Every finding on record at Crestmont North Nursing Home

THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on Self-Reported Incident Review (SRI), facility timeline, and facility policy review, medical record review and interview, the facility failed to ensure resident narcotic and anti-anxiety medications were not misappropriated. This finding affected three (Residents #26, #56 and #67) of four residents reviewed for misappropriation. The facility census was 62.Findings include: Review of the SRI Tracking #274552 dated 05/14/26 revealed a discovery of as needed doses of narcotic and anti-anxiety medications were missing. The SRI was unsubstantiated due to inconclusive evidence.Review of the undated facility investigation timeline revealed on 05/10/26 at approximately 11:30 A.M., Licensed Practical Nurse (LPN) #848 discovered two oxycodone narcotic tablets had been removed from Resident #67's oxycodone narcotic medication administration card and replaced with loratadine antihistamine tablets and then taped over the back. LPN #848 further discovered two of Resident #56's Ativan (lorazepam) antianxiety tablets were replaced with loratadine antihistamine tablets and then taped over the back. LPN #848 contacted LPN Assistant Director of Nursing (ADON) #804. LPN #848 immediately audited all narcotic drawers and discovered that Resident #26 was missing one Ativan antianxiety tablet. The missing Ativan antianxiety tablet slot in the medication card was empty and not substituted like Residents #56 and #67 medication cards.Review of Resident #26's medical record revealed the resident was admitted on [DATE] with diagnoses including schizoaffective disorder, hypertension and dementia.Review of Resident #26's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment.Review of Resident #26's physician order dated 11/11/25 for lorazepam 0.5 milligrams (mg) every four hours as needed for anxiety/restlessness.Review of Resident #56's medical record revealed the resident was admitted on [DATE] with diagnoses including anxiety disorder, depression and chronic obstructive pulmonary disease.Review of Resident #56's admission MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #56's physician orders revealed an order dated 04/25/26 (discontinued 05/07/26) for lorazepam oral tablet 0.5 mg give one tablet by mouth every eight hours as needed for anxiety for 30 days; and an order dated 05/08/26 for lorazepam oral tablet 0.5 mg give one tablet by mouth every eight hours as needed for anxiety.Review of Resident #67's medical record revealed the resident was admitted on [DATE] with diagnoses including hypotension, anxiety disorder and transient cerebral ischemic attack.Review of Resident #67's Annual MDS 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment.Review of Resident #67's medical record revealed an order dated 01/21/26 for oxycodone 5 mg give one tablet by mouth every six hours as needed for pain.During an interview on 06/09/26 at 2:27 P.M., the Director of Nursing (DON) revealed the police were contacted, the Medical Director was contacted, all residents controlled medications were audited, all staff were educated, and LPN #907 no longer worked in the facility. The DON requested past non-compliance (PNC).The deficiency was corrected on 05/15/26 when the facility implemented the following corrective actions:-On 05/10/26 LPN #907 worked from 7:00 P.M. to 7:00 A.M. and then counted Medication Cart A with LPN #847 and no concerns were identified with the narcotic count at that time. LPN #907 clocked out at 7:43 A.M. -On 05/10/26, LPN #848 who worked from 7:00 A.M. to 7:00 P.M., was counting the narcotics to take over Medication Cart A with LPN #847 who became ill during her shift. LPN #848 identified Resident #67's oxycodone narcotic card was taped and two of the pills were replaced with loratadine antihistamine tablets.-On 05/10/26, LPN #848 audited the remaining controlled medication cards in Medication Cart A and identified concerns with Residents #26 and 56's controlled medication administration cards.-On 05/11/26, the DON reviewed the facility video surveillance and observed LPN #907 placing tape on the back of a resident's medication card. -On 05/11/26 the DON interviewed LPN #907 who stated that she gave Resident #67 two tablets of the oxycodone 5 mg that was previously discontinued by accident and that she thought it was the resident's current Ativan medication. LPN #907 revealed she did not report the error because she was scared and self-terminated on this date following the interview. -On 05/11/26, the DON educated all nursing staff on medication administration, the seven resident rights of medication administration, the narcotic policy and the wasting policy.-On 05/12/26, DON #908 and Administrator #909 from a sister facility contacted the pharmacy to discuss details of the medication error and reporting needs. The pharmacy confirmed no further reporting was required.-On 05/14/26, DON #908 from a sister facility arrived at the facility and audited narcotic cards and copied all the narcotic cards and pharmacy narcotic tracking sheets for Residents #26, #56 and #57.-On 05/14/26, DON #908 from the sister facility audited all controlled medications for all residents in the facility.-On 05/15/26, DON #908 from the sister facility contacted the local police about the misappropriation, police report number 26001323.-On 05/15/26, DON #908 from the sister facility called the Medical Director to report the misappropriation.-On 05/15/26, DON #908 contacted the Ohio Board of Nursing for LPN #907's misappropriation of narcotics.-The DON was to complete controlled medication audits five times a week for one week and then three times a week for three weeks and then as needed.-The DON stated the misappropriation will be brought to the QA Committee on 06/17/26.This deficiency represents non-compliance investigated under Complaint Number 2659061.

