Every finding on record at Chamberlin Healthcare Center

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure food was stored, served, and prepared in a safe and sanitary manner. This had the potential to affect all of the residents residing in the facility except for one resident that the facility identified with an order for nothing by mouth. The facility census was 157 residents. Findings include: 1.Observation of dry storage on 05/11/26 at 9:39 A.M. revealed the following open and undated items: open bags of gravy mix, spaghetti noodles, macaroni noodles, two containers of peanut butter Interview 5/11/26 at 9:40 A.M. with Dietary Manager (DM) #250 verified the open and undated items. 2. Observation on 05/11/26 at 9:46 A.M. revealed there was an open container of mashed potato mix without a lid being stored on top of the steamer. Interview on 05/11/26 at 9:46 A.M.with DM #250 verifed that the mashed potato mix should be covered when stored. 3. Observation on 05/11/26 at 9:47 A.M. revealed a bowl of hard boiled eggs was being stored at room temperature on top of the steamer. Interview on 05/11/26 at 9:47 A.M with DM #250 verified the eggs were improperly stored and should have been kept below 41 degrees Fahrenheit (F) or above 135 degrees F. 4.Observation on 05/11/26 at 9:49 A.M. revealed the floor behind the grill was dirty. Interview on 05/11/26 at 9:49 A.M. with DM #250 verified the floor needed to be cleaned. 5. Observation on 05/11/26 at 9:52 A.M. revealed the walk in cooler fans were dirty with a build up of dust. Interview on 05/11/26 at 9:52 A.M. with DM #250 verified the fans were dirty. 6. Observation on 05/11/26 at 9:54 A.M. of the walk -in cooler revealed there were two pans of corn and one pan of mashed potatoes dated 05/08. The floors to the cooler were dirty and showed signs of rust. There was an undated and unlabeled tub of meat. Interview 05/11/26 at 9:58 A.M. with DM #250 verified that only one date was listed on the containers of vegetables and she could not verify if it was a preparation or discard date. DM #250 verified that the floors were dirty and difficult to clean due to the rust buildup. DM #250 verified the meat was unlabeled and undated. 7. Observation on 05/11/26 at 10:01 A.M. revealed there were utensils being stored in large containers on the clean dish rack. Further observation revealed that the containers were dirty with food debris inside. Interview on 05/11/26 at 10:01 A.M. with DM #250 verified that the containers storing the clean utensils were dirty. 8. Observation on 05/11/26 at 10:02 AM revealed the blade of the can opener was dirty and had a build up of food debris. Interview on 05/11/26 at 10:02 A.M. with DM #250 verified the blade was dirty. 9Observation on 05/11/26 at 10:03 A.M. revealed there was a bulk plastic container of brown sugar labeled health shake mix with a discard date of 04/13/26. Interview on 05/11/26 at 10:03 A.M. with DM #250 verified the brown sugar was recently placed in the container. DM #250 verified that the container must have not been cleaned properly prior to adding the brown sugar due to the old label still being on the container. 10. Observation on 05/11/26 at 10:09 A.M. of the beverage cooler revealed it contained the following nectar thickened chocolate milk containers: four dated 04/17/26, three dated 04/16/26, two dated 04/21/26. Interview on 05/11/26 at 10:09 A.M. with DM #250 verified that the drinks were expired and should have been discarded. Review of the facility policy titled Food Storage: Cold Foods dated February 2026 revealed all foods will be stored wrapped or covered, labeled and dated. Review of the facility policy titled Equipment dated September 2017 revealed all foodservice equipment will be clean, sanitary, and in proper working order. This deficiency represents noncompliance investigated under Complaint Number 1271694.

Based on medical record review, resident interview, observation, staff interview, and policy review, the facility failed to serve palatable meals at the preferred temperature. This affected one (Resident #9) and had the potential to affect all residents who received food from the kitchen. The facility identified one resident with orders for nothing by mouth. The facility census was 157 residents. Findings include: Review of the medical record for Resident #9 revealed an admission date of 10/05/24 with a diagnosis of degeneration of nervous system due to alcohol. Review of the Minimum Data Set assessment for Resident #9 dated 02/28/26 revealed the resident was cognitively intact. Interview on 05/11/26 at 2:03 P.M. with Resident #9 confirmed the food was served cold and did not taste good. Observation 05/13/26 at 2:28 P.M. of the test tray revealed the mashed potatoes were 109 degrees Fahrenheit (F) and the roast beef was 99 degrees F. The potatoes were bland in flavor and the roast beef was cold. Interview on 05/13/26 at 2:29 P.M. with the Dietary Manager (DM) verified the potatoes were bland and the roast beef was cold. Review of the facility policy titled Food: Quality and Palatability dated February 2023 revealed food will be palatable. This deficiency represents noncompliance investigated under Complaint Number 2987707 and Complaint Number 2578596 and Complaint Number 1271694.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure enhanced barrier precautions (EBP) were followed. This affected one (Resident #8) of three residents reviewed for infection control. The facility census was 157 residents.Findings include: Review of the medical record for Resident #8 revealed an admission date of 09/23/24 with diagnoses including Parkinson's disease, epilepsy, bipolar disease, chronic kidney disease, and obstructive and reflux uropathy. Review of the care plan for Resident #8 dated 10/09/24 revealed the resident requires EBP for indwelling catheter. Review of the Minimum Data Set (MDS) assessment for Resident #8 dated 02/26/26 revealed the resident had moderately impaired cognition and required staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #8 revealed an order dated 04/22/26 for EBP related to the presence of an indwelling catheter. Observation of Resident #8's room on 05/13/26 at 8:43 A.M. revealed there was no EBP sign on the resident's door nor was there any personal protective equipment (PPE) near the door or in the resident's room. Interview on 05/13/26 at 8:44 A.M. with Licensed Practical Nurse (LPN) #133 verified the facility did not have Resident #8 in EBP. Interview on 05/13/26 at 8:47 A.M. with Certified Nursing Assistant (CNA) #167 confirmed there was no sign on Resident #8's door regarding precautions and there were no gowns on the door or in or near the room. Review of the facility policy titled Enhanced Barrier Precautions undated revealed staff should post signs on the resident doors indicating when the resident was in EBP.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure privacy and dignity during medication administration. This affected one (Resident #138) of three residents reviewed for dignity. The facility census was 157 residents. Findings include: Review of the medical record for Resident #138 revealed an admission date of 10/09/14 with diagnoses including chronic kidney disease, aphasia following unspecified cerebrovascular disease, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of the Minimum Data Set (MDS) assessment for Resident #138 dated 05/03/26 revealed the resident had severely impaired cognition and was dependent on staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #138 revealed an order dated 05/09/26 Lantus insulin 15 units per subcutaneous injection every morning and at bedtime for diabetes. Observation on 5/12/26 at 8:51 A.M. revealed Licensed Practical Nurse (LPN) #149 administered a Lantus insulin injection to Resident #138 to the in a busy hallway in the common area. Interview on 05/12/26 at 8:52 A.M. with LPN #149 confirmed she had not provided privacy to Resident #138 during insulin administration. Interview on 05/14/26 at 9:18 A.M. with the Director of Nursing (DON) confirmed the expectation of administering injectable medications to residents should be based on resident preference and to maintain privacy. The DON stated if the resident is moderately or severely impaired and cannot express a preference, then insulin administration should be done in the privacy of the resident's room. Review of the policy titled Resident Rights undated revealed residents had the right to have their privacy respected when treatment, medication, or care was being administered including the right to not have treatment, medication or care performed in common areas such as hallways. This deficiency represents noncompliance investigated under Complaint Number 2987707 and Complaint Number 2618955 and Complaint Number 2578596.

Based on medical record review, observation, staff interviews, and policy review, the facility failed to provide timely incontinence care for a resident dependent on staff for care. This affected one (#51) of one resident reviewed for incontinence care. The facility census was 146. Findings included: Review of medical record for Resident #51 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, anxiety disorder, dementia, and major depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was severely cognitively impaired. Resident #51 required substantial maximal assistance for personal hygiene, bathing, transfers, lower body, toileting, and transfers. Resident #51 required partial assistance for dressing upper body. Review of plan of care dated 07/04/24 revealed that Resident #51 was at risk for incontinent of urine. Interventions were to apply barrier creams as needed, check resident for incontinence, and observe for signs and symptoms of urinary tract infection. Observation on 07/22/24, from 2:02 P.M. through 2:14 P.M., revealed Resident #51 walking around in the hallway wet and in view of other residents. Resident #51 was observed to be saturated with urine on her green scrub pants entire back side at bottom, around her waist and through the bottom of her shirt. Interview on 07/22/24 at 2:18 P.M., with Registered Nurse (RN) #113 verified Resident #51 was saturated in urine. RN #113 verified Resident #51 had moderate amount of saturated urine in brief, through her pants, at the waist of pants and through Resident #51's shirt. Interview on 07/24/24 at 2:35 P.M., with State tested Nurse Aide (STNA) #32 stated Resident #51 was a check and change. STNA #32 stated she had come in and checked and changed Resident #51, at the start of her shift, at 7:45 A.M. and again at 9:15 A.M. STNA #32 stated she had not got to check and change her before lunch. STNA #32 stated the nurse had come to tell her that the nurse did change her and Resident #51 was saturated with urine. Review of the policy titled, Perineal Care Male and Female dated 04/20/2017, revealed perineal care was performed on residents who were unable or unwilling to maintain body cleanliness and or who are incontinent of bowel and bladder. Perineal care will be care planned for each individual resident to meet his or her specific needs.

Based on observation, medical record review, resident interview, staff interview, and review of policies, the facility failed to provide safe storage for cigarettes and alcohol. This affected one (#128) of one resident reviewed for smoking. The facility failed to provide care planned fall interventions for residents at risk for falls. This affected two (#22, #103) of three residents reviewed for falls. The facility census was 146. Findings included: 1. Review of medical record for Resident #22 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, type two diabetes, Alzheimer's disease, dementia, and psychosis not due to a substance or physiological condition. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was assessed as having severe cognitive impairment. Resident #22 required supervision for eating. Resident #22 was dependent for oral hygiene, toileting, dressing upper and lower clothing, personal hygiene, bathing, and transfers. Resident #22 was able to ambulate by himself with no staff help or assisted devices. Review of Fall Risk Observation Tool dated 05/05/24 revealed that Resident #22 had poor recall and judgement, ambulatory without assistance, gait was weak walking and short steps, able to stand and walk, predisposing diseases and condition for three or more present. Review of plan of care dated 05/22/24 revealed interventions included: apply the dycem to wheelchair, assess risk for falls on admission, bed in lowest position, educate resident and representative, ensure resident was wearing appropriate non-skid footwear, ensure resident's room was free of accident hazards, ensure that the bed was locks are engaged, nurse to do orthostatic blood pressure each shift for three days and report abnormalities, place a sheet of dycem to wheelchair seat to prevent resident from sliding out of chair, provide activities, provide assistive devices as needed, physical therapy referral, and rearrange the room, and have personal items within reach. Observation on 07/22/24 at 2:10 P.M., revealed Resident #22 was walking the halls by himself with one regular sock on right foot, and right foot had a bare foot. Interview on 07/22/24 at 2:11 P.M., with State tested Nurse Aide (STNA) #393 verified Resident #22 was walking the hallways with one regular sock on and one foot barefoot. 2. Review of medical record for Resident #103 revealed an admitted [DATE]. Diagnoses included chronic pulmonary disease, Alzheimer's disease, illus, and cognitive communication deficit. Review of MDS assessment dated [DATE] revealed Resident #103 was severely cognitively impaired. Resident #103 required setups for all meals. Resident #103 required dependent oral hygiene, toileting, bathing, personal hygiene, dressing upper and lower body, and transfers. Review of plan of care dated 07/22/24 revealed Resident #103 was at risk for activity of daily living self-care related to assistance with activity of daily living, dementia, chronic pulmonary disease, and Alzheimer's. Interventions included grab bars to bed to aide with turning and repositioning, place shoes on and off, place call light within reach, and evaluation and treat per medical provider orders. Observation on 07/22/24 at 11:38 A.M., revealed Resident #103 was ambulating in lock down unit with her both bare feet and no socks on. Interview on 07/22/24 at 11:38 A.M., with STNA #22 confirmed Resident #103 had no shoes or nonskid socks on while ambulating in the hall. Review of the policy titled Fall Preventions and Management dated 03/06/24, stated an intervention was put in place after a fall to prevent future falls. Fall prevention and management was the process of identifying risk factors that can minimize the potential for falls and also a process to manage a resident's care if a fall occurs. 40471 3. Review of the medical record for Resident #128 revealed an admitted [DATE], with diagnoses including dementia with mild agitation, and bipolar disorder. Review of Resident #128's care plan revealed he had a substance use disorder related to alcohol use and were to observe resident's room for items. Review of policy entitled Resident Substance Abuse in facility was signed and dated by Resident #128 on 05/05/24 as acknowledgement of receipt. Interview and observation on 07/23/24 at 11:23 A.M., with Resident #128 revealed he had a pack of cigarettes on his person, with six cigarettes in it. Resident #128 stated he didn't smoke, that he used cigarettes for bargaining. Resident #128 also had an empty carton of hard tea (tea premixed with alcohol) and two individual serving boxes of wine in his room. Interview on 07/23/24 at 11:30 A.M., Registered Nurse (RN) #182 verified the presence of the drug-related items and the facility's policy was that cigarettes could not be traded or used to bargain. Review of the undated policy titled, Resident Substance Abuse in Facility, revealed residents may not possess, use or provide any illicit drugs or abuse drugs in any manner, and may not have drug-related paraphernalia in their possession while a resident in the facility.

Based on medical record, observation, staff interview, resident interview, and review of policies, the facility failed to ensure medications were provided with an open date when being utilized to ensure medications were not expired. This affected two (#13 and #127) residents observed during medication storage. The facility failed to ensure medications were not left at the bedside and were consumed when administered. This affected one (#117) randomly observed resident. The facility census was 146. Findings include: 1. Observation on [DATE] at 9:30 A.M., of the medication cart revealed Resident #13 had open bottle Keppra 100 mg/milliliter liquid and had no open date on bottle. Resident #13 also had an open bottle of Felbamate 600 mg/5 ml liquid with no open date on the bottle. Interview on [DATE] at 9:45 A.M., with Director of Nursing (DON) verified the nurse was to place a date on the medication when opened for both Keppra and Felbamate bottles. 2. Observation on [DATE] at 9:50 A.M., of the medication cart with Resident #127 had an open bottle of Valproic Acid 250 milligram/5 milliliter 16 ounces and had no open date. Resident #127 had second open bottle of Valproic Acid 250 mg/5 ml 16 ounces and had no open date. Interview on [DATE] at 9:55 A.M., with DON confirmed Resident #127 had two bottles of Valproic Acid were open, undated and had been used by staff for delivery of medication for Resident #127. Review of the policy titled, Storage of Medications, with revision date of [DATE], revealed the nurse shall place date opened sticker on the medication and record the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days from opening, unless the manufacturer recommends another date or regulations or guidelines require different dating. 40471 3. Review of medical record for Resident #117 revealed an admitted [DATE], with diagnoses including paranoid schizophrenia and delusional disorders. Review of physician's orders dated [DATE], revealed an order for risperidone 0.5 milligrams (mg) twice a day for paranoid schizophrenia; [DATE], Pantoprazole 40 mg daily for digestive aid; and Tamsulosin 0.4 mg daily for prostate health. Review of minimum data set assessment dated [DATE] revealed Resident #117 was cognitively intact and noted to refuse care at times. Resident #117 had a court appointed guardian. Observation and interview on [DATE] at 9:04 A.M., revealed a medication cup with three tablets in it, sitting on Resident #117's over the bedside table. Resident #117 verified the nurse had brought them in and left them so he could take them with his breakfast. Interview on [DATE] at 9:06 A.M., Registered Nurse (RN) #57 verified she did give Resident #117 medications but did not witness him take his medication, Resident #117 stated he wanted to take them with breakfast. RN #57 verified the medications were risperidone, Pantoprazole and Tamsulosin. Review of the policy titled, Storage of Medications, with revision date of [DATE], revealed only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) were permitted to access medications. Medication rooms, carts, and medication supplies are locked when they were not attended by persons with authorized access.

Based on medical record review, observation, resident interview, and staff interviews, the facility failed to ensure call lights were accessible to residents while in bed. This affected three (#51, #143, and #446) of three residents reviewed for call lights. The facility census was 146. Findings included: 1. Review of medical record for Resident #51 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, anxiety disorder, dementia, and major depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was severely cognitively impaired. Resident #51 required supervision with meals, required partial and moderate assistance with oral care, substantial maximal assistance for personal hygiene, bathing, transfers, lower body, and transfers. Review of plan of care dated 06/21/24 revealed Resident #51 was at risk for falls related to injury related to decreased cognition and safety. Interventions included assess for risk for falls, educate resident or representative, ensure resident's room was free of potential visible hazards, ensure that the bed locks are engaged, observe medication for side effects that may increase for falls, and place call bell within reach, and remind to call for assistance. Observation on 07/22/24 at 2:18 P.M., with Registered Nurse (RN) #113 verified Resident #51's call light was wrapped up and hanging on the wall at the plug in for the call light. Interview on 07/22/24 at 2:22 P.M., with RN #113 verified the call light for Resident #51 was wrapped up on the wall and unable to be reached or used by the resident. 2. Review of the medical record for Resident #143 revealed an admitted [DATE]. Diagnoses included major depressive disorder, type two diabetes, and overactive bladder. Review of MDS assessment dated [DATE] revealed that Resident #143 Brief Interview of Mental Status was 04 that indicated she was cognitively impaired. Resident #143 required supervision with or without setup for meals, dressing upper and lower body, transfers, toileting, personal hygiene, and bathing. Review of plan of care dated 07/11/24 revealed Resident #132 was at risk for falls related to cognition deficit, communication deficit, and use of psychotropic medications. Interventions included assess for risk for falls, educated resident or representative, ensure resident room was free of accident hazards, ensure that the bed locks are engaged, place call bell within reach, and observe for medication side effects and report. Observation on 07/22/24 at 2:18 P.M., with Registered Nurse (RN) #113 verified Resident #143's call light was wrapped up and hanging on the wall at the plug in for the call light. Interview on 07/22/24 at 2:22 P.M., with RN #113 verified the call lights for Resident #143 was wrapped up on the wall and unable to be reached or used by the resident. 3. Review of the medical record for Resident #446 revealed an admitted [DATE]. Diagnoses included psychosis and dementia. Review of MDS dated [DATE] revealed the assessment was in progress. Review of plan of care dated 07/22/24 revealed that Resident #446 was at risk for activity of daily living self-care performance related to dementia and psychosis. Observation on 07/22/24 at 11:16 A.M., of Resident #446 revealed the resident was in bed and the call light was under her mattress, between the frame and mattress. Interview on 07/22/24 at 11:16 A.M., with Resident #446 revealed she did not have a call light and had been at the facility for six days. Interview on 07/22/24 at 11:23 A.M., with Unit Manager #62 verified Resident #446's call light was under her mattress and unable to be reached.

Based on record review, staff interview, and policy review, the facility failed to ensure care plans were updated timely with fall interventions. This affected one (#139) of five residents reviewed for falls. The facility census was 146. Findings include: Review of the medical record for Resident #139 revealed an admitted [DATE]. Diagnoses included dementia, chronic obstructive pulmonary disease, unspecified severe protein-calorie malnutrition, hyperlipidemia, chronic atrial fibrillation, atherosclerotic heart disease of native coronary artery without angina pectoris, anemia, major depressive disorder, chronic kidney disease, aphasia, and unspecified psychosis not due to a substance or known physiological condition. Review of the facility assessment titled Fall Risk Observation Tool, dated 05/11/24, revealed Resident #139 was at risk for falls. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #139 had severely impaired cognition. Resident #139 was assessed to require supervision for eating, substantial/maximal assistance for oral hygiene, toileting, dressing, personal hygiene, bed mobility, and transfer, and was dependent for bathing. Review of the Interdisciplinary Team (IDT) progress note dated 07/16/24 revealed Resident #139 had a fall on 07/15/24 while attempting to lay on her bedside table. The new intervention was to remove the bedside table for safety and only use during meals. Review of the plan of care revised on 07/23/24 revealed Resident #139 was at risk for falls related to dementia. Interventions included ensuring room is free of accident hazards, ensuring non-skid footwear is worn, place call light within reach, and ensuring bed locks are engaged. Interview on 07/25/24 at 2:26 P.M., with Corporate Nurse #182 confirmed the intervention related to the bedside table was not added to the care plan. Review of the policy titled Fall Prevention and Management, revised on 03/06/24, revealed care plans should be updated with new fall interventions.

Based on record review, staff interview, and policy review, the facility failed to develop a care plan for a resident with vision impairment. This affected one (#52) of 29 residents reviewed for care planning. The facility census was 146. Findings include: Review of the Resident #52's medical record revealed an admitted [DATE], with diagnoses including type two diabetes mellitus with diabetic polyneuropathy, atherosclerotic heart disease of native coronary artery without angina pectoris, pure hypercholesterolemia, anxiety disorder, spinal stenosis, other intervertebral disc degeneration lumbar region, obsession compulsive disorder, depression, other chronic pain, insomnia, hypertension, chronic pain and tobacco use. Review of Resident #52's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be cognitively intact and Resident #52 required supervision with eating, oral hygiene, toileting, personal hygiene, lying to sitting, sitting to standing, chair transfers, toilet transfers, and tub transfers. Resident #52 required maximal assistance with showering and set up assistance with lower body dressing, upper body dressing, putting on and taking off footwear, rolling left and right, sitting to lying, and walking. Resident #52 had adequate vision with corrective lenses. Review of Resident #52's eye appointment dated 03/08/24 revealed Resident #52 had a cataract consult on 03/08/24 at 12:30 P.M. Review of Resident #52's post operative instructions for cataract surgery dated 04/11/24 revealed Resident #52 was to wear the eye shield while sleeping for seven nights after surgery. Review of Resident #52's care plan dated 07/23/24 revealed Resident #52 did not have a vision care plan or care plan for the use of corrective lenses or cataracts. Interview on 07/25/24 at 10:34 A.M., with Corporate Registered Nurse (CRN) #182 verified Resident #52 did not have a vision care plan. CRN #182 also confirmed Resident #52 had corrective lenses and a history of cataracts and cataract surgery. Review of the policy titled Plan of Care, dated 03/01/24, revealed the facility will provide a resident centered care plan that meets the psychosocial, physical, and emotional needs and concerns of the resident.

