nurses' station and kept him with her through her morning medication pass. On 07/01/13 at 10:05 A.M., Resident #15 was interviewed by the DON. The resident did not recall the incident and said he was not aware of anything happening between him and his roommate. On 07/01/13 at 10:15 A.M., Resident #3 was interviewed by the DON and denied telling his roommate he was a doctor and examining him. Review of a nursing note dated 07/01/13 at 12:30 P.M. revealed Resident #3 was observed rubbing the chest of a male resident, Resident #28, rubbing his shoulder, and then shook his hand. On 07/03/13 at 9:05 A.M., an interview was conducted with Resident #3. When he was asked about an incident with his former roommate and if he had touched him inappropriately Resident #3 stood up and said "No, I'm not talking to you anymore" and left the area. On 07/03/13 at 9:15 A.M., an interview was conducted with Resident #15. When the resident was asked if anyone had touched him or made him uncomfortable he said "I'm not really sure. He was rubbing against me and bumping against me." When asked again about sexual advances, he said, "No" and if they did he didn't know about it. The resident was pleasant and smiling during the interview and did not appear uncomfortable. On 07/03/13 at 5:30 P.M., nurses notes documented Resident #3 was observed seated on the side of a female resident, Resident #26, with his hand on her shoulder and holding her other hand which was resting on her knee. He was asked four times by staff to let go and would not. The nurse had to physically pry their hands apart. Nurses notes documented a review of the camera footage showed Resident #3 had kissed the female resident on the forehead during their encounter. On 07/04/13 at 8:43 A.M., nurses' notes documented Resident #3 leaning in for a hug after shaking the hand of a male resident (#13). He was reminded at that time what the police had said. The police were called and spoke with the resident about keeping his hands to himself. At 1:20 P.M., activity staff observed Resident #3 kissing female Resident #4 on the lips. Review of the camera footage showed Resident #3 walked past the female resident stopped, turned towards her and kissed her twice. Nursing notes documented the resident was reminded he was not to touch or kiss anyone and remained on 15 minute checks. On 07/04/13 at 8:43 A.M., the nurse was exiting room [ROOM NUMBER] to the middle lobby when she observed Resident #3 shaking hands with male Resident #13 with another hand on his shoulder leaning in for a hug. The resident was reminded what the police officer had said to him earlier about touching others. The police department, no time indicated, was documented as coming to the facility and speaking with Resident #3 about not touching others. A call to the physician was made at 10:30 A.M. and the physician ordered the resident on a hormone medication, [MEDICATION NAME] 10 milligrams daily. Review of nurses' notes dated 07/04/13 at 1:20 P.M. revealed activity staff alerted the nurse she observed Resident #3 kissing female Resident #4 on the lips. Camera footage reviewed showed Resident #4 was kissed twice by Resident #3. Interview with the DON on 07/05/13 at 10:30 A.M. revealed the physician had been called and continuous one-on-one monitoring was put in place for Resident #3. A staff member was observed on 07/05/13 sitting outside the resident's door and with him in the common areas throughout the day. On 07/08/13 at 8:48 P.M., a detective from the police department interviewed Resident #3 again. After the interview, he informed the DON and the surveyor Resident #3 had admitted lying Resident #15 across the bed and taking off his pants. He told the officer Resident #15 requested to be positioned that way, and he was hot. Observation of Resident #3 on 07/09/13 and 07/10/13 and review of monitoring sheets during the investigation revealed he continued on continuous one-on-one monitoring. Review of the facility Policy and Procedure for Abuse, Neglect, and Misappropriation of Property, dated 01/25/12, documented "Preventing Abuse: remove the resident from the area, environment, or person causing agitation. Charge nurse responsibilities included: observe, assess and document the condition of residents at frequent intervals." This citation substantiates Complaint Number OH 809.