Based on record review, observation, staff interview, and review of facility policy, the facility failed to ensure medications for Resident #4 were administered as ordered. A total of 27 medications were administered with two medications omitted, for a total of 29 medication opportunities. Three medication errors were identified, resulting in a medication error rate of 10.34%. This deficiency affected one resident (Resident #4) of four residents reviewed for medication administration. The facility census was 62.Findings include: Review of Resident #4's medical record showed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, mild cognitive impairment, and anxiety disorder.Review of the physician orders for Resident #4 revealed the following active orders dated 10/10/23:-Aspirin 81 milligrams (mg) chewable tablet, administer one tablet by mouth once daily for hypertension.-Thiamine 50 mg, administer one tablet by mouth three times daily as a vitamin supplement.-Cholecalciferol 25 micrograms (mcg), administer two tablets by mouth once daily for vitamin D deficiency.Review of Resident #4's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident had intact cognition.During an observation on 06/08/26 at 7:46 A.M., Licensed Practical Nurse (LPN) #805 administered 10 medications to Resident #4. Three medication errors were observed. LPN #805 administered aspirin enteric-coated (EC) 81 mg instead of the ordered aspirin 81 mg chewable. In addition, the nurse failed to administer the ordered cholecalciferol 25 mcg (two tablets) and thiamine 50 mg.During an interview on 06/08/26 at 10:01 A.M., LPN #805 confirmed the above findings.Review of the facility's Medication Administration Policy dated 02/2012 states that medications shall be administered in a safe and timely manner and as prescribed.This deficiency is an incidental finding identified during the complaint investigation.

Based on record review and staff interviews, the facility failed to ensure that a resident with severe cognitive impairment was not permitted to sign financial documents. This affected one resident (Resident #66) out of three residents reviewed for protection and management of personal funds. The facility census was 62.Findings include: Review of the medical record revealed Resident #66 was admitted on [DATE] with diagnoses including schizoaffective disorder-bipolar type, anxiety disorder, alcohol dependence, and dementia with mood disturbance. The resident was discharged on 03/25/26.Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] showed Resident #66 had severely impaired cognition.Review of guardianship documentation showed Resident #66 previously had a temporary guardian appointed from 10/01/18 through 02/10/19.Review of financial records showed Resident #66 signed an Authorization to Manage Resident Funds on 02/02/25. The resident later refused to sign trust account statements dated 09/30/25 and 12/31/25.During an interview on 06/09/26 at 9:40 A.M., the Administrator stated that the resident's niece initially volunteered for guardianship in August 2025. The resident's daughter, living in California, objected, so the facility assisted the daughter in obtaining guardianship. The daughter had not been involved in the resident's care at either the prior or current facility before that time.Review of the guardianship order showed Resident #66's daughter was appointed guardian on 01/23/26.During an interview on 06/09/26 at 2:26 P.M., the Administrator confirmed the facility allowed Resident #66 to sign her own financial documents despite her severely impaired cognition.This deficiency represents non-compliance investigated under Complaint Number 1367131 (OH00166888).

