Every finding on record at Covenant Village Care Center

Based on observations, interviews, and policy reviews the facility failed to ensure food was stored, prepared, and served under sanitary conditions. This had the potential to affect all residents consuming food prepared in the kitchen. No residents in the facility were nothing by mouth (NPO). The facility census was 104. Findings include:1. Observation on 06/08/26 at 8:55 A.M. of the ice machine located in the kitchen revealed small black spots on the inside upper lip of the ice machine. These black spots wiped off of this lip when rubbed with a clean paper towel.During an interview on 06/08/26 at 8:55 A.M. the Dietary Director (DD) #17 confirmed the existence of black spots on the inside upper lip of the ice machine which wiped off when rubbed with a clean paper towel. DD #17 reported the maintenance department manages the cleaning and cleaning schedule for the ice machine.During an interview on 06/11/26 at 1:29 P.M. the Regional Maintenance Director (RMD) #150 confirmed the ice machine is scheduled to be cleaned on a six-month cycle.Review of maintenance documentation revealed the kitchen ice machine was cleaned on 06/19/25 and 12/22/25.Review of a policy titled, Cleaning of Ice Machine, with a written/revised date of 08/25 revealed Every six months or more often if needed, defrost the ice machine and dismantle; clean and disinfect the ice machine per manufacturer's recommendation.2. Observation on 06/08/26 at 9:00 A.M. revealed a layer of brown particulates, which had the appearance of dust, on the light covers and on the front inside wall of the kitchen hood above the stove, oven, and fryer in the kitchen. During an interview on 06/08/26 at 9:00 A.M. the DD #17 confirmed the light covers and the front inside wall of the range hood had a layer of brown particulate and that these parts of the kitchen hood needed to be cleaned. DD #17 reported that maintenance manages the cleaning schedule for the range hood.During an interview on 06/11/26 at 1:29 P.M. the RMD #150 confirmed the kitchen hood is scheduled to be cleaned on a six-month basis. RMD #150 reported the kitchen hood was cleaned on 08/27/25 and on 02/23/26.Review of facility provided email with subject, Hood Cleaning Service Report - Covenant Village of [NAME] Township, and dated 08/27/25 revealed the kitchen hood was cleaned on 08/27/25.Review of a facility provided document titled, NFPA 96 Service Report, revealed the kitchen hood was cleaned on 02/23/26.Review of a facility policy titled, Cleaning/Inspection of Kitchen Hood, with a written/revised date of 05/13/21 revealed the kitchen hood should be cleaned at a minimum every six months.3. Observation on 06/09/26 at 11:23 A.M. of the kitchen revealed two garbage cans in the dish room, one garbage can in the kitchen next to the fryer, one garbage can in the kitchen next to the drink station, and one garbage can in the kitchen next to the grill. None of these garbage cans had lids or covers for them.During an interview on 06/09/26 at 12:44 P.M. the DD #17 reported they did not have garbage can lids for any of the garbage cans located in the dish room or kitchen.Review of a facility document titled, Environmental Services Inspection, and dated 12/25 revealed, It is the policy of this facility to regularly monitor environmental services to ensure the facility is maintained in a safe and sanitary manner and assessed on a regular basis.Review of the US Department of Health and Human Services, US Food and Drug Administration, Food Code 2017 revealed, Receptacles and waste handling units for refuse, recyclables, and returnables and for use with materials containing food residue shall be durable, cleanable, insect-and rodent-resistant, leakproof, and nonabsorbent.4. Observation on 06/09/26 at 11:25 A.M. of the kitchen tray line revealed that [NAME] #135 placed a thermometer probe into the following items: mixed vegetables, pureed mixed vegetables, pureed hamburger, and mechanical soft hamburger. [NAME] #135 wiped off the thermometer probe with a rubber glove in between inserting the probe in each of these food items. [NAME] #135 did not use any sanitizing solution to wipe off the probe between food items. During an interview on 06/09/26 at 11:25 A.M. [NAME] #135 confirmed she wiped the thermometer probe off with a rubber glove and did not clean the probe with any sanitizing solution in between inserting the probe into mixed vegetables, pureed mixed vegetables, pureed hamburger, and mechanical soft hamburger. Review of a facility document titled, Policy & Procedure Manual Resource: Minimum Cooking, Holding, and Reheating Temperatures, revealed this policy did not contain guidance on the process of obtaining food temperatures. This document provided a reference source of the US Department of Health and Human Services, US Food and Drug Administration, Food Code 2017.Review of the US Department of Health and Human Services, US Food and Drug Administration, Food Code 2017 revealed, Temperature measuring device probes must be sanitized to prevent contaminating products when internal temperatures are measured.

Based on observation, staff interview, and review of Center for Disease Control and Prevention (CDC), the facility failed to adhere to infection control practices as suggested by the CDC when wound care supplies of calcium alginate were being stored on the floor in a plastic bag. This had the potential affect one resident (#5) of three reviewed for wound care. The facility census was 104.Findings include:Medical record review of Resident #5 revealed admission on [DATE] with diagnoses including; complete lesion at C2 level of cervical spinal cord, paraplegia, pressure ulcer of right hip stage three. Review of Minimum Data Set, dated [DATE] for Resident #5 revealed the resident was cognitively intact, had upper and lower extremity impairment on both sides, utilized electric wheelchair for mobility, required substantial/maximal assistance with toileting hygiene, and was dependent for chair/bed-to-chair transfers.Review of physician order with start date of 06/10/26 for Resident #5 revealed Cleanse area to left ischium with saline, pat dry, apply collagen sprinkles and calcium alginate and cover with silicone foam dressing every day.Observation on 06/10/26 at 10:58 A.M. revealed thirty packs of calcium alginate being kept in a plastic bag on the floor of the medical storage room on 100 hall. Interview on 06/10/26 at 10:58 A.M. with Director of Nursing (DON) confirmed the thirty packs of calcium alginate in the plastic bag on the floor of the storage room. The DON stated that wound care supplies should not be stored on the floor.Review of CDC guidance titled, Sterilizing Practices Guideline for Disinfection and Sterilization in Healthcare Facilities (2008), revealed sterile supplies should be stored far enough from the floor (8 to 10 inches) in order to prevent contamination. Any package that has fallen or been dropped on the floor must be inspected for damage to the packaging and contents.

Based on observation, staff interview, record review, and policy review, the facility failed to ensure medications were locked in a medication cart. This had the potential to affect one resident (#84) of two residents who were independently mobile and cognitively impaired that resided on the100 hall. The facility census was 104.Findings include:Medical record review of Resident #84 revealed admission on [DATE] with diagnoses including; rhabdomyolysis, metabolic encephalopathy, ischemic cardiomyopathy. Review of Minimum Data Set, dated [DATE] revealed Resident #84 to be severely cognitively impaired, utilizes wheelchair for mobility and had no impairment in upper or lower extremities.Observation on 06/09/26 at 6:21 A.M. revealed the 100 hall medication cart to be unlocked with no staff around and Resident #84 within four feet of the unlocked medication cart.Interview on 06/09/26 at 6:21 A.M. with Director of Nursing confirmed the 100 hall medication cart was unlocked with no staff in the vicinity of the medication cart. DON confirmed Resident #84 was in close proximity to the unlocked cart. Review of facility policy titled, 5.0 Medication Storage, undated, revealed all medications will be stored in a locked cabinet, cart, or medication room.

Based on observation, staff interview, and policy review the facility failed to ensure residents were treated with respect and dignity when staff stood over residents as they fed them lunch. This affected two residents (#26 and #48) of twenty four reviewed for dining observation. The facility census was 104.Findings include:1. Medical record review of Resident #26 revealed an admission date of 02/01/25 with diagnoses including; Huntington's disease, ataxia, and dysphagia. Review of the care plan dated 01/30/23 revealed Resident #25 was dependent for eating and required one person assistance with being fed.Review of the minimum data set assessment dated [DATE] revealed Resident #25 was severely cognitively impaired and was dependent upon staff for bringing food and/or drink to mouth.2. Medical record review of Resident #48 revealed an admission date of 08/03/23 with diagnoses including; generalized idiopathic epilepsy and epileptic syndromes, Alzheimer's disease, downs syndrome. Review of the care plan dated 08/03/23 revealed Resident #48 required one person assistance with being fed.Review of the minimum data set assessment dated [DATE] revealed Resident #48 was severely cognitively and required substantial/maximal assistance with bringing food and/or drink to mouth.Observation on 06/08/26 at 11:50 A.M. in main dining room revealed Certified Nurse Assistant (CNA) #91 standing over Resident #48 at the dining table feeding resident. Further observation revealed CNA #141 standing over Resident #26 while feeding him lunch. Interview on 06/08/26 at 12:10 P.M. with CNA #91 confirmed she fed Resident #48 lunch while standing over her at the dining table.Interview on 06/08/26 at 1:08 P.M. with CNA #141 confirmed she fed Resident #26 lunch while standing over him at the dining table.Review of facility policy titled, Dignity, reviewed 3/2026 revealed the facility will promote resident dignity in dining.This deficiency represents non-compliance investigated under Complaint Number 3033707.

Based on observation, interview and record review, the facility failed to ensure a sanitary environment. This affected one, (Resident #54) of three residents reviewed for a sanitary environment. The facility census was 104.Findings include:Review of the medical record revealed Resident #54 was admitted to the facility on [DATE]. Diagnoses included huntington's disease, essential hypertension, ataxia, corticobasal degeneration, cognitive communication deficit, and dysphagia.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #54 has severe cognitive impairment, required partial assistance with eating, substantial assistance with toileting, substantial assistance with bathing, and partial assistance with personal hygiene.Observation and interview on 04/06/26 at 9:17 A.M. in Resident # 54 room with the Maintenance Director (MD) #82 and the Administrator revealed the floor was covered with small white spots, appearing to be paint chips stuck to floor. Continued observation and confirmation with the MD #82 and the Administrator revealed the wall next to the footboard had paint worn off about six inches by 12 inches, the wall next to the top bed rail had paint worn and black scuff marks measuring about 12 inches by 18 inches, and the wall next to the headboard has paint worn off measuring about one inch by eight inches. Continued interview at the same time with the MD #82 confirmed the walls and floor should be fixed prior to getting to this point.Review of the policy titled, Environmental Services Inspection, dated 12/2025, revealed it is the policy of this facility to regularly monitor environmental services to ensure the facility is maintained in a safe and sanitary manner and assessed on a regular basis. The Director of Environmental Services will perform random and/or routine inspections. All opportunities will be corrected immediately by environmental services personnel.This deficiency represents non-compliance investigated under Complaint Number 2970102 and Complaint Number 2722512.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure pain medications were available for a resident. This affected one, (Resident #2) of six residents reviewed for medications. The facility census was 104. Findings include:Review of the medical record revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses included discoid lupus erythematosus, depression, polyarthritis, cardiac arrhythmia, cervical disc disorder, other displaced fracture of upper end of left humerus and rheumatic mitral stenosis.Review of the most recent Minimum Data Set (MDS) 3.0 assessment still in progress dated 02/09/26 revealed Resident #2 was cognitively intact. Review of the medical record revealed Resident #2's hospital discharge orders dated 03/19/26 revealed Oxycodone (opioid) immediate release five milligrams (mg) every four hours as needed.Review of the medical record revealed Resident #2 had physician orders dated 03/27/26 at 2:45 P.M. revealed Oxycodone oral tablet five mg give one tablet every six hours as needed for pain related to other displaced fracture of upper end of left humerus.Review of the Medication Administration Record (MAR) for Resident #2 revealed Oxycodone was first given on 03/29/26 at 8:55 A.M with a pain level of nine.Interview on 03/30/26 at 10:57 A.M. with Resident #2 stated she had excruciating pain when she admitted and could not get the Oxycodone, and the facility was not able to give to her for 36 hours.Interview on 03/30/26 at 12:59 P.M. with the Director of Nursing (DON) revealed Resident #2 arrived with an order for Oxycodone from the hospital, the perscription was sent to specialty pharmacy, with no signature. The DON confirmed Resident #2 did not have the available ordered Oxycodone from 03/27/26 to 03/29/26. Review of the policy titled, Pain Assessment and Management, dated 08/2025, revealed review the medication administration record to determine how often the individual requests and receives as needed pain medication, and to what extent the administered medications relieve the resident's pain.This deficiency represents non-compliance investigated under Complaint Number 2788877 and 2722512.

