Every finding on record at Continuing Healthcare of Cuyahoga Falls

Based on record review, review of the facility ombudsman notification log and staff interview, the facility failed to ensure the State Long Term Care (LTC) Ombudsman Office was notified of resident discharges from the facility. This affected one resident (Resident #61) of one resident reviewed for discharge. The facility census was 56.Findings include:Review of the medical record for Resident #61 revealed an admission date of 10/07/25 with diagnoses including alcohol abuse, muscle weakness and difficulty in walking. Resident #61 was discharged from the facility on 02/19/26 to her personal residence.Review of the ombudsman notification log labeled, Ombudsman Transfer/Discharge Log for February 2026 (a monthly document sent to the State LTC Ombudsman Office to notify them of resident discharges from the facility) revealed Resident #61's discharge was not on the log.Interview with the Administrator on 05/20/26 at 2:15 P.M. verified Resident #61's discharge information was not sent to the State LTC Ombudsman Office as required.

Based on record review and staff interview the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were transmitted to the Centers for Medicare and Medicaid Services (CMS) within fourteen days of completion as required. This affected one resident (Resident #18) of one resident reviewed for resident assessments. The facility census was 56.Findings include:Review of the medical record for Resident #18 revealed an admission date of 12/24/25 with diagnoses including fractured back, major depressive disorder and insomnia. Resident #18 discharged back to the community with his spouse on 02/03/26.Review of MDS assessment records for Resident #18 revealed a Discharge Return Not Anticipated assessment dated [DATE]. The assessment was noted as completed but not transmitted directly to CMS as required.Interview with MDS Nurse #998 on 05/19/26 at 10:00 A.M. verified the Discharge Return Not Anticipated assessment dated [DATE] was not transmitted to CMS within fourteen days of completion as required.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure nebulizer masks and tubing were dated and stored appropriately. This affected two residents (Residents #55 and #56) out of two residents reviewed for respiratory care. The facility census was 56.Findings include:1. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (an abnormal heart rhythm), type two diabetes mellitus, depression, and chronic blood clots in the lower extremities.Review of the Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #55 was moderately cognitively impaired, sometimes rejected care, was independent with toileting and personal hygiene, and required supervision with transferring.Review of Resident #55's physician orders revealed an order for ipratropium-albuterol (medications that relax airway muscles and increase air flow to the lungs) inhalation solution 0.5 milligrams (mg)/2.5 mg per 3 milliliters (ml) every eight hours for shortness of breath (SOB) dated 01/08/26. The physician orders were absent from an order to change and date respiratory equipment.Observation on 05/18/26 at 9:55 A.M. revealed Resident #55's nebulizer (a medical device that turns liquid medication into a mist for inhalation into the lungs) mask was not stored appropriately in a bag and was undated.Observation on 05/19/26 at 11:42 A.M. with Licensed Practical Nurse (LPN) #329 revealed Resident #55's nebulizer mask was not stored appropriately in a bag and was undated. Interview at the time of the observation with LPN #329 verified the findings and stated that nebulizer masks were to be stored in a bag when not in use and dated. 2. Review of the medical record revealed Resident #56 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease stage four (severe kidney disease), type two diabetes mellitus, congestive heart failure, atrial fibrillation and SOB.Review of the Significant Change MDS 3.0 assessment dated [DATE] revealed Resident #56 was cognitively intact, did not reject care, required supervision assistance with activities of daily living, and received dialysis.Review of Resident #56's physician order dated 04/24/26 revealed an order to change the nebulizer mask, cup, and tubing weekly and to date the mask.Observation on 05/18/26 at 11:15 A.M. revealed Resident #56's nebulizer mask was not stored appropriately in a bag while not in use.Observation on 05/19/26 at 11:45 A.M. with LPN #329 revealed Resident #56's nebulizer mask was not stored in a bag while not in use. Interview at the time of the observation with LPN #329 verified the findings.Review of the facility policy titled, 'Nebulizer Aerosol Therapy' dated 08/2024 revealed the facility was to adhere to best practices for infection control. The nebulizer mask and tubing were to be changed weekly; the nebulizer storage bag was to be changed weekly; the nebulizer was to be stored in a bag to prevent contamination when not being used; and the mask was to be dated.

Based on medical record review, staff interviews, and an interview with a representative from the State Pre-admission Screening and Resident Review (PASRR) authority (The Ohio Department of Mental Health and Addiction Services), the facility failed to ensure PASRR recommendations for placement and related services were implemented and incorporated into the resident's comprehensive care plan. This deficient practice affected one resident (Resident #42) of two residents reviewed for PASRR assessments. The facility census was 56.Findings include:Review of the medical record for Resident #42 revealed an admission date of 05/19/25 with diagnoses including bipolar disorder, suicidal ideations, and seizures. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #42 was moderately cognitively impaired and independent in completing activities of daily living.Review of the Level II PASRR assessment completed by the Ohio Department of Mental Health and Addiction Services (OMHAS) dated 10/28/25 revealed Resident #42 did not require the services of a nursing facility. The assessment stated, in part, You (Resident #42) are not appropriate for continued nursing facility services. You require hands-on assistance with changing incontinence supplies only, which can be provided in an assisted living or other residential care setting. You are no longer receiving skilled rehabilitation services. Should you require such services in the future, they can be provided on an outpatient basis. It is recommended that you work with your behavioral health providers, facility staff, and others to develop a plan that meets your needs in order to prepare for discharge to the community.Additional review of Resident #42's medical record revealed since October 2025, there was no evidence of discharge planning, referrals, care conferences, or other efforts to transition Resident #42 to a more appropriate setting, as recommended by the PASRR authority.Interview with PASRR Representative #999 on 05/21/26 at 8:30 A.M. confirmed Resident #42 had a Level II mental illness designation and was denied continued stay approval by OMHAS per the 10/28/25 determination. The representative further confirmed Resident #42 appealed the decision; however, following a hearing held on 01/12/26, the denial was upheld by a third-party hearing officer in a written decision dated 01/15/26.Interview with Social Worker #500 on 05/21/26 at 9:44 A.M. confirmed Resident #42 remained in the facility without continued stay approval from the State PASRR authority.

Based on record review and interview, the facility failed to ensure parameters for Resident #49's blood pressure medications were monitored before administration. This affected one of five residents reviewed for unnecessary medications. The total census was 56.Findings include:Record review of Resident #49 revealed she was admitted [DATE] and had diagnoses including dementia, hypertension, and edema. She had an order dated 05/06/25 for amlodipine (an anti-hypertensive medication) to be given daily. The medication was to be held if her systolic blood pressure was under 110 or her heart rate was under 60. Review of her medication administration record revealed the amlodipine was given regularly with no evidence of the blood pressure and heart rate being assessed before administration. Review of her vital signs assessments revealed the heart rate and blood pressure were not being checked daily.Interview with the Director of Nursing on 05/20/26 at 5:05 P.M. confirmed the above findings.This deficiency represents non-compliance investigated under Complaint Number 2995801.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure respiratory medications were stored securely. This affected one resident (Resident #55) out of six residents reviewed for medication administration. The facility census was 56.Findings include:Review of the medical record revealed Resident #55 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (an abnormal heart rhythm), type two diabetes mellitus, depression, and chronic blood clots in the lower extremities.Review of the Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #55 was moderately cognitively impaired, sometimes rejected care, was independent with toileting and personal hygiene, and required supervision with transferring. Review of Resident #55's physician orders revealed an order for ipratropium-albuterol (medications that relax airway muscles and increase air flow to the lungs) inhalation solution 0.5 milligrams (mg)/2.5 mg per 3 milliliters (ml) every eight hours for shortness of breath dated 01/08/26. Observation on 05/19/26 at 11:42 A.M. with Licensed Practical Nurse (LPN) #329 revealed five unopened ipratropium-albuterol unit dose vials were stored on Resident #55's kitchenette counter near her nebulizer (a medical device that turns liquid medication into a mist for inhalation into the lungs). Interview at the time of the observation with LPN #329 verified the findings and that the unit dose vials were from the facility. LPN #329 stated she did not think Resident #55 had an order to self-administer ipratropium-albuterol.Further review of the medical record for Resident #55 revealed a Medication Self-Administration Safety Screen dated 11/07/25 which indicated ipratropium-albuterol was not a medication Resident #55 was able to self-administer.Review of the facility policy titled, Self-Administration of Medications, dated 09/2018 revealed bedside storage was to be used if a resident self-administered the medication.Review of the facility policy titled, Storage of Medication, dated 09/2018 revealed medications were to be stored securely and only accessible to licensed personnel, pharmacy personnel or staff members lawfully authorized to administer medications.

Based on observation, interview, record review, and policy review, the facility failed to ensure all doors of the secured unit remained in functioning order and failed to ensure Resident #18 was accurately assessed for risk of falls. This affected 17 residents (Residents #3, #10, #12, #16, #19, #24, #25, #28, #30, #38, #40, #42, #46, #47, #49, #51, and #53) of 17 residents residing on the secured unit and one resident (Resident #18) of three residents reviewed for falls. The facility census was 55. Findings Include:1. Observation of the secured unit on 03/29/26 at 1:57 P.M. revealed there were three entry and exit points. The Assistant Director of Nursing (ADON) was present during the observation and confirmed there were three entry and exit points to the unit. The door leading to the secured unit and dining room/kitchen area opened without having to push on the door for 15 seconds prior to opening. The door alarmed when opened but did not require a code be entered or a button to push to allow the door to open automatically. No staff members were located at the door to ensure residents were not able to leave the unit without staff knowledge. The ADON confirmed the secured unit door should be secured and the doors should not open immediately and that there was no one monitoring the door. Interview with Director of Support Services (DoSS) #559 on 03/29/26 at 3:35 P.M. revealed he discovered the doors leading on/off the secured unit were not working properly on 03/24/26. He placed a call to a local door repair company and they sent him a new customer form. After he submitted it he realized the company only serviced garage doors. On 03/26/26 DoSS #559 contacted a different company with a request for service and they contacted him via email on 03/27/26 with questions regarding the repairs. The Administrator said she was unaware the doors to the secured unit were not working properly. She said the facility would do whatever they need to do to have it repaired and while they are waiting for the repairs they would assign and employee to sit at the door to ensure no resident could leave the unit unsupervised. DoSS #559 said the doors must have stopped working properly recently as he monitors them weekly. He said they recently had a power surge and he felt that was what had caused the doors to malfunction. Interview with Anonymous Employee (AE) #604 on 03/30/25 at 4:00 P.M. confirmed the doors leading to the secured unit had not been working properly for awhile and had notified the facility that they were not working. AE #604 said she had heard the facility was now stationing an employee at the door to ensure residents were not able to leave the unit without supervision. Review of the secured unit's invoice and repair information dated 04/02/26 revealed on 03/31/26 a service call was requested by the facility as a door kept going into alarm and would not reset. Upon arrival at the facility the vendor met with DoSS #559 who took the vendor to the secured care unit that had three double door systems he wanted checked. The vendor found the double door system had only one lock on it with a push button reentry. The facility said they were not able to reset it and it would go into alarm mode all the time. The vendor inspected the door and found the lock was off on an angle causing the egress and armature to make good connections with the lock. This was due to the lock only having three screws in the mounting plate because the lock was misaligned and too far from the door by over 1/4 of an inch. The lock was realigned and six screws were placed in the lock mounting plate which pulled the lock to be at the correct angle. The egress wheel was also broken so the wheel was replaced and the egress adjusted. The system was tested several times and was function properly. The report indicated the doors were in rough shape and should be replaced because they are rubbing in the center of the doors and do not always close properly. Interview with the Administrator on 04/07/26 at 5:23 P.M. revealed she had not received a copy of the invoice and repair information until this day. She was not aware the vendor recommended replacing the doors to the secured unit. Review of the facility secured unit census revealed Residents #3, #10, #12, #16, #19, #24, #25, #28, #30, #38, #40, #42, #46, #47, #49, #51, and #53 resided on the secured unit. Review of the facility's Maintenance Requests policy, last revised January 2025, revealed all maintenance requests must be submitted through the systems electronic program tracker. Urgent or emergency issues (power outages, water leaks, Heating Ventilation Air Conditioning (HVAC) failure, safety hazards) must also be reported directly by phone or radio to the Department of Special Services or the Administrator in addition to entering them into the system. The electronic system serves as the facility's official log for all maintenance requests. The request must include the date, time, location, and a description of the issue. The DoSS will assign a priority level (Emergency, High, Routine) within the system. Emergency requests must be responded to immediately, high priority requests within 24 hours, and routine requests within three to five days. Once the repair is completed the DoSS or designee will close the request in the electronic record and document the corrective action taken and when it was completed. If the work cannot be completed within the expected timeframe, the delay and anticipated timeline must be documented in the system. Review of the work orders submitted to the facility's electronic system from December 28, 2025 through March 30, 2026 revealed no orders indicating the doors to the secured unit were not functioning properly. Review of the facility's Dementia Care policy, last revised December 2021, revealed providing care and services for residents living with dementia or dementia-like symptoms is an integral part of the person-centered care environment. This environment supports quality of life, meaningful relationships, and positive engagement. The necessary person-centered care and services that reflect the resident's goals, choices, and preferences while maximizing their dignity autonomy, privacy, socialization, independence, choice and safety. Staff providing care to residents with dementia or dementia-like symptoms are provided with training related to the management of dementia and will have competencies and skills to support the resident with dementia through the implementation of individualized approaches to cart that are directed toward understanding, preventing, relieving, and/or accommodating a resident's distress of loss of abilities. Residents with dementia or dementia-like symptoms may reside in a secured/locked area, if available in the facility, when clinical evaluation indicates the resident would benefit from such an environment and the resident, his or her family, and/or the resident representative have been provided information to make an informed decision regarding the care and services afforded in the secured/locked area to address the clinical and psychosocial/behavioral needs of the resident. 2. Review of the medical record for Resident #42 revealed an admission date of 11/14/25 with diagnoses including Alzheimer's disease, chronic kidney disease and hypertension. Review of the facility fall investigations from 11/27/25 through 02/10/26 for Resident #42 revealed she had falls on 12/18/25 at 9:00 A.M. which resulted in a skin tear, on 12/26/25 at 9:30 A.M. which resulted in a head injury, on 01/05/26 at 11:30 A.M. with no injury and on 01/07/26 at 11:45 A.M. with no injury. Review of the fall risk assessment dated [DATE] for Resident #42 revealed nursing staff had documented she had no history of falling in the previous three months. Due to the inaccuracy of the answer to the question, the assessment stated Resident #42 was not at risk for falls. Interview on 03/29/26 at 11:47 A.M. with Licensed Practical Nurse (LPN) #525 verified the fall risk assessment dated [DATE] for Resident #42 was incorrect. She verified Resident #42 had fallen four times during the assessment period and was at high risk for falls. This deficiency represents non-compliance investigated under Complaint Numbers 2801663 and 2962348.

Based on interview, record review, and policy review, the facility failed to provide the necessary dementia care and treatment to maintain the safety and well being residents on the dementia unit. This affected Resident #56 and had the ability to affect all 17 residents residing on the secured unit (Residents #3, #10, #12, #16, #19, #24, #25, #28, #30, #38, #40, #42, #47, #46, #49, #51, and #53). The facility census was 55. Findings Include:Resident #56 was admitted to the facility on [DATE] with diagnoses including vascular dementia severe without behavioral disturbance, major depressive disorder, alcohol dependence with alcohol induced persisting dementia, anxiety disorder, restlessness and agitation, and generalized anxiety disorder. The resident was transported to the hospital on [DATE] with no information regarding if the resident was admitted , transferred, or discharged .Review of the physician's orders for Resident #56 revealed on 01/29/26 and order was written for Depakote 125 milligrams (mg) (an anticonvulsant used as a mood stabilizer) three capsules given three times a day for vascular dementia, 02/01/26 an order was written for Zyprexa (an antipsychotic medication) 5 mg twice a day for vascular dementia, 02/23/26 an order was written for Ativan (an antianxiety medication) 1 mg four times a day for vascular dementia, 02/25/26 an order was written for Rexulti (an antipsychotic medication used to treat major depressive disorder, schizophrenia, or agitation associated with dementia due to Alzheimer's disease) 1 mg daily for vascular dementia, and an order was written on 01/30/26 for the resident to reside on the secured unit.Review of the quarterly comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 03/07/26, revealed Resident #56 was severely cognitively impaired. He exhibited behaviors of hallucinations, delusions, physical behaviors directed towards others for one to three days of the assessment period. He also exhibited behavioral symptoms not directed toward others for one to three days. He rejected care and wandered for one to three days of the assessment period. The resident required maximum assistance of staff for all personal care except eating.Review of the nursing progress notes from admission through discharge revealed Resident #56 exhibited increased agitation since admission. He wandered into other residents room putting clothes and other items in the toilets and exhibited exit seeking behaviors. The resident would become very aggressive and refuse medications. When staff redirected the resident from other residents rooms he would become very agitated and be very confused, spoke in a loud voice, and appeared more confused. On 12/16/25 at 7:14 A.M. Licensed Practical Nurse (LPN) #582 documented in the nursing progress notes Resident whipped his [NAME] out and urinated on the floor and wall. Staff intervened and provided redirection and assistance. And ensured the area was clean and disinfected. Incident was reported to nursing management. This behavior continued throughout his admission. Staff would find Resident #56 in female residents rooms, naked, and engaging in inappropriate sexual behavior on the female resident's bed. He would defecate in the hallways and attempt to rub feces on other residents. On 12/19/25 the resident was transferred for a psychiatric evaluation as the psychiatric practitioner said the facility was unable to manage his behaviors. The behaviors exhibited were anxiety, aggression, exit seeking, and being sexually aggressive with females on the secured unit as well as towards staff. The facility readmitted Resident #56 on 01/15/26 where he was placed on one to one supervision and placed on an unsecured unit due to a Covid-19 outbreak on the secured unit. Upon arrival the resident again started wandering into female residents rooms. On 01/19/26 the facility was again able to return to the secured unit where he remained on one to one supervision. His exit seeking behaviors continued as did entering female residents rooms. Resident #56 was again transferred for psychiatric evaluation 01/21/26 when the resident demonstrated combative behavior and aggression resulting in a self-inflicted injury. The resident was then transferred to a local emergency room (ER) for treatment. Upon return to the facility the resident continued his behaviors of wandering into female resident rooms insisting they were his wife, difficulty redirecting his behaviors, inappropriate urinating and defecating, and becoming more physically aggressive with staff and other residents. On 03/07/26 at 8:30 P.M. LPN #587 documented in the nursing progress notes that Resident #56 was observed in the hallway with his genitals exposed and refusing staff redirection to put his clothes on. LPN #587 and an aide attempted multiple times to get the resident to put on his underwear but without success. Resident #56 became physically aggressive towards LPN #587 and ripped her shirt off and pulled her hair out. The resident proceeded into a female resident's room (Resident #42), still naked, said this was his wife and forcefully attempted to get into the resident's bed. The female resident woke up and fell out of bed while attempting to get away from Resident #56. Emergency services was contacted due to the resident's behaviors and both residents were transferred to the ER for evaluation. No further documentation was found in the nursing progress notes regarding where Resident #56 went. No interdisciplinary team notes discussing the resident's behaviors were noted during Resident #56's stay in the facility.Review of Resident #56's care plans revealed a care plan was initiated on 12/04/25 for behaviors and was last revised on 02/01/26. The care plan was for behaviors and the resident was at risk for further episodes and injury. This was evidenced by the resident wandering in and out of resident rooms, removing clothing from other residents room and wearing it, placing paper towels in the toilets, and urinating on the floor. The interventions were to encourage him to attend social activities, explain things in a way he can understand, medication as ordered, monitor labs, chart behaviors, observe for early warning signs of behavior, and consult with psychiatric services as ordered. A second care plan was initiated on 12/04/25 for Mood/Behavior as resident has a history of alteration in mood or exhibition of behavioral symptoms related to Alzheimer's dementia, depression and psychosis with the same interventions as listed under the behaviors care plan. The Mood/Behavior care plan was not revised during Resident #56's stay at the facility. No risks or interventions were noted regarding the resident entering female residents rooms naked, insisting the resident was his wife, attempting to get into bed with the female residents, or making the resident one to one supervision upon his readmission to the facility on [DATE].Review of the referral progress notes and dementia care plan from the referring facility Resident #56 was transferred from prior to admission to the current facility revealed the behaviors the resident exhibited at the referring facility were the same behaviors he exhibited as he demonstrated at the current facility.Review of the facility census revealed Residents #3, #10, #12, #16, #19, #24, #25, #28, #30, #38, #40, #42, #47, #46, #49, #51, and #53 resided on the secured dementia unit.Interview with Anonymous Employee (AE) #600 on 03/29/26 at 1:12 P.M. revealed the Administrator tends to ignore staff concerns. Earlier in March 2026 they had a resident with behaviors. He was a man who would go into other residents rooms naked. AE #600 was told several times the Ombudsman was involved with the situation. The female residents were afraid of the naked resident. The Administrator kept brushing off staff concerns until a female resident fell and has not walked since the fall. The naked male ripped a nurses' shirt and pulled her hair. EA #600 confirmed the naked man was Resident #56 and he no longer resides in the facility.Interview with the Administrator and the Assistant Director of Nursing (ADON) on 03/30/26 at 10:50 A.M. revealed Resident #56 like to derobe sometimes according to the Administrator. He would urinate on tables on the secured unit. He thought all the female residents on his unit were his wife. The Administrator said she did not consider Resident #56 going into other residents rooms naked from the waist down and claiming the resident was his wife then trying to get in bed with them is a behavior that would be thought of as sexually inappropriate. This incident occurred on 03/07/26 and resident was transported from the facility by Emergency Medical Services. The ADON confirmed Resident #56 did not return to the facility. The ADON stated Resident #56 had scared Resident #42 and she fell out of bed attempting to get away from him. Resident #42 was also transferred to the ER for evaluation. The ADON stated Resident #42 is not ambulating like she used to and spends most of her time in a wheelchair but is starting to perk up a bit. The Administrator stated Resident #42 had perked up due to Resident #56 no longer residing in the facility.Interview with the Administrator on 04/01/26 at 5:30 P.M. regarding accepting Resident #56 as a resident revealed the facility's former Admissions/Marketer Director informed her she did not need to conduct an on-site review of Resident #56. The Administrator said she was hesitant as most facilities do not transfer good residents but the Admissions Director was adamant the Administrator not complete an on-site visit. The Administrator said she was aware the facility had transferred the resident from had resided on a secured all male unit. The Administrator said he never touched anyone but he did have behaviors. The resident would urinate in inappropriate places, wandered, and slept very little. The resident missed his wife and thought every female in the facility was her. As time went on Resident #56 became more aggressive. When asked why the facility readmitted him after psychiatric services transferred him for a psychiatric evaluation because the facility was unable to provide for his behavioral needs on 12/19/25 and remained hospitalized until 01/15/26, the Administrator said she felt the facility could deal with his behaviors on the secured unit. The Administrator said when Resident #56 returned to the facility in January 2026, they were unable to readmit him to the secured unit due to the unit being quarantined for Covid-19. They assigned one to one supervision for him. His behaviors of wandering continued while he was on the regular units. The Administrator said they did have several families emailing her about Resident #56 saying the facility should discharge him. The Administrator said she was unaware the female residents were barricading their doors to prevent him from entering their rooms as they were afraid of him. The Administrator said staff did not inform her of the residents concerns. Upon his return to the secured unit the Administrator said Resident #56's wife asked if the facility was planning on discharging him and the Administrator informed her there was no plan to discharge him. Then on 03/07/26 Resident #56 was wandering the unit naked from the waist down. The staff were unable to redirect him and the resident attacked LPN #587 and tore her braid off her head and ripped her shirt. The Administrator said she then issued an emergency discharge due to his inappropriate behaviors placing himself and others at risk for harm. Review of the facility's Dementia Care policy, last revised December 2021, revealed providing care and services for residents living with dementia or dementia-like symptoms is an integral part of the person-centered care environment. This environment supports quality of life, meaningful relationships, and positive engagement. The necessary person-centered care and services that reflect the resident's goals, choices, and preferences while maximizing their dignity autonomy, privacy, socialization, independence, choice and safety. Staff providing care to residents with dementia or dementia-like symptoms are provided with training related to the management of dementia and will have competencies and skills to support the resident with dementia through the implementation of individualized approaches to cart that are directed toward understanding, preventing, relieving, and/or accommodating a resident's distress of loss of abilities. Residents with dementia or dementia-like symptoms may reside in a secured/locked area, if available in the facility, when clinical evaluation indicates the resident would benefit from such an environment and the resident, his or her family, and/or the resident representative have been provided information to make an informed decision regarding the care and services afforded in the secured/locked area to address the clinical and psychosocial/behavioral needs of the resident.This deficiency represents non-compliance investigated under Complaint Number 2801663.

Based on observation, interview, record review, and policy review, the facility failed to ensure all doors of the secured unit remained in functioning order. This affected 17 residents (Residents #3, #10, #12, #16, #19, #24, #25, #28, #30, #38, #40, #42, #46, #47, #49, #51, and #53) of 17 residents residing on the secured unit. Findings Include:Observation of the secured unit on 03/29/26 at 1:57 P.M. revealed there were three entry and exit points. The Assistant Director of Nursing (ADON) was present during the observation and confirmed there were three entry and exit points to the unit. The door leading to the Buckeye unit and dining room/kitchen area would not open even after being pressed on for over one minute. No alarms sounded while the doors were pushed on. A code had to be entered to access/leave the unit. The ADON confirmed the doors should open and alarm after being pushed on for 15 seconds in order to allow egress from the unit.Interview with Director of Support Services (DoSS) #559 on 03/29/26 at 3:35 P.M. revealed he discovered the doors leading on/off the secured unit were not working properly on 03/24/26. He placed a call to a local door repair company and they sent him a new customer form. After he submitted it he realized the company only serviced garage doors. On 03/26/26 DoSS #559 contacted a different company with a request for service and they contacted him via email on 03/27/26 with questions regarding the repairs. The Administrator said she was unaware the doors to the secured unit were not working properly. She said the facility would do whatever they need to do to have it repaired and while they are waiting for the repairs they would assign and employee to sit at the door to ensure no resident could leave the unit unsupervised. DoSS #559 said the doors must have stopped working properly recently as he monitors them weekly. He said they recently had a power surge and he felt that was what had caused the doors to malfunction.Interview with Anonymous Employee (AE) #604 on 03/30/25 at 4:00 P.M. confirmed the doors leading to the secured unit had not been working properly for awhile and had notified the facility that they were not working. Review of the secured unit's invoice and repair information dated 04/02/26 revealed on 03/31/26 a service call was requested by the facility as a door kept going into alarm and would not reset. Upon arrival at the facility the vendor met with DoSS #559 who took the vendor to the secured care unit that had three double door systems he wanted checked. The facility had a double door system with two locks on the system with push button entry. The vendor was told this door was not going into egress. After inspecting the system the vendor determined the issue was caused because egress wires were removed from the panel. The vendor placed the wire back into the panel and adjusted egress. The vendor tested the system several times and everything was functioning properly. The east double door system has one lock on the system with push button reentry. The vendor was told egress was not working on the system. The vendor again inspected the door and discovered the egress wire was missing from the panel. The wire was replaced and the system tested and worked properly. The vendor then discovered the lock was loose. The issued was caused because the lock mounting plate only had tree screws and they were backing out. Larger screw were placed into the mounting plate with two additional screws into the mounting plate to ensure the lock will not move anymore. The doors were also in rough shape and should be replaced because they are rubbing in the center of the doors and do not always close properly.Interview with the Administrator on 04/07/26 at 5:23 P.M. revealed she had not received a copy of the invoice and repair information until this day. She was not aware the vendor recommended replacing the doors to the secured unit.Review of the facility's Maintenance Requests policy, last revised January 2025, revealed all maintenance requests must be submitted through the systems electronic program tracker. Urgent or emergency issues (power outages, water leaks, Heating Ventilation Air Conditioning (HVAC) failure, safety hazards) must also be reported directly by phone or radio to the Department of Special Services or the Administrator in addition to entering them into the system. The electronic system serves as the facility's official log for all maintenance requests. The request must include the date, time, location, and a description of the issue. The DoSS will assign a priority level (Emergency, High, Routine) within the system. Emergency requests must be responded to immediately, high priority requests within 24 hours, and routine requests within three to five days. Once the repair is completed the DoSS or designee will close the request in the electronic record and document the corrective action taken and when it was completed. If the work cannot be completed within the expected timeframe, the delay and anticipated timeline must be documented in the system.Review of the work orders submitted to the facility's electronic system from December 28, 2025 through March 30, 2026 revealed no orders indicating the doors to the secured unit were not functioning properly,This deficiency represents non-compliance investigated under Complaint Number 2962348.

Based on record review, interview and facility policy review, the facility failed to investigate an injury of unknown origin for Resident #18. This affected one (Resident #18) of three residents reviewed for investigation. The facility census was 55. Findings include:Review of the medical record of Resident #18 revealed an admission date of 06/07/22 with diagnoses including cerebral infarction (stroke), diabetes mellitus, hypertension, heart failure and need for personal assistance. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18's cognition was intact, he had no behaviors and had an impairment on one side of his body. Review of the nursing progress note dated 01/05/26 at 6:38 P.M. by Licensed Practical Nurse (LPN) #602 for Resident #18 revealed during breakfast an aide had noted he had swelling to the right side of his face. She stated she assessed him and noted his right top eye lid was swollen, resident cheeks were swollen and reddened. LPN #602 asked Resident #18 how he sustained the swollen and reddened eye and cheeks and he stated he did not know and he was not in pain. LPN #602 updated the Director of Nursing (DON) and the physician and received new orders. The nursing progress note did not state what the new orders were. Review of the progress note dated 01/06/26 by Nurse Practitioner (NP) #607 for Resident #18 revealed he was found to have a scab by his right eyebrow with swelling around his right eye and down into his cheek. She stated he was started on Clindamycin (antibiotic) 300 milligrams three times a day for seven days. NP #607 stated his face appeared less swollen and there was no pain or itching per the resident. It was noted Resident #18 was having some difficulty with vision out of his right eye due to the swelling of his eyelid. NP #607 stated Resident #18 had facial cellulitis (painful facial redness, swelling and warmth that is caused by bacteria entering through skin breaks or dental infections. Causes are usually skin trauma including cuts, scratches, insect bites, animal bites; dental infections or infection conditions such as acnes or boils). Interview on 03/30/26 at 9:33 A.M. with LPN #602 revealed she was on duty on 01/05/26 and was the nurse who assessed Resident #18's right eye. She stated an aide came to her and stated his eye had a scab and was swollen. She stated she spoke to Resident #18 who stated he did not know what had happened to his eye. She stated she updated NP #607 and the DON. LPN #602 stated NP #602 had ordered an antibiotic and would see the resident the following day. LPN #602 stated facility management had not interviewed her related to what had happened to Resident #18's eye and she had not performed an investigation as to how he had the scab or swelling. LPN #602 denied asking other staff how Resident #18 obtained the injury to his face. Interview on 03/30/26 at 9:36 A.M. with Resident #18 revealed he could recall that he had a scab and swelling to his right eye previously, a few months ago. He stated he could not remember how it had happened as his memory was bad because he had three strokes. Resident #18 stated he could not remember if he had ever been physically or verbally abused by staff. Interview on 03/30/26 at 10:50 A.M. with the Administrator revealed she was not made aware of the area to Resident #18's right eye and possible injury of unknown origin. She stated she had not reported it to the State Agency or investigated the incident as an injury of unknown origin. Interview on 04/08/26 at 2:01 P.M. with NP #607 revealed on 01/05/26 LPN #602 had called and described Resident #18's face to her. She stated she had started an antibiotic and then assessed him on her next visit which was 01/06/26. NP #607 stated she is not aware of what happened to Resident #18's face just that he had a scab above his eyebrow, his right eyelid was swollen as well as his cheeks. She stated Resident #18 did not have a history of cellulitis or injuries. Review of the facility policy titled, Abuse, Neglect, and Exploitation Prohibition, revised October 2024, defined injury of unknown course as a physical injury observed on a resident where the cause or origin could not be readily determined or explained. The policy stated the facility would conduct a timely investigation of any alleged injuries of unknown origin. The investigation should include gathering evidence, interviewing witnesses, conducting surveys as indicated, reviewing medical records and examining relevant documentation. The investigation findings would then be documented on appropriate state forms as applicable. This deficiency represents non-compliance investigated under Complaint Number 2963714.

Based on record review and interview, the facility failed to ensure dependent residents received showers as scheduled. This affected one (Resident #18) of three residents reviewed for showers. The facility census was 55. Findings include:Review of the medical record of Resident #18 revealed an admission date of 06/07/22 with diagnoses including cerebral infarction (stroke), diabetes mellitus, hypertension, heart failure and need for personal assistance. Review of Resident #18's care plan dated 06/07/22 revealed he had self-care deficit with his activities of daily living and needed total assistance of one staff member for bathing. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18's cognition was intact, he had no behaviors and had an impairment on one side of his body. He needed substantial to maximum assistance from staff for showers and bathing. Review of Resident #18's showers under the task section of the electronic record and shower sheets provided by the facility from dates 01/01/26 through 03/31/26 revealed he had not received showers as scheduled. Resident #18 was to receive two showers a week on Tuesdays and Fridays. The facility documentation revealed he had not received showers on 01/02/26, 01/06/26, 02/24/26, 03/03/26 and 03/27/26. Interview on 03/30/26 9:36 A.M. with Resident #18 revealed he was admitted to the facility because he had three strokes and could not remember things. Interview on 04/02/26 at 3:15 P.M. with the Administrator verified there were no other shower sheets or shower documentation available for Resident #18. Review of the facility policy titled, Activities of Daily Living-Highest Level of Functioning, revised on January 2026, revealed the facility would support each resident in maintaining or improving their highest practicable level of function related to activities of daily living based on the resident's needs, preferences and goals. This deficiency represents non-compliance investigated under Complaint Number 2962348.

