Every finding on record at Centerville Health and Rehab

Based on medical record review, staff interviews, resident interview, and policy interview, the facility failed to provide timely dental services for residents to obtain dentures. This affected one (Resident #53) of five residents sampled for dental services. The facility census was 81. Findings include: Review of the medical record revealed Resident # was admitted to the facility on [DATE]. Diagnoses included Chronic Obstructive Pulmonary Disease (COPD), unspecified dementia, unspecified anxiety disorder, nicotine dependence, and unspecified, cerebral infarction. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition, had verbal and self-directed behaviors, occasionally rejected care, and did not wander. Resident #43 required partial assistance with bathing and was independent with setup assistance for other activities of daily living (ADL). Review of care plan dated 05/21/26 revealed Resident #43 had potential for oral/dental health problems related to edentulous status and refused to go to appointment scheduled to obtain dentures on 05/21/26. Interventions included administering medications as ordered, coordinating dental care services, providing oral care, and monitoring/reporting any signs of dental problems. Review of progress note dated 06/27/25 at 12:59 A.M. revealed Nurse Practitioner (NP) #245 assessed Resident #43 on 06/26/25. She noted Resident #43 had no new complaints but was waiting for dentures from two weeks ago and asked nursing to follow up with the dental clinic to acquire dentures. Review of progress note dated 06/30/25 at 11:27 A.M. revealed nursing had contacted the clinic to ask about dentures and was informed the dentures were not at the clinic yet, but the clinic would mail Resident #43's dentures to the facility upon delivery. They anticipated they would receive the dentures in 15 days. Review of progress note dated 07/01/25 at 12:59 A.M. revealed NP #245 saw Resident #43 on 06/30/25 and noted he was very concerned that he had still not received his dentures. NP #245 requested staff call the dental office regarding dentures. Review of progress noted dated 09/30/25 at 3:44 P.M. revealed Licensed Practical Nurse (LPN) #108 completed a quarterly MDS assessment and noted Resident #43 was edentulous and wanted to see a dentist regarding dentures. Per Social Services, Resident #43 was on the list to be seen. Review of progress note dated 11/19/25 at 12:59 A.M. revealed NP #245 saw Resident #43 on 11/18/2025 and noted he had recently seen the dentist and was in the process of getting dentures. Review of progress notes dated 04/04/26 at 12:59 A.M. revealed NP #245 saw Resident #43 on 04/03/26 and noted he anticipated receiving his dentures within four to six weeks and expressed happiness about this since he had been waiting a year for new teeth. Review of progress note dated 05/27/26 at 1:45 P.M. revealed the facility contacted the dental office to follow-up regarding the resident's dentures. The dental office manager reported the resident's dentures were complete and Resident #43 was scheduled to be seen for dental services on 06/10/26 at the facility. During an interview on 12/27/26 at 12:17 P.M., Resident #43 stated he had been trying for over a year to get dentures. He stated he already had impressions made, and had a dental appointment scheduled for next month. During an interview on 05/28/26 at 1:41 P.M., LPN #108 confirmed Resident #43 was edentulous and she was unsure of why he did not have dentures yet. She stated she reported his concerns for dentures to social services to follow-up. During an interview on 05/28/26 at 2:57 P.M., NP #245 stated when Resident #43 admitted he stated he had gone to a dental clinic through his old facility. This facility called the clinic multiple times, and they did not answer their phone and had no service to leave a message. This facility decided to re-start the process. NP #245 stated Resident #43 complained to her during monthly wellness visits that he did not have his teeth. She reported his concerns to social services. NP #245 confirmed Resident #43 was edentulous and still did not have dentures. She stated Resident #43 reported to her that impressions were made and he should be getting his dentures soon. Review of policy titled Dental Services dated December 2016 revealed routine dental services were provided to residents through community dentists to provide dental services. Social Service representatives assisted residents with dental appointments.This deficiency represents non-compliance investigated under Complaint Number 3017235.

Based on medical record review, observations, staff interview, and policy review, the facility failed to maintain professional standards of infection control during medication administration. This affected two (Residents #3 and #6) of three residents sampled for medication administration. The facility census was 81. Findings include: 1) Review of the medical record revealed Resident #3 was admitted to the facility on [DATE]. Diagnoses included end stage renal disease with dependence on renal dialysis, type II diabetes, unspecified protein calorie malnutrition, chronic diastolic heart failure, and cirrhosis of the liver. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #3 was cognitively intact, had no behaviors, did not reject care, and did not wander. Review of the medical record revealed Resident #3 had physician orders for routine medications scheduled for morning administration including tamsulosin (used to treat urinary symptoms caused by an enlarged prostate [BPH]) 0.4 milligrams (mg), carvedilol (beta-blocker used to lower the heart's workload) 3.125 mg, clopidogrel (antiplatelet medication) bisulfate 75 mg, and sertraline (antidepressant) 100 mg. 2) Review of the medical record revealed Resident #6 was admitted to the facility on [DATE]. Diagnoses included Chronic Obstructive Pulmonary Disease (COPD), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type II diabetes, stage III chronic kidney disease, and unspecified vascular dementia. Review of the most recent MDS assessment dated [DATE] revealed the resident had moderately impaired cognition, had no behaviors, did not reject care, and did not wander. Review of the medical record revealed Resident #6 had physician orders for routine mediations scheduled for morning administration including Apixaban (anticoagulant) five mg, metoprolol succinate (beta blocker for heart) extended release (ER) 24 Hour 25 mg, Psyllium Fiber oral capsule, Cholecalciferol (vitamin D3) Oral Tablet 25 micrograms, gabapentin (treats nerve pain), Atorvastatin (cholesterol) 20 mg, amlodipine besylate (for blood pressure) 10mg, and Sertraline 100 mg.Observations made on 05/27/26 from 9:15 A.M. to 9:30 A.M., revealed Registered Nurse (RN) #146 prepared morning medications for Resident #3 including tamsulosin 0.4 mg, carvedilol 3.125 mg, clopidogrel 75 mg, and sertraline 100mg, and medications for Resident #6 including routine metoprolol ER 25 mg, gabapentin, atorvastatin 20 mg, amlodipine 10 mg, and sertraline 100 mg, by pushing the medications through the film tab into her hand and then dropping each medication from her hand into the pill cup. She poured over the counter medications including Resident #6's psyllium fiber oral capsule, cholecalciferol 25 micrograms, and as needed acetaminophen 325 mg into the lid of the bottle and transferred each pill to her hand before placing the pills in the medication cup.During an interview on 05/27/26 at 9:20 A.M., RN #146 confirmed she had touched the medications during administration. She further stated she worked at the hospital where you were not allowed to touch the medications, but at this type of facility, as long as the nurse sanitized her hands before starting medication pass and washed her hands with soap and water after every two residents, it was acceptable to touch medications unless it was something dangerous like finasteride or apixaban. Review of policy titled Medication Administration dated April 2019 revealed staff followed infection control procedures while administering medications.This deficiency represents non-compliance investigated under Complaint Number 2992788.

Based on record review, observations, staff and resident interviews and policy review, the facility failed to provide a private space for phone conversations without being overheard. This affected one (#80) out of three residents reviewed for reasonable access to privacy. The facility census was 78. Findings include: Review of the medical record for Resident #80 revealed an admission on [DATE] with diagnoses that include dementia without behaviors, anxiety and stroke. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #80 dated 09/30/25 revealed a brief interview for mental status score of 13 indicating a normal thinking and memory. Review of the plan of care for Resident #80 revealed resident requires a private room related to behaviors and psychosocial needs dated 09/29/25. Interventions include psychosocial support and remain in private room. Observation on 12/11/25 at 10:30 A.M. revealed Resident #80 was in his room resting in bed without a phone visualized. Interview on 12/16/25 at 11:00 A.M. with Licensed Practical Nurse (LPN) #117 stated the residents that want to use the phone can use the phone at the nurses' station. LPN #117 stated the 600 hall has one resident that routinely uses the nurses' station phone. LPN #117 stated the area where the phone is located does not provide for private communication due to the potential of visitors, staff, or residents overhearing the conversation inadvertently. Interview on 12/16/25 at 12:00 P.M. with Registered Nurse (RN) #111 stated the nursing station in the memory care unit had a cordless phone for residents to use. Observation on 12/16/25 at 12:00 P.M. revealed a cordless telephone base on the nursing station without the cordless phone in the base. Further observation of the cordless phone base revealed the unit was not attached to any power source, additionally RN #111 attached the phone to the base after connecting it to power and revealed the cordless phone was not charged or operational. Interview on 12/16/25 at 12:03 P.M. with RN #111 stated Resident #80 resident uses the phone at the nurses station to call his family. Additionally, stated that the staff will leave the area to provide privacy. RN #111 verified the area was not enclosed and would not be private in the event of staff/visitors entering the secured dementia unit. Interview on 12/16/25 at 1:30 P.M. with Administrator verified the cordless phones would not work with the current phone system. The Administrator stated the facility did not have a designated area for residents to use facility phones allowing for private conversations. Interview on 12/16/25 at 3:47 P.M. with Resident #80 verified he receives and makes calls from the phone at the nursing station. Resident #80 stated he has not been provided a cordless phone to ensure private conversations. Observation on 12/16/25 at 5:40 P.M. of Resident #80's room revealed there was a corded phone on the stand beside the bed. Interview on 12/16/25 at 5:45 P.M. with Certified Nursing Assistant (CNA) #176 verified Resident #80 did not have the phone in his previous room and did not know who or when the phone arrived in the room. CNA #176 verified the phone was not plugged into the phone jack. CNA #176 plugged the phone into the phone jack and verified the phone was not operational. CNA #176 stated Resident #80 just spoke with his family at the nurses station. CNA #176 stated she overheard the conversation regarding requests from the resident for cigarettes from a family member. Review of the facility policy titled Resident Rights and Responsibilities dated March 2017 referenced the Ohio Health Care Association, Federal and Ohio Resident Rights and facility Responsibilities pamphlet. Resident right number 21 stated the resident to reasonably request private and unrestricted communications. This deficiency represents non-compliance investigated under Complaint Number 2689549.

Based on record review, staff interview and policy review, the facility failed to ensure weekly skin assessments were conducted as scheduled for skin integrity monitoring. This affected one (#85) of three residents reviewed for preventative skin interventions. The facility census was 78. Findings included: Review of the medical record for Resident #85 revealed an admission on [DATE] with diagnoses including morbid obesity, lymphedema, chronic embolism and thrombosis, hereditary deficiency of clotting factor. Resident #85 was transferred to the hospital on [DATE] and expired on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #85 dated [DATE] revealed an intact cognition. Resident #85 required set up to maximum assistance with activities of daily living. Resident #85 was coded at risk for skin breakdown. Resident #85 was not coded with any pressure ulcers. Review of the plan of care for Resident #85 dated [DATE] revealed pressure ulcer risk due to assistance required in bed mobility, bowel incontinency and obesity. Interventions included complete Braden scale, conduct weekly skin inspections, provide pressure reducing devices and incontinent care with barrier cream. Review of the physician orders for Resident #85 revealed an order dated [DATE] to cleanse legs with soap and water, rinse and pat dry, apply triple antibiotic ointment to bilateral legs, wrap with Vaseline gauze and then Coban or ace wrap daily. Review of the facility progress note dated [DATE] at 6:38 A.M. revealed Resident #85 had bilateral lower extremities redness and warmth noted up to the hips. Physician was notified and all parties made aware of new orders to hold triamterene hydrochlorothiazide and obtain venous dopplers of bilateral lower extremities. Review of the facility's physicians' progress note dated [DATE] revealed an acute visit for evaluation of worsening lower extremity edema and redness. Review of the weekly skin check dated [DATE] was not completed as scheduled in the electronic health record. Interview on [DATE] at 1:30 P.M. with the Director of Nursing (DON) verified the skin assessment scheduled for [DATE] was not completed as scheduled. Review of the facility policy titled Prevention of Pressure Injuries dated [DATE] was silent to the facility procedure of weekly skin assessments. The policy states to evaluate the resident on admission for existing pressure injury risk factors and repeat the risk evaluation per the facility schedule and residents risk factors. This deficiency represents non-compliance investigated under Complaint Number 2688214.

Based on record review and staff interview, the facility failed to obtain laboratory tests as ordered. This affected one (#85) of three residents reviewed for laboratory services. The facility census was 78. Findings include: Review of the medical record for Resident #85 revealed an admission on [DATE] with diagnoses including morbid obesity, lymphedema, chronic embolism and thrombosis, hereditary deficiency of clotting factor. Resident #85 was transferred to the hospital on [DATE] and expired on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #85 dated [DATE] revealed an intact cognition. Resident #85 required set up to maximum assistance with activities of daily living. Resident #85 was coded as incontinent of bowel and bladder. Review of the plan of care for Resident #85 dated [DATE] revealed alteration in elimination of bowel and bladder and diuretic use. Interventions included check and change with care rounds as needed, laboratory tests as ordered, monitor and report changes in the ability to toilet or continence status. Review of the Nurse Practitioner orders for Resident #85 revealed an order dated [DATE] for a urine analysis with culture and sensitivity to rule out urinary tract infections and an order dated [DATE] for a urine analysis with culture and sensitivity. Review of the results tab in the electronic record for Resident #85 was silent for any results related to the ordered urine analysis on [DATE] and [DATE]. Review of the progress notes for Resident #85 were silent for any notification to the prescribing provider that the tests were not completed as ordered. Interview on [DATE] at 1:30 P.M. with the Director of Nursing (DON) verified the laboratory tests for Resident #85 were not collected as ordered. Additionally, the DON verified the medical record for Resident #85 did not contain any documentation related to the facility's failure to obtain the ordered laboratory urine analysis. This deficiency represents non-compliance investigated under Complaint Number 2688214.

Based on observation, interview, facility document review, and policy review, the facility failed to maintain the food prep areas in a sanitary manner, failed to ensure proper setup of the three-compartment sink; and failed to complete daily temperature logs for the dish machine. This affected all residents who received food from the kitchen. The facility census was 84.Findings include: Observations on 07/01/2025 at 9:34 AM, during an initial tour of the kitchen, revealed excessive accumulation of dust was observed on the ceiling vent above the food preparation table near the stove. Dietary Aide (DA) #2 was prepping burgers on the food preparation table. A pan of six burgers was observed sitting on the food preparation table underneath the ceiling vent. There was black buildup and excessive accumulation of dust on the ceiling vents above the food preparation table near the walk-in freezer. The ceiling paint was observed to be peeling above the food preparation table near the walk-in freezer. There was an excessive buildup of dust on a ceiling vent located directly above the drying rack where clean dishes were stored in the dishwashing room. The three-compartment sink was observed to not be properly set up. The first compartment was empty. The second compartment, which was designated for rinsing only, was filled with dishwater containing visible detergent suds. The third compartment, designated for sanitizing, contained water with a sanitizing solution. DA #2 was observed washing the dishes in the second compartment, placing the dishes into the third compartment, and then placing the dishes on a cart next to the third compartment to dry. DA #2 stated he was not using the first compartment of the three-compartment sink because it was clogged with trash. An observation on 07/03/2025 at 11:05 AM revealed there was an excessive buildup of dust on a ceiling vent located directly above the drying rack where clean dishes were stored in the dishwashing room. Interview on 07/04/2025 at 1:00 PM, DA #2 stated the sink had been clogged for at least eight months. He stated all three compartments were clogged, but the first compartment was the worst. DA #2 stated he had been trained on how to set up the three compartment sink. A Dish Machine Log, dated 03/2025, revealed no documentation of dishwashing temperatures and parts per million (ppm) for the chemical sanitizer on 03/14/2025 and 03/31/2025 for lunch and dinner services. On 03/15/2025, 03/21/2025, 03/22/2025, 03/24/2025, 03/25/2025, 03/26/2025, 03/28/2025, and 03/29/2025 for breakfast, lunch, and dinner services. On 03/16/2025 through 03/20/2025, 03/23/2025, 03/27/2025, and 03/30/2025 for dinner services. A Dish Machine Log, dated 04/2025, revealed no documentation of dishwashing temperatures and ppm for the chemical sanitize on 04/06/2025, 04/08/2025 through 04/11/2025, 04/13/2025, 04/14/2025, 04/16/2025, 04/18/2025, 04/20/2025, 04/22/2025, 04/24/2025, 04/25/2025, 04/28/2025, and 04/30/202, for the dinner services. A Dish Machine Log, dated 05/2025, revealed no documentation of dishwashing temperatures and ppm for the chemical sanitize on 05/01/2025, 05/04/2025 through 05/09/2025, 05/11/2025, 05/13/2025, 05/14/2025, 05/19/2025 through 05/22/2025, 05/26/2025 through 05/29/2025, and 05/31/2025 for dinner services. On 05/02/2025, 05/03/2025, 05/17/2025, 05/18/2025, and 05/30/2025 for breakfast, lunch, and dinner services. On 05/10/2025, 05/15/2025, 05/16/2025, 05/24/2025, and 05/25/2025 for lunch and dinner services. A Dish Machine Log, dated 06/2025, revealed no documentation of dishwashing temperatures and ppm for the chemical sanitize on 06/01/2025, 06/20/2025, and 06/21/2025 for breakfast, lunch, and dinner services. On 06/06/2025, 06/07/2025, and 06/27/2025 for breakfast and lunch services. On 06/13/2025, 06/14/2025 for lunch and dinner services. On 06/12/2025 and 06/15/2025 for dinner services. On 06/19/2025 and 06/05/2025 for lunch services and on 06/05/2025 for breakfast services. Interview on 07/04/2025 at 1:08 PM, the Dietary Manager (DM) stated staff should be documenting temperatures and the ppm for the chemical sanitizer levels three times a day at breakfast, lunch, and dinner. The DM stated the dish washers were responsible for documenting the temperatures on the Dish Machine Log. The DM stated he could not find a Dish Machine Log for January (2025). He stated maintenance staff would be responsible for cleaning the ceiling vents and scraping the paint on the ceiling when he reported the concern to him. He stated he usually reported concerns to maintenance staff verbally or by email. The DM stated he did not know the last time the ceiling vents were cleaned but needed to be clean because of the possibility of contamination. The DM stated that the second compartment on the three-compartment sink was used for rinsing, the first compartment was used for washing, and the last compartment was used for sanitizing. He stated just washing and sanitizing was not correct. The dishes should be rinsed with clean water and placed in sanitizer for at least sixty seconds. He stated DA #2 seemed to think the sink was clogged, but the compartment could be used. Interview on 07/07/2025 at 3:39 PM, the DM stated he was made aware of the sink being clogged the night before the survey started. He stated he thought it was coffee grounds clogging the sink. The DM stated he reported it to the Maintenance Director as soon as DA #2 reported it to him and the sink was repaired. Review of the facility policy titled Sanitization, revised 11/2022, revealed, manual washing and sanitizing is a three-step process for washing, rinsing, and sanitizing: a. Scrape food particles and wash using hot water and detergent; b. Rinse with hot water to remove soap residue; and c. Sanitize with hot water (at least 171 [degrees Fahrenheit] for 30 seconds) or chemical sanitizing solution. Chemical sanitizing solutions (e.g. [exempli gratia, for example], chlorine, iodine, quaternary ammonium compound) are used according to manufacturer's instructions.