Based on medical record, observation, resident interview, staff interview and policy reviews, the facility failed to ensure the proper transmission-based precautions were provided for a resident per physician orders. This affected one (#109) of one resident reviewed for infection control. The facility census was 146. Findings include: Review of medical record for Resident #109 revealed an admitted [DATE]. Diagnoses included chronic pulmonary disease, severe combined immunodeficiency with low T and B cells, and psychotic disorder with delusions. Review of physician order for Resident #109 dated 07/18/24 revealed an order for contact precautions every morning and bedtime due to Shingles. Resident #109 was allowed to come out of the room if rash was covered. Review of physician order for Resident #109 dated 07/20/24 revealed an order for the antibiotic Valtrex oral one gram to give one tablet twice a day for seven days for Shingles. Observation on 07/23/24 at 4:01 P.M., revealed Resident #109 had enhanced barrier precautions sign hanging on her door. Resident #109 was sitting in her room in wheelchair. Interview on 07/23/24 at 4:01 P.M., with Resident #109 stated she did not have shingles at this time. Interview on 07/23/24 at 4:02 P.M., with Licensed Practical Nurse (LPN) #52 stated she knew Resident #109 was on contact precaution. LPN #52 verified Resident #109 had only an enhanced barrier precaution sign hanging on her door. LPN #52 verified there should have been a contact precaution sign instead. Interview on 07/23/24 at 4:30 P.M., with Unit Manager (UM) #62 verified Resident #109 had shingles and a rash under her arm on the one side. UM #62 stated Resident #109 does not come out of her room at this time. UM #62 stated the facility did not make her stay in her room, Resident #109 stays in her room on her own choice. Review of the policy titled Surveillance for Infections, dated 02/28/22, revealed the purpose of policy was to provide guidance for monitoring infections for tracking, trending, and monitoring for outbreaks. Review of the policy titled Standard Precautions and Transmission Based Precautions dated 06/25/21, revealed the facility used two tier approach to precautions: standard precautions and transmission-based precautions based on resident's clinical condition utilizing Center of Disease Control (CDC) guidelines. The isolation precaution was the method of preventing the spread of contagious disease and microorganism transfer to others following CDC recommendations and guidelines.

Based on medical record review, observation, resident interview, staff interview, nursing home bill of rights review, and policy review, the facility failed to provide a clean and home like environment. This affected three (#22, #70, and #446) of 29 residents reviewed for environment. The facility census was 146. Findings Included: 1. Review of the medical record for Resident #22 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, type two diabetes, Alzheimer's disease, dementia, and psychosis not due to a substance or physiological condition. Review of MDS dated [DATE] revealed Resident #22 was severely cognitively impaired. Resident #22 required supervision for eating. Resident #22 was dependent for oral hygiene, toileting, dressing upper and lower clothing, personal hygiene, bathing, and transfers. Review of plan of care dated 05/22/24 revealed resident was at risk for falls and to apply the Dycem to wheelchair, assess risk for falls on admission, bed in lowest position, educate resident and representative, ensure resident was wearing appropriate non-skid footwear, ensure resident's room was free of accident hazards, ensure that the bed was locks are engaged, nurse to do orthostatic blood pressure each shift for three days and report abnormalities, place a sheet of Dycem to wheelchair seat to prevent resident from sliding out of chair, provide activities, provide assistive devices as needed, physical therapy referral, and rearrange the room, and have personal items within reach. 2. Review of the medical record for Resident #70 revealed an admitted [DATE]. Diagnoses included vascular dementia, major depression, and mood disorder. Review of MDS dated [DATE] revealed Resident #70 was severely cognitively impaired. Resident #70 required partial moderate assistance for dressing upper body. Resident #70 substantial maximal assistance dressing lower body, transfers, personal hygiene, bathing, toileting use, and placing shoes on and off feet. Review of plan of care dated 07/22/24 revealed that Resident #70 was at risk for falls related to gait balance problems, impaired cognition, and incontinence. Interventions included assessing risk for falls, educate resident wearing appropriate nonskid shoes, place call light in reach, ensure the bed locks are engaged, and provide adequate lighting at night. Observation on 07/22/24 at 11:51 A.M., revealed the room Resident #22 and Resident #70 resided in was observed to have a greasy, slippery, dirty floor. The surveyor and State tested Nurse Aide (STNA) #393 both slide on the floor when walking into residents' rooms. Interview on 07/22/24 at 11:52 A.M., with STNA #393 verified it was very slippery and greasy to walk on. STNA #393 stated a resident could fall on this dirty floor. 3. Review of the medical record for Resident #446 revealed an admission of 07/17/24. Diagnoses included psychosis, and dementia. Review of MDS assessment dated [DATE] revealed the MDS was in progress. Review of plan of care dated 07/22/24 revealed Resident #446 was at risk for a decrease in activity of daily living self-care performance related to dementia, and psychosis. Observation on 07/22/24 at 11:16 A.M., of Resident #446's room revealed the bed had no headboard, and clothes were in brown bags on top of her dresser. The dresser was observed to have old food crumbs, large brown harden unidentified stain, dried pink nail polish, and a full bottom drawer with clothes from the past resident. Interview on 07/22/24 at 11:16 A.M., with Resident #446 stated she had no headboard, and her dresser was dirty and had other resident's items in her dresser. Resident #446 stated she could not use the dresser due to it being filthy. Resident #446 stated she had been admitted six days ago, and the facility was a mess. Interview on 07/22/24 at 11:23 A.M., with Unit Manager (UM) #62 verified Resident #446 had no headboard, clothes were in brown bag on top of her dresser that was hers from her admission. UM #62 verified that Resident #446 dresser had old food crumbs, large brown unknown substance that was hardened, a yellow Lego piece, left over trash, dried pink nail polish, and a full bottom drawer with clothes from the past resident. Review of the undated policy titled, Housekeeping In Service revealed daily performance of damp mop of floor and use proper mop, germicide solution to disinfect the resident's floor. Review of the form titled, Nursing Home Residents [NAME] of Rights, dated 1987, revealed every resident had the right to receive medical care, nursing care, rehabilitative and restorative therapies, and personal hygiene in a safe, clean environment.

Based on record review and staff interview, the facility failed to ensure resident's code status matched in the hard (paper) and electronic chart. This affected two (#76 and #139) residents of 34 residents reviewed for advanced directives. The facility census was 146. Findings include: Review of the Resident #76's chart revealed Resident #76 admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, weakness, repeated falls, gastrostomy status, and hypothyroidism. Review of Resident #76's significant change Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's cognition was not assessed and Resident #76 required maximal assistance with upper body dressing, rolling left and right, sitting to lying, lying to sitting, sitting to standing, chair transfers, and walking ten feet. Resident #76 was dependent with oral hygiene, tub transfers, toileting, showering, lower body dressing, putting on and taking off footwear and personal hygiene. Review of Resident #76's electronic physician order dated 04/05/24 revealed Resident #76 was a do not resuscitate comfort care (DNRCC). The order was electronically signed by Resident #76's physician. Review of Resident #76's code status form in the hard chart dated 03/01/21 revealed Resident #76 was a do not resuscitate comfort care arrest (DNRCCA). The form was signed by Resident #76's physician. Interview on 07/23/24 at 4:01 P.M., with Corporate Registered Nurse (CRN) #182 verified Resident #76's code status did not match in the electronic chart and the hard chart. CRN #182 verified Resident #76 was listed as a DNRCC in the electronic chart and a DNRCCA in the hard chart. 44069 2. Review of the medical record for Resident #139 revealed an admitted [DATE]. Diagnoses included dementia, chronic obstructive pulmonary disease, unspecified severe protein-calorie malnutrition, hyperlipidemia, chronic atrial fibrillation, atherosclerotic heart disease of native coronary artery without angina pectoris, anemia, major depressive disorder, chronic kidney disease, aphasia, and unspecified psychosis not due to a substance or known physiological condition. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #139 had severely impaired cognition. Resident #139 was assessed to require supervision for eating, substantial/maximal assistance for oral hygiene, toileting, dressing, personal hygiene, bed mobility, and transfer, and was dependent for bathing. Review of the active physician orders in the electronic health record revealed an order for code status of Do Not Resuscitate Comfort Care Arrest (DNRCC-A). Review of the signed DNR paper form dated 07/10/24 revealed DNRCC was checked instead of DNRCC-A. Interview on 07/24/24 at 2:57 P.M., with CRN #183 verified the DNR paper form and the order in the electronic health record did not match.

Based on record review and staff interview, the facility failed to correctly code the Minimum Data Set (MDS) assessment for the proper discharge location. This affected one (#144) of three residents reviewed for discharge. The census was 146. Findings include: Review of Resident #144's medical record revealed an admitted [DATE] and discharge date of [DATE], with diagnoses including: cellulitis of right lower leg, schizophrenia, and schizoaffective disorder. Review of Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #144 was cognitively intact and required assistance for mobility, she was having hallucinations and delusions, and verbal behaviors. Review of care plan revealed a discharge plan to home or another facility. Review of progress note date 05/03/24 at 12:44 P.M., revealed Resident #144 signed out of facility against medical advice (AMA), it was explained to resident that by leaving against advice she cannot take medications with her and she releases the facility from all responsibility. Resident #144 verbalized understanding. Nurse practitioner aware. Review of the discharge MDS dated [DATE] revealed Section A2105 for Discharge Status revealed Resident #144 discharged to 04. Short-Term General Hospital (acute hospital, IPPS) rather than 01. Home/Community. Interview on 07/24/24 at 2:45 P.M., with Registered Nurse (RN) #181 verified Resident #144's MDS was coded incorrectly for the discharge destination to home.

Based on record review, review of facility Self-Reported Incidents (SRIs) staff interviews, review of witness statements, review of employee personnel file, and review of facility policy, the facility failed to prevent an incident of resident-to-resident abuse. This affected one (#100) of three residents reviewed for abuse. The facility census was 137. Findings include: Review of the medical record for Resident #100 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia, cocaine dependence, constipation, psychoactive substance abuse, pseudobulbar affect, anoxic brain damage, impulsiveness, ataxia, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) assessment 3.0 dated 07/14/23 for Resident #100 revealed the resident had severely impaired cognition. Resident #100 required extensive assistance from staff with transfers. Review of the September 2023 nursing notes for Resident #100 revealed no documentation regarding the resident being involved in the resident-to-resident physical abuse from Resident #115 recorded on 09/22/23. Review of medical record for Resident #115 revealed the resident was admitted to the facility on [DATE]. Diagnoses included transient ischemic attack (TIA), cerebral infarction (stroke), dementia, psychotic disturbance, mood disturbance, anxiety, essential primary hypertension, major depressive disorder, asthma, dysphagia, and hemiplegia and hemiparesis. Review of the quarterly MDS assessment dated [DATE] for Resident #115, revealed the resident was severely cognitively impaired. Further review of the MDS assessment revealed the resident required assistance from staff with bed mobility, transfers and required supervision from staff with walking. Review of plan of care revised on 09/15/23 for Resident #115 revealed the resident had behavior problems and had resident to resident altercations. Interventions included intervening as necessary to protect the rights and safety of others. Review of the nurse's progress notes for Resident #115 dated 09/22/23 at 3:31 P.M. authored by Registered Nurse (RN) #188 revealed the resident had a scratch wound on her face (from an earlier altercation with Resident #108). Resident #115 was assessed and found to be in no distress and in no pain. The nurse provided wound care to the scratch and the Assistant Director of Nursing (ADON), and the Nurse Practitioner were notified. The progress notes revealed no documentation regarding the physical abuse allegation involving Resident #115 hitting Resident #100. Review of a witness statement by Resident #100 dated 09/22/23 and collected by State tested Nursing Assistant (STNA) #239, revealed the resident was sitting by the dining room when two other residents (#115 and #108) were fighting. One resident (#115) was still mad after the incident and a woman (identified as Activities Leader (AL) #215) told the resident to get her and that resident hit Resident #100 on her left arm. Review of a witness statement authored by AL #215 dated 09/22/23, revealed Resident #115 hit another resident (Resident #108) and Mental Health Counselor (MHC) #600 broke it up. AL #215 asked Resident #115 to stop being a bully and when she touched the resident's hand, Resident #115 hit Resident #100. Review of a witness statement authored by RN #188 dated 09/22/23, revealed a staff member was provoking Resident #115 saying go get her but Resident #115 turned and hit Resident #100. Review of the facility's SRI tracking number 239557, created on 09/25/23 at 11:34 A.M., revealed an allegation of physical abuse was discovered on 09/22/23. Notes revealed Resident #108 was walking into the dining room when Resident # 115 grabbed Resident #108's clothing and pushed her. Resident #108 defended herself and inflicted scratches on Resident #115's face. The residents were immediately separated and both residents were assessed for injury. The Administrator, the Director of Nursing (DON), the physician, and the sponsor were notified. The SRI was closed on 09/29/23 at 2:48 P.M. and was unsubstantiated due to inconclusive evidence. Review of the facility's SRI tracking number 239560, created on 09/25/23 at 12:14 P.M., revealed an allegation of physical abuse was discovered on 09/22/23 at 12:55 P.M. The SRI indicated Resident #115 struck Resident #100 directly after Resident #115 had struck Resident #108. Notes indicated the resident's sponsors, the physician and the police were immediately notified. The investigation revealed an employee (MHC #600) overheard another employee (AL #215) telling Resident #115 to get her as in referring to Resident #115 getting Resident #108. Notes indicated Resident #115 then hit Resident #100. AL #215 was suspended pending an investigation. The SRI was closed on 09/29/23 at 12:07 P.M. and was unsubstantiated due to inconclusive evidence. Review of the witness statement from MHC #600 dated 09/25/23, revealed he was on the memory care unit when he observed Resident #115 walk past him and push Resident #108. MHC #600 stated he separated Resident #115 from Resident #108 with the assistance of STNA #239. MHC #600 stated after they separated the two Residents, he observed AL #215 continue to agitate Resident #115 by tapping Resident #115's arm and stating to Resident #115, go get her. MHC #600 observed AL #215 begin to play fight with Resident #115 which appeared to agitate Resident #115 even more. MHC #600 reported Resident #115 turned and hit Resident #100 until MHC #600 separated Resident #115 from Resident #100. Interview with Regional Clinical Director (RCD) (#503) on 10/19/23 at 12:44 P.M., indicated she came into the facility for the morning meeting on 09/25/23 and while she was reviewing progress notes, she discovered the incident between Resident #115 and Resident #108 on 09/22/23. While reviewing the incident between #115 and #108, she learned of the incident involving Resident #115 and Resident #100 on 09/22/23. RCD #503 indicated the former Administrator opened two different SRIs (239557 and 239560) on 09/25/23 as the facility continued to investigate. RCD #503 stated the incident happened at the end of AL #215's shift on 09/22/23 and she left the building was not scheduled to return until the following Tuesday (09/26/23). RCD #503 indicated AL #215 was suspended on 09/25/23 pending the outcome of the investigation. RCD #503 stated AL #215 denied the incident of encouraging Resident #115 to get Resident #108; however, the facility felt with the witness statements of the other staff members verifying the incident, they had to err on the side of caution related to the resident's safety and terminated AL #215 effective on 10/17/23. Interview with the STNA #239 on 10/26/23 at 9:19 A.M., revealed she approached the dining room when she observed Resident #115 hit Resident #108. STNA #239 stated it happened so fast that it was hard to tell what exactly happened. STNA #239 indicated she heard AL #215 say to Resident #115, go get her. STNA #239 stated Resident #115 then hit Resident #100. Interview with MHC #600 on 10/26/23 at 10:49 A.M., revealed he was standing in the hallway when he observed an altercation between Resident #115 and Resident #108. MHC #600 stated he was able to get the two residents separated and when he was trying to calm the two residents down, he observed AL #215 continue to agitate Resident #115 by encouraging her to get her (meaning Resident #108) and AL #215 was poking Resident #115's shoulder. MHC #600 stated AL #215 continued to agitate Resident #115, when Resident then hit Resident #100. MHC #600 stated he wrote a statement about his observations and gave it to the Human Resource Manager. MHC #600 stated he also spoke with the Regional Operations Manager (ROM) #505 regarding this incident. Interview with RN #188 on 10/26/23 at 4:31 P.M. indicated he was the nurse working on 09/22/23 and did not see any of the incident between Residents #115 and #108 or the incident between Residents #115 and #100. RN #188 stated he was told Resident #115 grabbed Resident #108 as she was walking in the dining room and Resident #108 reacted to the this and Resident #115 had scratches down both sides of her face. RN #188 stated he was told AL #215 encouraged Resident #115 to go get her meaning go after Resident #108. RN #188 stated Resident #115 was agitated and hit Resident #100. RN #188 indicated Resident #100 had no injuries. Review of the AL #215's personnel file revealed she was hired on 05/31/23 and terminated from the employment at the facility on 10/17/23. AL #215's employee file contained a disciplinary action dated 09/29/23 which indicated a reason for termination, flagrant poor performance indicating an irresponsible lack of knowledge or decision-making process, resulting in measurable loss to the company, whether monetary, in customer confidence or in employee relation issues. AL #215 was terminated following an incident involving residents on the memory care unit. Notes indicated there was an altercation between Resident #115 and Resident #108 and MHC #600 and STNA #239 broke it up. AL #215 was talking with Resident #115 and taping her on the shoulder which is a trigger to Resident #115's behaviors. AL #215 was egging her on and Resident #115 hit another resident (Resident #100). AL #215 was reported as not calming Resident #115 down but instead agitating Resident #115 further which triggered the second incident (Resident #115 striking Resident #100). AL #215 denied the incident and noted she was familiar with Resident #115 since she worked with the resident at another facility. Notes indicated MHC #600 and STNA #239 reported AL #215 further agitated Resident #115. Notes indicated the DON signed the termination letter on 09/29/23 and it was approved by the Human Resources office effective 10/17/23. Review of the undated facility policy titled, Ohio Abuse, Neglect, & Misappropriation, stated the it is the intent to ensure the facility was to prevent abuse, mistreatment, or neglect of residents. The policy revealed any allegation of abuse must be reported immediately to the Executive Director and to the state agency. The facility would take measures to protect residents from harm by immediately initiating an investigation. In the event a situation is identified as abuse, an investigation by the executive leadership will immediately begin. An employee who is alleged or accused of being a party to abuse will immediately be interviewed by the staff nurse, escorted off the premises by another staff member, interviewed by facility leadership for a written statement and not left alone. Documentation of the facts and findings will be completed in each resident medical record. This deficiency represents non-compliance investigated under Complaint number OH00146998.

Based on record review, review of facility Self-Reported Incidents (SRIs) staff interviews, review of witness statements, review of employee personnel file, and review of facility policy, the facility failed to ensure the facility's abuse policy was implemented when two separate incidents of resident-to-resident physical abuse occurred. This affected three (#108, #100 and #115) out of three residents reviewed for abuse. The facility census was 137. Findings include: Review of the medical record for Resident #108 revealed the resident was admitted to the facility on [DATE]. Diagnoses included Dementia, osteoarthritis, alcohol dependence, essential primary hypertension. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #108 dated 09/13/23, revealed the resident had mild cognitive impairment. Resident #108 required extensive assistance from staff with bed mobility and transfers. Review of the nurse's progress notes for Resident #108 dated 09/22/23, revealed the resident was going toward the dining room with her walker when Resident #115 grabbed her. Resident #108 then pushed Resident #115 which resulted in Resident #115 getting a scratch wound on her face. Review of the medical record for Resident #100 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia, cocaine dependence, constipation, psychoactive substance abuse, pseudobulbar affect, anoxic brain damage, impulsiveness, ataxia, and cognitive communication deficit. Review of the quarterly MDS assessment 3.0 dated 07/14/23 for Resident #100 revealed the resident had severely impaired cognition. Resident #100 required extensive assistance from staff with transfers. Review of the September 2023 nursing notes for Resident #100 revealed no documentation regarding the resident being involved in the resident-to-resident physical abuse from Resident #115 recorded on 09/22/23. Review of the medical record for Resident #115 revealed the resident was admitted to the facility on [DATE]. Diagnoses included transient ischemic attack (TIA), cerebral infarction (stroke), dementia, psychotic disturbance, mood disturbance, anxiety, essential primary hypertension, major depressive disorder, asthma, dysphagia, and hemiplegia and hemiparesis. Review of the quarterly MDS assessment dated [DATE] for Resident #115, revealed the resident was severely cognitively impaired. Further review of the MDS assessment revealed the resident required assistance from staff with bed mobility, transfers and required supervision from staff with walking. Review of the plan of care revised on 09/15/23 for Resident #115 revealed the resident had behavior problems and had resident-to-resident altercations. Interventions included intervening as necessary to protect the rights and safety of others. Review of the nurse's progress notes for Resident #115 dated 09/22/23 at 3:31 P.M. authored by Registered Nurse (RN) #188 revealed the resident had a scratch wound on her face (from an altercation with Resident #108). Resident #115 was assessed and found to be in no distress and in no pain. The nurse provided wound care to the scratch and the Assistant Director of Nursing (ADON), and the Nurse Practitioner were notified. The progress notes revealed no documentation regarding the resident-to-resident physical abuse involving Resident #115 hitting Resident #100. Review of a witness statement by State tested Nursing Assistant (STNA) #239 dated 09/22/23 revealed as she came down the hallway one resident (#108) was trying to enter the dining room when she passed another resident (#115) and Resident #115 expressed anger and grabbed onto Resident #108's clothing. Resident #108 pushed Resident #115 resulting in scratches down Resident #115's face. Review of a witness statement by Resident #108 dated 09/22/23 and collected by STNA #239 revealed the resident was walking into the dining room and Resident #115 blocked her way. As Resident #108 went to back up, Resident #115 grabbed her by her gown. Resident #108 was trying to get out her grip and pushed Resident #115. Review of a witness statement authored by Activities Leader (AL) #215 dated 09/22/23, revealed Resident #115 hit another resident (Resident #108) and Mental Health Counselor (MHC) #600 broke it up. AL #215 asked Resident #115 to stop being a bully and when she touched the resident's hand, Resident #115 hit Resident #100. Review of a witness statement by Resident #100 dated 09/22/23 and collected by STNA #239, revealed the resident was sitting by the dining room when two other residents (#115 and #108) were fighting. One resident (#115) was still mad after the incident and a woman (identified as AL #215) told the resident to get her and that resident hit Resident #100 on her left arm. Review of a witness statement authored by RN #188 dated 09/22/23, revealed a staff member was provoking Resident #115 saying go get her but Resident #115 turned and hit Resident #100. Review of the facility's SRI tracking number 239557, created on 09/25/23 at 11:34 A.M., revealed an allegation of physical abuse was discovered on 09/22/23. Notes revealed Resident #108 was walking into the dining room when Resident # 115 grabbed Resident #108's clothing and pushed her. Resident #108 defended herself and inflicted scratches on Resident #115's face. The residents were immediately separated and both residents were assessed for injury. The Administrator, the Director of Nursing (DON), the physician, and the sponsor were notified. The SRI was closed on 09/29/23 at 2:48 P.M. and was unsubstantiated due to inconclusive evidence. Review of the facility's SRI tracking number 239560, created on 09/25/23 at 12:14 P.M., revealed an allegation of physical abuse was discovered on 09/22/23 at 12:55 P.M. The SRI indicated Resident #115 struck Resident #100 directly after Resident #115 had struck Resident #108. Notes indicated the resident's sponsors; the physician and the police were immediately notified. The investigation revealed an employee (MHC #600) overheard another employee (AL #215) telling Resident #115 to get her as in referring to Resident #115 getting Resident #108. Notes indicated Resident #115 then hit Resident #100. AL #215 was suspended pending an investigation. The SRI was closed on 09/29/23 at 12:07 P.M. and was unsubstantiated due to inconclusive evidence. Review of the witness statement from MHC #600 dated 09/25/23, revealed he was on the memory care unit when he observed Resident #115 walk past him and push Resident #108. MHC #600 stated he separated Resident #115 from Resident #108 with the assistance of STNA #239. MHC #600 stated after they separated the two Residents, he observed AL #215 continue to agitate Resident #115 by tapping Resident #115's arm and stating to Resident #115, go get her. MHC #600 observed AL #215 begin to play fight with Resident #115 which appeared to agitate Resident #115 even more. MHC #600 reported Resident #115 turned and hit Resident #100 until MHC #600 separated Resident #115 from Resident #100. Interview with Regional Clinical Director (RCD) #503 on 10/19/23 at 12:44 P.M., indicated she came into the facility for the morning meeting on 09/25/23 and while she was reviewing progress notes, she discovered the incident between Resident #115 and Resident #108 on 09/22/23. While reviewing the incident between #115 and #108, she learned of the incident involving Resident #115 and Resident #100 on 09/22/23. RCD #503 indicated the former Administrator opened two different SRIs (239557 and 239560) on 09/25/23 as the facility investigated the allegations. RCD #503 verified their abuse policy was not implemented when two separate resident-to-resident physical abuse allegations occurred because the administration at the facility was not aware of the incidents until 09/25/23. RCD #503 stated the incident happened at the end of AL #215's shift on 09/22/23 and she left the building was not scheduled to return until the following Tuesday (09/26/23). RCD #503 indicated AL #215 was suspended on 09/25/23 pending the outcome of the investigation. RCD #503 stated AL #215 denied the incident of encouraging Resident #115 to get Resident #108; however, the facility felt with the witness statements of the other staff members verifying the incident, they had to err on the side of caution related to the resident's safety and terminated AL #215 effective on 10/17/23. Interview with STNA #239 on 10/26/23 at 9:19 A.M., revealed she approached the dining room when she observed Resident #115 hit Resident #108. STNA #239 stated it happened so fast that it was hard to tell what exactly happened. STNA #239 indicated she heard AL #215 say to Resident #115, go get her. STNA #239 stated Resident #115 then hit Resident #100. Interview with MHC #600 on 10/26/23 at 10:49 A.M., revealed he was standing in the hallway when he observed an altercation between Resident #115 and Resident #108. MHC #600 stated he was able to get the two residents separated and when he was trying to calm the two residents down, he observed AL #215 continue to agitate Resident #115 by encouraging her to get her (meaning Resident #108) and AL #215 was poking Resident #115's shoulder. MHC #600 stated AL #215 continued to agitate Resident #115, when Resident then hit Resident #100. MHC #600 stated he wrote a statement about his observations and gave it to the Human Resource Manager. MHC #600 stated he also spoke with the Regional Operations Manager (ROM) #505 regarding this incident. Interview with RN #188 on 10/26/23 at 4:31 P.M. indicated he was the nurse working on 09/22/23 and did not see any of the incident between Residents #115 and #108 or the incident between Residents #115 and #100. RN #188 stated he was told Resident #115 grabbed Resident #108 as she was walking in the dining room and Resident #108 reacted to the this and Resident #115 had scratches down both sides of her face. RN #188 stated he was told AL #215 encouraged Resident #115 to go get her meaning go after Resident #108. RN #188 stated Resident #115 was agitated and hit Resident #100. RN #188 indicated Resident #100 had no injuries. Review of the undated facility policy titled, Ohio Abuse, Neglect, & Misappropriation, stated the it is the intent of the facility to ensure the facility would prevent abuse, mistreatment, or neglect of residents. The policy revealed any allegation of abuse must be reported immediately to the Executive Director and to the state agency. The facility would take measures to protect residents from harm by immediately initiating an investigation. In the event a situation is identified as abuse, an investigation by the executive leadership will immediately begin. An employee who is alleged or accused of being a party to abuse will immediately be interviewed by the staff nurse, escorted off the premises by another staff member, interviewed by facility leadership for a written statement and not left alone. Documentation of the facts and findings will be completed in each resident medical record. This deficiency represents non-compliance investigated under Complaint number OH00146998.