Based on observation, interviews, policy review and record reviews, the facility failed to ensure residents' activity needs were assessed regularly and addressed in the care plans. This affected two Residents #40 and Resident #54 of three residents reviewed for care plans. The facility census was 104.Findings include:1. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE]. Diagnoses included dizziness, chronic embolism and thrombosis of unspecified vein, dysphagia, alzheimer's disease, and anxiety disorder.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 had severe cognitive impairment, was dependent with eating, dependent with bathing, and dependent with personal hygiene. Review of the Care Area Assessment Summary (CAA) dated 11/11/25, for Resident #40 revealed activities was triggered for a care area and care planning decision. Review of the care plan for Resident #40 revealed no goals or interventions for activities. Review of Resident #40 medical record revealed a completed activity assessment dated [DATE]. 2. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE]. Diagnoses included huntington's disease, essential hypertension, ataxia, corticobasal degeneration, cognitive communication deficit, and dysphagia.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #54 severe cognitive impairment, partial assistance with eating, substantial assistance with toileting, substantial assistance with bathing, and partial assistance with personal hygiene. Review of the Care Area Assessment Summary (CAA) dated 12/16/25, for Resident #54 revealed activities was triggered for a care area and care planning decision. Review of the care plan for Resident #54 revealed no goals or interventions for activities. Review of Resident #54 medical record revealed a completed activity assessment dated [DATE].Interview on 04/06/26 at 1:15 P.M. with the Activities Director (AD) #45 revealed there are no documented ongoing activity preferences or assessments for Resident #40 and Resident #54. Interview on 04/07/26 at 1:35 P.M. with the Director of Nursing (DON) confirmed that the Resident #40 and Resident #54 did not have activities listed in their care plans. The DON also confirmed that there was no quarterly assessments done for activities for Resident #40 and Resident #54 and the only assessments are listed above.Review of the policy titled, Care Plan Policy, dated 12/2019, revealed the comprehensive care plan must be person centered, have measurable goals with appropriate interventions to assist with obtaining those goals and contain all necessary information to allow the resident to receive care while maintaining their highest practicable well-being.Review of the policy titled, Activities, dated 08/2025, revealed comprehensive activity evaluations are completed upon admission, routinely, and as needed with a change in condition that affects activity participation. Comprehensive activity evaluations are used to develop and revise activity care plans that meet the individual choices, hobbies, and cultural preferences and interests of the residents. Activity evaluations and care plans should identify if a resident is capable of pursuing activities independently, or if supervision and assistance are needed. This deficiency represents non-compliance investigated under Complaint Number 2700708.

Based on observation, interview, record review and policy review, the facility failed to have a baseline care plan that included pain management and hearing loss. This affected one, (Resident #2) of six residents reviewed for the baseline care plan. The facility census was 104.Findings include:Review of the medical record revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses included discoid lupus erythematosus, depression, polyarthritis, cardiac arrhythmia, cervical disc disorder, other displaced fracture of upper end of left humerus and rheumatic mitral stenosis.Review of the most recent Minimum Data Set (MDS) 3.0 assessment still in progress dated 02/09/26 revealed Resident #2 was cognitively intact. Review of the baseline care plan dated 03/27/26 revealed Resident #2's pain was not assessed or added to the baseline care plan and hearing loss with a hearing aide was not assessed or added to the baseline care plan.Review of the medical record revealed Resident #2 revealed a hospital discharge order dated 03/19/26 for Oxycodone (opioid) immediate release five milligrams (mg) every four hours as needed.Review of the facility medical record revealed Resident #2 had physician orders dated 03/27/26 at 2:45 P.M. for Oxycodone oral tablet five mg give one tablet every six hours as needed for pain related to other displaced fracture of upper end of left humerus.Interview with Resident #2 on 03/30/26 at 10:57 A.M. revealed the resident had excruciating pain and could not get the Oxycodone, as the facility was not able to give to her for 36 hours. Further interview with Resident #2 revealed the resident had hearing loss and wore hearing aids.Interview on 04/02/26 at 10:32 A.M. with the MDS coordinator #42 confirmed Resident #2's baseline care plan did not have pain or hearing loss those should have been included.Review of the policy titled, Care Plan, dated 12/2019 revealed baseline care plan must include the minimum healthcare information necessary to properly care for a resident. This deficiency represents non-compliance investigated under Complaint Number 2700708.

Based on interview, record review and facility policy review, the facility failed to ensure a safe discharge. This affected one Resident #111 of three residents reviewed for discharge. The facility census was 104.Findings include:Review of the medical record revealed Resident #111 was admitted to the facility on [DATE] and discharged on 01/02/26. Diagnoses included atrial fibrillation, depression, mental disorder, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and essential hypertension.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #111 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) of eight, required set up awsistance for eating, substantial assistance with toileting, substantial assistance with bathing, and set up assistance for personal hygiene.Review of the Letter of Guardianship dated 12/02/25 revealed Resident #111 incompetent for an indefinite time period.Review of the Discharge summary dated [DATE] revealed Resident #111 discharged to own home, son will provide transportation, functional impairments listed as decision making, discharge paperwork reviewed with patient.Review of the social service note dated 01/02/26 at 10:44 A.M.for Resident #111 revealed call placed to resident daughter to follow up that she received the notification that the appeal was lost, left name and number to return call if she had any questions. Review of the social service progress note dated 01/02/2026 at 12:11 P.M. revealed Resident #111 to discharge home on [DATE] with Home Health Care (HHC), son will be providing transportation, no further discharge needs identified at this time.Review of the social service progress note for Resident #111 dated 01/02/2026 at 2:41 P.M. revealed resident discharged home with brother at this time. Discharge instructions reviewed with resident. All medications sent with resident. Paperwork signed.Review of the social service progress note for Resident #111 dated 01/02/2026 at 3:09 P.M. revealed spoke with resident regarding discharge plan and he was adamant he was returning home and would not stay in a Long Term Facility (LTC) facility or transfer to another LTC facility. Resident, per discussion with resident, does not have evidence the resident is incompetent to make his decisions. Resident verbalized the risk associated with living alone. Recommendation for alternative placement should be discussed when/if resident needs placement and discussed from family and assisted in that process when appropriate.Review of the HHC notification dated 01/02/26 for Resident #111 revealed HHC was planned and accepted on 01/02/26. Interview on 03/31/26 at 10:47 A.M. with Social Service Assistant (SSA) #6 and the Administrator revealed referral for HHC for Resident #111 was sent on day of discharge, Resident #111 made decision last minute to go home. SSA #6 stated the referral to HHC usually happens prior to the day of discharge. SS #6 confirmed Resident #111's Guardian did not give approval for the resident to discharge home and resident set up his own transportation, he said he was going to call his brother. Review of the policy titled, Transfer and Discharge, dated 04/28/25, revealed orientation for transfer or discharge will be provided and documented to ensure safe and orderly transfer or discharge from the facility, in a form and manner that the resident can understand.This deficiency represents non-compliance investigated under Complaint Number 2706399.

Based on staff interviews, interview with staff at oral surgeon's office, review of the weather history for Cincinnati, and record review, the facility failed to ensure residents were treated with respect and dignity. This affected one (#12) of two residents reviewed for dignity and respect. The facility census was 102. Findings include:Record review revealed Resident #12 was admitted to facility on 11/09/24. Diagnoses included zygomatic fracture (a break in the cheek bone) and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 required maximum assistance with toileting and dressing and utilized a wheelchair for mobility. Interview with Oral Surgery Office Staff (OSOS) #600 on 09/29/25 at 11:05 A.M. revealed Resident #12 came to the oral surgery clinic at Medical Center (MC) #500 on 01/08/25 for a morning appointment related to her zygomatic fracture. The oral surgery's office (OSO) was called by the MC #500's lobby desk reporting Resident #12 had been dropped off by transport company leaving her unattended in the lobby. Resident #12 was unsure of why she was there and where she was supposed to go. OSOS #600 stated she went to the lobby where she found Resident #12 sitting unaccompanied in a wheelchair, dressed only with a hospital gown and socks on a cold winter day. OSOS #600 revealed Resident #12 brought no paperwork from the facility and was not sure why she was being seen. OSOS #600 transported the resident to OSO. Interview on 11/25/25 at 1:14 P.M. with Facility Nursing Supervisor # 67 revealed she was not aware Resident #12 was out of the building for an appointment on 01/08/25, until the OSO called requesting information about who was supposed to accompany Resident #12 to her appointment. The caller also requested updated medical records be faxed to OSO, as well expressing her concern about how Resident #12 was dressed. Facility Nursing Supervisor #67 explained she would have to investigate the situation before she could answer the questions. Facility Nursing Supervisor #67 went to the facility floor staff who confirmed Resident #12 was out of the building at the OSO. Staff verified Resident #12 was sent without an escort and was dressed in a hospital gown as family had not brought her any clothing. Nursing Supervisor #67 assumed Resident #12 was sent out with blankets but did not observe the resident prior to leaving the building.Interview on 11/25/25 at 11:17 A.M. with Licensed Practical Nurse (LPN) #65 who was assigned to Resident #12 on 01/08/25 revealed caregiving staff were unaware Resident #12 had an early morning appointment. Staff caring for Resident #12 had to work quickly to get Resident #12 ready and out to transport van. LPN #65 revealed Resident #12 did not have any clothing of her own, so was sent dressed in two hospital gowns, one in front and one in back as well as socks. LPN #65 revealed she did not see Resident #12 getting on the van so was unsure what she was sent with to keep her warm. Interview with Housekeeping Director (HD) #61 on 11/25/25 at 4:30 P.M. revealed facility maintains a lost and found area in the laundry department which staff can use for residents who were going out and do not have appropriate clothing. HD #61 revealed she also has a closet of clothes in her office that have been donated just for that purpose for residents without clothes of their own. HD #61 revealed staff have been notified about the closet they can use for residents without clothes. Review of the weather history for Cincinnati on 01/08/25 revealed the temperature was a high of 25 degrees Fahrenheit (F) and a low of 18 degrees F.This deficiency represents non-compliance investigated under Complaint Number OH00161459 (1343852) and Complaint Number OH00161661 (1343853).