Based on observation, interview, and facility policy review, the facility failed to ensure medications and opened insulin vials were discarded when expired in two (Roosevelt, [NAME]) of four medication carts observed. The facility census was 84. Findings include: An observation on 07/03/2025 at 1:15 PM of the Roosevelt medication cart revealed a bottle of fish oil that contained 115 tablets, with an open date of 11/01/2024 and an expiration date of 04/2025. The medication cart revealed a vial of Humalog 100 units/milliliter (ml) insulin with an opened date of 05/24 (month/day). An observation on 07/03/2025 at 1:25 PM of the [NAME] medication cart with Licensed Practical Nurse (LPN) #22 revealed a vial of Humalog 100 units/ml with an open date of 05/27 (month/day). During an interview on 07/03/2025 at 1:20 PM, LPN #22 stated insulin was to be used within 28 days of being out of the refrigerator and opened. She stated staff were trained and expected to check for expired medication and dates when medications were opened. During an interview on 07/05/2025 at 12:52 PM, the DON stated Humalog vials were good for 28 days once opened, and expired supplies were the responsibility of everyone. The DON stated staff were trained and expected not to use expired medications. Review of a facility policy titled Medication Labeling and Storage, revised 02/2023, revealed in the section titled Medication Storage, if the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. The policy revealed the section titled Medication Labeling, included Multi-dose vials that have been opened or accessed (e.g. [exempli gratia, for example], needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

Based on observation, record review, interview, and review of manufacturer's guidelines, the facility failed to obtain laboratory tests as ordered by the physician for one (Resident #10) of five residents reviewed for unnecessary medications. Additionally, the facility failed to ensure expired blood glucose monitoring strips were discarded in four (Roosevelt, [NAME], [NAME], Jefferson) four medication cars observed. The facility census was 84. Findings include:Review of the medical record revealed Resident #10 admitted on [DATE]. Diagnoses included type 2 diabetes mellitus with diabetic polyneuropathy, hypertension, and atherosclerotic heart disease (ASHD) of native coronary artery without angina pectoris. Resident #10's care plan included a focus area initiated [DATE] that indicated the resident had a potential for alteration in hydration related to diabetes mellitus, potential for alteration in blood glucose due to insulin dependent diabetes mellitus, and impaired cardiovascular status related to ASHD and hypertension. Interventions directed staff to obtain and monitor lab/diagnostic work per physician order. Resident #10's physician orders included an order with a start date of [DATE] for ammonia level and hemoglobin A1c every 90 days for monitoring. An order with a start date of [DATE] included a complete blood count (CBC), comprehensive metabolic profile (CMP), and hepatic panel every 180 days for monitoring. Resident #10's electronic health record (EHR) revealed no laboratory (lab) results for the ammonia level ordered to be completed in [DATE] and [DATE] and no laboratory results for the CMP or CBC ordered to be completed in [DATE]. During an interview on [DATE] at 3:33 PM, the Director of Nursing (DON) stated they did not have the resident's lab results for the ammonia level for [DATE] or [DATE], or for the CMP and CBC for [DATE]. She stated they had a new physician group that started in January (2025), and they marked everything on the standing order list. However, when they actually came into the building they indicated that they did not want the routine labs to be done, but she forgot to go in and discontinue the orders. During an interview on [DATE] at 8:28 AM, the DON stated the nurse, or the provider, would put in the orders for labs. The nurse should then take off the order, put the order in the lab portal, and schedule it through the portal. She stated the order would show up on the treatment administration record and the third shift should print off the requisition and the list of everyone who gets a lab drawn that day. She stated she ran a list every day to see what orders had not been completed. She stated they also had a direct link to the lab. She stated nursing was responsible for following up on the labs. The DON stated the order for Resident #10's labs should have been discontinued. She stated it was an issue from when they switched from the old provider to the new provider. She stated she did not know if the provider was notified. 2. Review of the manufacturer guidelines for Assure Platinum Test Strips, revised 12/2023, revealed when the vial is first opened, write the date on the vial label. Use the test strips within three months of first opening the vial. An observation on [DATE] at 1:15 PM of the Roosevelt medication cart revealed one open bottle of Assure Platinum blood glucose test strips with no date as to when it was opened. An observation on [DATE] at 1:25 PM of the [NAME] medication cart with Licensed Practical Nurse (LPN) #22 revealed one open bottle of Assure Platinum blood glucose test strips with no date as to when it was opened. During an interview on [DATE] at 1:20 PM, LPN #22 stated she had no idea that glucose test strips were to be used within 90 days of opening. She stated staff were trained and expected to place dates on the test strips when they were opened. An observation on [DATE] at 1:30 PM of the [NAME] medication cart with Registered Nurse (RN) #7 revealed two open bottles of Assure Platinum blood glucose test strips with no date as to when it was opened. During a concurrent interview, RN #7 stated staff were trained and expected to check that a date was written on the outside of the blood glucose test strip bottle when opened. An observation on [DATE] at 1:32 PM of the [NAME] medication cart revealed one open bottle of Assure Platinum blood glucose test strips with no date as to when it was opened. During an interview on [DATE] at 1:35 PM, LPN #6 stated staff were trained and expected to check the bottles for a date on them when opened. During an interview on [DATE] at 12:52 PM, the Director of Nursing (DON) stated expired supplies were the responsibility of everyone. She stated she was not aware the blood glucose test strips were only good for 90 days. The DON stated staff were trained and expected not to use expired supplies and to date the glucose test strips (when opened).

Based on interview, record review, and facility policy review, the facility failed to ensure a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN, Form CMS-10055) was prior to the end of covered Medicare Part A services for one (Resident #43) of three sampled residents reviewed for beneficiary notifications. The census was 84. Findings include: Review of the medical record indicated the facility readmitted Resident #43 on 12/25/2024. According to the admission Record, the resident had a medical history that included diagnoses of paraplegia and acute kidney failure. A list of residents discharged from a Medicare covered Part A stay with benefit days remaining during the past six months revealed Resident #43 was discharged from a Medicare covered Part A stay on 02/04/2025 but remained in the facility.Resident #43's SNF [Skilled Nursing Facility] Beneficiary Notification Review form, completed by the facility, revealed the facility initiated Resident #43's discharge from Medicare Part A services when the resident's benefit days were not exhausted. The form indicated the facility issued a CMS-10123 Notice of Medicare Non-Coverage (NOMNC) but not a CMS-10055 SNF ABN. During an interview on 07/08/2025 at 8:28 AM, the Director of Nursing (DON) stated the business office had been responsible for issuing the SNF ABNs and NOMNCs. Now it was a collaboration with therapy, the business office, and social services. The DON had no explanation as to why the correct notice was not given to Resident #43. Review of the facility policy titled Medicare Advance Beneficiary and Medicare Non-Coverage Notices, revised 09/2022, revealed residents are informed in advance when changes will occur to their bills. The section of the policy titled, Skilled Nursing Facility Advance Beneficiary Notice (CMS form 10055) noted at bullet point #2, the facility issues the Skilled Nursing Facility Advance Beneficiary Notice (CMS form 10055) for the following trigging events including c. Termination - In the situation in which the facility proposes to stop furnishing all extended care items or services to a beneficiary because it expects that Medicare will not continue to pay for the items or services that a physician has ordered and the beneficiary would like to continue receiving the care, the SNF ABN is issued to the beneficiary before such extended care items or services are terminated. During an interview on 07/08/2025 at 9:08 AM, the Interim Administrator stated she had no explanation as to why Resident #43 did not receive the required notices.

Based on observation, interview, and facility policy review, the facility failed to ensure broken bathroom sink faucets in resident rooms, loose door handles to resident rooms, and missing tiles outside the therapy room were repaired to provide a homelike environment. This affected four resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) on two of six halls and the public hallway outside the therapy room. The facility census was 84. Findings included: An observation on 07/01/2025 at 9:57 AM revealed an area in the hallway outside the therapy room had an approximately three feet (ft) by three ft area of missing tiles with red cones placed on each side of the missing tiles. An observation on 07/07/2025 at 8:59 AM revealed the floor in the hallway outside the therapy room continued to have missing tiles with red cones blocking each side. An observation on 07/01/2025 at 12:11 PM revealed the bathroom sink in room [ROOM NUMBER] the faucet was broken, it could not be turned on or off completely, and it had constant running water. An observation on 07/01/2025 at 12:38 PM revealed the bathroom sink in room [ROOM NUMBER] had constant running water and the faucet was broken. An observation on 07/01/2025 at 12:57 PM revealed the door handle to room [ROOM NUMBER] was loose and broken. An observation on 07/03/2025 at 8:59 AM and on 07/04/2025 at 2:23 PM revealed the door handle to room [ROOM NUMBER] was loose. During an interview on 07/07/2025 at 8:23 AM, the Maintenance Supervisor (MS) stated he did not have a written plan for repairs for the facility but kept a list in his head and tried to prioritize as things came up. The MS stated the facility needed a lot of repairs and he had not been able to keep up with all the repairs. The MS stated he had a plan to fix the floor in the hallway but had not had time to do it. The MS stated he had also completed a lot of repairs he had not documented. The MS stated he knew that as the supervisor he was supposed to also do the paper work but he said he could not keep up with everything. During an interview on 07/07/2025 at 10:45 AM, Housekeeper (HSK) #14 stated if she saw something that needed repaired while she was cleaning she would text her supervisor. HSK #14 stated she did not write it down anywhere. During an interview on 07/07/2025 at 10:47 AM, HSK #13 stated if she saw something that needed repaired she would tell her supervisor and she would tell maintenance. HSK #13 stated she had not written anything down. During a concurrent observation and follow-up interview and on 07/07/2025 at 10:50 AM, the MS stated their plan was to fix the area of the hallway outside the therapy room that week, but other issues had come up over the weekend, and he had to prioritize what needed to be fixed. Upon entering the bathroom in room [ROOM NUMBER] the MS stated the sink was leaking and agreed the resident would not be able to use the faucet because the handle was loose and the faucet could not be turned on or off completely. The MS confirmed the leaking sink in room [ROOM NUMBER] and stated his assistant was fixing it that day (07/07/2025). The MS stated he had replaced at least four door handles last week but was not aware the doorhandles for room [ROOM NUMBER] or room [ROOM NUMBER] needed to be fixed. During an interview on 07/08/2025 at 9:08 AM, the Interim Administrator stated she was not aware of the leaking faucets. The Interim Administrator stated all repairs should be reported to the MS in the work order program, and they should be fixed. Review of the facility policy titled Safe and Homelike Environment, dated 09/29/2022, revealed in accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. The policy also indicated at bullet point #1, the facility will create and maintain, to the extent possible, a homelike environment that de-emphasizes the institutional character of the setting. Bullet point #3 noted housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment.This deficiency represents non-compliance investigated under Complaint Number 1289599.

Based on interview, record review, facility document review, and facility policy review, the facility failed to prevent staff verbal abuse for two (Resident #25 and Resident #66) of three residents reviewed for abuse. The facility census was 84. Findings included:1. Review of the medical record revealed the facility admitted Resident #25 on 01/17/2025. The resident had a medical history that included diagnoses of personal history of traumatic brain injury and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/18/2025, revealed Resident #25 had intact cognition. Review of the care plan revealed a focus area initiated on 01/27/2025 indicating the resident was at risk for impaired neurological status related to a history of traumatic brain injury. Interventions included staff to explain all procedures and reasons before performing them, monitor the resident for changes in condition, and have pleasant interactions, which reassures the resident when they were confused. During an interview on 07/05/2025 at 9:19 AM, Resident #25 stated Certified Nurse Aide (CNA) #3 told them to shut up. Resident #25 stated their previous roommate needed a lot of assistance and CNA #3 came and took the roommate to the bathroom. CNA #3 was not stable with the resident's wheelchair as CNA #3 was bumping against the wall. Resident #25 stated once CNA #3 and the roommate made it to the bathroom it sounded like the roommate had fallen. Resident #25 stated they went to the bathroom door to ask what was going on and CNA #3 told Resident #25 to shut up. Resident #25 stated they felt it was unprofessional for CNA #3 to tell them to shut up. Resident #25 stated that CNA #3 should not have talked to them like that. During an interview on 07/05/2025 at 9:45 AM, the interim Administrator was notified by the survey team that Resident #25 reported being told to shut up by CNA #3. Review of a Teachable Moment form, dated 04/26/2025, documented by Licensed Practical Nurse (LPN) #6, revealed CNA #3 was presented with a concern marked other. The concern indicated CNA #3 was argumentative with a resident and other staff. CNA #3 told a resident to Shut up. The form indicated CNA #3 refused to sign the document. The document was signed by Registered Nurse (RN) #5 and LPN #6. During a telephone interview on 07/04/2025 at 2:37 PM, LPN #6 stated Teachable Moments were used as a corrective action the staff were asked to sign, so staff saw them as a write-up. She stated a Teachable Moment was given to CNA #3 for arguing with a resident and telling the resident to Shut up. LPN #6 stated the resident was worried about their roommate and was not aware CNA #3 was in the bathroom with the resident when they were yelling back and forth with each other. She stated in the moment Resident #25 got loud first and was upset. During a telephone interview on 07/04/2025 at 1:43 PM, RN #5 stated the facility staff were aware of the issues with CNA #3. RN #5 stated she had discussed issues with upper management about CNA #3. Another nurse witnessed the aide tell a resident to shut up. The other nurse wrote up a Teachable Moment, with RN #5 present when it was provided to CNA #3. She stated she addressed the same concerns with the ADON and the DON. RN #5 stated she was told that CNA #3 had been investigated for verbal abuse and was cleared. During an interview on 07/04/2025 at 3:17 PM, the ADON stated Teachable Moments would be written by the nurse who would review it with the staff member and then the individual signed it. She stated there was an allegation that CNA #3 told a resident to shut up. The ADON stated there was an internal investigation and Resident #25 stated they (the resident) said something they (the resident) should not have. The ADON stated she thought the DON and the former Administrator gave CNA #3 a written warning. She stated she would probably consider the comment that CNA #3 made towards Resident #25 to shut up to be abuse. During an interview on 07/07/2025 at 2:15 PM, Resident #25 stated they felt relief and powerful to be able to tell what had occurred because of feeling helpless and powerless before. 2. Review of the medical record revealed the facility admitted Resident #66 on 02/19/2025. The resident had a medical history that included a diagnosis of anxiety disorder. Review of the quarterly MDS assessment, dated 06/04/2025, revealed Resident #66 had intact cognition. Review of the care plan, initiated 03/04/2025 and revised on 03/31/2025, indicated the resident had behaviors that included yelling at staff when care was being provided. Interventions included staff to tell the resident what they were going to do before they began and to speak to the resident unhurriedly and in a calm voice. During an interview on 07/01/2025 at 2:13 PM, Resident #66 stated CNA #3 had yelled at them. On 07/01/2025 at 2:49 PM, the survey team notified the interim Administrator and the DON that Resident #66 had alleged verbal abuse by CNA #3. During an interview on 07/03/2025 at 3:20 PM, the interim Administrator stated she had a conversation with Resident #66 about verbal abuse from an aide. She stated the allegation had already been investigated. During a follow-up interview on 07/05/2025 at 8:00 AM, Resident #66 stated when CNA #3 was their aide it made the resident feel angry, anxious, and teary-eyed, and it made the resident have panic attacks. During an interview on 07/05/2025 at 10:41 AM, Resident #66 stated at the end of May (2025) CNA #3 yelled, argued, and raised her voice with the resident related to the schedule and the amount of time it took for CNA #3 to answer their call light. Resident #66 stated CNA #3 told them they needed to get their facts straight about the call light being on for over an hour and a half. Resident #66 stated CNA #3 yelled and flung her arms around. Resident #66 stated they asked CNA #3 to have the nurse come to the room and CNA #3 ignored them. Then after about five minutes she got RN #5 to come in the room. Resident #66 stated when RN #5 entered the room they (the resident) had a panic attack. During an interview on 07/04/2025 at 1:43 PM, RN #5 stated Resident #66 had issues with CNA #3 where the resident would be upset to the point of tears because of not wanting the aide. RN #5 stated the facility was aware of the issues with CNA #3 because she discussed the concerns with upper management and had written Teachable Moment forms and presented them to CNA #3 as well. She stated she had expressed her concerns with the ADON and DON. She stated she was informed CNA #3 had been investigated, the matter was addressed, and the CNA was cleared. During an interview on 07/03/2025 at 7:51 PM, CNA #10 stated that around the end of May or June 2025, Resident #66 told her CNA #3 had yelled at the resident. CNA #10 stated she informed LPN #8 and Resident #66 told LPN #8 what happened During an interview on 07/04/2025 at 10:32 AM, LPN #8 stated Resident #66 told her CNA #3 had said some offensive things towards the resident and the resident desired not to have her as an aide. LPN #8 stated when the resident reported the issues with CNA #3 to her she contacted the Scheduler. She stated the Scheduler told her to write some things down but she forgot to do so. She stated she was told if a resident had a complaint to report it to the Scheduler first then to the ADON, and then to the DON. LPN #8 stated she thought the Scheduler did something with the information she reported to her and thought CNA #3 was written up. During an interview on 07/05/2025 at 3:53 PM, the former Administrator stated he thought the issue Resident #66 had involving an aide was the resident was on a phone call and the aide came to provide care and asked if the resident wanted care to be provided at that time, but there was nothing significant about it. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 04/2021, revealed residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Review of the facility policy titled Abuse and Neglect-Clinical Protocol, revised 03/2018, revealed abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.