Based on record review and interview, the facility failed to ensure resident assessments were accurately completed. This affected three (Residents #18, #42 and #48) of seven residents reviewed for assessments. The facility census was 55. Findings include:1. Review of the medical record for Resident #18 revealed an admission date of 06/07/22 with diagnoses including cerebral infarction (stroke), diabetes mellitus, hypertension, heart failure and need for personal assistance. Review of the fall risk assessment dated [DATE] for Resident #18 revealed he had fall in the previous three months. Review of the fall investigation dated 12/11/25 at 5:00 P.M. for Resident #18 revealed he was observed laying on the floor next to his bed. Resident #18 had attempted to transfer from the wheel chair to the bed without staff assistance and fell on the floor. He had no injuries noted on the investigation. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18's cognition was intact, he had no behaviors and had an impairment on one side of his body. On section J1800 of the assessment, facility staff had documented Resident #18 did not have any falls since admission or the prior MDS assessment. His last MDS was noted to be completed on 10/06/25. Interview on 03/30/26 at 10:50 A.M. with the Administrator verified the MDS dated [DATE] for Resident #18 was incorrect under section J as he had a fall without injury on 12/11/25 that should have been documented. 2. Review of the medical record for Resident #42 revealed an admission date of 11/14/25 with diagnoses including Alzheimer's disease, chronic kidney disease and hypertension. Review of the facility fall investigations from 11/27/25 through 02/25/26 for Resident #42 revealed she had falls on 12/18/25 at 9:00 A.M. which resulted in a skin tear, on 12/26/25 at 9:30 A.M. which resulted in a head injury, 01/05/26 at 11:30 A.M. with no injury and on 01/07/26 at 11:45 A.M. with no injury. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #42 had no falls documented on section J1800 for the question had she had any falls since admission or the prior MDS assessment. Her last MDS was completed on 11/26/25. Interview on 03/29/26 at 11:47 A.M. with Licensed Practical Nurse (LPN) #525 verified the MDS dated [DATE] for Resident #42 was incorrect under section J as she four falls since her admission MDS on 11/26/25 and one of those falls she sustained a head injury and should have been documented under major injury. 3. Resident #48 was admitted to the facility on [DATE] with diagnoses including bullous pemphigoid, morbid obesity, asthma, generalized anxiety disorder, major depressive disorder, heart disease, high blood pressure, and neuromuscular dysfunction of the bladder. Review of the physician's orders for Resident #48 revealed an order dated 08/27/24 to monitor for potential complications of an indwelling urinary catheter (a tube inserted into the bladder to allowing urine to flow into a drainage bag) such as redness, signs and symptoms of infection, obstruction, bladder spasms, blood tinged urine, or leakage around the catheter. Catheter care is to be completed daily and an as needed basis. Urinary output was to be monitored daily. Review of the annual comprehensive Minimum Data Set (MDS) 3.0 assessment for Resident #48, dated 01/02/26, revealed the resident was cognitively intact, has an indwelling foley catheter and is always incontinent of urine. Interview with Registered Nurse (RN) #19 on 04/08/26 at 10:00 A.M. confirmed Resident #48 MDS assessment was inaccurately coded as always incontinent of urine in the bowel and bladder section. Resident #48 is always continent of urine due to having a foley catheter.

Based on record review, interview and facility policy review, the facility failed to report an injury of unknown origin to the State Agency for Resident #18. This affected one (Resident #18) of three residents reviewed for reporting alleged violations. The facility census was 55. Findings include:Review of the medical record of Resident #18 revealed an admission date of 06/07/22 with diagnoses including cerebral infarction (stroke), diabetes mellitus, hypertension, heart failure and need for personal assistance. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18's cognition was intact, he had no behaviors and had an impairment on one side of his body. Review of the nursing progress note dated 01/05/26 at 6:38 P.M. by Licensed Practical Nurse (LPN) #602 for Resident #18 revealed during breakfast an aide had noted he had swelling to the right side of his face. She stated she assessed him and noted his right top eye lid was swollen, resident cheeks were swollen and reddened. LPN #602 asked Resident #18 how he sustained the swollen and reddened eye and cheeks and he stated he did not know and he was not in pain. LPN #602 updated the Director of Nursing (DON) and the physician and received new orders. The nursing progress note did not state what the new orders were. Review of the progress note dated 01/06/26 by Nurse Practitioner (NP) #607 for Resident #18 revealed he was found to have a scab by his right eyebrow with swelling around his right eye and down into his cheek. She stated he was started on Clindamycin (antibiotic) 300 milligrams three times a day for seven days. NP #607 stated his face appeared less swollen and there was no pain or itching per the resident. It was noted Resident #18 was having some difficulty with vision out of his right eye due to the swelling of his eyelid. NP #607 stated Resident #18 had facial cellulitis (painful facial redness, swelling and warmth that is caused by bacteria entering through skin breaks or dental infections. Causes are usually skin trauma including cuts, scratches, insect bites, animal bites; dental infections or infection conditions such as acnes or boils). Interview on 03/30/26 at 9:33 A.M. with LPN #602 revealed she was on duty on 01/05/26 and was the nurse who assessed Resident #18's right eye. She stated an aide came to her and stated his eye had a scab and was swollen. She stated she spoke to Resident #18 who stated he did not know what had happened to his eye. She stated she updated NP #607 and the DON. LPN #602 stated NP #602 had ordered an antibiotic and would see the resident the following day. LPN #602 stated facility management had not interviewed her related to what had happened to Resident #18's eye and she had not performed an investigation as to how he had the scab or swelling. LPN #602 denied asking other staff how Resident #18 obtained the injury to his face. Interview on 03/30/26 at 9:36 A.M. with Resident #18 revealed he could recall that he had a scab and swelling to his right eye previously, a few months ago. He stated he could not remember how it had happened as his memory was bad because he had three strokes. Resident #18 stated he could not remember if he had ever been physically or verbally abused. Interview on 03/30/26 at 10:50 A.M. with the Administrator revealed she was not made aware of the area to Resident #18's right eye and possible injury of unknown origin. She stated she had not reported it to the State Agency or investigated the possibility of an injury of unknown origin. Interview on 04/08/26 at 2:01 P.M. with NP #607 revealed on 01/05/26 LPN #602 had called and described Resident #18's face to her. She stated she had started an antibiotic and then assessed him on her next visit which was 01/06/26. NP #607 stated she is not aware of what happened to Resident #18's face just that he had a scab above his eyebrow, his right eyelid was swollen as well as his cheeks. She stated Resident #18 did not have a history of cellulitis or injuries. Review of the facility policy titled, Abuse, Neglect, and Exploitation Prohibition, revised October 2024, defined injury of unknown course as a physical injury observed on a resident where the cause or origin could not be readily determined or explained. The policy stated the facility would conduct a timely investigation of any alleged injuries of unknown origin. The investigation should include gathering evidence, interviewing witnesses, conducting surveys as indicated, reviewing medical records and examining relevant documentation. The investigation findings would then be documented on appropriate state forms as applicable. This deficiency represents non-compliance investigated under Complaint Number 2963714.

Based on interview, record review, and policy review, the facility failed to ensure Resident #56's immediate discharge was documented accurately and included in the medical record. This affected one resident (Resident #56) of one resident reviewed for discharge. The facility census was 55. Findings Include:Resident #56 was admitted to the facility on [DATE] with diagnoses including vascular dementia severe without behavioral disturbance, major depressive disorder, alcohol dependence with alcohol induced persisting dementia, anxiety disorder, restlessness and agitation, and generalized anxiety disorder. The resident was transported to the hospital on [DATE] with no information regarding if the resident was admitted , transferred, or discharged .Review of the physician's orders for Resident #56 revealed on 01/29/26 and order was written for Depakote 125 milligrams (mg) (an anticonvulsant used as a mood stabilizer) three capsules given three times a day for vascular dementia, 02/01/26 an order was written for Zyprexa (an antipsychotic medication) 5 mg twice a day for vascular dementia, 02/23/26 an order was written for Ativan (an antianxiety medication) 1 mg four times a day for vascular dementia, 02/25/26 an order was written for Rexulti (an antipsychotic medication used to treat major depressive disorder, schizophrenia, or agitation associated with dementia due to Alzheimer's disease) 1 mg daily for vascular dementia, and an order was written on 01/30/26 for the resident to reside on the secured unit.Review of the quarterly comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 03/07/26, revealed Resident #56 was severely cognitively impaired. He exhibited behaviors of hallucinations, delusions, physical behaviors directed towards others for one to three days of the assessment period. He also exhibited behavioral symptoms not directed toward others for one to three days. He rejected care and wandered for one to three days of the assessment period. The resident required maximum assistance of staff for all personal care except eating.Review of the nursing progress notes from admission through discharge revealed Resident #56 exhibited increased agitation since admission. He wandered into other residents room putting clothes and other items in the toilets and exhibited exit seeking behaviors. The resident would become very aggressive and refuse medications. When staff redirected the resident from other residents rooms he would become very agitated and be very confused, spoke in a loud voice, and appeared more confused. On 12/16/25 at 7:14 A.M. Licensed Practical Nurse (LPN) #582 documented in the nursing progress notes Resident whipped his [NAME] out and urinated on the floor and wall. Staff intervened and provided redirection and assistance. And ensured the area was clean and disinfected. Incident was reported to nursing management. This behavior continued throughout his admission. Staff would find Resident #56 in female residents rooms, naked, and engaging in inappropriate sexual behavior on the female resident's bed. He would defecate in the hallways and attempt to rub feces on other residents. On 12/19/25 the resident was transferred for a psychiatric evaluation as the nurse practitioner said the facility was unable to manage his behaviors. The behaviors exhibited were anxiety, aggression, exit seeking, and being sexually aggressive with females on the secured unit as well as towards staff. The facility readmitted Resident #56 on 01/15/26 where he was placed on one to one supervision and placed on an unsecured unit due to a Covid-19 outbreak on the secured unit. Upon arrival the resident again started wandering into female residents rooms. On 01/19/26 the facility was again able to return to the secured unit where he remained on one to one supervision. His exit seeking behaviors continued as did entering female residents rooms. Resident #56 was again transferred for psychiatric evaluation 01/21/26 when the resident demonstrated combative behavior and aggression resulting in a self-inflicted injury. The resident was then transferred to a local emergency room (ER) for treatment. Upon return to the facility the resident continued his behaviors of wandering into female resident rooms insisting they were his wife, difficulty redirecting his behaviors, inappropriate urinating and defecating, and becoming more physically aggressive with staff and other residents. On 03/07/26 at 8:30 P.M. LPN #587 documented in the nursing progress notes that Resident #56 was observed in the hallway with his genitals exposed and refusing staff redirection to put his clothes on. LPN #587 and an aide attempted multiple times to get the resident to put on his underwear but without success. Resident #56 became physically aggressive towards LPN #587 and ripped her shirt off and pulled her hair out. The resident proceeded into a female resident's room (Resident #42), still naked, said this was his wife and forcefully attempted to get into the resident's bed. The female resident woke up and fell out of bed while attempting to get away from Resident #56. Emergency services was contacted due to the resident's behaviors and both residents were transferred to the ER for evaluation. No further documentation was found in the nursing progress notes regarding where Resident #56 discharge. No interdisciplinary team notes discussing the resident's behaviors were noted during Resident #56's stay in the facility.Interview with the Administrator and the Assistant Director of Nursing (ADON) on 03/30/26 at 10:50 A.M. revealed Resident #56 like to derobe sometimes according to the Administrator. He would urinate on tables on the secured unit. He thought all the female residents on his unit were his wife. The Administrator said she did not consider Resident #56 going into other residents rooms naked from the waist down and claiming the resident was his wife then trying to get in bed with them is a behavior that would be thought of as sexually inappropriate. This incident occurred on 03/07/26 and resident was transported from the facility by Emergency Medical Services. The ADON confirmed Resident #56 did not return to the facility. The ADON stated Resident #56 had scared Resident #42 and she fell out of bed attempting to get away from him. Resident #42 was also transferred to the ER for evaluation. Interview with the Administrator on 04/01/26 at 5:30 P.M. regarding accepting Resident #56 as a resident revealed the facility's former Admissions/Marketer Director informed her she did not need to conduct an on-site review of Resident #56. The Administrator said she was hesitant as most facilities do not transfer good residents but the Admissions Director was adamant the Administrator not complete an on-site visit. The Administrator said she was aware the facility had transferred the resident from had resided on a secured all male unit. The Administrator said he never touched anyone but he did have behaviors. The resident would urinate in inappropriate places, wandered, and slept very little. The resident missed his wife and thought every female in the facility was her. As time went on Resident #56 became more aggressive. When asked why the facility readmitted him after psychiatric services transferred him for a psychiatric evaluation because the facility was unable to provide for his behavioral needs on 12/19/25 and remained hospitalized until 01/15/26, the Administrator said she felt the facility could deal with his behaviors on the secured unit. The Administrator said when Resident #56 returned to the facility in January 2026, they were unable to readmit him to the secured unit due to the unit being quarantined for Covid-19. They assigned one to one supervision for him. His behaviors of wandering continued while he was on the regular units. The Administrator said they did have several families emailing her about Resident #56 saying the facility should discharge him. The Administrator said staff did not inform her of the residents' concerns regarding Resident #56. Upon his return to the secured unit the Administrator said Resident #56's wife asked if the facility was planning on discharging him and the Administrator informed her there was no plan to discharge him. Then on 03/07/26 Resident #56 was wandering the unit naked from the waist down. The staff were unable to redirect him and the resident attacked LPN #587 and tore her braid off her head and ripped her shirt. The Administrator said she then issued an emergency discharge due to his inappropriate behaviors placing himself and others at risk for harm. The Administrator said she did not know what happened after they discharged him.Review of the discharge notice for Resident #56, dated 03/09/26, revealed the facility inaccurately identified the resident would be discharged home. The notice stated if less than 30 days were listed as the discharge date then he was given an immediate discharge as the resident's behaviors endangered the safety of the individuals in the home. The notice indicated the resident and his wife had the right to appeal the discharge. Information was provided on how to reach both the facility Ombudsman and the Administrator. Review of Resident #56's electronic health record revealed no information regarding an immediate discharge had been issued or that the resident's wife had received any information about why the discharge was issued.Interview with the Administrator on 04/02/26 at 3:15 P.M. regarding Resident #56's immediate discharge and the electronic health record not having any information regarding the discharge, revealed the Administrator stating the information was in the record. After reviewing the electronic health record with the Administrator she confirmed there was no documentation regarding the resident's discharge. The Administrator returned to her office and then immediately returned and provided a folder with the information she and Former Social Worker (FSW) #609 had worked on together regarding the immediate discharge. The Administrator provided a copy of the certified mail they sent to Resident #56's wife dated 03/09/26 and received by the wife on 03/11/26. The Administrator provided an undated note and unsigned noted that a detailed voicemail was left for the social worker at the facility where Resident #56 was admitted and informed him they would not be able to have the resident return to the facility as an emergent discharge for the safety of the facility's other residents who resided on Resident #56's unit. The resident's wife was notified of the emergent discharge of her husband as the resident was a safety risk to the other residents as he thinks all the women are his wife. The note stated the wife felt he would do better on an all male secured unit. Review of the immediate discharge notice sent to Resident #56's wife was dated 03/09/26. The discharge location was listed as the family home. The reason for the discharge was for the safety of individuals in the home being endangered. The contact information for the Ombudsman and the Administrator were provided. A copy of the notice was sent to the Office of General Counsel, Ohio Department of Health via email as well as a copy to the Ohio State Long-Term Care Ombudsman. The Administrator confirmed she did not document the information or scan the discharge notice into Resident #56's electronic health record.Review of the facility's Discharge/Transfer policy, last revised in June 2025, revealed the common discharge/transfer rationale was due to medical improvement; voluntary discharge or transfer; a medically emergent transfer, transfer to another healthcare facility for a higher level of care or specialized equipment; the transfer or discharge for resident welfare, and the resident's needs cannot be met in the facility; if the resident has failed, after reasonable and appropriate notice, to pay for ( or to have paid under Medicare or Medicaid) a stay at the facility; or if the resident has behavioral issues than cannot be safely managed in the current setting that endanger other individuals in the facility. When unplanned discharges occur the facility should provide as much specific information as possible in the discharge notice to notify the resident or why he/she is being discharged and how the discharge meets discharge criteria. The information must be documented in the resident's electronic health record.This deficiency represents non-compliance under Complaint Number 2968354.

Based on record review, observation and interview, the facility failed to ensure to audiology services and intervention were implemented properly. This affected two (Residents #21 and #32) of three residents reviewed for audiology services. The facility census was 55. Findings include: 1. Review of the medical record for Resident #21 revealed an admission date of 05/01/23 with diagnoses including diabetes mellitus, hypertension, depression and anxiety. Review of the care plan dated 01/04/22 for Resident #21 revealed she had a communication problem related to a mild hearing deficit and had bilateral hearing aids. Staff were to assist the resident with inserting and removing hearing aids and consult audiology as indicated. Review of Resident #21's physician orders revealed she had an order dated 08/06/25 for staff to insert hearing aids every morning and remove them at night. Her hearing aides were to be stored in the medication cart. Review of the nursing progress notes for Resident #21 revealed on 12/01/25 at 11:57 A.M. her hearing aids were lost and the social worker was requesting another pair. On 12/12/25 at 12:52 P.M. Resident #21's hearing aids arrived at the facility and were available for her to use. On 02/24/26 at 9:29 A.M. it was documented that Resident #21's hearing aids needed repaired. On 03/06/26 at 9:01 A.M. it was again documented that Resident #21's hearing aids were not working properly and the nurse practitioner and social worker were notified. On 03/07/26 at 5:44 A.M. the nurse had documented the hearing aids were broken. Review of the care plan meeting dated 01/26/26 held with facility staff, Resident #21 and her representative revealed the representative had asked about Resident #21's hearing aids. The note stated they would follow-up with the nursing staff. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #21 had adequate hearing with hearing aids. Resident #21 had intact cognition and had no behaviors. Review of the audiology visit on 04/01/26 and list of residents revealed Resident #21 was not seen by the audiologist. Observation and interview on 04/07/26 at 11:58 A.M. with Resident #21 and Licensed Practical Nurse (LPN) #525 revealed there was a wire that had come out of the right hearing aid. LPN #525 pushed the wire back into the hearing aid and asked if the resident would try them to see if they worked. Resident #21 stated she would try, however, was concerned she would not be able to hear as she had excessive wax in her ears and needed to be seen by the audiologist. Resident #21 stated she had not seen the audiologist in a long time and had wanted to see him on his last visit. Resident #21 stated she knew the audiologist was in the facility on 04/01/26 but did not have a visit. After LPN #525 placed the hearing aids in resident's bilateral ears, Resident #21 stated she thought they were working. Resident #21 stated to this surveyor and LPN #525 that the nursing staff did not place her hearing aids in daily as ordered. Interview on 04/07/26 at 12:39 P.M. with the Administrator verified the previous social worker made the audiology appointments for the facility. She stated the social worker no longer worked at the facility and there was no one covering until the new social worker started. The Administrator stated the last visit by the audiologist was on 04/01/26 and Resident #21 was not seen. Review of the facility policy titled, Ancillary Services Policy and Procedures, undated, revealed the facility would assist residents in obtaining routine audiology services. 2. Resident #32 was admitted to the facility on [DATE] with diagnoses including a right ilium fracture, a motor vehicle accident with injuries, chronic obstructive pulmonary disease (COPD), major depressive disorder, acute pain due to trauma, bipolar disorder with psychotic features, anxiety disorder, history of malignant carcinoid tumor of bronchus and lung, malignant neoplasm of the bladder, and a urostomy (a surgical opening created in the abdominal wall to divert urine outside the body when the bladder is removed, commonly due to cancer or injury). Review of the physician's orders for Resident #32 revealed an order dated 02/13/26 for audiology to evaluate and treat. Review of Resident #32's quarterly comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 01/05/26, revealed the resident was moderately cognitively impaired, had adequate hearing and did not need hearing aides, and was independent for personal care. Review of Resident #32's nursing progress notes revealed Assistant Director of Nursing (ADON) documented on 02/13/26 at 4:38 P.M. Resident #32 returned to the facility from a doctor's appointment her sister had taken her to. The physician discontinued two medications and ordered audiology to assess her. Review of the audiology visits for the residents since 09/11/24 revealed the audiologist had not examined Resident #32 during any of the visits. The most recent audiologist visit was 04/01/26. Resident #32 was not examined by the audiologist. Interview with Resident #32's sister (Family #596) on 03/29/26 at 2:25 P.M. revealed the resident was supposed to see the facility audiologist in January 2026 but for some reason they did not see her. The facility said they would have the audiologist see her on 02/11/26 but again they did not examine her. The facility said the audiologist went to the resident's former facility to see her. The facility told them they would arrange an emergency appointment with audiology. Three weeks later an appointment had still not been scheduled. On 02/13/26 Family #596 brought the resident back to the facility after a physician's appointment and gave the facility an order for audiology to see the resident as she needed her ears flushed as she was having difficulty hearing. On 02/19/26 the facility said Debrox ear drops were ordered to be given weekly but they were never administered. Family #596 said she has repeatedly met with the Administrator, the ADON, and the Ombudsman but nothing ever changes. Family #596 said she had to make an appointment with an audiologist outside of the facility to have the resident's ears flushed and now she can finally hear again. Interview with the ADON on 04/01/26 at 5:28 P.M. revealed the facility audiologist was here today and she will provide a list of who was seen. The ADON confirmed Resident #32 has never seen the audiologist since she was admitted . The ADON said it was possible Resident #32's sister had taken the resident to an outside provider as she does that a lot. Interview with the Administrator on 04/07/26 at 12:39 P.M. revealed no staff were currently covering the audiology services or any other ancillary services since Former Social Worker (FSW) #609 left. Review of the facility's undated Ancillary Services Policy and Procedures revealed the facility assists residents in obtaining routine and 24-hour emergency dental care as well as routine vision, audiology, and podiatry care. All coordination efforts, appointments and resident or representative notifications are to be documented in the resident's medical record. This deficiency represents non-compliance investigated under Complaint Number 2968354.

Based on record review and interview, the facility failed to ensure residents received pain medications as ordered. This affected one (Resident #21) of one reviewed for pain management. The facility census was 55. Findings include:Review of the medical record for Resident #21 revealed an admission date of 05/01/23 with diagnoses including diabetes mellitus, hypertension, depression and anxiety. Review of the care plan dated 01/04/22 for Resident #21 revealed she had alteration in comfort related to arthritis. Staff were to administer medications as ordered. Review of the physician's orders for Resident #21 revealed an order for Tramadol 50 milligrams (mg) three times a day for pain dated 12/27/25. Review of the narcotic logs for Resident #21 for February 2026 revealed she had utilized her last Tramadol 50 mg pill on 02/13/26 at 6:00 P.M. and had not received another Tramadol 50 mg pill until 02/17/26 at 2:00 P.M. Review of the Medication Administration Record (MAR) for February 2026 revealed Resident #21 received Tramadol 50 mg three times a day, one in the morning, one at 3:00 P.M. and one at 8:00 P.M. On 02/14/26 in the morning it was noted the Tramadol was not administered, on 02/14/26 at 3:00 P.M. the Tramadol was not administered, on 02/14/26 at 8:00 P.M. the Tramadol was administered, on 02/15/26 in the morning the Tramadol was administered, on 02/15/26 at 3:00 P.M. the Tramadol was administered, on 02/15/26 at 8:00 P.M. the Tramadol was not administered, on 02/16/26 in the morning the Tramadol was not administered, and on 02/16/26 at 3:00 P.M. the Tramadol was not administered. Review of the nursing progress notes for Resident #21 revealed on 02/14/26 at 8:50 A.M. the nurse stated she was waiting on the Tramadol 50 mg from the pharmacy for the resident. She stated the nurse practitioner was made aware of the missed dose. On 02/14/26 at 6:01 P.M. the nurse stated she was waiting on the Tramadol 50 mg as it was on hold until available. Nurse Practitioner was made aware of missed dose. There were no progress notes stating the Nurse Practitioner gave the order to hold the Tramadol 50 mg for Resident #21. On 02/16/26 at 2:35 A.M. the nurse stated the Tramadol 50 mg was on order. On 02/16/26 at 8:48 A.M. the nurse stated the Tramadol 50 mg was on order. There was no documentation on 02/15/26 related to the Tramadol 50 mg medication not being available or the physician being updated. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #21 had intact cognition and had no behaviors. Interview on 03/29/26 at 10:03 A.M. with Resident #21 revealed she did not always get her medications as ordered. She stated she either did not get her medications or they were late at times. Interview on 04/07/26 at 2:44 P.M. with Pharmacist #608 revealed the facility had received Tramadol 50 mg for Resident #21 on 01/31/26 with the amount of 30 pills and on 02/16/26 with 30 pills. She stated there was no Tramadol sent by the pharmacy during the time frame of 01/31/26 through 02/16/26 except for those two dates. Interview on 04/08/26 at 1:48 P.M. with the Interim Director of Nursing (DON) verified Resident #21 did not receive her Tramadol as ordered on the dates listed above. She also verified the Tramadol was not available in the facility between 02/14/26 through 02/16/26 for Resident #21 until 8:00 P.M. even though the nursing staff stated they had given the medication on 02/14/26 at 8:00 P.M., on 02/15/26 in the morning and on 02/15/26 at 3:00 P.M. Review of the facility policy titled, Medication Administration and Management, revised June 2019, revealed the nursing staff would administer medications as ordered by the physician. Review of the facility policy titled, Pain Management, revised November 2025, revealed the nursing staff would administer medications as ordered by the physician. Medication unavailability wound be documented. This deficiency represents non-compliance investigated under Complaint Number 2968354.

Based on interview, record review, policy review, and job description review, the facility failed to ensure Resident #21 and Resident #32 received ancillary services timely. This affected two residents (Residents #32 and #21) of four residents reviewed for medically related social services. The facility census was 55. Findings Include:1. Resident #32 was admitted to the facility on [DATE] with diagnoses including a right ilium fracture, a motor vehicle accident with injuries, chronic obstructive pulmonary disease (COPD), major depressive disorder, acute pain due to trauma, bipolar disorder with psychotic features, anxiety disorder, history of malignant carcinoid tumor of bronchus and lung, malignant neoplasm of the bladder, and a urostomy (a surgical opening created in the abdominal wall to divert urine outside the body when the bladder is removed, commonly due to cancer or injury). Review of the physician's orders for Resident #32 revealed an order dated 02/13/26 for audiology to evaluate and treat. Review of Resident #32's quarterly comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 01/05/26, revealed the resident was moderately cognitively impaired, had adequate hearing and did not need hearing aides, and was independent for personal care. Review of Resident #32's nursing progress notes revealed Assistant Director of Nursing (ADON) documented on 02/13/26 at 4:38 P.M. Resident #32 returned to the facility from a doctor's appointment her sister had taken her to. The physician discontinued two medications and ordered audiology to assess her. Review of the audiology visits for the residents since 09/11/24 revealed the audiologist had not examined Resident #32 during any of the visits. The most recent audiologist visit was 04/01/26. Resident #32 was not examined by the audiologist. Interview with Resident #32's sister (Family #596) on 03/29/26 at 2:25 P.M. revealed the resident was supposed to see the facility audiologist in January 2026 but for some reason they did not see her. The facility said they would have the audiologist see her on 02/11/26 but again they did not examine her. The facility said the audiologist went to the resident's former facility to see her. The facility told them they would arrange an emergency appointment with audiology. Three weeks later an appointment had still not been scheduled. On 02/13/26 Family #596 brought the resident back to the facility after a physician's appointment and gave the facility an order for audiology to see the resident as she needed her ears flushed as she was having difficulty hearing. On 02/19/26 the facility said Debrox ear drops were ordered to be given weekly but they were never administered. Family #596 said she has repeatedly met with the Administrator, the ADON, and the Ombudsman but nothing ever changes. Family #596 said she had to make an appointment with an audiologist outside of the facility to have the resident's ears flushed and now she can finally hear again. Interview with the ADON on 04/01/26 at 5:28 P.M. revealed the facility audiologist was here today and she will provide a list of who was seen. The ADON confirmed Resident #32 has never seen the audiologist since she was admitted . The ADON said it was possible Resident #32's sister had taken the resident to an outside provider as she does that a lot. Interview with the Administrator on 04/07/26 at 11:30 A.M. revealed the facility does not currently have a social worker or a social services designee. Former Social Worker (FSW) #609 quit on 03/16/26 when Former Director of Nursing (FDON) #595 also left the facility. They have been splitting the social service designee duties between herself, the ADON, the Business Office Manager, and therapy. The Administrator said she had previously been a licensed social worker but let her license lapse a few years ago. The facility has been accepting applications for the position but have not received many. They have received more for the DON position. The Administrator said they have an interim licensed social worker starting on 04/08/26 who they are hoping to hire if things go well. The interview continued at 12:39 P.M. when the Administrator stated no one was currently covering the audiology services or any other ancillary services since FSW #609 left. Review of the facility's undated Ancillary Services Policy and Procedures revealed the facility assists residents in obtaining routine and 24-hour emergency dental care as well as routine vision, audiology, and podiatry care. All coordination efforts, appointments and resident or representative notifications are to be documented in the resident's medical record. Review of the Social Services Director's (SSD) job description revealed the primary purpose of the SSD is to assist the Administrator to plan, organize, develop and direct the overall operation of the Social Services department. The SSD assists in developing and implementing policies and procedures for identifying the medically related social and emotional needs of the resident. 2. Review of the medical record for Resident #21 revealed an admission date of 05/01/23 with diagnoses including diabetes mellitus, hypertension, depression and anxiety. Review of the care plan dated 01/04/22 for Resident #21 revealed she had a communication problem related to a mild hearing deficit and had bilateral hearing aids. Staff were to assist the resident with inserting and removing hearing aids and consult audiology as indicated. Review of Resident #21's physician orders revealed she had an order dated 08/06/25 for staff to insert hearing aids every morning and remove them at night. Her hearing aides were to be stored in the medication cart. Review of the nursing progress notes for Resident #21 revealed on 12/01/25 at 11:57 A.M. her hearing aids were lost and the social worker was requesting another pair. On 12/12/25 at 12:52 P.M. Resident #21's hearing aids arrived at the facility and were available for her to use. On 02/24/26 at 9:29 A.M. it was documented that Resident #21's hearing aids needed repaired. On 03/06/26 at 9:01 A.M. it was again documented that Resident #21's hearing aids were not working properly and the nurse practitioner and social worker were notified. On 03/07/26 at 5:44 A.M. the nurse had documented the hearing aids were broken. Review of the care plan meeting dated 01/26/26 held with facility staff, Resident #21 and her representative revealed the representative had asked about Resident #21's hearing aids. The note stated they would follow-up with the nursing staff. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #21 had adequate hearing with hearing aids. Resident #21 had intact cognition and had no behaviors. Review of the audiology visit on 04/01/26 and list of residents revealed Resident #21 was not seen by the audiologist. Observation and interview on 04/07/26 at 11:58 A.M. with Resident #21 and Licensed Practical Nurse (LPN) #525 revealed there was a wire that had come out of the right hearing aid. LPN #525 pushed the wire back into the hearing aid and asked if the resident would try them to see if they worked. Resident #21 stated she would try, however, was concerned she would not be able to hear as she had excessive wax in her ears and needed to be seen by the audiologist. Resident #21 stated she had not seen the audiologist in a long time and had wanted to see him on his last visit. Resident #21 stated she knew the audiologist was in the facility on 04/01/26 but did not have a visit. After LPN #525 placed the hearing aids in resident's bilateral ears, Resident #21 stated she thought they were working. Resident #21 stated to this surveyor and LPN #525 that the nursing staff did not place her hearing aids in daily as ordered. LPN #525 stated she would educate the staff on ensuring her hearing aids were placed in her ears in the morning and taken out at night. Interview on 04/07/26 at 12:39 P.M. with the Administrator verified the previous social worker made the audiology appointments for the facility. She stated the social worker no longer worked at the facility and there was no one covering until the new social worker started. The Administrator stated the last visit by the audiologist was on 04/01/26 and Resident #21 was not seen. Review of the facility policy titled, Ancillary Services Policy and Procedures, undated, revealed the facility would assist residents in obtaining routine audiology services.