Based on closed medical record review, staff interviews, interview with Wound Nurse Practitioner (WNP) #175, review of facility policy, and review of guidelines from the National Pressure Injury Advisory Panel (NPIAP), the facility failed to adequately assess and monitor residents' skin and failed to timely identify pressure ulcers (a pressure ulcer is a localized injury of the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). This resulted in Actual Harm when Resident #104 who was admitted without pressure ulcers but was at risk for the development of pressure ulcers, subsequently developed an avoidable facility acquired pressure ulcer which was not identified until it had reached an advanced stage. Resident #104 developed a pressure ulcer which was first identified on 11/05/24 as a stage III (full-thickness skin loss in which adipose [fat] is visible) pressure ulcer on the resident's left gluteus with eschar (dead tissue). This affected one (#104) of three residents reviewed for pressure ulcers. The facility identified eight residents with pressure ulcers. The census was 103. Findings include: Review of the closed medical record for Resident #104 revealed an admitted [DATE] and discharged on [DATE]. Diagnoses included unspecified fracture of first lumbar vertebra, chronic diastolic (congestive) heart failure, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Admission Skin assessment dated [DATE], for Resident #104, revealed the resident was assessed to have intact skin and no identified pressure areas. Review of the daily nurse's assessments completed twice daily from 10/24/24 through 11/04/24 for Resident #104, revealed no documented evidence of any skin impairments. Review of the care plan dated 10/24/24 for Resident #104, revealed the resident was at risk for impaired skin integrity related to fragile skin and the resident was incontinent. Interventions included the following: Apply moisture barrier after each incontinent episode, float heels while in bed as the resident will allow, monitor Braden Scale assessment quarterly, monitor use of skin protective devices, assess condition of skin especially over bony prominences for breakdown, educate the resident on need to reposition, pressure reducing mattress to bed, resident to wear a TLSO (a brace used to limit motion in the thoracic, lumbar and sacral regions of the spine) brace when out of bed and skin checks under the TLSO brace every shift. Review of a physician order dated 10/25/24 for Resident #104, revealed an order to cleanse buttock with soap and water, pat dry and apply a barrier cream to buttocks twice daily and as needed. Review of a Braden Scale for Predicting Pressure Sore Risk dated 10/31/24 for Resident #104, revealed the resident was at low risk for developing pressures ulcers. Review of a physician order dated 11/04/24, revealed Resident #104 was ordered to have her buttocks cleansed with house wound cleanser, dried, Xeroform (a gauze impregnated with medication to aid in healing by controlling bacteria and keeping a wound moist) applied to open areas one in the middle of the buttocks and one on the left buttock, and covered with silicone (adhesive boarder) dressing. Place house barrier cream on remainder of the buttocks twice daily until healed. Review of the October 2024 and November 2024 treatment administration records (TAR) for Resident #104, revealed from 10/25/24 to 11/05/24, the nursing staff marked the treatment of cleansing the resident's buttock with soap and water, patted dry and applied a barrier cream twice daily as being completed. Review of an incident note dated 11/04/24 at 1:30 P.M. for Resident #104 and authored by Unit Manager/Licensed Practical Nurse (LPN) #69, revealed the nurse was informed by Certified Nursing Assistant (CNA) #124 who identified two new open wounds located on the resident's buttocks. LPN #69 assessed the resident and discovered two open areas on the resident's buttocks. One wound was in the middle of the resident's buttocks and measured approximately 1.5 centimeters (cm) in length by 0.5 cm in width by less than 0.1 cm in depth. The other wound was located on the resident's left buttocks and measured approximately 2.0 cm in length by 1.5 cm in width by less than 0.1 cm in depth. The nurse cleaned and dressed the resident's wounds. LPN #69 notified the physician. Review of a wound visit note for Resident #104, dated 11/05/24 at 1:09 P.M. and authored by WNP #175, revealed the resident had a new, facility acquired stage III pressure ulcer to the resident's left gluteus and the wound was first observed by the staff on 11/04/24. The pressure ulcer measured 7 cm in length by 4 cm in width by 0.3 cm in depth, the fat layer (subcutaneous tissue) was exposed and there was a medium amount of serosanguineous exudate (drainage) noted. The wound margin was distinct with the outline attached to the wound base and there was eschar tissue within the wound bed including adherent slough (peeling) and ecchymosis. WNP #175 recommended for the resident to have a low air loss(LAL) mattress, a ROHO cushion (specialized pressure reduction cushion) to the wheelchair, and offloading heels with pressure reducing boots. A treatment order to cleanse the resident's wound with house cleanser, pack the wound with Xeroform gauze (a moistened gauze that contains debriding agents and antibiotics) and cover the wound with a foam bordered dressing daily and as needed and weekly visits. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #104 had moderately impaired cognition and did not reject care. Resident did not have a pressure ulcer/injury but was at risk of developing pressure ulcers/injuries and needed pressure reducing devices for the bed. Resident #104 was dependent on staff for activities of daily living (ADLs). Interview with Director of Nursing (DON) on 12/02/24 at 1:19 P.M., verified Resident #104 developed a facility acquired pressure ulcer that was not identified until it had reached a stage III. Interview with WNP #175 on 12/02/24 at 4:35 P.M., revealed he evaluated Resident #104 on 11/05/24 and determined the resident had a stage III pressure ulcer to the resident's left gluteus. WNP #175 stated he measured the wound as one open area since the two wounds were close together and their margins were indistinct. Interview with LPN #68 on 12/02/24 at 4:40 P.M., revealed she was notified on 11/04/24 by CNA #125 that Resident #104 had open areas to his bottom. LPN #68 stated she observed two open areas to Resident #104's buttocks. LPN #68 stated she contacted WNP #175 and notified him of the open areas and the need to be evaluated. LPN #68 verified Resident #104 was at risk for developing pressure ulcers and the resident developed a facility acquired pressure ulcer which was first identified as a stage III by WNP #175. Review of the facility policy titled Pressure Ulcer Risk Assessment, not dated, revealed all residents should be assessed for pressure ulcer risk by utilizing a risk assessment tool on admission and then weekly times three weeks, and with each additional quarterly, annual, and with significant change assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. Staff will perform routine skin observations during daily care. Review of the NPIAP guidelines, dated 2014, pages 70-71 at (https://npiap.com/general/custom.asp?page=2014Guidelines), revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. The NPIAP Pressure Injury Stages, revealed if necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). This deficiency represents non-compliance investigated under Complaint Number OH00159654.

Based on medical record reviews, observations, resident interviews, staff interviews, and policy reviews, the facility failed to ensure resident call lights were in working order on the facility's 200-hall. This affected 12 residents (#12, #14, #19, #23, #32, #42, #54, #57, #59, #74, #91, and #94) of 27 residents reviewed for call lights. The facility census was 95. Findings include: 1. Review of the medical record of Resident #14 revealed an admitted [DATE]. Diagnoses included heart failure, weakness, macular degeneration, and generalized anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had moderately impaired cognition and required extensive assistance from staff with bed mobility and toileting and was dependent on staff for transfers. Multiple observations on 02/05/24 between 9:41 A.M. and 11:00 A.M. revealed Resident #14 had a non-functioning call lights and no other means to call for help. 2. Review of the medical record of Resident #23 revealed an admitted [DATE]. Diagnoses included cerebral infarction, muscle weakness, abnormalities of gait and mobility, unsteadiness on feet, anxiety disorder, and altered mental status. Review of the annual MDS assessment dated [DATE] revealed Resident #23 had intact cognition. Resident #23 required extensive assistance from staff for bed mobility, transfers, and toileting. Multiple observations on 02/05/24 between 9:41 A.M. and 11:00 A.M. revealed Resident #23 had a non-functioning call light and no other means to call for help. 3. Review of the medical record of Resident #54 revealed an admitted [DATE]. Diagnoses included pulmonary embolism, heart failure, dyspnea, peripheral vascular disease, dizziness and giddiness, and gastroesophageal reflux. Review of the MDS assessment dated [DATE] revealed Resident #54 had intact cognition. Resident #54 required partial/moderate assistance for toileting and transfers. Multiple observations on 02/05/24 between 9:41 A.M. and 11:00 A.M. revealed Resident #54 had a non-functioning call light and no other means to call for help. 4. Review of the medical record of Resident #91 revealed an admitted [DATE]. Diagnoses included dizziness and giddiness, overactive bladder, glaucoma, and muscle weakness. Review of the MDS assessment dated [DATE] revealed Resident #91 had moderately impaired cognition. Resident #91 required limited assistance from staff with bed mobility and locomotion, and extensive assistance from staff with transfers and toileting. Multiple observations on 02/05/24 between 9:41 A.M. and 11:00 A.M. revealed Resident #91 had a non-functioning call light and no other means to call for help. 5. Review of the medical record of Resident #19 revealed an admitted [DATE]. Diagnoses included encephalopathy, muscle weakness, unsteadiness on feet, lack of coordination, epilepsy, acute respiratory failure with hypoxia, generalized anxiety, and personal history of transient ischemic attack and cerebral infarction. Review of the quarterly MDS assessment dated [DATE] revealed Resident #19 had moderately impaired cognition and required staff assistance for mobility. Observation and interview on 02/05/24 at 10:22 A.M., with Resident #19 revealed the call light was not working when activated. During the observation, there was no back up device to call for assistance. Resident #19 stated her call light had not been working since the day prior and she had no other way to call for help except for using her telephone. 6. Review of the medical record of Resident #74 revealed an admitted [DATE]. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, chronic kidney disease, adult failure to thrive, chronic pain syndrome, muscle weakness, and left leg contracture. Review of the quarterly MDS assessment dated [DATE] revealed Resident #74 had intact cognition. Resident #74 was dependent on staff for toileting, bed mobility, and transfers. Multiple observations on 02/05/24 between 9:41 A.M. and 11:00 A.M. revealed Resident #74 had a non-functioning call light and no other means to call for help. 7. Review of the medical record of Resident #94 revealed and admitted [DATE]. Diagnoses included encephalopathy, compression of brain, cerebral edema, convulsions, cerebral infarction, and osteoarthritis of the right knee. Review of the MDS assessment dated [DATE] revealed Resident #94 had moderately impaired cognition. Resident #94 required substantial/maximal assistance from staff with toileting and partial/moderate assistance from staff with transfers and bed mobility. Multiple observations on 02/05/24 between 9:41 A.M. and 11:00 A.M. revealed Resident #94 had a non-functioning call light and no other means to call for help. 8. Review of the medical record of Resident #32 revealed an admitted [DATE]. Diagnoses included polyneuropathy, epilepsy, atrial fibrillation, muscle weakness, lack of coordination, and abnormalities of gait and mobility. Review of the quarterly MDS assessment dated [DATE] revealed Resident #32 had intact cognition. Resident #32 required supervision/touching assistance from staff for toileting, ambulation, and bed mobility. Observation and interview on 02/05/24 at 9:41 A.M. with Resident #32 revealed the call light was not working when pushed. During the observation, there was no back up device for the resident to use to call for assistance. Resident #32 stated her call light had not been working since the day prior and she had no other way to call for help except using her telephone. 9. Review of the medical record of Resident #12 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, atrial fibrillation, and falls. Review of the quarterly MDS assessment dated [DATE] revealed Resident #12 had intact cognition. Resident #12 required extensive assistance from staff for bed mobility. Interview and observation on 02/05/24 at 9:50 A.M. with Resident #12 stated her call light had not been working since 02/04/24 at 10:00 A.M. and she had no other means to alert staff of the need for assistance. At the time of the observation, no other back-up device was observed in the resident's room to call for assistance. 10. Review of the medical record of Resident #57 revealed an admitted [DATE]. Diagnoses included heart failure, rib fractures, falls, and hip pain. Review of the MDS assessment dated [DATE] revealed Resident #57 had moderately impaired cognition. Resident #57 required substantial/maximal assistance from staff for toileting and partial/moderate assistance from staff for bed mobility. Multiple observations on 02/05/24 between 9:41 A.M. and 11:00 A.M. revealed Resident #57 had a non-functioning call light and no other means to call for help. 11. Review of the medical record of Resident #42 revealed and admitted [DATE]. Diagnoses included atrial fibrillation, chronic obstructive pulmonary disease (COPD), depression, and congestive heart failure (CHF). Review of the MDS assessment dated [DATE] revealed Resident #42 had intact cognition. Resident #42 required extensive assistance from staff with toileting. Interview on 02/05/24 at 12:20 P.M. with Resident #42 stated his call light was not working during the weekend prior and had no other means to alert staff of the need for assistance. Resident #42 stated, the evening prior at approximately 10:00 P.M., she had to transfer herself to her wheelchair and leave her room to get help. 12. Review of the medical record of Resident #59 revealed an admitted [DATE]. Diagnoses included acute and chronic respiratory failure with hypercapnia, chronic respiratory failure with hypoxia, morbid obesity, chronic diastolic (congestive) heart failure, and anxiety disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #59 had intact cognition. Resident #59 required extensive assistance from staff for bed mobility, transfers, and toileting. Resident #59 had impaired functional range of motion to both lower extremities. Interview and observation on 02/05/24 at 11:08 A.M. with Resident #59 stated the call lights were not working during the weekend prior (02/03/24-02/04/24). Resident #59 stated her only means of alerting the staff of the need for help was to use her telephone to call the facility. Observation at the same time, Resident #59 activated her call light and the light above her door in the hallway did not illuminate. Further observation revealed Resident #59 did not have any other device at her bedside to use as a means to alert staff of the need for assistance. Interview on 02/05/24 at 11:09 A.M. with Licensed Practical Nurse (LPN) #370 verified Resident #59's call light was not functioning properly. Interview on 02/05/24 at 11:34 A.M. with Corporate Maintenance #603 and Maintenance Director (MD) #406 verified the call light system on the 200-hall was not working correctly. MD #406 stated he had not been contacted over the weekend when the call light system was found to be faulty and just learned about the call light system not working that morning and had contacted an outside company to come to the building for repair. Review of the facility policy titled Call Light Policy and Procedure, dated 11/2019, revealed all resident rooms would be equipped with call systems that sound at the nurse's station and a light will illuminate in the hallway so staff can readily see a resident has activated their call light.