Based on interview, record review, facility document review, and facility policy review, the facility failed to report allegations of abuse to the administrator and the state survey agency for two (Resident #25 and Resident #66) of three residents reviewed for abuse. The census was 84. Findings include:1. Review of the medical record revealed the facility admitted Resident #25 on 01/17/2025. The resident had a medical history that included diagnoses of personal history of traumatic brain injury and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/18/2025, revealed Resident #25 had intact cognition. Review of the care plan revealed a focus area initiated on 01/27/2025 indicating the resident was at risk for impaired neurological status related to a history of traumatic brain injury. Interventions included staff to explain all procedures and reasons before performing them, monitor the resident for changes in condition, and have pleasant interactions, which reassures the resident when they were confused. During an interview on 07/05/2025 at 9:19 AM, Resident #25 stated Certified Nurse Aide (CNA) #3 told them to shut up. Resident #25 stated their previous roommate needed a lot of assistance and CNA #3 came and took the roommate to the bathroom. CNA #3 was not stable with the resident's wheelchair as CNA #3 was bumping against the wall. Resident #25 stated once CNA #3 and the roommate made it to the bathroom it sounded like the roommate had fallen. Resident #25 stated they went to the bathroom door to ask what was going on and CNA #3 told Resident #25 to shut up. Resident #25 stated they felt it was unprofessional for CNA #3 to tell them to shut up. Resident #25 stated that CNA #3 should not have talked to them like that. Review of a Teachable Moment form, dated 04/26/2025, provided by Licensed Practical Nurse (LPN) #6, revealed CNA #3 was presented with a concern marked other. The concern indicated CNA #3 was argumentative with a resident and other staff. CNA #3 told a resident to Shut up. The form indicated CNA #3 refused to sign the document. The document was signed by Registered Nurse (RN) #5 and LPN #6. During a telephone interview on 07/04/2025 at 2:37 PM, LPN #6 stated Teachable Moments were used as a corrective action the staff were asked to sign, so staff saw them as a write-up. She stated a Teachable Moment was given to CNA #3 for arguing with a resident and telling the resident to Shut up. LPN #6 stated the resident was worried about their roommate and was not aware CNA #3 was in the bathroom with the resident when they were yelling back and forth with each other. She stated in the moment Resident #25 got loud first and was upset. She stated that once a Teachable Moment form was completed, she gave it to the Director of Nursing (DON), then the DON would provide it to the Human Resources (HR) Director. LPN #6 stated she contacted the Assistant Director of Nursing (ADON) for guidance about the incident with CNA #3. During a telephone interview on 07/04/2025 at 1:43 PM, RN #5 stated the facility staff were aware of the issues with CNA #3. RN #5 stated she had discussed issues with upper management about CNA #3. Another nurse witnessed the aide tell a resident to shut up. The other nurse wrote up a Teachable Moment, with RN #5 present when it was provided to CNA #3. She stated she addressed the same concerns with the ADON and the DON. RN #5 stated she was told that CNA #3 had been investigated for verbal abuse and was cleared. During an interview on 07/04/2025 at 3:17 PM, the ADON stated Teachable Moments would be written by the nurse who would review it with the staff member and then the individual signed it. She stated there was an allegation that CNA #3 told a resident to shut up. The ADON stated there was an internal investigation and Resident #25 stated they (the resident) said something they (the resident) should not have. The ADON stated she thought the DON and the former Administrator gave CNA #3 a written warning. She stated she would probably consider the comment that CNA #3 made towards Resident #25 to shut up to be abuse. The facility's self-reported incident list, for the timeframe from 07/01/2024 through 07/01/2025, indicated no report was made to the state survey agency regarding Resident #25. During an interview on 07/04/2025 at 3:45 PM, the DON stated if there was a complaint related to abuse or neglect, then the facility policy would be followed. She stated Teachable Moments were given by the nursing staff to address actions that needed to be stopped. The DON stated once she reviewed the forms, she addressed the issue with the staff member, and if she felt the nurse handled the situation, then the form went into the staff member's personnel file. She stated she was not aware of any other abuse concerns involving CNA #3. The DON stated upon review of CNA #3's personnel file it contained no Teachable Moment forms. The DON stated if she had been told that CNA #3 had told a resident to shut up then an investigation would have been completed because that would have been considered abuse. She stated that no investigation had been carried out previously regarding Resident #25 being told to shut up. The facility's self-reported incident list, for the timeframe from 07/01/2024 through 07/01/2025 revealed no report was made to the state survey agency regarding Resident #25. During an interview on 07/04/2025 at 4:43 PM, the interim Administrator stated staff were trained and expected to report abuse to the Administrator as soon as it happened. She stated if a resident had been told to shut up, she would expect it to be reported and an investigation to take place. 2. Review of the medical record revealed the facility admitted Resident #66 on 02/19/2025. The resident had a medical history that included a diagnosis of anxiety disorder. Review of the quarterly MDS assessment, dated 06/04/2025, revealed Resident #66 had intact cognition. Review of the care plan, initiated 03/04/2025 and revised on 03/31/2025, indicated the resident had behaviors that included yelling at staff when care was being provided. Interventions included staff to tell the resident what they were going to do before they began and to speak to the resident unhurriedly and in a calm voice. During an interview on 07/01/2025 at 2:13 PM, Resident #66 stated that CNA #3 had yelled at them. On 07/01/2025 at 2:49 PM, the survey team notified the interim Administrator and the Director of Nursing (DON) that Resident #66 had alleged verbal abuse by CNA #3. The facility's self-reported incident list, for the timeframe from 07/01/2024 through 07/01/2025 revealed no report was made to the state survey agency regarding Resident #66. During an interview on 07/05/2025 at 10:41 AM, Resident #66 stated at the end of May (2025) CNA #3 yelled, argued, and raised her voice with the resident related to the schedule and the amount of time it took for CNA #3 to answer their call light. Resident #66 stated CNA #3 told them they needed to get their facts straight about the call light being on for over an hour and a half. Resident #66 stated CNA #3 yelled and flung her arms around. Resident #66 stated they asked CNA #3 to have the nurse come to the room and CNA #3 ignored them. Then after about five minutes she got RN #5 to come in the room. Resident #66 stated when RN #5 entered the room they (the resident) had a panic attack. During an interview on 07/03/2025 at 7:51 PM, CNA #10 stated that around the end of May or June 2025, Resident #66 told her CNA #3 had yelled at the resident. CNA #10 stated she informed LPN #8 and Resident #66 told LPN #8 what happened During an interview on 07/04/2025 at 10:32 AM, LPN #8 stated Resident #66 told her CNA #3 had said some offensive things towards the resident and the resident desired not to have her as an aide. LPN #8 stated when the resident reported the issues with CNA #3 to her she contacted the Scheduler. She stated the Scheduler told her to write some things down but she forgot to do so. She stated she was told if a resident had a complaint to report it to the Scheduler first then to the ADON, and then to the DON. LPN #8 stated she thought the Scheduler did something with the information she reported to her and thought CNA #3 was written up. During an interview on 07/03/2025 at 3:20 PM, the interim Administrator stated she had a conversation with the resident about verbal abuse from an aide. She stated the resident had a service issue with the aide, therefore, she did not make a report to the state survey agency. During an interview on 07/05/2025 at 2:26 PM with the interim Administrator and the [NAME] President of Clinical Services, it was reported they did not report the allegation of verbal abuse involving Resident #66 because it had been investigated, but they could not find the investigation. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 04/2021, revealed residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The policy revealed at bullet point #9 to investigate and report any allegations within timeframes required by federal requirements. Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 2001, revealed all reports of resident abuse are reported to local, state and federal agencies (as required by current regulations. The policy revealed at bullet point #1 if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicions to the following persons or agencies, which included, the state licensing/certification agency responsible for surveying/licensing the facility. The policy revealed immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on interview, record review, facility document review, and facility policy review, the facility failed to ensure allegations of abuse were investigated and failed to prevent further abuse by removing the emoployee from duty after an allegation of abuse. This affected two (Resident #25 and Resident #66) of three residents reviewed for abuse. The facility census was 84. Findings included:1. Review of the medical record revealed the facility admitted Resident #25 on 01/17/2025. The resident had a medical history that included diagnoses of personal history of traumatic brain injury and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/18/2025, revealed Resident #25 had intact cognition. Review of the care plan revealed a focus area initiated on 01/27/2025 indicating the resident was at risk for impaired neurological status related to a history of traumatic brain injury. Interventions included staff to explain all procedures and reasons before performing them, monitor the resident for changes in condition, and have pleasant interactions, which reassures the resident when they were confused. During an interview on 07/05/2025 at 9:19 AM, Resident #25 stated Certified Nurse Aide (CNA) #3 told them to shut up. Resident #25 stated their previous roommate needed a lot of assistance and CNA #3 came and took the roommate to the bathroom. CNA #3 was not stable with the resident's wheelchair as CNA #3 was bumping against the wall. Resident #25 stated once CNA #3 and the roommate made it to the bathroom it sounded like the roommate had fallen. Resident #25 stated they went to the bathroom door to ask what was going on and CNA #3 told Resident #25 to shut up. Resident #25 stated they felt it was unprofessional for CNA #3 to tell them to shut up. Resident #25 stated that CNA #3 should not have talked to them like that. Review of a Teachable Moment form, dated 04/26/2025, documented by Licensed Practical Nurse (LPN) #6, revealed CNA #3 was presented with a concern marked other. The concern indicated CNA #3 was argumentative with a resident and other staff. CNA #3 told a resident to Shut up. The form indicated CNA #3 refused to sign the document. The document was signed by Registered Nurse (RN) #5 and LPN #6. During a telephone interview on 07/04/2025 at 2:37 PM, LPN #6 stated Teachable Moments were used as a corrective action the staff were asked to sign, so staff saw them as a write-up. She stated a Teachable Moment was given to CNA #3 for arguing with a resident and telling the resident to Shut up. LPN #6 stated the resident was worried about their roommate and was not aware CNA #3 was in the bathroom with the resident when they were yelling back and forth with each other. She stated in the moment Resident #25 got loud first and was upset. She stated that once a Teachable Moment form was completed, she gave it to the Director of Nursing (DON), then the DON would provide it to the Human Resources (HR) Director. LPN #6 stated she contacted the Assistant Director of Nursing (ADON) for guidance about the incident with CNA #3. During a telephone interview on 07/04/2025 at 1:43 PM, RN #5 stated the facility staff were aware of the issues with CNA #3. RN #5 stated she had discussed issues with upper management about CNA #3. Another nurse witnessed the aide tell a resident to shut up. The other nurse wrote up a Teachable Moment, with RN #5 present when it was provided to CNA #3. She stated she addressed the same concerns with the ADON and the DON. RN #5 stated she was told that CNA #3 had been investigated for verbal abuse and was cleared. During an interview on 07/04/2025 at 3:17 PM, the ADON stated Teachable Moments would be written by the nurse who would review it with the staff member and then the individual signed it. She stated there was an allegation that CNA #3 told a resident to shut up. The ADON stated there was an internal investigation and Resident #25 stated they (the resident) said something they (the resident) should not have. The ADON stated she thought the DON and the former Administrator gave CNA #3 a written warning. She stated she would probably consider the comment that CNA #3 made towards Resident #25 to shut up to be abuse. The facility was unable to provide an investigation of verbal abuse towards Resident #25. Review of CNA #3's timesheet revealed she worked on 04/26/2025 (date of alleged abuse) from 6:52 AM to 7:16 PM and on 04/27/2025 from 7:28 AM to 7:23 PM. Review of the facility's daily assignment sheets revealed CNA #3 was assigned as the aide for Resident #25 on 04/26/2025, 04/27/2025, 05/10/2025, 05/11/2025, 05/18/2025, 06/21/2025, and 06/22/2025. During an interview on 07/04/2025 at 3:45 PM, the DON stated that if there was a complaint related to abuse or neglect then the facility policy would be followed. She stated Teachable Moments were given by the nursing staff to address actions that needed to be stopped. The DON stated that once she reviewed the forms, she addressed the issue with the staff member, and if she felt the nurse handled the situation, then the form went into the staff member's personnel file. She stated that upon review of CNA #3's personnel file it contained no Teachable Moment forms. The DON stated if she had been told CNA #3 had told a resident to shut up an investigation would have been completed because that would have been considered abuse. The DON verified no investigation had been carried out regarding Resident #25 being told to shut up. During an interview on 07/04/2025 at 4:43 PM, the interim Administrator stated if a resident had been told to shut up, she would expect it to be reported and an investigation to take place. During an interview on 07/05/2025 at 2:26 PM with the interim Administrator and the [NAME] President of Clinical Service verified the allegation involving Resident #25 had been investigated but they could not find the investigation due to not knowing where the former Administrator kept his files. 2. Review of the medical record revealed the facility admitted Resident #66 on 02/19/2025. The resident had a medical history that included a diagnosis of anxiety disorder. Review of the quarterly MDS assessment, dated 06/04/2025, revealed Resident #66 had intact cognition. Review of the care plan, initiated 03/04/2025 and revised on 03/31/2025, indicated the resident had behaviors that included yelling at staff when care was being provided. Interventions included staff to tell the resident what they were going to do before they began and to speak to the resident unhurriedly and in a calm voice. During an interview on 07/01/2025 at 2:13 PM, Resident #66 stated that CNA #3 had yelled at them. During an interview on 07/03/2025 at 3:20 PM, the interim Administrator stated she had a conversation with Resident #66 about verbal abuse from an aide. She stated the allegation had already been investigated. During an interview on 07/05/2025 at 10:41 AM, Resident #66 stated at the end of May (2025) CNA #3 yelled, argued, and raised her voice with the resident related to the schedule and the amount of time it took for CNA #3 to answer their call light. Resident #66 stated CNA #3 told them they needed to get their facts straight about the call light being on for over an hour and a half. Resident #66 stated CNA #3 yelled and flung her arms around. Resident #66 stated they asked CNA #3 to have the nurse come to the room and CNA #3 ignored them. Then after about five minutes she got RN #5 to come in the room. Resident #66 stated when RN #5 entered the room they (the resident) had a panic attack. Resident #66 stated CNA #3 had been in their room that day (07/05/2025) when the resident had initiated a call light. Resident #66 stated the DON was aware the CNA was in her room because the DON instructed CNA #3 to turn off the call light. The facility was unable to provide an investigation of verbal abuse towards Resident #66. During an interview on 07/03/2025 at 7:51 PM, CNA #10 stated that around the end of May or June 2025, Resident #66 told her CNA #3 had yelled at the resident. CNA #10 stated she informed LPN #8 and Resident #66 told LPN #8 what happened. She stated no upper management staff interviewed or asked her any questions about the incident or interviewed any other residents. During an interview on 07/04/2025 at 10:32 AM, LPN #8 stated Resident #66 told her CNA #3 had said some offensive things towards the resident and the resident desired not to have her as an aide. LPN #8 stated when the resident reported the issues with CNA #3 to her she contacted the Scheduler. She stated the Scheduler told her to write some things down but she forgot to do so. She stated she was told if a resident had a complaint to report it to the Scheduler first then to the ADON, and then to the DON. LPN #8 stated she thought the Scheduler did something with the information she reported to her and thought CNA #3 was written up. During an interview on 07/05/2025 at 2:26 PM with the interim Administrator and the [NAME] President of Clinical Services they verified it was reported that the allegation involving Resident #66 had been investigated but they could not find the investigation due to not knowing where the former Administrator kept his files. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 04/2021, revealed residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The policy revealed at bullet point #9 to investigate and report any allegations within timeframes required by federal requirements. Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 2001, revealed all reports of resident abuse are thoroughly investigated by facility management. The policy revealed investigating Allegations included 1. All allegations are thoroughly investigated. The administrator initiates investigations. 7. The individual conducting the investigation as a minimum a. reviews the documentation and evidence; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; c. observes the alleged victim, including his or her interactions with staff and other residents; d. interviews the person(s) reporting the incident; e. interviews any witnesses to the incident; f. Interviews the resident (as medically appropriate) or the resident's representative; g. interviews the resident's attending physician as needed to determine the resident's condition; h. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; i. interviews the resident's roommate, family members, and visitors; j. interviews other residents to whom the accused employee provides care or services; k. reviews all events leading up to the alleged incident; and l. documents the investigation completely and thoroughly. The policy revealed 11. Upon conclusion of the investigation, the investigator records the findings of the investigation on approved documentation forms and provides the completed documentation to the administrator.

Based on interview, record review, and a review of the facility's policy, the facility failed to notify the Office of the State Long Term Care Ombudsman and failed to provide written bed-hold notices for two (Resident #22 and Resident #17) of two residents reviewed for hospitalization. The facility census was 84 Findings include: 1. Review of the medical record revealed the facility admitted Resident #22 on [DATE]. The resident had a medical history that included a diagnosis of multiple sclerosis. Resident #22's progress notes dated [DATE] at 12:00 PM indicated the resident was transferred to the emergency room (ER) for an evaluation and treatment. Resident #22's progress notes dated [DATE] at 10:38 PM that indicated the resident returned to the facility from the hospital at 7:30 PM. Resident #22's progress notes dated [DATE] at 11:51 PM indicated the resident's family member called emergency medical services (EMS) due to suspecting the resident was having a stroke. The note revealed EMS took the resident to a local hospital. A progress note dated [DATE] at 12:31 AM indicated the resident remained in the hospital. Resident #22's progress notes dated [DATE] at 8:13 PM indicated the resident refused further medication for treatment of a new onset of pain and was adamant about being sent to the hospital. Resident #22's progress notes dated [DATE] at 7:40 AM indicated the resident was being admitted to the hospital. Resident #22's medical record revealed no documented evidence that the facility provided the resident/resident's family with a bed hold notice or notified the Ombudsman for the resident's hospitalizations on [DATE], [DATE], and [DATE]. Interview on [DATE] at 9:09 AM, Registered Nurse (RN) #20 stated she had only sent monthly notifications to the Ombudsman for residents that discharged home or discharged to other facilities. She stated she did not send monthly notifications for discharges to the hospital. She verified Resident #22's name was not on the monthly lists sent to the Ombudsman. Interview on [DATE] at 1:28 PM, Registered Nurse (RN) #20 stated they looked in the Business Office Manager's (BOM) office and could not find bed holds notices. Interview on [DATE] at 12:32 PM, Social Worker (SW) #19 stated she ran a report of resident discharges at the beginning of each month and emailed the report to the Ohio State Ombudsman and the [NAME] County Ombudsman. SW #19 stated she had only been sending them discharge information that included residents who left against medical advice (AMA), discharged home or to another facility, or were deceased . She stated that she was not aware until a few days prior she was supposed to send the Ombudsman a notification when a resident was hospitalized . Interview on [DATE] at 4:22 PM, the Director of Nursing (DON) stated that the BOM was responsible for completing bed hold notices. However, the DON stated she did not believe the BOM was sending the notices because they could not find any documentation. The DON stated the Social Worker was responsible for sending notifications to the Ombudsman. Interview on [DATE] at 4:33 PM, the Administrator stated she was not sure whether social services staff or the BOM was responsible for sending the notifications to the Ombudsman and was not sure of the facility's process. The Administrator stated the BOM should have been sending bed hold notices to the hospital with the resident when they were transferred. Review of the facility policy titled Transfer or Discharge, Facility Initiated, revised 10/2022, revealed under the section titled, Notice of Transfer or Discharge (Emergent or Therapeutic Leave), included 4. Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable (e.g. [exempli gratia, for example], in a monthly list of residents that includes all notice content requirements). 5. Notice of Facility Bed-Hold and Return policies are provided to the resident and representative within 24 hours of emergency transfer. 2. Review of the medical record revealed the facility admitted Resident #17 on [DATE]. The resident had a medical history that included a diagnosis of acute and chronic respiratory failure with hypercapnia. Resident #17's progress notes dated [DATE] indicated the resident requested to be sent to the ER and was sent to the hospital via EMS. Resident #17's progress notes dated [DATE] indicated the resident was readmitted to the facility. Resident #17's progress notes dated [DATE] indicated the resident was transferred to the hospital for an evaluation after a fall. Resident #17 returned to the facility on [DATE]. Resident #17's progress notes dated [DATE] that indicated a nurse practitioner sent the resident to the ER due to decreased arousal and level of consciousness. The resident returned to the facility on [DATE]. There was no documented evidence the facility provided Resident #17 with a bed hold notice or the Ombudsman was notified when the resident was transferred to the hospital on [DATE], [DATE], and [DATE]. During an interview on [DATE] at 8:28 AM, the DON stated the business office staff were responsible for issuing bed hold notices when a resident went to the hospital. However, she stated they were not able to find any bed hold notices for Resident #17 when the resident was hospitalized . The DON stated social services staff were responsible for notifying the Ombudsman when residents went to the hospital and stated she did not know whether the Ombudsman was notified of Resident #17's hospitalizations. During an interview on [DATE] at 9:08 AM, the Administrator stated the Social Worker, or the DON should provide a bed hold notice when the resident was being discharged to the hospital, unless it was in the middle of the night; then the nurse should provide the notice. She stated that if the resident did not get a notice when discharged /transferred, the admissions staff should deliver the notice to the resident. The Administrator stated they could not locate bed hold notices for Resident #17. She stated that social services staff should be responsible for notifying the Ombudsman.