Based on record review, staff interviews, review of facility's self-reported incidents (SRIs), review of witness statements, and review of facility policy review, the facility failed to timely report allegations of resident-to-resident physical abuse to the state agency. This affected three (#108, #100 and #115) out of three residents reviewed for abuse. The facility census was 137. Findings include: Review of the medical record for Resident #108 revealed the resident was admitted to the facility on [DATE]. Diagnoses included Dementia, osteoarthritis, alcohol dependence, essential primary hypertension. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #108 dated 09/13/23, revealed the resident had mild cognitive impairment. Resident #108 required extensive assistance from staff with bed mobility and transfers. Review of the nurse's progress notes for Resident #108 dated 09/22/23, revealed the resident was going toward the dining room with her walker when Resident #115 grabbed her. Resident #108 then pushed Resident #115 which resulted in Resident #115 getting a scratch wound on her face. Review of the medical record for Resident #100 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia, cocaine dependence, constipation, psychoactive substance abuse, pseudobulbar affect, anoxic brain damage, impulsiveness, ataxia, and cognitive communication deficit. Review of the quarterly MDS assessment 3.0 dated 07/14/23 for Resident #100 revealed the resident had severely impaired cognition. Resident #100 required extensive assistance from staff with transfers. Review of the September 2023 nursing notes for Resident #100 revealed no documentation regarding the resident being involved in the resident-to-resident physical abuse allegation from Resident #115 recorded on 09/22/23. Review of the medical record for Resident #115 revealed the resident was admitted to the facility on [DATE]. Diagnoses included transient ischemic attack (TIA), cerebral infarction (stroke), dementia, psychotic disturbance, mood disturbance, anxiety, essential primary hypertension, major depressive disorder, asthma, dysphagia, and hemiplegia and hemiparesis. Review of the quarterly MDS assessment dated [DATE] for Resident #115, revealed the resident was severely cognitively impaired. Further review of the MDS assessment revealed the resident required assistance from staff with bed mobility, transfers and required supervision from staff with walking. Review of the plan of care revised on 09/15/23 for Resident #115 revealed the resident had behavior problems and had resident to resident altercations. Interventions included intervening as necessary to protect the rights and safety of others. Review of the nurse's progress notes for Resident #115 dated 09/22/23 at 3:31 P.M. and authored by Registered Nurse (RN) #188 revealed the resident had a scratch wound on her face (from an altercation with Resident #108). Resident #115 was assessed and found to be in no distress and in no pain. The nurse provided wound care to the scratch and the Assistant Director of Nursing (ADON), and the Nurse Practitioner were notified. The progress notes revealed no documentation regarding the resident-to-resident physical abuse allegation involving Resident #115 hitting Resident #100. Review of a witness statement by State tested Nursing Assistant (STNA) #239 dated 09/22/23 revealed as she came down the hallway one resident (#108) was trying to enter the dining room when she passed another resident (#115) and Resident #115 expressed anger and grabbed onto Resident #108's clothing. Resident #108 pushed Resident #115 resulting in scratches down Resident #115's face. Review of a witness statement by Resident #108 dated 09/22/23 and collected by STNA #239 revealed the resident was walking into the dining room and Resident #115 blocked her way. As Resident #108 went to back up, Resident #115 grabbed her by her gown. Resident #108 was trying to get out her grip and pushed Resident #115. Review of a witness statement authored by Activities Leader (AL) #215 dated 09/22/23, revealed Resident #115 hit another resident (Resident #108) and Mental Health Counselor (MHC) #600 broke it up. AL #215 asked Resident #115 to stop being a bully and when she touched the resident's hand, Resident #115 hit Resident #100. Review of a witness statement by Resident #100 dated 09/22/23 and collected by STNA #239, revealed the resident was sitting by the dining room when two other residents (#115 and #108) were fighting. One resident (#115) was still mad after the incident and a woman (identified as AL #215) told the resident to get her and that resident hit Resident #100 on her left arm. Review of a witness statement authored by RN #188 dated 09/22/23, revealed a staff member was provoking Resident #115 saying go get her but Resident #115 turned and hit Resident #100. Review of the facility's SRI tracking number 239557, created on 09/25/23 at 11:34 A.M., revealed an allegation of physical abuse was discovered on 09/22/23. Notes revealed Resident #108 was walking into the dining room when Resident # 115 grabbed Resident #108's clothing and pushed her. Resident #108 defended herself and inflicted scratches on Resident #115's face. The residents were immediately separated and both residents were assessed for injury. The Administrator, the Director of Nursing (DON), the physician, and the sponsor were notified. The SRI was closed on 09/29/23 at 2:48 P.M. and was unsubstantiated due to inconclusive evidence. Review of the facility's SRI tracking number 239560, created on 09/25/23 at 12:14 P.M., revealed an allegation of physical abuse was discovered on 09/22/23 at 12:55 P.M. The SRI indicated Resident #115 struck Resident #100 directly after Resident #115 had struck Resident #108. Notes indicated the resident's sponsors; the physician and the police were immediately notified. The investigation revealed an employee (MHC #600) overheard another employee (AL #215) telling Resident #115 to get her as in referring to Resident #115 getting Resident #108. Notes indicated Resident #115 then hit Resident #100. AL #215 was suspended pending an investigation. The SRI was closed on 09/29/23 at 12:07 P.M. and was unsubstantiated due to inconclusive evidence. Review of the witness statement from MHC #600 dated 09/25/23, revealed he was on the memory care unit when he observed Resident #115 walk past him and push Resident #108. MHC #600 stated he separated Resident #115 from Resident #108 with the assistance of STNA #239. MHC #600 stated after they separated the two Residents, he observed AL #215 continue to agitate Resident #115 by tapping Resident #115's arm and stating to Resident #115, go get her. MHC #600 observed AL #215 begin to play fight with Resident #115 which appeared to agitate Resident #115 even more. MHC #600 reported Resident #115 turned and hit Resident #100 until MHC #600 separated Resident #115 from Resident #100. Interview with Regional Clinical Director (RCD) (#503) on 10/19/23 at 12:44 P.M., indicated she came into the facility for the morning meeting on 09/25/23 and while she was reviewing progress notes, she discovered the incident between Resident #115 and Resident #108 on 09/22/23. While reviewing the incident between #115 and #108, she learned of the incident involving Resident #115 and Resident #100 on 09/22/23. RCD #503 indicated the former Administrator opened two different SRIs (239557 and 239560) on 09/25/23 as the facility investigated the allegations. RCD #503 verified the two separate resident-to-resident physical abuse allegations were not timely reported to the state agency because the administration at the facility was not aware of the incidents until 09/25/23. Interview with STNA #239 on 10/26/23 at 9:19 A.M., revealed she approached the dining room when she observed Resident #115 hit Resident #108. STNA #239 stated it happened so fast that it was hard to tell what exactly happened. STNA #239 indicated she heard AL #215 say to Resident #115, go get her. STNA #239 stated Resident #115 then hit Resident #100. Interview with MHC #600 on 10/26/23 at 10:49 A.M., revealed he was standing in the hallway when he observed an altercation between Resident #115 and Resident #108. MHC #600 stated he was able to get the two residents separated and when he was trying to calm the two residents down, he observed AL #215 continue to agitate Resident #115 by encouraging her to get her (meaning Resident #108) and AL #215 was poking Resident #115's shoulder. MHC #600 stated AL #215 continued to agitate Resident #115, when Resident then hit Resident #100. MHC #600 stated he wrote a statement about his observations and gave it to the Human Resource Manager. MHC #600 stated he also spoke with the Regional Operations Manager (ROM) #505 regarding this incident. Interview with RN #188 on 10/26/23 at 4:31 P.M. indicated he was the nurse working on 09/22/23 and did not see any of the incident between Residents #115 and #108 or the incident between Residents #115 and #100. RN #188 stated he was told Resident #115 grabbed Resident #108 as she was walking in the dining room and Resident #108 reacted to the this and Resident #115 had scratches down both sides of her face. RN #188 stated he was told AL #215 encouraged Resident #115 to go get her meaning go after Resident #108. RN #188 stated Resident #115 was agitated and hit Resident #100. RN #188 indicated Resident #100 had no injuries. Review of the undated facility policy titled, Ohio Abuse, Neglect, & Misappropriation, stated the it is the intent of the facility to ensure the facility would prevent abuse, mistreatment, or neglect of residents. The policy revealed any allegation of abuse must be reported immediately to the Executive Director and to the state agency. The facility would take measures to protect residents from harm by immediately initiating an investigation. In the event a situation is identified as abuse, an investigation by the executive leadership will immediately begin. An employee who is alleged or accused of being a party to abuse will immediately be interviewed by the staff nurse, escorted off the premises by another staff member, interviewed by facility leadership for a written statement and not left alone. Documentation of the facts and findings will be completed in each resident medical record. This deficiency represents non-compliance investigated under Complaint number OH00146998.

Based on record review, observation, staff interview, review of the facility policy, and review of the guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to thoroughly assess the resident's skin, failed to timely identify a resident's pressure ulcer until it reached an advanced stage, and failed to ensure pressure ulcer prevention interventions were in place. This resulted in Actual Harm to Resident #110 who was at risk for pressure ulcers and the facility found Resident #110's pressure ulcer as an unstageable pressure ulcer (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar) to his left hip and did not assess the wound upon identification of the wound. This affected one (Resident #110) of three residents reviewed for pressure ulcers. The facility identified two residents with pressure ulcers. The facility census was 110. Findings include: Review of the medical record for Resident #110 revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, chronic obstructive pulmonary disease (COPD), encephalopathy, and acute and chronic respiratory failure with hypoxia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #110 was cognitively intact and required extensive assistance of one staff with activities of daily living (ADLs.) Review of the pressure ulcer risk assessment dated [DATE] revealed Resident #110 was at high risk for the development of pressure ulcers. Review of the care plan, last updated 03/22/23, revealed Resident #110 had impaired skin integrity and was at risk for further altered skin integrity and poor healing ability due to immobility, history of cerebrovascular accident with left hemiplegia, weakness, cardiac illness, and seizure disorder. Resident had a stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed.) to his left hip. Interventions included the following: to administer treatments as ordered by medical provider, apply barrier creams post incontinent episodes, complete skin at risk assessment upon admission/readmission, quarterly, and as needed, complete weekly skin checks, educate the resident/resident representative on need for turning and repositioning, evaluate wound daily, low air loss mattress, and provide heel protectors when in bed as resident will tolerate. Review of the weekly skin check for Resident #110 dated 10/26/22 revealed the resident had no new skin issues. There were no further weekly skin checks documented from 10/27/22 to 12/11/22. Review of the nurse progress note for Resident #110 dated 12/11/22 revealed Licensed Practical Nurse (LPN) #340 documented Resident #110 had a new open area noted to the left hip and a treatment order was put in place. There was no assessment of the new open area to the left hip to include measurements and a description of the wound until 12/20/22. Review of the physician orders for Resident #110 dated 12/11/22 revealed an order to cleanse the wound to the left hip with normal saline (NS), pat dry, apply Medihoney to wound then cover with gauze and an AND pad once daily. On 12/17/22, there was an order to encourage Resident #110 to wear heel protectors when in bed, as tolerated by the resident. Review of the wound nurse practitioner (NP) evaluation for Resident #110 dated 12/20/22 revealed the pressure ulcer to the resident's left hip measured 3.84 centimeters (cm) in length by 3.84 cm in width. The wound bed was covered with 100% slough/eschar and was classified by the wound NP as an unstageable pressure ulcer. Treatment was initiated for the resident's left hip pressure ulcer. Other recommendations included the following: low air loss mattress, frequent turning, repositioning, and offloading, heel protection, and pressure reduction to bony prominences. Review of the wound NP evaluation for Resident #110 dated 03/28/23 per the facility wound care nurse, revealed the wound to the resident's left hip measured 4.26 cm in length by 3.10 cm in width with undermining of 3.5 cm. Wound was noted to be an in-house acquired pressure ulcer and now presented as a stage IV pressure ulcer with exposed muscle, exposed tendon, and exposed bone. Observation on 03/29/23 at 12:53 P.M. of Resident #110 revealed the resident was resting on a low air loss mattress. Resident's heels were resting directly on the mattress and were not floating. Interview on 03/29/23 at 12:53 P.M. with State tested Nursing Assistant (STNA) #555 confirmed Resident #110 had a bandage on his left heel and his feet were resting directly on the mattress. STNA #555 stated she was unsure if Resident #110 had orders for heel protectors since he was on a special mattress. Observation and interview on 03/29/23 at 3:55 P.M. with LPN #615 revealed Resident #110 was resting on a low air loss mattress. There was a dressing in place to the resident's left heel which was dated 03/29/23. LPN #615 confirmed Resident #110 had a pressure ulcer to his left hip. LPN #615 stated she wasn't sure if the resident had a physician's order for heel protectors, but she would place one on his left foot since he had an ulcer on that foot. #615 confirmed Resident #110's heels were resting directly on the mattress and were not floating. After the interview with LPN #615, she placed a heel protector boot on resident's left foot which he tolerated well. Observation of wound care for Resident #110 on 03/30/23 at 7:48 A.M. with LPN #800 and the Director of Nursing (DON) revealed the resident had a baseball sized pressure ulcer to his left hip with undermining and exposed muscle. LPN #800 cleansed the wound with normal saline and applied gauze soaked with Hydrogel to pack the wound and covered the wound with a clean dry dressing. After wound treatment was completed, the DON applied bilateral heel protector boots to the resident's feet which the resident tolerated well. Interview on 03/30/23 at 8:02 A.M. with the DON confirmed Resident #110 had a physician's order to wear heel protectors to both feet while in bed. The subsequent interview on 03/30/23 at 12:42 P.M. with the DON confirmed the residents should have weekly skin checks which should be recorded in the resident's electronic medical record. The DON confirmed Resident #110 had a skin check completed on 10/26/22 which indicated there were no new skin issues. The DON confirmed there were no skin checks recorded for Resident #110 from 10/27/22 through 12/11/22. The DON confirmed LPN #340 identified Resident #110 had an open area on 12/11/22 and she obtained a treatment order. The DON confirmed the facility did not assess the wound nor did the record include a description of the wound until the wound NP evaluated the wound on 12/20/22 and classified it as an unstageable pressure ulcer. The DON confirmed she was not in her role at the time Resident #110's wound developed so she was unsure why the resident was not evaluated by the wound NP until 12/20/22. Interview on 03/30/23 at 2:45 P.M. with LPN #340 confirmed she noticed Resident #110 had an area to his left hip which looked like a scabbed area and was brownish in color and was about two inches wide in diameter. LPN #340 confirmed she did not attempt to classify the wound and did not document a description of the wound but she did leave a note for the DON so they could arrange for the wound NP to take a look at the area because she thought it might be a pressure ulcer. Review of the facility policy titled Skin Care and Wound Management Overview, dated 05/30/19, revealed each resident should be evaluated weekly for changes in skin condition. Pressure ulcer documentation should be included in the medical record for all pressure ulcers. The facility would implement prevention strategies to decrease the potential for developing pressure ulcers and/or to promote the healing of existing wounds and would communicate these strategies to the care team. Review of the NPUAP guidelines dated 2014 revealed the facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. Ideally, heels should be free of all pressure, a state sometimes called floating heels. Pressure can be relieved by elevating the lower leg and calf from the mattress by placing a pillow under the lower legs, or by using a heel suspension device that floats the heel. Consequently, the pressure will instead spread to the lower legs, and the heels will no longer be subjected to pressure. This deficiency represents non-compliance investigated under Complaint Number OH00141073.

Based on record review, observation, resident interview, staff interview, and review of the facility policy the facility failed to ensure residents were provided with a dignified dining experience. This affected two (Residents #81 and #102) of three residents reviewed for dining. The facility census was 110. Findings include: Review of the medical record for Resident #102 revealed an admitted [DATE] with a diagnoses including Alzheimer's disease and dementia with behavior disturbance. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #102 was cognitively impaired and required supervision and set up assistance with eating. Review of the medical record for Resident #81 revealed an admitted [DATE] with a diagnoses including eating disorder, cardiac arrhythmia, and dementia without behavioral disturbance. Review of the MDS assessment dated [DATE] revealed Resident #81 was cognitively impaired and was independent with eating with set up help only required. Observations on 03/29/23 from 12:57 P.M. to 1:25 P.M. revealed lunch trays were delivered to the dining room at 12:57 P.M. Residents #81, #96, and #102 were seated at a table together. At 1:00 P.M., Resident #96 received her tray and began feeding herself. At 1:15 P.M., Resident #81 stated she was upset because Resident #96 was almost done eating and she hadn't even been offered something to drink yet. At 1:17 P.M., State tested Nursing Assistant (STNA) #715 brought a tray to Resident #81, and she began feeding herself. Resident #81 was done consuming her meal at the time Resident #81's tray was delivered and she left the dining room. STNA #715 then brought a tray to Resident #102 and began to feed Resident #102 from a standing position. Resident #102 started to get out of her chair and STNA redirected her to sit down and gave Resident #102 verbal cues to eat. STNA #715 was attempting to assist Resident #102 from a standing position for about two minutes. The Director of Nursing (DON) brought a chair to STNA #715 and encouraged STNA #715 to feed Resident #102 from a seated eye to eye position. Resident #102 then consumed the food and did not attempt to get up from the table. Interview on 03/29/23 at 1:23 P.M. with the DON confirmed all residents at a table should be served at the same time when possible for a more dignified dining experience. The DON confirmed meal trays were delivered to the floor at 12:57 P.M., and trays for Residents #81, #96, and #102 were all available on the cart at that time and could have been served together. The DON also confirmed it was considered a dignity issue to stand over a resident to feed them. Review of the facility policy titled Routine Resident Care, dated 01/19/22, revealed the facility staff would provide assistance with eating and maintaining adequate fluid and nutritional intake. This deficiency represents non-compliance investigated under Complaint Number OH00141401.

Based on record review, staff interview, and review of the facility policy, the facility failed to ensure the resident's care plans reflected the care and presence of implantable cardiac devices. This affected one (Resident #1) of three residents reviewed for cardiac devices. The facility census was 110 residents. Findings include: Review of the medical record for Resident #1 revealed a readmitted [DATE] with diagnoses including chronic obstructive pulmonary disease, hypertensive heart disease, atrial fibrillation, atherosclerotic heart disease, and presence of pacemaker. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact. Resident #1 died in the facility on [DATE]. Review of the cardiology visit note dated [DATE] revealed Resident #1 came to the office for a device check of her implantable cardioverter defibrillator (ICD) which was found to be in place and functioning properly. Review of the [DATE] monthly physician orders revealed Resident #1 had an appointment on [DATE] with the cardiologist for a device check. Review of the written statement by the Director of Nursing (DON) dated [DATE] (one day after Resident #1 passed away) revealed the DON called the cardiologist's office to find out if Resident #1's ICD did or did not have any external monitor which needed to be maintained by the facility. The statement confirmed the cardiologist's office was able to monitor the ICD remotely. Review of the care plan for Resident #1 revealed it did not include information regarding care or presence of an ICD. Interview on [DATE] at 12:42 P.M. with the DON confirmed Resident #1 had an ICD which was able to be monitored remotely by the cardiologist. The DON confirmed she called the cardiologist's office on [DATE] following Resident #1's death on [DATE] to obtain clarification on how the device worked as resident's representative had questioned if the device was in place and functioning at the time of the resident's death. Review of the facility's policy titled Plan of Care Overview, dated [DATE], revealed the facility would develop a care plan in coordination with the resident and/or resident's representative which was the written treatment provided for a resident that was resident-focused and provided for optimal personalized care. This deficiency represents non-compliance investigated under Complaint Number OH00141494. This deficiency is an example of continued non-compliance from the survey dated [DATE].