Based on record review and interview, the facility failed to ensure resident that care plan meetings were held quarterly as required. This affected three (Residents #23, #48, and #66) of three residents reviewed for care plan meetings. The facility census was 62.Findings include:1. Review of the medical record revealed Resident #66 was admitted on [DATE] with diagnoses including schizoaffective disorder-bipolar type, anxiety disorder, alcohol dependence, and dementia with mood disorder. The resident was discharged on 03/25/26.Review of the Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] showed Resident #66 had severely impaired cognition, no behaviors, and required total staff assistance for bed mobility and transfersReview of the Care Conference Forms, notes, and emails showed care conferences were held on 07/17/25, 01/23/26, 02/03/26, and 03/10/26. There were no documented care conferences from admission until 07/17/25, nor between 07/17/25 and 01/23/26, as required.2. Review of the medical record for Resident #23 revealed an admission date of 01/22/25 with diagnoses including dementia, type II diabetes mellitus, anxiety, and gastro-esophageal reflux disease (GERD). The only care plan meeting available was 05/07/26, nearly 15 months after admission. Review of the Quarterly MDS 3.0 assessment dated [DATE] revealed Resident #23 had severely impaired cognition.3. Review of the medical record for Resident #48 revealed an admission date of 12/12/25 with diagnoses including opioid dependence, nicotine dependence, cannabis abuse, GERD, chronic obstructive pulmonary disease (COPD), post-traumatic stress disorder (PTSD), paraplegia, major depressive disorder, and psychoactive substance abuse with psychoactive substance-induced dementia. Resident #48 had a Legal Guardian. The only care conference available was dated 06/04/26, six months after admission.Review of the Quarterly MDS 3.0 assessment dated [DATE] revealed resident #48 was cognitively intact. During an interview on 06/09/26 at 2:40 P.M., the Director of Nursing (DON) confirmed that no additional care conference documentation was available for any of the above residents.This deficiency represents non-compliance investigated under Complaint Number 1367131 (OH00166888).

Based on record review, interview, and review of the facility policy, the facility failed to ensure Resident #66's skin was assessed per the physician's orders. This finding affected one (Resident #66) of three residents reviewed for wound care. The facility census was 62.Findings include: Review of Resident #66's medical record revealed the resident was admitted on [DATE] and discharged on 03/25/26 with diagnoses including schizoaffective disorder-bipolar type, chronic obstructive pulmonary disease, and generalized anxiety.Review of Resident #66's physician orders revealed an order dated 01/14/25 (discontinued 03/27/26) for weekly skin assessments on shower days. Document under assessments every day shift on Tuesday and Friday.Review of Resident #66's Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment.Review of Resident #66's Weekly Skin Data Collection dated 01/09/26 revealed the resident had no new skin issues and a head-to-toe skin observation was completed. No further skin assessments were completed from 01/01/26 to 03/25/26.Review of Resident #66's medical record, skin assessments and progress notes from 01/01/26 to 03/25/26 did not reveal evidence of skin assessments (except for 01/09/26).During an interview on 06/09/26 at 8:00 A.M., the Director of Nursing (DON) confirmed Resident #66's medical record did not have evidence of skin assessments from 01/01/26 to 03/25/26 when the resident was discharged to a hospice facility.Review of the undated Wound Prevention policy revealed weekly skin checks would be conducted by the licensed nurse. This would be documented in the resident's Electronic Medical Record (EMR).This deficiency represents non-compliance investigated under Complaint Number 1367131 (OH00166888).

Based on record review and resident and staff interviews, the facility failed to ensure the residents were provided routine and timely notices when their resident's funds exceeded the Supplement Security Income (SSI) resource limit for one person. This affected four (Resident #17, #29, #31 and #47) of seven residents reviewed for personal funds. The facility census was 68. Findings Include: 1. Review of the Authorization to Manage Resident Funds dated 01/20/21 revealed Resident #47 authorized the facility to manage her money. Review of the spend-down notice dated 04/05/25 revealed Resident #47 had $9,060.24 in her account that needed to be spent down some of the money, so she did not exceed the limit, or it would have to be submitted to Medicaid. The spend down notice was signed by Resident #47 on 04/05/25. Review of the current account balance on 05/29/25 revealed Resident #47 had $10,987.24. Interview on 05/27/25 at 10:00 A.M. with Resident #47 stated she could not remember how much money she had in her account but was given a spend down notice by the facility. She stated she has not spent any of her money because she did not know what she needed. 