Based on record review, interview, and facility policy review, the facility failed to revise a care plan for one (Resident #19) of one resident reviewed for tube feedings. The facility census was 84. Findings include: Review of the medical record revealed Resident #19 was admitted on [DATE]. Diagnoses included multiple sclerosis and oropharyngeal dysphagia (a disorder or impairment in initiating a swallow). Review of the Minimum Data Set assessment, dated 04/17/2025, revealed Resident #19 had severe impairment in cognitive skills for daily decision-making and had a short-term and long-term memory problem. The MDS indicated the resident had a feeding tube while they were a resident at the facility. Resident #19's current physician orders included an order dated 01/02/2025 for nothing by mouth (NPO) diet and enteral feeding of 2calorie formula at 60 milliliters (ml) an hour continuously with a 50 ml an hour fluid flush every shift with a 1320 ml total based on a 22-hour runtime. Review of Resident #19's care plan initiated 8/17/2021 identified the resident was at risk for malnutrition. Interventions directed staff to honor food preferences within scope of diet (initiated 01/11/2022); monitor/document/report as need any signs and symptoms of dysphagia to include holding food in mouth, several attempts at swallowing, refusing to eat, and appears concerned during meals (initiated (01/11/2022); provide supervision, encouragement, cueing, or assist as needed to complete meals (initiated 08/17/2021); provide/serve diet as ordered, monitor intakes and record every meal, and report consistently poor intake to the dietitian (initiated 01/11/2022); and serve altered texture diet as ordered (initiated 08/17/2021). The Care Plan Report was revised to indicate the resident had a feeding tube placed on 06/19/2023. Interventions directed staff to elevate the head of the bed to 30 degrees while the tube feeding was running (initiated 06/22/2023); provide fluid flushes as ordered (initiated 06/22/2023); and provide tube feed as ordered (initiated 06/22/2023). The care plan was not revised to identify the resident's NPO status. During an interview on 07/05/2025 at 12:34 PM, the Corporate MDS Coordinator stated the facility did not currently have an MDS Coordinator, so she and another corporate person had been coming in for the last month or so to do the MDSs and care plans. She stated any acute changes to the care plan could be completed by the nursing staff. The care plan was reviewed quarterly, annually, and with any significant change to ensure it was up to date and accurate. She stated that if a resident was changed to being strictly NPO then the old interventions regarding oral intake should be resolved. During another interview on 07/05/2025 at 1:15 PM, the Corporate MDS Coordinator verified Resident #19's care plan had interventions that indicated to provide the diet as ordered. She stated Resident #19 was NPO with no pleasure feedings, so the care plan should have reflected that and that the resident was not receiving meals. During an interview on 07/08/2025 at 8:28 AM, the Director of Nursing (DON) stated the care plan should be updated by nursing staff. She verified the interventions regarding the oral intake should have been removed for Resident #19. During an interview on 07/08/2025 at 9:08 AM, the Interim Administrator stated the care plan should have been revised to reflect that Resident #19 was not taking anything by mouth. She stated it should have been done at the time the resident received an order to be NPO. It also should have been caught when reviewed quarterly. Review of facility policy titled Care Plans, Comprehensive Person-Centered, dated 03/2022, revealed assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS [Minimum Data Set] assessment.

Based on observations, record review, staff, and resident interviews, and review of facility policy, the facility failed to ensure a clean, safe, comfortable environment for all residents. This affected 11 (#02, #06, #19, #31, #32, #35, #38, #44, #53, #70, and #71) residents who resided in the facility. The facility census was 77. Findings include: Review of the medical record for Resident #53 revealed the resident was admitted on [DATE]. Diagnoses included hypoxemia, amyotrophic lateral sclerosis (ALS), gastro-esophageal reflux disease (GERD), essential primary hypertension, obstructive sleep apnea (OSA), and diabetes mellitus (DM). Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #53 was cognitively intact. Resident #53 was dependent on staff for Activities of Daily Living (ADLs). Observation of the facility on 05/13/25 at 11: 30 A.M. with the Director of Housekeeping and Laundry #134 revealed the following findings: a) Resident #02's bathroom was heavily soiled with dirt, debris and an unknown black substance in the corners, the floor was extremely sticky and the cover over the toilet tank was too large and did not properly fit. b) Resident #06's bathroom floor was very sticky, heavily soiled and had black stains throughout the floor. c) The wall behind Resident #19's bed was shredded and torn, the floor around her toilet had an unknown black substance, the cove base below the sink was loose and separated from the wall and there were numerous ceramic tiles missing. d) The wall behind Resident #31's bed was damaged and had exposed drywall, the heater wall was chipped and contained rusted areas, the floor around the toilet was heavily soiled, and the assist bars around the toilet were not secured. e) The wall behind Resident #32's bed was damaged and had exposed drywall, the cove base was separated from the wall under the bathroom sink, and the floor in bathroom was soiled and sticky. f) Resident #35's bed had a heavily soiled sheet with food and debris all over it, the floor had food and debris scattered throughout and the floor was extremely sticky. g) Resident #38's bathroom was heavily soiled and stained around the base of the toilet, and in the corners of the bathroom. h) Resident #44's bathroom floor was very sticky, heavily soiled with dirt and debris, and had a large yellow stain around the base of the toilet. i) Resident #70 and Resident #71's entire floor was heavily soiled with a black substance. j) Resident #53's room had numerous chipped ceramic tiles, and the floor was heavily soiled and extremely sticky k) The ice machine in the 200- hallway was heavily soiled, had rusted spots all over the ice machine hopper door. The ice machine had something splattered on it and there was a brown ring inside where the ice was stored. Interview with Director of Housekeeping and Laundry #134 immediately following these observations, verified the above findings. Interview with Resident #53 on 05/13/25 at 2:15 P.M., revealed she was very embarrassed about her room when friends and family visited. Resident #53 stated she ordered a shelf and a rug to try and make the bathroom look more homelike. Review of the facility policy titled, Homelike Environment, dated February 2021, confirmed the facility Residents are provided a safe, clean, comfortable, and homelike environment. The facility staff and management maximize a personalized homelike environment including a clean, sanitary, and orderly environment, and a clean bed This deficiency represents non-compliance investigated under Complaint Number OH00165544.

Based on observation, resident and staff interview, medical record review, and policy review, the facility failed to ensure the facility was free from pests. This affected one (#26) of four residents reviewed for effective pest control. The facility census was 78. Findings include: Review of the medical record for Resident #26 revealed an admission date of 07/09/24. Diagnoses included cerebral infarction, bipolar disorder, personal history of traumatic brain injury, insomnia, hyperlipidemia, epilepsy, osteoarthritis, aphasia, hemiplegia and hemiparesis following a cerebral infarction, and cerebellar ataxia. Review of Resident #26's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed as cognitively intact. Interview on 05/06/25 at 3:04 P.M. with a Registered Nurse (RN) #204 and Certified Nurse Aide (CNA) #224 reported they both saw live roaches in Resident #26's bathroom. Observation and interview on 05/06/25 at 3:06 P.M. with the Administrator confirmed the presence of five to six live cockroaches behind Resident #26's refrigerator. Interview on 05/06/25 at 3:45 P.M. with Resident #26 confirmed there were cockroaches behind his refrigerator on 05/06/25. Resident #26 reported the issue had been ongoing and stated the facility had treated his room previously. Resident #26 stated he did drop his entire food tray on the floor the previous day and it took over an hour before it was fully cleaned up. Review of the undated pest control policy revealed it was the policy of the facility to maintain an effective pest control program that eradicated and contained common household pests and rodents. The facility would maintain an agreement with a qualified outside pest service to provide comprehensive pest control services on a regular and scheduled basis. The facility would maintain a reporting system of any issues arising between scheduled visits. This deficiency represents non-compliance investigated under Complaint Number OH00165096 and a recite from the complaint survey dated 03/04/25 and 04/04/25.

Based on observation, resident and staff interview, medical record review, and policy review, the facility failed to ensure the facility was free from pests. This had potential to affect all 81 facility residents. The census was 81. Findings include: 1. Review of Resident #11's medical record revealed the resident admitted to the facility on [DATE] with diagnoses including multiple fractures of the ribs right side, pain in unspecified joint, congestive heart failure, chronic obstructive pulmonary disease unspecified, legal blindness, urinary tract infection, angina pectoris and heartburn. Review of Resident #11's admission assessment dated [DATE] revealed the resident was oriented to person, place, time, and situation. Interview with Resident #11 on [DATE] at 8:14 A.M. revealed the resident saw a large cockroach in her bathroom a few days ago that was over one inch long. 2. Review of Resident #19's medical record revealed the resident admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus with diabetic polyneuropathy, chronic obstructive pulmonary disease, mood disorder due to known physiological condition, arthropathy and unspecified convulsions. Review of Resident #19's admission assessment dated [DATE] revealed Resident #19 was alert and oriented to person, place, and situation. Interview with Resident #19 on [DATE] at 8:19 A.M. revealed the resident saw a cockroach in his room near his doorway a few days ago. 3. Review of Resident #24's medical record revealed the resident admitted to the facility on [DATE] with diagnoses including congestive heart failure, type two diabetes mellitus without complications, bipolar disorder, anxiety disorder, muscle weakness, hyperlipidemia and hypertension. Review of Resident #24's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Interview with Resident #24 on [DATE] at 8:20 A.M. revealed the resident saw multiple cockroaches since residing at the facility. Interview with Licensed Practical Nurse (LPN) #208 on [DATE] at 8:00 A.M. revealed she saw a cockroach in the facility last week. Interview with Registered Nurse (RN) #223 on [DATE] at 8:04 A.M. revealed she saw bugs in the facility, but could not identify them as cockroaches. Interview with Certified Nurse Aide (CNA) #131 on [DATE] at 8:05 A.M. revealed she saw a cockroach on the [NAME] unit on [DATE]. Observation of the kitchen on [DATE] at 8:25 A.M. revealed a deceased cockroach on the floor under the food preparation table by the cereal and a deceased cockroach under the bread cart. Interview with Dietary Supervisor #500 on [DATE] at 8:25 A.M. verified there was a deceased cockroach on the floor under the food preparation table by the cereal and a deceased cockroach under the bread cart. Observation of the dining room on [DATE] at 9:56 A.M. revealed a deceased cockroach on the floor in the corner of the dining room. There was also a deceased cockroach located near the ice machine prior to the kitchen entrance. Interview with Dietary Supervisor #500 on [DATE] at 9:56 A.M. verified the deceased cockroach on the floor in the corner of the dining room and the deceased cockroach located near the ice machine prior to the kitchen entrance. Review of the facility's undated pest control program policy revealed the facility will maintain an effective pest control program that eradicates and contains common household pests and rodents. This deficiency represents non-compliance investigated under Complaint Number OH00163750 and continued non-compliance from the survey dated [DATE].

Based on observations, staff and resident interviews, interview with the Pest Control Representative, review of pest control notes, and review of facility policy, the facility failed to maintain the kitchen and dining room area free from pests. This had potential to affect all 74 facility residents. Findings include: Review of pest control notes dated 09/30/24, 10/22/24, 11/27/24, 01/03/25 and 01/27/25 revealed the facility had treatments completed for roaches and mice traps were monitored. Observation and interview on 03/04/25 from 9:40 A.M. to 10:05 A.M. with Kitchen Manager (KM) #205 revealed facility had mice a few weeks ago but they had been treated. Observation of the food area found an extremely large amount of brownish black pellets. KM #205 verified these to be mouse excrement. These were found on baking sheets; in the roboku; in boxes of paper products; in boxes and containers of food such as chips, gelatin, condiments, and packaging with pop cans; on cookie sheets with food on it; and on the silverware holder. KM #205 could not confirm if the mouse droppings were new or old. Two large trashcans were also found to be uncovered. Two smaller trashcans had trash in them with no trash bag and were uncovered. KM confirmed the trash cans had no lids and he was unsure if the facility had lids for any trashcans. Observation and interview on 03/04/25 at 10:06 A.M. with Dietary Aide (DA) #210 confirmed both living and dead roaches were observed in the dining room in the last week. DA #210 confirmed roaches were found mainly along the side of the room closest to the staff hallway and the doors to the hallway. The area was observed to have a thick black line on the floor of dirt and debris including crumbs along the wall with a crevice that held the debris. Interview on 03/04/25 at 12:45 P.M. with the Pest Control Representative revealed the facility had been getting services for pest control. She reported the pest control agent would give recommendations to the facility on how to help rid pests in between visits. These recommendations could include cleaning, dealing with trash, and getting rid of pest debris such as excrement and dead insects to see new movement vs old movement. She also reported the facility was not paid up to date for services from 11/2024 through 02/2024. Interview and observation on 03/04/25 at 1:46 P.M. with Maintenance Director (MD) #225 and the Administrator confirmed observation of a black line along the dining room wall. MD #225 confirmed they had replaced base boards but the new ones did not fit the same way and facility needed a piece of quarter round to cover the crevice. They confirmed dirt and debris, including food crumbs, get swept and pushed into the crevice which would be enticing for insects, mice, or other pests. MD #225 confirmed the pest control company had provided directions for prep prior to their arrival for spaces they intend to treat, but also had given some basic instructions on cleanliness and keeping areas free of food and debris to help prevent ongoing issues. MD #225 confirmed he had not been checking on how staff follow those recommendations. Review of facility policy titled Sanitation, dated 11/2022, revealed food service areas shall be maintained in a clean and sanitary manner, kept free and clear of garbage and debris and protected from rodents and insects. Kitchen waste shall be stored in clean leakproof tightly closed containers and disposed of daily and garbage containers shall be affixed with lids or otherwise covered. This deficiency represents non-compliance investigated under Master Complaint Number OH00162699, OH00162474 and OH00161757.

Based on observations, staff interview, and resident interviews, facility failed to ensure resident rooms were maintained in clean, working order. This affected three (#23, #46, and #50) of three residents reviewed for environment. The facility census was 74. Findings include 1. Observation on 03/04/25 at 11:51 P.M. in Resident #46's room with Licensed Practical Nurse (LPN) #220 revealed the floor around the packaged terminal air conditioner (PTAC) heating and cooling unit had several floor tiles which were loose. The floor on the right and left side was dark and appeared to be missing a floor surface. The left side had a hole about the size of a thumb in the flooring. A built-in shelf to the right of the PTAC machine was broken and caved in. Interview at the time of the observation with LPN #220 confirmed the observations. 2. Observation on 03/04/25 at 9:40 A.M. of Resident #50's room revealed a floor board was loose and had fallen off the closet/wall and was sitting upside down on the floor. Both closet doors were broken and off the hinges. Interview on 03/04/25 at 11:53 P.M. with LPN #220 confirmed the observations. 3. Interview on 03/04/25 at 12:18 P.M. with Resident #23 and a family member reported when she has the PTAC unit running on heat it gets dusty and has a bad smell. Resident #23 also stated it was dirty. Observation on 03/04/25 at 1:46 P.M. with Maintenance Director #225 revealed Resident #23's PTAC was dirty and had clumps of leaves and dirt. Interview at this time with Maintenance Director #225 verified the observation. He stated it was about due for a quarterly cleaning. This deficiency represents non-compliance investigated under Complaint Number OH00162474.