Based on observation, medical record review, resident and staff interview and review of the facility smoking policy and procedure, the facility failed to provide adequate supervision of residents assessed as unsafe to manage smoking materials (cigarettes/lighter/matches) without supervision. This resulted in Immediate Jeopardy for one resident (#3) who was assessed as requiring supervision with smoking and smoking materials. This involved one of three sampled residents who were identified by the facility as smokers. The facility identified a total of 18 residents who currently smoke in a facility census of 36. On 07/08/13 at 1:00 P.M., the Director of Nursing (DON) was notified that Immediate Jeopardy began on 06/29/13 at 7:00 A.M. when Licensed Practical Nurse (LPN) #66 observed and smelled cigarette smoke in the bedroom of Resident #3. At this time, Resident #3 was asked to hand over the cigarettes and a lighter he had in his possession to LPN #66. There were no other interventions implemented at this time. Again, on 07/05/13 at approximately 12:00 A.M. upon entering Resident #3's room, staff could smell cigarette smoke and Resident #3 was seen closing the drawer to his night stand. With Resident #3 and two STNA's (#15 and #16) present, the nurse searched the resident's room. There were two burning cigarettes found in the night stand drawer. A pack of Marlboro containing four cigarettes and a lighter, belonging to Resident #20, was also found on the top of the resident ' s wardrobe as well as a cigarette butt. The resident admitted to taking the cigarettes and lighter from the nursing station while it was unattended. The resident was re-educated on the smoking policy stating, "I know, I almost burnt my dads' trailer down too." The Immediate Jeopardy was removed and corrected on 07/05/13 at 11:30 A.M. when the facility implemented the following corrective actions: ? On 07/05/13 at 10:30 A.M., Resident #3 was placed on one-on-one constant visual supervision by staff. ? On 07/05/13, the facility identified no other residents as having behaviors of smoking in unauthorized areas, or possessing cigarettes and lighters. ? On 07/05/13 at 11:00 A.M., an in-service was held for all facility employees related to the one-on-one policy which stated anyone smoking in unauthorized areas would be placed on one-on-one supervision for 24 to 48 hours. All employees not in-serviced directly were contacted by phone. ? On 07/05/13 at 11:30 A.M., an in-service was held for all licensed nurses regarding the smoking policy and securing all smoking materials (cigarettes/lighters/matches) in a locked area. All staff not in-serviced directly were contacted by phone. ? On 07/08/13 between 2:00 P.M. and 6:00 P.M., a search of all resident rooms was conducted with no cigarettes, lighters, or matches found. ? Observation of cigarettes and lighters on 07/09/13 at 9:30 A.M. revealed the smoking materials were secured per facility policy. ? Interviews with LPN #10 and LPN #12 on 07/09/13 at 10:30 A.M. revealed they had been in-serviced on the one-on-one policy and the policy on securing smoking materials. Both LPN's were able to communicate the newly implemented smoking policy that instructed staff to lock up cigarettes in a secure area, and were able to communicate the procedure as written regarding residents who were designated as "supervised." ? Interview with State tested Nursing Assistants (STNAs) #13 and #14 on 07/09/13 at 10:40 A.M. revealed both had been in-serviced on the one-on-one policy and the policy on securing smoking materials. Both were able to verbalize the newly implemented smoking policy and procedure as written regarding residents who were designated as "supervised " . ? Two residents (#10 and #17) identified as "supervised" smokers were interviewed on 07/09/13 at 10:45 A.M. They stated they are always supervised by two to three staff members. They are given their cigarettes outside where staff light them and then keep possession of the lighter. They all said they do not re-enter the building with any cigarette butts. Findings include: Review of the medical record of Resident #3 revealed [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] from a psychiatric hospital where he had been placed due to grossly impaired judgment, behavior or capacity to recognize reality, inability to meet life demands, risk to self, and benefit from hospital treatment. Resident #3's admission assessment dated [DATE] identified the resident as ambulatory and independent with his activities of daily living. He was also assessed as having a past history of poor judgment regarding safety of self and others and was assessed as needing supervision with smoking. Resident #3's plan of care for smoking developed on 06/28/13 included supervision at all times with smoking and all tobacco and lighting products would be held. He signed the facility smoking policy on 07/01/13. Review of a nurse's note dated 06/29/13 at 7:00 A.M., documented as a late entry by LPN Supervisor #66, revealed upon arrival staff reported the resident was smoking in his room. There was smoke observed hanging in the air. The resident denied smoking. LPN #66 pointed to the air and said we can all smell it and told the resident "look you can see it in the air". Resident #3 looked at LPN #66 and smiled as she told him to get the cigarettes and lighter that were missing from the common area. Resident #3 then walked over to his clothing, got the cigarettes and lighter and handed them to the nurse. Review of nurses' notes dated 07/05/13 at 12:00 A.M. documented by LPN #8 revealed Resident #20, who was the facility's only independent smoker, came to the nursing station to get her cigarettes and lighter. Resident #20 stated she threw her cigarettes on the desk at the nursing station after smoking outside the building earlier that evening. LPN #8 was unable to find her cigarettes. Resident #20 made the nurse aware Resident #3 had been asking her for cigarettes throughout the day. LPN #8, STNA #15, STNA #16 and Resident #20 knocked on Resident #3's door. Upon entering the room, staff could smell cigarette