2. Review of the Authorization to Manage Resident Funds revealed Resident #17 authorized the facility to manage his money on 05/11/18. Review of the spend-down notice dated 04/05/25 revealed Resident #17 had $3,140.88 in his account and he needed to spend down his money, to ensure his money would not have to be sent back to Medicaid. Review of the current balance on 05/29/25 revealed Resident #17 had #3,140.88 still in his account. Interview on 05/27/25 at 3:31 P.M. with Resident #17 stated the facility does manage his account and he has received notice that he need to spend some of the money or it would have to be given to Medicaid. 3. Review of Resident #29's medical record revealed Resident #29 had a legal guardian. Review of the Authorization to Manage Resident Funds revealed Resident #29 signed for the facility to manage her funds on 02/14/18. Review of the quarterly statement from January 2025 through March 2025 revealed Resident #29 had $5,154.98 in her account. Review of the spend-down notice dated 04/05/25 revealed it was given to Resident #20 and not her legal guardian. Resident #29 had $5,154.98 in her account and needed to spend down her money, to ensure it would not have to be sent to Medicaid for being over the limit of funds allowed. Review of the current balance on 05/29/25 revealed $5,655.98 in her account at that time. 4. Review of the Authorization to Manage Resident Funds revealed Resident #31 signed for the facility to manage funds on 06/06/23. Review of the quarterly statement from January 2025 through March 2025 revealed Resident #31 had $8,471.69 in her account. Review of the spend-down notice dated 04/05/25 revealed Resident #31 had $8,830.69 in his account and needed to spend-down his money or it would have to be sent to Medicaid for being over the limit of money allowed in his account. Interview on 05/27/25 at 11:45 A.M. with Resident #31 stated he had an account with the facility and he did receive a letter stating he needed to spend down his money or it would have to be sent back. Interview on 5/29/25 at 11:03 A.M. with the Administrator confirmed Resident #17, #29, #31, and #47 had fund exceeding the SSI resource limit for one resident. The Administrator stated residents on Medicaid have a liability that they have to pay the facility which generally leaves the residents with $50 a month but the county was not taking the liability out of resident funds. The county office needs to fix the problem so the money can be distributed.

3. Record review of Resident #26 revealed she was admitted to the facility 03/21/25. Diagnoses included PTSD. Her care plan identified potential for behaviors related to PTSD including accusatory behaviors, but did not clarify what caused the PTSD or potential triggers or situations to avoid. Review of her progress notes, care plan, assessments, and psychiatry service notes revealed no documentation of the cause, triggers, or ongoing effects of the PTSD. Interview with the Director of Nursing (DON) on 05/29/25 at 9:35 A.M. confirmed Resident #26's medical record did not contain an assessment for trauma informed care related to the resident's of PTSD and did not address the needs of the trauma survivor by minimizing triggers and/or re-traumatization. The DON said PTSD was managed with an outside counseling service who only provided their information on request alongside the facility psychiatric service. She said the surveyor would have to speak with Resident #26 to find out the source of her PTSD. Interview with Resident #26 on 05/29/25 at 9:55 A.M. revealed she was diagnosed with PTSD roughly five years ago when a man entered the woman's bathroom with her, grabbed her throat, and broke her nose. She denied having specific triggers but said the PTSD was the reason she currently took anxiety medications. The facility identified Residents #12, #19, #22, #26, #58, #61 and #63 with PTSD. Review of the facility policy titled Trauma- Informed and Culturally Competent Care dated August 2022 revealed the purpose of the policy was to guide staff in providing care that was culturally competent, and trauma informed in accordance with professional standards of practice and to address the needs of trauma survivors by minimizing triggers and/or re-traumatization. All staff were to receive training about trauma and trauma informed care, and nursing staff were to be trained on trauma screening and assessment tools. The facility was to select a screening and assessment tool to be utilized to identify the need for further assessment and care. The assessment was to be an in-depth process of evaluating the presence of symptoms, their relationship to trauma and identification of triggers. The policy revealed that they should develop individualized care plans that identified and decreased the exposure to triggers that may re-traumatize. 2. Review of medical record for Resident #12 revealed an admission date of 12/05/24. Diagnoses included PTSD. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had impaired cognition. Review of Psychiatric Evaluations dated 03/26/25 and 04/20/25 and completed by Psych Nurse Practitioner (NP) #901 revealed Resident #12 had a history of heroin withdrawal, anxiety, PTSD, insomnia and depression. The note revealed Resident #12 reported the problems began after being shot years ago and reported current stressors were his living situation and being shot. The note revealed alleviating factors including stretching. NP #901 recommended his diagnosis of PTSD required ongoing monitoring. There was no other information regarding his PTSD including other triggers and/or interventions. Review of undated care plan revealed Resident #12 had the potential for behaviors related to PTSD, visual/ audio hallucinations, and accusing staff members. Interventions included administering medications, document behaviors, informing the physician of worsening behaviors, and intervene as needed to protect the rights and safety of others. There was nothing in the care plan in regard to triggers and/or personalized interventions to prevent re-traumatization related to his PTSD. Interview on 05/28/25 at 9:16 A.M. with Registered Nurse (RN) #355 verified Resident #12 had a diagnosis of PTSD and she was unsure regarding any triggers Resident #12 had. She verified there was nothing in Resident #12's care plan regarding any specific triggers and/ or interventions related to his PTSD. Interview on 05/28/25 at 10:13 A.M. and on 05/29/25 at 9:35 A.M. with Director of Nursing verified she was unsure what psych had regarding his PTSD and verified nothing was in his care plan regarding triggers and/or interventions to eliminate or mitigate triggers that may cause re-traumatization of the resident. She also verified the facility had no training/ education to staff regarding trauma- informed care. Based on record review, facility policy review, and resident and staff interview, the facility failed to comprehensively assess and develop a comprehensively plan of care for residents with Post Traumatic Stress Disorder (PTSD). This affected three (Residents #12, #26, and #61) of three residents reviewed for PTSD. The facility identified seven residents (Residents #12, #19, #22, #26, #58, #61 and #63) with PTSD. The facility census was 68. Findings include: 1. Review of the medical record for Resident #61 revealed an admission date of 04/28/25. Diagnoses included PTSD. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 was cognitively intact. Resident #61's medical record did not have an assessment for trauma informed care related to the resident's of PTSD and did not address the needs of the trauma survivor by minimizing triggers and/or re-traumatization. Interview on 05/29/25 at 9:35 AM with the Director of Nursing (DON) confirmed the facility did not assess Resident #61 for triggers or symptoms of PTSD. She confirmed Resident #61 was a good historian and would accurately and willingly share information if asked.

Based observation, staff interview, record review, and review of facility policy, the facility failed to ensure Resident #23 was free of significant medication errors. This affected one (#23) of five residents observed for medication administration. The facility census was 68. Findings include: Review of the medical record for Resident #23 revealed an admission date of 04/22/25. Diagnoses included malignant neoplasm of oropharynx (middle section of the pharynx/ throat), rheumatoid arthritis, hypotension, and convulsions. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had impaired cognition and had a PEG tube. Review of undated care plan revealed Resident #23 was at risk for aspiration related to tube feeding as he had a malignant neoplasm of the oropharynx. Interventions included check placement of percutaneous endoscopic gastrostomy (PEG) tube prior to tube feedings, assess tube site daily for infection, flush PEG tube as ordered and notify physician of any changes. There was nothing in the care plan regarding crushing his medications and mixing together (cocktailing) all at once. Review of May 2025 physician orders revealed Resident #23 had the following orders to be given every day at 9:00 A.M.: Primidone 50 milligram (mg) tablet per PEG tube for seizures, Hydroxychorolonequine sulfate 200 mg tablet per PEG tube for arthritis, and Midodrine 5.0 mg tablet per PEG tube for hypotension. There was no order to crush the medications and mix together (cocktailing). Observation on 05/27/25 at 9:32 A.M. revealed Registered Nurse (RN) #367 prepared Resident #23's medications: Primidone 50 mg tablet, Hydroxychorolonequine sulfate 200 mg tablet, and Midodrine 5.0 mg tablet and then proceeded to take all the medications and crushed them together. RN #367 then mixed the combined crushed medications with water in a medication cup. RN #367 proceeded to administer a water flush and then the combined crushed medications followed by a water flush per Resident #23's PEG tube. Interview on 05/27/25 at 9:54 A.M. with RN #367 verified she crushed the Primidone, Hydroxychorolonequine sulfate, and Midodrine and administered the combined medications all at once. She verified there was no order to cocktail or mix all the medications together and administer at the same time. She verified she was unaware if it was reviewed with the physician regarding potential side effects/interactions if the medications were administered together. Interview on 05/27/25 at 10:33 A.M. with the Director of Nursing verified Resident #23 did not have an order to mix the medications together and administer all at the same time (cocktailing). She verified if there was no order the medications should not have been crushed and given all at one time. Review of undated facility procedure titled Administering Medications Through an Enteral Tube revealed the purpose of the procedure was to provide guidelines for the safe administration of medications through an enteral tube. The procedure revealed to dilute the crushed medication with 30 milliliter (ml) or more of water and administer each medication separately.