Based on medical record review, review of the National Alliance on Mental Illness (NAMI.org) website, observation, staff interview, pharmacy technician interview, and facility policy review, the facility staff failed to ensure a resident received ordered monthly psychoactive injections. This resulted in actual harm when the resident's behaviors escalated to include multiple episodes of violent screaming, the resident experienced a decline in her ability to complete her activities of daily living (ADLs), requiring staff to provide assistance with ambulation and eating, and the resident had a decline in her bowel and bladder functioning which led to episodes of incontinence. This affected one Resident (#01) of five reviewed for medications. The facility census was 88. Findings include: Medical record review revealed Resident #01 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #01's care plan revealed her baseline behaviors at admission on 04/12/19 included yelling, becoming agitated with excessive noise, sad, tearful, and nervous with hallucinations/delusions. The interventions included providing medications as ordered and evaluating for effectiveness and monitoring for increased behaviors every shift. Review of Resident #01's physician order [REDACTED]. Review of Resident #01's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition. The resident was able to transfer, ambulate, and used the toilet with the supervision of one staff. She required set up help only for eating and hygiene, and was always continent of bowel and bladder. Review of Resident #01's Medication Administration Record [REDACTED]#102, and on 01/17/20 by agency RN #101. Review of Resident #01's monthly notes from the visiting psychological consultant dated 12/10/19 revealed the resident's sister passed away on 11/28/19, and she was more tearful, and yelling out for family members. She was increasingly anxious and was started on [MEDICATION NAME] (antianxiety), 0.5 milligrams (mg), twice per day. Review of Resident #01's progress note dated 01/03/20 revealed the resident was yelling out for two to three hours during the night and saying the cops were going to take her brother to jail. On 01/10/20, the resident spit out all of her medications across the room, and was screaming. On 01/23/20 the resident was noted with increased agitation, delusions, and anxiety. Review of Resident #01's MDS assessment dated [DATE] revealed the resident had a significant decline and now required the extensive assistance of two staff for transfers with no ambulation, and the extensive assistance of one staff for all ADLS, including eating. She was now always incontinent of bowel and bladder, and using incontinence products Review of Resident #01's monthly note from the visiting psychological consultant dated 01/31/20, revealed the resident reported feeling an increase in anxiety and nervousness. Staff also reported the resident was more anxious On 02/07/20, Resident #01 was given [MEDICATION NAME] and it was ineffective. The staff were unsuccessful in redirecting the resident. On 02/12/20, the resident had increased agitation, delusions, and anxiety. Review of Resident #01's progress note dated 02/21/20 revealed it was noted the resident had not been administered her monthly [MEDICATION NAME] injections since October 2019. It was also noted the resident had increase behaviors, agitation, anxiety and [MEDICAL CONDITION]. Observations of Resident #01 on 03/04/20 at 9:00 A.M. to 11:00 A.M., and from 1:30 P.M. to 3:45 P.M., revealed the resident was quiet and participating in activities. Interview on 03/04/20 at 9:45 A.M. with Registered Nurse (RN) #100 revealed she had contacted the pharmacy on around 02/20/20 when she discovered the last [MEDICATION NAME] injection for Resident #01 was delivered to the facility on [DATE], and administered that date. She confirmed the resident had missed the injections on 11/17/19, 12/17/19, 01/17/20, and 02/17/20. RN #100 confirmed there were two errors, the first was failing to order the [MEDICATION NAME] injection from the pharmacy monthly as required, and the second error was the [MEDICATION NAME] injections were initialed as administered on 11/17/19 by agency RN #103, on 12/17/19 by former LPN #102, and on 01/17/20 by agency RN #101, however the injections were not given. Phone interview with Pharmacy Technician #120 on 03/04/20 at 3:17 P.M. confirmed Resident #01's monthly [MEDICATION NAME] injections had not been sent to the facility since 10/17/19, until the facility contacted them and one was sent on 02/20/20. Interview on 03/04/20 at 3:45 P.M. with LPN #105 revealed on 01/28/20 she completed a significant change MDS assessment for Resident #01 due to the decline in no longer ambulating, requiring the use of a stand up lift with two staff for transfers, requiring the extensive assistance of one staff for all ADLs, including eating. LPN #105 further revealed the resident was now was always incontinent of bowel and bladder, and was using incontinence products. LPN #105 verified the resident had been violently screaming, grabbing staff, and cursing more at the time of the significant change. The LPN revealed the past few days since the resident received the [MEDICATION NAME] injection on 02/20/20, there was some improvement with the resident's yelling out, anxiety, [MEDICAL CONDITION], and agitation, especially during the day. A group interview on 03/04/20 at 4:00 P.M. with Activity Staff #106, #107, and Activity Director #110 confirmed Resident #01 was engaged in activities today and was not yelling out. They all stated the resident was yelling out less the past two weeks. Interview with RN #126 on 03/06/20 at 11:00 A.M. revealed the past week the resident was quieter and calmer. Interview with State tested Nursing Assistant (STNA) #130 on 03/06/20 at 11:05 A.M. revealed the resident was screaming less overall the past week. Review of the NAMI.org website revealed missing a dose of [MEDICATION NAME] could increase your risk for a relapse in symptoms. Do not stop taking the medication without talking with your healthcare provider. In order for the medication to work properly it should be taken as ordered. Review of the facility's Medication Administration policy from the Lippincott Nursing Procedures 8th Editions 2019, page 557, revealed to reduce the risk of errors, medications are to be administered at the proper time, prescribed dosage, and correct route. This was an incidental finding discovered during the complaint investigation.

Based on medical record review, observations, staff, physician and resident interview and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to assess Resident #10's use of a bed pan to identify risk factors and develop an individualized care plan regarding pressure ulcer risk factors related to the use of the device. This resulted in actual harm when Resident #10 was left on a bed pan for an undetermined amount of time subsequently resulting in the development of an avoidable unstageable (due to necrosis) pressure ulcer to the left buttock and an unstageable deep tissue injury to the right buttock both requiring debridement. This affected one (#10) of three resident reviewed for skin breakdown. Facility census was 85. Findings include: Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #10 is documented in the medical record as being her own responsible person and listed as first contact. Resident does have a guardian and a son is listed as contact #2; however, as being his or her own responsible party the resident would receive notification and not the family of changes in condition. Review of the 10/09/19 discharge Minimum Data Set (MDS) titled return anticipated revealed the resident's memory is intact, the resident had no delusions, hallucinations, or behaviors during the review period. The resident is dependent on staff for toileting, extensive assist for bed mobility, limited assist with dressing and personal hygiene and supervision for eating. The resident is coded as occasionally incontinent for bowel and bladder. The resident received seven days of antipsychotic, antianxiety, antidepressant medications, four days of opioid medication and three days of antibiotic medication. The resident is coded as having one stage II pressure ulcer and one deep tissue injury. Review of care plans revealed the resident has behaviors of refusing care of being turned and refusing showers the care plan was initiated in (YEAR). The care plan was updated on 10/17/19 to include the resident has periods of time where he/she sits on the bed pan for long periods of time. Review of the care plan revealed Resident #10 has an at risk for skin break down care plan related to weakness, impaired mobility incontinence, falls and [MEDICAL CONDITION] dated 06/04/18 with the most recent revision being dated 09/28/18. Interventions include weekly skin inspection dated 06/04/18, low air loss mattress dated 10/29/19, and a toileting toileting plan dated 09/28/19. Review of medical record revealed the resident progress notes first indicated the resident had a skin alteration to her buttock on 10/04/19 at 2:43 P.M. which revealed a new order, cleanse areas to right and left buttock pat dry, apply foam dressing daily and as needed (PRN). Review of Resident #10 progress notes for the 12 months revealed there was no documentation of the resident having behaviors of sitting on the bed pan for long periods of time. Review of medical record revealed there were no documented behaviors in the resident medical record and all completed MDS assessments were reviewed and the resident was not coded as having any delusions, hallucinations or any type of behavior or refusal of care. Review of wound physician consult note dated 10/02/19 revealed Resident #10 was seen at the request of the referring physician and the resident had multiple wounds that were present for greater than one day. The consult note indicated there is no pain indicated with this condition. The resident is documented as alert to person place time and situation with no distress. The etiology of the wounds is listed as pressure with additional wound detail being explained as a bed pan injury. The note describes the wound to the left buttock as unstageable (due to necrosis) measuring 3.2 centimeters (cm) x 7.0 cm x not measurable, surface area is 22.40 square centimeters (cm 2), the wound is documented as having light serous exudate and the tissue is described as thick adherent devitalized necrotic tissue 50 percent (%) and granulation tissue 50%. The consult note revealed surgical excisional debridement procedure with an indication for the procedure to remove necrotic tissue and establish the margins of viable tissue. The consult note revealed the resident was explained the procedure recommendation with risk benefit and possible subsequent additional procedures on 10/02/19 and the resident was agreeable to proceed with the procedure. The procedure was described as: wound was cleansed with normal saline and anesthesia was achieved using topical [MEDICATION NAME]. Then with clean surgical technique 15 blade was used to surgically excise 11.2 cm 2 of devitalized tissue and necrotic subcutaneous fat and surrounding connective tissues were removed at a depth of 0.1 cm and healthy bleeding tissue was observed. Homeostasis was achieved and a clean dressing was applied. Post operative recommendations plan of care and recommendations and updates to the plan of care were document in the assessment and plan section below. Review of the assessment and plan section revealed the resident was recommended to have house barrier cream and off load the area per facility protocol. Review of the wound consult note dated 10/09/19 indicated wound measured at 3.0 cm x 7.0 cm x not measurable. The tissue is described as thick adherent devitalized necrotic tissue 20% and granulation tissue 80%. The resident need subsequent debridement of the wound to the left buttock and the procedure was described as wound was cleansed with normal saline and anesthesia was achieved using topical [MEDICATION NAME]. Then with clean surgical technique 15 blade was used to surgically excise 21.00 cm 2 of devitalized tissue and necrotic subcutaneous fat and surrounding connective tissues were removed at a depth of 0.1 cm and healthy bleeding tissue was observed. Homeostasis was achieved and a clean dressing was applied. Review of the assessment and plan section revealed the resident was recommended to have house barrier cream and off load the area per facility protocol. Wound consult note from 10/16/19 indicated the wound measured 3.0 cm x 6.0 cm x not measurable, the tissue is described as thick adherent devitalized necrotic tissue 20% and granulation tissue 80%. The resident required subsequent debridement of the wound to the left buttock and the procedure was described as: wound was cleansed with normal saline and anesthesia was achieved using topical [MEDICATION NAME]. Then with clean surgical technique 15 blade was used to surgically excise 18.0 cm 2 of devitalized tissue and necrotic subcutaneous fat and surrounding connective tissues were removed at a depth of 0.2 cm and healthy bleeding tissue was observed. Homeostasis was achieved and a clean dressing was applied. Review of the assessment and plan section revealed the house barrier cream was discontinued and a foam dressing was to be applied daily and off load the area per facility protocol. The right buttock wound is described on the initial wound consult note on 10/02/19 as an unstageable deep tissue injury with intact skin the wound measured 0.8 cm x 7.0 cm with a surface area of 5.60 cm 2. The wound had no exudate and the recommendation was to off load wound bed and reposition. Treatment recommended was house barrier cream. The right buttock wound was described in the wound consult note on 10/09/19 as 0.6 cm x 2.5 cm x 0.1 cm. the recommendation was to continue to off load per facility protocol and use house barrier cream. The right buttock wound was described in the wound consult note on 10/16/19 as resolved. During an interview and observation of Resident #10's wound on 10/30/19 at 7:40 [NAME]M. with the wound physician #200 it was revealed the resident has a stage III pressure ulcer on her left buttock from what he believes is a bed pan injury. The physician stated the resident is alert and could tell the staff or request to be moved off the bed pan, however, she is also morbidly obese and if she fell asleep, she may not recognize she is on the bed pan as her skin would fold over the bed pan and rest on the bed. The physician during the wound assessment and dressing change did indicate the right buttock wound had healed and the left has improved from last week. The wound was observed to be circular and measured 1.0 cm x 1.2 cm with slough in the wound bed. The peri wound is pink. The wound physician recommended continuing the current treatment. The wound was cleansed and the treatment of [REDACTED]. The resident denied pain prior to or during the dressing change. During an interview with Resident #10 on 10/30/19 at 7:45 [NAME]M. the resident revealed she was left on a bed pan by State tested Nursing Assistant (STNA) #150 but the resident could not state the day. The resident stated the staff did not take her off the bed pan all night. The resident was asked if she activated her call light and the resident responded she did everything to get off the bed pan, and she was not taken off during the night. During an interview with Registered Nurse (RN) #160 on 10/30/19 at 10:38 [NAME]M. revealed the wound on Resident #10 was identified on 10/02/19 and the wound physician saw the wound on 10/02/19. RN #160 verified the wound physician stated the etiology as pressure and a bed pan injury. RN #160 stated the resident has behaviors of wanting to sit on the bed pan for long periods of time and uses the call light to alert staff of his/her need to be removed from the bed pan. RN #160 stated the facility's investigation was able to narrow the timeframe of the injury to between 09/30/19 and 10/02/19. RN #160 stated the resident named a staff member who put him/her on the bed pan and did not remove the resident from the bed pan; however the staff member was not scheduled to work or on the facilities punch detail during the time frame in questions. RN #160 agreed there was no behavior documentation for the resident sitting on the bed pan for long periods of time as the facility charts by exception and this is the normal toileting pattern for Resident #10. RN #160 confirmed the identified risk factor associated with Resident #10 using the bed pan and the associated care plan was not addressed under after the development of the pressure ulcer to the coccyx. During an interview with STNA #180 on 10/30/19 at 3:43 P.M. confirmed she was the STNA who got Resident #10 off a bed pan one morning and the resident had a black area on her buttock and the entire area where the bed pan was touching the resident's bottom was reddened in the shape of a bed pan. STNA #180 stated the resident would usually indicate when he/she was finished using the bed pan and wanted off the bed pan, but he/she probably fell asleep and an agency STNA was caring for the resident that night and forgot the resident was on the bedpan. STNA #180 stated at shift report the agency STNA said nothing about the resident refusing to get off the bed pan. STNA #180 stated there was black in one place on Resident #10's wound. STNA #180 stated he/she works four days a week on this hallway and if Resident #10 was not encouraged to do anything the resident would stay in the bed all day every day. Review of information from the NPUAP revealed a deep tissue injury is intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage III or Stage IV). Do not use deep tissue injury to describe vascular, traumatic, neuropathic, or dermatologic conditions. Additionally, medical device related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system. This deficiency substantiates Complaint Number OH 869.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of hospital records, review of laboratory results, review of the Nursing Drug Handbook, 36th Edition, facility policy review, and staff interview, the facility failed to ensure a resident on oral anticoagulant therapy ([MEDICATION NAME]) was appropriately monitored in accordance with physician orders. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm to Resident #38 when she was found to have a critically high [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) greater than 106 seconds (PT) and greater than 17.5 (INR) respectively. This affected one (#38) of three residents reviewed who received anticoagulant (blood thinning) medication. The facility census was 96. On 05/08/19 at 4:45 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 04/02/19 when the facility failed to hold Resident #38's [MEDICATION NAME] as ordered by the physician. The resident continued to receive [MEDICATION NAME] 5 milligrams (mg) daily on 04/03/19, 04/04/19, 04/06/19, 04/07/19 and 04/08/19 and 7.5 mg on 04/05/19 without any INR monitoring until 04/09/19 when the regularly scheduled weekly INR was drawn. The laboratory results were received on 04/09/19 at 6:48 P.M. and revealed Resident #38 had a critically elevated INR level of 17.5 (normal therapeutic range 2.0 to 3.0). The resident was sent to the emergency room (ER) on 04/09/19 with a repeat INR level of 28.0 and received one dose of 10 mg of [MEDICATION NAME] (Vitamin K) to lower the resident's INR. The Immediate Jeopardy was removed on 04/11/19 when Resident #38 was sent to the ER for a medical evaluation and treatment, all other residents currently receiving anticoagulant therapy were reviewed and facility in-service education on anticoagulant medications and the facility's protocols was conducted. The deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 04/24/19 when the facility implemented the following corrective actions: · On 04/09/19 at 11:57 P.M., Resident #38 was sent to the ER for an evaluation and treatment. · On 04/10/19, the DON reviewed the medical records of the other two residents (#13 and #61) who were currently receiving anticoagulant medication in the facility to ensure their INR levels were within acceptable therapeutic ranges and laboratory monitoring was being completed as ordered by the physician. There were no other identified issues with anticoagulant therapy medication orders, or laboratory testing found. · On 04/11/19, the DON began in-services to all full time and part time nurses addressing [MEDICATION NAME] administration, the signs and symptoms of bleeding, documentation of the assessment of signs and symptoms of bleeding, abnormal laboratory results, immediate communication with the physician, and ensuring laboratory orders are put in the computer in Point Click Care (PCC). All education was completed on 04/11/19 and nurses currently on extended leave will be in-serviced prior to the start of their shift. · The DON or designee completed monitoring of residents receiving anticoagulant medications for accuracy on 04/11/19, 04/12/19, 04/15/19, 04/16/19, 04/17/19, 04/18/19, 04/19/19, 04/22/19, 04/23/19, and 04/24/19. The DON or designee will continue to audit 100% of residents currently being administered anticoagulant medication five times a week to ensure all anticoagulant orders are being administered as ordered, as well as laboratory orders being completed. · On 05/09/19 from 9:45 A.M. to 12:45 P.M., interviews with Licensed Practical Nurses (LPNs) #10, LPN #40 and LPN #50 indicated they received education on anticoagulants, the use of the monitoring tool to track PT/INR levels, anticoagulant orders, and laboratory orders. Findings include: Medical record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #38's plan of care related to anticoagulant therapy dated 03/28/19 revealed interventions included to complete laboratory tests as ordered by the physician and to report any abnormal laboratory results to the physician. Interventions also included to monitor/document and report to the physician any signs and symptoms of anticoagulant complications identified as blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, lethargy, shortness of breath, and sudden changes in mental status. Review of Resident #38's physician order [REDACTED]. Review of the nurse's progress note dated 04/01/19 completed by LPN #70 revealed the physician was notified Resident #38's INR results were 4.4. The physician ordered to hold the resident's [MEDICATION NAME] for two days and to recheck the INR on 04/03/19. There was no evidence the recheck of the INR was completed on 04/03/19. Review of Resident #38's (MONTH) 2019 Medication Administration Record [REDACTED]. The resident received 5 mg of [MEDICATION NAME] on 04/02/19, 04/03/19, 04/04/19, 04/06/19, 04/07/19 and 04/08/19. On 04/05/19, Resident #38 received 7.5 mg of [MEDICATION NAME]. Review of the nurse's progress note dated 04/09/19 at 4:01 P.M. revealed the scheduled weekly INR results were received and it was greater than 17.5. The PT was greater than 106. The Medical Director was notified, and an order was received to send Resident #38 to the ER. Emergency services was notified and transported the resident to the hospital. Review of the hospital records dated 04/09/19 revealed Resident #38 was admitted to the hospital with [REDACTED]. A repeat INR was drawn in the ER and the level came back greater than 28.0. The resident was administered one dose of 10 mg of [MEDICATION NAME] to lower the INR. Review of the hospital's INR results revealed Resident #38's INR was 18.8 on 04/11/19, 9.7 on 04/12/19, and 5.0 on 04/13/19. The resident was discharged back to the facility on [DATE]. During an interview on 05/08/19 at 10:28 A.M. with the DON she confirmed the order to recheck Resident #38's INR on 04/03/19 was not completed. She further confirmed the resident's [MEDICATION NAME] was not held on 04/03/19 as ordered, and the resident continued to receive [MEDICATION NAME] through 04/09/19. Review of facility policy titled, Anticoagulant Therapy, dated 03/2017 revealed all residents requiring [MEDICATION NAME] or [MEDICATION NAME] administration will have a PT/INR drawn as ordered by the physician to determine effectiveness of therapy and subsequent dosages. Licensed nurses will monitor the required lab completion and administration of the anticoagulant. Review of the Nursing Drug Handbook, 36th edition, identifies [MEDICATION NAME] as an anticoagulant and used as treatment of [REDACTED]. The medication should be used with caution and the most serious risk of therapy is hemorrhage (bleeding). The dosage is adjusted according to the INR results and the elderly tend to require lower dosages to produce a therapeutic level of anticoagulation. Under black box warning it indicates to regularly inspect patient for bleeding gums, bruises on arms or legs, petechiae (red or purple spots on the skin), nosebleeds, melena (dark and sticky stools), tarry stool, hematuria and hematemesis (blood in vomit). This deficiency substantiates Master Complaint Number OH 985.