Based on observation, interview, and record review, the facility failed to ensure Resident #32's medical record accurately reflected ostomy care. This affected one resident (Resident #32) of one resident reviewed for ostomy care. The facility census was 55. Findings Include:Resident #32 was admitted to the facility on [DATE] with diagnoses of a motor vehicle accident with multiple fractures, chronic obstructive pulmonary disease, major depressive disorder, bipolar disorder with psychotic features, obstructive and reflux uropathy, anxiety disorder, artificial openings of urinary tract status, malignant neoplasm of bladder, and history of malignant carcinoid tumor of the bronchus and lung. Review of the physician's orders dated 09/12/25 revealed Resident #32 was to have urostomy care on day shift every three days. Staff are to remove the bag and wafer, cleanse the site with normal saline, observe for any abnormalities of the skin/ostomy, apply skin prep to the stoma border, allow the areas to dry, then apply a new wafer and bag. Interview with Family Member (FM) #596, the sister and Power of Attorney for Resident #32, on 03/29/26 at 2:25 P.M. revealed the resident has a urostomy (a surgical opening for draining urine from the body) but the facility does not know how to provide care for it. The facility is supposed to check and empty the urostomy bag every two hours. The facility does not clean the bag and it smells. She provides the supplies for her sister's care and labels them for the date they need to be changed and places them in her sister's closet. Every three days the bag is supposed to be replaced. But the staff still does not change it. Review of the March 2026 Medication Administration Record (MAR) for Resident #32 revealed on 03/29/26 Licensed Practical Nurse (LPN) #576 had changed the urostomy bag in the morning. Observation of Resident #32's urostomy bag on 03/29/26 at 2:35 P.M revealed the bag in placed was soiled in appearance. The bag was stained a dirty yellowish brown. This was observed by two surveyors and FM #596. LPN #576 documented she had changed the ostomy bag that morning. Interview with ADON on 04/01/26 at 5:28 P.M. confirmed nurses should not document a task has been completed if it has not been done. This deficiency represents non-compliance investigated under Complaint Number 2968354.

Based on observation, review of the facility menus, interview with staff, and review of facility policy, the facility failed to follow the lunch menu for the residents. This affected all 63 residents in the facility who received their meals from the dining room. The facility census was 63.Findings Include:Review of the menu for 02/25/26 revealed the facility was to serve a corn dog, cheesy mashed potatoes, mixed vegetables, white bread and yellow cake for lunch.Observation of meal service on 02/25/26 at 11:40 A.M. revealed [NAME] #130 was serving corn dogs, regular mashed potatoes, mixed vegetables and vanilla pudding. There was no cheese in the mashed potatoes, no bread was given to the residents and they did not have yellow cake.On 02/25/26 at 12:15 P.M. an interview with [NAME] #130 revealed she did not make the mashed potatoes cheesy and there was not a reason why she did not. She stated they did not have the yellow cake, so they were serving pudding instead and verified they forgot to give the residents bread.On 02/25/26 at 4:15 P.M. an interview with Corporate Dietary Manager #128 stated she was not aware they did not serve cheesy potatoes or bread for the lunch meal. She stated she did know they had not made the yellow cake and substituted the pudding. She sated the cook the night before did not make the cake so they could not serve it. She verified they did have the yellow cake in stock to make; it just was not made.Review of the facility policy titled, Menus, dated 06/2019 revealed menus would be planned to meet the nutritional needs and preferences of the residents and were in accordance with the recommended dietary allowances of the Food and Nutritional Board of National Research Council, National Academy of Sciences. It noted the facility would make appropriate substitutions when items on the menu were not available and to record these substitutions and keep the records on file with the menus. Substitutions offered were to be similar in nutritional values to the food being offered.

Based on observations, interview, and review of facility policy, the facility failed to maintain a safe sanitary kitchen. This affected all 63 residents who ate their meals from the facility kitchen. The facility census was 63.Findings Include: Observations of the kitchen with Corporate Dietary Manager #128 on 02/25/26 at 10:10 A.M. revealed the following concerns:a. There were two 50-gallon trash cans with no lids on them. b. The utensil drawer with the scoops and ladles had a red, sticky substance spilled down inside the drawer with the scoops and ladles laying in it.c. The stainless stain shelf under the steam table had food and a yellow liquid spilled on it.d. There were three three-tiered red food carts which were soiled with food debris and a white liquid dried on them.e. Two-large tubs of rice crispy cereal were not labeled as to when they were opened.f. Two five-pound packages of semi frozen tubes of hamburger were in the stainless stain sink soaking in warm water.g. The dry storage had several pieces of cardboard and paper littering the floor.h. In the refrigerator there was a small square stainless steel pan with something white and hard in it without a label as to identify it or when it was made, a bag of lettuce open to air with no date when opened, a bag of bacon bits was observed as not dated when opened, and the Reach-In refrigerator #2 had a large round container and three pitchers of a red liquid with no date or identifying label.Interviews with Corporate Dietary Manager #128 throughout the tour of the kitchen verified the above findings.Observation on 02/25/26 at 12:15 P.M. revealed the two five-pound tubes of hamburger were still in the sink defrosting in stagnant cool water.Observation on 02/25/26 at 2:35 P.M. with Corporate Dietary Manager #128 revealed the two five-pound tubes of hamburger were out of the water just sitting on the sink, they were cool to touch. [NAME] #130 took the temperature of the hamburger, with Corporate Dietary Manger #128 and Dietary Manager #131 watching, which revealed the temperature of the first tube was 57.8 degrees Fahrenheit (F) and the second roll was 49.8 degrees F. Corporate Dietary Manager #128 verified the temperature was not safe and told Dietary Manager #131 they had to throw the meat away because it was not safe to consume. Dietary Manager #131 asked what they were supposed to do for supper because he did not have any more hamburger to use, she stated they would just have to make meatless spaghettis sauce.Review of the facility policy titled, Food Safety in Receiving and Storage, dated 08/12/19 revealed food would be received and stored by methods to minimize contamination and bacteria growth. It stated to place food that was repackaged on a leak-proof, pest-proof, non-absorbent, sanitary container with a tight-fitting lid and label both the container and its lid with the common name of the contents and the date it was transferred to the new container.Review of the facility policy titled, Sanitation and Food Safety in Food Service. dated 06/2019 revealed the Nutrition/Culinary Service Director (NSD) would assume responsibility for the food safety and sanitation of the Nutrition Culinary Department. The NSD developed, implemented, and monitored a cleaning schedule that assigned specific cleaning responsibilities to specific individuals.

Based on medical record review, staff interview, review of imaging reports, review of hospital records, and facility policy review, the facility failed to ensure complaints and origins of pain were comprehensively evaluated and timely reported to a physician. This resulted in Actual Harm on 07/11/25 when Resident #150, who had severely impaired cognition and who was dependent on staff for all activities of daily living (ADLs), was identified to have bruising and pain in her right hip and was observed by staff grabbing her right thigh. Resident #150's pain medication was changed from as needed to routine, and Resident #150 continued to have pain with no evidence of a thorough pain assessment or assessment of range of motion to the affected extremity. Between 07/11/25 and 07/16/25, Resident #150 continued to have breakthrough pain. On 07/16/25, Resident #150's pain was rated at a 10 out of 10 (worst possible pain) and the physician[SS1] was notified and ordered an x-ray examination, and it was determined Resident #150 had a fractured right hip. This affected one Resident (#150) of three residents reviewed for accidents and change in condition. The facility census was 50. Findings include:Review of the closed medical record for Resident #150 revealed diagnoses including but not limited to, dementia, an unspecified fracture of shaft of left tibia (04/11/25), unspecified fracture of right femur (07/17/25), Type II diabetes mellitus, repeated falls, unspecified protein-calorie malnutrition, and hereditary and idiopathic neuropathy. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] for Resident #150 revealed a Brief Interview for Mental Status (BIMS) score of 4 which indicated severely impaired cognition. Review of the ADLs for Resident #150 revealed she used a wheelchair and required maximum assist for dressing and personal hygiene, was incontinent of bowel and bladder, and was dependent on staff for toileting, bathing, rolling left to right, and transferring. Review of the physician order for Resident #150 revealed an order dated 04/11/25 for Percocet (Oxycodone with Acetaminophen) [a narcotic medication used to treat moderate to severe pain] oral tablet 5-325 milligram (mg) two tablets by mouth every four hours as needed for severe pain. Review of Resident #150's care plan dated revised 04/24/25 revealed an ADL self-performance deficit related to diagnosis of diabetes mellitus, congenital postural curvature of the spine, history of a right hip fracture, and a history of a left tibia and fibula fracture in April 2025. Interventions included but were not limited to skin inspection weekly with any concerns reported to the nurse, staff to turn and reposition in bed as needed, transfers using the Hoyer (mechanical lift used to safely transfer individuals with limited mobility), and report declines in ADLs to physician. Review of a skin assessment dated [DATE] for Resident #150 revealed intact skin, with no areas of concern or impending wound development. Review of the witness statement dated 07/07/25 and 07/08/25 from Certified Nursing Assistant (CNA) #259 revealed Resident #150 ate about 50-75% of meals and was noted to grab her leg due to pain. Resident #150 was noted to be in pain while changing her and was medicated but continued to complain of pain throughout the day despite medication. Review of the nursing progress note dated 07/09/25 timed at 8:18 P.M. revealed Resident #150 reported severe pain all over her body and 2 tablets of as needed (PRN) Percocet 5-325 mg tablets were administered as ordered. Review of the nursing progress note dated 07/10/25 timed at 9:02 A.M. for Resident #150 indicated two tablets of Percocet 5-325 mg oral tablet were given for severe pain. Repositioning and distraction were noted to be ineffective. A note timed at 3:19 P.M. noted an additional dose of Percocet was given to Resident #150 for severe pain in her left leg, and repositioning and distraction were noted to be ineffective. An additional note timed at 9:23 P.M. revealed two tablets of Percocet 5-325 mg oral tablet were given to Resident #150 due to severe pain. Review of the 07/11/25 nursing progress noted timed at 3:13 P.M. for Resident #150 revealed two tablets of Percocet 5-325 mg oral tablet were given for pain in her legs and repositioning and distraction were noted to be ineffective. An additional note timed at 4:08 P.M. revealed Resident #150 had a bruise on her left leg. Resident #150 was noted to squeeze the leg in the area of the bruise when in pain. Resident #150 stated she squeezes her leg to make it feel better. No further discoloration was noted. A new order for Percocet was received from the nurse practitioner. Review of the physician order dated 07/11/25 revealed a new order for Oxycodone 10 mg by mouth five times a day for pain related to encounter for orthopedic aftercare. An additional order dated 07/11/25 for Acetaminophen (an over-the-counter mild pain reliever) 500 mg by mouth five times a day for pain. The Oxycodone and Acetaminophen were scheduled to be administered at the same times. Review of the 07/11/25 nursing progress note timed at 9:00 P.M. revealed two tablets of Percocet 5-325 mg oral tablets were given to Resident #150 for reports of severe pain. Review of change of condition assessment dated [DATE] for Resident #150 revealed the resident had a bruise to her right front thigh and pain in her leg. The assessment did not include any evidence range of motion (ROM) was evaluated or that a functional assessment was performed. Review of the 07/11/25 witness statement from CNA #254 revealed she reported bruising to Registered Nurse (RN) #234 and Director of Nursing (DON) #283 which were small and yellowish in color. The CNA noted the bruises appeared to be self-inflicted from hands on right thigh. Review of the witness statement dated 07/11/25 from the previous Director of Nursing (DON) #283 revealed the CNA requested the nurse and DON #283 to look at Resident #150 in bed. DON #283 indicated a few bruises were noted when Resident #150 took her hands and placed them around her right thigh and that the bruises appeared to be self-inflicted. Review of Resident #150's Medication Administration Record (MAR) for July 2025 revealed on 07/12/25, the resident reported pain ratings of five at 6:00 A.M., three at 10:00 A.M., and five at 6:00 P.M. On 07/13/25, the resident reported pain ratings of a two at 6:00 A.M., three at 10:00 A.M., a one at 2:00 P.M., and a two at 10:00 P.M. On 07/14/25, the resident reported pain levels of a two at 6:00 A.M., three at 10:00 A.M., and four at 6:00 P.M. Review of a nursing progress note dated the 07/15/25 and timed at 4:40 P.M. revealed Resident #150 continued to show signs of pain and general discomfort with ecchymosis (bruising) noted to her right thigh and inguinal (groin) area. Review of a skin assessment dated [DATE] for Resident #150 revealed intact skin, new area identified on front of right thigh. The new area was described as a small yellow and blue colored bruise where Resident #150 placed her fingers to lift her leg. Two bruises were noted on each side of her right thigh. Review of Resident #150's MAR for July 2025 revealed on 07/15/25, the resident reported pain ratings of three at 6:00 A.M., five at 10:00 A.M., six at 2:00 P.M., two at 6:00 P.M., and a six at 10:00 P.M. Review of a nursing progress note dated 07/16/25 and timed at 5:26 P.M. revealed Resident #150 was alert and expressed pain during the shift. A large bruise was observed on the resident's right thigh. Supervisor (unnamed) was made aware and stated resident was awaiting an orthopedic follow-up appointment. Resident #150 was observed not eating much during meals this shift. A subsequent note timed at 11:54 P.M. revealed Resident #150 reported excruciating pain to her right hip. The physician was notified and the nurse put in an order for x-rays to be done due to bruises to the right hip and sensitivity to the area. An x-ray was to be completed in the morning. The note did not mention if the resident's ROM had been assessed or if a functional assessment had been performed. Review of Resident #150's MAR for July 2025 revealed on 07/16/25, the resident reported pain ratings of a five at 6:00 A.M., three at 2:00 P.M., four at 6:00 P.M., and an eight at 10:00 P.M. On 07/17/25 at 6:00 A.M, Resident #150's pain was rated as a ten out of ten. Review of an x-ray examination report dated 07/17/25 revealed Resident #150 had an acute right hip fracture to the intertrochanteric ridge. Review of a change in condition note dated 07/17/25 and timed at 1:05 P.M. revealed the results of the x-ray concluded an acute right hip fracture to the intertrochanteric ridge. Orders were placed to send Resident #150 to a local emergency room. Resident #150 left the facility at 1:19 P.M. Review of the nursing progress note dated 07/17/25 and timed at 11:32 P.M. revealed Resident #150 was admitted to the local hospital with a diagnosis of a right femur fracture. Review of a facility self-reported incident (SRI) dated 07/17/25 revealed an injury of unknown origin was reported for Resident #150's hip fracture. The facility submitted their final report on 07/24/25 and concluded the injury was the result of non-witnessed mechanical trauma in the context of severe osteoporosis and prior hardware failure and determined no abuse or mistreatment occurred. Review of a hospital Discharge summary dated [DATE] revealed Resident #150 was treated at a local hospital for a diagnosis of right intertrochanteric hip fracture, dementia, and recurrent falls and noted that upon hospital discharge, hospice care was recommended. X-ray results of the right hip on 07/17/25 revealed an acute, mildly displaced right intertrochanteric fracture. The report noted the resident's family declined surgical intervention and opted for hospice care. Resident #150 did not return to the facility. Review of the facility incident log from 06/01/25 to 08/06/25 did not reveal any incidents or falls for Resident #150. Review of the witness statement dated 07/23/25 from CNA #235 revealed on 07/15/25 she helped CNA #234 change Resident #150 in bed and observed the bruising on her thigh which appeared to be yellow in color and reported it to the nurse and DON. Review of the witness statement dated 07/24/25 from Director of Rehabilitation #282 revealed therapy did seated occupational therapy with Resident #150 in July 2025 and did not do physical therapy. Interview on 08/06/25 at 10:23 A.M. with CNA #235 revealed she was helping CNA #247 change Resident #150 on 07/09/25 and when they went to roll Resident #150 over, they noticed yellow and purplish bruising. They went to tell Licensed Practical Nurse (LPN) #284 and RN #234 who stated they were already aware of the bruising. Interview on 08/06/25 at 10:31 A.M. with CNA #247 revealed she went in with CNA #235 to change Resident #150 on 07/09/25 and noticed a large bruise on her inner hip. CNA #247 went to get the nurse, and the nurse stated it was yellow and appeared to be an older bruise. When CNA #247 and CNA #235 turned Resident #150 onto her side, the back of her hip was purple, and she told the nurse she needed to go to the hospital. CNA #247 stated she reported it to LPN #284 on 07/09/25 and again the next time she worked on 07/11/25 to RN #234 and Unit Manger #218. CNA #247 stated a few days prior, she had noticed Resident #150 had not been eating or drinking well and was moaning during shift and had reported it on 07/09/25 and was told by RN #234 and Unit Manager #218 they would keep an eye on it and medicate Resident #150. Phone interview on 08/06/25 at 5:25 P.M. with Registered Nurse (RN) #234 revealed CNA #247 called her into Resident #150's room on 07/11/25 to look at bruising with DON #283. RN #234 then called the physician and got an order for scheduled pain medication. RN #234 stated the bruising appeared older and yellow. RN #234 stated Resident #150 would squeeze her thighs and the bruising appeared to be where she grabbed her thighs. Interview on 08/07/25 at 6:12 A.M. with LPN #241 revealed she was told by LPN #284 in the first few days of July about the bruising on Resident #150, but the resident was not sent out for evaluation until a couple of weeks later. LPN #241 stated when the bruising was first observed, it appeared to be smaller and did not appear to be concerning, and Resident #150 was unaware how it happened. The second time, a couple weeks later, the bruising was observed it was much larger and was yellowish, indicating an older bruise. Interview on 08/07/25 at 6:25 A.M. with CNA #228 revealed she first noticed the bruising in the middle of July, and it had already been reported. The bruising appeared small, and dark in color. Resident #150 appeared to be in pain despite the resident receiving pain medication. CNA #228 reported the bruising got worse and Resident #150 seemed more confused. On 07/16/25, prior to the x-ray, Resident #150 seemed to be in considerable pain, was moaning, and would grab her right thigh. Interview on 08/07/25 at 7:26 A.M. with CNA #234 revealed she reported Resident #150 having pain and rubbing her hip around 07/06/25 to RN #234 who talked with DON #283. A couple days later she reported Resident #150 was not eating or drinking well. When CNA #234 asked Resident #150 if she was in pain she nodded yes. CNA #234 stated when she washed her up on 07/10/25, the resident had pain, and she reported it to DON #283. The bruising appeared purple in color. Following reporting the resident's pain to DON #283, Resident #150 appeared to be in more pain and was not sent out until 07/17/25. Resident #150 was not wanting to get out of bed due to her pain and when she was being changed, she was moaning in pain. Interview on 08/07/25 at 12:25 P.M. with the Assistant Director of Nursing (ADON) revealed Resident #150 was unable to voice concerns about pain or bruising. RN #234 contacted her on 07/11/25 and they thought the bruising was from Resident #150 grabbing her thighs with her hands. On 07/16/25, when Resident #150 was having extreme pain, an x-ray was completed, and she was sent out for further evaluation of the right hip fracture. The ADON confirmed she was unable to provide evidence that the physician was notified of continued breakthrough pain between 07/11/25 and 07/16/25 when the x-ray was ordered. Telephone interview on 08/07/25 at 12:48 P.M. with RN #237 revealed after 07/11/25, Resident #150's pain medications (Oxycodone 10 mg) were scheduled. RN #237 reported Resident #150 appeared to be more confused and her quality of life seemed to be declining. RN #237 stated she had reported her concerns, but the concerns were falling on deaf ears. RN #237 stated when communicating with the previous shift nurse, they both felt the increased pain medications were causing Resident #150 to be less alert and not addressing the resident's pain. The two nurses had discussed Resident #150 and had concerns she would need to have an x-ray examination or need to be sent out (to the hospital) to address her condition change. Interview on 08/07/25 at 2:33 P.M. with the Administrator revealed they were not aware of Resident #150 sustaining any falls and proceeded to investigate Resident #150's fracture as an injury of unknown origin following the x-ray examination results obtained on 07/17/25. The Administrator reported that the facility staff believed Resident #150's bruising was not suspicious, had been caused by her squeezing her leg, the bruising appeared to be Resident #150's handprint, and they did not open a SRI until 07/17/25. Review of the facility policy titled Change in Condition Communication revised 06/2019 revealed to notify the physician of the change in medical condition. The nurse will document all assessments and changes in the resident's condition in the medical record. All attempts to notify the physician and family members will be thoroughly documented in the resident's medical record. The guidelines are not intended to substitute for good nursing judgement. If the nurse feels uncomfortable with a situation, he/she should not delay contacting the physician or call 911 if it appears to be life-threatening event. The above applies 24 hours a day, seven days a week. This deficiency represents non-compliance investigated under Complaint Number 2576681.

Based on medical record review, staff interview, review of the facility investigation and facility policy review, the facility failed to thoroughly investigate the root cause of Resident #27's repeated falls on 03/16/25, 03/30/25, and 04/08/25, and failed to implement appropriate fall prevention interventions for Resident #27 to prevent further falls. Actual Harm occurred on 04/08/25 when Resident #27 fell attempting to transfer herself to the bathroom unsupervised resulting in a fall requiring hospitalization with a distal left tibia fracture. This affected one (Resident #27) of two residents reviewed for falls. The facility census is 50. Findings include: Review of the medical record for Resident #27 revealed an admission date of 12/26/22 and a readmission date of 04/11/25. Diagnoses included fracture of the shaft of the left tibia, hypertension, and type two diabetes mellitus. Review of the care plan dated 12/27/22 revealed Resident #27 has had falls and a potential for injury. Interventions included maintaining a clear pathway and monitoring for side effects of psychotropic medications. Updated interventions included encourage Resident #27 to wear briefs at all times (03/18/25), Resident #27 was to be in a tilt-in-space wheelchair and tilt when Resident #27 wants to rest (03/25/25). Review of the fall risk assessments dated 02/04/25 revealed Resident #27 was at risk for falls. Additional fall risk assessments completed on 03/17/25, 03/30/25, and 04/08/25 revealed Resident #27 was at high risk for falls. Review of the nursing progress note dated 03/16/25 revealed Resident #27 was observed on the floor alongside her bed. Resident #27 was alert and oriented to person only, and unable to describe the events that occurred. Resident #27 was assessed, and no injury was noted. The physician and Resident #27's family were notified. No new orders or fall prevention interventions were implemented at that time. Review of the fall investigation 03/16/25 did not include if the resident was incontinent at the time of the fall, if she was attempting to go to the bathroom at the time of the fall, when she was last toileted, what footwear she was wearing, or if the call light was activated. The Interdisciplinary Team (IDT) implemented an intervention on 03/18/25 to ensure Resident #27 wore briefs at all times as a result of the fall on 03/16/25. Review of the nursing progress note dated 03/30/25 at 6:47 P.M. revealed Resident #27 was observed on the floor in her bathroom. Her wheelchair was in a locked position beside her in front of the sink. The nurse assessed injuries and Resident #27 reported no pain or discomfort at that time. The physician and Resident #27's family were notified. No new orders or fall prevention interventions were implemented at that time. Review of the fall investigation dated 03/30/25 did not include if the resident was incontinent at the time of the fall, if she was attempting to go to the bathroom at the time of the fall, if she was wearing a brief at the time of the fall, when she was last toileted, what footwear she was wearing, or if the call light was activated. The IDT implemented a new fall prevention intervention to apply non-slip strips to Resident #27's bathroom floor in front of the sink on 03/31/25 as a result of the fall on 03/30/25. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had severe cognitive impairment. Resident #27 required extensive assistance with all activities of daily living. Resident #27 was frequently incontinent of urine and bowel. Review of the nursing progress note dated 04/08/25 at 3:02 P.M. revealed Resident #27's roommate informed the nurse that Resident #27 was on the floor in the bathroom. Resident #27 was assessed, and she reported pain in her left leg. The physician and Resident #27's family were notified. An order for an x-ray was obtained. Resident #27 was placed at the nurse's station in her chair as she kept attempting to transfer herself when left alone. Review of the nursing progress note dated 04/08/25 at 10:57 P.M. revealed Resident #27's x-ray of her left leg showed fractures. The nurse called 911, and Resident #27 was sent to the hospital. Resident #27's physician, family, and Director of Nursing (DON) were notified. Review of the fall investigation dated 04/08/25 revealed Resident #27 was attempting to transfer herself when she fell. She was complaining of left leg pain. The physician was notified and an order for a left hip x-ray was ordered. Resident #27 was placed at the nurse's station for extra monitoring. The fall investigation did not reveal if the call light was activated, what time Resident #27 was last toileted before her fall at 3:02 P.M., if she had a brief on as implemented on 03/18/25, if she was tilted back in the tilt-in-space wheelchair as implemented on 03/25/25, if the non-slip strips were on the bathroom floor as implemented on 03/31/25, or what type of footwear she was wearing. Review of the hospital paperwork dated 04/11/25 revealed Resident #27 was discharged from the hospital with a final diagnosis of left distal tibia shaft fracture. Review of the physician's order dated 04/11/25 revealed an order for 5-325 milligrams of Percocet (opioid pain medication) one to two tablets every four hours as needed for pain. Interview on 06/10/25 at 11:22 A.M. with the DON confirmed Resident #27 fell on [DATE] and suffered a fracture of her left tibia. The DON confirmed after every fall, the IDT meets to go over interventions. The DON reported she was not working at the facility at the time of the falls. Interview on 06/10/25 at 12:20 P.M. with Regional Nurse #610 revealed the facility did put a note in the investigation that non-slip strips were added to Resident #27's floor in front of the bathroom sink on 03/31/25 as a result of the fall on 03/30/25, but they did not update the care plan. Regional Nurse #610 confirmed that the facility did not thoroughly investigate the root cause of the falls that occurred on 03/16/25 and 03/30/25 and did not implement appropriate fall prevention interventions determined by a root cause analysis after each fall. She verified that making sure Resident #27, who was falling attempting to transfer herself to the bathroom, was wearing a brief at all times was not an appropriate intervention. Review of the facility policy titled Fall Management, revised July 2024, revealed the facility will develop an individualized fall prevention plan for each resident identified at risk. After a fall the interdisciplinary team will review fall incidents to determine contributing factors, implement appropriate interventions, and adjust the resident's care plan accordingly. This deficiency represents non-compliance investigated under Master Complaint Number OH00166603.