Based on observations, medical record review, staff interviews, review of a police report, review of guardianship documents, review of the facilities investigation, review of the facilities self-reported incidents (SRIs) and policy review, the facility failed to provide adequate supervision to prevent the elopement of Resident #48 who had severely impaired cognition, was at risk for elopement and resided on a secured memory care unit. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death on [DATE] when Resident #48 eloped from the facility without staff knowledge. The lack of adequate supervision and timely response to interventions resulted in Resident #48 leaving the secured memory unit through a coded and alarmed door and then exited the facility through a window in an uninhabited solarium area in the front of the building. Resident #48 was found by facility staff 30 minutes later approximately 0.25 miles (,d+[DATE] mille) away in a highly trafficked shopping center and across a busy four lane road which had a 25 Miles Per Hour (MPH) posted speed limit. This affected one (Resident #48) of three residents assessed at risk for elopement in the facility. The facility census was 113. On [DATE] at 3:44 P.M., the Administrator was notified Immediate Jeopardy began on [DATE] at 1:35 P.M., when Resident #48 was not provided with adequate supervision and eloped from the facility. Resident #48 had a history of dementia, was cognitively impaired and at risk for elopement. Resident #48 was found at 1:40 P.M by facility staff approximately 0.25 miles away from the facility in a highly trafficked shopping center and across a busy four lane road. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 2:30 P.M., a headcount was completed on all units to ensure each resident was accounted for and equaling 110 residents. This was completed by the on-duty nursing team, and they reported the headcount back to the Director of Nursing (DON) for verification. On [DATE] at 4:00 P.M., the codes (on the keypads) to all three exits off the memory care unit were changed by Regional Maintenance Supervisor #114. The codes were working appropriately prior to and after the codes were changed. On [DATE] at 5:00 P.M., Maintenance Staff #76 completed an audit to validate all windows, window screens and doors were secured and functioning appropriately. Only one window in the Solarium needed to be fixed to not open, and all others were appropriately secured. On [DATE], a head-to-toe skin assessment, a pain assessment, a Braden scale assessment (risk for developing pressure injury), Brief Interview for Mental Status (BIMs) assessment, a wandering assessment, and neurological checks were initiated on Resident #48 without concern. Resident #48 ate pizza in the Administrator's office. Resident #48 was placed on one-on-one (1:1) supervision until he was sent to the psychiatric hospital for an inpatient psychiatric stay. On [DATE], privacy code boxes (to cover the keypads) were purchased with an estimated arrival date of [DATE]. On [DATE], the Administrator was educated by Regional Director of Clinical Operations #115 on elopement risk, elopement behavior and proactive preventative measures and what to do when an elopement occurs using the elopement prevention and elopement management policy. [DATE] at 6:17 P.M, education was completed by the Administrator with all facility staff and current agency staff regarding elopement risk, elopement behavior and proactive preventative measures and what to do when an elopement occurs using the elopement prevention and elopement management policy. On [DATE] at 7:16 P.M., the DON and Licensed Practical Nurse (LPN) Unit Manager #113 completed the wander/elopement assessments on all residents. No new residents were identified as elopement risks. Wandering care plans were audited and updated by DON and LPN Unit Manager #113. Any resident identified at risk had their plan of care updated with interventions individualized to prevent elopement up to and including 1:1 or increased supervision and each resident's information has been added to the facility elopement binder by LPN Unit Manager #113. This was completed on [DATE] at 8:00 A.M. On [DATE] at 8:30 P.M., the Administrator completed an elopement Drill. The drill was completed flawlessly. On [DATE], to monitor ongoing compliance, elopement drills will be completed by the Administrator every shift once a week times four weeks, then every shift every two weeks times four weeks then every shift once a month times one month. On [DATE], to monitor compliance, Maintenance Staff #76 will complete an audit to validate all windows, window screens and doors are secure and functioning appropriately three times a week times four weeks, then three times a week every two weeks times four weeks then three times a week for one week for one month. On [DATE], to monitor ongoing compliance, the resident's progress notes will be reviewed by the DON or designee daily for three weeks for exit seeking behaviors. On [DATE], surveyor completed review of the medical records for residents (#51, #58 and #72), identified as elopement risks and revealed no concerns related to actual elopement from the facility, elopement risk assessments were current and accurate, and care plans were initiated and updated with appropriate interventions to prevent elopement. On [DATE] between 9:00 A.M. and 3:00 P.M., LPNs #87, #111, and #105 and State tested Nursing Assistants (STNAs) #85, #86, and #112 verified they were educated on resident elopement and wandering as well as responding to resident alarms. All staff members interviewed were knowledgeable of the content of each education provided by the facility. On [DATE], the DON or designee will report to the Ad Hoc Quality Assurance and Performance Improvement (QAPI) committee the findings related to compliance audits and the QAPI committee will determine when compliance is achieved or if ongoing monitoring is required. Although the Immediate Jeopardy was removed, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of medical record for Resident #48 revealed an admitted [DATE] with diagnoses including dementia, chronic viral Hepatitis-C, opioid dependence, other symbolic dysfunctions, hypertension, alcohol dependence in remission, personal history of Coronavirus (COVID-19), and other symptoms and signs involving cognitive functions and awareness. Review of the guardianship order dated [DATE] for Resident #48, revealed the resident was incompetent due to mental disability and therefore was incapable of taking proper care of himself and his property and guardianship was necessary. A guardian of the person was appointed. Review of the wandering or elopement assessments from [DATE] to [DATE] for Resident #48, revealed the resident had no wandering assessments completed. Review of the progress note dated [DATE] for Resident #48, revealed the resident was admitted to the facility from another skilled nursing facility. Review of the admission initial evaluation dated [DATE] and locked on [DATE] for Resident #48, revealed the resident was placed on a secured unit due to him having a diagnosis of dementia. Review of the elopement risk care plan dated [DATE] for Resident #48, revealed the resident was at risk for elopement related to dementia and cognitive loss. Interventions included 1:1, assess for hunger, thirst, ambulation and toileting needs, complete wandering evaluation upon admission, readmission, quarterly and as needed, evaluate for the need of a secured unit, notify medical provider as needed, notify medical provider and resident representative of behavior changes, notify staff of elopement risk, obtain a current photograph and list of identifiable characteristics and place in the elopement risk identification book and provide diversionary activities as needed. Review of the secured unit care plan dated [DATE] for Resident #48, revealed the resident required a secured unit for behaviors, elopement risk and poor cognition. Interventions included evaluate the need for a secured unit, obtain medical provider order to include diagnosis and exhibited behaviors which require the need, obtain consent from the resident or resident's representative, notify the medical provider and the resident's representative of behavior changes, provide diversionary activities as needed, and redirect when appropriate. Review of the progress note dated [DATE] for Resident #48, revealed the resident left the facility without supervision and was brought back into the facility. No injuries were noted, and Resident #48 denied pain at that time. Review of the progress note dated [DATE] for Resident #48, revealed the nurse spoke with the guardian regarding the occurrence. Review of the physician's order dated [DATE] and discontinued [DATE] for Resident #48, revealed the resident required 1:1 supervision every shift for supervision and monitoring. Review of the wandering observation tool dated [DATE] for Resident #48, revealed the resident was at risk for elopement or unsafe wandering. Review of the facility's elopement report dated [DATE], revealed Resident #48 went missing on [DATE] at 1:35 P.M. Resident #48 was last seen in his room at 1:10 P.M. by staff. Resident #48 was found on [DATE] at 1:40 P.M. in the parking lot across the street. The physician, Administrator, DON, resident's representative, and police were notified. Resident #48 left the facility without supervision and was brought back to the facility. No injuries were noted, and Resident #48 denied pain at that time. Resident #48 stated he did not want to be here. Review of the police report dated [DATE], revealed the police received a phone call from the Administrator about a missing person at 1:57 P.M. Further review of the police report revealed Resident #48 was missing from the memory care unit. The facility had an unknown clothing description or time frame. The Administrator called back and reported Resident #48 was located across the street in the ACE hardware parking lot and all was okay. Review of the facility's SRIs revealed there was no SRIs related to Resident #48's elopement on [DATE]. Review of STNA #51's witness statement dated [DATE], revealed they noticed Resident #58 gone when he did not eat his meal and they looked around for him. Review of LPN #105's witness statement dated [DATE], revealed prior to lunch Resident #48 was asking LPN #105 if she had any medication for him but she informed him that he got all his prescribed medications that morning, so she did not have anything else for him. During lunch the STNAs were passing trays and that is when they noticed he was not in his room or in the dining room. They proceeded to check all rooms, bathrooms, and closets in each room with no success, so LPN #105 contacted the DON. Management and other staff helped look all over the building and outside until the resident was located safely. Review of the facility's elopement tool dated [DATE], revealed Resident #48 eloped off the memory care unit and was last seen about 1:00 P.M. to 1:10 P.M. on [DATE] when Resident #48 was asking the nursing staff about his medications. Resident #48 was wearing a hoodie, jeans, and gold jewelry. It was 58 degrees Fahrenheit outside. The tool indicated the STNA went to take Resident #48 his lunch tray about 1:35 P.M. and noticed Resident #48 was not in his room. The door did not alarm but was functioning. Resident #48 was placed on 1:1 upon return and resident was ordered to go to the psychiatric hospital. Resident #48's guardian was notified, and the police were contacted but were not needed. Review of the facility's elopement in-service dated [DATE], revealed six STNAs and two LPNs were educated on elopements. LPN #105 that worked on Resident #48's unit at the time of the elopement was not educated. Review of the progress note dated [DATE] for Resident #48, revealed the resident was sent out to the psychiatric hospital related to behaviors. Review of the progress note dated [DATE] for Resident #48, revealed the resident returned to the facility from the psychiatric hospital. Review of the physician's order dated [DATE] for Resident #48, revealed the resident was ordered to be admitted to a secured unit. Review of the readmission Minimum Data Set (MDS) assessment for Resident #48 dated [DATE], revealed Resident #48 was severely cognitively impaired, and Resident #48 was independent with bed mobility and toileting. Resident #48 required supervision with transfers, dressing, eating and personal hygiene and did not have any noted wandering. Observation of Resident #48 on [DATE] at 8:27 A.M. revealed the resident to be walking around his room without assistance. Interview with Resident #48 on [DATE] at 8:27 A.M. revealed Resident #48 denied ever leaving the facility without supervision. Interview with the DON and the Administrator on [DATE] at 10:23 A.M., revealed the DON was notified Resident #48 eloped from the facility on [DATE]. The DON reported she was notified that Resident #48 could not be found around lunch time. The facility was searched, and she and Therapy Manager #107 went to search for Resident #48 outside the facility. The DON stated they found Resident #48 near the shopping center across the road from the facility. The DON reported Resident #48 was placed on 1:1 upon returning to the facility until Resident #48 was sent to the psychiatric hospital. The Administrator stated all the codes in the facility were changed after the incident and one privacy box was added to a key pad but privacy boxes were not placed on all secured door key pads. Telephone interview with STNA #54 on [DATE] at 10:30 A.M., revealed STNA #54 was working on the memory care unit on [DATE]. STNA #54 stated she noticed Resident #48 was not on the unit during lunch and they searched all the rooms and closets on the unit. STNA #54 stated they notified the front desk and the DON. STNA #54 reported other departments assisted with looking around the facility and outside of the facility. STNA #54 stated Resident #48 was found across the street at the grocery store and Resident #48 was missing from the facility approximately 45 minutes from the time staff noticed Resident #48 missing to the time he was found. STNA #54 reported she was not sure how Resident #48 got out of the facility. Interview with Maintenance Staff #76 on [DATE] at 1:20 P.M. revealed the window in the solarium on the closed unit was pulled open and the screen was pushed out on [DATE] indicating Resident #48 had gone out the window. Maintenance Staff #76 stated the solarium was outside of Resident #48's secured memory care unit and he was not sure how Resident #48 got off the unit. Maintenance Staff #76 stated all windows were nailed closed after the incident. Interview with the Administrator on [DATE] at 2:05 P.M. revealed the facility did not complete elopement risk assessments on all residents after Resident #48 eloped from the facility on [DATE]. Telephone interview with Local Law Enforcement #106 on [DATE] at 8:56 A.M., revealed the police were contacted on [DATE] due to Resident #48 being missing from the facility. Resident #48 was found across the street at the hardware store prior to police arrival. Telephone interview on [DATE] at 10:06 A.M. with LPN #105 revealed LPN #105 was working at the facility on [DATE]. LPN #105 stated Resident #48 was at the nurse's station right before lunch asking about his medications. LPN #105 reported staff were passing trays approximately 15 to 20 minutes later when they noticed Resident #48 was missing. The staff on the unit looked up and down the hallway and notified the DON. LPN #105 stated staff searched inside and outside the building and Resident #48 was found across the street in the grocery store parking lot. LPN #105 reported it was 30 to 45 minutes between the time staff noticed Resident #48 missing to when Resident #48 was found. LPN #105 stated the DON had told her that Resident #48 could not have a wander guard because he had cut the last one off at his prior facility. LPN #105 reported she was not sure how the resident got out of the facility. Interview with Therapy Manager #107 on [DATE] at 12:44 P.M., revealed she was notified that Resident #48 was missing on [DATE] and she and another staff member went out in her car to search for Resident #48. Therapy Manager #107 stated she saw Resident #48 across the street by the shopping center when she turned the corner out of the parking lot. Therapy Manager #107 stated she did not know what time it was when she found Resident #48 but stated it was shortly after lunch. Telephone interview with Physician #300 on [DATE] at 4:52 P.M., revealed Resident #48 was cognitively impaired and had a guardian. Physician #300 verified Resident #48 was appropriate and should remain on a secured unit due to cognition. Review of an undated secured unit consent revealed Resident #48's guardian verbally consented for Resident #48 to reside on a secured unit. Review of the undated STNA #53's witness statement revealed STNA #53 noticed that Resident #48 was missing when STNA #53 did not see him on the unit, and he did not eat his tray for lunch. Resident #48 was previously at the nurse's station asking about his medicine. STNA #53 did a sweep and advised the nurse about this, and they did another sweep and called the receptionist and advised to her call the DON. The nurse took over from there. During the sweep in the solarium the window was off set to the side and the screen was out. Review of the undated STNA #50's witness statement revealed STNA #50 did not see Resident #48 walk off the unit, and she last checked a little before lunch and Resident #48 was in his room looking for his chain he wears around his neck. Review of the undated facility policy titled Elopement Management revealed an elopement is defined as when a resident leaves the premises or a safe area without authorization or the necessary supervision. The facility is to immediately initiate procedures to locate any resident or patient that is unaccounted for. Notification of appropriate parties will comply with state and federal regulations. Following the location of the involved resident, the facility leadership will review prevention systems to identify performance opportunities. Failure to provide adequate supervision for cognitively impaired residents who leave the facility or safe areas and are unaccounted for is considered an elopement. Review of a facility policy titled Abuse, Neglect and Misappropriation dated [DATE], revealed alleged violations of neglect, exploitation, misappropriation of resident property or mistreatment that do not result in serious bodily injury must be reported no later than 24 hours. The self-report will be made to the state survey agency if appropriate. This deficiency represents non-compliance investigated under Complaint Number OH00140721.

Based on medical record review, observations, staff interview, review of hospital records, and review of the United States (US) Food and Drug Administration (FDA) for Benadryl (antihistamine/allergies), the facility failed to ensure residents received the necessary behavioral health care and services to maintain the highest practicable physical, mental, and psychosocial well-being. This resulted in Actual Harm when Resident #02 obtained over the counter (OTC) Benadryl on numerous occasions, the resident had an intentional overdose on the Benadryl and the resident was subsequently transferred to the hospital on 12/14/22 and admitted for psychiatric services. This affected one (Resident #02) of three residents reviewed for behavioral health services. The facility census was 111. Findings include: Review of medical record for Resident #02, revealed the resident was admitted on [DATE] with diagnoses including, but not limited to, paranoid schizophrenia, mood disorder, subglottic stenosis, intestinal obstruction, umbilical hernia, tracheostomy status, and dysphagia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #02 had no cognitive deficits, required supervision and limited assistance with activities of daily living (ADLs). Review of the care plan dated 11/03/22, revealed Resident #02 had a behavior problem related to recent placement of a tracheostomy, schizophrenia, mood disorder, insomnia, convulsions, and related to being newly admitted . Resident #02 was known to be physically aggressive with staff, cheek medications, crawl on the floor, pour liquids on floor, remove tracheostomy cannula, and refuse to let staff replace it, throw objects, refuse assistance, and rearrange furniture and place dresser drawers on the floor. The care plan did not address any indication resident was to be monitored for behaviors of substance abuse and/or hoarding medications. The care plan was updated on 12/15/22, after surveyor verified the current care plan indicated resident would hide and consume Benadryl without orders. Review of a health status note from the previous facility dated 10/23/22, revealed Resident #02 was discovered with Benadryl in her room. Notes indicated most of the Benadryl packages were empty. Notes indicated the packages were removed from the resident's room and Resident #02 was educated on the importance of not taking medication that the nurses did not provide to her. Review of social services notes dated 11/14/22, revealed the facility spoke to the resident's guardian. Notes indicated the Guardian reported Resident #02 had a history of assaulting staff when she was not taking her medication and reported resident cheeked her medications and threw them away. Notes indicated social services would inform the administrative staff about resident's behavior. Review of a nursing note dated 11/15/22, revealed Resident #02 had been placing herself on the floor and crawling around, spilling soda and water all over the floor, rearranging the bed, removing dresser drawers out of the dresser, and placing them on the floor. Notes indicated Resident #02 needed some food heated up and staff discovered a bottle of Benadryl in her food from LaRosas Pizza that resident requested to be heated up. Notes indicated it was unknown if Resident #02 ingested any Benadryl and resident denied taking any. Notes indicated the nurse and State Test Nurse's Aide (STNA) straightened up the room, cleaned the floor, and instructed Resident #02 to get back in bed and lie down. Review of the nursing note dated 11/16/22 at 1:02 P.M., revealed Resident #02 removed her tracheostomy cannula. Notes indicated the nurse inserted a new sterile tracheostomy cannula and applied new collar. Notes indicated the nurse observed two open bottles of Benadryl in Resident #02's room and removed and discarded both bottles. Notes indicated Resident #02 was noted with an unsteady gait and continued to ambulate. The nurse educated Resident #02 with regards to behaviors observed this shift. Review of the nursing note dated 11/16/22 at 6:25 P.M. revealed that Resident #02 had been removing her tracheostomy cannula throughout the day, without successful redirection. It was noted that Resident #02 was crawling/rolling around on the floor and would not ambulate like she normally would. Notes indicated upon resident assessment, several empty and half full bottles of Benadryl were discovered in Resident #02's room, and some pills appeared to be chewed up and spit up. Resident #02 also threw all her belongings around her room and dumped liquid all over the floor. Notes indicated when staff tried to reinsert Resident #02's tracheostomy, the resident became aggressive and started to be combative and throwing items at the doorway when staff tried to enter her room. Notes indicated Resident #02's mother/guardian stated this type of behavior was typical for Resident #02 when she ingested Benadryl. Notes indicated the guardian was unaware of how resident had Benadryl in her possession. Notes indicated the previous shift nurse had removed two bottles of Benadryl and there were five more bottles discovered and removed. Nurse contacted the on-call physician and received an order to send Resident #02 out via 911 to nearest hospital for evaluation. Review of hospital records dated 11/17/22 for admission on 11/16/22, revealed Resident #02 was admitted to inpatient for altered mental status (AMS) and increased agitation. Review of a nursing note dated 11/19/22, revealed Resident #02 had a change in mental status with decreased muscle strength and poor coordination. Resident #02 was alert and oriented but was slow to respond to commands. Vital signs were blood pressure 110/70 (normal), pulse 114 (elevated) (normal 60-100), respirations were 22 (elevated) (normal 12-20) with labored breathing, temperature was 98 degrees Fahrenheit (normal), and oxygen saturation was 94 percent (decreased) (normal 96-100) percent on room air. Notes indicated Resident #02 lost her balance and fell on the floor while seated in her wheelchair. The on-call physician was notified and gave orders to send Resident #02 to the emergency room (ER) for an evaluation and treatment. Notes indicated there was a large amount of Benadryl discovered in Resident #02's room and Resident #02 was unable to voice if any Benadryl had been consumed. Resident #02 was transported to hospital. Review of Physician's Assistant (PA) convergence consultation note dated 11/19/22 revealed there was a notification from nursing staff that Resident #02 was unable to walk, had poor coordination, was slow to respond to commands, had mild tremors, and during the call, resident fell out of her wheelchair which was not Resident #02's normal baseline behavior. Notes indicated Resident #02 had a psychiatric history with multiple psychiatric medications. Notes indicated the staff found a large quantity of presumed Benadryl and multiple unknown medications in Resident #02's room and it was unclear what resident actually took, and resident was unable to verbalize at this point. Notes indicated Resident #02 was ordered to be sent to the hospital due to unknown ingestion of substances. Review of hospital records for date of service on 11/19/22, revealed Resident #02 presented to the ER with tachycardia. Hospital notes indicated the facility was concerned that Resident #02 may have ingested Benadryl. Review of the nursing note dated 11/22/22, revealed Resident #02 was noted to be agitated and pulled her tracheostomy cannula out twice. Notes indicated the nurse was able to replace cannula both times without incident. Resident #02 continued with non-sensical behaviors and placing herself on the floor. Notes indicated staff assisted Resident #02 into bed and noted a Benadryl pill in the bed. Notes indicated Resident #02 had been noted with Benadryl previously. Staff asked Resident #02 if they could look for more Benadryl and Resident #02 agreed. Notes indicated staff found two open bottles and several 12-count blister packs of Benadryl. Based on packaging and bottles, there should have been 126 Benadryl's but only 73 Benadryl's were accounted for. Staff asked Resident #02 if she consumed the Benadryl and Resident #02 affirmed, she had taken the Benadryl. Notes indicated Resident #02 was transferred to ER via 911. Review of the hospital records for date of service on 11/22/22, revealed Resident #02 presented to the ER for concerns of suicidal ideation and overdose on Benadryl. Resident #02 was treated and released back to the facility. Review of social services note dated 11/23/22, revealed guardian of Resident #02 was present with resident's father on campus. Guardian self-reported she wanted Resident #02 to remain on a locked unit for resident's care and safety. Notes indicated the guardian reported she was very concerned about her daughter and wanted the best for her. Review of an alert note dated 11/28/22, revealed Resident #02 was seen in the hallway rocking back and forth with labored breathing. Notes indicated Resident #02 had a history of Benadryl abuse. Notes indicated the nurse went into Resident #02's room and found nine empty blister packs (12 count each for a total of 108) in her pillowcase. Notes indicated nurse continued to search Resident #02's room and found three bottles and five more blister packs. The on-call physician was notified and gave orders to send Resident #02 to the ER via 911. Review of PA's convergence progress note dated 11/28/22, revealed Resident #02 was seen sitting on the floor and the nurse reported that they found about 108 pills of Benadryl missing from the medication bubble wraps with the current problem being Benadryl overdose. Resident #02 appeared to have had a Benadryl overdose causing a paradoxical reaction (When a medication has an effect that's the opposite of what's expected). Review of the hospital records for date of service on 11/28/22, revealed Resident #02 presented to the ER for concerns that she ingested 20 to 30 Benadryl due to empty pill containers found in Resident #02's bed. Resident #02 was treated and released back to the facility. Review of the nursing noted dated 12/04/22 at 2:25 P.M., revealed Resident #02 got off the unit without staff assistance. Resident #02 was seen by staff outside of the facility, on the main street and staff assisted resident back to her room. Notes indicated the psychiatric physician was notified and gave an order to put Resident #02 on one-on-one (1:1) care until he could evaluate the resident. Notes indicated Resident #02 was educated multiple times that she needed to be assisted when she went outside. Review of a nursing note dated 12/04/22 at 5:34 P.M., revealed Resident #02 was found with multiple packages of Benadryl in her room. The nurse suspected Resident #02 of taking some of the medications and found three empty packs. Notes indicated the physician was notified and gave orders to hold evening medications and monitor. Review of the initial psychiatric evaluation dated 12/05/22, revealed Resident #02 had a long history of mental illness and had a history of substance abuse and currently abusing Benadryl. The plan indicated Resident #02 would benefit from a more secure behavioral unit nursing home. Review of the nursing note dated 12/14/22, revealed Resident #02 was observed in her room by the interim Director of Nursing (DON) with a bottle of Benadryl. Notes indicated when the resident was asked to give the bottle to staff, Resident #02 refused and hid the bottle on her person. Notes indicated Resident #02 refused to allow the DON to assess her. Notes indicated the DON called the psychiatric physician, and an order was given to send Resident #02 to the ER. Review of hospital records for date of service on 12/14/22, revealed Resident #02 was admitted for possible intentional overdose of Benadryl with approximately half of the bottle. Resident #02 denied overdosing on Benadryl, however, Benadryl pills were found in her sock. Resident #02 was placed on a 72-hour hold with security at bedside. Resident #02's belongings were searched, and the resident had numerous Benadryl pills in a sock that security destroyed. Review of the nursing note dated 12/15/22 recorded as late entry, revealed Resident #02 was admitted to the hospital on 72-hour hold (psychiatric hold). An interview on 12/15/22 at 11:35 A.M. with the interim DON reported that Resident #02 was her own person, did not have a guardian and did not want to be on a secured unit. When the facility was asked if they performed any room sweeps, the DON reported the resident was her own person, and she could refuse. An observation on 12/15/22 at 12:15 P.M. of Resident #02's room with the interim DON, revealed open and empty capsules of Benadryl all over the room in various places. An additional observation in the medication supply room immediately afterwards with the interim DON, revealed blister packs of Benadryl with 12 tablets to each sheet on the shelf. At the time of the observations, the interim DON verified that the Benadryl was confiscated from Resident #02's room. An interview on 12/15/22 at approximately 4:30 P.M. with the interim DON reported that the hospital had admitted Resident #02 on 12/14/22 for 72-hour psych hold due to ingestion of Benadryl, history of admissions, and an attempt to cut her wrist. The interim DON stated that the bottles recently found in the resident's room were different sizes. The DON stated she thought Resident #02 was opening the capsules and possibly snorting them, however, denied knowledge of how Resident #02 was getting Benadryl into the facility. When the DON was asked if facility had investigated to find out how Resident #02 was getting Benadryl, she indicated she had no answers to provide. A telephone interview on 12/20/22 at 10:51 A.M. with the Physician/Medical Director (MD) #510 reported that Resident #02 was well known to her from previous facilities. MD #510 reported resident had had a long history of mental illness, Benadryl abuse and the facility should have known her history prior to her being admitted and resident needed to be on a secured unit for her own safety. Review of a nursing note dated 12/20/22 at 10:00 P.M., revealed resident was readmitted to the facility. Review of a behavior note dated 12/21/22, revealed Resident #02 asked the 1:1 staff member if she could accompany resident outside to get some air. Resident #02 went to the first floor accompanied by staff. Notes indicated Resident #02 walked to the dollar store and stole two sodas and a bottle of Benadryl. Notes indicated when Resident #02 returned to the facility all stolen items were confiscated and given to the officer that came to the facility due to the incident. Resident #02 was in her room being closely monitored. Review of the Social Services note dated 12/21/22 at 10:46 A.M., revealed writer was informed of an incident with resident going to the local store. Notes indicated resident was in the hallway crying, visibly upset and resident indicated her anxiety was high. Notes indicated a 1:1 staff was present. A telephone interview on 12/28/22 at 9:40 A.M. with Resident #02's Guardian #500, reported the facility was informed about Resident #02's Benadryl ingestion behaviors, which was the main reason why the resident was initially transferred to the facility so the resident could be housed on a secured unit. Resident #02's guardian reported when she went to visit, she questioned the social worker as to why Resident #02 was not on the secured unit, which was the main purpose of the resident's transfer, and the social worker noted resident was not appropriate for the locked unit. During a telephone interview on 12/29/22 at 2:16 P.M. with Regional Director of Operations (RDO) #325, when questioned how Resident #02 got to the store, RDO #325 replied that staff was not allowed to leave facility grounds to go with her and could not stop her because she was her own person. Review of the online resource tool from the Probate Court of [NAME] County, Ohio (https://www.probatect.org/court-records) revealed Resident #02's mother had been her legal guardian since 03/14/18 with an indefinite status for resident history of schizophrenia. Review of the U.S. Food and Drug Administration (FDA) information revealed they released a warning in 09/2020 regarding the dangers of taking more than the recommended doses for the over-the-counter Benadryl allergy medication. The toxicities associated with Benadryl are dose dependent. Common signs and symptoms of overdose include confusion, urinary retention, tachycardia, blurry vision, dry mouth, irritability, and hallucinations. With ingestions greater than one gram of Benadryl may result in delirium, psychosis, seizures, coma, and death. Review of undated facility policy titled Admission Evaluation revealed the facility would provide resident centered care that met the psychosocial, physical, and emotional needs and concerns of the resident. A systematic evaluation was completed by a licensed nurse upon admission/readmission to assist in determining the most effective and appropriate care needs of each resident to the facility.