Based on medical record review, review of social media post, staff interviews, resident interview, and facility policy review, the facility failed to protect Resident #1 from mental abuse when two nurses posted the resident's private health information on social media. This resulted in actual harm when Resident #1 suffered humiliation and felt degraded from the post. This affected one (#1) of three residents reviewed for abuse. The facility census was 95. Findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was intact. Review of the screenshot (undated) posted on social media (Facebook Messenger) timed at 10:18 A.M., revealed Licensed Practical Nurse (LPN) #50 sent a message to LPN #60 on social media and asked if Resident #1 had told her she had a sore throat. LPN #50's message revealed Resident #1 had said she had told several State tested Nursing Assistants (STNAs) that she had told her nurse. LPN #50's message revealed the resident drove her (expletive) crazy and she had not told her (expletive) anything. LPN #60 replied to the message and revealed she had told LPN #45 and Physician #75 was notified twice, once on the phone, and once in person of the resident's sore throat. LPN #60 further replied to LPN #50's message and said when Physician #75 was notified the resident had a sore throat, he said it was probably a [MEDICAL CONDITION] (STD), and if she didn't have a fever or other symptoms, what did she want him to do. This was followed by five laughing emoji's by LPN #60. LPN #50 replied to the message and said it probably was a STD and she was glad she was not at the facility. LPN #60 replied to the message indicating Resident #1 cried because Physician #75 would not see her. Review of the Employee Progressive Action Memorandum dated 02/10/19 revealed LPN #50 had a category two violation whereby the offenses were considered improper conduct subject to progressive discipline up to, and including, termination. The violation was due to LPN #50 was talking about a resident on social media. Staff was re-educated on the social media policy and LPN #50 was taken off of the resident's assignment per request by resident. The corrective action was to not communicate on any social media sites regarding resident concerns. LPN #50 agreed to the corrective action. On 03/16/19 at 12:07 P.M., interview with Resident #1 revealed LPN #50 and LPN #60 were posting messages on Facebook Messenger about her. Someone took a screenshot of the message and sent it to her. She said the person who sent it to her was a male who no longer worked in the facility. Resident #1 said her name was on the message. She said she had made a copy of the message and gave it to the Director of Nursing (DON) and the Administrator. The resident said she felt degraded and had cried over the message posted several times. On 03/16/19 at 2:35 P.M., interview with the DON revealed Resident #1 had not shown her the screenshot that was posted on social media, and she was seeing if for the first time today (03/16/19). However, the DON confirmed LPN #50 did received corrective counseling for the incident on 2/10/19. The DON revealed Resident #1 had told her she did not want LPN #50 or LPN #60 to take care of her. The DON revealed the message posted on social media between LPN #60 and LPN #50 was done from a work computer. She said it was her understanding, it was a private message between the two nurses. The DON revealed neither of the nurses were suspended and no other nurses were inserviced regarding social media. She confirmed the facility had not completed a thorough investigation which would include interviewing other staff and other residents. Nor, was a Self-Reported Incident (SRI) filed with the state agency in a timely manner. On 03/16/19 at 2:50 P.M., interview with LPN #60 revealed the social media post was a private conversation with LPN #50. LPN #60 revealed she did not have her phone, so she used the work computer. She said she did not know who took the screenshot of the message. LPN #60 verified there was no date on the message and thought the incident might have occurred around the first of the year. LPN #60 said she did put Resident #1's first name in the message and wondered if that would be a Health Insurance Portability and Accountability Act (HIPAA) violation. She said Resident #1 told the DON what the messages had said. LPN #60 said the message posted on social media was shameful and inappropriate. Review of the facility's Abuse, Mistreatment, Neglect, Injuries of Unknown Source and Misappropriation of Resident Property Policy dated 11/17, revealed the facility would not tolerate mistreatment, abuse, exploitation of neglect of it's residents or misappropriation of resident property by anyone. Verbal abuse was defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms of residents or their families, or within their hearing distance, regardless of their age, ability to understand or disability. Mental abuse includes humiliation, harassment, threats of punishment or deprivation. In order to protect resident privacy and prevent mental abuse, facility employees, vendors and consultants are prohibited from taking or using photographs, videos or recordings in any manner that would demean or humiliate a resident. Once the Administrator are notified, an investigation or suspicion will be conducted. The person investigating the incident should generally take the following actions: Interview the resident, the accused and all witnesses. Witnesses generally include anyone who witnessed or heard the incident, came in close contact with the resident the day of the incident and employees who worked closely with the accused employee (s) and/or alleged victim the day of the incident. Also, obtain written statements from the resident, if possible, the accused, and each witness. After completion of the investigation, all of the evidence should be analyzed, and the Administrator will make a determination regarding the allegation or suspicion is substantiated. The results of the investigation will be reported to the Administrator and a final report will be submitted to Ohio Department of Health, after the investigation is completed but no later than five working days after discovery of the incident. A review of the Social Media Policy dated 05/01/17 revealed the company provided training on appropriate use of social media, however it is ultimately the employee's responsibility to understand the risks involved with posting information on any social media platform that he or she used. Use of social media during work hours is prohibited unless it is being used in the course of one's official duties. Employees are expected to follow the requirements of the Health Insurance Portability and Accountability Act (HIPAA) as well as stated laws and the company's confidentiality policies with regard to private health information. This means that employees may not make social media posts or statements about residents that include any kind of information that would allow others to identify those residents. If the facility became aware of or receives a report of a social media post that violated this policy, an investigation would be conducted by facility leadership. This deficiency substantiates Complaint Number OH 073.

Based on medical record review, observation of a pressure ulcer treatment, staff interview, and review of the facility's pressure ulcer policy, review of the National Pressure Ulcer Advisory Panel (NPUAP) website the facility failed to prevent the development of an avoidable stage III pressure ulcer to Resident (#116) and failed to timely implement a treatment for [REDACTED].#76). This affected two Residents (#76 and #116) of three reviewed for pressure ulcers and resulted in actual harm to one Resident (#116) who developed an avoidable stage III. The facility identified four residents who currently have pressure ulcers in the facility. The census was 101. Findings include: 1. Review of Resident #116's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #116 was assessed by staff as being severely cognitively impaired, totally dependent for bed mobility and transfers. Review of the minimum date set (MDS) completed on 03/08/17 revealed Resident #116 had no unhealed pressure ulcers. Review of a dietary noted dated 03/10/17 revealed Resident #116 was documented as having intact skin. Review of a nursing progress note dated 03/19/17 revealed an area to the sacrum of Resident #116 was noted. The open area was documented as appearing to be a moisture lesion from frequent incontinence. The wound bed was documented as being red with no drainage or sign/symptoms of infection noted. A stage was not given to the open area and no measurements were given. A physician order dated 03/19/17 was to clean the open area to the coccyx with normal saline (NS) and apply duoderm [MEDICATION NAME] dressing) every three days and as needed (PRN). Review of the treatment administration record (TAR) for March 2017 revealed the ordered treatments on 03/22/17 and 03/25/17 were not documented as being completed. Review of a nursing progress note dated 03/26/17 at 12:31 P.M. revealed treatment was completed to Resident #116's coccyx. The open area measured 4 centimeters (cm) x 2.5 cm, with yellow sloth and foul smelling yellow green drainage was noted. The nurse documented as cleaning with NS, applying calcium alginate (wound cleansing treatment) and covering with heart shaped [MEDICATION NAME] (foam wound dressing). Review of a skin integrity event dated 03/26/17 revealed Resident #116 was documented a having a stage III pressure ulcer to the coccyx measuring 4 cm x 2.5 cm and containing slough. A physician order dated 03/27/17 was to discontinue current treatment to coccyx, clean open area with NS, pat dry, cover wound bed with calcium alginate dressing and then apply [MEDICATION NAME] dressing. Review of a weekly wound assessment dated [DATE] revealed Resident #116 was documented as having a pressure ulcer to the coccyx that was unable to be staged, covered with sloth and measured 1.5 cm x 2.5 cm x 0.3 cm. Review of a weekly wound assessment dated [DATE] revealed Resident #116 as documented as having a stage III pressure ulcer to the coccyx ,contained granulated tissue and measured 1.5 cm x 2 cm x 0.3 cm. The Director of Nursing (DON) was documented as completing both of these wound assessments. Review of the care plan for a stage III pressure ulcer to the coccyx was initiated on 03/31/17 Review of the TAR's for March and April 2017 revealed the coccyx dressing change was ordered daily and PRN. Further review revealed that there was no documentation of treatments being administered on 03/27/17, 03/28/17, 03/29/17, 03/30/17, 03/31/17, 04/01/17, 04/02/17, 04/03/17, 04/04/17, 04/06/17 04/08/17, 04/09/17, 04/10/17 and 04/11/17. During an interview with Registered nurse (RN) #40 on 04/12/17 at 3:42 P.M. revealed when she found Resident #116's pressure ulcer on 03/19/17 she thought it was a stage II. RN #40 stated she thought she had measured the wound. RN #40 stated she helped another nurse change the wound dressing about a week ago and she thought the wound looked about the same. Wound care was observed for Resident #116 on 04/12/17 at 4:50 P.M. with licensed practical nurse (LPN) #210. LPN #210 removed the old dressing, cleansed the wound, measured and applied the new dressing as ordered. LPN #210 staged the wound as stage III with measurements of 2 cm x 3 cm. LPN #210 did not give a depth measurement. The coccyx wound was observed with a red wound bed, subcutaneous tissue involvement, did not have any obvious signs of slough or signs of infection. In an interview on 04/13/17 at 7:58 A.M. with LPN # 150 she stated when she changed Resident #116's wound dressing on 03/26/17 a duoderm dressing was on it, the wound had a lot of drainage and slough, the wound bed was deep with several layers involved and was a stage III pressure ulcer. LPN #150 stated she confirmed the staging with another nurse, LPN #50. LPN #150 stated the wound dressing change ordered on [DATE] was to be done daily and was not correctly transcribed on the physician order sheet. LPN #50 confirmed the treatment ordered daily on the TAR for April 2017. During an interview on 04/13/17 at 11:31 A.M. and at 2:15 P.M., the DON confirmed Resident #116's pressure ulcer to the coccyx was first documented in a progress note on 03/19/17. The DON confirmed there was no size or staging given in this documentation. The DON confirmed the pressure ulcer was first staged on 03/26/17 as a stage III. The DON confirmed the ordered treatments could not be verified as being administered as ordered and acknowledged the missing documentation of treatments on the March and April 2017 TARs. The DON confirmed she had staged the coccyx wound as an unstageable pressure on 03/30/17 and a stage III pressure ulcer on 04/05/17. The DON confirmed Resident #116 had no documented skin integrity concern prior to 03/19/17. Review of a facility document titled Quality Assurance Skin Record Pressure revealed Resident #116's pressure ulcer was first identified as a stage III to the coccyx measuring 1.5 cm x 2 x 0.3 cm on 03/26/17. Review of the facility's policy titled Pressure Ulcer Assessment and Staging revealed a physician's order for treatment should include type of treatment, how often to be done, how to be cleaned and the site of the application. Further review revealed a stage III pressure ulcer has full thickness loss involving damage to or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. the ulcer presents clinically as as deep crater with or without undermining of adjacent tissue. Review of the National Pressure Ulcer Advisory Panel (NPUAP) website revealed a stage III involved full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. 2. Review of medical record for Resident #76 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Further review documented hospice was implemented on 02/08/16. Review of weekly wound assessment dated [DATE] documented Resident #117 had a stage two pressure area on the left outer buttock. It measured 0.4 cm by 0.4 cm with no depth. Further review documented no intervention was necessary at this this time. Review of physicians orders from 06/29/16 through 07/05/16 lacked any documentation of a physicians order being implemented to treat Resident #117 pressure ulcer. Review of treatment record for 07/01/16 through 07/05/16 lacked any documentation of a treatment being completed for Resident #117's pressure ulcer. At this time it revealed barrier cream was to be applied to the groin and buttocks every shift and PRN, it further revealed a State tested Nursing Assistant (STNA) may apply. Further review documented this order was in place since 04/17/16. Review of weekly wound assessment dated [DATE] documented Resident #117 had a stage two pressure area to her left outer buttock measuring 1.9 cm by 1.7 cm with no depth. It indicated the intervention were somewhat effective and it noted the area to the buttocks did not have any further breakdown. Review of physicians order dated 07/06/16 documented a [MEDICATION NAME] dressing was to be applied to the bilateral hips and to the open area on the left hip every five days and as needed. On 04/12/17 at 2:30 P.M. interview with the DON verified there was no treatment put into place at the time the resident was assessed as having a stage two pressure area to her left outer buttock on 6/29/16. She further verified there was no evidence of a treatment being implemented when the area was first observed. She verified a treatment wasn't initiated until 07/06/16. Review of the facility policy titled pressure ulcer assessment and staging dated April 2016 documented when a pressure ulcer is identified a treatment program will be imitated and monitored to promote wound healing.

Based on review of resident medical records, a facility self-reported incident (SRI), interviews with staff and residents and review of the facility's abuse policy, the facility staff failed to immediately report an allegation of visitor to resident sexual abuse to the administrator, take action to protect other residents after an allegation was made, and immediately initiate an investigation into the incident. This resulted in Immediate Jeopardy for one (#5) of four residents reviewed for sexual abuse and 69 additional female residents (#1, #2, #4, #6, #7, #10, #15, #16, #17, #19, #20, #21, #23, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #38, #39, #41, #42, #43, #44, #47, #49, #50, #51, #53, #56, #58, #59, #60, #63, #67, #68, #70, #71, #72, #73, #74, #75, #76, #77, #78, #80, #81, #82, #83, #84, #85, #86, #88, #89, #92,#97, #99, #101, #102, #103, #107, #108) who resided in the facility. The facility census was 109. On 07/18/14 at 11:04 A.M., the Administrator, Licensed Practical Nurse (LPN) #12 and the Director of Nursing (DON) were notified that Immediate Jeopardy began on 07/10/14 at 3:00 P.M. when Resident #5 reported to Physical Therapist Assistant (PTA) #30 that Visitor #1 had fondled her breasts after he transported her to her room and assisted her to bed. PTA #30 did not immediately report the allegation of sexual abuse by Resident #5 to administrative staff, take action to ensure protection of the alleged victim and other female residents in the facility, and immediately initiate an investigation into the incident until 07/10/14 at 3:30 P.M. allowing Visitor #1 to remain unsupervised in the facility for 30 minutes until he had left the facility. The Immediate Jeopardy was removed on 07/18/14 at 7:30 P.M. when the facility implemented the following corrective actions: ? On 07/10/14 at 3:45 P.M., the DON instructed LPN #18 to see if Visitor #1 was still in the building. At this time, LPN #18 verified Visitor #1 had left the facility. ? On 07/10/14 at 3:55 P.M., the Administrator instructed staff to interview and assess all female residents inquiring if they had experienced any unwanted visitors or if they had been touched inappropriately. The assessments were completed at 6:20 P.M. by Registered Nurse (RN) #22 and LPN's #12 and #18. ? On 07/10/14 at 4:10 P.M., the Administrator notified the local Sheriff 's department that Resident #5 was sexually assaulted. ? On 07/10/14 at 5:10 P.M., the Administrator and LPN #12 began in-servicing all staff to include licensed staff, state tested nursing assistants (STNA's), dietary, activities, office personnel, housekeeping, laundry and therapy on the facility's abuse policies and procedures that included immediate reporting and protection of residents. ? On 07/10/14 at 6:00 P.M., all staff currently in the facility were in-serviced by the DON and Admissions Designee #46 that Visitor #1 was not to be in the building until further notice. A notification of this was placed at all of the nurses' stations. ? On 07/14/14 at 9:00 A.M., the Administrator and Admissions Designee #46 held a meeting with Visitor #1 informing him that he could only visit Resident #60 on Mondays, Tuesdays, Thursdays and Fridays from 2:00 P.M. until 4:00 P.M. and his visits would be supervised by facility staff. ? On 07/17/14, the Administrator implemented a sign in-and sign-out sheet for Visitor #1 located at the front of the building at the receptionist desk. ? On 07/17/14 from 1:10 P.M. until 2:50 P.M., interviews were conducted with RN #51 and STNA's #50, #52 and #53 and confirmed they were knowledgeable of the abuse policies and procedures and the visiting restrictions for Visitor #1. ? On 07/17/14 at 7:30 P.M., the Administrator, DON, RN 's #10 and #48, and LPN #12 completed an audit to ensure all staff were in-serviced on abuse policies and procedures and the supervised visits for Visitor #1. ? On 07/18/14, the Administrator implemented a "Line of Sight Monitoring Tool" to document Visitor #1's location and activity every 15 minutes during his visits in the facility. Only department heads are to supervise the visits. ? On 07/18/14 at 7:30 P.M., the Administrator in-serviced all department heads about the "Line of Sight Monitoring Tool". ? On 07/21/14 at 2:45 P.M., observation of RN #10 supervising Visitor #1 was made and verified RN #10 was utilizing the Line of Sight Monitoring Tool. ? On 07/22/14 from 9:05 A.M. until 9:25 A.M., interviews were conducted with Occupational Therapy Assistant #35, LPN #12, LPN #18 and LPN #20 and verified they were knowledgeable of the abuse policies and procedures and the visiting restrictions for Visitor #1. Although the Immediate Jeopardy was removed on 07/18/14 at 7:30 P.M., the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as all staff members (RN #55 and STNA #54) had not been in-serviced on the abuse policies and procedures and the supervised visits for Visitor #1 and not enough time had elapsed to evaluate whether the facilities corrective action was being monitored for on-going compliance. Findings include: Review of the medical record for Resident #5 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and was able to make her needs known. Review of the facility SRI dated 07/11/14 revealed on 07/10/14 Visitor #1 had assisted Resident #5 to her room and fondled her breasts. Resident #5 indicated Visitor #1 was in her room no more than 10 minutes, and he did not sit down. The facility substantiated sexual abuse had occurred. Review of the statement to the local Sheriff investigating the allegation, dated 07/10/14 and signed by Resident #5, revealed around 1:30 P.M. on 07/10/14 she was outside smoking with Visitor #1. She went inside and Visitor #1 pushed her wheelchair to her room. Visitor #1 assisted her to bed and he placed his hands through the back of her gown and fondled her breasts. "He said he liked my nipples and they were pretty". She told him "no and to stop" but he kept fondling her breasts. He finally stopped when she crossed her arms over her chest. PTA #30 entered the room at 3:00 P.M. and took her to therapy. Around 3:30 P.M., PTA #30 took Resident #5 outside to smoke and Visitor #1 was there. Resident #5 stated she felt very uncomfortable around him. During an interview on 07/17/14 at 9:50 A.M. with Resident #5 she stated that she was in her room the day the incident occurred and she really did not know Visitor #1 very well. She stated she definitely did not give him permission to touch her. She stated he was touching her breasts for about a minute and she told him to quit. He didn't stop until she crossed her arms over her chest. She stated PTA #30 came into her room and Visitor #1 left. Resident #5 stated she immediately told PTA #30 that Visitor #1 had fondled her breasts. She stated she had discussed it with the Sheriff and she did not want to press charges. A second interview with Resident #5 was attempted on 07/18/14 at 1:15 P.M. and Resident #5 stated she did not want to discuss the incident any further. Interview on 07/17/14 at 11:40 A.M. with the Administrator revealed she had a meeting with Visitor #1 on 07/14/14 at 9:00 A.M. Visitor #1 admitted that he touched Resident #5's breasts and he knew it was wrong. The Administrator informed him that he would have to have supervised visits on Mondays, Tuesdays, Thursdays and Fridays. The Administrator stated, at that time, she did not require Visitor #1 to sign-in or sign-out. Interview with State tested Nurse Aide (STNA) #14 on 07/17/14 at 1:05 P.M. revealed he was unaware of any visitor on supervised visits. Interview with STNA #16 on 07/17/14 at 1:25 P.M. revealed she was unaware of any visitor on supervised visits. Observation on 07/17/14 at 2:20 P.M. revealed Visitor #1 was visiting a Resident #60 in a private room. The Administrator had a desk pulled out in the hallway and was looking through papers on her desk. The desk was approximately 50 feet from the doorway of Resident #60's room. There were three resident rooms between the Administrator and the Resident #60's room. Interview on 07/17/14 at 3:00 P.M. with PTA #30 revealed on 07/10/14 at 3:00 P.M. she went to Resident #5's room to do therapy. Her door was shut and she knocked before she entered. She noticed Visitor #1 was standing next to Resident #5's bed and Resident #5 was sitting on her bed facing him. PTA #30 stated this was unusual because Resident #5 did not usually have any men in her room and Resident #5 looked distressed. PTA #30 informed Visitor #1 that it was time for Resident #5's therapy and would he excuse them. As soon as Visitor #1 left the room, Resident #5 reported that he had felt her up. Resident #5 stated Visitor #1 transferred her from the wheelchair to the bed and he slipped his hands inside her gown and fondled her breasts. Resident #5 stated she told him to stop but he wouldn't. He stated he liked how her nipples looked. PTA #30 stated she proceeded to complete therapy with Resident #5 for about 15 minutes. PTA #30 stated during the therapy session she discussed the incident with Resident #5 and tried to convince her to report it to the DON. She convinced Resident #5 to report the incident to the DON. Resident #5 wanted to go smoke before she reported it to the DON. PTA #30 stated as she was on her way to take Resident #5 outside to smoke she stopped by the therapy room to drop off some equipment. PTA #30 left Resident #5 unattended in the hallway and when she came back Visitor #1 was standing next to Resident #5 ' s wheelchair with his hands on the handles. Resident #5 was aware that Visitor #1 was next to her and she looked distressed. PTA #30 took Resident #5 outside to smoke, per her request, and Visitor #1 followed them outside to smoke as well. Visitor #1 stayed outside with them for five to eight minutes and then stated he was going home to mow his grass. Interview on 07/17/14 at 4:50 P.M. with the DON revealed she was unaware if all staff had been trained on the supervised visits for Visitor #1. The DON had a list of staff and she was highlighting names of staff that had been trained. She was unsure who some of the staff members were and at 5:00 P.M. she stated not all of the facility staff had been trained. Interview on 07/18/14 at 1:35 P.M. with the DON revealed she did not receive a statement from PTA #30 until 07/17/14 in reference to the incident on 07/10/14 with Resident #5. The DON stated she instructed her to write a statement the day the incident occurred but did not physically receive the statement until 07/17/14 after the surveyor was in the facility investigating the incident. Review of the facility policy entitled "Abuse, Mistreatment, Neglect, Injuries of Unknown Source, and Misappropriation of Resident Property" dated 08/15/12 revealed sexual abuse includes sexual harassment, sexual coercion, or sexual assault. Staff should report all incidents immediately to their direct supervisors. Staff should not leave a resident unattended, unless it is necessary to summon assistance. Staff should not move the resident until he or she has been assessed by a nurse supervisor for possible injuries. All allegations of abuse must be reported immediately to both the Administrator and the Ohio Department of Health. During the investigation the facility will obtain written statements from the resident, the accused, and each witness. The facility will take action to protect the resident(s) including preventing access to the resident. This deficiency substantiates Complaint Number OH 578.