Based on resident and staff interviews, review of resident council meeting notes, and record review, the facility failed to address resident concerns timely and ensure staff only attend the meetings if the residents invited them to attend. This affected three (#47, #78, and #88) of four residents who attended the resident council meeting. The facility census was 95. Findings include: Review of the Resident Council meeting notes from September 2023 to January 2024 revealed there was no evidence the facility was following up with the concerns voiced from the residents during resident council meetings. Several staff members attended each resident council meeting. 1. Record review for Resident #47 revealed she was admitted to the facility on [DATE]. Diagnoses included morbid obesity, anxiety disorder, and depression. Review of the Minimum Data Set (MDS) assessment, dated 01/29/24, revealed Resident #47 was cognitively alert. 2. Record review for Resident #78 revealed he was admitted to the facility on [DATE]. Diagnoses included diabetes mellitus (DM) type II, and depression. Review of the Minimum Data Set (MDS) assessment, dated 11/20/23, revealed Resident #78 was cognitively intact. 3. Record review for Resident #88 revealed she was admitted to the facility on [DATE]. Diagnoses included acute and chronic respiratory failure and congestive heart failure. Review of the Minimum Data Set (MDS) assessment, dated 02/25/23, revealed Resident #88 was cognitively intact. Interviews with the residents during the resident council meeting on 02/07/24 at 1:24 P.M. revealed Residents #47, #78, #88 voiced concerns to the management staff and felt they were not addressed. Residents #47, #78, and #88 stated they have requested a policy to ensure the resident council meetings and concerns were handled appropriately, however, they were told they do not have a policy regarding resident council. The residents stated the current way the resident council meetings were held included all managers from every department were present at the meeting. Resident #47 stated some residents were not comfortable with all department managers at the meeting. Resident #88 stated she has a concern related to the courtyard doors and has been told the request for handicap was part of the capital expense request but management did not follow up with her related to the issue of the courtyard. Resident #88 stated the facility hung a sign on the courtyard door and it states residents must be able to operate the doors or have someone with them that can. Follow up interview on 02/08/24 at 1:51 P.M. with Resident #88 revealed she was concerned about the courtyard door because she was in a motorized wheelchair and her controls were on the right side of her chair. Resident #88 stated she must manipulate and hold the heavy door while working on her wheelchair. Resident #88 stated she was also concerned because one time she was not able to get the door open and get back into the facility. Resident #88 stated they have posted signs that state you should have someone go with you if you cannot operate the doors. Resident #88 started to ask the Administrator about the status of the doors, and he explained it was a capital improvement and they were waiting for an answer. Interview on 02/08/24 at 9:21 A.M. with the Administrator confirmed the facility does not have a resident council policy. The Administrator confirmed all managers attend the resident council meeting. The Administrator explained by having managers present allows the managers to address issues. The Administrator stated the facility was not required to do anything to the courtyard doors because there was nothing wrong with the doors. The Administrator stated staff was available to help residents with the courtyard doors. The Administrator was unable to confirm if any staff members had addressed the resident concerns regarding the courtyard doors. Interview on 02/08/24 at 2:09 P.M. with Maintenance Supervisor (MS) #406 confirmed he remembered the issue of the garden doors coming up in resident council, however, he could not state what month it was. MS #406 stated the residents voiced concern with the courtyard doors being heavy and hard to open and that was why the facility posted signs on the door.

Based on record reviews, staff interviews, review of the facility's policy, and observations, the facility failed to ensure a resident's safety devices for the prevention of falls were functioning and failed to complete a thorough fall investigation into a resident's fall. This affected two (Residents #27 and #95) of seven residents reviewed for falls. The facility census was 95. Findings include: 1. Record review for Resident #95 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #95 included cerebral infarction and history of fracture of left femur prior to admission. Review of the Minimum Data Set, (MDS) assessment dated [DATE] revealed Resident #95 had severely impaired cognition and required partial assistance with bed mobility. Review of the plan of care, dated 12/21/23, revealed Resident #95 was at risk for falls due to decreased mobility and included an intervention of pressure alarm to the bed, ordered on 01/20/24. Observation on 02/08/24 at 1:56 P.M. with Licensed Practical Nurse Supervisor (LPNS) #357 revealed Resident #95's bed alarm did not sound when tested by LPNS #357 and there was no green indicator light on the alarm box. There were exposed wires with clear adhesive tape partially attached to the exposed wires. The clip, attached to the end of the wires, was attached to the alarm box but missing a secure hook. The connecting wires appeared to have a malfunctioning connection with the alarm box. Interview with LPNS #357 verified Resident #95's bed alarm did not sound and should have sounded at a volume the staff could hear from the hallway. LPNS #357 stated the alarm box should have had a green flashing light on the exterior of the box to permit a visual check to ensure the alarm was correctly functioning. LPNS #357 verified the clip had exposed wires, was partially taped, and was missing a secure hook. LPNS #357 verified the alarm box green light was not flashing indicating the alarm box, was not functioning, and would not sound. 2. Closed record review for Resident #27 revealed the resident was admitted to the facility on [DATE] and discharged to home with family on 02/01/24. Diagnoses included encephalopathy, chronic kidney disease, anxiety disorder, dementia, and psychosis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had moderately impaired cognition. Review of the plan of care, dated 01/04/24, revealed Resident #27 was at high risk for falls and an intervention included for a bed and chair alarm. Review of the physician orders dated 01/20/24 revealed Resident #27 had an order for a pressure alarm while in bed for safety. A wheelchair alarm was ordered on 01/23/24. Review of January 2024 Medication Administration Record revealed Resident #27 had orders to check the pressure alarm to bed and to the wheelchair functioning and placement every shift were signed as provided on the 7:00 A.M shift and the 7:00 P.M. shift on 01/28/24. Review of the nursing note dated 01/28/24 at 2:30 P.M. revealed Resident #27 was found on the floor at the foot of the bed by Licensed Practical Nurse (LPN) #477. There was no nursing note the bed alarm and/or wheelchair alarms were sounding. Review of the Interdisciplinary Team (IDT) meeting notes, dated 01/29/24 at 10:40 A.M., revealed Resident #27's fall on 01/28/24 included a new intervention of adding anti-rollback system to the wheelchair. There was no documentation of the wheelchair alarm sounding during the fall. Interview and review of the fall investigation dated 01/28/24 with the Director of Nursing (DON) on 02/07/24 at 3:34 P.M. verified Resident #27 was found on the floor in his room near the bed. The DON stated the analysis of the incident was Resident #27 walked from his wheelchair, which he was last observed seated during the lunch meal, to his bed and fell . The DON verified the fall investigation, the IDT meeting and the nursing note did not have documentation addressing if the interventions of the bed or chair alarms were sounding. The DON verified the wheelchair alarm should have sounded on 01/28/24 as Resident #27 was last observed in the wheelchair. Review of the facility's policy titled Fall Prevention Policy and Procedure dated 11/14/21 revealed the facility will implement an intervention after a fall to reduce the risk of reoccurrence of an injury. This deficiency represents non-compliance investigated under Complaint Number OH00150360.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure oxygen tubing was changed, labeled, and dated per the physician's order, plan of care, and facility policy and the facility failed to ensure oxygen was administered in a safe manner. This affected one (#49) of one resident reviewed for oxygen use. The facility identified 15 residents who used oxygen. The facility census was 95. Findings include: Review of the medical record for Resident #49 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had severely impaired cognition. The resident utilized a wheelchair for mobility. The resident received oxygen during the assessment period. Review of the care plan dated 01/18/21 revealed Resident #49 had altered respiratory status related to COPD and emphysema. Interventions included to administer oxygen as per physician orders and change oxygen tubing weekly, date, and initial. Review of the physician orders dated 03/01/23 revealed there was an order to administer oxygen at two liters per minute per nasal cannula at bedtime and as needed. An order dated 04/06/21 revealed to change and date oxygen tubing weekly. Observation on 02/05/24 at 10:19 A.M. revealed Resident #49 was lying in bed. Two sets of oxygen tubing were noted on the floor. The nose pieces of each set were observed resting directly on the floor. The tubing connected to the oxygen concentrator was dated 01/14/24 and the tubing connected to the portable oxygen tank attached to the resident's wheelchair was not dated. Observation and interview on 02/05/24 at 10:26 A.M. with Registered Nurse (RN) #600 verified Resident #49's oxygen tubing was on the floor, the tubing connected to the concentrator was dated 01/14/24, and the tubing connected to the portable oxygen tank on the resident's wheelchair was not dated. RN #600 stated she was unsure how often oxygen tubing should be changed. RN #600 then picked up the tubing from the floor and applied it to Resident #49's nose. Interview with RN #600 at the time of the observation verified she picked the tubing up off the floor and applied it to the resident's nose. RN #600 stated she should have given the resident new tubing before applying it to the resident's nose. Interview on 02/08/24 at 2:28 P.M. with the Director of Nursing (DON) stated oxygen tubing should be changed weekly and dated at that time. The DON verified it was not appropriate to pick up tubing from the floor and place on a resident's nose. The DON further stated the appropriate action would be to obtain new tubing before applying the tubing to the resident's nose. Review of the facility's policy titled Oxygen Administration, dated 11/21/21, revealed oxygen tubing should be discarded and replaced every seven days.

Based on resident and staff interview, record review, and facility policy review, the facility failed to ensure residents were routinely seen by the physician after alternate visits with the nurse practitioner. This affected two (Residents #47 and #78) of two residents reviewed for physician visits. The facility census was 95. Findings include, 1. Record review for Resident #47 revealed she was admitted to the facility on [DATE]. Her diagnoses included chronic kidney disease, diabetes mellitus (DM) type II, morbid obesity, lymphedema, hypothyroidism, essential primary hypertension, osteoarthritis, gastro esophageal reflux disease, anxiety disorder, and depression. Review of the most recent Minimum Data Set (MDS) assessment, dated 01/29/24, revealed Resident #47 was cognitively alert. Review of the physician visits from 01/01/23 to 01/31/24 revealed Resident #47 was assessed by the physician on 01/10/23. Resident #47 was assessed by a Nurse Practitioner on the following dates: 03/09/23, 04/26/23, 06/07/23, 08/15/23, 10/01/23, 11/26/23, 12/21/23, and 01/24/24. Interviews on 02/07/24 at 1:39 P.M. during the Resident Council Meeting revealed Resident #47 stated she had not been assessed by the physician. Resident #47 stated she does not understand why a physician has not assessed her and the assessments have only been by the nurse practitioners. Interview on 02/08/24 at 10:22 A.M. with the Director of Nursing (DON) confirmed the physician failed to assess Resident #47 since January 2023 and Resident #47 has only been assessed by the Nurse Practitioner in the past twelve months. 2. Record review for Resident #78 revealed he was admitted to the facility on [DATE]. His diagnoses included cellulitis, diabetes mellitus (DM) type II, tachycardia, essential primary hypertension, depression, edema, and insomnia. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/20/23, revealed Resident #78 was cognitively intact. Review on the physician visits from 02/01/23 to 02/07/24 revealed Resident #78 was assessed by the physician on 03/07/22. Resident #78 was assessed by the Nurse Practitioner on 02/21/23, 06/30/23, 08/15/23, 10/22/23, 11/16/23, 12/21/23, and 01/24/24. Interviews on 02/07/24 at 1:39 P.M. during the Resident Council Meeting revealed Resident #78 stated he had not been assessed by the physician. Resident #78 stated he does not understand why a physician has not assessed him and the assessments have only been by the nurse practitioners. Interview on 02/08/24 at 10:22 A.M. with the Director of Nursing (DON) confirmed Resident #78 has not been assessed by a physician since 03/07/22. The DON confirmed Resident #78 has only been assessed by a Nurse Practitioner in the past eleven months. Review of the facility policy titled Physician Services, dated January 2024, revealed the intent of the policy is to ensure medical supervision of the care of each resident by a physician and needs are provided throughout the resident's stay. At the option of the physician, required visits in skilled nursing facilities (SNFs), after the initial visit, may alternate between personal visit by the physician and visits by a physician assistant, nurse practitioner, or clinical nurse specialist.