Based on observations, medical record review, review of the visiting wound service center notes, interview with the wound care physician and wound consultant nurse, staff interviews, review of the National Pressure Ulcer Advisory Panel (NPUAP) pressure ulcer staging guide, and review of facility policy, the facility failed to complete comprehensive skin assessments, implement pressure reducing interventions, notify the physician of the development of pressure ulcers, initiate or consistently provide physician ordered treatments and failed to utilize proper infection control practices to prevent the development of avoidable pressure ulcers and/or promote the healing of existing pressure ulcers for four (#94, #104 #23 and #46) of four residents reviewed for pressure ulcers. This resulted in Immediate Jeopardy for three (#94, #104 and #23) of four residents reviewed who suffered serious harm as follows: (1) Resident #94 acquired an avoidable unstageable pressure ulcer to the left heel with 100 per cent (%) eschar without evidence of a timely assessment and pressure reducing interventions implemented. Furthermore, Resident #94 developed an avoidable Stage 3 pressure ulcer to the right heel which subsequently deteriorated as a result of the facility's failure to follow physician orders [REDACTED].#104 acquired an avoidable unstageable pressure ulcer to the left Achilles as a result of the facility's failure to implement pressure reducing interventions and complete timely assessments when the resident was initially identified with a Stage 1 pressure ulcer to the left heel; and (3) Resident #23 developed an unstageable pressure ulcer to the resident's left upper buttocks as a result of the facility's failure to notify the physician, obtain orders and implement pressure reducing interventions. Additionally, one (#46) of four residents was placed at risk for more than minimal harm that is not Immediate Jeopardy for failure to implement physician orders [REDACTED]. On 11/17/16 at 12:17 P.M., the Director of Nursing (DON) was notified that Immediate Jeopardy began on 10/15/16 when Resident #94 was identified with a pressure ulcer to the left heel. On 10/19/16 the wound specialist staged the pressure ulcer as an unstageable pressure ulcer with 100 % eschar (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar). Furthermore, on 10/26/16, Resident #94 developed an avoidable Stage 3 pressure ulcer (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) to the right heel with 100 % granulation which subsequently deteriorated as a result of the facility's failure to follow physician orders [REDACTED]. The Immediate Jeopardy continued on 11/12/16 when Resident #104 developed a Stage 1 pressure ulcer to her left heel and the facility failed to implement physician ordered interventions which resulted in the deterioration of the resident's wound. On 11/16/16 Resident #104 was noted with an unstageable pressure ulcer to her left Achilles. The Immediate Jeopardy continued on 11/14/16 when Resident #23 developed an unstageable pressure ulcer to her left upper buttocks and the facility failed to notify the physician and obtain orders. The Immediate Jeopardy was removed on 11/18/16 when the facility implemented the following corrective actions: · On 11/17/16 at 2:00 P.M., the DON, Registered Nurses (RN) #97 and #9 and Licensed Practical Nurses (LPN) #5, #24, #11 and #9 initiated head to toe skin sweeps on all current in house residents. The skin sweeps were completed on 11/17/16 at 10:00 P.M. No other residents were identified with any new pressure ulcers. · On 11/17/16, the facility implemented the following four new policies and procedures: (1) Skin Risk Protocol; (2) Skin Care Policy; (3) Skin Assessment/Condition Protocol; and (4) Possible Skin Care Interventions Tool for Care Planning. Prior to the implementation of the four new policies, the facility only had a written policy for the Braden Scale assessment tool (utilized for predicting pressure ulcer risk). The new policies and procedures addressed specific items to assess for skin breakdown such as skin color, temperature and turgor, red, discolored or darkening skin areas, blisters, dry or rough skin, breaks or sores on the skin, drainage or exudate, swelling and scabs. The new policies and procedures indicate any skin abnormalities are to be reported to the nurse and physician immediately and a list of possible interventions per the level of risk are included. · On 11/17/16 at 2:00 P.M, the DON and LPN #47 provided in-service education to all licensed nurses and State tested Nursing Assistants (STNAs) on the new policies and procedures. Education was completed on 11/18/16 at 9:00 A.M. · Effective 11/18/16, the DON will assign skin sweeps for five residents to the floor nurses to complete weekly. The DON will review the skin sweeps and compare them to the plan of care and treatment orders. The DON will complete the random audits of the skin sweeps on the five residents each week for four weeks, then monthly for three months. The results will be reviewed with the Quality Assurance (QA) committee. Although the Immediate Jeopardy was removed on 11/18/16, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing weekly audits to monitor for on-going compliance. Findings include: 1) Review of Resident #94's medical record revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the last Braden Scale tool dated 04/04/16 revealed the resident was at high risk for skin breakdown. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was severely impaired. The resident was dependent on two staff for bed mobility, transfer and toilet use. She was dependent on one staff for dressing and required supervision with setup help only for eating. Resident #94 was dependent on one staff for bathing. The MDS documented Resident #94 was always incontinent of bowel and bladder function. Review of the plan of care for potential impairment to skin integrity revealed interventions which included avoid scratching and keep hands and body parts from excessive moisture. Identify/document potential causative factors and eliminate/resolve where possible. Keep skin clean and dry. Use lotion on dry skin and obtain blood work such as complete blood count with differential, blood cultures and culture and sensitivity of any open wounds as ordered by the physician. Review of the weekly skin reviews revealed they were not completed weekly. They were completed on 08/30/16, 09/20/16, and on 10/11/16. Review of the weekly skin review dated 10/11/16 documented no skin issues noted on the feet (between toes, toenails, and heels). Review of the nursing notes dated 10/15/16 at 8:45 A.M. documented an STNA (not identified) notified the writer of resident complaints of discomfort to the left heel. Yellow/brownish drainage was noted to the resident's sock and to the pillowcase. The left heel felt mushy to touch, tender to touch, and no discoloration was noted to the left heel. The area was cleansed with normal saline and covered with a dry dressing. Instructed staff to leave the resident's gym shoe off this shift and to elevate feet in bed at all times. The physician was faxed about the resident's left heel treatment, awaiting response. The oncoming nurse was made aware of the resident's left heel, voiced understanding and will continue to monitor the resident. Review of the skin/wound note dated 10/15/16 at 8:57 A.M. documented wound location to the left heel. There was moderate amount, yellow/brownish drainage and there was no discoloration in the skin. Resident #94 had mild pain she rated as a two on a scale of one to 10. The area was covered with a dry dressing and wrapped with [MEDICATION NAME]. Currently awaiting response from the physician. There was no further description of the wound. Review of the skin/wound note dated 10/15/16 at 10:21 A.M. revealed a physician order [REDACTED]. Apply No Sting Barrier Film to the surrounding skin. Cover with foam dressing and change twice a day until resolved. The [DIAGNOSES REDACTED]. Review of Wound Physician (WP) #304's note dated 10/19/16 (not timed) revealed the pressure ulcer to the left heel was unstageable with 100% eschar. The wound measured two centimeters (cm) by six cm by zero cm. The treatment was to apply [MEDICATION NAME] to wound bed, cover with dry dressing every day and as needed (PRN). Review of WP #304's note dated 10/26/16 (not timed) revealed the pressure ulcer remained unstageable with 100% eschar. The wound now measured four cm by six cm by zero cm. There was also a Stage 3 pressure ulcer documented to the right heel with 100% granulation. The wound measured one centimeter by 0.5 cm by 0.1 cm. The treatment was Collagen gel to wound bed and cover with dry clean dressing daily and PRN. Review of the skin/wound documentation dated 10/26/16 at 8:08 P.M. indicated to use [MEDICATION NAME] until collagen arrives. Review of WP #304's note dated 11/02/16 (not timed) documented Resident #94's left heel should be treated with [MEDICATION NAME] and a dry clean dressing. The wound measured three cm by six cm by 0.1 cm. The right heel ulcer measured 0.8 cm by 0.8 cm by zero cm. The tissue type was 100% granulation. Treatment was changed to skin prep daily. Review of WP #304's note dated 11/09/16 documented the resident refused treatment. Review of the wound notes for 11/09/16 documented the resident refused to be seen by the wound physician. Will continue with current treatment and wound physician will attempt to see next week. There was no documentation the facility attempted to assess the wounds since the resident refused to be seen by the wound physician. On 11/15/16 at 10:31 A.M., observation of Resident #94 revealed she was lying in bed with her heels in direct contact with the mattress. At the time of the observation, LPN #5 was interviewed and verified the resident's heels were lying directly on the mattress. LPN #5 verified Resident #94 had pressure ulcers on both of her heels. On 11/15/16 at 5:40 P.M. an observation was made with LPN #5 who verified the resident's heels were resting directly on the surface of the mattress. There was a pillow under the resident's knees. LPN #5 repositioned the pillow to offload the resident's heels from the mattress. Review of WP #304's note dated 11/16/16 (not timed) documented the pressure ulcer to the left heel was unstageable. The tissue was 4% slough and 96% eschar. The wound measured 2.4 cm by 5.6 cm by zero cm. The treatment continued with [MEDICATION NAME] gel. The right heel was documented as unstageable and measured 0.9 cm by 0.4 cm. The treatment was unchanged. On 11/16/16 at 1:10 P.M., an observation was made of WP #304 assessing the pressure ulcers of Resident #94 as RN #97 completed the treatment to both heels. RN #97 washed her hands, donned gloves and sat on the floor to perform the treatment. RN #97 completed the treatment to the left heel first. She removed the old dressing which was dated 11/16/16 from the left heel. The dressing had a scant amount of serous drainage on the gauze. RN #97 measured the pressure ulcer on the left heel and assessed the resident's toe nails. She did not change her gloves or wash her hands. RN #97 applied [MEDICATION NAME] to a gauze, placed the gauze on the pressure ulcer and wrapped the foot with gauze. RN #97 remained seated on the floor. She did not change her gloves or wash her hands. She proceeded to complete the treatment to the right heel. She cleansed the resident's right heel with normal saline, applied [MEDICATION NAME] to the right heel and wrapped the foot with gauze. On 11/17/16 at 11:22 A.M., observation of Resident #94 revealed the resident had a pillow under her heels. Her heels were noted in direct contact with the pillow that was under her heels. At the time of the observation, LPN #11 was interviewed and verified the resident's heels were resting directly on the pillow. The nurse repositioned the pillow under the resident's lower extremities to offload her heels. 2) Review of Resident #104's medical record revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS assessment documented she did not have any pressure ulcers but was at risk for pressure ulcers. Review of the Braden Scale dated 06/20/16 documented she was at risk for pressure ulcers. Review of the quarterly MDS assessment dated [DATE] documented she was severely impaired for daily decision making skills. She did not reject care or have behaviors. She required extensive staff assistance of one or two with activities of daily living except she was independent with eating. She did not have any pressure ulcers or other skin issues but was at risk for pressure ulcers. Review of a nurse's note dated 11/12/16 at 6:30 A.M. documented the resident had a cornified area to the left outer heel and the skin was intact. There were no measurements of the area. The note documented a new physician order [REDACTED]. On 11/14/16 at 11:50 A.M., an observation was made of Resident #104 lying in bed with socks on and her bilateral heels were noted directly on the mattress. She did not have heel protectors on. During an interview at 12:03 P.M., STNA #34 verified the resident did not have any heel protectors on. STNA #34 stated she was not sure if the resident was supposed to wear heel protectors. During an interview on 11/15/16 at 10:25 A.M., LPN #14 indicated Resident #104 had a Stage 1 pressure ulcer to her left heel. During the interview the medical record was reviewed with LPN #14 who verified there was no description or measurements of the pressure ulcer. Review of a nurse's note dated 11/15/16 at 11:27 A.M. documented waiting on heel boots. On 11/15/16 at approximately 11:30 A.M., an observation was made of Resident #104 lying in bed with socks on. Both of her heels were lying directly on the mattress. On 11/16/16 at 2:35 P.M., an observation was made of Resident #104's left heel with LPN #14. During the observation the resident was noted with two pressure areas. At the time of the observation, WP #304 described the left heel pressure ulcer as a 2 cm by 1.9 cm deep tissue injury with intact skin. He described the left Achilles pressure ulcer as a 1 cm by 0.4 cm unstageable ulcer with 100% eschar. Wound consultant LPN #305 stated it was concerning the facility had a couple of residents that were found with unstageable pressure ulcers. LPN #14 stated he was unaware Resident #104 had two pressure ulcers. LPN #14 stated the resident did not have heel protectors. He verified an order was received on 11/15/16 to either float her heels or use heel protectors. He verified at the time of the wound observation the resident did not have heel protectors on and her heels were not being floated. On 11/17/16 at 11:53 A.M., an observation with STNA #60 was made of Resident #104. The resident was lying in bed with her bilateral heels directly on the mattress. There was a pillow on the bed and one on the floor. STNA #60 verified the resident's heels were not being floated. On 11/17/16 at 1:30 P.M., an observation with LPN #5 was made of Resident #104. The resident was lying in bed with her bilateral heels on top of a pillow. LPN #5 verified the resident did not have heel protectors on and her heels were not being floated. She stated she would provide education to the STNA. 3) Review of Resident #23's medical record revealed she was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the admission assessment dated [DATE] documented she had a left heel pressure ulcer. It did not contain measurements, description or stage of the pressure ulcer. Review of the admission MDS assessment dated [DATE] documented she had one unstageable suspected deep tissue injury to the right heel that was present on admission. It documented she was at risk for pressure ulcers. The medical record did not contain any additional documentation of the ulcer including weekly skin grids until 08/17/16. Review of the pressure ulcer care plan dated 08/10/16 documented an unstageable right heel ulcer with interventions to keep affected area clean and dry, treatment as ordered, turn and reposition no less than every two hours and as needed, and a wound consult as needed. Review of a physician order [REDACTED]. During an interview on 11/14/16 at 11:55 A.M., LPN #45 indicated Resident #23 had an unstageable pressure ulcer to her right heel. Review of a nurse's note dated 11/14/16 at 5:53 P.M. documented the resident had an open area on her left upper buttock that measured 1.5 cm by 2 cm. There was no measurement of the depth, description or stage of the wound. It was documented the area was cleansed with normal saline and a dry dressing was put in place. Further documentation revealed the on- coming nurse would notify the family of the area and any treatments put into place. There was no documentation the physician was notified or that a treatment order was received. Review of the physician orders [REDACTED]. Review of the resident's Treatment Administration Record (TAR) revealed no treatment was being performed to the area on the left upper buttock. On 11/16/16 at 8:55 A.M., an observation with LPN #23 was made of Resident #23. The resident had bilateral heel boots in place and her right heel was wrapped with gauze but the physician ordered ABD pad was not in place. LPN #23 verified the ABD pad was not in place but could not explain why it wasn't there. During an interview on 11/16/16 at 10:22 A.M., the DON stated she could not find wound documentation for the right heel from admission (07/26/16) through 08/17/16. During an observation on 11/16/16 at 1:38 P.M. with WP #304, wound consultant LPN #305 and RN #97 of Resident # 23's right heel revealed an undated ABD pad was in place to the right heel. It was not secured with a gauze wrap. RN #97 stated per the physician orders [REDACTED]. WP #304 described the right heel ulcer measurements as 5 cm by 3.9 cm, 100 % eschar, and unstageable. At 1:50 P.M., WP #304 left Resident #23's room after completing his assessment of the pressure ulcer. Both RN #97 and wound consultant LPN #305 denied the resident had any other open areas or pressure ulcers. At this time, staff was advised of documentation in the medical record of an open area on the resident's left upper buttock. Observation of the resident's left upper buttock revealed an open area with no dressing in place. RN #97 stated the wound should have had a treatment and dressing in place. WP #304 was called back into the room and stated the ulcer on the resident ' s left upper buttock was unstageable and measured 1.3 cm by 1.2 cm with 100% slough. 4) Review of Resident #46's medical record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #46 has received Hospice services since 10/10/15 for end stage dementia. Review of an MDS assessment dated on 10/02/16 documented the resident had a Stage 3 pressure ulcer which was not present on admission. Review of progress notes and a wound assessment dated [DATE] documented a new Stage 2 pressure ulcer on the coccyx. At the time of the wound development, Resident #46's plan of care included pressure prevention measures including pressure reduction mattress and pressure reduction cushion to chair, multipodus boots to heels, assisting with turning and repositioning and keeping skin dry and clean. Nutritional supplements were in place and weekly skin checks were documented. A treatment order was obtained and the wound was monitored. However, when the pressure ulcer was first observed by the wound nurse practitioner on 10/13/15, it was staged as a Stage 3 pressure ulcer with measurements of 1 cm x 0.5 cm x 0.3 cm. A low air loss mattress was added on 10/28/15. On 07/27/16, the outside wound care consultant service company changed and during the initial assessment of Resident #46, the coccyx wound was staged as a Stage 4 with measurements of 1.5 cm x 1 cm x 0.5 cm. Further medical record review revealed Resident #46 was seen weekly in-house by the outside wound consultant. The wound consultant documented the weekly evaluations and made adjustments to the treatments. On 10/26/16 the pressure ulcer to the coccyx was down staged to a Stage 3 pressure ulcer by a consulting wound physician. The wound measurements were 1 cm x 0.5 cm x 0.3 cm. There was no documentation any surgical intervention of the wound had occurred. Review of the current plan of care and physician orders [REDACTED]. During an observation on 11/14/16 at 2:27 P.M. of Resident #46, the resident was lying in bed, without socks or heel protectors. Both heels were lying directly on the low air loss mattress. During an observation on 11/16/16 at 2:54 P.M. of Resident #46, the resident ' s heels were in contact with the low air loss mattress and no heel boots were in place. No heel boots were observed in the room. An observation with WP #304 and LPN #14 on 11/16/16 at 2:59 P.M. revealed Resident #46 was lying on her back. LPN #14 repositioned the resident on her side and pulled the clean, dry attends back. No dressing was observed on the resident's coccyx wound. LPN #14 reported the dressing was soiled and was removed by staff shortly prior to the observation. The wound to the coccyx measured 1 cm x 0.4 cm x 0.3 cm with undermining at 9 - 12 o'clock at 0.6 cm. The wound showed 100% granulation tissue. Upon observation of the wound, WP #304 exited the room. LPN #14 exited the resident's room and was standing near the treatment cart. WP #304 instructed LPN #14 to change the current treatment order from a dry dressing, to clean with normal saline, pat dry and apply [MEDICATION NAME] and a clean, dry dressing. While WP #304 was speaking to LPN #14, he was observed pulling several pieces of 4 x 4 and 2 x 2 gauze from bulk packages with bare ungloved hands. LPN #14 searched through the treatment cart, opened drawers and touched multiple surfaces with ungloved hands while holding the gauze. Once the supplies were obtained, LPN #14 obtained a clean towel and entered Resident #46's room to provide wound care. During an observation on 11/16/16 at 3:11 P.M., LPN #14 provided wound care to Resident #46. LPN #14 laid the clean towel on Resident #46's bed and placed the 4 x 4 and 2 x 2 gauze he was holding in his bare hands on the towel. LPN #14 prepared to use the gauze for wound care. The surveyor intervened and asked if he intended to use the gauze after he handled multiple, possibly contaminated surfaces and touched the gauze with his ungloved hands. LPN #14 indicated the treatment cart was cleaned at the start and end of each shift and the wound care was a clean procedure. However, the nurse did set the dressings aside and stated he would use different gauze. LPN #14 washed his hands, applied clean gloves, but then pulled the garbage can towards him with one hand. When asked about this, LPN #14 reported it was alright because he used the discarded gauze to act as a buffer between the glove and the garbage can. LPN #14 cleansed the wound with normal saline, patted dry, removed his gloves, washed his hands, applied clean gloves, applied [MEDICATION NAME], a clean dry dressing, taped the dressing in place and dated the dressing. Immediately after the treatment, LPN #14 was interviewed and verified when LPN #14 initially entered the room Resident #46 did not have heel boots in place and her heels were in contact with the bed. LPN #14 stated he did not think the resident needed the heel boots while she was in bed since she had a low air loss mattress. LPN #14 stated he believed she still had the heel protectors, but after a brief search, could not locate them. During an observation with LPN #5 on 11/17/16 at 1:30 P.M., Resident #46 was observed lying in bed without heel protectors on; her heels were not floated and were in direct contact with the mattress. LPN #5 verified the resident's heels should be floated. LPN #5 searched Resident #46's room and could not locate the resident's ordered heel protectors. Review of the NPUAP revealed an unstageable pressure ulcer is defined as full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar and a Stage 3 pressure ulcer is defined as 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. Review of the only policy the facility had in place titled Braden Assessment and dated 07/2016 revealed assessments are to be completed upon admission and quarterly thereafter and are to be completed on a PRN basis for a change in resident's status. Interventions are to be put in place for residents who are at high risk for skin breakdown based on the Braden Assessment. Interventions include but are not limited to: Floating heels, skin prep and every 2 hour turns.