Based on observation, record review, review of staffing (schedules, daily staffing assignment sheets, and employee punch detail), review of a facility concern log, review of resident council minutes, review of the facility Staffing policy and procedure, review of the Facility Assessment, and interviews the facility failed to maintain sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This resulted in Immediate Jeopardy and actual harm on 02/06/23 when there was insufficient staff to ensure Resident #55 who was dependent on staff for care went from 2:00 A.M. to 1:25 P.M. without incontinence care even after repeated requests resulting in the development of a Stage II pressure ulcer (partial thickness wound at the epidermis and dermis level) to her left buttock that was bleeding with excoriation and redness surrounding. The Immediate Jeopardy and actual harm continued 02/08/23 when Resident #52, who required total dependence from two staff for incontinence care and was assessed to be always incontinent of bowel and bladder, went from 5:30 A.M. to 9:34 A.M. without incontinence care after repeated requests for care were made. Resident #52 was found saturated in urine and bowel movement with a dried brown ring on her bottom sheet resulting in excoriation with redness on her peri area and excoriation with bleeding and redness to her bilateral buttocks. The Immediate Jeopardy continued 02/17/23 when 15 residents, Resident #13, #17, #19, #21, #31, #33, #46, #49, #56, #60, #68, #72, #73, #76 and #235, who resided on the [NAME] unit did not receive medication administration, pain assessments or oxygen saturation monitoring due to a lack of staff onsite to provide care. A staffing concern (that did not rise to an Immediate Jeopardy level) occurred on 02/06/23 when the facility failed to ensure Agency Licensed Practical Nurse (LPN) #852 had access to the Electronic Medical Administration Record (EMAR) to administer medications resulting in a significant medication error for Resident #34 as the resident did not receive her seizure medication timely. A staffing concern (that did not rise to an Immediate Jeopardy level) also occurred when the facility did not ensure showers were completed per the care plan and resident's preferences for Residents #39, #45, #50 and #78 due to lack of staff. This affected three residents (#52, #55 and #68) reviewed for incontinence care, one resident (#34) observed during medication administration, 15 residents (13, #17, #19, #21, #31, #33, #46, #49, #56, #60, #68, #72, #73, #76 and #235) residing on the [NAME] unit, four residents (#39, #45, #50 and #78) reviewed for showers, eight residents interviewed and/or who had voiced staffing concerns (#83, #21, #82, #186, #34, #185, #61 and #8) and had the potential to affect all 84 residents residing in the facility. On 02/16/23 at 4:57 P.M. the Administrator and Regional Director of Clinical Services #859 were notified Immediate Jeopardy began on 02/06/23 when a lack of staff resulted in situations of neglect of resident care, including timely incontinence care and medication administration. The Immediate Jeopardy continued on 02/08/23 related to a lack of staff to provide timely incontinence care and on 02/17/23 when there were not enough licensed staff on duty to ensure medications and assessments were completed for residents on the [NAME] unit. The Immediate Jeopardy was removed on 02/22/23 when the facility implemented the following corrective actions: On 02/16/23 at 6:55 P.M. an audit was completed by Unit Manager/ Licensed Practical Nurse (LPN) #974 to ensure that all staff required to use the electronic medical records for medication administration had access. This was verified as completed 02/16/23. On 02/16/23 at 11:42 P.M. Resident #55 was assessed by Regional Clinical Nurse #859 for negative outcomes related to the lack of timely incontinence care. Resident #55 refused to have skin assessed despite education and multiple attempts. Resident has treatment order in place to left buttocks which was ordered on 02/07/23 by Wound NP #968. Resident was updated of current treatment regimen to left buttock and verbalized understanding. This was verified as completed 02/16/23. On 02/16/23 at 11:26 P.M. Resident #52 was assessed by Unit Manager/ LPN #974 for negative outcomes related to the lack of timely incontinence care. Resident #52 has a treatment in place to peri area which was ordered on 02/15/23 by Wound Nurse Practitioner (NP) #968. Resident was updated of new treatment regimen and verbalized understanding. On 02/16/23 at 7:00 P.M. a skin assessment was completed on all residents by Unit Manager/ LPN #975 and Unit Manager/ LPN #974, and Regional Clinical Nurse #859 to ensure that timely and appropriate incontinence care was provided, and residents are free from neglect of care needs by staff. On 02/16/23 at 8:00 P.M. facility current staffing levels were reviewed by the Administrator to ensure adequate staffing for the facility. On 02/17/23 at 8:30 A.M. facility staffing levels were reviewed by Administrator to ensure sufficient staffing to meet resident needs. On 02/17/23 at 9:00 A.M. an audit was completed by Unit Manager/ LPN #974 to ensure that all staff required to use the electronic medical records for medication administration had access. On 02/17/23 at 10:30 A.M. all residents who can be interviewed were questioned on if they have experienced abuse, neglect, exploitation, or misappropriation while in the facility, and if they are receiving timely personal care. Interviews were completed by Administrator, Admissions #806, Environmental Director #842, Human Resources #821, Medical Records/Housekeeping #835, Licensed Social Worker (LSW) #819, Activities #803, and Dietary Manager #808. On 02/17/23 at 1:40 P.M. Resident #34 was assessed by Unit Manager/ LPN #974 for negative outcomes related to not receiving a seizure medication in the appropriate time frame. On 02/17/23 at 1:30 P.M. A medication error report was completed by Unit Manager/ LPN #975 including physician notification and family notification for Resident #34. On 02/17/23 at 1:48 P.M. an audit was completed by Regional Nurse #976 on all residents receiving seizure medication to ensure all medications were administered timely. On 02/17/23 at 2:00 P.M. the Administrator, Director of Nursing, Scheduler #826, Unit Manager/ LPN #974, and Unit Manager/ LPN #975 were educated by Regional Director of Operations #977 on adequate staffing levels to provide timely and appropriate care. On 02/17/23 at 2:00 P.M. a staffing meeting was held by the Administrator to review daily schedule and ensure adequate staffing for the facility. On 02/17/23 at 2:15 P.M. an Ad Hoc Quality Assurance and Performance Improvement (QAPI) was completed including Medical Director #978 via phone. On 02/18/23 at 9:20 A.M. current staffing and schedule were reviewed by Scheduler #826, LSW #819, and Regional Nurse #976 to ensure facility was meeting adequate staffing. On 02/18/23 at 1:00 P.M. Scheduler #826 and [NAME] President (VP) of Clinical Services #977 reviewed schedules for 02/18/23-02/20/23. On 02/18/23 at 1:12 P.M. Scheduler #826 sent weekend schedule to Administrator, Regional Nurse #976, VP of Clinical Services #979, Regional Director of Operations #977, VP of Operations #980, and Human Resources #821 to ensure corporate team had access to facility schedules. On 02/18/23 at 2:15 P.M. Regional Nurse #976 posted on-call list and phone numbers at each nurses' station to ensure all staff have contact numbers for any clinical or staffing concerns. The on-call contact list included: Regional Nurse #976, VP of Clinical Services #979, Regional Director Operations #977, and VP of Operations #980. Beginning on 02/18/23 a plan for audits to be conducted by DON/designee daily to ensure all residents receive timely and appropriate incontinence care and medications were given per physician order and electronic medical record access for all required employees for four weeks then weekly for four weeks then ongoing as needed. Audits verified as completed on 02/18/23, 02/19/23, 02/20/23, and 02/21/23. Beginning on 02/18/23 a plan for resident and/or responsible party interviews to be conducted by the Administrator/designee daily to ensure that all residents remain free from neglect and are receiving adequate and timely personal care. The interviews will be completed with five residents daily for four weeks and then five residents weekly for four weeks then ongoing as needed. Audits verified as completed on 02/18,23, 02/19/23, 02/20/23, and 02/21/23. Beginning on 02/18/23 a plan for audits to be conducted by the Administrator/designee to ensure sufficient staffing to maintain appropriate care for all residents, 5 times weekly for 8 weeks and ongoing as needed. Audits verified as completed on 02/18/23, 02/19/23, 02/20/23, and 02/21/23. Staff education as part of the facility abatement plan was initiated on 02/16/23 and continued through 02/22/23: On 02/16/23 at 9:00 P.M. the interdisciplinary management team (Administrator, Admissions #806, Environmental Director #842, Human Resources #821, Medical Records/Housekeeping #835, Licensed Social Worker (LSW) #819, Activities #803, Dietary Manager #808 with Regional Clinical Nurse #859 began education for staff including clinical topics on timely and appropriate incontinence care, the facility Quality of Life and Dignity policy, answering call lights timely and prevention of pressure ulcer development. Interview with staff on 02/21/23 from 5:05 A.M. to 5:48 A.M. revealed Agency LPN #989, #983, LPN # 848, Agency STNA #988, #984, #985, and STNA #990 were not educated prior to working at the facility. On 02/21/23 at 7:45 A.M. Regional Nurse #976 and Administrator notified of staff not educated prior to start of shift. Interviews with staff on 02/22/23 from 9:59 A.M. to 10:12 A.M. revealed LPN #820 and Agency STNA # 944 did not receive education prior to working at the facility. On 02/22/23 at 10:25 A.M. Regional Director of Operation #977 was notified of staff not being educated prior to shift. On 2/22/23 at 1:00 P.M. the facility implemented a plan to ensure a department head would be assigned to each shift change to ensure education was provided to each employee entering the facility prior to working their assignment. Interview on 02/22/23 from 2:02 P.M. to 2:10 P.M. LPN #820 and Agency STNA #944 received education. All findings will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations. Although the Immediate Jeopardy was removed on 02/22/23, 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) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: 1. Record review for Resident #55 revealed an admitted [DATE] with diagnoses including congestive heart failure, diabetes, chronic kidney disease, morbid obesity, and hypertension. Review of the care plan dated 09/01/20 revealed Resident #55 had an alteration in elimination related to bowel and bladder incontinence. Interventions included check and change every two hours and as needed, monitor for skin redness and irritation, and provide incontinence care as needed. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #55 had intact cognition and required extensive assist of one staff with bed mobility and was totally dependent of two staff with transfers. She required extensive assist of two staff with toileting. She was always incontinent of bowel and bladder. She was at risk for pressure ulcers but had no pressure ulcers during the seven-day assessment reference period. Review of the care plan dated 01/24/23 revealed Resident #55 had actual impaired skin integrity from moisture associated skin damage (MASD) to her right thigh. Interventions included provide wound care per physician order and skin assessment per policy. Review of the Braden scale pressure ulcer risk assessment dated [DATE] and completed by Licensed Practical Nurse (LPN) #971 revealed Resident #55 was at high risk for pressure ulcers due to her sensory perception was very limited, constantly moist, bedfast, and problem with friction and shear. Review of the February 2023 physician's orders, revealed Resident #55 had an order to cleanse her left and right inner thighs, apply collagen to the wound base, and cover with a foam dressing every day shift due to excoriation dated 01/08/23. A new order was obtained on 02/07/23 to cleanse her left buttock with normal saline, apply alginate and a foam dressing due to skin compromise (new open area). Review of the Weekly Observation Tool dated 02/01/23 and completed by LPN/ Unit Manger #809 revealed Resident #55 had facility acquired impaired skin to her left inner thigh from the friction of her brief. There were no measurements, and the treatment was to continue. Review of the Weekly Observation Tool dated 02/01/23 and completed by LPN/ Unit Manger #809 revealed Resident #55 had facility acquired MASD to her right thigh area due to friction and body fluids. The treatment was to continue as ordered. Interview on 02/06/23 at 10:15 A.M. with Resident #55 revealed she activated her call light and staff answered her call light on 02/06/23 at 8:00 A.M. She revealed she told staff that she needed changed, and they turned off her light and walked out of the room. She revealed she was still waiting the staff to come back. She was unable to name the staff as she stated the staff were all from agency, and stated she had different staff almost every day. Interview on 02/06/23 at 10:35 A.M. with Agency State tested Nursing Assistant (STNA) #854 revealed she was the aide assigned to Resident #55, and she had been on the unit alone for three hours. She revealed she had 27 residents and had not provided the residents (including Resident #55) incontinence care as she had just finished with breakfast trays. Interview and observation on 02/06/23 at 11:17 A.M. with Resident #55 revealed staff had not come back to provide incontinence care. She again stated she had asked at 8:00 A.M. She revealed the last time she was changed was on 02/06/23 at 2:00 A.M. She revealed staff always said they would be back after they answered her call light, but they never returned. Observation on 02/06/23 at 11:59 A.M. revealed Resident #55 yelled out as Agency STNA #854 walked by her room. Resident #55 stated to Agency STNA #854 that she was still waiting to be changed and stated she had been waiting since 8:00 A.M. Agency STNA #854 stated to Resident #55 that she was waiting for Agency LPN #852 to do her dressing change and she was going to change her at the same time. Agency STNA #854 also told to Resident #55 that she also had to finish changing two other residents down the hall and then she would get to her. Observation on 02/06/23 at 12:38 P.M. revealed Agency STNA #854 asked Agency LPN #852 to let her know when she was ready to change Resident #55's dressings as she was going to change her at the same time. Agency LPN #852 stated she was ready anytime. Agency STNA #854 then stated, well right now, I am going to chart and stuff. Agency STNA #853 who also was assigned Resident #55's unit came up to the nursing station at the same time and proceeded to remain at the nursing station from 12:38 A.M. to 12:45 P.M. on her personal phone and Agency STNA #854 continued to document. Observation revealed on 02/06/23 at 12:45 P.M. Agency STNA #854 stated to Agency LPN #852 oh well, trays are here now. Observation on 02/06/23 at 1:25 P.M. revealed Agency LPN #852 asked Agency STNA #853 to assist her in doing Resident #55's incontinence care and wound care. While in the room, Resident #55 requested only Agency LPN #852 complete her incontinence care and wound care. Agency LPN #852 then proceeded to provide incontinence care. Observation revealed Resident #55's brief was heavily saturated in urine as Agency LPN #852 stated if she had to estimate, Resident #55 had urinated at least five times. Observation also revealed Resident #55 was incontinent of a moderate amount of bowel movement and parts of the bowel movement were dried to her bilateral inner thighs. Agency LPN #852 was asked to describe her skin integrity and she revealed her peri area and buttocks were excoriated with redness and bleeding. She revealed Resident #55 was tender to touch as Resident #55 stated ouch, ouch when provided incontinence care. Resident #55 then proceeded to say it was very sore and tender as she had not been changed since 2:00 AM. (almost 12 hours). Agency LPN #852 completed her wound dressing changes as ordered. She then noted a new open area to Resident #55's left buttock. Agency LPN #852 described the new open area as a Stage II pressure ulcer that measured 1.0 centimeter (cm) in length by 1.0 cm in width, and she revealed she was unable to determine the depth as there was a large amount of bleeding. She revealed the area was surrounded by redness. Resident #55 then became upset and started to cry as Agency LPN #852 was informing her of the new area. Resident #55 again stated that she had not been changed since 2:00 A.M. and that she had asked at 8:00 A.M. and then also again after that, and nobody changed her. She revealed now she had another pressure ulcer and that she would never get healed. Interview on 02/06/23 at 2:15 P.M. with Resident #55's daughter revealed she had informed management staff multiple times regarding her mother not getting changed at least every two hours and that even after she brought up the concern, things had not improved. She felt the facility never had enough staff on to meet her needs as she had been at the facility multiple times and had witnessed her mother request assistance and the staff stated she had to wait as there was not enough staff to get to her. She revealed she was upset because her mother had a new pressure ulcer because the facility did not provide the care she needed. Review of nursing note dated 02/06/23 at 2:07 P.M. and completed by Agency LPN #852 revealed during wound care Resident #55 was found to have another small open area to her left buttock with moderate amount of blood. The area was about 1.0 cm in size. The wound was cleaned with normal saline, and a dressing was applied. Interview on 02/07/23 at 3:12 P.M. with the Director of Nursing revealed incontinence care was to be completed every two hours and/ or as needed if it was needed prior. Review of the facility policy labeled, Perineal Care, dated October 2010, revealed the purpose of this procedure was to provide cleanliness and comfort to the resident, prevent infection and skin irritation, and observe the residents skin condition. The policy did not include language to provide perineal care timely. 2. Review of the medical record for Resident #52 revealed an admitted [DATE] with diagnoses including atrial fibrillation, diabetes, morbid obesity, and congestive heart failure. Review of the care plan dated 06/02/22 revealed Resident #52 had an alteration in elimination. She was incontinent of bowel and bladder. Interventions included incontinence care as needed and monitor skin for redness and irritation. Review of the care plan dated 06/02/22 revealed Resident #52 was at risk for impaired skin integrity due to morbid obesity. Interventions included barrier cream after each incontinent episode, skin assessment as ordered, and turn and reposition as ordered. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #52 had intact cognition. She required extensive assist of two staff with bed mobility. She was totally dependent of two staff with toileting and transfers. She was always incontinent of bowel and bladder. Review of an email dated 01/17/23 at 8:28 P.M. from LPN #820 to Regional Director of Clinical Services #859 revealed LPN #820 answered Resident #52's call light, and she had expressed that she was waiting to be changed. The email noted STNA #856 had answered her call light on 01/17/23 at 6:30 P.M. and turned her call light off and stated she would return. The email noted LPN #820 stated she had asked STNA #856 to answer Resident #52's call light. The email noted she followed up with Resident #52 who stated STNA #856 had not provided incontinence care. The email revealed Resident #52 was lying in bowel movement for an hour, and STNA #856 left the facility without changing the resident. Review of the Weekly Skin assessment dated [DATE] and completed by LPN #971 revealed Resident #52's skin was intact, and no issues were noted. Review of the Braden scale pressure ulcer risk assessment dated [DATE] authored by LPN #971 revealed Resident #52 was at high risk for skin breakdown. Interview on 02/06/23 at 9:48 A.M. and on 02/07/23 at 11:02 A.M. with Resident #52 revealed it five to six hours to get changed most the time. She revealed she would activate her call light and when staff answered her call light, she would ask to get changed and staff would say they would be back, but they did not return for several hours. She revealed on 02/05/23 she was not changed for over 12 hours even though she had asked several times. She revealed several weeks ago an STNA #856 had answered her call light at approximately 6:30 P.M. and said she would be back but never returned. She revealed she notified LPN #820 and she stated she would have STNA #856 change her. She revealed STNA #856 never changed her as she left at the end of her shift. She revealed she did not end up getting changed until approximately 8:00 P.M. She revealed LPN #820 stated she would notify management of the concern, but they had never followed up with her regarding the incident. Interview on 02/07/23 at 8:31 A.M. with LPN #820 revealed she reported an incident she felt was neglect a few weeks ago as STNA #856 had answered Resident #52's call light and Resident #52 had asked to be changed, and STNA #856 stated she would be back. She revealed Resident #52 had also reported to her that she needed changed so she had instructed STNA #856 to change Resident #52, but she never changed her and left the facility. She revealed she reported the incident to Regional Director of Clinical Services #859 in writing. She revealed she had witnessed this occur multiple times especially from the agency staff as they would sit behind the nursing station and not assist the residents with incontinence care. Interview on 02/07/23 at 3:12 P.M. with the Director of Nursing revealed incontinence care was to be completed every two hours and/ or as needed if it was needed prior. Interview on 02/07/23 at 4:30 P.M. with Activities #803 revealed she held Resident Council Meetings monthly. She revealed on 11/29/22 several residents, including Resident #52, revealed they had not been receiving proper care including timely incontinence care. She revealed on 01/25/23 residents complained of being left soiled, including Resident #52. She revealed the facility had not had consistent management and it was hard as she filled out individual grievance reports to voice residents' concerns after the resident council meeting but felt the issues were not addressed as the same concerns continued monthly. Interview and observation on 02/08/23 at 8:32 A.M. revealed Resident #52 had her call light on, and a strong odor of urine and bowel movement was coming from her room. She had tears in her eyes and stated, it is happening again as her call light had been on since 7:45 A.M. as she needed changed as she was lying in a soiled mess. She revealed she had a bowel movement, and her skin was burning. Observation on 02/08/23 at 8:46 A.M. revealed the Administrator answered the resident's call light and Resident #52 explained she needed changed. The Administrator asked what nursing station she was assigned to (since her room was in the middle of the two nursing stations). The Administrator proceeded to the nursing station and left the resident's call light on. Observation on 02/08/23 at 9:14 A.M. revealed Agency STNA #862 answered Resident #52's call light and the resident again stated she needed changed. Agency STNA #862 revealed she would tell the resident's aide and proceeded to notify STNA #833. Observation on 02/08/23 at 9:22 A.M. revealed STNA #833 walked into Resident #52's room and told Resident #52 she had to collect breakfast trays and then would provide her incontinence care. Observation on 02/08/23 at 9:34 A.M. of incontinence care completed by STNA #833 and STNA #857 for Resident #52 revealed the resident had excoriation with redness on her peri area and excoriation with bleeding and redness to her buttocks. Resident #52's brief was heavily saturated with urine as well as a large brown dried ring on the resident's bottom sheet. The resident had also been incontinent of large amount of bowel movement. STNA #833 verified the above findings. Resident #52 stated she had not been changed since 5:30 A.M. STNA #833 revealed there was only one aide on the unit on night shift, and she was not able to get to Resident #52 prior. Review of the facility policy labeled, Perineal Care, dated October 2010, revealed the purpose of this procedure was to provide cleanliness and comfort to the resident, prevent infection and skin irritation, and observe the residents skin condition. The policy did not include language to provide perineal care timely. 3. On 02/17/23 review of the facility staffing schedule revealed there was four nurses (one Registered Nurse (RN) and three LPN's) scheduled 7:00 A.M. to 7:00 P.M. and two nurses (two LPN's) scheduled 7:00 P.M. to 7:00 A.M. as two LPNs from agency did not show up per the Daily Assignment Sheet. The facility census was 85. On 02/18/23 at 8:05 A.M. interview with LPN #848 revealed she was scheduled 7:00 P.M. to 7:00 A.M. and they had two nurses that did not show up for their shift at 7:00 P.M. She revealed Agency LPN #993 was on 02/17/23 from 7:00 A.M. to 7:00 P.M. and came to her at approximately 10:30 P.M. to hand her the keys for the [NAME] unit. She revealed Agency LPN #993 stated she was only supposed to stay till 7:00 P.M. and had not passed any of the medications that were scheduled (HS - 8:00 P.M.) per the MAR for the residents residing on the unit. LPN #848 revealed she was unable to administer any of the medications on the [NAME] unit as she had her own unit to complete. She verified residents on the [NAME] unit did not receive their medications, were not assessed for pain and had no monitoring of their oxygen saturation level on 02/17/23 scheduled for HS-8:00 P.M. She revealed the physician and/or responsible party was not notified of medications not being administered/assessments not being completed. She revealed she had attempted to contact Regional Director of Clinical Services #859 (acting Director of Nursing), Administrator, and Scheduler #826 by phone to update them regarding medications not being passed due to lack of staffing, but she did not receive a call back. On 02/18/23 at 9:02 A.M. and 10:55 A.M. interview with Scheduler #826 revealed her phone was broke and she was unable to receive any calls and/or messages. She revealed she let Regional Director of Clinical Nurse #859 know prior that her phone was not working and had provided her a different number to call her on regarding staffing issues. She revealed the staff on the floor were not provided this number. On 02/18/23 at 9:08 A.M. interview with Agency LPN #993 revealed she was scheduled 02/17/23 from 7:00 A.M. to 7:00 P.M. on the [NAME] unit. She revealed her relief at 7:00 P.M. did not show up. She revealed she had contacted Scheduler #826 and notified her that her relief did not show up but received no return call. She also called Regional Director of Clinical Nurse #859 but was unable to leave a message as her voicemail box was full. She verified she did not administer any medications that were scheduled at HS- 8:00 P.M. on the [NAME] unit as she was only scheduled till 7:00 P.M. and was also busy completing her other assigned work including documentation. She revealed she left the facility at approximately 10:58 P.M. and had given the keys and report which included that she did not administer the HS medications on the [NAME] unit on 02/17/23. On 02/18/23 from 9:25 A.M. to 9:32 A.M. revealed Resident #13, #17, #19, #21, #31, #33, #46, #49, #56, #60, #68, #72, #73, #76 and #235, who resided on the [NAME] unit that did not receive their medications were cognitively impaired and unable to be interviewed. On 02/18/23 at 10:21 A.M. and 11:09 A.M. interview with Regional Nurse #976 revealed she spoke with Regional Director of Clinical Nurse #859 who stated that she had gone out of state and was in a remote area and unable to receive phone calls. Regional Nurse #976 verified Regional Director of Clinical Nurse #859 was the acting Director of Nursing for the facility and stated she placed a notice at the nursing station to contact MDS/Registered Nurse (RN) #824 of any nursing concerns. Regional Nurse #976 verified she was unable to locate the notice/ posting at the nursing stations regarding to contact MDS/ RN #826. She revealed she spoke with the Administrator who denied getting any phone calls. She revealed she had just found out about Scheduler #826's phone not working and was unable to receive calls. On 02/18/23 at 10:58 A.M. interview with RN #981 revealed she worked on 02/17/23 from 7:00 A.M. to 12:45 A.M. on 02/18/23. She revealed she had only been scheduled to work from 7:00 A.M. to 7:00 P.M. but her relief did not show up. She revealed she had contacted Regional Director of Clinical Services #859, and Administrator multiple times and left multiple messages until finally when she attempted to reach Regional Director of Clinical Services #859 the mailbox stated it was full. She revealed they did not return her call so that she could notify them of the insufficient staffing at the facility as two nurses did not show up to replace Agency LPN #993 or herself. The following residents were affected by the lack of available staff on 02/17/23 to provide care, including medication administration and assessments as ordered to prevent incidents of neglect: a. Review of the medical record for Resident #13 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, acute respiratory failure with hypoxia, major depression, and moderate protein-calorie malnutrition. Review of the February 2023 Medication Administration Record (MAR) for Resident #13 revealed she had an order that included: Remeron 7.5 mg (antidepressant) by mouth at bedtime (MAR indicated to be given HS 8:00 P.M.). She also had an order for the nurse to assess her pain level at night. The MAR revealed the Remeron 7.5 mg was not administered, and pain level was not assessed on 02/17/23. b. Review of medical record for Resident #68 revealed an admitted [DATE] with diagnoses including dementia, anxiety, and major depression. Review of February 2023 MAR for Resident #68 revealed she was to have her pain level assessed at night. The MAR revealed her pain level was not assessed on 02/17/23. c. Review of medical record for Resident #21 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, insomnia, hypertension, and asthma. Review of the February 2023 MAR for Reside [TRUNCATED]

Based on observation, record review, facility policy and procedure review, and interview the facility failed to ensure residents were provided adequate and timely personal care to prevent incidents of neglect. This resulted in Immediate Jeopardy and actual harm on 02/06/23 when Resident #55, who required extensive assist of two staff for activities of daily living care and was assessed to be always incontinent of bowel and bladder, went from 02/06/23 at 2:00 A.M. to 1:25 P.M. before being provided incontinence care after repeated requests. Resident #55 was observed to be saturated in urine and dried bowel movement on her bilateral thighs area resulting in the development of a Stage II pressure ulcer (partial thickness wound at the epidermis and dermis level) to her left buttock that was bleeding with excoriation and redness surrounding. The Immediate Jeopardy and actual harm continued 02/08/23 when Resident #52, who required total dependence from two staff for incontinence care and was assessed to be always incontinent of bowel and bladder, went from 02/08/23 at 5:30 A.M. to 9:34 A.M. without incontinence care after repeated requests. Resident #52 was found saturated in urine and bowel movement with a dried brown ring on her bottom sheet resulting in excoriation with redness on her peri area and excoriation with bleeding and redness to her bilateral buttocks. The Immediate Jeopardy continued 02/17/23 when 15 residents, Resident #13, #17, #19, #21, #31, #33, #46, #49, #56, #60, #68, #72, #73, #76 and #235, who resided on the [NAME] unit did not receive medication administration, pain assessments or oxygen saturation monitoring due to a lack of staff onsite to provide care. A situation of neglect (that did not rise to an Immediate Jeopardy level) occurred on 02/06/23 when the facility failed to ensure Agency Licensed Practical Nurse (LPN) #852 had access to the Electronic Medical Administration Record (EMAR) to administer medications resulting in a significant medication error for Resident #34 as the resident did not receive her seizure medication timely. A situation of neglect (that did not rise to an Immediate Jeopardy level) occurred on 02/25/23 when STNA staff failed to provide incontinence care timely at the resident's request. Resident #59 was assisted out of bed by staff at approximately 8:00 A.M. The resident then reported to STNA #857 and STNA #475 he needed changed and was told by STNA #475 that she had already cleaned him up before he had gotten up in his wheelchair and told him to roll back that way despite being incontinent of bowel movement. STNA #475 verified she told Resident #59 this as she stated the workload was heavy and she had another resident who needed care. STNA #857 verified she witnessed STNA #475 and Resident #59's interaction and revealed she then assisted Resident #59 with incontinence care and changed him at approximately 9:00 A.M. She confirmed he was incontinent of bowel and urine. Resident #59 revealed he was furious STNA #475 was not going to change him despite being incontinent of bowel and stated the STNA had done this on prior occasions as well. The resident indicated he later left the facility without notifying staff because he was not staying at a facility that treated him in that manner. This affected three residents (#52, #55 and #59) reviewed for incontinence care, one resident (#34) observed during medication administration, 15 residents (13, #17, #19, #21, #31, #33, #46, #49, #56, #60, #68, #72, #73, #76 and #235) residing on the [NAME] unit and had the potential to affect all 84 residents residing in the facility. On 02/16/23 at 4:57 P.M. the Administrator and Regional Director of Clinical Services #859 were notified Immediate Jeopardy began on 02/06/23 when a lack of staff resulted in situations of neglect of resident care. The Immediate Jeopardy continued on 02/08/23 as a result of continued incidents of neglect of resident care. The Immediate Jeopardy continued on 02/17/23 when there were not enough licensed staff on duty to ensure medications and assessments were completed for residents on the [NAME] unit resulting in resident neglect. The Immediate Jeopardy was removed on 02/22/23 when the facility implemented the following corrective actions: On 02/16/23 at 6:55 P.M. an audit was completed by Unit Manager/ Licensed Practical Nurse (LPN) #974 to ensure that all staff required to use the electronic medical records for medication administration had access. This was verified as completed 02/16/23. On 02/16/23 at 7:59 P.M. the Administrator submitted a Self-Reported Incident (SRI) related to an allegation of neglect involving Resident #52. On 02/16/23 at 11:42 P.M. Resident #55 was assessed by Regional Clinical Nurse #859 for negative outcomes related to the lack of timely incontinence care. Resident #55 refused to have skin assessed despite education and multiple attempts. Resident has treatment order in place to left buttocks which was ordered on 02/07/23 by Wound NP #968. Resident was updated of current treatment regimen to left buttock and verbalized understanding. This was verified as completed 02/16/23. On 02/16/23 at 11:26 P.M. Resident #52 was assessed by Unit Manager/ LPN #974 for negative outcomes related to the lack of timely incontinence care. Resident #52 has a treatment in place to peri area which was ordered on 02/15/23 by Wound Nurse Practitioner (NP) #968. Resident was updated of new treatment regimen and verbalized understanding. On 02/16/23 at 7:00 P.M. a skin assessment was completed on all residents by Unit Manager/ LPN #975 and Unit Manager/ LPN #974, and Regional Clinical Nurse #859 to ensure that timely and appropriate incontinence care was provided, and residents are free from neglect of care needs by staff. On 02/16/23 at 8:00 P.M. facility current staffing levels were reviewed by the Administrator to ensure adequate staffing for the facility. On 02/17/23 at 8:30 A.M. facility staffing levels were reviewed by Administrator to ensure sufficient staffing to meet resident needs. On 02/17/23 at 9:00 A.M. an audit was completed by Unit Manager/ LPN #974 to ensure that all staff required to use the electronic medical records for medication administration had access. On 02/17/23 at 10:30 A.M. all residents who can be interviewed were questioned on if they have experienced abuse, neglect, exploitation, or misappropriation while in the facility, and if they are receiving timely personal care. Interviews were completed by Administrator, Admissions #806, Environmental Director #842, Human Resources #821, Medical Records/Housekeeping #835, Licensed Social Worker (LSW) #819, Activities #803, and Dietary Manager #808. On 02/17/23 at 11:42 A.M. the Administrator submitted an SRI related to an allegation of neglect for Resident #55. On 02/17/23 at 1:40 P.M. Resident #34 was assessed by Unit Manager/ LPN #974 for negative outcomes related to not receiving a seizure medication in the appropriate time frame. On 02/17/23 at 1:30 P.M. A medication error report was completed by Unit Manager/ LPN #975 including physician notification and family notification for Resident #34. On 02/17/23 at 1:48 P.M. an audit was completed by Regional Nurse #976 on all residents receiving seizure medication to ensure all medications were administered timely. On 02/17/23 at 2:00 P.M. the Administrator, Director of Nursing, Scheduler #826, Unit Manager/ LPN #974, and Unit Manager/ LPN #975 were educated by Regional Director of Operations #977 on adequate staffing levels to provide timely and appropriate care. On 02/17/23 at 2:00 P.M. a staffing meeting was held by the Administrator to review daily schedule and ensure adequate staffing for the facility. On 02/17/23 at 2:15 P.M. an Ad Hoc Quality Assurance and Performance Improvement (QAPI) was completed including Medical Director #978 via phone. On 02/18/23 at 9:20 A.M. current staffing and schedule were reviewed by Scheduler #826, LSW #819, and Regional Nurse #976 to ensure facility was meeting adequate staffing. On 02/18/23 at 1:00 P.M. Scheduler #826 and [NAME] President (VP) of Clinical Services #977 reviewed schedules for 02/18/23-02/20/23. On 02/18/23 at 1:12 P.M. Scheduler #826 sent weekend schedule to Administrator, Regional Nurse #976, VP of Clinical Services #979, Regional Director of Operations #977, VP of Operations #980, and Human Resources #821 to ensure corporate team had access to facility schedules. On 02/18/23 at 2:15 P.M. Regional Nurse #976 posted on-call list and phone numbers at each nurses' station to ensure all staff have contact numbers for any clinical or staffing concerns. The on-call contact list included: Regional Nurse #976, VP of Clinical Services #979, Regional Director Operations #977, and VP of Operations #980. Beginning on 02/18/23 a plan for audits to be conducted by DON/designee daily to ensure all residents receive timely and appropriate incontinence care and medications were given per physician order and electronic medical record access for all required employees for four weeks then weekly for four weeks then ongoing as needed. Audits verified as completed on 02/18/23, 02/19/23, 02/20/23, and 02/21/23. Beginning on 02/18/23 a plan for resident and/or responsible party interviews to be conducted by the Administrator/designee daily to ensure that all residents remain free from neglect and are receiving adequate and timely personal care. The interviews will be completed with five residents daily for four weeks and then five residents weekly for four weeks then ongoing as needed. Audits verified as completed on 02/18,23, 02/19/23, 02/20/23, and 02/21/23. Beginning on 02/18/23 a plan for audits to be conducted by the Administrator/designee to ensure sufficient staffing to maintain appropriate care for all residents, 5 times weekly for 8 weeks and ongoing as needed. Audits verified as completed on 02/18/23, 02/19/23, 02/20/23, and 02/21/23. Staff education as part of the facility abatement plan was initiated on 02/16/23 and continued through 02/22/23: On 02/16/23 at 9:00 P.M. the interdisciplinary management team (Administrator, Admissions #806, Environmental Director #842, Human Resources #821, Medical Records/Housekeeping #835, Licensed Social Worker (LSW) #819, Activities #803, Dietary Manager #808 with Regional Clinical Nurse #859 began education for staff including clinical topics on timely and appropriate incontinence care, the facility Quality of Life and Dignity policy, answering call lights timely and prevention of pressure ulcer development. Interview with staff on 02/21/23 from 5:05 A.M. to 5:48 A.M. revealed Agency LPN #989, #983, LPN #848, Agency STNA #988, #984, #985, and STNA #990 were not educated prior to working at the facility. On 02/21/23 at 7:45 A.M. Regional Nurse #976 and Administrator notified of staff not educated prior to start of shift. Interviews with staff on 02/22/23 from 9:59 A.M. to 10:12 A.M. revealed LPN #820 and Agency STNA #944 did not receive education prior to working at the facility. On 02/22/23 at 10:25 A.M. [NAME] President of Clinical Services #979 was notified of staff not being educated prior to shift. On 2/22/23 at 1:00 P.M. the facility implemented a plan to ensure a department head would be assigned to each shift change to ensure education was provided to each employee entering the facility prior to working their assignment. Interview on 02/22/23 from 2:02 P.M. to 2:10 P.M. LPN #820 and Agency STNA #944 received education. All findings will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations. Although the Immediate Jeopardy was removed on 02/22/23, 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) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: 1. Record review for Resident #55 revealed an admitted [DATE] with diagnoses including congestive heart failure, diabetes, chronic kidney disease, morbid obesity, and hypertension. Review of the care plan dated 09/01/20 revealed Resident #55 had an alteration in elimination related to bowel and bladder incontinence. Interventions included check and change every two hours and as needed, monitor for skin redness and irritation, and provide incontinence care as needed. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #55 had intact cognition and required extensive assist of one staff with bed mobility and was totally dependent of two staff with transfers. She required extensive assist of two staff with toileting. She was always incontinent of bowel and bladder. She was at risk for pressure ulcers but had no pressure ulcers during the seven-day assessment reference period. Review of the care plan dated 01/24/23 revealed Resident #55 had actual impaired skin integrity from moisture associated skin damage (MASD) to her right thigh. Interventions included provide wound care per physician order and skin assessment per policy. Review of the Braden scale pressure ulcer risk assessment dated [DATE] and completed by Licensed Practical Nurse (LPN) #971 revealed Resident #55 was at high risk for pressure ulcers due to her sensory perception was very limited, constantly moist, bedfast, and problem with friction and shear. Review of the February 2023 physician's orders, revealed Resident #55 had an order to cleanse her left and right inner thighs, apply collagen to the wound base, and cover with a foam dressing every day shift due to excoriation dated 01/08/23. A new order was obtained on 02/07/23 to cleanse her left buttock with normal saline, apply alginate and a foam dressing due to skin compromise (new open area). Review of the Weekly Observation Tool dated 02/01/23 and completed by LPN/ Unit Manger #809 revealed Resident #55 had facility acquired impaired skin to her left inner thigh from the friction of her brief. There were no measurements, and the treatment was to continue. Review of the Weekly Observation Tool dated 02/01/23 and completed by LPN/ Unit Manger #809 revealed Resident #55 had facility acquired MASD to her right thigh area due to friction and body fluids. The treatment was to continue as ordered. Interview on 02/06/23 at 10:15 A.M. with Resident #55 revealed she activated her call light and staff answered her call light on 02/06/23 at 8:00 A.M. She revealed she told staff that she needed changed, and they turned off her light and walked out of the room. She revealed she was still waiting the staff to come back. She was unable to name the staff as she stated the staff were all from agency, and stated she had different staff almost every day. Interview on 02/06/23 at 10:35 A.M. with Agency State tested Nursing Assistant (STNA) #854 revealed she was the aide assigned to Resident #55, and she had been on the unit alone for three hours. She revealed she had 27 residents and had not provided the residents (including Resident #55) incontinence care as she had just finished with breakfast trays. Interview and observation on 02/06/23 at 11:17 A.M. with Resident #55 revealed staff had not come back to provide incontinence care. She again stated she had asked at 8:00 A.M. She revealed the last time she was changed was on 02/06/23 at 2:00 A.M. She revealed staff always said they would be back after they answered her call light, but they never returned. Observation on 02/06/23 at 11:59 A.M. revealed Resident #55 yelled out as Agency STNA #854 walked by her room. Resident #55 stated to Agency STNA #854 that she was still waiting to be changed and stated she had been waiting since 8:00 A.M. Agency STNA #854 stated to Resident #55 that she was waiting for Agency LPN #852 to do her dressing change and she was going to change her at the same time. Agency STNA #854 also told to Resident #55 that she also had to finish changing two other residents down the hall and then she would get to her. Observation on 02/06/23 at 12:38 P.M. revealed Agency STNA #854 asked Agency LPN #852 to let her know when she was ready to change Resident #55's dressings as she was going to change her at the same time. Agency LPN #852 stated she was ready anytime. Agency STNA #854 then stated, well right now, I am going to chart and stuff. Agency STNA #853 who also was assigned Resident #55's unit came up to the nursing station at the same time and proceeded to remain at the nursing station from 12:38 A.M. to 12:45 P.M. on her personal phone and Agency STNA #854 continued to document. Observation revealed on 02/06/23 at 12:45 P.M. Agency STNA #854 stated to Agency LPN #852 oh well, trays are here now. Observation on 02/06/23 at 1:25 P.M. revealed Agency LPN #852 asked Agency STNA #853 to assist her in doing Resident #55's incontinence care and wound care. While in the room, Resident #55 requested only Agency LPN #852 complete her incontinence care and wound care. Agency LPN #852 then proceeded to provide incontinence care. Observation revealed Resident #55's brief was heavily saturated in urine as Agency LPN #852 stated if she had to estimate, Resident #55 had urinated at least five times. Observation also revealed Resident #55 was incontinent of a moderate amount of bowel movement and parts of the bowel movement were dried to her bilateral inner thighs. Agency LPN #852 was asked to describe her skin integrity and she revealed her peri area and buttocks were excoriated with redness and bleeding. She revealed Resident #55 was tender to touch as Resident #55 stated ouch, ouch when provided incontinence care. Resident #55 then proceeded to say it was very sore and tender as she had not been changed since 2:00 AM. (almost 12 hours). Agency LPN #852 completed her wound dressing changes as ordered. She then noted a new open area to Resident #55's left buttock. Agency LPN #852 described the new open area as a Stage II pressure ulcer that measured 1.0 centimeter (cm) in length by 1.0 cm in width, and she revealed she was unable to determine the depth as there was a large amount of bleeding. She revealed the area was surrounded by redness. Resident #55 then became upset and started to cry as Agency LPN #852 was informing her of the new area. Resident #55 again stated that she had not been changed since 2:00 A.M. and that she had asked at 8:00 A.M. and then also again after that, and nobody changed her. She revealed now she had another pressure ulcer and that she would never get healed. Interview on 02/06/23 at 2:15 P.M. with Resident #55's daughter revealed she had informed management staff multiple times regarding her mother not getting changed at least every two hours and that even after she brought up the concern, things had not improved. She revealed she was upset because her mother had a new pressure ulcer because the facility did not provide the care she needed. Review of nursing note dated 02/06/23 at 2:07 P.M. and completed by Agency LPN #852 revealed during wound care Resident #55 was found to have another small open area to her left buttock with moderate amount of blood. The area was about 1.0 cm in size. The wound was cleaned with normal saline, and a dressing was applied. Interview on 02/07/23 at 3:12 P.M. with the Director of Nursing revealed incontinence care was to be completed every two hours and/ or as needed if it was needed prior. Review of a facility self-reported incident, dated 02/17/23 revealed the facility reported an incident of neglect involving Resident #55 to the State agency. The SRI revealed the resident was not provided timely incontinence care. Review of the SRI revealed the facility substantiated the incident of neglect. Review of the facility policy labeled, Perineal Care, dated October 2010, revealed the purpose of this procedure was to provide cleanliness and comfort to the resident, prevent infection and skin irritation, and observe the residents skin condition. The policy did not include language to provide perineal care timely. 2. Review of the medical record for Resident #52 revealed an admitted [DATE] with diagnoses including atrial fibrillation, diabetes, morbid obesity, and congestive heart failure. Review of the care plan dated 06/02/22 revealed Resident #52 had an alteration in elimination. She was incontinent of bowel and bladder. Interventions included incontinence care as needed and monitor skin for redness and irritation. Review of the care plan dated 06/02/22 revealed Resident #52 was at risk for impaired skin integrity due to morbid obesity. Interventions included barrier cream after each incontinent episode, skin assessment as ordered, and turn and reposition as ordered. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #52 had intact cognition. She required extensive assist of two staff with bed mobility. She was totally dependent of two staff with toileting and transfers. She was always incontinent of bowel and bladder. Review of an email dated 01/17/23 at 8:28 P.M. from LPN #820 to Regional Director of Clinical Services #859 revealed LPN #820 answered Resident #52's call light, and she had expressed that she was waiting to be changed. The email noted STNA #856 had answered her call light on 01/17/23 at 6:30 P.M. and turned her call light off and stated she would return. The email noted LPN #820 stated she had asked STNA #856 to answer Resident #52's call light. The email noted she followed up with Resident #52 who stated STNA #856 had not provided incontinence care. The email revealed Resident #52 was lying in bowel movement for an hour, and STNA #856 left the facility without changing the resident. Record review revealed a facility investigation, dated 1/20/23 completed by Regional Director of Clinical Services #859. The investigation revealed on 01/17/23 she had received a message by email from LPN #820 regarding Resident #52 not being changed timely by STNA #856. The investigation revealed on 01/18/23 Regional Director of Clinical Services #859 spoke with Former LPN/ Unit Manager #971, and he had provided information the resident did get changed. Review of the Weekly Skin assessment dated [DATE] and completed by LPN #971 revealed Resident #52's skin was intact, and no issues were noted. Review of the Braden scale pressure ulcer risk assessment dated [DATE] authored by LPN #971 revealed Resident #52 was at high risk for skin breakdown. Interview on 02/06/23 at 9:48 A.M. and on 02/07/23 at 11:02 A.M. with Resident #52 revealed it five to six hours to get changed most the time. She revealed she would activate her call light and when staff answered her call light, she would ask to get changed and staff would say they would be back, but they did not return for several hours. She revealed on 02/05/23 she was not changed for over 12 hours even though she had asked several times. She revealed several weeks ago an STNA #856 had answered her call light at approximately 6:30 P.M. and said she would be back but never returned. She revealed she notified LPN #820 and she stated she would have STNA #856 change her. She revealed STNA #856 never changed her as she left at the end of her shift. She revealed she did not end up getting changed until approximately 8:00 P.M. She revealed LPN #820 stated she would notify management of the concern, but they had never followed up with her regarding the incident. Interview on 02/07/23 at 8:31 A.M. with LPN #820 revealed she reported an incident she felt was neglect a few weeks ago as STNA #856 had answered Resident #52's call light and Resident #52 had asked to be changed, and STNA #856 stated she would be back. She revealed Resident #52 had also reported to her that she needed changed so she had instructed STNA #856 to change Resident #52, but she never changed her and left the facility. She revealed she reported the incident to Regional Director of Clinical Services #859 in writing. She revealed she had witnessed this occur multiple times especially from the agency staff as they would sit behind the nursing station and not assist the residents with incontinence care. Interview on 02/07/23 at 9:34 A.M. with Regional Director of Clinical Services #859 revealed she had never received an email and/ or anything in writing from any staff member regarding Resident #52 not being changed in a timely manner by staff including a staff member leaving the facility after Resident #52 had requested to be changed and a nurse requesting the staff to change her. During a follow up interview on 02/07/23 at 12:40 P.M. Regional Director of Clinical Services #859 revealed she had just remembered there had been an investigation that was completed regarding the allegation Resident #52 and LPN #820 had made on 01/17/23. She stated she had forgotten about it until she was looking through her stuff. She verified the complaint/concern was not placed on the grievance log and denied filing a self-reported incident to the State agency related to an incident of neglect. She verified in the email LPN #820 had stated Resident #52 had been lying in bowel movement and not changed for an hour after repeated requests to be changed, and STNA #856 assigned to care for Resident, #52 left the facility without changing her. Interview on 02/07/23 at 3:12 P.M. with the Director of Nursing revealed incontinence care was to be completed every two hours and/ or as needed if it was needed prior. Interview on 02/07/23 at 4:30 P.M. with Activities #803 revealed she held Resident Council Meetings monthly. She revealed on 11/29/22 several residents, including Resident #52, revealed they had not been receiving proper care including timely incontinence care. She revealed on 01/25/23 residents complained of being left soiled, including Resident #52. She revealed the facility had not had consistent management and it was hard as she filled out individual grievance reports to voice residents' concerns after the resident council meeting but felt the issues were not addressed as the same concerns continued monthly. Interview and observation on 02/08/23 at 8:32 A.M. revealed Resident #52 had her call light on, and a strong odor of urine and bowel movement was coming from her room. She had tears in her eyes and stated, it is happening again as her call light had been on since 7:45 A.M. as she needed changed as she was lying in a soiled mess. She revealed she had a bowel movement, and her skin was burning. Observation on 02/08/23 at 8:46 A.M. revealed the Administrator answered the resident's call light and Resident #52 explained she needed changed. The Administrator asked what nursing station she was assigned to (since her room was in the middle of the two nursing stations). The Administrator proceeded to the nursing station and left the resident's call light on. Observation on 02/08/23 at 9:14 A.M. revealed Agency STNA #862 answered Resident #52's call light and the resident again stated she needed changed. Agency STNA #862 revealed she would tell the resident's aide and proceeded to notify STNA #833. Observation on 02/08/23 at 9:22 A.M. revealed STNA #833 walked into Resident #52's room and told Resident #52 she had to collect breakfast trays and then would provide her incontinence care. Observation on 02/08/23 at 9:34 A.M. of incontinence care completed by STNA #833 and STNA #857 for Resident #52 revealed the resident had excoriation with redness on her peri area and excoriation with bleeding and redness to her buttocks. Resident #52's brief was heavily saturated with urine as well as a large brown dried ring on the resident's bottom sheet. The resident had also been incontinent of large amount of bowel movement. STNA #833 verified the above findings. Resident #52 stated she had not been changed since 5:30 A.M. STNA #833 revealed there was only one aide on the unit on night shift, and she was not able to get to Resident #52 prior. Review of a facility self-reported incident, dated 02/16/23 revealed the facility substantiated an incident of neglect, mistreatment, and abuse for Resident #52 regarding the incident that had occurred on 01/17/23 at 6:30 P.M. The SRI revealed Regional Director of Clinical Services #859 was notified by LPN #820 Resident #52 reported to LPN #820 she turned on her call light and STNA #856 had answered and stated she would be back to assist her. The SRI revealed LPN #820 noticed Resident #52's call light on again and requested STNA #856 to assist Resident #52. The SRI revealed at the end of the shift LPN #820 checked on Resident #52 and Resident #52 verbalized she had not been changed. Interview on 02/27/23 at 9:28 A.M. with Administrator revealed he was not aware of the allegation of neglect for Resident #52 on 01/17/23. He revealed Regional Director of Clinical Services #859 had received the allegation on 01/17/23 but had not reported it to him; therefore, he had not completed an SRI. Review of the facility policy labeled, Perineal Care, dated October 2010, revealed the purpose of this procedure was to provide cleanliness and comfort to the resident, prevent infection and skin irritation, and observe the residents skin condition. The policy did not include language to provide perineal care timely. 3. On 02/17/23 review of the facility staffing schedule revealed there were four nurses (one Registered Nurse (RN) and three LPN's) scheduled 7:00 A.M. to 7:00 P.M. and two nurses (two LPN's) scheduled 7:00 P.M. to 7:00 A.M. as two LPNs from agency did not show up per the Daily Assignment Sheet. The facility census was 85. On 02/18/23 at 8:05 A.M. interview with LPN #848 revealed she was scheduled 7:00 P.M. to 7:00 A.M. and they had two nurses that did not show up for their shift at 7:00 P.M. She revealed Agency LPN #993 was on 02/17/23 from 7:00 A.M. to 7:00 P.M. and came to her at approximately 10:30 P.M. to hand her the keys for the [NAME] unit. She revealed Agency LPN #993 stated she was only supposed to stay till 7:00 P.M. and had not passed any of the medications that were scheduled (HS - 8:00 P.M.) per the MAR for the residents residing on the unit. LPN #848 revealed she was unable to administer any of the medications on the [NAME] unit as she had her own unit to complete. She verified residents on the [NAME] unit did not receive their medications, were not assessed for pain, and had no monitoring of their oxygen saturation level on 02/17/23 scheduled for HS-8:00 P.M. She revealed the physician and/or responsible party was not notified of medications not being administered/assessments not being completed. She revealed she had attempted to contact Regional Director of Clinical Services #859 (acting Director of Nursing), Administrator, and Scheduler #826 by phone to update them regarding medications not being passed due to lack of staffing, but she did not receive a call back. On 02/18/23 at 9:02 A.M. and 10:55 A.M. interview with Scheduler #826 revealed her phone was broke and she was unable to receive any calls and/or messages. She revealed she let Regional Director of Clinical Nurse #859 know prior that her phone was not working and had provided her a different number to call her on regarding staffing issues. She revealed the staff on the floor were not provided this number. On 02/18/23 at 9:08 A.M. interview with Agency LPN #993 revealed she was scheduled 02/17/23 from 7:00 A.M. to 7:00 P.M. on the [NAME] unit. She revealed her relief at 7:00 P.M. did not show up. She revealed she had contacted Scheduler #826 and notified her that her relief did not show up but received no return call. She also called Regional Director of Clinical Nurse #859 but was unable to leave a message as her voicemail box was full. She [TRUNCATED]