Based on review of resident medical records, a facility self-reported incident (SRI), interviews with staff and residents and review of the facility's abuse policy, the facility staff failed to implement their policy regarding immediate reporting of a potential incident of sexual abuse to the Administrator of the facility, take action to protect the residents after the incident occurred and immediately initiate an investigation into the incident. This resulted in Immediate Jeopardy for one (#5) of four residents reviewed for sexual abuse and 69 additional female residents (#1, #2, #4, #6, #7, #10, #15, #16, #17, #19, #20, #21, #23, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #38, #39, #41, #42, #43, #44, #47, #49, #50, #51, #53, #56, #58, #59, #60, #63, #67, #68, #70, #71, #72, #73, #74, #75, #76, #77, #78, #80, #81, #82, #83, #84, #85, #86, #88, #89, #92,#97, #99, #101, #102, #103, #107, #108) who resided in the facility. The facility census was 109. On 07/18/14 at 11:04 A.M., the Administrator, Licensed Practical Nurse (LPN) #12 and the Director of Nursing (DON) were notified that Immediate Jeopardy began on 07/10/14 at 3:00 P.M. when Resident #5 reported to Physical Therapist Assistant (PTA) #30 that Visitor #1 had fondled her breasts after he transported her to her room and assisted her to bed. PTA #30 did not immediately report the allegation of sexual abuse by Resident #5 to administrative staff, take action to ensure protection of the alleged victim and other female residents in the facility, and immediately initiate an investigation into the incident until 07/10/14 at 3:30 P.M. allowing Visitor #1 to remain unsupervised in the facility for 30 minutes until he had left the facility. The Immediate Jeopardy was removed on 07/18/14 at 7:30 P.M. when the facility implemented the following corrective actions: ? On 07/10/14 at 3:45 P.M., the DON instructed LPN #18 to see if Visitor #1 was still in the building. At this time, LPN #18 verified Visitor #1 had left the facility. ? On 07/10/14 at 3:55 P.M., the Administrator instructed staff to interview and assess all female residents inquiring if they had experienced any unwanted visitors or if they had been touched inappropriately. The assessments were completed at 6:20 P.M. by Registered Nurse (RN) #22 and LPN's #12 and #18. ? On 07/10/14 at 4:10 P.M., the Administrator notified the local Sheriff 's department that Resident #5 was sexually assaulted. ? On 07/10/14 at 5:10 P.M., the Administrator and LPN #12 began in-servicing all staff to include licensed staff, state tested nursing assistants (STNA's), dietary, activities, office personnel, housekeeping, laundry and therapy on the facility's abuse policies and procedures that included immediate reporting and protection of residents. ? On 07/10/14 at 6:00 P.M., all staff currently in the facility were in-serviced by the DON and Admissions Designee #46 that Visitor #1 was not to be in the building until further notice. A notification of this was placed at all of the nurses' stations. ? On 07/14/14 at 9:00 A.M., the Administrator and Admissions Designee #46 held a meeting with Visitor #1 informing him that he could only visit Resident #60 on Mondays, Tuesdays, Thursdays and Fridays from 2:00 P.M. until 4:00 P.M. and his visits would be supervised by facility staff. ? On 07/17/14, the Administrator implemented a sign in-and sign-out sheet for Visitor #1 located at the front of the building at the receptionist desk. ? On 07/17/14 from 1:10 P.M. until 2:50 P.M., interviews were conducted with RN #51 and STNA's #50, #52 and #53 and confirmed they were knowledgeable of the abuse policies and procedures and the visiting restrictions for Visitor #1. ? On 07/17/14 at 7:30 P.M., the Administrator, DON, RN 's #10 and #48, and LPN #12 completed an audit to ensure all staff were in-serviced on abuse policies and procedures and the supervised visits for Visitor #1. ? On 07/18/14, the Administrator implemented a "Line of Sight Monitoring Tool" to document Visitor #1's location and activity every 15 minutes during his visits in the facility. Only department heads are to supervise the visits. ? On 07/18/14 at 7:30 P.M., the Administrator in-serviced all department heads about the "Line of Sight Monitoring Tool". ? On 07/21/14 at 2:45 P.M., observation of RN #10 supervising Visitor #1 was made and verified RN #10 was utilizing the Line of Sight Monitoring Tool. ? On 07/22/14 from 9:05 A.M. until 9:25 A.M., interviews were conducted with Occupational Therapy Assistant #35, LPN #12, LPN #18 and LPN #20 and verified they were knowledgeable of the abuse policies and procedures and the visiting restrictions for Visitor #1. Although the Immediate Jeopardy was removed on 07/18/14 at 7:30 P.M., the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as all staff members (RN #55 and STNA #54) had not been in-serviced on the abuse policies and procedures and the supervised visits for Visitor #1 and not enough time had elapsed to evaluate whether the facilities corrective action was being monitored for on-going compliance. Findings include: Review of the medical record for Resident #5 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and was able to make her needs known. Review of the facility SRI dated 07/11/14 revealed on 07/10/14 Visitor #1 had assisted Resident #5 to her room and fondled her breasts. Resident #5 indicated Visitor #1 was in her room no more than 10 minutes, and he did not sit down. The facility substantiated sexual abuse had occurred. Review of the statement to the local Sheriff investigating the allegation, dated 07/10/14 and signed by Resident #5, revealed around 1:30 P.M. on 07/10/14 she was outside smoking with Visitor #1. She went inside and Visitor #1 pushed her wheelchair to her room. Visitor #1 assisted her to bed and he placed his hands through the back of her gown and fondled her breasts. "He said he liked my nipples and they were pretty". She told him "no and to stop" but he kept fondling her breasts. He finally stopped when she crossed her arms over her chest. PTA #30 entered the room at 3:00 P.M. and took her to therapy. Around 3:30 P.M., PTA #30 took Resident #5 outside to smoke and Visitor #1 was there. Resident #5 stated she felt very uncomfortable around him. During an interview on 07/17/14 at 9:50 A.M. with Resident #5 she stated that she was in her room the day the incident occurred and she really did not know Visitor #1 very well. She stated she definitely did not give him permission to touch her. She stated he was touching her breasts for about a minute and she told him to quit. He didn't stop until she crossed her arms over her chest. She stated PTA #30 came into her room and Visitor #1 left. Resident #5 stated she immediately told PTA #30 that Visitor #1 had fondled her breasts. She stated she had discussed it with the Sheriff and she did not want to press charges. A second interview with Resident #5 was attempted on 07/18/14 at 1:15 P.M. and Resident #5 stated she did not want to discuss the incident any further. Interview on 07/17/14 at 11:40 A.M. with the Administrator revealed she had a meeting with Visitor #1 on 07/14/14 at 9:00 A.M. Visitor #1 admitted that he touched Resident #5's breasts and he knew it was wrong. The Administrator informed him that he would have to have supervised visits on Mondays, Tuesdays, Thursdays and Fridays. The Administrator stated, at that time, she did not require Visitor #1 to sign-in or sign-out. Interview with State tested Nurse Aide (STNA) #14 on 07/17/14 at 1:05 P.M. revealed he was unaware of any visitor on supervised visits. Interview with STNA #16 on 07/17/14 at 1:25 P.M. revealed she was unaware of any visitor on supervised visits. Observation on 07/17/14 at 2:20 P.M. revealed Visitor #1 was visiting a Resident #60 in a private room. The Administrator had a desk pulled out in the hallway and was looking through papers on her desk. The desk was approximately 50 feet from the doorway of Resident #60's room. There were three resident rooms between the Administrator and the Resident #60's room. Interview on 07/17/14 at 3:00 P.M. with PTA #30 revealed on 07/10/14 at 3:00 P.M. she went to Resident #5's room to do therapy. Her door was shut and she knocked before she entered. She noticed Visitor #1 was standing next to Resident #5's bed and Resident #5 was sitting on her bed facing him. PTA #30 stated this was unusual because Resident #5 did not usually have any men in her room and Resident #5 looked distressed. PTA #30 informed Visitor #1 that it was time for Resident #5's therapy and would he excuse them. As soon as Visitor #1 left the room, Resident #5 reported that he had felt her up. Resident #5 stated Visitor #1 transferred her from the wheelchair to the bed and he slipped his hands inside her gown and fondled her breasts. Resident #5 stated she told him to stop but he wouldn't. He stated he liked how her nipples looked. PTA #30 stated she proceeded to complete therapy with Resident #5 for about 15 minutes. PTA #30 stated during the therapy session she discussed the incident with Resident #5 and tried to convince her to report it to the DON. She convinced Resident #5 to report the incident to the DON. Resident #5 wanted to go smoke before she reported it to the DON. PTA #30 stated as she was on her way to take Resident #5 outside to smoke she stopped by the therapy room to drop off some equipment. PTA #30 left Resident #5 unattended in the hallway and when she came back Visitor #1 was standing next to Resident #5 ' s wheelchair with his hands on the handles. Resident #5 was aware that Visitor #1 was next to her and she looked distressed. PTA #30 took Resident #5 outside to smoke, per her request, and Visitor #1 followed them outside to smoke as well. Visitor #1 stayed outside with them for five to eight minutes and then stated he was going home to mow his grass. Interview on 07/17/14 at 4:50 P.M. with the DON revealed she was unaware if all staff had been trained on the supervised visits for Visitor #1. The DON had a list of staff and she was highlighting names of staff that had been trained. She was unsure who some of the staff members were and at 5:00 P.M. she stated not all of the facility staff had been trained. Interview on 07/18/14 at 1:35 P.M. with the DON revealed she did not receive a statement from PTA #30 until 07/17/14 in reference to the incident on 07/10/14 with Resident #5. The DON stated she instructed her to write a statement the day the incident occurred but did not physically receive the statement until 07/17/14 after the surveyor was in the facility investigating the incident. Review of the facility policy entitled "Abuse, Mistreatment, Neglect, Injuries of Unknown Source, and Misappropriation of Resident Property" dated 08/15/12 revealed sexual abuse includes sexual harassment, sexual coercion, or sexual assault. Staff should report all incidents immediately to their direct supervisors. Staff should not leave a resident unattended, unless it is necessary to summon assistance. Staff should not move the resident until he or she has been assessed by a nurse supervisor for possible injuries. All allegations of abuse must be reported immediately to both the Administrator and the Ohio Department of Health. During the investigation the facility will obtain written statements from the resident, the accused, and each witness. The facility will take action to protect the resident(s) including preventing access to the resident. This deficiency substantiates Complaint Number OH 578.