Based on medical record review, observation and staff interviews, the facility failed to prevent the development of a contracture for one (#94) of two resident reviewed for contractures. This resulted in harm for Resident #94 who was not provided interventions to prevent or maintain a contracture from becoming worse. The facility identified five residents with contractures. The resident census was 66. Findings include: Medical record review revealed Resident #94 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #94 was noted with a severe cognitive impairment and was not interviewable. Review of the latest comprehensive assessment dated [DATE] revealed Resident #94 was dependent on two persons for bed mobility, transfer and toilet use. She was dependent on one staff for dressing and required the extensive assistance of one staff for personal hygiene and she was dependent on one staff for bathing. The assessment further revealed Resident #94 had no range of motion impairment for upper or lower bilateral extremities. Review Resident #94's plan of care for a contracture dated 04/15/16 revealed the resident had an alteration in musculoskeletal status related to contracture of left hand/forearm, as well as [DIAGNOSES REDACTED]. There was no intervention of range of motion exercises for the resident. Review of Occupational Therapy Plan of Care dated 08/11/16 revealed Resident #94 had a contracture of the left hand. The motor control, and fine motor control of the left upper extremity was severely impaired. Review of the monthly summary dated 08/29/16 revealed Resident #94 had fair muscle tone. There was no documentation of a contracture of her left upper extremity in the summary. Review of physician progress notes [REDACTED].#94 had left hand swelling, and was contracted. And xray was noted to be negative for fracture. The progress note further revealed the contracture was a chronic problem, an OT (Occupational Therapy) consult was requested. The progress note revealed Resident #94 may benefit from a splint, muscle relaxant and possible [MEDICATION NAME] injection, will continue to monitor. Review of physician order [REDACTED]. Review of OT's progress and discharge summary dated 10/17/16 revealed the long term goal was for Resident #94 to appropriately have a left hand splint orthotic to her left upper extremity and to monitor skin condition for effective contracture prevention and skin integrity. Review of the Restorative Care Program dated 10/18/16 revealed not to start the restorative care program until the splint was received. The goals for restorative were to tolerate the splint for up to eight hours to maintain range of motion. Family interview on 11/15/16 at 10:06 A.M. stated something was wrong with Resident #94's arm about a month ago. Observation on 11/15/16 at 10:31 A.M. revealed Licensed Practical Nurse (LPN) #5 repositioned Resident #94 in bed. Resident #94 was observed with a contracture of her left hand without any splint or brace. LPN #5 stated not too long ago Resident #94 could use both hands. She was not sure if the resident was receiving any treatments for her contracture. Interview with the Program Director (PD) #202 on 11/17/16 at 9:23 A.M. revealed all residents were screened and re-evaluated. The OT evaluated Resident #94 and submitted the recommendations to her insurance. She stated the claim was denied as it was not her primary insurance. She stated the facility needed to order the splint and submit it through her secondary insurance. The splint was just received two days ago. PD #202 wrote a restorative plan and was going to start doing restorative. She stated Restorative Staff was always getting pulled to the floor. PD #202 stated she would have expected the facility to notify them of a residents' contracture. She stated therapy found the contracture when they screened all the residents. Therapy wanted the left upper extremity to be in a neutral hand position. PD #202 further stated no treatment was provided by therapy to Resident #94 since August 2016. PD #202 stated she was unaware there was a physician order [REDACTED].#94's left upper extremity since 08/11/16.

Based on observation, record review, staff interview and review of the facility's self reported incident (SRI) and abuse policy the facility failed to ensure a resident was free from physical abuse. This affected one resident (#101) of three residents reviewed for abuse. This resulted in harm to Resident #101 who was pushed by Resident #17 and suffered a fractured distal radius bone. The census was 131. Findings include: 1. Review of Resident #101's medical record revealed an admission date of [DATE] and pertinent [DIAGNOSES REDACTED]. Review of the Minimum Data Set Assessment ((MDS) dated [DATE] documented Resident #101 required supervision for bed mobility and transfer. MDS dated [DATE] documented Resident #101 had a decline and required limited assistance of staff for bed mobility and transfer. Review of the behavior tool dated 11/27/15 documented Resident #101 with a history of behaviors of wandering and exit seeking. Acute behaviors included anxiety, restlessness and wandering with exit seeking behaviors. Interventions included redirection and walking around the unit. Review of the behavior tool dated 12/04/15 documented a history of sleep disturbance with acute behaviors of anxiety, restlessness, wandering with exit seeking behavior. Interventions included redirection, a snack or television. Review of the nursing notes dated 11/29/15 at 10:40 P.M. documented the writer heard a sound that sounded like someone had fallen. The nurse ran to the dining room and found Resident #101 on the floor in a supine position. His legs were spread apart and he was holding his left arm against his [MEDICATION NAME]. Resident #101 was moaning and stated his arm hurt. The resident was lying between the television and the first table facing the television in the dining room. Resident #101 said he was standing by the television when Resident #17 came up and pushed him onto the floor. Resident #101 was alert, oriented to name and place and vitals were assessed: blood pressure was 135/71, pulse was 67 beats per minute and respirations were 20 per minute. His range of motion was within normal limits for all extremities with the exception of his left arm. Resident #101 was crying out with attempts to move left arm. He was given Tylenol 325 milligrams (mg) for pain per the physician PRN (as needed) order. A call was made to the physician and a new order was given for an x-ray of the left forearm. Resident #101's family was notified. Review of the nursing notes dated 11/30/15 at 6:33 A.M. documented the x-ray results were positive with an acute appearing left forearm fracture. The physician was called and requested Resident #101 be sent to the hospital. The squad arrived at 7:00 A.M. and the resident was transferred to the hospital related to the fracture of his left forearm. Review of the nursing notes dated 11/30/15 at 9:00 A.M. documented Resident #101 returned from the hospital with a splint on his left forearm from below the elbow to his wrist. Per the hospital, the splint was to remain in place continuously until his follow up appointment with an Orthopedist. On 01/11/16 at 9:20 A.M. Resident #101 was observed ambulating in the hallway with a cast on his left arm. On 01/11/15 at 2:33 P.M. an interview with Nurse Aide #20 (NA#20) was conducted. NA #20 said Resident #101 still fed himself and changed his clothes 15 times a day. She said the fracture had slowed him down but his life had not changed. She said he was still able to button and unbutton his pants. On 01/11/15 at 2:35 P.M. an interview was conducted with Resident #101. When asked if his arm hurt he replied yes. When asked if he knew how he hurt his arm he replied yes. Resident #101 was unable to verbalize his thoughts. 2. Review of Resident #17's medical record revealed an admission date of [DATE] and pertinent [DIAGNOSES REDACTED]., depression, [MEDICAL CONDITION] and [MEDICAL CONDITION]. Review of Resident #17's care plan revised on 05/17/15 indicated resident with actual behavior of physical aggression, struck another resident with a history of harm to others, striking other residents and behavior of threatening others. Another care plan revised on 08/24/15 documented the resident experienced fluctuation in mood and behavior and had episodes of physical aggression directed towards others. Interventions included to observe resident for signs or symptoms of increased agitation, identify triggers and intervene to remove triggers to avoid escalation. Review of the annual MDS dated [DATE] documented Resident #17 had a moderate cognitive impairment, no short or long term memory impairments, no [MEDICAL CONDITION], disorganized thinking, altered level of consciousness or psychomotor [MEDICAL CONDITION]. There was no evidence of an acute change in mental status. Resident #17 felt depressed two to six days of the assessment period. He did not demonstrate hallucinations or delusions. Physical behavior directed toward others was not demonstrated, no verbal behavioral symptoms directed towards other or other behavioral symptoms not directed towards others. He demonstrated rejection of care over one to three days of the assessment period, and the resident did not have a wandering behavior. Review of the behavior tool for Resident #17 dated 11/24/15 documented he had a history of [REDACTED]. Television was identified as an intervention for the resident. Review of the nursing notes dated 11/29/15 at 10:40 P.M. documented Resident #17 was sitting in a chair at the back of the dining room. The resident said Resident #101 turned the television off even though he told him not to do it. Resident #101 was standing by the television and Resident #17 pushed him on the floor. The physician and guardian were notified. Review of the SRI's for Resident #17 revealed he had altercations with other residents on 10/13/13, 01/29/14, 06/23/14, 08/04/14, 09/17/14, 04/01/15, 04/25/15, 08/21/15, and 11/29/15. Review of an in-service dated 11/30/15 documented Licensed Practical Nurse (LPN) #12 instructed unit staff when Resident #17 spoke in a louder voice to other residents, it was an indicator of increased agitation. Staff were educated if Resident #17 was displaying this behavior they were to personally assess and de-escalate the situation Review of the nursing notes dated 12/01/15 at 11:35 A.M. documented Resident #17 was seen by the Psychiatrist. No new [DIAGNOSES REDACTED].#17 was calm on exam, but mood no longer stable. The Psychiatrist documented there was no evidence of [MEDICAL CONDITION] but dangerousness was high, especially with history of prior violence, too. The Psychiatrist increased Resident #17's [MEDICATION NAME] (mood stabilizer) to 500 mg for one week then increased to 750 mg at bedtime. Review of the behavior tool for Resident #17 dated 12/08/15 documented disruptive behavior, socially inappropriate behavior and assaultive as a history of behaviors. Snacks and television were identified as interventions to address these behaviors. On 01/11/16 at 9:20 A.M. Resident #17 was observed sitting at the dining room table playing cards with another resident. Resident #17 had a calm demeanor as he played cards. At 10:37 A.M. he continued to play cards with another resident. At 10:45 A.M. the other resident left the dining room and Resident #17 was observed sitting in a wheelchair. At 10:47 A.M. an activity aide asked him if he wanted to join in with two other residents who were playing cards. Resident #17 was agreeable and joined in the card game. At 10:52 A.M. Resident #17 lost the card game and was observed to remain calm towards the other residents. At 11:09 A.M. he continued playing cards. On 01/11/15 at 2:26 P.M. an interview was conducted with Resident #17, he said everything was fine. When asked if he had felt anxious or agitated the resident said he felt fine. Resident #17 denied having any problems with other residents. He stated he had a fight three or four months ago. Resident #17 stated a resident was not listening to him when he told the other resident to leave the television alone. Resident #17 stated he pushed the resident and he hurt the other resident's arm. The resident stated he stayed to himself and did not pay other residents any attention. On 12/10/15 at 2:30 P.M. an interview was conducted with LPN #11. LPN#11 stated she did periodic walk throughs and tried to keep the residents out in the common area. She said Resident #17 was usually quiet, able to make his needs known and independent with activities of daily living. She indicated the resident typically was quiet and did not cause any problems. She felt Resident #17 was pleasant and appropriate for the unit. LPN #11 indicated Resident #101 was quiet and wandered. She said Resident #101 liked to play games and puzzles. She said Resident #101 was quiet and had a history of [REDACTED]. On 12/10/15 at 4:43 P.M. an interview was conducted with LPN #10. She indicated she conducted staff interviews about the occurrence between Resident #101 and Resident #17. She also interviewed two other residents who resided on the unit. The two residents denied witnessing the occurrence and denied being afraid of anyone. She shared documentation that indicated Resident #101 and Resident #17 were on 15 minute checks after the occurrence. LPN#10 stated she felt Resident #17 was appropriate for the unit. However, should his behaviors increase or escalate he would be transferred to the behavior unit. On 12/10/15 at 2:41 P.M. an interview was conducted with NA #20 she indicated Resident #17 could be aggressive but usually he was quiet. If the resident became aggressive he was easy to talk to and able to be redirected. The NA said she felt the resident was appropriate for the unit as he typically did not bother anyone. She did not see the resident as a threat to other residents. On 12/10/15 at 3:02 P.M. an interview was conducted with NA #22 he said he had received inservice on resident behaviors. Resident #17 could run from one end of the spectrum to the other end. He said Resident #17 was quiet until someone invaded his space. He stated he felt Resident #17 was appropriate for the unit. The NA said Resident #101 was always going to the door to leave, he was independent and did not cause any problems. On 01/11/15 at 3:51 P.M. an interview with the Medical Director was conducted. The Medical Director said he was aware of the incident where Resident #101 was pushed and fractured his arm. He said he was going to discuss Resident #17 at the next quarterly Quality Assurance meeting later this month. The Medical Director stated he planned on discussing this issue with the Attending Physician and the Psychiatrist. Review of the SRI tracking number dated 11/30/15 under the category of physical abuse of resident to resident was completed. It was reported Resident #17 pushed Resident #101 to the floor when Resident #101 turned off the television. Resident #101 complained of left arm pain. Staff members on the unit were interviewed and stated this was unwitnessed by them. After being alerted to the incident, the nurse on the unit immediately entered the common area and noted Resident #101 on the floor. The resident complained of left arm pain so the physician was notified and an order for [REDACTED].#17 who was noted at the time to be without signs and symptoms of anger or aggression. Resident #101 was transported to the hospital and the x-ray reports identified a left forearm fracture. The psychiatrist came in to see the residents the following day. He increased Resident #17 mood stabilizer medication ([MEDICATION NAME]) to better manage his behaviors associated with his [DIAGNOSES REDACTED]. A care conference was scheduled with Resident #17's Power of Attorney (POA) to discuss the possibility of transferring Resident #17 to the behavior unit should his behaviors escalate. Both residents had a [DIAGNOSES REDACTED]. The facility conducted a thorough investigation and substantiated the abuse. A review was conducted on the facility's abuse policy that was effective 07/01/13 and revised 11/13. The policy documented it was a violation of State and Federal law for any person, including another resident to abuse a resident. This deficiency substantiated Control Number OH 876.