Based on observation, record review, facility policy and procedure review, and interview the facility failed to ensure Resident #52 and Resident #55, who required staff assistance for activities of daily living care, received adequate and timely incontinence care. This resulted in Immediate Jeopardy and actual harm on 02/06/23 when Resident #55, who required extensive assist of two staff for activities of daily living care and was assessed to be always incontinent of bowel and bladder, went from 02/06/23 at 2:00 A.M. to 1:25 P.M. before being provided incontinence care after repeated requests. Resident #55 was observed to be saturated in urine and dried bowel movement on her bilateral thighs area resulting in the development of a Stage II pressure ulcer (partial thickness wound at the epidermis and dermis level) to her left buttock that was bleeding with excoriation and redness surrounding. The Immediate Jeopardy and actual harm continued on 02/08/23 when Resident #52, who required total dependence from two staff for incontinence care and was assessed to be always incontinent of bowel and bladder, went from 02/08/23 at 5:30 A.M. to 9:34 A.M. without incontinence care after repeated requests. Resident #52 was found saturated in urine and bowel movement with a dried brown ring on her bottom sheet resulting in excoriation with redness on her peri area and excoriation with bleeding and redness to her bilateral buttocks. On 02/16/23 at 4:57 P.M. the Administrator and Regional Director of Clinical Services #859 were notified Immediate Jeopardy began on 02/06/23 when staff failed to provide Resident #55 incontinence care after repeated requests resulting in the development of a Stage II pressure ulcer to her left buttock that was bleeding with excoriation and redness surrounding and on 02/08/23 when staff failed to provide Resident #52 incontinence care after repeated requests resulting in excoriation with bleeding and redness to her bilateral buttocks. In addition, concerns that did not rise to Immediate Jeopardy were identified related to the facility failure to ensure Resident #8, #10, and #26 were assisted with proper denture care and provided dentures for use prior to meals. This affected two residents (#52 and #55) reviewed for incontinence care, three residents (#8, #10 and #26) reviewed for oral/denture status and had the potential to affect 68 additional residents (#1, #2, #3, #4, #5, #7, #8, #9, #10, #11, #12, #13, #14, #16, #17, #18, #19, #20, #21, #22, #24, #25, #26, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #60, #61, #62, #64, #66, #67, #68, #69, #72, #73, #74, #75, #76, #77, #78, and #80) who were assessed to be incontinent of bowel and/or bladder. The facility census was 84. The Immediate Jeopardy was removed on 02/22/23 when the facility implemented the following corrective actions: On 02/16/23 at 11:26 P.M. Resident #52 was assessed by Unit Manager/ LPN #974 for negative outcomes related to the lack of timely incontinence care. Resident #52 has a treatment in place to peri area which was ordered on 02/15/23 by Wound Nurse Practitioner (NP) #968. Resident was updated of new treatment regimen and verbalized understanding. On 02/16/23 at 11:42 P.M. Resident #55 was assessed by Regional Clinical Nurse #859 for negative outcomes related to the lack of timely incontinence care. Resident #55 refused to have skin assessed despite education and multiple attempts. Resident has treatment order in place to left buttocks which was ordered on 02/07/23 by Wound NP #968. Resident was updated of current treatment regimen to left buttock and verbalized understanding. On 02/16/23 at 7:00 P.M. all 68 additional residents who were identified to be incontinent were assessed by Unit Manager/ Licensed Practical Nurse (LPN) #975 and Unit Manager/ LPN #974 to ensure that timely and appropriate incontinence care was provided. On 02/16/23 at 8:00 P.M. the Administrator reviewed current staffing levels to ensure adequate staffing for the facility. On 02/17/23 at 10:30 A.M. residents who were interviewable were asked if they felt staff met their needs timely and if their call light was answered in a timely manner. Interviews were completed by the Administrator, Admissions #806, Environmental Director #842, Human Resources #821, Medical Records/Housekeeping #835, Licensed Social Worker (LSW) #819, Activities #803, and Dietary Manager #808. On 02/17/23 at 2:00 P.M. the Administrator, Director of Nursing, Scheduler #826, Unit Manager/ LPN #974, and Unit Manager/ LPN #975 were educated by Regional Director of Operations #977 on adequate staffing levels to provide timely and appropriate care. On 2/17/23 at 2:00 P.M. a staffing meeting was held by Administrator to review daily schedule and ensure adequate staffing for the facility. On 02/17/23 at 2:15 P.M. an Ad Hoc Quality Assurance Performance Improvement (QAPI) was completed including Medical Director #978 via phone. On 02/18/23 at 9:20 A.M. current staffing and schedules were reviewed by Scheduler #826, LSW #819, and Regional Nurse #976 to ensure facility was meeting adequate staffing. Beginning on 02/18/23 the facility implemented audits to be conducted by DON/designee to ensure all residents received timely and appropriate incontinence care, daily for four weeks then weekly for four weeks then ongoing as needed. Audits were verified as completed on 02/18,23, 02/19/23, 02/20/23, and 02/21/23. Beginning on 02/18/23 a plan for resident and/or responsible party interviews to be conducted by the Administrator/designee to ensure that all residents receive timely and adequate personal care. The interviews will be completed with five residents daily for four weeks and then five residents weekly for four weeks and then ongoing as needed. Interviews verified as completed on 02/18,23, 02/19/23, 02/20/23, and 02/21/23. Beginning on 02/18/23 a plan for audits to be conducted by the Administrator/designee to ensure sufficient staffing to maintain appropriate care for all residents, five times weekly for eight weeks and ongoing as needed. Audits verified as completed on 02/18/23, 02/19/23, 02/20/23, and 02/21/23. Staff education as part of the facility abatement plan was initiated on 02/16/23 and continued through 02/22/23. On 02/16/23 at 9:00 P.M. the interdisciplinary management team (Administrator, Admissions #806, Environmental Director #842, Human Resources #821, Medical Records/Housekeeping #835, Licensed Social Worker (LSW) #819, Activities #803, Dietary Manager #808 with Regional Clinical Nurse #859 began education for staff including clinical topics on timely and appropriate incontinence care, the facility Quality of Life and Dignity policy, answering call lights timely and prevention of pressure ulcer development. Interview with staff on 02/21/23 from 5:05 A.M. to 5:48 A.M. revealed Agency LPN #989, #983, LPN #848, Agency STNA #988, #984, #985, and STNA #990 were not educated prior to working at the facility. On 02/21/23 at 7:45 A.M. Regional Nurse #976 and Administrator notified of staff not educated prior to start of shift. Interviews with staff on 02/22/23 from 9:59 A.M. to 10:12 A.M. revealed LPN #820 and Agency STNA #944 did not receive education prior to working at the facility. On 02/22/23 at 10:25 A.M. [NAME] President of Clinical Services #979 was notified of staff not being educated prior to shift. On 2/22/23 at 1:00 P.M. the facility implemented a plan to ensure a department head would be assigned to each shift change to ensure education was provided to each employee entering the facility prior to working their assignment. Interview on 02/22/23 from 2:02 P.M. to 2:10 P.M. LPN #820 and Agency STNA #944 received education. All findings will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations. Although the Immediate Jeopardy was removed on 02/22/23, 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) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: 1. Record review for Resident #55 revealed an admitted [DATE] with diagnoses including congestive heart failure, diabetes, chronic kidney disease, morbid obesity, and hypertension. Review of the care plan dated 09/01/20 revealed Resident #55 had an alteration in elimination related to bowel and bladder incontinence. Interventions included check and change every two hours and as needed, monitor for skin redness and irritation, and provide incontinence care as needed. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #55 had intact cognition and required extensive assist of one staff with bed mobility and was totally dependent of two staff with transfers. She required extensive assist of two staff with toileting. She was always incontinent of bowel and bladder. She was at risk for pressure ulcers but had no pressure ulcers during the seven-day assessment reference period. Review of the care plan dated 01/24/23 revealed Resident #55 had actual impaired skin integrity from moisture associated skin damage (MASD) to her right thigh. Interventions included provide wound care per physician order and skin assessment per policy. Review of the Braden scale pressure ulcer risk assessment dated [DATE] and completed by Licensed Practical Nurse (LPN) #971 revealed Resident #55 was at high risk for pressure ulcers due to her sensory perception was very limited, constantly moist, bedfast, and problem with friction and shear. Review of the February 2023 physician's orders, revealed Resident #55 had an order to cleanse her left and right inner thighs, apply collagen to the wound base, and cover with a foam dressing every day shift due to excoriation dated 01/08/23. A new order was obtained on 02/07/23 to cleanse her left buttock with normal saline, apply alginate and a foam dressing due to skin compromise (new open area). Review of the Weekly Observation Tool dated 02/01/23 and completed by LPN/ Unit Manger #809 revealed Resident #55 had facility acquired impaired skin to her left inner thigh from the friction of her brief. There were no measurements, and the treatment was to continue. Review of the Weekly Observation Tool dated 02/01/23 and completed by LPN/ Unit Manger #809 revealed Resident #55 had facility acquired MASD to her right thigh area due to friction and body fluids. The treatment was to continue as ordered. Interview on 02/06/23 at 10:15 A.M. with Resident #55 revealed she activated her call light and staff answered her call light on 02/06/23 at 8:00 A.M. She revealed she told staff that she needed changed, and they turned off her light and walked out of the room. She revealed she was still waiting the staff to come back. She was unable to name the staff as she stated the staff were all from agency, and stated she had different staff almost every day. Interview on 02/06/23 at 10:35 A.M. with Agency State tested Nursing Assistant (STNA) #854 revealed she was the aide assigned to Resident #55, and she had been on the unit alone for three hours. She revealed she had 27 residents and had not provided the residents (including Resident #55) incontinence care as she had just finished with breakfast trays. Interview and observation on 02/06/23 at 11:17 A.M. with Resident #55 revealed staff had not come back to provide incontinence care. She again stated she had asked at 8:00 A.M. She revealed the last time she was changed was on 02/06/23 at 2:00 A.M. She revealed staff always said they would be back after they answered her call light, but they never returned. Observation on 02/06/23 at 11:59 A.M. revealed Resident #55 yelled out as Agency STNA #854 walked by her room. Resident #55 stated to Agency STNA #854 that she was still waiting to be changed and stated she had been waiting since 8:00 A.M. Agency STNA #854 stated to Resident #55 that she was waiting for Agency LPN #852 to do her dressing change and she was going to change her at the same time. Agency STNA #854 also told to Resident #55 that she also had to finish changing two other residents down the hall and then she would get to her. Observation on 02/06/23 at 12:38 P.M. revealed Agency STNA #854 asked Agency LPN #852 to let her know when she was ready to change Resident #55's dressings as she was going to change her at the same time. Agency LPN #852 stated she was ready anytime. Agency STNA #854 then stated, well right now, I am going to chart and stuff. Agency STNA #853 who also was assigned Resident #55's unit came up to the nursing station at the same time and proceeded to remain at the nursing station from 12:38 A.M. to 12:45 P.M. on her personal phone and Agency STNA #854 continued to document. Observation revealed on 02/06/23 at 12:45 P.M. Agency STNA #854 stated to Agency LPN #852 oh well, trays are here now. Observation on 02/06/23 at 1:25 P.M. revealed Agency LPN #852 asked Agency STNA #853 to assist her in doing Resident #55's incontinence care and wound care. While in the room, Resident #55 requested only Agency LPN #852 complete her incontinence care and wound care. Agency LPN #852 then proceeded to provide incontinence care. Observation revealed Resident #55's brief was heavily saturated in urine as Agency LPN #852 stated if she had to estimate, Resident #55 had urinated at least five times. Observation also revealed Resident #55 was incontinent of a moderate amount of bowel movement and parts of the bowel movement were dried to her bilateral inner thighs. Agency LPN #852 was asked to describe her skin integrity and she revealed her peri area and buttocks were excoriated with redness and bleeding. She revealed Resident #55 was tender to touch as Resident #55 stated ouch, ouch when provided incontinence care. Resident #55 then proceeded to say it was very sore and tender as she had not been changed since 2:00 AM. (almost 12 hours). Agency LPN #852 completed her wound dressing changes as ordered. She then noted a new open area to Resident #55's left buttock. Agency LPN #852 described the new open area as a Stage II pressure ulcer that measured 1.0 centimeter (cm) in length by 1.0 cm in width, and she revealed she was unable to determine the depth as there was a large amount of bleeding. She revealed the area was surrounded by redness. Resident #55 then became upset and started to cry as Agency LPN #852 was informing her of the new area. Resident #55 again stated that she had not been changed since 2:00 A.M. and that she had asked at 8:00 A.M. and then also again after that, and nobody changed her. She revealed now she had another pressure ulcer and that she would never get healed. Interview on 02/06/23 at 2:15 P.M. with Resident #55's daughter revealed she had informed management staff multiple times regarding her mother not getting changed at least every two hours and that even after she brought up the concern, things had not improved. She revealed she was upset because her mother had a new pressure ulcer because the facility did not provide the care she needed. Review of nursing note dated 02/06/23 at 2:07 P.M. and completed by Agency LPN #852 revealed during wound care Resident #55 was found to have another small open area to her left buttock with moderate amount of blood. The area was about 1.0 cm in size. The wound was cleaned with normal saline, and a dressing was applied. Interview on 02/07/23 at 3:12 P.M. with the Director of Nursing revealed incontinence care was to be completed every two hours and/ or as needed if it was needed prior. Review of the facility policy labeled, Perineal Care, dated October 2010, revealed the purpose of this procedure was to provide cleanliness and comfort to the resident, prevent infection and skin irritation, and observe the residents skin condition. The policy did not include language to provide perineal care timely. 2. Review of the medical record for Resident #52 revealed an admitted [DATE] with diagnoses including atrial fibrillation, diabetes, morbid obesity, and congestive heart failure. Review of the care plan dated 06/02/22 revealed Resident #52 had an alteration in elimination. She was incontinent of bowel and bladder. Interventions included incontinence care as needed and monitor skin for redness and irritation. Review of the care plan dated 06/02/22 revealed Resident #52 was at risk for impaired skin integrity due to morbid obesity. Interventions included barrier cream after each incontinent episode, skin assessment as ordered, and turn and reposition as ordered. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #52 had intact cognition. She required extensive assist of two staff with bed mobility. She was totally dependent of two staff with toileting and transfers. She was always incontinent of bowel and bladder. Review of an email dated 01/17/23 at 8:28 P.M. from LPN #820 to Regional Director of Clinical Services #859 revealed LPN #820 answered Resident #52's call light, and she had expressed that she was waiting to be changed. The email noted STNA #856 had answered her call light on 01/17/23 at 6:30 P.M. and turned her call light off and stated she would return. The email noted LPN #820 stated she had asked STNA #856 to answer Resident #52's call light. The email noted she followed up with Resident #52 who stated STNA #856 had not provided incontinence care. The email revealed Resident #52 was lying in bowel movement for an hour, and STNA #856 left the facility without changing the resident. Review of the Weekly Skin assessment dated [DATE] and completed by LPN #971 revealed Resident #52's skin was intact, and no issues were noted. Review of the Braden scale pressure ulcer risk assessment dated [DATE] authored by LPN #971 revealed Resident #52 was at high risk for skin breakdown. Interview on 02/06/23 at 9:48 A.M. and on 02/07/23 at 11:02 A.M. with Resident #52 revealed it took five to six hours to get changed most the time. She revealed she would activate her call light and when staff answered her call light, she would ask to get changed and staff would say they would be back, but they did not return for several hours. She revealed on 02/05/23 she was not changed for over 12 hours even though she had asked several times. She revealed several weeks ago an STNA #856 had answered her call light at approximately 6:30 P.M. and said she would be back but never returned. She revealed she notified LPN #820 and she stated she would have STNA #856 change her. She revealed STNA #856 never changed her as she left at the end of her shift. She revealed she did not end up getting changed until approximately 8:00 P.M. She revealed LPN #820 stated she would notify management of the concern, but they had never followed up with her regarding the incident. Interview on 02/07/23 at 8:31 A.M. with LPN #820 revealed she reported an incident she felt was neglect a few weeks ago as STNA #856 had answered Resident #52's call light and Resident #52 had asked to be changed, and STNA #856 stated she would be back. She revealed Resident #52 had also reported to her that she needed changed so she had instructed STNA #856 to change Resident #52, but she never changed her and left the facility. She revealed she reported the incident to Regional Director of Clinical Services #859 in writing. She revealed she had witnessed this occur multiple times especially from the agency staff as they would sit behind the nursing station and not assist the residents with incontinence care. Interview on 02/07/23 at 3:12 P.M. with the Director of Nursing revealed incontinence care was to be completed every two hours and/ or as needed if it was needed prior. Interview on 02/07/23 at 4:30 P.M. with Activities #803 revealed she held Resident Council Meetings monthly. She revealed on 11/29/22 several residents, including Resident #52, revealed they had not been receiving proper care including timely incontinence care. She revealed on 01/25/23 residents complained of being left soiled, including Resident #52. She revealed the facility had not had consistent management and it was hard as she filled out individual grievance reports to voice residents' concerns after the resident council meeting but felt the issues were not addressed as the same concerns continued monthly. Interview and observation on 02/08/23 at 8:32 A.M. revealed Resident #52 had her call light on, and a strong odor of urine and bowel movement was coming from her room. She had tears in her eyes and stated, it is happening again as her call light had been on since 7:45 A.M. as she needed changed as she was lying in a soiled mess. She revealed she had a bowel movement, and her skin was burning. Observation on 02/08/23 at 8:46 A.M. revealed the Administrator answered the resident's call light and Resident #52 explained she needed changed. The Administrator asked what nursing station she was assigned to (since her room was in the middle of the two nursing stations). The Administrator proceeded to the nursing station and left the resident's call light on. Observation on 02/08/23 at 9:14 A.M. revealed Agency STNA #862 answered Resident #52's call light and the resident again stated she needed changed. Agency STNA #862 revealed she would tell the resident's aide and proceeded to notify STNA #833. Observation on 02/08/23 at 9:22 A.M. revealed STNA #833 walked into Resident #52's room and told Resident #52 she had to collect breakfast trays and then would provide her incontinence care. Observation on 02/08/23 at 9:34 A.M. of incontinence care completed by STNA #833 and STNA #857 for Resident #52 revealed the resident had excoriation with redness on her peri area and excoriation with bleeding and redness to her buttocks. Resident #52's brief was heavily saturated with urine as well as a large brown dried ring on the resident's bottom sheet. The resident had also been incontinent of large amount of bowel movement. STNA #833 verified the above findings. Resident #52 stated she had not been changed since 5:30 A.M. STNA #833 revealed there was only one aide on the unit on night shift, and she was not able to get to Resident #52 prior. Review of the facility policy labeled, Perineal Care, dated October 2010, revealed the purpose of this procedure was to provide cleanliness and comfort to the resident, prevent infection and skin irritation, and observe the residents skin condition. The policy did not include language to provide perineal care timely. 3. Review of the medical record for Resident #8 revealed an admitted [DATE] with diagnoses including dementia, mild protein calorie malnutrition, hypertension, and congestive heart failure. Review of the Dental Progress Note dated 01/09/23 and authored by Dentist #863 revealed he completed a periodic exam for Resident #8. He revealed she had no natural teeth, and her dentures were well fitting. Review of the care plan dated 01/09/23 revealed Resident #8 was at risk for oral and dental health problems related to dentures. Interventions included coordinate arrangements for dental care, monitor and document signs of oral problems, and provide mouth care. Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #8 had impaired cognition. She required total dependence of two staff with bed mobility and transfers. She was unable to ambulate. She required extensive assist of one staff with personal hygiene and limited assist of one staff with eating. She had no natural teeth. Review of the February 2023 Physician Orders revealed Resident #8 was on a mechanical soft diet. Interview on 02/06/23 at 3:50 P.M. with Resident #8's daughter revealed she had visited several times when her mother was eating, and the facility had not placed her dentures inside her mouth causing difficulty for Resident #8 to eat. Resident #8's daughter revealed she had brought this concern up many times to the administration, but it continued to occur. Observation on 02/07/23 at 8:55 A.M. revealed Resident #8 was in her bed with her breakfast tray in front of her. She was trying to bite into an English muffin and was having difficulty biting a piece off as she did not have dentures in her mouth. Observation revealed her dentures were in the bathroom in the denture cup. She then proceeded to set the English muffin back down without taking a bite and closed her eyes not attempting to eat any further. Interview on 02/07/23 with STNA #818 revealed she had provided Resident #8 her breakfast tray. She verified she had not provided Resident #8 her dentures prior to providing her tray and stated, Yes she should have had her dentures in for breakfast. 4. Review of the medical record for Resident #26 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes, dementia, gastroesophageal reflux disease, and major depression. Review of the care plan dated 02/09/22 revealed Resident #26 was at risk for oral problems related to edentulous (no teeth) status. Interventions included monitor for signs of oral problems and provide mouth care as per activities of daily living personal hygiene. Review of the Dental Progress Note dated 02/17/22 revealed Dentist #864 completed a periodic exam and noted Resident #26 had upper and lower dentures. She revealed the dentures fit well, and the resident was satisfied. Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #26 had impaired cognition. He required extensive assist of one staff with bed mobility, and limited assist of one staff with personal hygiene. He was independent with set-up help for eating. He had no natural teeth. Review of the February 2023 Physician Orders revealed Resident #26 was on a regular mechanical soft diet. Observation and interview on 02/07/23 at 9:05 A.M. with Resident #26 revealed his breakfast tray was sitting on his over the bed table, and he was lying on his bed. He revealed he did not have his dentures in. He revealed staff did not offer his dentures when they had delivered his tray. He stated, I do not think they would even if I asked. He revealed the staff were always in a hurry, and he felt he received no assistance from staff with his care. He revealed it would be nice to have been offered his dentures as he felt he does eat better with his dentures in his mouth. Observation revealed his upper and lower dentures were in his bathroom in a denture cup. Interview on 02/07/23 at 9:14 A.M. with LPN #820 verified Resident #26's dentures were sitting in a denture cup in his bathroom. She revealed she thought he placed his own dentures in his mouth and usually was not a big breakfast eater anyway. 5. Record review for Resident #10 revealed an admitted [DATE] with diagnoses including psychosis, chronic obstructive pulmonary disease, hypertension, and Alzheimer's disease. Review of the Dental Progress Note dated 02/07/20 revealed Resident #10 had a comprehensive dental exam. She had upper and lower dentures, and the dentures fit well. Review of the care plan dated 05/25/22 revealed Resident #10 was edentulous and had upper and lower dentures. Interventions included coordinate arrangements for dental care, frequent mouth inspections, monitor for signs of oral and dental problems, and provide mouth care as per activities of daily living personal hygiene. Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #10 had impaired cognition. She was totally dependent of two staff with bed mobility and transfers. She was totally dependent of one staff with personal hygiene and required extensive assist of one staff with eating. She had no natural teeth. Review of the February 2023 physician ordered revealed Resident #10 was on a pureed diet. Observation on 02/07/23 at 9:17 A.M. revealed Agency STNA #857 was feeding Resident #10 in her room. Agency STNA #857 revealed she had not attempted to put in Resident #10's dentures prior to assisting with feeding. She revealed she did not realize she had dentures. Observation revealed in Resident #10's bathroom there was a denture cup with dentures in it. Attempted to interview Resident #10 on 02/07/23 at 9:19 A.M. but unable due to cognitive ability. Review of the list of residents provided by the facility on 02/06/23 of residents that had dentures revealed it included Residents #8, #10, and #26. Interview on 02/07/23 at 3:12 P.M. with the Director of Nursing verified Residents #8, #10, and #26 had dentures, and staff should have assisted the residents with oral care including the assistance of providing dentures prior to breakfast. Review of the facility policy labeled, Dentures, Cleaning and Storing, dated October 2010, revealed the purpose of the policy was to cleanse and freshen the resident's mouth, clean the resident's dentures, and to prevent infections of the mouth. The policy revealed the resident was to be provided denture care before breakfast and at bedtime. The policy revealed to instruct and assist the resident as needed to rinse his or her mouth after each meal. The policy revealed encourage the resident to keep dentures in as much as possible as when dentures were left out the bone structure to the mouth changes and the gums shrink causing dentures to fit improperly. This deficiency represents non-compliance investigated under Complaint Number OH00140369, OH00140222, OH00139918, OH00139084 and OH00138338.