Based on observation and staff interview, the facility failed to post daily staffing data at the beginning of each shift. This had the potential to affect all 95 residents who resided in the facility. Findings include, Observation and interview on 02/06/24 at 3:52 P.M. revealed the facility did not have Benefits Improvement and Protection Act (BIPA) information posted including the current census and list of licensed and unlicensed nursing staff directly responsible for the resident care at the beginning of a shift. Human Resource Director (HRD) #337 walked to a table located next to the receptionist area and held up a picture frame with a flyer posted inside. HRD #337 stated the BIPA should be posted in the picture frame. HRD #337 confirmed she attempted to post the BIPA in the picture frame, however, someone continued to move it. Observation on 02/08/24 at 7:52 A.M. revealed no BIPA was posted on the table located near the receptionist desk. Observation and interview on 02/08/24 at 8:00 A.M. revealed HRD #337 walked toward the receptionist desk with a paper in hand. HRD #337 confirmed she had the BIPA in her hands and had not posted it at the beginning of the shift.

Based on observation, record review, interview and policy review, the facility failed to ensure incontinence care was provided correctly and gloves were changed from dirty to clean. This affected one (Resident #55) of three residents reviewed for incontinence care. The facility identified there were The census was 97. Findings included: Medical record review for Resident #55 revealed an admitted [DATE]. Medical diagnoses included a stroke. Review of his quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #55 was cognitively intact. His functional status was extensive assistance for bed mobility, transfers, and toileting. He was frequently incontinent for bladder and occasionally incontinent for bowel. Observation of Resident #55 on 04/26/23 at 8:58 A.M. revealed he was lying in the bed and State tested Nursing Assistants (STNA) #120 and #200 got the resident out of bed with the Hoyer lift. He was taken to the bathroom, a soiled brief was removed and he was placed on the toilet. When he was finished STNA #120 wiped the stool from the resident's buttocks and placed a clean incontinent brief on him. She then dressed him for the day. She did not clean the resident's front peri area. She did not change her gloves or wash her hands after performing care. During interview on 04/26/23 at 9:20 A.M., STNA #120 stated she did not clean the resident's front peri area and he had urinated in his brief. She also confirmed she should have washed her hands and changed her gloves after wiping stool from the resident's bottom. Review of policy titled Incontinence, dated 11/01/21, revealed the facility will provide care to minimize risk of skin breakdown and prevent infections. Procedure is as followed for a male resident: a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area starting with urethra and working outward. (Gently rinse and dry the area.) (1) Retract foreskin of the uncircumcised male. (2) Wash and rinse urethral area using a circular motion. (3) Continue to wash the perineal area including the penis, scrotum, and inner thighs. Do not reuse the same washcloth or water to clean the urethra. c. Thoroughly rinse perineal area in same order, using fresh water and clean washcloth. e. Reposition foreskin of uncircumcised male. f. Instruct or assist the resident to turn on his side with his upper leg slightly bent, if able. g. Rinse washcloth and apply soap or skin cleansing agent. h. Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks. i. Dry area thoroughly. 8. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. 9. Reposition the bed covers. Make the resident comfortable. This was an incidental deficiency discovered during the course of this complaint investigation.

Based on medical record review, staff interview, review of the transfer form, and policy review, the facility failed to provide a notice of discharge to hospitalized residents and the ombudsman after a facility-initiated discharge. This affected one resident (#100) of three residents reviewed for discharge. The facility census was 94. Findings include: Review of the medical record for the Resident #100 revealed an admitted [DATE] and a discharged date of 05/20/2022. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #100 had moderately impaired cognition, had both hallucinations and delusions, had daily verbal, physical, and self-directed behaviors, frequently rejected care, and did not wander. Resident #100 required limited assistance for bed mobility, and transfers, extensive assistance with dressing, toilet use, personal hygiene, eating, and locomotion. Review of the transfer form dated 05/06/2022 revealed Resident #100 was transferred to a local hospital for hallucinations and threatening other residents. Review of the medical record revealed Resident #100 had no recapitulation of stay or discharge summary in the record. During an interview on 08/24/2022 at 3:18 P.M., the Admissions #04 said the upper management had an extensive conversation about how the facility could no longer meet Resident #100's needs, and Resident #100 was already in the hospital when this conversation occurred. The Administrator, the Director of Nursing (DON), and Admissions #04 went to the hospital and evaluated Resident #100, date not specified, after the hospital had stabilized her as best as they could. Resident #100 continued to make statements of people rolling down the hall and it annoyed her. The team was worried about general resident safety because Resident #100 remained agitated. The team explored their options and asked the hospital to reach out to places who treated those types of behaviors. The facility never said they would not take Resident #100 back. The social worker at the hospital worked with Resident #100's case manager, and all agreed Resident #100 needed placement at a behavioral facility. The facility continued to hold Resident #100's bed, and she was not discharged from the facility until it was established she had placement at another facility. During an interview on 08/25/2022 at 10:14 A.M., the Receptionist #35 stated she sent discharge letters and bed hold notifications to the residents or the responsible party. Receptionist #35 stated there was no letter of discharge sent to Resident #100 after she was discharged . During an interview on 08/25/2022 at 10:25 A.M., the Administrator restated Resident #100 was not discharged when she was sent to the hospital, and the facility made it very clear to the hospital they would take her back. The hospital agreed to keep Resident #100 there because it wasn't safe for her to return to the facility. The resident was on a medical-surgical unit and received care to stabilize her. The facility was clear Resident #100 could return; however, the facility felt she would benefit from alternate services. There was no discharge letter or letter to the ombudsman because Resident #100 was not discharged . Review of policy titled Covenant Village Discharge Planning Process, undated revealed the discharge planning team assure that all residents discharged to another facility or level of care were provided adequate information about the facility options and the information was incorporated into the discharge plan. This deficiency substantiates Complaint Number OH 036.