Based on clinical record review, review of a facility self-reported incident (SRI), observations, interviews with facility staff, residents and physicians, review of the facility's Sexual Risk Protocol and Sexual Activity Scale, and the facility's Resident Abuse policy and procedures, the facility failed to ensure Resident #49 was free from sexual abuse by Resident #17. This resulted in Immediate Jeopardy for one (#49) of three sampled female residents identified with dementia and wandering behaviors on the locked female unit. The facility identified 18 of 21 residents on the locked female unit had behaviors of wandering. The facility identified two (#4 and #17) of 18 residents on the locked male unit had inappropriate sexual behaviors. The facility census was 91. On 09/07/12 at 2:17 P.M., the Administrator, Assistant Director of Nursing (ADON) #40 and ADON #60 were notified Immediate Jeopardy began on 08/13/12 at 3:00 P.M. when Registered Nurse (RN) #99 noticed the door to Resident #17's room was closed and jammed shut with a cane on the inside. RN #99 accessed the resident's room and found Resident #49 lying on Resident #17's bed with her pants and incontinence brief pulled down and Resident #17 fondling Resident #49's private area. The Immediate Jeopardy was removed on 09/07/12 at 3:30 P.M. when Resident #17 was discharged from the facility. 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) until it was corrected on 09/11/12 when the facility implemented the following corrective actions: ? On 08/13/12 at 3:15 P.M., Resident #17 and Resident #49 were placed on every 15 minute checks for 72 hours. ? On 08/14/12, Maintenance Staff #30 inspected and made necessary adjustments to the locked door between the locked male and female units and changed the access code. ? On 08/22/12 and 08/23/12, the Director of Nursing inserviced nursing staff regarding Abuse reporting. ? On 08/31/12, Maintenance Staff #30 again changed the access code to the locked door between the male and female units due to a report that a resident let a staff member through the doors. ? On 09/07/12, one-on-one supervision was provided to Resident #17 until his discharge from the facility. ? On 09/07/12, the Maintenance Department began changing all codes to locked doors in the facility twice a week. ? Beginning 09/07/12 and completed on 09/11/12, the Administrator and ADON's #40 and #60 in-serviced all direct care staff regarding reporting procedures for abuse and facility reporting procedures in the event any resident on a secured unit left the unit unsupervised. ? On 09/11/12, Assistant Director of Nursing #40 completed sexual risk assessments on all residents and re-educated all nurses on the facility's protocol for implementation and use of the sexual risk assessment. ? On 09/10/12 and 09/11/12, interviews with nurses, state tested nurse aides, laundry staff and activity aides verified they were in-serviced and re-educated regarding the facility's abuse policy. ? Random observations on 09/07 through 09/11/12 revealed no evidence of any resident to resident sexual contact. Findings include: Review of the closed clinical record of Resident #17 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The latest quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact. Review of Resident #17's plans of care revealed no care plans related to Resident #17 having the access code to the door between the locked male and female units or his inappropriate sexual behaviors. Review of nurse's notes documented by Licensed Practical Nurse (LPN) #25 on 06/15/12 at 9:16 A.M., revealed Resident #17 asked a female staff member to lay down with him in bed. The notes documented the resident was told they were not permitted to do that and he stated "they do nothing right." Nurses notes documented education was provided about what was appropriate and the resident stated he understood. Nurse's notes by LPN #25 dated 06/22/12 at 8:15 A.M. indicated Resident #17 asked her to sit on his lap when he was in bed. LPN #25 explained to the resident she could not do that and it was inappropriate. The notes indicated education was provided and the resident stated he understood. Nurse's notes by LPN #25 dated 07/20/12 at 8:13 A.M., stated when giving Resident #17 his morning medication, he stated he wanted to have sex and he was a gentleman and nobody had to know. The notes documented LPN #25 explained to the resident it was inappropriate and Resident #17 stated okay and continued to eat his breakfast. Review of the clinical record of Resident #49 revealed she was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of nurse's notes dated 07/25/12 at 7:00 P.M. revealed Resident #49 wandered off the locked female unit and was found on the locked male unit. The notes documented the alarm had sounded with each episode. On 07/26/12 at 7:20 A.M., Resident #49 was documented as exit seeking and had wandered off the unit three times that day. At 8:00 P.M., Resident #49 was documented as exit seeking and wandered onto the locked male unit after continuously pushing on the door. Review of the admission MDS assessment dated [DATE] revealed Resident #49 had short and long term memory problems and was severely impaired for daily decision making. Further review of the MDS revealed the resident had difficulty focusing attention and following what was said on a continuous basis. She was noted to have incoherent conversations, unclear and illogical flow of ideas, to wander on a daily basis and significantly intrude on the privacy of others. Review of Resident #49's plan of care for risk for injury related to wandering, revealed interventions included to monitor and report changes in the resident's behavior, restlessness and pacing. Review of Resident #49's nurse's notes by the DON dated 08/13/12 at 3:25 P.M. revealed it was reported to her Resident #49 had wandered onto the locked male unit. The notes indicated Resident #49 was found in Resident #17's room with her bottom article of clothing down and Resident #17 was making sexual contact with her. A full skin assessment was completed with no abnormalities noted. Review of Resident #17's nurse's notes by the DON dated 08/13/12 at 4:45 P.M., revealed Resident #17 was in his room and had his room door jammed shut with his cane. Resident #17 was making sexual contact with a female resident. Resident #17 was fully dressed. The resident's physician and guardian were notified. A physician's orders [REDACTED]. Review of a facility Self-Reported Incident (SRI) dated 08/13/12, completed by the DON and ADON #40, revealed Resident #49 was off the locked female unit. The SRI noted facility staff went to the locked male unit (adjacent to the locked female unit) and found Resident #17's door jammed shut from the inside with a cane. The staff was able to open the door and found Resident #49 lying on Resident #17's bed with her pants and brief pulled down. Resident #17 was fondling Resident #49's private area. Resident #49 was escorted back to her room and a head to toe assessment was completed with no injury or trauma noted. The facility physician was notified of the incident and Residents #49 and #17 were placed on every 15 minute checks. To prevent future incidents the code to the door between the units was changed by maintenance. No other additional information found in the investigation. Review of Social Service Worker (SSW) #10's progress notes dated 08/14/12 at 6:30 P.M., revealed it was reported to him Resident #17 had jammed his room door shut with his cane and had a female peer (Resident #49) in his room. The notes stated Resident #49's bottom article of clothing was down and Resident #17 was engaged in sexual contact. Review of Resident #49's nurse's notes dated 08/15/12 at 3:03 A.M. revealed Resident #49 had made several attempts to go through the locked door to the male unit. Review of a psychiatric evaluation completed on 08/16/12 revealed the physician received a fax from the facility indicating Resident #17 was involved in a sexual altercation with an incompetent resident. There were also concerns Resident #17 had been continuing to show inappropriate sexual behaviors. He was started on an [MEDICATION NAME]. The evaluation further stated Resident #17 was fully alert and oriented. Review of nurse's notes documented by LPN #19 dated 08/31/12 at 1:42 A.M. revealed Resident #17 sat at the door that leads to the locked female unit and twice opened the door to the unit entering the code into the key pad to allow laundry staff onto the unit. The notes indicated ADON #40 was notified. Progress notes by ADON #40 dated 08/31/12 at 1:05 P.M. revealed Resident #17's niece was notified to discuss moving Resident #17 to a semi-private room, away from the locked door to the female unit, due to him finding out the code (to the locked female unit) and letting other residents through the door. The note stated Resident #17 would be moved that day. Random observations from 09/06/12 through 09/11/12 revealed Resident #49 was on the locked female unit continuously ambulating independently throughout the unit. On 09/11/12 at 11:00 A.M. Resident #49 was observed ambulating down the hallway of the locked female unit towards the locked door leading to the male unit. Resident #49 was observed to look through the window and attempted to push the door open. The resident was re-directed by staff. Attempts to interview Resident #49 were unsuccessful as she only answered with "no" to questions or did not answer at all. During an interview on 09/06/12 at 12:50 P.M., the DON stated the incident on 08/13/12 was the only incident she was aware of where Resident #49 had gotten over to the locked male unit. The DON stated Resident #49's mother had come to visit that day and reported she could not find the resident. She stated the staff began looking in resident rooms and found Resident #49 in Resident #17's room, on his bed, unclothed from the waist down, with Resident #17 touching Resident #49 in her "private area". The DON stated she interviewed the staff witness, RN #99 about the incident however; no documentation of the interview or a written statement was completed. The DON further stated they suspected Resident #17 had gotten the access code to the locked door and let Resident #49 on to the locked male unit. The DON stated that was the only time she was aware Resident #17 obtained the access code. The DON further stated they planned to move Resident #17 further away from the door so he could not obtain the code so easily, however, they had not done so as of yet due to not having access to a phone line in another room for his personal phone. During an interview on 09/07/12 at 3:30 P.M., ADON #40 confirmed Resident #17 had not yet been moved to another room due to not having access to a phone line for his use. Interview with Activities Aide (AA) #75 on 09/07/12 at 10:30 A.M. revealed she once found Resident #49 in Resident #17's room on the locked male unit. AA #75 could not remember the date she observed this. AA #75 stated the door to Resident #17's room was partially opened and Resident #49 was sitting on Resident #17's bed. She stated Resident #17 was observed standing beside the bed and both residents were fully clothed. She stated she went and got state tested nurse aide (STNA) #100 so Resident #49 could be taken back to her unit. AA #75 stated the alarm to the door was not sounding and she was not sure how Resident #49 got over to the locked male unit. AA #75 stated the staff changed the access code to the locked male unit because Resident #17 knew the code. Interview with STNA #100 on 09/07/12 at 12:30 P.M. verified AA #75 told her Resident #49 was in Resident #17's room sitting on his bed. STNA #100 stated she could not remember the date of the incident however, was sure it was in the morning shortly after breakfast because she remembered she was doing her morning checks and changes on residents. STNA #100 stated she took Resident #49 back to the female unit and told the charge nurse where the resident had been found. STNA #100 stated she did not know how Resident #49 got through the locked door to the male unit. Interview with LPN #19 on 09/10/12 at 10:50 A.M., revealed laundry worker (LW) #88 informed her on 08/31/12 Resident #17 was letting him and staff through the locked door by putting in the access code. LPN #19 further stated she had not seen Resident #17 use the code, however, was informed by staff he had obtained the access code and let Resident #49 over to the male unit. Interview with STNA #55 on 09/10/12 at 11:51 A.M. revealed she worked on the locked male and female units. STNA #55 stated on 08/13/12 she was working the locked male unit providing care in a resident's room when RN #99 came over from the locked female unit asking if she had seen Resident #49. STNA #55 stated they started looking and noted Resident #17's door was jammed shut with his cane. She stated she went into the resident room next door and gained access to Resident #17's room through the shared bathroom. STNA #55 stated she observed Resident #49 lying on Resident #17's bed with her shirt pulled up over her breasts. She stated Resident #17 was fully clothed and standing beside the bed. STNA #55 stated the locked door to the unit was not alarming. She stated Resident #17 must have let Resident #49 on the unit or she came through the door behind staff. STNA #55 stated the incident took place shortly after 3:00 P.M. Interview with the facility's consultant social worker (SSW )#10 on 09/10/12 at 1:10 P.M. revealed he interviewed Resident #17 and the resident confirmed the sexual contact with Resident #49 had occurred. SSW #10 stated Resident #17 stated the sexual contact was consensual and he had nothing further to say. SSW #10 further stated he attempted to interview Resident #49, however, was unsuccessful, as the resident only responded with one word answers to a few of the questions. During a telephone interview with RN #99, on 09/10/12 at 2:00 P.M., she stated she was working on the locked female unit on 08/13/12 and could not find Resident #49. She stated she went to the locked male unit to see if Resident #49 had gotten over there. RN #99 stated she found Resident #49 in Resident #17's room lying on his bed with her pants and incontinence brief pulled down. She stated Resident #17 was fully clothed and fondling Resident #49's private area. RN #99 stated she notified ADON #40 and was told to do every 15 minute checks on Resident #49 and to write an incident report. She further stated she left a message with the resident's physician regarding the incident and no new orders were received. An interview with ADON #40 on 09/10/12 at 2:37 P.M. verified Resident #49 had been found on the locked male unit numerous times since her admission to the facility on [DATE]. She stated Resident #49 was very quick and would get through the door behind staff because they were not ensuring the door was closed after they went through it. She further revealed Resident #17 observed staff put in the access code and memorized it. During an interview on 09/10/12 at 3:15 P.M., Resident #17 stated Resident #49 would come into his room numerous times and would take off her clothes. Resident #17 stated several times when he returned to his room from smoking, Resident #49 would be lying on his bed. Resident #17 confirmed he had jammed the door to his room shut with his cane when Resident #49 was lying on his bed. He stated Resident #49 removed her pants and he touched her private area. Resident #17 could not remember the date of the incident. He stated the sexual contact was consensual. When asked if he had any other sexual contact with Resident #49, Resident #17 stated he didn't want to talk about it anymore. Interview with Certified Nurse Practitioner (CNP) #1 on 09/11/12 at 11:30 A.M. revealed she provided care for Resident #17 and had personally seen Resident #17 put the correct access code in to unlock the doors between the locked male and female units many times, as recent as last week. She further stated Resident #17 was cognitively intact and definitely knew what it meant if someone were to ask him to have sex. CNP #1 stated in her professional opinion if Resident #17 were asked to have sex, he would not say no. CNP #1 stated she was informed of the inappropriate sexual contact between Resident #17 and Resident #49 and ordered an [MEDICATION NAME] to try to manage his sexually inappropriate behaviors. She stated she also ordered a psychiatric evaluation. Interview with LW #88 on 09/11/12 at 2:00 P.M. revealed he was trying to access the locked door on the second floor between the locked female and male units, however, he did not know the access code. He stated Resident #17 was on the male unit watching him and noted he did not know the correct code. LW #88 stated Resident #17 then put the correct code in for him and let him onto the unit. LW #88 stated he informed the charge nurse on 08/31/12 that Resident #17 had the access code to the locked door and had let him on the unit. A telephone interview with LPN #25 on 09/12/12 at 9:30 A.M. revealed she routinely worked on the locked male unit. LPN #25 stated Resident #17 had been sexually inappropriate to her numerous times asking her to have sex with him or asking her to sit on his lap. She stated she had to take Resident #49 back to her unit from the locked male unit on a daily basis. LPN #25 stated she was not sure if Resident #49 came through the doors behind staff or if Resident #17 put in the access code and let her through, as the alarm never sounded. She stated she reported the incidents to her charge nurse whenever she found Resident #49 on the male unit and informed her of Resident #17's inappropriate sexual comments. Interview with Resident #49's physician on 09/13/12 at 1:00 P.M. confirmed the facility called her and left a message regarding the incident between Resident #49 and Resident #17. The physician stated she did not call the facility with any new orders as a head to toe assessment was completed by nursing staff with no negative findings. She stated the incident had to be initiated by Resident #17 as he was fully alert and oriented and Resident #49 was totally incompetent. Review of the facility's Abuse policy and procedures dated 10/18/11, revealed the policy stated the facility would follow state and federal guidelines on preventing abuse, neglect, mistreatment, exploitation and misappropriation of property. Abuse shall include physical harm, pain, mental anguish, verbal abuse, sexual abuse or involuntary seclusion. Sexual abuse includes, but is not limited to sexual harassment, sexual coercion or sexual assault. Further review of the policy revealed the facility identifies and investigates all suspicion or allegations of abuse. Results of the investigation are reported by the Administrator or designee to officials in accordance with State and Federal Law. If the abuse is substantiated, the incident is reported to the local law enforcement agency, licensing/certification boards and the attorney general's office for further actions. All allegations of abuse will be reported to the Ohio Department of Health as soon as possible, but no more than 24 hours after the alleged incident is discovered. Review of the facility's Sexual Risk Protocol dated 08/2009 revealed the Protocol stated a sexual aggression risk scale would be completed on residents that were showing signs and symptoms of sexually aggressive behavior that was putting others at substantial risk. There was no evidence that Resident #17 had been assessed for his sexual aggression per facility protocol. This certification deficiency substantiates Complaint Control Number OH 103.

Based on clinical record review, review of a facility self-reported incident (SRI), review of the facility's abuse policy and staff interviews, the facility failed to ensure staff followed the facility's abuse policy when an incident of sexual abuse occurred between Resident #49 by Resident #17 and failed to report the sexual abuse to a local law enforcement agency. This resulted in Immediate Jeopardy for one (#49) of three sampled female residents identified with dementia and wandering behaviors on the locked female unit. The facility identified 18 of 21 residents on the locked female unit had behaviors of wandering. The facility identified two (#4 and #17) of 18 residents on the locked male unit had inappropriate sexual behaviors. The facility census was 91. On 09/07/12 at 2:17 P.M., the Administrator, Assistant Director of Nursing (ADON) #40 and ADON #60 were notified Immediate Jeopardy began on 08/13/12 at 3:00 P.M. when Registered Nurse (RN) #99 noticed the door to Resident #17's room was closed and jammed shut with a cane on the inside. RN #99 accessed the resident's room and found Resident #49 lying on Resident #17's bed with her pants and incontinence brief pulled down and Resident #17 fondling Resident #49's private area. The Immediate Jeopardy was removed on 09/07/12 at 3:30 P.M. when Resident #17 was discharged from the facility. 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) until it was corrected on 09/11/12 when the facility implemented the following corrective actions: ? On 08/13/12 at 3:15 P.M., Resident #17 and Resident #49 were placed on every 15 minute checks for 72 hours. ? On 08/14/12, Maintenance Staff #30 inspected and made necessary adjustments to the locked door between the locked male and female units and changed the access code. ? On 08/22/12 and 08/23/12, the Director of Nursing inserviced nursing staff regarding Abuse reporting. ? On 08/31/12, Maintenance Staff #30 again changed the access code to the locked door between the male and female units due to a report that a resident let a staff member through the doors. ? On 09/07/12, one-on-one supervision was provided to Resident #17 until his discharge from the facility. ? On 09/07/12, the Maintenance Department began changing all codes to locked doors in the facility twice a week. ? Beginning 09/07/12 and completed on 09/11/12, the Administrator and ADON's #40 and #60 in-serviced all direct care staff regarding reporting procedures for abuse and facility reporting procedures in the event any resident on a secured unit left the unit unsupervised. ? On 09/11/12, Assistant Director of Nursing #40 completed sexual risk assessments on all residents and re-educated all nurses on the facility's protocol for implementation and use of the sexual risk assessment. ? On 09/10/12 and 09/11/12, interviews with nurses, state tested nurse aides, laundry staff and activity aides verified they were in-serviced and re-educated regarding the facility's abuse policy. ? Random observations on 09/07 through 09/11/12 revealed no evidence of any resident to resident sexual contact. Findings include: Review of the closed clinical record of Resident #17 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The latest quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact. Review of Resident #17's plans of care revealed no care plans related to Resident #17 having the access code to the door between the locked male and female units or his inappropriate sexual behaviors. Review of the clinical record of Resident #49 revealed she was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of nurse's notes dated 07/25/12 at 7:00 P.M. revealed Resident #49 wandered off the locked female unit and was found on the locked male unit. The notes documented the alarm had sounded with each episode. On 07/26/12 at 7:20 A.M., Resident #49 was documented as exit seeking and had wandered off the unit three times that day. At 8:00 P.M., Resident #49 was documented as exit seeking and wandered onto the locked male unit after continuously pushing on the door. Review of Resident #49's nurse's notes by the Director of Nursing (DON) dated 08/13/12 at 3:25 P.M. revealed it was reported to her Resident #49 had wandered onto the locked male unit. The notes indicated Resident #49 was found in Resident #17's room with her bottom article of clothing down and Resident #17 was making sexual contact with her. A full skin assessment was completed with no abnormalities noted. Review of Resident #17's nurse's notes by the DON dated 08/13/12 at 4:45 P.M., revealed Resident #17 was in his room and had his room door jammed shut with his cane. Resident #17 was making sexual contact with a female resident. Resident #17 was fully dressed. The resident's physician and guardian were notified. A physician's orders [REDACTED]. Review of a facility Self-Reported Incident (SRI) dated 08/13/12, completed by the DON and ADON #40, revealed Resident #49 was off the locked female unit. The SRI noted facility staff went to the locked male unit (adjacent to the locked female unit) and found Resident #17's door jammed shut from the inside with a cane. The staff was able to open the door and found Resident #49 lying on Resident #17's bed with her pants and brief pulled down. Resident #17 was fondling Resident #49's private area. Resident #49 was escorted back to her room and a head to toe assessment was completed with no injury or trauma noted. The facility physician was notified of the incident and Residents #49 and #17 were placed on every 15 minute checks. To prevent future incidents the code to the door between the units was changed by maintenance. No other additional information found in the investigation. During an interview on 09/06/12 at 12:50 P.M., the DON stated the incident on 08/13/12 was the only incident she was aware of where Resident #49 had gotten over to the locked male unit. The DON stated Resident #49's mother had come to visit that day and reported she could not find the resident. She stated the staff began looking in resident rooms and found Resident #49 in Resident #17's room, on his bed, unclothed from the waist down, with Resident #17 touching Resident #49 in her "private area". The DON stated she interviewed the staff witness, RN #99 about the incident however; no documentation of the interview or a written statement was completed. She further revealed there was no other documentation of an investigation of the incident other than the facility self reported incident (SRI)sent to the State survey agency. Interview with Assistant Director of Nursing (ADON) #40 on 09/07/12 at 4:00 p.m., 09/10/12 at 12:15 p.m. and 2:37 p.m. revealed no additional documentation of the investigation was completed in regard to the SRI of 08/13/12 of sexual abuse, other than the SRI itself. ADON #40 revealed she interviewed RN #99 who witnessed the sexual abuse, however could not provide the documentation. She further revealed she did not interview alert and oriented Resident #17 about the incident. Interview with STNA #55 on 09/10/12 at 11:51 A.M. revealed she worked on the locked male and female units. STNA #55 stated on 08/13/12 she was working the locked male unit providing care in a resident's room when RN #99 came over from the locked female unit asking if she had seen Resident #49. STNA #55 stated they started looking and noted Resident #17's door was jammed shut with his cane. She stated she went into the resident room next door and gained access to Resident #17's room through the shared bathroom. STNA #55 stated she observed Resident #49 lying on Resident #17's bed with her shirt pulled up over her breasts. She stated Resident #17 was fully clothed and standing beside the bed. STNA #55 stated the locked door to the unit was not alarming. She stated Resident #17 must have let Resident #49 on the unit or she came through the door behind staff. STNA #55 stated the incident took place shortly after 3:00 P.M. STNA #55 further stated she was not interviewed by the DON or Administrator, nor asked to provide a written statement regarding the incident. During a telephone interview with RN #99, on 09/10/12 at 2:00 P.M., she stated she was working on the locked female unit on 08/13/12 and could not find Resident #49. She stated she went to the locked male unit to see if Resident #49 had gotten over there. RN #99 stated she found Resident #49 in Resident #17's room lying on his bed with her pants and incontinence brief pulled down. She stated Resident #17 was fully clothed and fondling Resident #49's private area. RN #99 stated she notified ADON #40 and was told to do every 15 minute checks on Resident #49 and to write an incident report. RN #99 further revealed she was not interviewed by the DON or Administrator. During interview on 09/11/2 at 12:40 p.m. the Administrator confirmed local law enforcement was not notified of the resident to resident sexual abuse. He further revealed Resident #49 was not sent to the hospital for an evaluation. Review of the facility's Resident Abuse policy and procedure dated 10/18/2011 revealed the facility will follow state and federal guidelines on preventing abuse, neglect, mistreatment, exploitation and misappropriation of property. Abuse shall include physical harm, pain, mental anguish, verbal abuse, sexual abuse or involuntary seclusion. Sexual abuse includes, but is not limited to sexual harassment, sexual coercion or sexual assault. Further review of the policy revealed it is the responsibility of all staff to promote a safe environment for the residents. The Administrator takes the following actions to assure that the investigation is conducted effectively: If the incident was a sexual assault occurring within the last 48 hours, the resident is transferred to a hospital emergency room . The physician and family are notified of the transfer. The hospital staff and law officers determine if a rape examination should be conducted. Further review of the policy revealed results of the investigation are reported by the Administrator or designee to officials in accordance with State and Federal Law. This certification deficiency substantiates Complaint Control Number OH 103.

Based on clinical record review, review of a facility self-reported incident (SRI), review of the facility's abuse policy and staff interviews, the facility failed to thoroughly investigate a staff witnessed resident to resident sexual abuse of Resident #49 by Resident #17 and failed to report the sexual abuse to a local law enforcement agency. This resulted in Immediate Jeopardy for one (#49) of three sampled female residents identified with dementia and wandering behaviors on the locked female unit. The facility identified 18 of 21 residents on the locked female unit had behaviors of wandering. The facility identified two (#4 and #17) of 18 residents on the locked male unit had inappropriate sexual behaviors. The facility census was 91. On 09/07/12 at 2:17 P.M., the Administrator, Assistant Director of Nursing (ADON) #40 and ADON #60 were notified Immediate Jeopardy began on 08/13/12 at 3:00 P.M. when Registered Nurse (RN) #99 noticed the door to Resident #17's room was closed and jammed shut with a cane on the inside. RN #99 accessed the resident's room and found Resident #49 lying on Resident #17's bed with her pants and incontinence brief pulled down and Resident #17 fondling Resident #49's private area. The Immediate Jeopardy was removed on 09/07/12 at 3:30 P.M. when Resident #17 was discharged from the facility. 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) until it was corrected on 09/11/12 when the facility implemented the following corrective actions: ? On 08/13/12 at 3:15 P.M., Resident #17 and Resident #49 were placed on every 15 minute checks for 72 hours. ? On 08/14/12, Maintenance Staff #30 inspected and made necessary adjustments to the locked door between the locked male and female units and changed the access code. ? On 08/22/12 and 08/23/12, the Director of Nursing inserviced nursing staff regarding Abuse reporting. ? On 08/31/12, Maintenance Staff #30 again changed the access code to the locked door between the male and female units due to a report that a resident let a staff member through the doors. ? On 09/07/12, one-on-one supervision was provided to Resident #17 until his discharge from the facility. ? On 09/07/12, the Maintenance Department began changing all codes to locked doors in the facility twice a week. ? Beginning 09/07/12 and completed on 09/11/12, the Administrator and ADON's #40 and #60 in-serviced all direct care staff regarding reporting procedures for abuse and facility reporting procedures in the event any resident on a secured unit left the unit unsupervised. ? On 09/11/12, Assistant Director of Nursing #40 completed sexual risk assessments on all residents and re-educated all nurses on the facility's protocol for implementation and use of the sexual risk assessment. ? On 09/10/12 and 09/11/12, interviews with nurses, state tested nurse aides, laundry staff and activity aides verified they were in-serviced and re-educated regarding the facility's abuse policy. ? Random observations on 09/07 through 09/11/12 revealed no evidence of any resident to resident sexual contact. Findings include: Review of the closed clinical record of Resident #17 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The latest quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact. Review of Resident #17's plans of care revealed no care plans related to Resident #17 having the access code to the door between the locked male and female units or his inappropriate sexual behaviors. Review of the clinical record of Resident #49 revealed she was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of nurse's notes dated 07/25/12 at 7:00 P.M. revealed Resident #49 wandered off the locked female unit and was found on the locked male unit. The notes documented the alarm had sounded with each episode. On 07/26/12 at 7:20 A.M., Resident #49 was documented as exit seeking and had wandered off the unit three times that day. At 8:00 P.M., Resident #49 was documented as exit seeking and wandered onto the locked male unit after continuously pushing on the door. Review of Resident #49's nurse's notes by the Director of Nursing (DON) dated 08/13/12 at 3:25 P.M. revealed it was reported to her Resident #49 had wandered onto the locked male unit. The notes indicated Resident #49 was found in Resident #17's room with her bottom article of clothing down and Resident #17 was making sexual contact with her. A full skin assessment was completed with no abnormalities noted. Review of Resident #17's nurse's notes by the DON dated 08/13/12 at 4:45 P.M., revealed Resident #17 was in his room and had his room door jammed shut with his cane. Resident #17 was making sexual contact with a female resident. Resident #17 was fully dressed. The resident's physician and guardian were notified. A physician's orders [REDACTED]. Review of a facility Self-Reported Incident (SRI) dated 08/13/12, completed by the DON and ADON #40, revealed Resident #49 was off the locked female unit. The SRI noted facility staff went to the locked male unit (adjacent to the locked female unit) and found Resident #17's door jammed shut from the inside with a cane. The staff was able to open the door and found Resident #49 lying on Resident #17's bed with her pants and brief pulled down. Resident #17 was fondling Resident #49's private area. Resident #49 was escorted back to her room and a head to toe assessment was completed with no injury or trauma noted. The facility physician was notified of the incident and Residents #49 and #17 were placed on every 15 minute checks. To prevent future incidents the code to the door between the units was changed by maintenance staff. No other additional information found in the investigation. During an interview on 09/06/12 at 12:50 P.M., the DON stated the incident on 08/13/12 was the only incident she was aware of where Resident #49 had gotten over to the locked male unit. The DON stated Resident #49's mother had come to visit that day and reported she could not find the resident. She stated the staff began looking in resident rooms and found Resident #49 in Resident #17's room, on his bed, unclothed from the waist down, with Resident #17 touching Resident #49 in her "private area". The DON stated she interviewed the staff witness, RN #99 about the incident, however, no documentation of the interview or a written statement was completed. She further revealed there was no other documentation of an investigation of the incident other than the facility self reported incident (SRI) sent to the State survey agency. Interview with Assistant Director of Nursing (ADON) #40 on 09/07/12 at 4:00 p.m., 09/10/12 at 12:15 p.m. and 2:37 p.m., revealed no additional documentation of the investigation was completed in regard to the SRI of 08/13/12 of sexual abuse, other than the SRI itself. ADON #40 revealed she interviewed RN #99 who witnessed the sexual abuse, however, could not provide the documentation. She further revealed she did not interview alert and oriented Resident #17 about the incident. Interview with STNA #55 on 09/10/12 at 11:51 A.M. revealed she worked on the locked male and female units. STNA #55 stated on 08/13/12 she was working the locked male unit providing care in a resident's room when RN #99 came over from the locked female unit asking if she had seen Resident #49. STNA #55 stated they started looking and noted Resident #17's door was jammed shut with his cane. She stated she went into the resident room next door and gained access to Resident #17's room through the shared bathroom. STNA #55 stated she observed Resident #49 lying on Resident #17's bed with her shirt pulled up over her breasts. She stated Resident #17 was fully clothed and standing beside the bed. STNA #55 stated the locked door to the unit was not alarming. She stated Resident #17 must have let Resident #49 on the unit or she came through the door behind staff. STNA #55 stated the incident took place shortly after 3:00 P.M. STNA #55 further stated she was not interviewed by the DON or Administrator, nor asked to provide a written statement regarding the incident. During a telephone interview with RN #99, on 09/10/12 at 2:00 P.M., she stated she was working on the locked female unit on 08/13/12 and could not find Resident #49. She stated she went to the locked male unit to see if Resident #49 had gotten over there. RN #99 stated she found Resident #49 in Resident #17's room lying on his bed with her pants and incontinence brief pulled down. She stated Resident #17 was fully clothed and fondling Resident #49's private area. RN #99 stated she notified ADON #40 and was told to do every 15 minute checks on Resident #49 and to write an incident report. RN #99 further revealed she was not interviewed by the DON or Administrator. During interview on 09/11/2 at 12:40 p.m. the Administrator confirmed local law enforcement was not notified of the resident to resident sexual abuse. He further revealed Resident #49 was not sent to the hospital for an evaluation. Review of the facility's Resident Abuse policy and procedure dated 10/18/2011 revealed the facility will promptly and thoroughly investigate reports of abuse. Sexual abuse includes, but is not limited to sexual harassment, sexual coercion or sexual assault. The investigation may consist of interviews with the person(s) reporting the incident, interviews with any witnesses to the incident, an interview with the resident, if possible, interviews with staff members having contact with the resident during the period/shift of the alleged incident, interviews with the resident's roommate, family members and visitors. This certification deficiency substantiates Complaint Control Number OH 103.