Based on record review, interviews, and facility policy review the facility failed to ensure Resident #335, who had a diagnosis of paranoid schizophrenia received appropriate treatment, including the administration of anti-psychotic medications to ensure the resident maintained the highest practicable mental and psychosocial well-being. Actual Harm occurred on [DATE] when Resident #335 was transferred and admitted for in-patient psychiatric care with increased hallucinations and suicidal ideation, a deterioration in the resident's mental well-being. Prior to the hospitalization , the facility failed to ensure the psychoactive medication, Clozaril (anti-psychotic medication used to treat mental/mood disorders including schizophrenia) was administered as ordered. The resident was hospitalized until [DATE]. This affected one resident (#335) of six residents reviewed for medication administration. The facility census was 84. Findings include: Review of the medical record revealed Resident #335 was admitted on [DATE] with diagnoses including paranoid schizophrenia and major depressive disorder. Review of Resident #335's census documentation revealed the resident was transferred to the hospital on [DATE]. The resident was readmitted to the facility on [DATE]. Review of the psychiatric progress note, dated [DATE] by Nurse Practitioner (NP) #450 revealed a chief complaint of increased suicidal ideation and thinking people are demons. The resident was disoriented, had delusions, and had auditory and visual hallucinations. NP #450 provided a new order to increase the resident's Clozaril to 200 milligrams (mg) twice daily. Review of the physician's orders for Resident #335 revealed an order (dated [DATE]) for Clozaril (Clozapine) 200 mg, one tablet twice a day for behaviors. On [DATE], the order for 200 mg twice daily was discontinued. A new order was provided by NP #450 to administer 275 mg twice daily for hallucinations. Resident #335 also had an order (dated [DATE]) to obtain Clozapine levels every Monday for therapeutic drug level monitoring and an order (dated [DATE]) to assess Resident #335's behaviors every shift. Review of the care plan, dated [DATE] revealed Resident #335 received anti-psychotic medications and had a diagnosis of schizophrenia. The plan reflected the order, dated [DATE] to increase Clozaril per NP #450 to decrease hallucinations. Interventions included to administer medications as ordered. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #335 had intact cognition. The MDS assessment noted the resident had received anti-psychotic medications six of seven days during the assessment reference period and the medications were received on a daily routine basis. The assessment also noted the resident had delusions. Review of the Medication Administration Record (MAR) for [DATE], revealed Clozaril 200 mg was not administered as ordered at bedtime on [DATE], [DATE], [DATE], [DATE], [DATE] or in the morning on [DATE], [DATE], [DATE] or [DATE]. The Clozapine levels were drawn as ordered. Resident #335 was noted to have behaviors at night on [DATE] and [DATE] as well as on day shift on [DATE]. Review of the MAR for February 2023 revealed Clozaril 25 mg, Clozaril 50 mg and Clozaril 200 mg (total of 275 mg) were not administered in the morning on [DATE] or [DATE] or at bedtime on [DATE] or [DATE]. Resident #335 was noted to have behaviors on day shift on [DATE] and at night on [DATE]. Review of the laboratory results, dated [DATE] revealed the resident's Clozapine serum level was 60 nanograms/milliliter (ng/mL) and Norclozapine serum was 40 ng/mL with a combined total of 100 ng/mL (normal/therapeutic ,d+[DATE] ng/mL), which revealed it was not at a therapeutic level. The laboratory data reference stated patients dosed with 400 mg Clozapine daily for four weeks were most likely to exhibit a therapeutic effect when the sum of Clozapine and Norclozapine concentrations were at least 450 ng/mL. Review of the resident's nursing progress notes revealed on [DATE] at 11:09 P.M. Clozaril 200 mg was not given due to staff not being able to locate the medication. On [DATE] at 1:44 P.M. social services met with the resident and he stated he wanted to die and life was not worth living. Resident #335 was noted to have delusions of a curse being placed on him. He did confirm to social services that he had suicidal thoughts and was going to ask staff to give him a razor blade. Social services was able to de-escalate him and nursing was updated. On [DATE] at 8:01 P.M. Clozaril was not administered due to being on order. On [DATE] at 4:20 A.M. Clozaril was not administered due to being on order. On [DATE] at 5:54 A.M. Clozaril was not administered and stated it was not applicable. On [DATE] at 8:44 P.M. Clozaril was not administered due to being on order. On [DATE] at 5:59 P.M. Clozaril was not administered due to being on order. On [DATE] at 12:59 P.M. nursing updated the medical doctor of missed medication and noted it was okay to medication is filled by pharmacy. On [DATE] at 7:33 P.M. it was noted Resident #335 was having behaviors and stated he was stressed and was requesting psych services. Nursing stated the previous shift notified the physician of the behavior. On [DATE] at 7:59 P.M. Clozaril was not administered due to medication not being available and the Clozapine serum level was faxed to the pharmacy. The note revealed nursing would administer the medication as soon as it was delivered. On [DATE] at 10:00 P.M. Licensed Practical Nurse (LPN) #989 noted another nurse had made her aware that Resident #335 had been without his antipsychotic medications for days. LPN #989 updated the pharmacy and the pharmacy representative stated they needed the updated Clozapine levels to release the medication. LPN #989 stated Resident #335 appeared confused, speech unclear and garbled. On [DATE] at 11:31 A.M. another resident reported to nursing staff Resident #335 had been having hallucinations with seeing animals and demons. Nursing staff placed him near the nurses station for monitoring. On [DATE] at 4:19 P.M. Resident #335 was having increased hallucinations. NP #450 was updated and provided a new order to increase Clozaril dosage from 200 mg twice daily to 275 mg twice daily to attempt to reduce hallucinations. On [DATE] at 8:48 P.M. Clozaril was not administered due to being on order. On [DATE] at 5:01 A.M. Clozaril was not administered due to being on order. On [DATE] at 11:25 P.M. a nursing note revealed at 10:50 P.M. Resident #335 spoke to the nurse and stated he was going to hell because he sinned. He stated he wished to die and then attempted to cut open his skin with his fingernail. He stated he had a plan to kill himself and was going to slit his wrist with a razor blade if he got one. Nursing placed the resident in the lobby where he was observed having hallucinations and attempted to scratch his arm until he died . The on-call Nurse Practitioner was called and provided an order to send the resident to the hospital for suicidal ideation and hallucinations. On [DATE] at 11:26 P.M. it was noted the Clozaril bedtime dose was not available. Review of a discharge form, dated [DATE] from the psychiatric hospitalization at Akron City Hospital revealed Resident #335 was admitted on [DATE] for behavioral health. His primary diagnosis was hallucinations. A behavioral health psycho-social assessment, dated [DATE] revealed the resident was admitted directly from the emergency department due to suicidal ideation, thoughts of self-harm, hallucinations, and delusional thought content. The assessment revealed the resident had been non compliant with medications for three to four days prior to admission. Review of the Department of Psychiatry History and Physical revealed the resident had not taken his Clozapine for the previous two days prior to hospitalization . He was noted to be depressed, had decreased energy, suicidal ideation, anxiety, hallucinations, and delusions. Interview on [DATE] at 3:08 P.M. with NP #450 revealed he saw Resident #335 on a monthly basis. He stated it was problematic Resident #335's Clozaril medication was not given as ordered as the medication needed to be titrated to be at a therapeutic level. NP #450 revealed for Clozaril to be therapeutic, it needed consistent dosing. The NP would not verify the psychiatric hospitalization for Resident #335 was caused by the facility not administering the medications as ordered, however, the NP indicated it would cause a worsening of symptoms. NP #450 revealed if he would have been made aware of Resident #335 missing the doses listed above, he would've restarted the medication at different dose to re-titrate the medication. Interview on [DATE] at 3:30 P.M. with Director of Nursing (DON) #2 verified Resident #335 did not receive his Clozaril as ordered by NP #450 for the dates listed above. Review of the facility policy titled, Administering Medications, revised [DATE], revealed medications must be administered in accordance with the orders. This deficiency represents non-compliance investigated under Complaint Numbers OH00139918, OH00138866, OH00138859 and OH00138338.

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure timely assessments and adequate interventions were implemented to prevent the development of pressure ulcers. Actual Harm occurred on 11/17/22 when Resident #66, who was diagnosed on [DATE] with a new right wrist and pubis fracture and required extensive assist with activities of daily living including bed mobility and transfers, developed an unstageable pressure ulcer (full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar) to the coccyx with a lack of evidence of adequate and effective interventions being in place prior to the development. This affected two residents (Resident #66 and #55) of three residents reviewed for pressure ulcers. The facility census was 84. Findings included: 1. Review of the medical record for Resident #66 revealed an admitted [DATE] with diagnoses including adjustment disorder with depressed mood, vascular dementia, hypertension, right wrist fracture, and pubis fracture. Review of the unsigned Admission Packet- V12 dated 09/21/22 revealed Resident #66's skin was intact. The admission packet included a Braden Scale pressure ulcer risk assessment that did not indicate if Resident #66 was at risk of developing pressure ulcers. The admission packet revealed the resident had slightly limited sensory perception and was occasionally moist. Review of the care plan dated from 09/21/22 to 11/18/22 revealed no care plan was in place for Resident #66 regarding risk for developing pressure ulcers and/or any interventions to prevent pressure ulcers including after she returned from the hospital on 10/29/22 following treatment for a fracture to her right wrist and pubis area. Review of the Braden Scale pressure ulcer risk assessments for Resident #66 from 09/22/22 to 01/31/23 revealed Resident #66 was not re-assessed again for her risk of developing a pressure ulcer including on 10/29/22 when she returned from the hospital with fractures to her right wrist and pubis area or when a significant change in status Minimum Data Set (MDS) 3.0 assessment was completed on 11/08/22. Review of the nursing note dated 10/28/22 at 3:16 P.M. and completed by Licensed Practical Nurse (LPN) #967 revealed Resident #66 had fallen and stated she felt she had broken her hip. The resident was transferred to the hospital. Review of the nursing note dated 10/29/22 at 10:00 A.M. and completed by LPN/ Unit Manager #809 revealed Resident #66 returned from the hospital on 10/28/22 at approximately 11:30 P.M. and was diagnosed with right wrist and pubis fractures. Review of the significant change MDS 3.0 assessment dated [DATE] revealed Resident #66 had impaired cognition. The assessment revealed the resident required extensive assistance of one staff for bed mobility, dressing, toileting, and personal hygiene. She required extensive assist of two staff with transfers. She was at risk for pressure ulcers and had no pressure ulcers noted at that time. Review of the nurses note dated 11/17/22 at 1:39 P.M. authored by LPN #965 revealed the LPN went in to give Resident #66 a total bed bath and noticed an unstageable wound on her coccyx area. The note revealed the LPN had the wound care nurse measure and treat the wound. The note revealed new treatment orders were obtained. Review of the Wound Weekly Observation Tool, dated 11/17/22, and completed by Former LPN/ Wound Nurse #966 revealed Resident #66 had an unstageable facility acquired pressure ulcer that was first identified on 11/17/22. The wound measured 5.6 centimeters (cm) in length by 4.8 cm in width and the depth was undetermined. The wound contained 75 percent slough (dead tissue that may have a yellow or white appearance) as well as necrotic (dead tissue that usually is black in nature). The area had a moderate amount of serosanguinous (clear drainage that may contain blood) drainage. The assessment revealed a treatment was ordered: cleanse wound with normal saline, pat dry, apply nickel thick Santyl (chemical topical agent used to debride/ remove dead tissue) to wound bed, cover with calcium alginate (dressing for moderately to heavily exudative wounds) and place bordered foam dressing every shift and as needed. Review of the care plan dated 11/18/22 revealed Resident #66 was at risk for impaired skin integrity secondary to fracture. Interventions included barrier cream, elevate heels, inspect skin during routine care, and lift sheet on chair and bed for positioning. Review of the Wound Progress Note dated 12/14/22 and completed by Wound Nurse Practitioner (NP) #968 revealed Resident #66 had a Stage IV (full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar may be present on some parts of the wound bed, often include undermining and tunneling) wound to her sacrum area. The wound measured 2.8 cm in length, 2.5 cm in width, 1.2 cm in depth and was tunneling 1.8 cm at 12 o'clock. The area contained minimal slough. Review quarterly MDS 3.0 assessment dated [DATE] revealed Resident #66 had impaired cognition. She required total dependence of two staff with bed mobility. She required extensive assist of two staff with transfers, toileting, and dressing. She was unable to ambulate. She was at risk for unhealed pressure ulcers and had one unstageable pressure ulcer that was not present on admission. Review of the February 2023 physician's orders revealed Resident #66 had an order to cleanse her coccyx wound with normal saline, pat dry, apply nickel thick Santyl to wound bed, cut and place alginate to size of wound bed and cover with a border foam dressing every day and as needed, encourage side to side repositioning every two hours, and a low air loss mattress. Review of the care plan last revised 02/02/23 revealed Resident #66 had actual impaired skin integrity ulcer to her sacrum area. Interventions included encourage to turn and reposition every two hours as tolerated, low air loss mattress, wound care as ordered, and skin assessments per policy that was added 11/18/22. Interview on 02/07/23 at 11:12 A.M. with Resident #66 revealed she had hurt her wrist and hip during a fall several months ago. She revealed she now had a pressure ulcer to her coccyx area. She was unable to provide any further details regarding her pressure ulcer due to cognitive impairment. Observation on 02/07/23 at 12:23 P.M. of wound care for Resident #66, completed by LPN/ Unit Manager #809 revealed the resident had a pressure ulcer to her coccyx/ sacrum area. LPN/ Unit Manager #809 revealed the wound was smaller in size as it started out as an unstageable the size of a 50-cent piece and now was the size of a dime. She described the wound bed with no slough and healthy tissue surrounding. Interview on 02/07/23 at 12:35 P.M. with LPN/ Unit Manger #809 verified Resident #66's wound was first identified on 11/17/22 as a facility acquired unstageable pressure ulcer. She verified the Wound Weekly Observation Tool dated 11/17/22 noted the wound to contained 75 percent slough as well as necrotic tissue. She stated, honestly, I do not know why it was not found at an earlier stage as it should have been. She verified the MDS 3.0 assessment dated [DATE] revealed Resident #66 required extensive assist from staff for transfers and bed mobility. She verified Resident #66 had returned from the hospital on 10/29/22 with fractures to her right wrist and pubis area. She verified a Braden scale pressure ulcer risk assessment was not completed on return from hospital on 10/29/22 nor on 11/08/22 when a significant change in condition MDS 3.0 assessment was completed. She revealed pressure ulcer risk assessments should be completed on admission, quarterly, and upon a change in condition. She verified a pressure ulcer risk assessment for Resident #66 was only completed on 09/21/22 and 01/31/23. Interview on 02/07/23 at 3:12 P.M. with the Director of Nursing verified a Braden Scale for pressure ulcer risk assessment was to be done on admission, quarterly, and upon a change in condition. She verified Resident #66 should have been assessed upon return from the hospital with a new fracture to right wrist and pubis area for risk of pressure ulcer development as this was a change in condition for her. She also verified a care plan should have been implemented upon return from the hospital for a potential for impaired skin integrity prior to her developing an unstageable pressure ulcer. Interview on 02/08/23 at 12:50 P.M. with Regional Director of Clinical Services #859 revealed she attempted to find additional wound consults completed by a physician and/or a nurse practitioner (NP) as she consulted the outside wound care provider but indicated the first Wound Progress Note completed by Wound NP #968 was dated 12/14/22 and was the first they had on file. She revealed she was unable to locate any further consults for Resident #66. Review of the facility policy labeled Prevention of Pressure Ulcer/ Injuries, dated July 2017, revealed the purpose of the policy was to provide information regarding the identification of pressure ulcers, injury risk factors, and interventions for specific risk factors. The policy revealed the residents care plan should identify risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. The policy revealed risk assessments were to be completed on admission and upon any change in condition. The policy revealed the staff should inspect skin daily when performing activities of daily living personal care. 2. Record review for Resident #55 revealed an admitted [DATE] with diagnoses including congestive heart failure, diabetes, chronic kidney disease, morbid obesity, and hypertension. Review of the care plan dated 09/01/20 revealed Resident #55 had an alteration in elimination related to bowel and bladder incontinence. Interventions included check and change every two hours and as needed, monitor for skin redness and irritation, and provide incontinence care as needed. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #55 had intact cognition and required extensive assist of one staff with bed mobility and was totally dependent of two staff with transfers. She required extensive assist of two staff with toileting. She was always incontinent of bowel and bladder. She was at risk for pressure ulcers but had no pressure ulcers during the seven-day assessment reference period. Review of the care plan dated 01/24/23 revealed Resident #55 had actual impaired skin integrity from moisture associated skin damage (MASD) to her right thigh. Interventions included provide wound care per physician order and skin assessment per policy. Review of the Braden scale pressure ulcer risk assessment dated [DATE] and completed by Licensed Practical Nurse (LPN) #971 revealed Resident #55 was at high risk for pressure ulcers due to her sensory perception was very limited, constantly moist, bedfast, and problem with friction and shear. Review of the February 2023 physician's orders, revealed Resident #55 had an order to cleanse her left and right inner thighs, apply collagen to the wound base, and cover with a foam dressing every day shift due to excoriation dated 01/08/23. A new order was obtained on 02/07/23 to cleanse her left buttock with normal saline, apply alginate and a foam dressing due to skin compromise (new open area). Review of the Weekly Observation Tool dated 02/01/23 and completed by LPN/ Unit Manger #809 revealed Resident #55 had facility acquired impaired skin to her left inner thigh from the friction of her brief. There were no measurements, and the treatment was to continue. Review of the Weekly Observation Tool dated 02/01/23 and completed by LPN/ Unit Manger #809 revealed Resident #55 had facility acquired MASD to her right thigh area due to friction and body fluids. The treatment was to continue as ordered. Interview on 02/06/23 at 10:15 A.M. with Resident #55 revealed she activated her call light and staff answered her call light on 02/06/23 at 8:00 A.M. She revealed she told staff that she needed changed, and they turned off her light and walked out of the room. She revealed she was still waiting the staff to come back. She was unable to name the staff as she stated the staff were all from agency, and stated she had different staff almost every day. Interview on 02/06/23 at 10:35 A.M. with Agency State tested Nursing Assistant (STNA) #854 revealed she was the aide assigned to Resident #55, and she had been on the unit alone for three hours. She revealed she had 27 residents and had not provided the residents (including Resident #55) incontinence care as she had just finished with breakfast trays. Interview and observation on 02/06/23 at 11:17 A.M. with Resident #55 revealed staff had not come back to provide incontinence care. She again stated she had asked at 8:00 A.M. She revealed the last time she was changed was on 02/06/23 at 2:00 A.M. She revealed staff always said they would be back after they answered her call light, but they never returned. Observation on 02/06/23 at 11:59 A.M. revealed Resident #55 yelled out as Agency STNA #854 walked by her room. Resident #55 stated to Agency STNA #854 that she was still waiting to be changed and stated she had been waiting since 8:00 A.M. Agency STNA #854 stated to Resident #55 that she was waiting for Agency LPN #852 to do her dressing change and she was going to change her at the same time. Agency STNA #854 also told to Resident #55 that she also had to finish changing two other residents down the hall and then she would get to her. Observation on 02/06/23 at 12:38 P.M. revealed Agency STNA #854 asked Agency LPN #852 to let her know when she was ready to change Resident #55's dressings as she was going to change her at the same time. Agency LPN #852 stated she was ready anytime. Agency STNA #854 then stated, well right now, I am going to chart and stuff. Agency STNA #853 who also was assigned Resident #55's unit came up to the nursing station at the same time and proceeded to remain at the nursing station from 12:38 A.M. to 12:45 P.M. on her personal phone and Agency STNA #854 continued to document. Observation revealed on 02/06/23 at 12:45 P.M. Agency STNA #854 stated to Agency LPN #852 oh well, trays are here now. Observation on 02/06/23 at 1:25 P.M. revealed Agency LPN #852 asked Agency STNA #853 to assist her in doing Resident #55's incontinence care and wound care. While in the room, Resident #55 requested only Agency LPN #852 complete her incontinence care and wound care. Agency LPN #852 then proceeded to provide incontinence care. Observation revealed Resident #55's brief was heavily saturated in urine as Agency LPN #852 stated if she had to estimate, Resident #55 had urinated at least five times. Observation also revealed Resident #55 was incontinent of a moderate amount of bowel movement and parts of the bowel movement were dried to her bilateral inner thighs. Agency LPN #852 was asked to describe her skin integrity and she revealed her peri area and buttocks were excoriated with redness and bleeding. She revealed Resident #55 was tender to touch as Resident #55 stated ouch, ouch when provided incontinence care. Resident #55 then proceeded to say it was very sore and tender as she had not been changed since 2:00 AM. (almost 12 hours). Agency LPN #852 completed her wound dressing changes as ordered. She then noted a new open area to Resident #55's left buttock. Agency LPN #852 described the new open area as a Stage II pressure ulcer that measured 1.0 centimeter (cm) in length by 1.0 cm in width, and she revealed she was unable to determine the depth as there was a large amount of bleeding. She revealed the area was surrounded by redness. Resident #55 then became upset and started to cry as Agency LPN #852 was informing her of the new area. Resident #55 again stated that she had not been changed since 2:00 A.M. and that she had asked at 8:00 A.M. and then also again after that, and nobody changed her. She revealed now she had another pressure ulcer and that she would never get healed. Interview on 02/06/23 at 2:15 P.M. with Resident #55's daughter revealed she had informed management staff multiple times regarding her mother not getting changed at least every two hours and that even after she brought up the concern, things had not improved. She revealed she was upset because her mother had a new pressure ulcer because the facility did not provide the care she needed. Review of nursing note dated 02/06/23 at 2:07 P.M. and completed by Agency LPN #852 revealed during wound care Resident #55 was found to have another small open area to her left buttock with moderate amount of blood. The area was about 1.0 cm in size. The wound was cleaned with normal saline, and a dressing was applied. Interview on 02/07/23 at 3:12 P.M. with the Director of Nursing revealed incontinence care was to be completed every two hours and/ or as needed if it was needed prior. Review of the facility policy labeled, Perineal Care, dated October 2010, revealed the purpose of this procedure was to provide cleanliness and comfort to the resident, prevent infection and skin irritation, and observe the residents skin condition. The policy did not include language to provide perineal care timely. This deficiency represents non-compliance investigated under Complaint Number OH00139084.

Based on observation, interview, and record review, the facility failed to ensure pressure ulcer interventions were in place, wound assessments were accurate, and treatments were completed as ordered for Resident #19, Resident #25, and Resident #57. Harm occurred when preventive pressure ulcer interventions were not in place for Resident #25, and the resident developed an unstageable pressure ulcer to the left lateral foot. This affected three residents (Resident #19, Resident #25, Resident #57) out of three residents reviewed for pressure ulcers. Findings include: 1. Review of the medical record for Resident #19 revealed an admitted [DATE]. Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #19 did not have any pressure areas upon admission to the facility. Review of Resident #19 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 11/08/21 revealed the turn and reposition the resident every two hours for skin care. Review of Resident #19's admission Braden Risk Assessment, dated 10/20/21, revealed he was at high risk for the development of pressure ulcers. Review of the Resident #19's pressure skin grid, dated 11/03/21, revealed he had developed a pressure ulcer on his left ear. The wound measured 0.3 centimeters (cm) length by 0.2 cm in width. The area was superficial with red viable tissue. The area was not staged. The ear wound healed 11/10/21. Review of Resident #19's Pressure skin grid, dated 11/17/21, revealed the resident had a healed pressure ulcer to his left buttocks. Continued review of the facility pressure skin grids revealed that the facility did not document when the pressure ulcer started or completed staging on the area. Review of Resident #19's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident was cognitively impaired and needed extensive assistance with two plus physical assist for bed mobility. Review of Resident #19's Treatment Administration Record (TAR) revealed the resident's order to pad and protect bilateral heels every shift was not done on 11/04/21, 11/17/21, 11/19/21, 11/22/21, 12/01/21, 12/02/21, 12/09/21, 12/10/21, 21/11/21, 12/15/21, 12/16/21, 12/17/21, and 12/27/21. The TAR revealed the resident was not turned and repositioned every two hours on 11/17/21, 11/19/21, 11/22/21, 12/01/21, 12/02/21, 12/09/21, 12/10/21, 12/11/21, 12/1521, 12/16/21, 12/17/21, and 12/27/21. Review of Resident #19's Pressure Skin Grid, dated 12/29/21, revealed Resident #19 had developed an unstageable pressure ulcer to the residents left lateral foot. The area measured 2 cm by 1 cm. The area had dark tissue and appeared as a closed scab. Review of Resident #19's physicians orders revealed an order on 12/29/21 to apply skin prep to the residents left lateral plantar foot, place an abdominal pad, and wrap with kerlix daily on night shift. Review of Resident #19 January 2022 TAR revealed Resident #19's left lateral foot treatment was not completed on 01/03/22. Interview on 01/10/21 at 10:00 A.M. with Licensed Practical Nurse (LPN) #42 revealed she was the facility wound nurse. She confirmed she was not made aware of Resident #19's pressure ulcer on his buttocks until it was already healed. She also confirmed there was not documentation the wound was ever staged or evidence of when it first developed. She also confirmed pressure ulcer treatments and turning and repositioning as ordered were not in place for Resident #19 consistently as ordered. Interview on 01/05/22 at 5:35 A.M. with LPN #115 revealed staffing on night shift could be better. She revealed wound treatments are missed due to low staffing and not having time to get them done. She continued when they are understaffed on night shift, residents are not able to be turned and repositioned every two hours, and timely incontinence care is not provided. LPN #115 worked throughout the entire facility. Interview on 01/05/22 at 6:34 A.M. with LPN #136 revealed staffing in the facility was terrible. LPN #136 revealed at times all the assigned nursing tasks were not completed due to low staffing. LPN #136 also revealed residents are not always turned and repositioned every two hours. LPN #126 worked throughout the entire facility. 2. Review of Resident #25 medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #25's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident required total assistance of one person for bed mobility and total assistance of one person physical assistance for transfers. Resident #25 was admitted with two stage four pressure areas. One to the the Left ischium and one to the sacrum. Review of Resident #25's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 12/22/21 revealed a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #25's care plan, dated 12/30/21, revealed the resident was at risk for impaired skin integrity related to lack of mobility. Interventions included resident educated on the need to limit time up in wheelchair, to change her position in bed every two hours and for comfort, complete treatments per order, and utilize pressure reduction devices if ordered. Review of the December 2021 Treatment Administration Record (TAR) revealed Resident #25 treatment to her left ischium was not completed twice a day on 12/24/21, 12/26/21, 12/27/21, and 12/29/21. Resident #25's sacrum treatment was not completed twice a day on 12/24/21, 12/26/21, 12/27/21, and 12/29/21. Interview on 01/05/22 at 8:10 A.M. with Resident #25 revealed she does not get turned every two hours and she sometimes lays all day in the same position. She continued her treatments get pushed to different shifts or do not get done at all. She believed this was due to low staffing in the facility. Interview on 01/05/22 at 1:56 PM with Administrator confirmed the facility does not have evidence Resident #25's pressure ulcer treatments were completed as ordered for the month of December 2021. 3. Review of Resident #57's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #57's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 12/01/21 revealed a treatment to cleanse sacral wound with normal saline, pat dry, skin prep peri wound, fill wound with Dakins moistened gauze and cover with foam dressing, twice daily until resolved. On 12/22/21 the sacral wound order changed to cleanse sacral wound with normal saline, pat dry, skin prep to peri-wound, cover wound bed with Santyl then fill wound with Dakin's moistened gauze, and cover with foam dressing twice daily. Review of Resident #57's December 2021 and January 2022 TAR revealed the resident's sacral wound treatment was not completed as ordered on 12/02/21, 12/05/21, 12/06/21, 12/07/21, 12/09/21, 12/10/21, 12/11/21, 12/13/21, 12/14/21, 12/15/21, 12/16/21, 12/17/21, 12/20/21, 12/25/21, 12/27/21, 12/30/21, 01/02/22, 01/03/22, and 01/04/22. Observation on 01/10/22 at 9:36 A.M. revealed Resident #57 to be lying on her back, her head of bed was slightly raised, and her heels were directly on the bed. Interview on 01/10/22 at 9:36 A.M. with LPN #42 confirmed Resident #57 had an order to float her bilateral heels while she was in bed, and they were not floated as ordered. LPN #42 then placed a pillow under Resident #57's heels. Interview on 01/05/22 at 5:35 A.M. with LPN #115 revealed staffing on night shift could be better. She revealed wound treatments are missed due to low staffing and not having time to get them done. She continued when they are understaffed on night shift, residents are not able to be turned and repositioned every two hours, and timely incontinence care is not provided. LPN #115 worked throughout the entire facility. Interview on 01/05/22 at 6:34 A.M. with LPN #136 revealed staffing in the facility was terrible. LPN #136 revealed at times all the assigned nursing tasks were not completed due to low staffing. LPN #136 also revealed residents are not always turned and repositioned every two hours. LPN #126 worked throughout the entire facility. Interview on 01/05/22 at 1:56 P.M. with Administrator confirmed that the facility does not have evidence that Resident #57's pressure ulcer treatments were completed as ordered for the month of December and January. Review of undated facility policy titled Pressure Ulcer Prevention and Risk Identification revealed If a new skin area is identified a licensed nurse will initiate a skin grid/measurement flow record. The skin grid will be updated every seven days until resolved. This deficiency substantiates Complaint Numbers OH 640 and OH 544.