Based on review of resident medical records, a facility self-reported incident (SRI), interviews with staff and residents and review of the facility's abuse policy, the facility failed to ensure a female resident was free from sexual abuse. This resulted in Immediate Jeopardy for one (#5) resident who was sexually abused by a visitor. This affected one (#5) of four residents reviewed for sexual abuse. The facility identified 69 additional female residents who resided in the facility. The facility census was 109. On 07/18/14 at 11:04 A.M., the Administrator, Licensed Practical Nurse (LPN) #12 and the Director of Nursing (DON) were notified that Immediate Jeopardy began on 07/10/14 at 3:00 P.M. when Resident #5 reported to Physical Therapist Assistant (PTA) #30 that Visitor #1 had fondled her breasts after he transported her to her room and assisted her to bed. PTA #30 did not immediately report the allegation of sexual abuse by Resident #5 to administrative staff, take action to ensure protection of the alleged victim and other female residents in the facility, and immediately initiate an investigation into the incident until 07/10/14 at 3:30 P.M. allowing Visitor #1 to remain unsupervised in the facility for 30 minutes until he had left the facility. The Immediate Jeopardy was removed on 07/18/14 at 7:30 P.M. when the facility implemented the following corrective actions: ? On 07/10/14 at 3:45 P.M., the DON instructed LPN #18 to see if Visitor #1 was still in the building. At this time, LPN #18 verified Visitor #1 had left the facility. ? On 07/10/14 at 3:55 P.M., the Administrator instructed staff to interview and assess all female residents inquiring if they had experienced any unwanted visitors or if they had been touched inappropriately. The assessments were completed at 6:20 P.M. by Registered Nurse (RN) #22 and LPN's #12 and #18. ? On 07/10/14 at 4:10 P.M., the Administrator notified the local Sheriff 's department that Resident #5 was sexually assaulted. ? On 07/10/14 at 5:10 P.M., the Administrator and LPN #12 began in-servicing all staff to include licensed staff, state tested nursing assistants (STNA's), dietary, activities, office personnel, housekeeping, laundry and therapy on the facility's abuse policies and procedures that included immediate reporting and protection of residents. ? On 07/10/14 at 6:00 P.M., all staff currently in the facility were in-serviced by the DON and Admissions Designee #46 that Visitor #1 was not to be in the building until further notice. A notification of this was placed at all of the nurses' stations. ? On 07/14/14 at 9:00 A.M., the Administrator and Admissions Designee #46 held a meeting with Visitor #1 informing him that he could only visit Resident #60 on Mondays, Tuesdays, Thursdays and Fridays from 2:00 P.M. until 4:00 P.M. and his visits would be supervised by facility staff. ? On 07/17/14, the Administrator implemented a sign in-and sign-out sheet for Visitor #1 located at the front of the building at the receptionist desk. ? On 07/17/14 from 1:10 P.M. until 2:50 P.M., interviews were conducted with RN #51 and STNA's #50, #52 and #53 and confirmed they were knowledgeable of the abuse policies and procedures and the visiting restrictions for Visitor #1. ? On 07/17/14 at 7:30 P.M., the Administrator, DON, RN 's #10 and #48, and LPN #12 completed an audit to ensure all staff were in-serviced on abuse policies and procedures and the supervised visits for Visitor #1. ? On 07/18/14, the Administrator implemented a "Line of Sight Monitoring Tool" to document Visitor #1's location and activity every 15 minutes during his visits in the facility. Only department heads are to supervise the visits. ? On 07/18/14 at 7:30 P.M., the Administrator in-serviced all department heads about the "Line of Sight Monitoring Tool". ? On 07/21/14 at 2:45 P.M., observation of RN #10 supervising Visitor #1 was made and verified RN #10 was utilizing the Line of Sight Monitoring Tool. ? On 07/22/14 from 9:05 A.M. until 9:25 A.M., interviews were conducted with Occupational Therapy Assistant #35, LPN #12, LPN #18 and LPN #20 and verified they were knowledgeable of the abuse policies and procedures and the visiting restrictions for Visitor #1. Although the Immediate Jeopardy was removed on 07/18/14 at 7:30 P.M., the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as all staff members (RN #55 and STNA #54) had not been in-serviced on the abuse policies and procedures and the supervised visits for Visitor #1 and not enough time had elapsed to evaluate whether the facilities corrective action was being monitored for on-going compliance. Findings include: Review of the medical record for Resident #5 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and was able to make her needs known. Review of the facility SRI dated 07/11/14 revealed on 07/10/14 Visitor #1 had assisted Resident #5 to her room and fondled her breasts. Resident #5 indicated Visitor #1 was in her room no more than 10 minutes, and he did not sit down. The facility substantiated sexual abuse had occurred. Review of the statement to the local Sheriff investigating the allegation, dated 07/10/14 and signed by Resident #5, revealed around 1:30 P.M. on 07/10/14 she was outside smoking with Visitor #1. She went inside and Visitor #1 pushed her wheelchair to her room. Visitor #1 assisted her to bed and he placed his hands through the back of her gown and fondled her breasts. "He said he liked my nipples and they were pretty". She told him "no and to stop" but he kept fondling her breasts. He finally stopped when she crossed her arms over her chest. PTA #30 entered the room at 3:00 P.M. and took her to therapy. Around 3:30 P.M., PTA #30 took Resident #5 outside to smoke and Visitor #1 was there. Resident #5 stated she felt very uncomfortable around him. During an interview on 07/17/14 at 9:50 A.M. with Resident #5 she stated that she was in her room the day the incident occurred and she really did not know Visitor #1 very well. She stated she definitely did not give him permission to touch her. She stated he was touching her breasts for about a minute and she told him to quit. He didn't stop until she crossed her arms over her chest. She stated PTA #30 came into her room and Visitor #1 left. Resident #5 stated she immediately told PTA #30 that Visitor #1 had fondled her breasts. She stated she had discussed it with the Sheriff and she did not want to press charges. A second interview with Resident #5 was attempted on 07/18/14 at 1:15 P.M. and Resident #5 stated she did not want to discuss the incident any further. Interview on 07/17/14 at 11:40 A.M. with the Administrator revealed she had a meeting with Visitor #1 on 07/14/14 at 9:00 A.M. Visitor #1 admitted that he touched Resident #5's breasts and he knew it was wrong. The Administrator informed him that he would have to have supervised visits on Mondays, Tuesdays, Thursdays and Fridays. The Administrator stated, at that time, she did not require Visitor #1 to sign-in or sign-out. Interview with State tested Nurse Aide (STNA) #14 on 07/17/14 at 1:05 P.M. revealed he was unaware of any visitor on supervised visits. Interview with STNA #16 on 07/17/14 at 1:25 P.M. revealed she was unaware of any visitor on supervised visits. Observation on 07/17/14 at 2:20 P.M. revealed Visitor #1 was visiting a Resident #60 in a private room. The Administrator had a desk pulled out in the hallway and was looking through papers on her desk. The desk was approximately 50 feet from the doorway of Resident #60's room. There were three resident rooms between the Administrator and the Resident #60's room. Interview on 07/17/14 at 3:00 P.M. with PTA #30 revealed on 07/10/14 at 3:00 P.M. she went to Resident #5's room to do therapy. Her door was shut and she knocked before she entered. She noticed Visitor #1 was standing next to Resident #5's bed and Resident #5 was sitting on her bed facing him. PTA #30 stated this was unusual because Resident #5 did not usually have any men in her room and Resident #5 looked distressed. PTA #30 informed Visitor #1 that it was time for Resident #5's therapy and would he excuse them. As soon as Visitor #1 left the room, Resident #5 reported that he had felt her up. Resident #5 stated Visitor #1 transferred her from the wheelchair to the bed and he slipped his hands inside her gown and fondled her breasts. Resident #5 stated she told him to stop but he wouldn't. He stated he liked how her nipples looked. PTA #30 stated she proceeded to complete therapy with Resident #5 for about 15 minutes. PTA #30 stated during the therapy session she discussed the incident with Resident #5 and tried to convince her to report it to the DON. She convinced Resident #5 to report the incident to the DON. Resident #5 wanted to go smoke before she reported it to the DON. PTA #30 stated as she was on her way to take Resident #5 outside to smoke she stopped by the therapy room to drop off some equipment. PTA #30 left Resident #5 unattended in the hallway and when she came back Visitor #1 was standing next to Resident #5 ' s wheelchair with his hands on the handles. Resident #5 was aware that Visitor #1 was next to her and she looked distressed. PTA #30 took Resident #5 outside to smoke, per her request, and Visitor #1 followed them outside to smoke as well. Visitor #1 stayed outside with them for five to eight minutes and then stated he was going home to mow his grass. Interview on 07/17/14 at 4:50 P.M. with the DON revealed she was unaware if all staff had been trained on the supervised visits for Visitor #1. The DON had a list of staff and she was highlighting names of staff that had been trained. She was unsure who some of the staff members were and at 5:00 P.M. she stated not all of the facility staff had been trained. Interview on 07/18/14 at 1:35 P.M. with the DON revealed she did not receive a statement from PTA #30 until 07/17/14 in reference to the incident on 07/10/14 with Resident #5. The DON stated she instructed her to write a statement the day the incident occurred but did not physically receive the statement until 07/17/14 after the surveyor was in the facility investigating the incident. Review of the facility policy entitled "Abuse, Mistreatment, Neglect, Injuries of Unknown Source, and Misappropriation of Resident Property" dated 08/15/12 revealed sexual abuse includes sexual harassment, sexual coercion, or sexual assault. Staff should report all incidents immediately to their direct supervisors. Staff should not leave a resident unattended, unless it is necessary to summon assistance. Staff should not move the resident until he or she has been assessed by a nurse supervisor for possible injuries. All allegations of abuse must be reported immediately to both the Administrator and the Ohio Department of Health. During the investigation the facility will obtain written statements from the resident, the accused, and each witness. The facility will take action to protect the resident(s) including preventing access to the resident. This deficiency substantiates Complaint Number OH 578.

Based on clinical record review, observation, interviews with staff and the county medical coroner, review of a police report, review of facility policy and procedures on restraints and review of manufacturer's guidelines for restraints, the facility failed to ensure the resident's environment remained free of accident hazards from a reverse seat belt resulting in Immediate Jeopardy for one (Resident #105) of 11 sampled residents. The facility identified eleven residents with restraints. On [DATE] at 2:00 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at approximately 9:00 P.M. when Resident #105 was observed by Licensed Practical Nurse (LPN) #3 seated on the floor with the reverse seat belt intact on the wheelchair and around his neck. The resident was noted with a red face, cyanotic lips, and no carotid pulse or breath sounds present. Cardiopulmonary resuscitation (CPR) was initiated by the facility nurses and continued via emergency squad personnel upon their arrival. The resident was subsequently pronounced dead at the facility by a physician contacted by the emergency squad personnel. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: ? On [DATE], eleven residents identified with restraints were put on half hour checks to assure safety and their restraints were checked every shift. ? On [DATE], [DATE] and [DATE], all nursing staff, along with 28 other staff members were inserviced regarding the use of restraints including proper application, release and removal by the DON, LPNs' #6 and #181 and Registered Nurse (RN) #16. ? On [DATE], all nursing staff on duty was able to verbalize checking restraints every half hour, releasing restraints and repositioning every one hour. ? On [DATE], the eleven residents with restraints were re-assessed for the use of their specific restraint and restraint reductions were implemented to a least restrictive device or discontinued. ? On [DATE], the facility assessment team began to monitor resident restraints daily and document the safety of the restraint on a new facility "Resident Safety Flow Sheet". 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 harm that is not Immediate Jeopardy). The facility removed all rear releasing seat belts, but failed to have a procedure in place to comprehensively assess residents for the risks and benefits of continued restraint use and determine what device was least restrictive for that resident. Findings include: Review of the closed medical record of Resident #105 revealed an admission date of [DATE], and [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], identified as an admission assessment documented the resident had short and long term memory problems and his cognitive skill level was some difficulty in new situations only. He had no identified behavioral symptoms. He required the supervision of one staff member for transfers and walking in his room. He was frequently incontinent of bladder and continent of bowel. He had no restraints. Review of the physician orders [REDACTED]. The care plan dated [DATE] for the problem of "potential for trauma/falls" included interventions to observe, record, and report all unsafe conditions and situations, clip alarm at all times, check battery function and device placement every shift, reverse seat belt, check every 30 minutes, and release every hour. Review of the resident's restraint assessment dated [DATE] revealed the resident was placed in the reverse seat belt due to unassisted transfers and an unsteady gait. The assessment did not indicate the reverse seat belt was determined to be the least restrictive device for the resident and did not address safety measures to prevent the resident from sliding. The risks and benefits associated with the use of the rear release seat belt were not documented. The assessment did not identify any less restrictive restraint alternatives had been attempted prior to the application of the rear release seat belt. Further review revealed a physician order [REDACTED]. Nurse's notes dated [DATE] stated a reverse seat belt device was in place due to unassisted transfer attempts with unsteady gait. The nurse's note further stated the device was a restraint and medical factors included weakness, disease process, unsteady gait and impulsive behaviors. The nursing notes dated [DATE] at 2:22 P.M. stated the resident was agitated regarding the reverse seat belt. While sitting in the chair the resident grabbed the belt and stated "remove this from me immediately". The current Minimum Data Set (MDS) assessment dated [DATE] identified as a significant change, stated the resident was rarely understood and sometimes understood others, had short and long term memory problems, made poor decisions and was resistant to care multiple times per day. The assessment further indicated Resident #105 required extensive physical assistance of one staff person with transfers, limited assistance of one staff person with ambulation, had balance deficits, utilized a walker and wheelchair, had [DIAGNOSES REDACTED]. His bowel continence had declined, with the resident frequently incontinent of bowel. He now utilized a restraint daily, described a chair which prevented rising. He was not receiving any physical therapy, occupational therapy or restorative programs. The resident's most recent restraint assessment was dated [DATE] and identified the resident continued to use a reverse seat belt. The assessment did not indicate the resident's behavior of sliding down in his wheelchair with the reverse seat belt in place. It contained no documentation of the risks or benefits associated with the use of the restraint. The assessment did not identify any less restrictive restraint alternatives had been attempted since the application of the rear release seat belt in [DATE]. Nurse's notes dated [DATE] at 3:03 A.M. stated at approximately 9:00 P.M., LPN #3 entered Resident #105's room to administer medications and upon entering the room, found the resident with his upper shoulders on the seat of the wheelchair and his buttocks on the floor. The reverse seat belt was noted between the resident's neck and chin area, his face was reddened and his lips were blue. The resident was unresponsive and LPN #3 called out for LPN #10 to assist. LPN #3 released the seat belt and the resident was lowered to the floor. LPN #3 documented the resident was checked for a carotid pulse and breath sounds, both of which were not present. LPN #3 and LPN #10 initiated cardiopulmonary resuscitation (CPR) and continued until the emergency squad personnel arrived at 9:04 P.M. and took over. Resident #105 was pronounced dead at the facility by a physician contacted by emergency squad personnel at 9:20 P.M. Review of the resident's death certificate signed by the coroner on [DATE] revealed the immediate cause of the resident's death was strangulation. The death certificate identified the injury occurred when the resident's head became caught in a seat belt. The death certificate stated the resident's date and time of death was [DATE] at 9:20 P.M. Observations were made of residents on [DATE] and [DATE]. Restraints were applied correctly. During interview on [DATE] at 1:05 P.M., State tested Nurse Aide (STNA) #56 stated she was responsible for the care of Resident #105 on [DATE] from 7:00 P.M. to 7:00 A.M. shift. STNA #56 stated she and STNA #115 stood the resident up on [DATE] between 8:00 P.M. and 8:15 P.M. to check him for incontinence and sat him back down in his wheelchair. STNA #56 stated STNA #115 refastened the reverse seat belt to the rear of the resident's wheelchair. STNA #56 stated she did not see how STNA #115 fastened the seat belt as she was in front of the resident at the time. STNA #56 stated after Resident #105 was restrained with the reverse seat belt she and STNA #115 left the room and she did not see the resident again before he died . During interview on [DATE] at 2:45 P.M., LPN #3 stated on [DATE] from 7:00 P.M. to 7:00 A.M. she was assigned and responsible for all the residents on the unit Resident #105 resided (a secured dementia unit) as well as another unit. LPN #3 stated she did rounds with the day shift nurse on the dementia unit about 7:00 P.M. and then went to the other unit where she remained from about 7:30 P.M. to 9:00 P.M. LPN #3 stated she went back to the dementia unit about 9:00 P.M. and got her medication cart to pass medications. LPN #3 stated another nurse stopped her and asked about supplies and she then proceeded to Resident #105's room. LPN #3 stated she opened the resident's door and observed the resident in the room alone with his buttocks on the floor, his head and neck at the seat of the wheelchair and the fastened seat belt around the resident's neck. LPN #3 stated the resident's face was deep red and his lips were purple. LPN #3 stated she yelled for LPN #10 who immediately responded. LPN #3 stated she removed the seat belt from the back of the wheelchair on one side and that it was not difficult to release. LPN #3 stated she did not have to adjust the seat belt to get it off but just slid it off the back of the lower tilt bar on the back of the chair. LPN #3 stated she checked the resident and he had no signs of life so they initiated CPR until the emergency squad personnel arrived and took over. LPN #3 stated the emergency squad personnel continued CPR until they called a physician at the hospital who pronounced the resident dead. During interview on [DATE] at 3:17 P.M., STNA #115 stated she and STNA #56 were responsible for the care of Resident #105 on [DATE] from 7:00 P.M. to 7:00 A.M. STNA #115 stated the resident slid down in the wheelchair often because the seat of the wheelchair was "slick". STNA #115 stated nursing staff had been informed of the resident sliding down in the seat. STNA #115 stated the resident had no cushion or non-skid material in the seat of the wheelchair on [DATE]. STNA #115 stated she and STNA #56 checked the resident at 8:00 P.M.; he was facing the door and his call light was behind him on the bed. STNA #115 verified she refastened the resident's seat belt after he was checked for incontinence at 8:00 P.M. STNA #115 stated she slid the belt loop over the bottom tilt bar of the wheelchair and STNA #56 stated it was okay so she left it as it was. STNA #115 stated she did not recheck the seat belt because STNA #56 stated it was okay. STNA #115 stated they left the resident in the wheelchair facing the door and left the door ajar. STNA #115 stated she was not in the building when the resident was found as she had left for her break. Interview on [DATE] at 5:10 P.M. with LPN #28 revealed the resident slid down in the wheelchair all the time. LPN #28 stated STNA #67 had reported this as well. LPN #28 stated the resident had no non-skid material such as Dycem or a cushion in the wheelchair and no alarm. Interview on [DATE] at 5:55 P.M. with STNA #67 revealed she was assigned to Resident #105 about three times per week. STNA #67 stated the resident slid down in the wheelchair every day and the nurse aides had to pull him up multiple times per day. STNA #67 stated the resident had no cushion, non-skid material, or alarm device on the wheelchair. STNA #67 stated the resident had non-skid material (Dycem) for a while but had not for at least a month before he died . STNA #67 stated the resident would put his feet on the bed and try to slide down in the wheelchair to get in the bed that way. During interview on [DATE] at 6:05 P.M., STNA #38 stated anytime Resident #105 was close to a bed he wanted to get in it. STNA #38 stated the resident was always scooting down in the wheelchair to try to get in the bed. STNA #38 stated the resident would put his feet on the bed and one time (not sure of date) he saw the resident scooting out of the seat to try to get in the bed feet first with the seat belt still on. STNA #38 stated at one time non-skid material (Dycem) had been placed in the seat of the resident's wheelchair to try to keep him from sliding down but someone had removed it and it was not in place the week the resident died . STNA #38 stated there was no alarm device on the resident's wheelchair the entire week prior to his death. Registered Nurse #16, an assessment nurse, stated during telephone interview on [DATE] at 3:25 P.M., the former Director of Nursing had applied the rear release seat belt restraint to the resident. She stated the rear release seat belt was not trialed. She could not articulate what the facility's procedure was to trial restraint devices. She stated they often trial restraints on residents without physician orders [REDACTED]. She said there was no significant event that preceded the application of the rear release seat belt to the resident. She had no knowledge the resident had ever slid in the wheelchair in attempts to get out of the restraint. The Licensed Practical Nurse (LPN) #6, who was the restorative nurse, stated during telephone interview on [DATE] at 3:45 P.M., the facility only does an electronic assessment that is part of their electronic charting software. It does not contain any comprehensive assessment of the risks and benefits for the restraint. She stated the floor nurses decide what type of restraint is most appropriate for residents, obtains the physician order [REDACTED]. The floor nurses complete the initial electronic restraint assessment. LPN #6 stated she then does a restraint assessment quarterly, but this assessment does not coincide with the MDS assessment performed by the assessment nurse. She also stated she had no knowledge the resident had ever slid in the wheelchair in attempts to get out of the restraint. Nurses and nurse aides were interviewed on [DATE] and all indicated they had received inservice training on how to apply restraints correctly. The inservice training did not include how to properly assess a resident for the least restrictive device. Seven additional residents identified with restraints were reviewed. All had the facility's electronic assessment titled "device" which stated if the "device" restricted freedom of movement, but the electronic charting did not describe the specific risks and benefits to those individual resident who utilized restraints. Review of manufacturer's information dated [DATE] for the reverse seat belt utilized by Resident #105, revealed the document stated contraindications for the use of the reverse seat belt included patients who slid down in the chair. Application of the device instructions included to place the belt at the patient waist, place both straps behind the patient and pass the ends through the space between the wheelchair seat and backrest, cross the straps behind the wheelchair, and use the slider buckles to adjust the straps so the belt fits snugly. It was noted the belt should not be so snug as to interfere with the patient's breathing and that you should be able to slide your open hand between the device and the patient. The manufacturer's document stated to never place a patient wearing a restrictive device in a place where he/she is not easily monitored. Review of the facility's undated "Restraint (Physical)" policy and procedures, revealed the policy and procedures stated to place residents in supervised areas, check frequently and place call light within reach if the resident is able to use it. This deficiency substantiates Complaint Number OH 597.