2. Review of medical record for Resident #23 revealed an admission date of 04/22/25. Diagnoses included malignant neoplasm of oropharynx (middle section of the pharynx/ throat) and hypotension. Review of undated care plan revealed Resident #23 was at risk for impaired gas exchange related to malignant neoplasm of the oropharynx requiring a tracheostomy. Intervention included ensure trach ties were always secured, give humidified oxygen as prescribed, observe for changes in level of consciousness, observe respiratory rate, depth, and quality, and suction as needed. The undated care plan revealed Resident #23 had alteration in cardiac status. Interventions included administer oxygen as ordered and monitor vitals as indicated. Review of admission Minimum Data Set (MDS) dated [DATE] revealed Resident #23 had impaired cognition. He had a tracheostomy and had oxygen. Review of May 2025 physician orders for Resident #23 revealed his oxygen was to be at 35 percent with a two liter oxygen bleed per his trach collar. Observation on 05/27/25 at 9:23 A.M. revealed Resident #23's oxygen setting was at seven liters, and his trach collar mask was lying on his bed next to him. He displayed no signs of respiratory distress. Observation on 05/27/25 at 9:23 A.M. revealed Registered Nurse (RN) #367 entered Resident #23's room to obtain his blood pressure and oxygen saturation rate. She proceeded to reapply his tracheostomy mask collar over his tracheostomy and verified the oxygen rate was seven liters. She then exited the room to prepare Resident #23's medications. Observation on 05/27/25 at 9:32 A.M. revealed RN #367 re-entered Resident #23's room to administer his medications through his feeding tube and provide his aerosol treatment. She proceeded to remove her gloves, perform hand hygiene and leave the room without adjusting his oxygen setting as ordered. Interview on 05/27/25 at 9:54 A.M. with RN #367 revealed she was unsure what Resident #23's physician order was regarding his oxygen setting. She reviewed Resident #23's physician orders and then verified Resident #23 had an order for oxygen at two liters, not seven liters. She verified she had not looked at the order after reapplying his trach collar while preparing his medications as she revealed she did not know it was at the wrong setting. Interview on 05/27/25 at 10:33 A.M. with Director of Nursing (DON) verified Resident #23 had an order for two liters of oxygen and not seven liters. The facility identified Residents #6, #16, #21, #22, #23, #46, #52, #54, #58 and #222 who resided in the facility and utilized oxygen. Review of the facility policy titled Oxygen Administration dated October 2010 revealed the purpose of the guidelines was for safe oxygen administration. The nurse was to verify there was a physician order and review the order for oxygen administration. Based on observation, record review, policy review, and staff interview, the facility failed to ensure oxygen was administered according to physician orders and ensure there was sign on the resident's door to address oxygen was in use. This affected two (Residents #23 and #58) of three residents reviewed for oxygen. The facility identified 10 current residents (Residents #6, #16, #21, #22, #23, #46, #52, #54, #58 and #222) who utilized oxygen. The facility census was 68. Findings include: 1. Review of the medical record for Resident #58 revealed an admission date of 10/09/23. Diagnosis included chronic obstructive pulmonary disease (COPD). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 was cognitively intact. She required supervision for showering and was independent in eating, oral hygiene, toileting and personal hygiene. She had a diagnosis of COPD and was not on oxygen. Review of the physicians order stated 05/28/25 revealed Resident #58 was on two liters of oxygen as needed and the tubing and nasal cannula should be changed weekly. Review of the care plan revision dated 05/28/25 revealed Resident #58 was on oxygen therapy due to respiratory illness. Interventions included giving medications as ordered, serving and documenting for side effects and effectiveness, observing for signs and symptoms of respiratory distress and providing reassurance to alleviate anxiety. Observation on 05/27/25 at 9:13 A.M. revealed an oxygen tank and oxygen tubing in Resident #58's room. No sign indicating the use of oxygen was observed on Resident #58's door. Interview on 05/27/25 with Licensed Practical Nurse (LPN) #316 confirmed Resident #58 used oxygen as needed and did not have the appropriate signage on her bedroom door. Review of the facility policy titled Oxygen Administration dated October 2010 revealed a no smoking or oxygen in use sign would be in place for any resident who used oxygen.