Based on closed record review, review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in Immediate Jeopardy and serious life-threatening harm for Resident #73 on 06/10/21 when Resident #73 arrived at an outside orthopedic follow-up appointment. Resident #73, who was alert and oriented with oxygen therapy, presented disoriented, cool to touch and had a dangerously low oxygen level. It was determined there was no oxygen in the portable liquid oxygen tank. This affected one of one resident requiring oxygen therapy who had a leave of absence (LOA) from the facility. The facility identified six residents (Residents #4, #19, #23, #31, #45, and #65) who had orders for oxygen therapy. The facility census was 72. On 06/30/21 at 3:30 P.M., the Administrator and the Director of Nursing (DON) were notified Immediate Jeopardy began on 06/10/21 at 9:50 A.M. when Resident #73 arrived at the outside doctor appointment without continuous oxygen in place as planned to maintain oxygen levels for effective breathing. The resident presented with signs and symptoms of [CONDITION(S)] hypoxemia (the blood in the body cannot maintain oxygen levels which could cause shortness of breath and could become serious and even fatal) including being disoriented, cool to touch and having an oxygen level of 45 percent which was measured using a pulse oximeter (a small device used to measure the oxygen level in the blood). Normal blood oxygen levels are between 95 and 100 percent. A reading of 88 percent or below signals [CONDITION(S)] (the body cannot maintain oxygen levels in the blood or tissues). The Immediate Jeopardy was removed on 07/01/21 when the facility implemented the following correction actions: · Resident #73 no longer resides in the facility. · On 06/29/21 by 9:00 A.M. the DON educated all nurses (including contracted agency nurses) and State tested Nurse Aides (STNAs) related to residents who required oxygen while going out for appointments, leave of absences (LOAs), or for any other reason. The education clarified it was the nurse's responsibility to assure the proper type of oxygen supply tank was provided and to ensure the tank was full of oxygen before the resident left the facility to ensure there was an adequate amount of oxygen supply to last for the LOA. Further, all oxygen was to be handled by the nurse only, when applying, reapplying, or filling liquid [MEDICATION(S)]. The STNAs can monitor the gauge, but any changes must be done by the nurse. · On 06/30/21 by 4:00 P.M., the DON completed a whole house audit of residents who were ordered oxygen and who had gone out on LOAs or appointments. There were no resident appointments or LOAs for the affected residents in the last 30 days. · On 06/30/21 by 5:45 P.M., the DON verified the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Residents checked were on concentrators in their rooms. Documentation is in place on the Treatment Administration Record (TAR) for oxygen monitoring for all six residents. · On 07/01/21 at 8:00 A.M., the DON completed education for all 13 nurses and 20 STNAs on management of e-tank system, managing liquid oxygen portable concentrators, on verifying oxygen and documenting verification prior to the resident going out on LOA. Education includes facility policy on oxygen use, filling, and storage. · The DON/Designee will perform an audit two times a week and as needed for four weeks, then randomly thereafter to verify oxygen had been monitored and the verification was documented prior to the resident leaving the facility for an LOA. · The DON/Designee will educate new staff on the management of E-tanks, liquid oxygen concentrators, and residents who are ordered oxygen and go out on LOAs or appointments upon hire, quarterly, and as needed. · Any unusual findings will be reported to the QAPI for prompt resolution. The DON will monitor this area for compliance on an ongoing basis. Although the Immediate Jeopardy was removed on 07/01/21, the deficiency remains at Severity Level II (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 their corrective action and auditing tools. Findings include: Resident #73 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the Treatment Administration Record (TAR) revealed there was no evidence the five liters of continuous oxygen was monitored to ensure it was in place at all times as ordered. Neither the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nurse progress note dated 05/28/21 revealed Resident #73 complained of an increase in shortness of breath (SOB). A chest x-ray was ordered which revealed the resident had pneumonia and medications were ordered to treat the pneumonia. Review of the 05/28/21 telephone physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .M. for the 10:00 A.M. appointment. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #73 was alert and oriented and able to make her needs known but required extensive assistance of one to two staff for activities of daily living. Further review of the alteration in oxygen exchange/perfusion [CONDITION(S)] care plan revealed Resident #73 was to receive oxygen as ordered by the physician. There was no mention of the rate or type of equipment to be used. Review of the nurse's note dated 06/10/21 at 2:38 P.M., written by Licensed Practical Nurse (LPN) #115, revealed Resident #73 went out and had returned from the appointment. There was no evidence of any concerns related to the resident having signs and symptoms of [CONDITION(S)] and/or hypoxemia from lack of oxygen supply. Review of the orthopedic office visit physician note dated 06/10/21 revealed Resident #73 arrived at the appointment from the nursing home and was met there by Family #73. Review of the note revealed Resident #73 was supposed to be on continuous oxygen at six liters but Resident #73 arrived today from the facility with a portable liquid oxygen tank which was empty. Resident #73's blood oxygen level was 45 percent on room air. Resident #73's skin was pale, cool to touch and the resident was disoriented. The office had an oxygen tank that was applied at six liters and Resident #73's blood oxygen levels quickly returned to her baseline of upper 80's to low 90's percent. Resident #73's skin color returned to pink, was warm to touch and the resident stated she was feeling much better after the oxygen was applied. On 06/27/21 at 12:55 P.M., interview with the DON indicated on 06/10/21 the orthopedic office called and said Resident #73 ran out of oxygen. The DON stated she thought it was agency staff who did not fill the tank with oxygen. The DON stated she would normally do a one to one education with her staff but since it was agency she did not do anything even though they are contracted agency staff who agree to work for a period of time. The DON verified there was no education or investigation completed. The DON stated she thought Resident #73 had difficulty breathing due to anxiety because her blood oxygen levels were always within normal limits. On 06/27/21 at 10:40 A.M., interview with Registered Nurse (RN) #103 revealed the aides were able to change oxygen supply types for residents but if the resident was going on an outing, she would double check the oxygen. On 06/28/21 at 12:01 P.M., phone interview with LPN #115 verified Resident #73's daughter called her while the resident was at the doctor's appointment saying the resident did not have any oxygen and needed the facility to bring up a tank so the resident could return to the facility. LPN #115 verified the resident was on an oxygen concentrator that was plugged into the wall while at the facility. This type of oxygen supply could not be taken to the doctor's appointment, so a different type needed to be used. LPN #115 verified she did not obtain any oxygen for the resident to take to the appointment because STNA #116 did as she and Physical Therapy Assistant (PTA) #109 got Resident #73 ready for the appointment. LPN #115 stated STNAs were able to fill oxygen tanks including for transportation and were able to manage oxygen concentrators while the residents were in the facility. LPN #115 verified she did not document anything about the incident. On 06/27/21 at 1:20 P.M., interview with LPN #106 revealed she thought the aides can adjust oxygen and was not sure who's responsibility it was to fill portable oxygen tanks because none of the residents had gone anywhere in over a year. On 06/28/21 at 2:40 P.M., phone interview with Orthopedic Medical Assistant ([NAME]) #117, from the resident's orthopedic doctor's office, revealed most residents requiring oxygen come with oxygen tanks that hold a large amount of oxygen but Resident #73 presented with a small portable liquid oxygen tank that could be carried on your shoulder. [NAME] #117 verified Resident #73 was out of it, which was not normal with confused conversation and poor skin coloring. Family #73 and [NAME] #117 verified there was no oxygen in the portable liquid oxygen tank when Resident #73 arrived at the office shortly before 10:00 A.M. Resident #73's blood oxygen level was checked and found to be in the low 40's so they provided her with oxygen from one of their E-tanks at six liters and quickly Resident #73 changed, became oriented and felt much better. On 06/29/21 at 9:28 A.M., phone interview with the DON verified she was not concerned about Resident #73 running out of oxygen while at the doctor's appointment because this kind of stuff happens all the time in doctor offices and in the three other facilities where she had previously worked. The DON verified she did not do an investigation because it had happened in the past. The DON indicated it was the nurse's responsibility to ensure the oxygen tanks were filled. The DON verified she did not do an in-service with the staff at the time of the incident. On 06/30/21 at 4:30 P.M., interview with RN #111, with observation of the oxygen storage areas, revealed the facility had one portable liquid oxygen tank shoulder strap type that was empty but was capable of providing up to six liters of oxygen per minute. In another storage area there were seven long silver cylinder E-tanks all stored together but RN #111 was not able to tell if any of them had oxygen in them. The facility also had several transfilling oxygen tanks, but RN #111 was not able to tell which ones contained oxygen. RN #111 stated they did not use the E-tanks nor the portable liquid oxygen tanks very often and would have to ask someone how to fill them. On 06/30/21 at 4:50 P.M., interview with STNA #112 revealed she was able to handle oxygen, was not sure if she was able to fill oxygen tanks and place on a resident but if a nurse asked, she would. She has adjusted oxygen that was not in place correctly on the nose. On 06/30/21 at 5:00 P.M., interview with the DON, with the Administrator and Corporate RN #119 present, revealed Resident #73's doctor's office was 3.2 miles away from the facility. Resident #73 left the facility for the doctor's office on 06/10/21 at 9:15 A.M. and did not return until 2:30 P.M. The DON verified the nurses were supposed to choose the appropriate portable oxygen tank and ensure it was full and set it up for the resident to deliver the correct amount/liters of oxygen. The STNAs were not to make any changes to the oxygen equipment. The DON verified she did not do an investigation in an attempt to see who provided the portable liquid oxygen tank to Resident #73 nor why it was not filled. The DON verified no disciplinary action was taken and no education to any staff was completed. The DON verified Resident #73 was on five liters of oxygen and the portable liquid oxygen tank used for the office visit, if full, would have only provided oxygen for two hours at that rate. The DON verified Resident #73 was gone from the facility for five hours on 06/10/21. On 06/30/21 at 5:30 P.M., interview with RN #113 revealed she was an agency nurse and had received no education about where oxygen was stored or providing portable tanks to residents. RN #113 stated the facility probably got the tanks delivered full and was not aware the nurses were to fill the tanks when needed. On 07/01/21 at 10:00 A.M., phone interview with Transporter #114, from the outside contracted transportation company, verified when he picked up Resident #73 from the facility he thought it was unusual she did not have one of the long silver cylinder oxygen E-tanks he was used to seeing when the staff brought residents outside to get in the van. Transporter #114 stated he picked up Resident #73 about 9:15 A.M. from the facility and arrived at the doctor's office at about 9:50 A.M. where he was met by Family #73 to assist Resident #73 with the office visit. Transporter #114 stated he was surprised Family #73 jumped up and immediately approached Resident #73 with concern and went right to the oxygen tank and said it was empty as soon as he brought Resident #73 to the office. Transporter #114 stated he then left the office since Family #73 was with the resident. On 07/01/21 at 10:50 A.M., phone interview with Family #73 revealed she took care of Resident #73 at home prior to her recent [CONDITION(S)] and when she saw that small liquid oxygen tank coupled with Resident #73's appearance she knew she was not getting any oxygen. Family #73 stated the office staff immediately took action and when Resident #73 was provided with oxygen she returned to her normal self. Family #73 verified the resident was alert and oriented and was aware how important it was to always have her oxygen on. The resident was very anxious about having difficulty breathing and would never remove the oxygen intentionally. Family #73 stated maybe when the resident adjusted her glasses the tubing would slip out of a nostril, but the resident immediately put it back in place. The only other time the tubing could come out of the nostrils was during sleep accidentally and the resident was very fearful of this. Family #73 stated she called the facility to get someone to bring up some oxygen to get the resident back to the facility from the 06/10/21 doctor's appointment but LPN #115 stated they did not do that. Family #73 stated she called back and requested LPN #115 talk to the DON because the resident could not be without oxygen. Family #73 did not receive any call backs or communication from the facility. Family #73 then called the facility and spoke with the DON who then had staff bring an E-tank so the resident could be transported back to the facility. Family #73 verified there was no back up oxygen provided by the facility for the doctor's appointment. On 07/02/21 at 12:09 P.M., interview with the Medical Director verified LPN #115 did not document the entire situation that occurred during the 06/10/21 office visit including no mention of concerns that were expressed with running out of oxygen and there was no other documentation (investigation) to verify what actually happened. The Medical Director verified documentation was very important. On 07/12/21 at 11:21 A.M., follow up phone interview with Family #73 reiterated she was at the doctor's office when Resident #73 arrived at 9:50 A.M., and presented with gray skin color, was disoriented and having difficulty breathing. Family #73 immediately requested LPN #200 to check Resident #73. It was determined there was no oxygen coming from the nasal cannula and further check of the liquid oxygen tank revealed there was no oxygen in the tank. The resident was immediately placed on the office's portable oxygen and she returned to her normal skin color, with unlabored breathing and was alert and oriented. Resident #73 was having a lot of pain and was ordered [MEDICATION(S)] four milligrams (mg) four times a day as well as, as needed [MEDICATION(S)] every 12 hours for pain. Resident #73 was due for her scheduled dose at 12:00 P.M. but the facility did not provide any pain medication. The resident was complaining of pain when she laid down for an x-ray. The doctor did not like the results of the x-ray and wanted a different view. LPN #200 called the facility to see if they could get her scheduled dose of [MEDICATION(S)] but was told no. Family #73 informed LPN #200 she had a prescription bottle at home of Resident #73's [MEDICATION(S)] and only lived five minutes away and offered to go and get it. Family #73 obtained the prescription bottle and a four mg dose was given to Resident #73 between 12:15 P.M. and 12:30 P.M. so she could get the second x-rays. Family #73 said she was nervous because she did not want Resident #73 to be over medicated when she returned to the facility and asked LPN #200 to contact the facility so they knew she received a dose of the [MEDICATION(S)]. On 07/12/21 at 11:59 A.M., phone interview with LPN #200, from the orthopedic office, verified when Resident #73 arrived at the office the family informed her she did not have any oxygen. LPN #200 immediately assessed Resident #73 who was having difficulty breathing and her color was gray. LPN #200 checked the oxygen supply and found there was no oxygen coming through the nasal cannula, she then checked to make sure the tubing was connected correctly and found it was but when checking the tank itself there was no oxygen in the tank so LPN #200 immediately obtained an office supply of oxygen and placed it on Resident #73 who then returned to her baseline. Resident #73 was expressing a lot of pain during the office visit making it difficult to obtain x-rays. LPN #200 verified she contacted the nursing home to see if someone could bring Resident #73's pain medication and when the last time was she'd received any. LPN #115 stated she was told Resident #73 was due for her next dose of four mg of [MEDICATION(S)] at 12:00 P.M. and was given the last dose at 6:16 A.M. LPN #200 informed the family they did not have any pain medications available and the family indicated the resident had a prescription bottle at home of four mg of [MEDICATION(S)]. The bottle was obtained and shown to LPN #200 who verified it was the resident's four mg [MEDICATION(S)] from when the resident lived at home prior to the [CONDITION(S)]. LPN #200 verified she again called LPN #115 who stated it was okay to give the medication. LPN #200 also informed the orthopedic doctor so she was aware of the situation. LPN #200 informed the family to do what they needed to do when deciding if the [MEDICATION(S)] should be given. LPN #200 stated she did not see any medications being given to the resident while at the office visit. LPN #200 verified the family was in contact with the facility DON multiple times related to needing the [MEDICATION(S)] for pain. Review of the oxygen therapy policy, not dated, revealed all residents on oxygen must have the liters per minute (LPM) and the type of device prescribed by the physician. Oxygen concentrators may be used for up to five LPM. The Venturi mask (also known as an air-entrainment mask to deliver a known oxygen concentration for residents on controlled oxygen therapy). was recommended for [CONDITION(S)] residents to reduce the risk of oxygen-induced ventilation depression. Always have an oxygen back-up system on hand in case of equipment failure. The portable liquid oxygen tank would provide oxygen for three hours at five LPM and the portable cylinder E-tank would provide oxygen for two hours when running at five LPM. Review of the WebMD report (https://www.webmd.com/asthma/guide/[CONDITION(S)]-hypoxemia) revealed when your body doesn't have enough oxygen, you could get hypoxemia or [CONDITION(S)]. These are dangerous conditions. Without oxygen, your brain, liver, and other organs can be damaged just minutes after symptoms start. Hypoxemia (low oxygen in your blood) can cause [CONDITION(S)] (low oxygen in your tissues) when your blood doesn't carry enough oxygen to your tissues to meet your body's needs. The word [CONDITION(S)] is sometimes used to described both problems. Most common symptoms include change in color of your skin, confusion, cough, fast heart rate, rapid breathing, SOB, slow heart rate, sweating and/or wheezing. If you have symptoms call 911 immediately. Review of the WebMD report (https://www.webmd.com/lung/[CONDITION(S)]/[CONDITION(S)]-[CONDITION(S)]) related to signs and symptoms of [CONDITION(S)] revealed this kind of [CONDITION(S)] can start a chain reaction that leads to low oxygen in the blood (or hypoxemia). Hypoxemia is a key reason for the SOB with [CONDITION(S)]. In turn hypoxemia can cause [CONDITION(S)] in other parts of the body (tissue [CONDITION(S)]). This happens when your blood doesn't carry enough oxygen to your tissues. Tissue [CONDITION(S)] can affect any cells that don't get enough oxygen or use it properly. Tissue [CONDITION(S)] can become serious and even fatal. Although [CONDITION(S)] hypoxemia and [CONDITION(S)] both stem from a lack of oxygen, you can have one without the other. Symptoms with either [CONDITION(S)] or hypoxemia include SOB, cough, wheezing, anxiety, upset, restless and skin turning pale. If it gets worse you could pass out, skin and lips could look blue. Serious [CONDITION(S)] can cause your heart and breathing to stop suddenly (cardiorespiratory arrest). It can also damage your brain and other organs within minutes. With hypoxemia, your breathing and heart rates might go up. It can also cause muscle loss and/or fatigue and may lead to thinking problems such as slower mental speed and inattention. Get medical help right away with signs of [CONDITION(S)].

Based on medical record review, review of personnel files, review of a facility Self-Reported Incident (SRI) and associated investigation documents, review of the on-line Summit County Sheriff's Office Head Count with Photo's Report, interview with the local police detective, interviews with facility staff, and review of the facility's policy titled Abuse, Neglect, and Exploitation of residents and Misappropriation of Property, the facility failed to ensure a resident was protected from further sexual abuse after an observation was made of inappropriate care and sexual abuse. This resulted in Immediate Jeopardy and sexual assault for one (#1) resident when State tested Nursing Assistant (STNA) #2 was observed behind the privacy curtain with his pants down to his ankles at the bedside of Resident #1 who was cognitively impaired and required only female caregivers due to being known to exhibit sexually inappropriate behaviors. This affected one (#1) of seven residents reviewed relative to investigations of facility SRIs submitted in the past month alleging abuse. The facility census was 100 residents. On 06/27/18 at 12:05 P.M., the administrator was informed that Immediate Jeopardy began on 06/04/18 at 3:30 P.M. when STNA #1 observed STNA #2 with his pants down to his ankles while standing behind the privacy curtain at the bedside of Resident #1. STNA #1 reported this at 3:41 P.M. to the administrator and Director of Nursing (DON) who then responded to the incident by assessing Resident #1 and removing STNA #2 from the resident care areas, and contacting the local police. Resident #1 was sent to the hospital on [DATE] for evaluation, and returned to the facility on [DATE]. According to public records, STNA #2 was arrested on 06/05/18 and is being held in jail for a rape charge. The Immediate Jeopardy was removed on 06/05/18 when the facility implemented the following corrective actions. · On 06/04/18 at 3:56 P.M., Certified Nurse Practitioner (CNP) #80 and Registered Nurse (RN) #10 assessed Resident #1 who was without visible injury and in no distress. The resident was fully clothed and seated in her wheelchair at the time CNP #80 went to examine the resident. · On 06/04/18 at 3:56 P.M., the perpetrator (STNA #2) was removed from the unit and taken to a conference room in a location away from resident living areas. STNA #2 remained in the conference room with administrative staff and/or the police. The facility started their investigation from there and then the police took over. · On 06/04/18 at 4:04 P.M., the DON called the local police to the facility regarding the observations made by STNA #1 and their investigation of sexual abuse. · On 06/04/18 at 4:10 P.M., local police arrived at the facility and took over the investigation. · On 06/04/18 at 4:45 P.M., Resident #1 was transported to the hospital for evaluation. · On 06/04/18 at 4:45 P.M., Social Worker (SW) #20 and SW #21 interviewed the three interviewable residents on the Hampton Hills dementia unit who did not express any abuse concerns or observations. · On 06/04/18 at 4:45 P.M., the Administrator, DON, Activity Director #23, Dietary Manager #24, RN Unit Manager #22, Human Resources Director Licensed Practical Nurse (LPN) #12, Minimum Data Set assessment LPN #13, SW #20, SW #21, Admissions Director #25, Unit Manager LPN #11 and Acting Therapy Director #82 all initiated a whole house education on the facility's policy and procedure titled Abuse, Neglect, and Exploitation of residents and Misappropriation of Property. All staff were in-serviced including 25 LPNs, nine RNs, 59 STNAs, three Activity personnel, 17 Dietary personnel, nine Housekeeping personnel, one Marketing employee, one Medical Records employee, one Business Office Manager, two Maintenance personnel, two Social Workers, four Physical Therapists, five Physical Therapy Assistants, two Occupational Therapists, six Occupational Therapy Assistants, and two Speech Therapists. · On 06/04/18 at 4:45 P.M., the DON initiated the completion of head to toe assessments of 23 additional residents who were not interviewable on the Hampton Hills dementia unit. There were no signs of physical abuse observed with these residents. · On 06/04/18 at 5:05 P.M., the facility submitted an SRI regarding an allegation of sexual abuse to the Ohio Department of Health. · On 06/04/18 at 5:30 P.M., the police left the facility with STNA #2. · On 06/05/18, SW #21 interviewed all remaining 27 interviewable residents in the facility regarding abuse, with no allegations of abuse reported. · On 06/05/18, the DON reviewed the Kardex documentation to ensure the STNAs were knowledgeable regarding the seven facility residents that had preferences for female caregivers only. · On 06/05/18, one-on-one education was completed with RN #10 and STNA #1 regarding the facility policy for Abuse, Neglect, and Exploitation of residents and Misappropriation of property, stressing the importance of protecting the resident as priority. · On 06/06/18, the administrator changed the staffing on the Hampton Hills dementia unit so that only female caregivers worked on this unit. · On 06/06/18, the administrator and DON began random staff interviews about abuse to assess their understanding after staff education. Twenty-eight staff were interviewed between 06/06/18 and 06/08/18 with no identified issues. · On 06/07/18, SW #21 began monitoring of two random residents per day, five days a week, through an abuse related interview, which will continue for at least four weeks. · On 06/07/18, the DON and the unit manager (LPN#11) began observing staff to ensure they were following the care needs described on the Kardex. This monitoring will be ongoing. · On 06/14/18, the administrator began conducting new hire orientation for abuse prevention and reporting according to the facility policy, which will continue indefinitely. · On 06/21/18, the DON began conducting new hire orientation for all staff for customer service and all nursing and STNA staff for reviewing and following the resident Kardex for care concerns. · On 06/21/18, the DON conducted a Pink Dot in-service for all nursing and therapy staff regarding which residents required female only caregiving for pericare or showers, which would be indicated with a small pink sticker outside of those resident's doors. 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 was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident resided on a secured unit for memory impaired residents. According to the Minimum Data Set (MDS) assessment, dated 05/18/18, Resident #1 was dependent on the staff for dressing, toileting, mobility, eating, and transfers. Resident #1 had severely impaired cognition, was incontinent of bowel and bladder and required a wheelchair for locomotion. The plan of care initiated 09/07/17 indicated Resident #1 had inappropriate sexual behavior and required only female caregivers. Review of the facility's SRI, dated 06/04/18 at 4:34 P.M., revealed the facility substantiated an act of alleged sexual abuse towards Resident #1 from a male STNA #2. According to the SRI, STNA #1 witnessed STNA#2 with his pants down around his ankles and bare legs showing behind a privacy curtain while providing care to Resident #1. STNA #1 suspected inappropriate behavior taking place and immediately left the room, without moving Resident #1 to safety, so she could go and notify the unit RN #10. RN #10 did not move Resident #1 to safety or remove STNA #2 from the unit prior to going directly to the administrator to report the allegation with STNA#1. The administrator and DON called the police, removed STNA #2 from the unit, and sent Resident #1 to the hospital to be examined. The facility began interviewing (three) residents on the unit who could be interviewed and assessed 23 additional residents who could not give appropriate answers. STNA #1 signed a witness statement on 06/04/18 at 3:41 P.M. RN #10 signed a witness statement at 3:45 P.M. The facility indicated on the SRI they completed their investigation on 06/08/18 at 4:06 P.M. Review of the facility's investigation report and investigation timeline created by the facility dated 06/04/18 revealed Resident #1 was verified as safe at 3:56 P.M and STNA #2 was removed from the unit at 3:56 P.M. Local law enforcement arrived at the facility at 4:10 P.M. and took over the investigation. At 4:45 P.M., Resident #1 was transported to the hospital for evaluation. At 5:30 P.M., STNA #2 left the facility with the local police. Review of the local law enforcement report, dated 06/08/18, revealed that STNA #2 was taken into police custody on 06/04/18 with the crime code listed as forcible rape. On 06/05/18, the DON conducted one-to-one counseling with STNA #1 and RN #10 regarding the facility policy for Abuse, Neglect, and Exploitation of residents and Misappropriation of property, stressing the importance of protecting the resident as a priority. Associated forms were signed by STNA #1, RN #10, and the DON, and were witnessed by the administrator on 06/05/18. Review of the hospital records dated 06/09/18 revealed Resident#1 was admitted to the hospital on [DATE] for examination after sexual assault and was discharged back to the facility on [DATE]. admitting [DIAGNOSES REDACTED]. During observations made on 06/24/18 at 11:50 A.M., 11:59 A.M., and 3:03 P.M. revealed Resident #1 was calm, smiling, making good eye contact with staff and peers and demonstrated a good appetite at lunch. Resident #1 was alert but completely disoriented to person, place and time, and used a wheelchair. An interview was conducted on 06/24/18 at 12:48 P.M. with STNA #1 who witnessed the incident. The interview revealed STNA #1 had asked STNA #2 to change Resident #1 because her undergarment was soiled during an activity, and STNA #1 had not had her lunch break yet that day. STNA #1 explained that she knew it was wrong to ask STNA #2 to change her because Resident #1 was required to have only female caregivers due to inappropriate sexual behaviors exhibited by Resident #1. STNA #1 explained that she usually took her lunch at 2:30 P.M. but since she and STNA #2 were the only STNA's working on the unit that day she was running behind on her lunch break and really wanted to take a break. STNA #2 agreed to change the resident for her and took Resident #1 to her room to be changed at approximately 3:00 P.M. STNA #1 returned to the unit at approximately 3:28 P.M. and found it peculiar that Resident #1 was not back out in the common area for an activity. STNA #1 stated she went directly to Resident #1's room and found the door was closed. As she opened the door to enter the room she saw STNA #2's bare legs with pants around his ankles behind the privacy curtain. STNA #1 immediately asked if STNA #2 needed any help and STNA #2 replied no, I got this as he pulled up his pants. STNA #1 stated she panicked and left the room abruptly without checking the resident and started to toilet another resident when she came to her senses and went to tell RN #10. STNA #1 explained that the observation of the alleged abuse happened at 3:30 P.M and at 3:41 P.M. she was in the administrator's office writing her witness statement. STNA #1 said she was so shocked at what she witnessed she never thought to check the condition of the Resident #1. An interview was conducted on 06/24/18 at 12:50 P.M. with RN #10. RN #10 revealed she was the nurse on the unit that day but did not see what happened to Resident #1. RN #10 stated she was notified of the situation by STNA #1 at approximately 3:30 P.M. and they both immediately went to tell the administrator without first moving Resident #1 to safety or removing STNA #2 from other residents on the unit. RN #10 revealed she did not see what condition Resident #1 was in before she left the unit with STNA #1. Interviews on 06/24/18 at 12:46 P.M. and 1:05 P.M. with STNA #1 and RN #10 verified neither employee moved Resident #1 to safety before leaving the unit to report the allegation of abuse. STNA #1 verified that she did not return to the unit to check on Resident #1 before signing a witness statement at 3:41 P.M. which was 11 minutes after witnessing the incident. RN #10 verified that she did not return to the unit to check on Resident #1 before signing a witness statement at 3:45 P.M. which was 15 minutes after STNA #1 alerted her to the incident. Interview on 06/24/18 at 2:52 P.M. with the local police department verified STNA #2 remained in jail awaiting a hearing. An interview was conducted on 06/24/18 at 3:25 P.M. with the administrator and DON. The administrator stated they substantiated the allegation of sexual abuse because they could not be certain what exactly went on behind the curtain in Resident #1's room that day when STNA #2 was providing care in an inappropriate position. They felt that based on the statement given by STNA #1 it was enough to remove STNA #2 from duty, turn him into police and substantiate the sexual abuse. Staff interviews were conducted on 06/24/18 from 12:46 P.M. to 3:00 P.M. with STNA #3, STNA #4, LPN #11, Laundry Aide #50, Housekeeper #40, Activity Director #23 and Social Service Director #21 to confirm their understanding of the abuse policy and procedure for reporting abuse. The interviews verified the staff were knowledgeable on the abuse policy and procedure, and they had just recently been in-serviced by administration regarding abuse prevention. An interview was conducted on 06/26/18 at 2:03 P.M. with a local police detective who verified STNA #2 was currently in jail with a rape charge, as indicated on the online Summit County Sheriff's Office Head Count with Photo's Report. A telephone interview was conducted on 06/27/18 at 11:42 A.M. with Resident #1's Nurse Practitioner (NP). The NP revealed that she had Resident #1 on her list of residents to see on 06/04/18. She reported she found Resident #1 fully dressed, and her wig in place as usual while she was sitting in the common area. The NP was uncertain of the time but indicated that it was no more than five minutes before the administrator and DON came onto the floor to check Resident #1 and began looking for STNA #2 (which both indicated on their investigation timeline was 3:56 P.M.). The NP explained that since she had just checked Resident #1 over she did not check her again upon the request of the administrator and DON instead ordering them to send her out to the hospital for an examination due to the nature of the allegation. A telephone interview was conducted on 06/27/18 at 11:50 A.M. with Resident #1's physician. The physician revealed Resident #1's overall health was declining in general due to the dementia, and she can only speak in a manner that she was completely unable to make any reliable sense with what she says to anyone. The physician verified he was notified of the alleged sexual abuse by his NP on 06/04/18, and he had been in to examine her as of the third week in (MONTH) (YEAR). An interview with the administrator on 06/27/18 at 2:00 P.M. revealed STNA #2's employment status was indefinitely suspended pending the outcome of the police investigation. The administrator stated STNA #2 was currently in jail according to the local police public records, and he will not be returning to the facility. Review of the facility policy, titled Abuse, Neglect, and Exploitation of residents and Misappropriation of Property, dated 05/20/18, revealed facility residents will be protected from verbal, mental, sexual or physical abuse, corporal punishment, mistreatment, neglect, involuntary seclusion, exploitation and misappropriation of property. In addition, this required the protection of residents during investigation and reporting of incidents. The policy stated, When an allegation of abuse is identified the facility recognizes its obligation to keep residents safe and protect them from any harm to whatever extent possible. However, there was no evidence that STNA #1 immediately acted to protect Resident #1 after observing STNA #2 behind the privacy curtain with his pants down to his ankles in the presence of Resident #1. This deficiency substantiates facility Self Reported Incident Control Number OH 457.