Based on record review and interview, the facility failed to ensure two residents (#34 and #37) received the physician ordered wound treatments to prevent pressure ulcers from increasing in size and to promote healing of pressure ulcers. This affected two of four sampled residents with pressure sores and of 15 residents identified as having pressure sores with a facility census of 125. Findings include: 1. Review of Resident #34's accumulative [DIAGNOSES REDACTED]. The resident was alert and oriented. Review of his skin assessment and plan of care dated 03/09/11 revealed the resident was identified at risk for the development of skin injury and breakdown related to his medical conditions. One of the interventions listed on the current plan of care with an initiation date of 03/09/11 was to complete all treatments as ordered. On 06/01/11 at 8:15 A.M. the "weekly skin condition progress reports", the medication/treatment administration records, and the physician's orders [REDACTED]. Review of the reports revealed the facility did not consistently document the treatments were completed as ordered. Wound Care Nurse #2 and the Director of Nursing stated that the treatment administration records had numerous blanks and missed documentation. Review of the weekly skin condition progress reports, medication and /treatment administration records, and physician's orders [REDACTED]. A) The Resident was admitted on [DATE] with a 0.5 centimeter (cm) by 1 cm open/pressure area to his left ischium. According to the report the depth was marked as not applicable upon his 03/09/11 admission. Review of the weekly documentation revealed this open area became progressively larger during his stay. The last documentation about this open area prior to his 05/15/11 discharge was on 05/09/11. The 05/09/11 wound documentation identified the area as an unstageable pressure area measuring 8 cm by 5 cm. The documentation stated the nurse was unable to determine the depth and stated the area had a mild odor and yellow/gray serosanguinous drainage. According to the MAR and physician's orders [REDACTED]. Review of the MAR revealed this was not documented as being completed at all (the treatment was not done per the documentation on the MAR) on 03/13/11, 03/20/11, 03/24/11, 03/28/11, 03/29/11, 03/30/11, 04/02/11, and 04/03/11 and was documented as being completed only one time per day on 03/14/11, 03/19/11, 03/22/11, 03/23/11, 03/25/11, 03/26/11, 03/27/11, 03/31/11, 04/01/11, and 04/04/11. According to the MAR, the physician discontinued this treatment on 04/05/11. According to the MAR, the resident had an order initiated on 03/29/11 for Peleverus spray to the left ischium, pat dry, apply foam adhesive dressing and change every two days and as needed. Review of the MAR for March revealed that there was no documentation to indicate this treatment was completed in March. Review of the MAR for April revealed this treatment was completed on 04/01/11 and 04/05/11 and was not completed every two days as ordered. According to the MAR this treatment was discontinued on 04/05/11. Review of the April MAR revealed this resident had a treatment order dated 04/05/11 for Peleverus spray to bilateral ischiums, pat dry, apply alginate Ag to the wound and a foam dressing and change every two days. Review of the April MAR revealed this treatment was not initiated until 04/09/11, four days after it was ordered and was discontinued on 04/13/11. Review of the April MAR and physician's orders [REDACTED]. Review of the MAR revealed this treatment was not documented as completed one time on 04/22/11. According to the MAR on 04/13/11, the physician wrote and order for Peleverus spray to the left ischial wound, pat dry, apply skin prep to the skin surrounding the wound, apply a thin layer of [MEDICATION NAME] to the wound bed, cover with dry dressing and secure with tape every evening. Review of the April MAR revealed this treatment was not documented as having been completed on 04/15/11, 04/20/11, 04/22/11, 04/23/11, and on 04/26/11. According to the MAR this treatment was discontinued on 04/28/11. Interview with Wound Care Nurse #2 on 06/01/11 at 8:15 A.M. and review of the physician's orders [REDACTED]. Review of the April MAR revealed the resident had an treatment initiated on 04/28/11 for Peleverus spray to the left ischium, pat dry, apply skin prep the skin surrounding the wound, apply Santyl, and cover with gauze and tape daily. According to the MAR this was to be completed everyday at noon. The April and May MAR lacked documentation the treatment was completed on 04/29/11 and 05/10/11. Review of the May MAR revealed the resident had a treatment ordered for Peleverus spray to the left ischium, pat dry, apply skin prep to the skin surrounding the wound, apply [MEDICATION NAME], gauze, and tape every evening at midnight. Review of the documentation on the MAR revealed the treatment was not documented as completed on 05/01/11, 05/02/11, 05/04/11, 05/05/11, 05/06/11, 05/11/11, and 05/13/11. B) The Resident was admitted on [DATE] with a surgical wound to the right ischium that according to the wound documentation and interview with Wound Nurse #2 on 06/01/11 at 8:15 A.M. turned into a pressure area on 03/13/11. According to the documentation on 03/09/11, the area was documented as a .3 cm by 1 cm with less than .1 depth surgical wound. On 03/13/11, the area was a 4 cm by 3.5 cm open area with an depth that was unable to be determined. On 04/12/11, the wound documentation described the area as as a 8 cm by 5 cm stage 3 pressure ulcer. The last documentation of the area prior to his 05/15/11 discharge was on 05/09/11 and described this area as a 6.5 cm by 3.8 cm open area with yellow and gray slough and a moderate amount of serosanguinous drainage. The documentation stated the nurse was unable to determine the depth of this area. According to the physician's orders [REDACTED]. Review of the MAR revealed his treatment was not completed at all on 03/13/11, 03/14/11, 03/20/11, 03/24/11, 03/28/11, 03/29/11, 03/30/11 and was documented as only being completed one time per day on 03/10/11, 03/15/11, 03/19/11, 03/23/11, 03/25/11, 03/26/11, 03/27/11, 03/31/11, and 04/01/11 through 04/04/11. This order was discontinued on 04/05/11 per the MAR. Review of the physician's orders [REDACTED]. Review of the April MAR revealed this treatment was not documented as being completed on 04/21/11 and 04/22/11. an order for [REDACTED]. Review of the April MAR revealed this treatment was not documented as completed on 04/15/11, 04/18/11, 04/19/11, 04/22/11, 04/23/11, and 04/26/11. According to the MAR and interview with Wound Nurse #2, the times of these treatments were changed on 04/28/11 from morning and evening to noon and midnight at the request of the resident. According to the MAR on 04/28/11 an order was initiated for Peleverus spray to the right ischium, pat dry, apply skin prep to the skin surrounding the wound, apply Santyl to the wound bed, and apply gauze and change daily at noon According to the April MAR, this treatment was only completed on 04/30/11 in April and was not completed on 04/28/11 or 04/29/11. Review of the May MAR revealed this was not completed on 05/10/11. According to the May MAR the resident's order for Peleverus spray to the right ischium, pat dry, apply skin prep to the skin surrounding the wound, apply [MEDICATION NAME] to the wound bed, cover with gauze and tape and change every day at midnight was not completed on 05/01/11, 05/05/11, 05/06/11, and 05/13/11. C) The Resident was admitted on [DATE] with a 3.5 cm by 3.5 cm by less than 0.1 cm deep pressure ulcer on his right buttock. The last documentation available for this area was on 03/22/11 and at that time the area was 0.5 cm by 0.5 cm with less than .1 cm depth. According to the physician's orders [REDACTED]. Review of the March and April MAR revealed this treatment was not documented as being completed at all on 03/13/11, 03/14/11, 03/19/11, 03/20/11, 03/24/11 through 03/30/11, 04/04/11 through 04/08/11, 04/11/11, 04/15/11, 04/17/11, 04/21/11, and 04/22/11. According to the April MAR this order was discontinued on 04/28/11. According to the MAR, an order was initiated on 04/28/11 for Peleverus spray to the right upper buttock, pat dry, apply skin prep to the skin surrounding the wound, apply Santyl, gauze, and tape and change every evening. According to the MAR for April and May, this was not completed on 04/28/11, 04/29/11, and 05/10/11. In addition, an order was initiated on 04/28/11 for Peleverus spray to the right upper buttock, pat dry, apply skin prep to the skin surrounding the wound, apply [MEDICATION NAME], gauze and tape each evening. Review of the MAR for April and May revealed it was not documented as completed on 04/29/11, 05/01/11, 05/11/11, and 05/13/11. D) According to a document titled Skin Grid-Pressure, on 04/05/11, a stage II .25 cm by 2.5 cm open area was found on the resident's coccyx. It was less than .1 cm deep and was red with serosanguinous drainage. The last documentation of this area was on 04/05/11, when the area was documented as a stage II that measured 2 cm by 1.5 cm and was red with a scant amount of serosanguinous drainage. According to the MAR on 04/28/11, an order was initiated for Peleverus spray to the coccyx, pat dry, apply skin prep to the skin surrounding the wound, apply Santyl, gauze and tape each evening. Review of the April documentation revealed this was only completed on 04/30/11 in April and was not completed on 04/29/11. Review of the MAR for May revealed the treatment was not documented as completed on 05/10/11. According to the April MAR and physician's orders [REDACTED]. Review of the MAR revealed this treatment was not initiated until 04/09/11 and it was not changed from 04/19/11 through 04/23/11. The treatment was discontinued on 04/28/11 according to the MAR. According to the May MAR the resident had a treatment order for Peleverus spray to the coccyx, pat dry, apply skin prep to the skin surrounding the wound, apply [MEDICATION NAME], gauze, and tape every evening. Review of the MAR for May revealed this treatment was not documented as completed on 05/01/11, 05/04/11, 05/05/11, 05/06/11, 05/11/11, and 05/13/11. E) According to a document titled Skin Grid-Pressure, on 04/28/11 a pressure/deep tissue injury was noted on the resident's right dorsal foot. The area measured 2 cm by 4 cm when first discovered. The last documentation of the area was on 05/09/11 when the area was documented as a 1.1 cm by 4.2 cm unstageable open area. The documentation stated the area was black necrotic tissue with [DIAGNOSES REDACTED] (redness) noted surrounding the tissue. Review of the April MAR revealed on 04/29/11 a treatment was initiated for Peleverus spray to right dorsal foot, pat dry, and apply dry dressing daily. Review of the April MAR revealed there was not documentation that this treatment was completed in April. There is no documentation on the April MAR for this treatment. According to the May MAR it was not completed on 05/10/11. F) According to a skin grid documentation completed on 04/29/11, on 04/28/11 a 3.5 cm by 1.8 cm by less that 0.1 cm deep open area with serosanguinous drainage was found on the resident's left calf. The last documentation of this area was on 05/06/11 when the area was documented as 3 cm by 1.5 cm less than 0.1 cm in depth red with serosanguinous drainage. Review of the April MAR revealed on 04/28/11 a treatment for [REDACTED]. This treatment was only documented as being completed one time daily on 04/29/11, 05/03/11, 05/04/11, 05/05/11, 05/06/11, 05/11/11, and 05/12/11 and not two times a day as ordered. On 06/02/11 at 4:30 P.M. a telephone interview was conducted with Resident #34 because he was still in the hospital. During interview he stated that his treatments were not completed as ordered. He stated some days he did not get any treatments to his open areas and on other days he might get some of the treatments but not all of them. He stated that he felt that this was the reason he ended up in the hospital [MEDICAL CONDITION]. G) Review of the weekly skin condition documentation sheets and interview with Wound Care Nurse #2 on 06/01/11 at 8:15 A.M. revealed the SR was admitted the the facility on 03/09/11 with a 10 cm by 7.5 cm deep tissue injury to his right heel. According to the documentation, the nurse was unable to determine the depth of this open area. The last documentation of this area was on 05/06/11 and described the area as a 6.4 cm by 4.4 cm pressure area with an undetermined depth, discolored, and with a moderate amount of drainage. According to the March MAR and admission orders [REDACTED]. Review of the MAR for March and April revealed this was not documented as being completed at all on 03/13/11, 03/20/11, 03/24/11, 03/28/11, 03/29/11, 03/30/11, 04/02/11, 04/03/11, and 04/05/11 and was documented as being completed only one time per day on 03/14/11, 03/15/11, 03/16/11, 03/19/11, 03/22/11, 03/25/11, 03/26/11, 03/27/11, 03/31/11, 04/01/11, and 04/04/11. According to the April MAR this treatment was discontinued on 04/05/11. According to the MAR on 04/05/11 a treatment for [REDACTED]. Review of the MAR revealed this treatment was not documented as completed until 04/09/11, four days after it was ordered. According to the MAR, the treatment was discontinued on 04/13/11. According to the MAR on 04/14/11 a treatment of [REDACTED]. Review of the MAR revealed this treatment was not documented as being completed on 04/21/11 and 04/22/11. According to the MAR on 04/28/11 Peleverus spray to the bilateral heel ulcers, pat dry, apply skin prep to the skin surrounding the wound, apply Santyl to wound bed, gauze and tape every day at noon was initiated. The April MAR only had the treatment documented as completed on 04/30/11. There was no documentation that the treatment was completed on 04/28/11 or 04/29/11. In addition, the April MAR had a treatment initiated on 04/28/11 for Peleverus spray to bilateral heels, pat dry, apply skin prep to the skin surrounding the wound, apply [MEDICATION NAME] to wound bed, gauze, and tape and change every evening at midnight. According to the April MAR, this treatment was not documented as having been completed on 04/29/11. H) Review of the weekly skin condition documentation sheets and interview with Wound Care Nurse #2 on 06/01/11 at 8:15 A.M. revealed Resident #34 was admitted to the facility on [DATE] with a 2 cm by 1.5 cm [MEDICAL CONDITION] to his left upper heel, a 1.5 cm by 2.5 cm [MEDICAL CONDITION] to his left lateral heel, and an area to the very back of his heel. Wound Nurse #2 stated she was unable to locate any documentation about the areas to the very back of his heel. She stated during his stay the three open areas increased in size and merged into one big area. Review of the weekly skin documentation sheets completed by Wound Nurse #2 revealed that on 03/29/11 the area on the left lateral heel merged with the area on the left heel and on 04/05/11 the area on the left upper heel merged with the area on the left lateral heel. The last documentation of this wound was on 05/06/11 and described the area as 7.5 cm by 4 with moderate serosanguinous discolored drainage and a depth that was unable to be determined. The resident had an order initiated on 03/09/11 for Peleverus spray to the left lateral heel, pat dry, apply Santyl to wound bed and cover with gauze wrap every day. Review of the MAR revealed the treatment was not documented as completed on 03/13/11, 03/14/11, 03/20/11, 03/21/11, 03/26/11, 03/27/11, and 03/28/11. This treatment was discontinued on 03/29/11. The resident had an order initiated on 03/09/11 for Peleverus spray to the left heel ulcer, pat dry, and apply skin prep two times a day. Review of the March and April MAR revealed this treatment was not documented as being completed at all on 03/13/11, 03/20/11, 03/24/11, 03/28/11, 03/29/11, 03/30/11, 04/02/11, 04/03/11, and 04/05/11 and was only documented as being completed one time a day on 3/14/11, 3/19/11, 3/25/11, 3/26/11, 03/27/11, 04/01/11, and 04/04/11. According to the April MAR this treatment was discontinued on 04/05/11. The resident had an order initiated on 03/09/11 for Peleverus spray to the left upper heel ulcer, pat dry, apply skin prep twice a day. According to the MAR this treatment was discontinued on 03/28/11 when the areas merged together. Review of the MAR revealed this was not documented as being completed at all on 03/13/11, 03/20/11, 03/24/11, 03/28/11, 03/29/11, 03/30/11. 04/07/11, and 04/28/11 and was documented as only being completed one time per day on 03/14/11, 03/16/11, 03/19/11, 03/25/11, 03/26/11, 03/27/11, 03/30/11, 04/01/11 through 04/04/11, 04/06/11, 04/08/11, 04/11/11, 04/15/11, 04/19/11, 04/20/11, 04/21/11, 04/23/11, and 04/26/11. According to the MAR on 03/14/11 a treatment to spray eschar areas on the left foot with skin prep twice a day was initiated. Review of the April MAR revealed this treatment was not documented as being completed at all on 04/06/11, 04/07/11, 04/22/11, 04/28/11, 04/29/11, 04/30/11 and was documented as only being completed one time during the day on 04/01/11 through 04/05/11, 04/08/11, 04/11/11, 04/15/11, 04/15/11 through 04/21/11, 04/23/11, 04/25/11, and 04/26/11. According to the MAR on 04/05/11 a treatment for [REDACTED]. Review of the MAR revealed this treatment was not documented as completed until 04/09/11, four days after it was ordered. According to the MAR the treatment was discontinued on 04/13/11. According to the MAR on 04/14/11 a treatment of [REDACTED]. Review of the MAR revealed this treatment was not documented as being completed on 04/21/11 and 04/22/11. According to the MAR on 04/28/11 Peleverus spray to the bilateral heel ulcers, pat dry, apply skin prep to the skin surrounding the wound, apply Santyl to wound bed, gauze and tape every day at noon was initiated. The April MAR only had the treatment documented as having been completed on 04/30/11. There was no documentation that the treatment was completed on 04/28/11 or 04/29/11. There was not documentation on the May MAR to indicate this treatment was completed on 05/10/11 and 05/11/11. In addition the April and May MAR had a 04/28/11 treatment for [REDACTED]. According to April and May MAR this treatment was not documented as completed on 04/29/11, 05/01/11, 05/04/11, 05/05/11, 05/06/11, 05/11/11, and 05/13/11. On 06/02/11 at 4:30 P.M. a telephone interview was conducted with Resident #34 because he was still in the hospital. During interview he stated that his treatments were not completed as ordered. He stated some days he did not get any treatments to his open areas and on other days he might get some of the treatments but not all of them. He stated that he felt that this was the reason he ended up in the hospital [MEDICAL CONDITION]. 2. Resident #37 had resided at the facility since 12/06/10. She had [DIAGNOSES REDACTED]. Review of an active skin condition/causative factor evaluation dated 01/09/11 in Resident #37's medical record revealed she developed an open area on her right heel on 01/09/11. According to this evaluation form, the resident was at risk for the development of skin breakdown due to her multiple diagnoses. According to the current plan of care dated 01/19/11, one of the interventions was to complete treatments as ordered by the physician. Review of weekly skin condition assessment form dated 01/09/11 revealed she developed a pressure sore on her right heel. The first documentation describing the area was on 01/10/11 when the area was identified as 5.5 cm by 7 cm by less than 0.1 cm deep. The last documentation of the area was dated 05/25/11. The 05/25/11 documentation described the area as a 4.5 cm by 4.8 cm unstageable open area with a depth that was unable to be determined, a moderate amount of yellow serosanguinous drainage, and a mild foul odor. Review of the physician's orders [REDACTED]. The treatment record documented the treatment was not started until 04/07/11, three days after the physician ordered the treatment. Once applied on 04/07/11, the dressing was not changed again until 04/13/11 a week later. It was changed as ordered on [DATE] and not changed again until 04/21/11, five days later. On 04/30/11 the [MEDICATION NAME] dressing was discontinued and a new treatment was ordered for a [MEDICATION NAME] agent and a dry dressing to the area. During interview with the resident on 05/31/11 at 10:10 A.M. she stated that the facility did not always complete the treatment timely or follow the doctor's order when doing the treatment to her foot. On 05/31/11 at 1:10 P.M. Wound Nurse #2 was observed completing the treatment to the area on the right heel. During the treatment, both Wound Nurse #2 and the Resident #37 stated that prior to a 05/12/11 appointment at a wound clinic, the facility was not following the physician's orders [REDACTED]. According to the nurse and resident, it was not until the physician at the would clinic questioned how often the wound was being cleansed that they realized they were not following the physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Both the Wound Nurse #2 and the resident stated this order was not followed from 04/30/11 through 05/11/11 because the nurse was using Peleverus spray to cleanse the wound and not soap and water as ordered by the physician. This citation substantiated Complaint Number OH 836.