Based on medical record review, review of the hospital record, resident and staff interview, review of a [MEDICATION(S)] Plus Medical Encyclopedia document, and review of facility policy, the facility failed to safely and properly turn a resident during incontinence care. Actual Harm occurred when State tested Nursing Assistant (STNA) #50 rolled Resident #01 away from her with no guards and Resident #01 rolled out of a raised bed onto the floor resulting in bilateral femur fractures with a dislocated right ankle requiring a five day hospital stay. This affected one (Resident #01) out of three residents reviewed for falls. The facility census was 93. Findings include: Review of the medical record for Resident #01 revealed an admitted [DATE] with diagnoses including [CONDITION(S)], [CONDITION(S)], diabetes, and [CONDITION(S)]. Review of Resident #01's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #01 had mild cognitive deficits and required extensive assistance with two plus persons physical assist for bed mobility. Review of Resident #01's care plan dated 11/09/21 revealed Resident #01 had an activity of daily living self-care performance deficit related to her multiple diagnoses. Further review of the care plan revealed Resident #01 had an intervention dated 11/09/21 for one to two people extensive assistance with bed mobility. Review of Resident #01's MDS note dated 02/08/22 revealed Resident #01 required total assist of two staff with bathing, and required extensive assist of two staff for bed mobility and toileting. Review of the fall follow up note dated 02/10/22 revealed STNA #50 was in Resident #01's room providing morning care. STNA #50 turned Resident #01 onto her left side, and Resident #01 grabbed the side rail of the bed and turned. STNA #50 stated Resident #01's bilateral legs went off the side of the bed by the window, Resident #01 fell on to her knees then fell forward onto the ground between the bed and the bedside table, hit the bedside table, and then hit her face/head on the ground. STNA #50 stated she was unsure if Resident #01 hit the bedside table with her head or her right shoulder. Resident #01 began to call out Help me. Staff were in the room with Resident #01. The Supervisor was made aware and entered Resident #01's room as well. Resident #01 was assessed from head to toe for injury. Resident #01's right leg appeared shorter than the left leg. Resident #01 was also noted with swelling/hematoma to the left side of her forehead. Resident #01 stated she was in pain, and when asked where she responded, all over. Resident #01's vital signs were obtained. 911 was called, and Resident #01 was taken to a local hospital emergency department (ED) for evaluation. The Supervisor called report to the hospital and family. Review of hospital records with a date of service of 02/10/22 revealed in the ED, Resident #01 had extensive imaging which showed bilateral femur fractures and an ankle dislocation. Review of Resident #01's right ankle x-ray dated 02/10/22 revealed there was a chronic appearing fracture deformity of the ankle. Review of Resident #01's right tibia and fibula x-ray dated 02/10/22 revealed there was a partially visualized right ankle fracture dislocation. Review of Resident #01's right femur x-ray dated 02/10/22 revealed an acute traumatic comminuted impacted appearing fracture involving the right distal femoral metadiaphysis with possible extension into the intracondylar notch. Review of Resident #01's left femur x-ray dated 02/10/22 revealed an acute traumatic displaced distal left femoral metadiaphysis fracture. Interview on 03/02/22 at 1:40 P.M. with the Director of Nursing (DON) revealed STNA #50 was providing care to Resident #01 by herself when she rolled Resident #01 away from her and Resident #01 fell out of the raised bed onto the floor. A phone interview on 03/02/22 at 5:25 P.M. with STNA #50 revealed she frequently provided care to Resident #01. STNA #50 stated she was providing care to Resident #01 by herself on 02/10/22, when STNA #50 rolled Resident #01 away from STNA #50 onto Resident #01's left side, and Resident #01 fell out of the bed on the opposite side of where STNA #50 was standing. STNA #50 stated she was unable to prevent Resident #01 from falling. Interview on 03/07/22 at 2:56 P.M. with STNA #60 revealed when she is providing care without assistance, she never rolls the resident away from herself and always rolls the resident towards herself in order to prevent them from falling out of the bed. STNA #60 reported she never provided care to Resident #01 alone. Review of the [MEDICATION(S)] Plus Medical Encyclopedia document titled Turning Patients Over in Bed, undated, found at https://medlineplus.gov/ency/patientinstructions/ 6.htm, revealed the following steps should be followed when turning a patient from their back to their side or stomach: explain to the patient what you are planning to do so the person knows what to expect, encourage the person to help if possible; stand on the opposite side of the bed the patient will be turning towards, and lower the bed rail. Move the patient towards you, then put the side rail back up. Step around to the other side of the bed and lower the side rail. Ask the patient to look towards you, this will be the direction in which the person is turning. The following steps should be followed when turning a patient: if you can, raise the bed to a level that reduces back strain for you, make the bed flat. Get as close to the person as you can. You may need to put a knee on the bed to get close enough to the patient. Place one of your hands on the patient's shoulder and your other hand on the hip. Standing with one foot ahead of the other, shift your weight to your front foot (or knee if you put your knee on the bed) as you gently pull the patient's shoulder toward you. Then shift your weight to your back foot as you gently pull the person's hip towards you. Review of the facility policy titled Fall Prevention Policy and Procedure, dated 11/14/21, revealed the facility will provide adequate care and supervision to residents to prevent avoidable accidents. This deficiency substantiates Complaint Number OH 297.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on medical record review, review of a facility Self-Reported incident (SRI), observations, review of personnel files, staff, resident and police detective interviews and review of facility policies, the facility failed to ensure residents were free from mental and emotional abuse by facility a staff member. This resulted in Immediate Jeopardy and the potential for psychosocial harm for one resident (#42) and two to three additional unidentified residents when Housekeeper #161 engaged in an act meant to humiliate and dehumanize the resident's by taking multiple inappropriate photographs including photographs of unidentified residents lying in bed with their thighs/incontinence brief exposed, of an unidentified female resident's genitalia exposed and of Resident #42's face without the resident's permission and not in accordance with facility policy. The photographs were then admitted ly used by Housekeeper #161 for personal sexual gratification, resulting in outcomes which one would expect a reasonable person in a similar situation to suffer, subsequently treating the resident as an inanimate object having no emotions or feelings and causing embarrassment and shame for the resident. This affected one (#42) of three residents reviewed during the survey and two to three additional unidentified residents as indicated by the police. The facility census was 88. On 02/28/18 at 2:15 P.M., the Administrator, Executive Director and the Director of Nursing (DON) were notified that Immediate Jeopardy began on 02/04/18 at approximately 8:55 A.M. when Housekeeper #136 found a cellular (cell) phone in the facility basement which contained multiple photographs of unidentified residents and one photograph of Resident #42's face. The photographs were of unidentified resident's lying in bed with their bare thighs and adult incontinence briefs exposed. There was also one photograph of an unidentified female residents' genitalia exposed. The police estimated two, possibly three different unidentified residents were observed in the photographs. The cell phone was identified as belonging to Housekeeper #161 who admitted to police that he took the photographs for his own sexual gratification. The Immediate Jeopardy was removed on 02/05/18 when staff education was provided regarding the identification of abuse, the abuse policy and procedures, maintaining the residents' rights to privacy and confidentiality during the provision of personal care and utilization of cell phones and/or photographing mobile devices. The deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 02/16/18 when the facility implemented the following corrective actions: · On 02/04/18 at 11:15 A.M., the Administrator contacted the police department and notified them of the inappropriate photographs taken. · On 02/04/18 at 11:30 A.M., the Administrator instructed the supervisory staff to start in-services on Abuse, Neglect, Misappropriation and Exploitation with all staff in the facility. The in-service training was completed on 02/05/18. · On 02/04/18 at 11:56 A.M., the police arrived at the facility and a report was filed. · On 02/04/18 at 12:20 P.M., the facility submitted the initial SRI to the Ohio Department of Health. · On 02/04/18 at 1:15 P.M., Resident #42 was interviewed by the police and facility staff. The resident was unaware her photograph had been taken. · On 02/04/18 at 2:07 P.M., the Administrator implemented a mass text message/in-service and sent it to all employees regarding the facilities Abuse, Neglect and Misappropriation Policy as well as the Cell Phone Usage Policy. · On 02/04/18 at 2:15 P.M., the DON began interviewing all residents and staff regarding inappropriate photographs. The interviews continued and were completed on 02/05/18 and no negative findings were reported. · On 02/06/18, the Quality Assessment and Assurance (QA&A) committee met to review the identified concern and discuss staff competency. · On 02/06/18, the QA&A committee began implementing monitoring. The monitoring was conducted three times a week for one week and two times a week for one week. The monitoring was completed on 02/05/18, 02/07/18, 02/09/18, 02/12/18 and 02/16/18. There were no further concerns identified. · On 02/06/18 at 7:30 A.M. and 2:30 P.M., the Administrator conducted a mandatory follow-up in-service regarding resident privacy, abuse, neglect, misappropriation, exploitation and crime reporting. The training was completed on 02/06/18. · On 02/07/18 and 02/08/18, the Administrator met with interviewable residents regarding abuse and inappropriate photographs. No negative findings were reported. · On 02/08/18, the facility's Quality Assurance and Performance Improvement (QAPI) committee held a meeting including the Medical Director to discuss the incident. · On 02/28/18, Resident #23 and #29 were interviewed and their medical records were reviewed. No concerns were identified with privacy or abuse concerns. · On 02/28/18 between 2:30 P.M. and 3:00 P.M., Licensed Practical Nurse (LPN) #94, LPN #95, LPN #96, Housekeeper #97, Housekeeper #98, Speech Therapist #98, Registered Nurse (RN) #99, Maintenance Staff #100, Housekeeper #101, Housekeeper #102, LPN #103, State tested Nursing Assistant #104 and Front Desk Staff #105 were all interviewed regarding resident privacy and abuse. There were no negative findings identified and all were knowledgeable regarding the privacy and abuse training. Findings include: Review of Resident #42's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated no cognitive impairments. Further review of the MDS revealed the resident needed extensive assistance of one assistance with walking in and out of her room, and locomotion on the unit. The resident needed minimal assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Review of the SRI dated on 02/04/18 revealed Housekeeper #136 found a cell phone in the laundry room in the basement of the facility. Housekeeper #136 opened the phone to see who it belonged to when she discovered inappropriate photographs on the phone. Housekeeper #136 took the phone to her supervisor who called the Administrator. The Administrator came to the facility and started the investigation. The police were called and the owner of the cell phone was identified as Housekeeper #161. Housekeeper #161 admitted he took the pictures; however, refused any further comment. The DON and the nursing staff started interviewing residents and doing skin assessments. The Administrative staff also began educating the staff regarding abuse, privacy and cell phone usage. The SRI substantiated abuse occurred. Observations of Resident #42 on 02/27/18 at 11:30 A.M. revealed the resident was lying in her bed with her eyes closed. The resident did not awaken at response to her name. Observations on 02/27/18 at 3:00 P.M. revealed Resident #42 was sitting in a chair in her room. The resident was alert and oriented. Interview on 02/27/18 at 3:05 P.M. with Resident #42 revealed she was told that some photographs had been taken. Resident #42 stated she had no idea this had happened and noted she must have been sleeping if her picture was taken. Resident #42 stated she felt sorry for Housekeeper #161 because he was fired and he was always so nice to her. Resident #42 noted she had spoken with multiple people regarding this occurrence including the police, the Social Worker and Administrator. Resident #42 stated she just could hardly believe this incident happened. Interview with Housekeeper #136 on 02/27/18 at 3:45 P.M. revealed on 02/04/18 at approximately 9:00 A.M. she found a cell phone lying in the facility basement on a table in the laundry room. Housekeeper #136 stated she picked the cell phone up to see who it belonged too. The cell phone was not locked so she could access it to attempt to determine who the phone belonged too. Housekeeper #136 stated when she opened the phone up she was shocked to find pictures of residents with their bare thighs exposed and in adult briefs. Housekeeper #136 revealed there was also one picture of a female resident's genitalia. Housekeeper #136 revealed she immediately showed her supervisor what she discovered. Interview on 02/27/18 at 5:20 P.M. with Police Detective #199 revealed an officer was called to the facility on [DATE] at 11:15 A.M. Police Detective #199 stated he was not the officer who initially responded to the facility, however he is the investigating detective. Police Detective # 199 noted the pictures were entered into evidence and could not be viewed by the surveyor. Police Detective #199 noted there were several inappropriate photographs. He estimated two possibly three different body types were noted in the photographs but the specific residents could not be identified. Some of the photographs were of residents from the backside showing their bare thighs and adult briefs. Police Detective #199 stated only one showed the face of a resident which was verified as Resident #42. Police Detective #199 stated there was another photograph of a female lying on her back with her knees bent showing her genitalia; however, the resident could not be identified. Police Detective #199 noted the perpetrator (Housekeeper #161) admitted he did not post the photographs or share them with any one and that he took the photographs for his personal use for sexual gratification. Police Detective #199 noted Housekeeper #161 was currently in custody and is being charged with voyeurism. Interview with the Administrator on 02/28/18 at 9:30 A.M. revealed an employee (Housekeeper #136) had discovered a cell phone with photographs of residents on it. Most of the photographs were taken from the backside of the resident's showing bare thighs and their adult briefs. The Administrator stated there was one photograph showing a frontal view of a female's genitals. The Administrator stated the facility could not identify which residents were in these photographs. The Administrator noted an immediate investigation was started after the discovery of the photographs and the police were called. The Administrator stated Housekeeper #161 admitted to taking the photographs but did not disclose who the residents were or the date when they were taken. The Administrator revealed only one picture had a resident's face in it and it was Resident #42. Review of Housekeeper #161's employee personnel file revealed he was hired 05/27/15. Housekeeper #161 had reference checks completed and passed a drug screen. Housekeeper #161 had a BCI (Bureau of Criminal Investigation) check completed and had no negative findings. Housekeeper #161 had perfect attendance and had previously been employee of the month. Housekeeper #161 had no negative findings during his evaluations of performance. Housekeeper #161 had been in-serviced on the abuse and cell phone usage policies upon hire and yearly thereafter. Review of the facility policy titled Addendum to HCMG Summary of Policies with a revision date of 08/2016 revealed taking, viewing, showing, or otherwise distributing photographs, videos, or other content of a lewd or indecent nature during working time or while on Company property with a cell phone or other handheld device is strictly prohibited. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property with a revised date of 02/2018 revealed Abuse is the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse, including abuse facilitated or enabled through use of technology, such as through use of photographs and recording devices to demean or humiliate a resident. This deficiency substantiates Complaint Number OH 192.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on medical record review, review of a facility Self-Reported Incident (SRI), observations, review of personnel files, staff, resident and police detective interviews and review of facility policies, the facility failed to implement policies prohibiting resident abuse and inappropriate use of cellular phones to ensure residents were free from mental and emotional abuse by facility a staff member. This resulted in Immediate Jeopardy and the potential for psychosocial harm for one resident (#42) and two to three additional unidentified residents when Housekeeper #161 engaged in an act meant to humiliate and dehumanize the residents by taking multiple inappropriate photographs including photographs of unidentified residents lying in bed with their thighs/incontinence brief exposed, of an unidentified female resident's genitalia exposed and of Resident #42's face without the resident's permission and not in accordance with facility policy. The photographs were then admitted ly used by Housekeeper #161 for personal sexual gratification, resulting in outcomes which one would expect a reasonable person in a similar situation to suffer, subsequently treating the resident as an inanimate object having no emotions or feelings and causing embarrassment and shame for the resident. This affected one (#42) of three residents reviewed during the survey and two to three additional unidentified residents as indicated by the police. The facility census was 88. On 02/28/18 at 2:15 P.M., the Administrator, Executive Director and the Director of Nursing (DON) were notified that Immediate Jeopardy began on 02/04/18 at approximately 8:55 A.M. when Housekeeper #136 found a cellular (cell) phone in the facility basement which contained multiple photographs of unidentified residents and one photograph of Resident #42's face. The photographs were of unidentified resident's lying in bed with their bare thighs and adult incontinence briefs exposed. There was also one photograph of an unidentified female residents' genitalia exposed. The police estimated two, possibly three different unidentified residents were observed in the photographs. The cell phone was identified as belonging to Housekeeper #161 who admitted to police that he took the photographs for his own sexual gratification. The Immediate Jeopardy was removed on 02/05/18 when staff education was provided regarding the identification of abuse, the abuse policy and procedures, maintaining the residents' rights to privacy and confidentiality during the provision of personal care and utilization of cell phones and/or photographing mobile devices. The deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 02/16/18 when the facility implemented the following corrective actions: · On 02/04/18 at 11:15 A.M., the Administrator contacted the police department and notified them of the inappropriate photographs taken. · On 02/04/18 at 11:30 A.M., the Administrator instructed the supervisory staff to start in-services on Abuse, Neglect, Misappropriation and Exploitation with all staff in the facility. The in-service training was completed on 02/05/18. · On 02/04/18 at 11:56 A.M., the police arrived at the facility and a report was filed. · On 02/04/18 at 12:20 P.M., the facility submitted the initial SRI to the Ohio Department of Health. · On 02/04/18 at 1:15 P.M., Resident #42 was interviewed by the police and facility staff. The resident was unaware her photograph had been taken. · On 02/04/18 at 2:07 P.M., the Administrator implemented a mass text message/in-service and sent it to all employees regarding the facilities Abuse, Neglect and Misappropriation Policy as well as the Cell Phone Usage Policy. · On 02/04/18 at 2:15 P.M., the DON began interviewing all residents and staff regarding inappropriate photographs. The interviews continued and were completed on 02/05/18 and no negative findings were reported. · On 02/06/18, the Quality Assessment and Assurance (QA&A) committee met to review the identified concern and discuss staff competency. · On 02/06/18, the QA&A committee began implementing monitoring. The monitoring was conducted three times a week for one week and two times a week for one week. The monitoring was completed on 02/05/18, 02/07/18, 02/09/18, 02/12/18 and 02/16/18. There were no further concerns identified. · On 02/06/18 at 7:30 A.M. and 2:30 P.M., the Administrator conducted a mandatory follow-up in-service regarding resident privacy, abuse, neglect, misappropriation, exploitation and crime reporting. The training was completed on 02/06/18. · On 02/07/18 and 02/08/18, the Administrator met with interviewable residents regarding abuse and inappropriate photographs. No negative findings were reported. · On 02/08/18, the facility's Quality Assurance and Performance Improvement (QAPI) committee held a meeting including the Medical Director to discuss the incident. · On 02/28/18, Resident #23 and #29 were interviewed and their medical records were reviewed. No concerns were identified with privacy or abuse concerns. · On 02/28/18 between 2:30 P.M. and 3:00 P.M., Licensed Practical Nurse (LPN) #94, LPN #95, LPN #96, Housekeeper #97, Housekeeper #98, Speech Therapist #98, Registered Nurse (RN) #99, Maintenance Staff #100, Housekeeper #101, Housekeeper #102, LPN #103, State tested Nursing Assistant #104 and Front Desk Staff #105 were all interviewed regarding resident privacy and abuse. There were no negative findings identified and all were knowledgeable regarding the privacy and abuse training. Findings include: Review of Resident #42's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated no cognitive impairments. Further review of the MDS revealed the resident needed extensive assistance of one assistance with walking in and out of her room, and locomotion on the unit. The resident needed minimal assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Review of the SRI dated on 02/04/18 revealed Housekeeper #136 found a cell phone in the laundry room in the basement of the facility. Housekeeper #136 opened the phone to see who it belonged to when she discovered inappropriate photographs on the phone. Housekeeper #136 took the phone to her supervisor who called the Administrator. The Administrator came to the facility and started the investigation. The police were called and the owner of the cell phone was identified as Housekeeper #161. Housekeeper #161 admitted he took the pictures; however, refused any further comment. The DON and the nursing staff started interviewing residents and doing skin assessments. The Administrative staff also began educating the staff regarding abuse, privacy and cell phone usage. The SRI substantiated abuse occurred. Observations of Resident #42 on 02/27/18 at 11:30 A.M. revealed the resident was lying in her bed with her eyes closed. The resident did not awaken at response to her name. Observations on 02/27/18 at 3:00 P.M. revealed Resident #42 was sitting in a chair in her room. The resident was alert and oriented. Interview on 02/27/18 at 3:05 P.M. with Resident #42 revealed she was told that some photographs had been taken. Resident #42 stated she had no idea this had happened and noted she must have been sleeping if her picture was taken. Resident #42 stated she felt sorry for Housekeeper #161 because he was fired and he was always so nice to her. Resident #42 noted she had spoken with multiple people regarding this occurrence including the police, the Social Worker and Administrator. Resident #42 stated she just could hardly believe this incident happened. Interview with Housekeeper #136 on 02/27/18 at 3:45 P.M. revealed on 02/04/18 at approximately 9:00 A.M. she found a cell phone lying in the facility basement on a table in the laundry room. Housekeeper #136 stated she picked the cell phone up to see who it belonged too. The cell phone was not locked so she could access it to attempt to determine who the phone belonged too. Housekeeper #136 stated when she opened the phone up she was shocked to find pictures of residents with their bare thighs exposed and in adult briefs. Housekeeper #136 revealed there was also one picture of a female resident's genitalia. Housekeeper #136 revealed she immediately showed her supervisor what she discovered. Interview on 02/27/18 at 5:20 P.M. with Police Detective #199 revealed an officer was called to the facility on [DATE] at 11:15 A.M. Police Detective #199 stated he was not the officer who initially responded to the facility, however he is the investigating detective. Police Detective # 199 noted the pictures were entered into evidence and could not be viewed by the surveyor. Police Detective #199 noted there were several inappropriate photographs. He estimated two possibly three different body types were noted in the photographs but the specific residents could not be identified. Some of the photographs were of residents from the backside showing their bare thighs and adult briefs. Police Detective #199 stated only one showed the face of a resident which was verified as Resident #42. Police Detective #199 stated there was another photograph of a female lying on her back with her knees bent showing her genitalia; however, the resident could not be identified. Police Detective #199 noted the perpetrator (Housekeeper #161) admitted he did not post the photographs or share them with any one and that he took the photographs for his personal use for sexual gratification. Police Detective #199 noted Housekeeper #161 was currently in custody and is being charged with voyeurism. Interview with the Administrator on 02/28/18 at 9:30 A.M. revealed an employee (Housekeeper #136) had discovered a cell phone with photographs of residents on it. Most of the photographs were taken from the backside of the resident's showing bare thighs and their adult briefs. The Administrator stated there was one photograph showing a frontal view of a female's genitals. The Administrator stated the facility could not identify which residents were in these photographs. The Administrator noted an immediate investigation was started after the discovery of the photographs and the police were called. The Administrator stated Housekeeper #161 admitted to taking the photographs but did not disclose who the residents were or the date when they were taken. The Administrator revealed only one picture had a resident's face in it and it was Resident #42. Review of Housekeeper #161's employee personnel file revealed he was hired 05/27/15. Housekeeper #161 had reference checks completed and passed a drug screen. Housekeeper #161 had a BCI (Bureau of Criminal Investigation) check completed and had no negative findings. Housekeeper #161 had perfect attendance and had previously been employee of the month. Housekeeper #161 had no negative findings during his evaluations of performance. Housekeeper #161 had been in-serviced on the abuse and cell phone usage policies upon hire and yearly thereafter. Review of the facility policy titled Addendum to HCMG Summary of Policies with a revision date of 08/2016 revealed taking, viewing, showing, or otherwise distributing photographs, videos, or other content of a lewd or indecent nature during working time or while on Company property with a cell phone or other handheld device is strictly prohibited. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property with a revised date of 02/2018 revealed Abuse is the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse, including abuse facilitated or enabled through use of technology, such as through use of photographs and recording devices to demean or humiliate a resident. This deficiency substantiates Complaint Number OH 192.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on medical record review, review of a facility Self-Reported Incident (SRI), observations, review of personnel files, staff, resident and police detective interviews and review of facility policies, the facility failed to ensure residents rights to privacy and confidentiality were maintained by a facility staff member. This resulted in Immediate Jeopardy and the potential to cause psychosocial harm for one resident (#42) and two to three additional unidentified resident's when Housekeeper #161 engaged in an act meant to humiliate and dehumanize the residents by taking multiple inappropriate photographs including photographs of unidentified residents lying in bed with their thighs/incontinence brief exposed, of an unidentified female resident's genitalia exposed and of Resident #42's face without the resident's permission and not in accordance with facility policy. The photographs were then admitted ly used by Housekeeper #161 for personal sexual gratification, resulting in outcomes which one would expect a reasonable person in a similar situation to suffer, subsequently treating the resident as an inanimate object having no emotions or feelings and causing embarrassment and shame for the resident. This affected one (#42) of three residents reviewed during the survey and two to three additional unidentified residents as indicated by the police. The facility census was 88. On 02/28/18 at 2:15 P.M., the Administrator, Executive Director and the Director of Nursing (DON) were notified that Immediate Jeopardy began on 02/04/18 at approximately 8:55 A.M. when Housekeeper #136 found a cellular (cell) phone in the facility basement which contained multiple photographs of unidentified residents and one photograph of Resident #42's face. The photographs were of unidentified resident's lying in bed with their bare thighs and adult incontinence briefs exposed. There was also one photograph of an unidentified female residents' genitalia exposed. The police estimated two, possibly three different unidentified residents were observed in the photographs. The cell phone was identified as belonging to Housekeeper #161 who admitted to police that he took the photographs for his own sexual gratification. The Immediate Jeopardy was removed on 02/05/18 when staff education was provided regarding the identification of abuse, the abuse policy and procedures, maintaining the residents' rights to privacy and confidentiality during the provision of personal care and utilization of cell phones and/or photographing mobile devices. The deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 02/16/18 when the facility implemented the following corrective actions: · On 02/04/18 at 11:15 A.M., the Administrator contacted the police department and notified them of the inappropriate photographs taken. · On 02/04/18 at 11:30 A.M., the Administrator instructed the supervisory staff to start in-services on Abuse, Neglect, Misappropriation and Exploitation with all staff in the facility. The in-service training was completed on 02/05/18. · On 02/04/18 at 11:56 A.M., the police arrived at the facility and a report was filed. · On 02/04/18 at 12:20 P.M., the facility submitted the initial SRI to the Ohio Department of Health. · On 02/04/18 at 1:15 P.M., Resident #42 was interviewed by the police and facility staff. The resident was unaware her photograph had been taken. · On 02/04/18 at 2:07 P.M., the Administrator implemented a mass text message/in-service and sent it to all employees regarding the facilities Abuse, Neglect and Misappropriation Policy as well as the Cell Phone Usage Policy. · On 02/04/18 at 2:15 P.M., the DON began interviewing all residents and staff regarding inappropriate photographs. The interviews continued and were completed on 02/05/18 and no negative findings were