Based on medical record review, review of personnel files, review of a facility Self-Reported Incident (SRI) and associated investigation documents, review of the on-line Summit County Sheriff's Office Head Count with Photo's Report, interview with the local police detective, interviews with facility staff, and review of the facility's policy titled Abuse, Neglect, and Exploitation of residents and Misappropriation of Property, the facility failed to ensure staff implemented their policy in order to protect residents after observing a sexual abuse situation by a staff member to a resident. This resulted in Immediate Jeopardy and sexual assault for one (#1) resident when State tested Nursing Assistant (STNA) #2 was observed behind the privacy curtain with his pants down to his ankles at the bedside of Resident #1 who was cognitively impaired and required only female caregivers due to being known to exhibit sexually inappropriate behaviors. This affected one (#1) of seven residents reviewed relative to investigations of facility SRIs submitted in the past three months alleging abuse. The facility census was 100 residents. On 06/27/18 at 12:05 P.M., the administrator was informed that Immediate Jeopardy began on 06/04/18 at 3:30 P.M. when STNA #1 observed STNA #2 with his pants down to his ankles while standing behind the privacy curtain at the bedside of Resident #1. STNA #1 reported this at 3:41 P.M. to the administrator and Director of Nursing (DON) who then responded to the incident by assessing Resident #1 and removing STNA #2 from the resident care areas, and contacting the local police. Resident #1 was sent to the hospital on [DATE] for evaluation, and returned to the facility on [DATE]. According to public records, STNA #2 was arrested on 06/05/18 and is being held in jail for a rape charge. The Immediate Jeopardy was removed on 06/05/18 when the facility implemented the following corrective actions. · On 06/04/18 at 3:56 P.M., Certified Nurse Practitioner (CNP) #80 and Registered Nurse (RN) #10 assessed Resident #1 who was without visible injury and in no distress. The resident was fully clothed and seated in her wheelchair at the time CNP #80 went to examine the resident. · On 06/04/18 at 3:56 P.M., the perpetrator (STNA #2) was removed from the unit and taken to a conference room in a location away from resident living areas. STNA #2 remained in the conference room with administrative staff and/or the police. The facility started their investigation from there and then the police took over. · On 06/04/18 at 4:04 P.M., the DON called the local police to the facility regarding the observations made by STNA #1 and their investigation of sexual abuse. · On 06/04/18 at 4:10 P.M., local police arrived at the facility and took over the investigation. · On 06/04/18 at 4:45 P.M., Resident #1 was transported to the hospital for evaluation. · On 06/04/18 at 4:45 P.M., Social Worker (SW) #20 and SW #21 interviewed the three interviewable residents on the Hampton Hills dementia unit who did not express any abuse concerns or observations. · On 06/04/18 at 4:45 P.M., the Administrator, DON, Activity Director #23, Dietary Manager #24, RN Unit Manager #22, Human Resources Director Licensed Practical Nurse (LPN) #12, Minimum Data Set assessment LPN #13, SW #20, SW #21, Admissions Director #25, Unit Manager LPN #11 and Acting Therapy Director #82 all initiated a whole house education on the facility's policy and procedure titled Abuse, Neglect, and Exploitation of residents and Misappropriation of Property. All staff were in-serviced including 25 LPNs, nine RNs, 59 STNAs, three Activity personnel, 17 Dietary personnel, nine Housekeeping personnel, one Marketing employee, one Medical Records employee, one Business Office Manager, two Maintenance personnel, two Social Workers, four Physical Therapists, five Physical Therapy Assistants, two Occupational Therapists, six Occupational Therapy Assistants, and two Speech Therapists. · On 06/04/18 at 4:45 P.M., the DON initiated the completion of head to toe assessments of 23 additional residents who were not interviewable on the Hampton Hills dementia unit. There were no signs of physical abuse observed with these residents. · On 06/04/18 at 5:05 P.M., the facility submitted an SRI regarding an allegation of sexual abuse to the Ohio Department of Health. · On 06/04/18 at 5:30 P.M., the police left the facility with STNA #2. · On 06/05/18, SW #21 interviewed all remaining 27 interviewable residents in the facility regarding abuse, with no allegations of abuse reported. · On 06/05/18, the DON reviewed the Kardex documentation to ensure the STNAs were knowledgeable regarding the seven facility residents that had preferences for female caregivers only. · On 06/05/18, one-on-one education was completed with RN #10 and STNA #1 regarding the facility policy for Abuse, Neglect, and Exploitation of residents and Misappropriation of property, stressing the importance of protecting the resident as priority. · On 06/06/18, the administrator changed the staffing on the Hampton Hills dementia unit so that only female caregivers worked on this unit. · On 06/06/18, the administrator and DON began random staff interviews about abuse to assess their understanding after staff education. Twenty-eight staff were interviewed between 06/06/18 and 06/08/18 with no identified issues. · On 06/07/18, SW #21 began monitoring of two random residents per day, five days a week, through an abuse related interview, which will continue for at least four weeks. · On 06/07/18, the DON and the unit manager (LPN#11) began observing staff to ensure they were following the care needs described on the Kardex. This monitoring will be ongoing. · On 06/14/18, the administrator began conducting new hire orientation for abuse prevention and reporting according to the facility policy, which will continue indefinitely. · On 06/21/18, the DON began conducting new hire orientation for all staff for customer service and all nursing and STNA staff for reviewing and following the resident Kardex for care concerns. · On 06/21/18, the DON conducted a Pink Dot in-service for all nursing and therapy staff regarding which residents required female only caregiving for pericare or showers, which would be indicated with a small pink sticker outside of those resident's doors. 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 was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident resided on a secured unit for memory impaired residents. According to the Minimum Data Set (MDS) assessment, dated 05/18/18, Resident #1 was dependent on the staff for dressing, toileting, mobility, eating, and transfers. Resident #1 had severely impaired cognition, was incontinent of bowel and bladder and required a wheelchair for locomotion. The plan of care initiated 09/07/17 indicated Resident #1 had inappropriate sexual behavior and required only female caregivers. Review of the facility's SRI, dated 06/04/18 at 4:34 P.M., revealed the facility substantiated an act of alleged sexual abuse towards Resident #1 from a male STNA #2. According to the SRI, STNA #1 witnessed STNA#2 with his pants down around his ankles and bare legs showing behind a privacy curtain while providing care to Resident #1. STNA #1 suspected inappropriate behavior taking place and immediately left the room, without moving Resident #1 to safety, so she could go and notify the unit RN #10. RN #10 did not move Resident #1 to safety or remove STNA #2 from the unit prior to going directly to the administrator to report the allegation with STNA#1. The administrator and DON called the police, removed STNA #2 from the unit, and sent Resident #1 to the hospital to be examined. The facility began interviewing (three) residents on the unit who could be interviewed and assessed 23 additional residents who could not give appropriate answers. STNA #1 signed a witness statement on 06/04/18 at 3:41 P.M. RN #10 signed a witness statement at 3:45 P.M. The facility indicated on the SRI they completed their investigation on 06/08/18 at 4:06 P.M. Review of the facility's investigation report and investigation timeline created by the facility dated 06/04/18 revealed Resident #1 was verified as safe at 3:56 P.M and STNA #2 was removed from the unit at 3:56 P.M. Local law enforcement arrived at the facility at 4:10 P.M. and took over the investigation. At 4:45 P.M., Resident #1 was transported to the hospital for evaluation. At 5:30 P.M., STNA #2 left the facility with the local police. Review of the local law enforcement report, dated 06/08/18, revealed that STNA #2 was taken into police custody on 06/04/18 with the crime code listed as forcible rape. On 06/05/18, the DON conducted one-to-one counseling with STNA #1 and RN #10 regarding the facility policy for Abuse, Neglect, and Exploitation of residents and Misappropriation of property, stressing the importance of protecting the resident as a priority. Associated forms were signed by STNA #1, RN #10, and the DON, and were witnessed by the administrator on 06/05/18. Review of the hospital records dated 06/09/18 revealed Resident#1 was admitted to the hospital on [DATE] for examination after sexual assault and was discharged back to the facility on [DATE]. admitting [DIAGNOSES REDACTED]. During observations made on 06/24/18 at 11:50 A.M., 11:59 A.M., and 3:03 P.M. revealed Resident #1 was calm, smiling, making good eye contact with staff and peers and demonstrated a good appetite at lunch. Resident #1 was alert but completely disoriented to person, place and time, and used a wheelchair. An interview was conducted on 06/24/18 at 12:48 P.M. with STNA #1 who witnessed the incident. The interview revealed STNA #1 had asked STNA #2 to change Resident #1 because her undergarment was soiled during an activity, and STNA #1 had not had her lunch break yet that day. STNA #1 explained that she knew it was wrong to ask STNA #2 to change her because Resident #1 was required to have only female caregivers due to inappropriate sexual behaviors exhibited by Resident #1. STNA #1 explained that she usually took her lunch at 2:30 P.M. but since she and STNA #2 were the only STNA's working on the unit that day she was running behind on her lunch break and really wanted to take a break. STNA #2 agreed to change the resident for her and took Resident #1 to her room to be changed at approximately 3:00 P.M. STNA #1 returned to the unit at approximately 3:28 P.M. and found it peculiar that Resident #1 was not back out in the common area for an activity. STNA #1 stated she went directly to Resident #1's room and found the door was closed. As she opened the door to enter the room she saw STNA #2's bare legs with pants around his ankles behind the privacy curtain. STNA #1 immediately asked if STNA #2 needed any help and STNA #2 replied no, I got this as he pulled up his pants. STNA #1 stated she panicked and left the room abruptly without checking the resident and started to toilet another resident when she came to her senses and went to tell RN #10. STNA #1 explained that the observation of the alleged abuse happened at 3:30 P.M and at 3:41 P.M. she was in the administrator's office writing her witness statement. STNA #1 said she was so shocked at what she witnessed she never thought to check the condition of the Resident #1. An interview was conducted on 06/24/18 at 12:50 P.M. with RN #10. RN #10 revealed she was the nurse on the unit that day but did not see what happened to Resident #1. RN #10 stated she was notified of the situation by STNA #1 at approximately 3:30 P.M. and they both immediately went to tell the administrator without first moving Resident #1 to safety or removing STNA #2 from other residents on the unit. RN #10 revealed she did not see what condition Resident #1 was in before she left the unit with STNA #1. Interviews on 06/24/18 at 12:46 P.M. and 1:05 P.M. with STNA #1 and RN #10 verified neither employee moved Resident #1 to safety before leaving the unit to report the allegation of abuse. STNA #1 verified that she did not return to the unit to check on Resident #1 before signing a witness statement at 3:41 P.M. which was 11 minutes after witnessing the incident. RN #10 verified that she did not return to the unit to check on Resident #1 before signing a witness statement at 3:45 P.M. which was 15 minutes after STNA #1 alerted her to the incident. Interview on 06/24/18 at 2:52 P.M. with the local police department verified STNA #2 remained in jail awaiting a hearing. An interview was conducted on 06/24/18 at 3:25 P.M. with the administrator and DON. The administrator stated they substantiated the allegation of sexual abuse because they could not be certain what exactly went on behind the curtain in Resident #1's room that day when STNA #2 was providing care in an inappropriate position. They felt that based on the statement given by STNA #1 it was enough to remove STNA #2 from duty, turn him into police and substantiate the sexual abuse. Staff interviews were conducted on 06/24/18 from 12:46 P.M. to 3:00 P.M. with STNA #3, STNA #4, LPN #11, Laundry Aide #50, Housekeeper #40, Activity Director #23 and Social Service Director #21 to confirm their understanding of the abuse policy and procedure for reporting abuse. The interviews verified the staff were knowledgeable on the abuse policy and procedure, and they had just recently been in-serviced by administration regarding abuse prevention. An interview was conducted on 06/26/18 at 2:03 P.M. with a local police detective who verified STNA #2 was currently in jail with a rape charge, as indicated on the online Summit County Sheriff's Office Head Count with Photo's Report. A telephone interview was conducted on 06/27/18 at 11:42 A.M. with Resident #1's Nurse Practitioner (NP). The NP revealed that she had Resident #1 on her list of residents to see on 06/04/18. She reported she found Resident #1 fully dressed, and her wig in place as usual while she was sitting in the common area. The NP was uncertain of the time but indicated that it was no more than five minutes before the administrator and DON came onto the floor to check Resident #1 and began looking for STNA #2 (which both indicated on their investigation timeline was 3:56 P.M.). The NP explained that since she had just checked Resident #1 over she did not check her again upon the request of the administrator and DON instead ordering them to send her out to the hospital for an examination due to the nature of the allegation. A telephone interview was conducted on 06/27/18 at 11:50 A.M. with Resident #1's physician. The physician revealed Resident #1's overall health was declining in general due to the dementia, and she can only speak in a manner that she was completely unable to make any reliable sense with what she says to anyone. The physician verified he was notified of the alleged sexual abuse by his NP on 06/04/18, and he had been in to examine her as of the third week in (MONTH) (YEAR). An interview with the administrator on 06/27/18 at 2:00 P.M. revealed STNA #2's employment status was indefinitely suspended pending the outcome of the police investigation. The administrator stated STNA #2 was currently in jail according to the local police public records, and he will not be returning to the facility. Review of the facility policy, titled Abuse, Neglect, and Exploitation of residents and Misappropriation of Property, dated 05/20/18, revealed facility residents will be protected from verbal, mental, sexual or physical abuse, corporal punishment, mistreatment, neglect, involuntary seclusion, exploitation and misappropriation of property. In addition, this required the protection of residents during investigation and reporting of incidents. The policy stated, When an allegation of abuse is identified the facility recognizes its obligation to keep residents safe and protect them from any harm to whatever extent possible. There was no evidence that STNA #1 followed the facility policy by immediately acting to protect Resident #1 after observing STNA #2 behind the privacy curtain with his pants down to his ankles in the presence of Resident #1. This deficiency substantiates facility Self Reported Incident Control Number OH 457.

Based on medical record review, review of personnel files, review of a facility Self-Reported Incident (SRI) and associated investigation documents, review of the on-line Summit County Sheriff's Office Head Count with Photo's Report, interview with the local police detective, interviews with facility staff, and review of the facility's policy titled Abuse, Neglect, and Exploitation of residents and Misappropriation of Property, the facility failed to ensure residents were free from sexual abuse by a staff member. This resulted in Immediate Jeopardy and sexual assault for one (#1) resident when State tested Nursing Assistant (STNA) #2 was observed behind the privacy curtain with his pants down to his ankles at the bedside of Resident #1 who was cognitively impaired and required only female caregivers due to being known to exhibit sexually inappropriate behaviors. This affected one (#1) of seven residents reviewed relative to investigations of facility SRIs submitted in the past month alleging abuse. The facility census was 100 residents. On 06/27/18 at 12:05 P.M., the administrator was informed that Immediate Jeopardy began on 06/04/18 at 3:30 P.M. when STNA #1 observed STNA #2 with his pants down to his ankles while standing behind the privacy curtain at the bedside of Resident #1. STNA #1 reported this at 3:41 P.M. to the administrator and Director of Nursing (DON) who then responded to the incident by assessing Resident #1 and removing STNA #2 from the resident care areas, and contacting the local police. Resident #1 was sent to the hospital on [DATE] for evaluation, and returned to the facility on [DATE]. According to public records, STNA #2 was arrested on 06/05/18 and is being held in jail for a rape charge. The Immediate Jeopardy was removed on 06/05/18 when the facility implemented the following corrective actions. · On 06/04/18 at 3:56 P.M., Certified Nurse Practitioner (CNP) #80 and Registered Nurse (RN) #10 assessed Resident #1 who was without visible injury and in no distress. The resident was fully clothed and seated in her wheelchair at the time CNP #80 went to examine the resident. · On 06/04/18 at 3:56 P.M., the perpetrator (STNA #2) was removed from the unit and taken to a conference room in a location away from resident living areas. STNA #2 remained in the conference room with administrative staff and/or the police. The facility started their investigation from there and then the police took over. · On 06/04/18 at 4:04 P.M., the DON called the local police to the facility regarding the observations made by STNA #1 and their investigation of sexual abuse. · On 06/04/18 at 4:10 P.M., local police arrived at the facility and took over the investigation. · On 06/04/18 at 4:45 P.M., Resident #1 was transported to the hospital for evaluation. · On 06/04/18 at 4:45 P.M., Social Worker (SW) #20 and SW #21 interviewed the three interviewable residents on the Hampton Hills dementia unit who did not express any abuse concerns or observations. · On 06/04/18 at 4:45 P.M., the Administrator, DON, Activity Director #23, Dietary Manager #24, RN Unit Manager #22, Human Resources Director Licensed Practical Nurse (LPN) #12, Minimum Data Set assessment LPN #13, SW #20, SW #21, Admissions Director #25, Unit Manager LPN #11 and Acting Therapy Director #82 all initiated a whole house education on the facility's policy and procedure titled Abuse, Neglect, and Exploitation of residents and Misappropriation of Property. All staff were in-serviced including 25 LPNs, nine RNs, 59 STNAs, three Activity personnel, 17 Dietary personnel, nine Housekeeping personnel, one Marketing employee, one Medical Records employee, one Business Office Manager, two Maintenance personnel, two Social Workers, four Physical Therapists, five Physical Therapy Assistants, two Occupational Therapists, six Occupational Therapy Assistants, and two Speech Therapists. · On 06/04/18 at 4:45 P.M., the DON initiated the completion of head to toe assessments of 23 additional residents who were not interviewable on the Hampton Hills dementia unit. There were no signs of physical abuse observed with these residents. · On 06/04/18 at 5:05 P.M., the facility submitted an SRI regarding an allegation of sexual abuse to the Ohio Department of Health. · On 06/04/18 at 5:30 P.M., the police left the facility with STNA #2. · On 06/05/18, SW #21 interviewed all remaining 27 interviewable residents in the facility regarding abuse, with no allegations of abuse reported. · On 06/05/18, the DON reviewed the Kardex documentation to ensure the STNAs were knowledgeable regarding the seven facility residents that had preferences for female caregivers only. · On 06/05/18, one-on-one education was completed with RN #10 and STNA #1 regarding the facility policy for Abuse, Neglect, and Exploitation of residents and Misappropriation of property, stressing the importance of protecting the resident as priority. · On 06/06/18, the administrator changed the staffing on the Hampton Hills dementia unit so that only female caregivers worked on this unit. · On 06/06/18, the administrator and DON began random staff interviews about abuse to assess their understanding after staff education. Twenty-eight staff were interviewed between 06/06/18 and 06/08/18 with no identified issues. · On 06/07/18, SW #21 began monitoring of two random residents per day, five days a week, through an abuse related interview, which will continue for at least four weeks. · On 06/07/18, the DON and the unit manager (LPN#11) began observing staff to ensure they were following the care needs described on the Kardex. This monitoring will be ongoing. · On 06/14/18, the administrator began conducting new hire orientation for abuse prevention and reporting according to the facility policy, which will continue indefinitely. · On 06/21/18, the DON began conducting new hire orientation for all staff for customer service and all nursing and STNA staff for reviewing and following the resident Kardex for care concerns. · On 06/21/18, the DON conducted a Pink Dot in-service for all nursing and therapy staff regarding which residents required female only caregiving for pericare or showers, which would be indicated with a small pink sticker outside of those resident's doors. 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 was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident resided on a secured unit for memory impaired residents. According to the Minimum Data Set (MDS) assessment, dated 05/18/18, Resident #1 was dependent on the staff for dressing, toileting, mobility, eating, and transfers. Resident #1 had severely impaired cognition, was incontinent of bowel and bladder and required a wheelchair for locomotion. The plan of care initiated 09/07/17 indicated Resident #1 had inappropriate sexual behavior and required only female caregivers. Review of the facility's SRI, dated 06/04/18 at 4:34 P.M., revealed the facility substantiated an act of alleged sexual abuse towards Resident #1 from a male STNA #2. According to the SRI, STNA #1 witnessed STNA#2 with his pants down around his ankles and bare legs showing behind a privacy curtain while providing care to Resident #1. STNA #1 suspected inappropriate behavior taking place and immediately left the room, without moving Resident #1 to safety, so she could go and notify the unit RN #10. RN #10 did not move Resident #1 to safety or remove STNA #2 from the unit prior to going directly to the administrator to report the allegation with STNA#1. The administrator and DON called the police, removed STNA #2 from the unit, and sent Resident #1 to the hospital to be examined. The facility began interviewing (three) residents on the unit who could be interviewed and assessed 23 additional residents who could not give appropriate answers. STNA #1 signed a witness statement on 06/04/18 at 3:41 P.M. RN #10 signed a witness statement at 3:45 P.M. The facility indicated on the SRI they completed their investigation on 06/08/18 at 4:06 P.M. Review of the facility's investigation report and investigation timeline created by the facility dated 06/04/18 revealed Resident #1 was verified as safe at 3:56 P.M and STNA #2 was removed from the unit at 3:56 P.M. Local law enforcement arrived at the facility at 4:10 P.M. and took over the investigation. At 4:45 P.M., Resident #1 was transported to the hospital for evaluation. At 5:30 P.M., STNA #2 left the facility with the local police. Review of the local law enforcement report, dated 06/08/18, revealed that STNA #2 was taken into police custody on 06/04/18 with the crime code listed as forcible rape. On 06/05/18, the DON conducted one-to-one counseling with STNA #1 and RN #10 regarding the facility policy for Abuse, Neglect, and Exploitation of residents and Misappropriation of property, stressing the importance of protecting the resident as a priority. Associated forms were signed by STNA #1, RN #10, and the DON, and were witnessed by the administrator on 06/05/18. Review of the hospital records dated 06/09/18 revealed Resident#1 was admitted to the hospital on [DATE] for examination after sexual assault and was discharged back to the facility on [DATE]. admitting [DIAGNOSES REDACTED]. During observations made on 06/24/18 at 11:50 A.M., 11:59 A.M., and 3:03 P.M. revealed Resident #1 was calm, smiling, making good eye contact with staff and peers and demonstrated a good appetite at lunch. Resident #1 was alert but completely disoriented to person, place and time, and used a wheelchair. An interview was conducted on 06/24/18 at 12:48 P.M. with STNA #1 who witnessed the incident. The interview revealed STNA #1 had asked STNA #2 to change Resident #1 because her undergarment was soiled during an activity, and STNA #1 had not had her lunch break yet that day. STNA #1 explained that she knew it was wrong to ask STNA #2 to change her because Resident #1 was required to have only female caregivers due to inappropriate sexual behaviors exhibited by Resident #1. STNA #1 explained that she usually took her lunch at 2:30 P.M. but since she and STNA #2 were the only STNA's working on the unit that day she was running behind on her lunch break and really wanted to take a break. STNA #2 agreed to change the resident for her and took Resident #1 to her room to be changed at approximately 3:00 P.M. STNA #1 returned to the unit at approximately 3:28 P.M. and found it peculiar that Resident #1 was not back out in the common area for an activity. STNA #1 stated she went directly to Resident #1's room and found the door was closed. As she opened the door to enter the room she saw STNA #2's bare legs with pants around his ankles behind the privacy curtain. STNA #1 immediately asked if STNA #2 needed any help and STNA #2 replied no, I got this as he pulled up his pants. STNA #1 stated she panicked and left the room abruptly without checking the resident and started to toilet another resident when she came to her senses and went to tell RN #10. STNA #1 explained that the observation of the alleged abuse happened at 3:30 P.M and at 3:41 P.M. she was in the administrator's office writing her witness statement. STNA #1 said she was so shocked at what she witnessed she never thought to check the condition of the Resident #1. An interview was conducted on 06/24/18 at 12:50 P.M. with RN #10. RN #10 revealed she was the nurse on the unit that day but did not see what happened to Resident #1. RN #10 stated she was notified of the situation by STNA #1 at approximately 3:30 P.M. and they both immediately went to tell the administrator without first moving Resident #1 to safety or removing STNA #2 from other residents on the unit. RN #10 revealed she did not see what condition Resident #1 was in before she left the unit with STNA #1. Interview on 06/24/18 at 2:52 P.M. with the local police department verified STNA #2 remained in jail awaiting a hearing. An interview was conducted on 06/24/18 at 3:25 P.M. with the administrator and DON. The administrator stated they substantiated the allegation of sexual abuse because they could not be certain what exactly went on behind the curtain in Resident #1's room that day when STNA #2 was providing care in an inappropriate position. They felt that based on the statement given by STNA #1 it was enough to remove STNA #2 from duty, turn him into police and substantiate the sexual abuse. Staff interviews were conducted on 06/24/18 from 12:46 P.M. to 3:00 P.M. with STNA #3, STNA #4, LPN #11, Laundry Aide #50, Housekeeper #40, Activity Director #23 and Social Service Director #21 to confirm their understanding of the abuse policy and procedure for reporting abuse. The interviews verified the staff were knowledgeable on the abuse policy and procedure, and they had just recently been in-serviced by administration regarding abuse prevention. An interview was conducted on 06/26/18 at 2:03 P.M. with a local police detective who verified STNA #2 was currently in jail with a rape charge, as indicated on the online Summit County Sheriff's Office Head Count with Photo's Report. A telephone interview was conducted on 06/27/18 at 11:42 A.M. with Resident #1's Nurse Practitioner (NP). The NP revealed that she had Resident #1 on her list of residents to see on 06/04/18. She reported she found Resident #1 fully dressed, and her wig in place as usual while she was sitting in the common area. The NP was uncertain of the time but indicated that it was no more than five minutes before the administrator and DON came onto the floor to check Resident #1 and began looking for STNA #2 (which both indicated on their investigation timeline was 3:56 P.M.). The NP explained that since she had just checked Resident #1 over she did not check her again upon the request of the administrator and DON instead ordering them to send her out to the hospital for an examination due to the nature of the allegation. A telephone interview was conducted on 06/27/18 at 11:50 A.M. with Resident #1's physician. The physician revealed Resident #1's overall health was declining in general due to the dementia, and she can only speak in a manner that she was completely unable to make any reliable sense with what she says to anyone. The physician verified he was notified of the alleged sexual abuse by his NP on 06/04/18, and he had been in to examine her as of the third week in (MONTH) (YEAR). An interview with the administrator on 06/27/18 at 2:00 P.M. revealed STNA #2's employment status was indefinitely suspended pending the outcome of the police investigation. The administrator stated STNA #2 was currently in jail according to the local police public records, and he will not be returning to the facility. Review of the facility policy, titled Abuse, Neglect, and Exploitation of residents and Misappropriation of Property, dated 05/20/18, revealed facility residents will be protected from verbal, mental, sexual or physical abuse, corporal punishment, mistreatment, neglect, involuntary seclusion, exploitation and misappropriation of property. In addition, this required the protection of residents during investigation and reporting of incidents. The policy indicated, When an allegation of abuse is identified the facility recognizes its obligation to keep residents safe and protect them from any harm to whatever extent possible. STNA #1 did not follow the facility policy by not immediately acting to protect Resident #1 after observing STNA #2 behind the privacy curtain with his pants down to his ankles in the presence of Resident #1. This deficiency substantiates facility Self Reported Incident Control Number OH 457.

Based on staff and resident interview and record review the facility failed to ensure pain medication was administered to a resident per the physician's orders [REDACTED].#212's pain escalated from a two on the 1 to 10 scale to a 9 on the scale of 10 resulting in the resident being agitated, anxious and crying. This affected one of one resident (Resident #212) reviewed during Stage 2 for pain management. The facility census was 114 residents. Findings include: Record review of Resident #212's clinical record revealed the resident was admitted to the facility on [DATE] at 3:45 P.M. with [DIAGNOSES REDACTED]. Review of Resident #212's admission plan of care dated 12/04/16 revealed the potential for alternation in comfort related to history of cervical stenosis and the surgical procedure laminectomy. Resident #212's plan of care goal was for the resident to be free from pain or have pain at a tolerable level through 03/04/17. Interventions included to determine the resident's ability to communicate pain status and implement the pain assessment tool which best met the resident's ability. The pain scale of 1- 10 was to be utilized. Additional interventions included to monitor and evaluate frequency and intensity of pain; medicate for pain as needed (prn) and evaluate effectiveness; keep physician informed of pain management; utilize alternative pain relief measures: massage, decreasing stimuli in environment, relaxation techniques and visualization. Review of Resident #212's pain management control progress notes/assessment tool dated 12/04/16 at 4:00 P.M. completed by Registered Nurse (RN) #120 revealed the resident verbalized pain. The pain was described as gradual and intermittent. The pain location was documented as the neck and back. The pain was rated at a severity of two out of ten. Pain was perceived as stabbing, sharp and ache. RN #120 documented the pain resulted in a limitation of the resident's mobility. Interventions included medication administration per physician assistant (PA), nurse practitioner (NP), or medical doctor (MD) orders only. Give prn only. Assist resident with a position of comfort. RN #120 documented under General Pain Comments at 3:45 P.M. the resident was admitted to room [ROOM NUMBER] and was informed as soon as medication available he would be medicated for his pain. Review of Resident #212's nursing progress notes dated 12/04/16 at 8:30 P.M. revealed the resident's pain level was measured at the acute pain level 9 out of 10 with the pain as onset gradual, pain was continuous and location was his neck. Resident #212 described the pain as throbbing, ache and pressure. The pain was described as affecting [MEDICAL CONDITION]. Resident #212 displayed non verbal signs and symptoms of pain as: restlessness, agitation, anxiety and nausea. Pain medication was obtained and administered at 8:32 P.M., over four hours after Resident #212 requested his pain medications at 3:45 P.M. Review of the Electronic Medication Administration Record [REDACTED].M. on 12/04/16. Review of Resident #212's Controlled Drug Receipt/Record/Disposition Form dated 12/04/16 at 8:25 P.M. revealed two tablets of [MEDICATION NAME] 5/325 were removed from the starter kit by Licensed Practical Nurse (LPN) #121 and administered to Resident #212. Interview with Resident #212 on 12/05/16 at 3:51 P.M. revealed the resident was to receive pain medication, ([MEDICATION NAME]) two pain pills every four hours and one [MEDICATION NAME] every 8 hours. Resident #212 stated he had his [MEDICATION NAME] at 11:42 A.M. before he left the hospital for the facility. Resident #212 stated he asked for pain medication and rated it at a 8 out of 10 on the pain scale. Resident #212 stated he was told by RN #120 she had to call the pharmacy to get permission to get the medication from the starter box and then Resident #212 would be medicated for pain. Resident #212 stated the pain got so bad he was crying in pain. Resident #212 stated he waited and it was not until another nurse come on duty that he was given his pain medication. Interview with the Director of Nurses (DON) on 12/07/16 at 2:00 P.M. revealed the facility had a pharmacy starter kit in which Resident #212's [MEDICATION NAME] 5/325 mg's could have been obtained. The DON stated it was the pharmacy policy (not the facility's) for nurses to call the pharmacy and obtain permission to open the starter box to obtain the pain medication. The DON stated she verified with RN #120 that Resident #212 provided her with the hand written prescription for the [MEDICATION NAME] 5/325 milligrams take two tablets by mouth every four hours as needed for pain on admission at 3:45 P.M. The DON stated RN #120 obtained permission from the pharmacy to remove the two tablets from the starter box at 5:10 P.M. The DON verified the medication was signed out and administered by Licensed Practical Nurse (LPN) #121 at 8:25 P.M., almost five hours after Resident #212 complained of pain in his neck. The DON stated she could not obtain an answer from RN #120 as to why it took so long for the resident to receive his pain medication. The DON verified Resident #212 was not administered his pain medication timely after the pharmacy gave permission for the medication to be taken from the starter kit at 5:10 P.M.

Based on interview and record review the facility failed to implement the appropriate number of staff during a transfer for Resident #43 and failed to implement the appropriate assistance with personal care for Resident #52. This resulted in actual harm when Resident #43 and Resident #52 each sustained a fall with a fracture. This affected two of four residents reviewed for falls. The facility census was 98. Findings include: 1. Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance of two staff for bed mobility and transfers. Review of a nurses note dated 09/09/13 timed 3:00 P.M. indicated Resident #43 complained of severe right knee pain with edema at the site. The staff were unable to fully assess range of motion due to resident refusal and resistance to care from all staff. The nurse practitioner was notified and ordered an X-ray to be done the morning of 09/10/13. Review of a nursing note dated 09/10/13 timed 1:30 P.M. indicated to send Resident #43 to the hospital for evaluation due to a fractured supracondylar femur. Review of the facility investigation of the incident dated 09/10/13 revealed on 09/07/13 State tested Nursing Assistant (STNA) #10 knocked on the door of Resident #43, looking for her co-worker, STNA #6. Review of STNA #10's statement revealed she noticed Resident #43 on the floor and STNA #6 stated the resident had become combative and was lowered to the floor. STNA #6 requested the assistance of STNA #10 to get the resident up and into her wheelchair. The statement indicated the resident complained of leg pain. Review of the statement of STNA #6 revealed she was preparing to transfer the resident to the wheelchair when she began to climb out of the bed and started to fall and was lowered to the floor. STNA #6 was no longer employed at the facility. Review of the facility Self Reported Incident (SRI) to the State Agency dated 09/11/13 revealed the incident was not reported to the charge nurse by either STNA #6 or STNA #10. There was no evidence in the medical record of the incident. The medical record contained several nursing notes documented after the fracture was diagnosed marked as late entries. The notes indicated Resident #43 had complained of pain to her lower extremities several times between 09/07/13 and the time the fracture was diagnosed on [DATE]. During an interview with STNA #10 on 11/25/13 at 2:45 P.M. she verified that she had not notified the nurse of the fall that occurred on 09/07/13. Interview with the director of nursing (DON) on 11/25/13 at 4:00 P.M. verified STNA #6 was transferring Resident #43 by herself on 09/07/13 when she fell to the floor, resulting in a fracture to her right distal femur. The director of nursing verified Resident #43 was assessed as requiring the extensive assistance of two staff members for mobility in bed and transfers. 2. Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance of two staff members for transferring including to or from bed, chair, wheelchair or when in a standing position. Review of nursing notes dated 10/31/13 timed 2:08 P.M. revealed Resident #52 had received a skin tear to her right forearm. Review of a skin note dated 10/31/13 timed 1:55 P.M. revealed the skin tear measured 2.3 centimeters (cm) long by 0.2 cm wide by 0.1 cm deep to the back of the right upper forearm and steri-strips were applied to the area. Review of the facility incident report revealed STNA #11 was assisting Resident #52 with her morning care and the resident became incontinent while standing at the bedside. STNA #11 left Resident #52 standing alone at the bedside while she went into the bathroom to gather equipment. When STNA #11 returned she found Resident #52 leaning over with her right forearm on the bedside table. The investigation indicated the resident stated she had lost her balance. Review of the facility SRI to the State Agency dated 11/07/13 indicated "the bedside table that (resident name) had leaned on was bent indicating considerable force occurred when (resident name) leaned on the table." Review of a nurses note dated 11/06/13 timed 9:25 P.M. indicated there was bruising to Resident #52's arm related to the incident on 10/31/13. An X-ray was obtained and revealed an ulnar midshaft fracture with displacement. Resident #52 was transferred to the hospital. Interview with the DON on 11/26/13 at 9:30 A.M. revealed Resident #52 returned to the facility on [DATE] with a sling to her right arm and went to an orthopedic appointment on 11/12/13 where her arm was put in a cast from the fingers to above the elbow. The DON verified the investigation indicated Resident #52 was left at the bedside standing alone when she lost her balance and leaned onto the overbed table, resulting in a skin tear and a later identified fracture to her arm. The DON verified Resident #52 was assessed to require the assistance of two staff members to stand and needed assistance to maintain her balance. The DON verified this level of assistance was not provided to Resident #52 resulting in the fracture and skintear. This was an incidental finding at the time of the Complaint Investigation.