smoke and Resident #3 was seen closing the drawer to his night stand. With Resident #3 and two STNA's present, the nurse searched the residents' room. There were two burning cigarettes in the night stand drawer. A pack of Marlboro containing four cigarettes and a lighter, belonging to Resident #20, were found on the top of the resident's wardrobe as well as a cigarette butt. The resident admitted to taking the cigarettes and lighter from the nursing station while it was unattended. The resident was re-educated on the smoking policy stating, "I know, I almost burnt my dads' trailer down too." Nurses' notes documented the staff provided continuous one-on-one supervision with the resident as 15 minute checks were ineffective at this time. An interview with STNA #11 on 07/05/13 at 11:45 A.M. revealed all smokers are to be supervised except for Resident #20. She said the staff lights the resident's cigarettes and staff keep the lighter. They observe the residents during smoking and check them before re-entering the building in case they try to put cigarettes into their pockets. She stated Resident #20 gives her cigarettes and lighter back to the nurse when she re-enters the building after smoking. On 07/05/13 at 1:20 P.M., LPN #8 was interviewed and stated, "last night we found that the 15 minute checks were not enough when we caught him (Resident #3) smoking in his room". She stated she documented the incident in the nursing notes. She stated Resident #3 got the cigarettes and lighter from behind the nursing station. She stated Resident #20 didn't return her cigarettes and lighter to the staff but put them on the desk at the nursing station. She stated she did one-on-one monitoring with Resident #3 while doing paper work but went back to the 15 minute checks when she had to do her morning medication pass. Interview with Assistant Director of Nursing (ADON) #7 on 07/05/13 at 2:15 P.M. revealed the smoking area was on the front porch of the facility with staff present. ADON #7 stated the staff gives each resident a cigarette and then lights the cigarettes. The cigarettes and lighter are kept locked up in the front office. An interview with the DON on 07/05/13 at 2:30 P.M. revealed there was not an incident report completed and given to her on the smoking incident with Resident #3 on 06/29/13 and no new interventions were put into place at that time. During an interview with Resident #20 on 07/05/13 at 3:00 P.M. she stated she put her cigarettes and lighter at the nursing station and didn ' t give them directly to the nurse the last time she went out to smoke. Review of the smoking sign-in and sign-out sheet for 07/04/13 used by Resident #20 revealed she signed out at 10:27 P.M. and back in at 10:41 P.M. Interview with Assistant Director of Nursing (ADON) #7 on 07/05/13 at 2:15 P.M. revealed the smoking area was on the front porch of the facility with staff present. ADON #7 stated the staff gives each resident a cigarette and staff lights the cigarettes. The cigarettes and lighter are kept locked up in the front office. An interview with the DON on 07/05/13 at 2:30 P.M. revealed there was not an incident report given to her on the smoking incident with Resident #3 on 06/29/13 and no new interventions were put into place at that time. During an interview with the DON on 07/08/13 at 12:40 P.M. revealed it was believed Resident #3 went behind the nursing station and got the cigarettes and lighter from there. She stated Resident #20's cigarettes and lighter are kept there in a cubby hole and are not locked up. She stated the resident must have come behind the nursing station and got them. She stated she told the staff to lock them up but did not know when she told staff to do so. She further stated they had an as needed (PRN) nurse on duty from another facility the evening of 07/05/13 and she did not know about locking up the cigarettes after the resident returned from smoking. On 07/08/13 at 2:00 P.M., interview with LPN/Supervisor #66 via the telephone revealed he was the nurse on duty the morning of 06/29/13 at 7:00 A.M. He stated when he arrived at the facility the night nurse asked him to go check Resident #3's room because they thought it smelled like smoke. He stated he was the nurse who admitted the resident and upon admission he had explained the facility policy on smoking and took his cigarettes and lighter. He stated when he entered Resident #3's room it smelled like smoke and at first the resident denied smoking, but when asked again, turned over four cigarettes and a lighter. He stated he felt the resident had gotten them from the nursing station. LPN #66 stated after taking the cigarettes and lighter from Resident #3 he told the staff they needed to lock Resident #20's cigarettes up and not leave them out. He stated he did not write an incident report about it because he thought the night shift nurse should have. LPN #66 stated he did search Resident #3's room quickly, checked his drawers and clothing but found no further cigarettes, butts, or lighters. He stated there have been times Resident #20 has left her cigarettes at the station and not returned them to the nursing staff. Review of the smoking policy, dated 04/17/12, revealed residents understand and agree they will refrain from smoking while in the facility except in designated smoking areas with supervision and will not share lit/non-lit cigarettes for others. They are also educated on not smoking in their sleeping room, bathroom or other unauthorized areas. A resident who is their "own person" and wishes to smoke independently must sign themselves in and out of the facility each time they want to smoke and they may smoke on the porch. Unsupervised residents may not keep cigarettes and lighter on their person until signing out to smoke. Cigarettes and lighters must be returned to staff after signing back into the facility. The resident who is their own person is to return directly to the nurse's station after smoking to sign themselves back in and return the cigarettes and lighter before resuming any regular activities. This citation substantiates Complaint Number OH 809.