reported. · On 02/06/18, the Quality Assessment and Assurance (QA&A) committee met to review the identified concern and discuss staff competency. · On 02/06/18, the QA&A committee began implementing monitoring. The monitoring was conducted three times a week for one week and two times a week for one week. The monitoring was completed on 02/05/18, 02/07/18, 02/09/18, 02/12/18 and 02/16/18. There were no further concerns identified. · On 02/06/18 at 7:30 A.M. and 2:30 P.M., the Administrator conducted a mandatory follow-up in-service regarding resident privacy, abuse, neglect, misappropriation, exploitation and crime reporting. The training was completed on 02/06/18. · On 02/07/18 and 02/08/18, the Administrator met with interviewable residents regarding abuse and inappropriate photographs. No negative findings were reported. · On 02/08/18, the facility's Quality Assurance and Performance Improvement (QAPI) committee held a meeting including the Medical Director to discuss the incident. · On 02/28/18, Resident #23 and #29 were interviewed and their medical records were reviewed. No concerns were identified with privacy or abuse concerns. · On 02/28/18 between 2:30 P.M. and 3:00 P.M., Licensed Practical Nurse (LPN) #94, LPN #95, LPN #96, Housekeeper #97, Housekeeper #98, Speech Therapist #98, Registered Nurse (RN) #99, Maintenance Staff #100, Housekeeper #101, Housekeeper #102, LPN #103, State tested Nursing Assistant #104 and Front Desk Staff #105 were all interviewed regarding resident privacy and abuse. There were no negative findings identified and all were knowledgeable regarding the privacy and abuse training. Findings include: Review of Resident #42's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated no cognitive impairments. Further review of the MDS revealed the resident needed extensive assistance of one assistance with walking in and out of her room, and locomotion on the unit. The resident needed minimal assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Review of the SRI dated on 02/04/18 revealed Housekeeper #136 found a cell phone in the laundry room in the basement of the facility. Housekeeper #136 opened the phone to see who it belonged to when she discovered inappropriate photographs on the phone. Housekeeper #136 took the phone to her supervisor who called the Administrator. The Administrator came to the facility and started the investigation. The police were called and the owner of the cell phone was identified as Housekeeper #161. Housekeeper #161 admitted he took the pictures; however, refused any further comment. The DON and the nursing staff started interviewing residents and doing skin assessments. The Administrative staff also began educating the staff regarding abuse, privacy and cell phone usage. The SRI substantiated abuse occurred. Observations of Resident #42 on 02/27/18 at 11:30 A.M. revealed the resident was lying in her bed with her eyes closed. The resident did not awaken at response to her name. Observations on 02/27/18 at 3:00 P.M. revealed Resident #42 was sitting in a chair in her room. The resident was alert and oriented. Interview on 02/27/18 at 3:05 P.M. with Resident #42 revealed she was told that some photographs had been taken. Resident #42 stated she had no idea this had happened and noted she must have been sleeping if her picture was taken. Resident #42 stated she felt sorry for Housekeeper #161 because he was fired and he was always so nice to her. Resident #42 noted she had spoken with multiple people regarding this occurrence including the police, the Social Worker and Administrator. Resident #42 stated she just could hardly believe this incident happened. Interview with Housekeeper #136 on 02/27/18 at 3:45 P.M. revealed on 02/04/18 at approximately 9:00 A.M. she found a cell phone lying in the facility basement on a table in the laundry room. Housekeeper #136 stated she picked the cell phone up to see who it belonged too. The cell phone was not locked so she could access it to attempt to determine who the phone belonged too. Housekeeper #136 stated when she opened the phone up she was shocked to find pictures of residents with their bare thighs exposed and in adult briefs. Housekeeper #136 revealed there was also one picture of a female resident's genitalia. Housekeeper #136 revealed she immediately showed her supervisor what she discovered. Interview on 02/27/18 at 5:20 P.M. with Police Detective #199 revealed an officer was called to the facility on [DATE] at 11:15 A.M. Police Detective #199 stated he was not the officer who initially responded to the facility, however he is the investigating detective. Police Detective # 199 noted the pictures were entered into evidence and could not be viewed by the surveyor. Police Detective #199 noted there were several inappropriate photographs. He estimated two possibly three different body types were noted in the photographs but the specific residents could not be identified. Some of the photographs were of residents from the backside showing their bare thighs and adult briefs. Police Detective #199 stated only one showed the face of a resident which was verified as Resident #42. Police Detective #199 stated there was another photograph of a female lying on her back with her knees bent showing her genitalia; however, the resident could not be identified. Police Detective #199 noted the perpetrator (Housekeeper #161) admitted he did not post the photographs or share them with any one and that he took the photographs for his personal use for sexual gratification. Police Detective #199 noted Housekeeper #161 was currently in custody and is being charged with voyeurism. Interview with the Administrator on 02/28/18 at 9:30 A.M. revealed an employee (Housekeeper #136) had discovered a cell phone with photographs of residents on it. Most of the photographs were taken from the backside of the resident's showing bare thighs and their adult briefs. The Administrator stated there was one photograph showing a frontal view of a female's genitals. The Administrator stated the facility could not identify which residents were in these photographs. The Administrator noted an immediate investigation was started after the discovery of the photographs and the police were called. The Administrator stated Housekeeper #161 admitted to taking the photographs but did not disclose who the residents were or the date when they were taken. The Administrator revealed only one picture had a resident's face in it and it was Resident #42. Review of Housekeeper #161's employee personnel file revealed he was hired 05/27/15. Housekeeper #161 had reference checks completed and passed a drug screen. Housekeeper #161 had a BCI (Bureau of Criminal Investigation) check completed and had no negative findings. Housekeeper #161 had perfect attendance and had previously been employee of the month. Housekeeper #161 had no negative findings during his evaluations of performance. Housekeeper #161 had been in-serviced on the abuse and cell phone usage policies upon hire and yearly thereafter. Review of the facility policy titled Addendum to HCMG Summary of Policies with a revision date of 08/2016 revealed taking, viewing, showing, or otherwise distributing photographs, videos, or other content of a lewd or indecent nature during working time or while on Company property with a cell phone or other handheld device is strictly prohibited. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property with a revised date of 02/2018 revealed Abuse is the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse, including abuse facilitated or enabled through use of technology, such as through use of photographs and recording devices to demean or humiliate a resident. This deficiency substantiates Complaint Number OH 192.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on closed medical record review, staff interview, review of hospital reports and review of policy and procedure the facility failed to ensure staff provided supervision to a resident with a history of falls. This affected one Resident (#101) of four reviewed for falls. This resulted in actual harm to Resident #101 when a staff member left the resident on the toilet and the resident fell off the toilet and sustained a fracture. Facility census of 90. Findings include: Review of a closed medical record revealed Resident #101, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the minimum data set (MDS) assessment dated [DATE] revealed Resident #101 had severely impaired cognation. Review of a fall assessment dated [DATE] revealed Resident #101 was identified as being a high fall risk due to her poor safety awareness, impulsiveness, osteoporosis and history of falls. Review of the care plan for falls revealed the facility had made updates after every fall, a total of 13, since Resident #101's admission. Interventions included frequent orientation to room, bathroom call light and facility, low bed, labs monitored, medications reviewed, rule out orthostatic blood pressure, maintain uncluttered environment, monitor safety/prevention devices for application, instruct on use of adaptive equipment, nursing assistants to check alarm for proper placement with each episodes of care delivery, observe and report unsafe conditions, pressure alarm to bed to remind resident of need for assistance to transfer and alert staff resident may be attempting to transfer without assistance, check function and placement every shift, pressure alarm to reclining chair, replace alarm batteries every month, resident has been noted to be non-compliant with alarms by ignoring them or just not hearing them, therapy request to screen resident for transfers and ambulation and toileting program to include resident to be toileted between 5:00 A.M. and 6:00 A.M. daily, toilet resident upon rising, before and after meals and at bedtime. Review of Resident #101's falls revealed she sustained three falls from 04/19/16 to 05/10/16. On 04/19/16 she fell in her bathroom and fractured her right wrist, on 04/28/16 she fell in front of her bathroom door and suffered a hematoma to the back of her head, and on 05/10/16 she fell in her bathroom and suffered fractures to her upper cervical spine. On 04/19/16 at 10:30 A.M., Licensed Practical Nurse (LPN) #127, heard a noise coming from Resident #101's room. Upon entering the bathroom LPN #127 observed Resident#101 on the floor with an empty water pitcher in her hand, she was banging the water pitcher on the floor. Her alarm was alarming but the sound was muffled as Resident #101 had placed it in the trash can next to her recliner and covered it with her sweatshirt. Resident #101 informed LPN #127 she was trying to get water for her pitcher. Resident #101 said she spilled the water and fell after stepping in the water. A new intervention after this fall was to increase the number of times her water pitcher was filled each day. Review of a portable x-ray report dated 04/19/16 confirmed Resident #101 had suffered an impacted distal radial fracture to her right wrist. Resident #101 underwent surgery on 04/27/16 for the repair of the fractured wrist. On 04/28/26 at 6:40 A.M., LPN #5 documented when she entered Resident #101's room she observed her laying on the floor in front of the bathroom door. Resident #101 was laying face up on her back with her feet facing the toilet and the right side of her head was next to the open bathroom door. Resident #101's legs were on the bathroom floor and her buttocks and head were lying on her bedroom floor. Resident #101 was unable to tell LPN #5 what had happened. Resident #101 was grimacing and favoring her right wrist which had been operated on the day before for a fracture from a previous fall. Upon assessing Resident #101, LPN #5 found a tennis ball size hematoma on the back of Resident #101's head. The physician was notified of the fall and ordered the resident to be transferred per nine-one-one (911) to the hospital. Resident #101 returned from the hospital on the same day with no additional injuries found. A new intervention was for a new alarm that would be placed behind the chair or head of the bed. The alarm would not only sound when Resident #101 attempted to get up but it would also send a message to the work phone carried by the residents assigned nurse aide. On 05/10/16 no time noted former nurse aide #2 heard an alarm sounding from Resident #101's room. When she entered the room Resident #101 was attempting to ambulate to the bathroom and her alarm was laying in the trash can covered by trash. Former nurse aide #2 assisted Resident #101, into the bathroom and onto the toilet. Former nurse aide #2 left Resident #101 alone sitting on the toilet. Former nurse aide #2 went into another residents room to inform nurse aide #4 she had left Resident #101 on the toilet alone and was going on her break. At 9:45 P.M., LPN #10 heard Resident #101 yelling out. When she entered the residents room Resident #101 was lying on the floor of the bathroom on her left side. After assessing the resident, LPN #10 confirmed the resident had a hematoma to the left side of her head, bruise to her left arm and abrasions to the left side of her face. Resident #101 requested to be put back on the toilet as she was not done using it. After using the toilet Resident #101 was put back to bed with assistance from the staff. A call was placed to the physician at 10:20 P.M. The physician was informed of the fall and injuries but did not give any new orders. At 11:40 P.M., LPN #10 left a message for Resident #101's son asking him to call the facility. At 3:50 A.M., the son returned the call and requested for his mom to be sent out to the emergency room for an assessment and treatment. At 4:45 A.M., the emergency medical transport (EMT) arrived. At this time the resident was noted with swelling and bruising of her left eye. Resident #101 complained of pain and feeling nauseated. The EMT squad left the facility at 5:00 A.M. to transport the resident to the hospital. A review of the computed tomography (CT) scan of Resident #101's cervical spine preformed at the hospital on [DATE] revealed the resident had suffered an acute fracture of the cervical spine at C1 and C2 including type 2 odontoid fractures. The CT scan also confirmed there was no hemorrhage in the brain. The CT of Resident #101's face revealed the residents soft tissues had a large amount of swelling overlaying the left side of her face. On 07/14/16 at 2:00 P.M., an interview was conducted with the Director of Nursing (DON). The DON confirmed former nurse aide #2 had heard a muffled alarm and went into Resident #101's room to see what was going on. When former nurse aide #101 entered the room she observed Resident #101 standing up and ambulating toward the bathroom. Former nurse aide #2 assisted Resident #101 onto the toilet and then left the room. The DON confirmed former nurse aide #2 should not have left the resident on the toilet alone. A review of the facilities policy and procedure for fall prevention revised 01/2016 revealed the facility would provide adequate care and supervision to residents to prevent avoidable accidents. As a result of the incident the facility took the following actions to correct the deficient practice: - On 05/11/16, the DON sent a mass message out to all nurses and nurse aides. The message stated that if a resident had an alarm they were not to be left unattended on the commode in the bathroom by staff. The message instructed the staff to return a text stating they had read the message and understood it. The staff also had to sign an inservice form stating they had received this inservice when they returned to work. The DON presented the copies of the returned text messages as well as the signed inservice sheet. - On 05/11/16 all residents medical records were audited by the DON and supervisors to identify residents at fall risk. All of the resident's identified at risk who were using alarms had a new intervention added to their care plans. The intervention was to not leave the resident unattended on the commode in the bathroom. - On 05/11/16 the facility implemented laminated signs that indicated If this resident utilizes alarms for safety, the resident may not be left unattended, on commode in bathroom. These signs have been hung in every resident's bathrooms. - On 05/11/16 the facility implemented monitoring of all falls. Each day falls are discussed in morning meeting. - With each nursing meeting since the fall a brief couching is presented to ensure all staff are aware that any resident using an alarm is not to be left alone in the bathroom without supervision. This deficiency substantiates Complaint Number OH 493