Based on observation, staff interview, record review, facility policy review, and review of the Center for Disease Control and Prevention (CDC) guidance, the facility failed to initiate and use enhanced barrier precautions (EBP) for residents with indwelling medical devices during high contact resident care activities. The facility also failed to ensure staff followed infection control procedures during catheter care. This affected two (#12 and #23) of two residents reviewed for EBP and one (#12) of one resident reviewed for catheter care. The facility identified nine residents on EBP and two residents with catheters. The facility census was 68. Findings include: 1. Review of the medical record for Resident #23 revealed an admission date of 04/22/25. Diagnoses included malignant neoplasm of oropharynx (middle section of the pharynx/ throat), rheumatoid arthritis, hypotension and convulsions. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had impaired cognition and had a percutaneous endoscopic gastrostomy (PEG) tube and a tracheostomy. Review of the care plan dated 05/27/25 revealed Resident #23 was on EBP due to his tracheostomy. Intervention included EBP would be used for the duration of his stay at the facility or until no longer meeting criteria and educate resident/ family on EBP. Observation on 05/27/25 at 9:23 A.M. revealed on the outside of Resident #23's door frame upon entrance to his room, there was a sign indicating Resident #23 was on EBP and everyone was to wear gloves and a gown for the following high contact resident care activities: dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs, and device care including feeding tube and tracheostomy. There was a bag hanging on Resident #23's door with personal protective equipment (PPE) including gloves and gowns. Observation on 05/27/25 at 9:23 A.M. revealed Registered Nurse (RN) #367 entered Resident #23's room to obtain his blood pressure and oxygen saturation rate. She donned gloves but no gown. She proceeded to take his blood pressure, but the automatic blood pressure was low, so she proceeded to retake his blood pressure utilizing a manual cuff. She then proceeded to reapply his tracheostomy mask collar over his tracheostomy. RN #367 then removed her gloves, performed hand hygiene and left Resident #23's room to prepare his morning medications. Observation on 05/27/25 at 9:32 A.M. revealed RN #367 re-entered Resident #23's room to administer his medications through his PEG tube and provide his aerosol treatment. RN #367 proceeded to perform hand hygiene, apply gloves but did not apply a gown. RN #367 administered Resident #23's morning medications, water flushes, and enteral tube feeding through his PEG tube. RN #367 then administered his albuterol sulfate inhalation nebulizer solution (breathing treatment) .083 percent three ml per his tracheostomy. Then, she proceeded to remove her gloves, perform hand hygiene and leave the room. During both encounters 05/27/25 at 9:23 A.M. and 05/27/25 at 9:32 A.M. RN #367's nursing uniform was noted to come into direct contact with Resident #23. Interview on 05/27/25 at 9:54 A.M. with RN #367 verified there was a sign on Resident #23's entrance to his room indicating he was on EBP. RN #367 verified she should have worn a gown for Resident #23's care including during his care of his PEG tube and tracheostomy. Interview on 05/27/25 at 10:33 A.M. with Director of Nursing (DON) verified Resident #23 was on EBP and RN #367 should have worn a gown while administering medications and feeding through his PEG tube as well as when providing care to his tracheostomy including reapplying trach collar and administering his aerosol treatment. 2. Review of the medical record review for Resident #12 revealed an admission date of 12/05/24. Diagnoses included chronic obstructive pulmonary disease (COPD), paraplegia, neuromuscular dysfunction of the bladder, and pressure ulcer to sacral region. Review of undated care plan revealed Resident #12 was to be on EBP due to chronic wounds and suprapubic catheter. Interventions included EBP would be used for the duration of his stay or until qualifying criteria no longer met, educate resident/ family on EBP, and staff would wear appropriate PPE for high contact resident activities. The undated care plan revealed Resident #12 had an alteration in voiding pattern related to indwelling catheter due to neuromuscular dysfunction of the bladder. Interventions included change catheter bag per policy, check tubing for kinks, monitor for infection, and position catheter bag and tubing below level of bladder. There was nothing in the care plan regarding catheter care and how to empty the catheter bag. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had impaired cognition and he had an indwelling catheter and pressure ulcers. Review of May 2025 physician orders revealed Resident #12 was on EBP due to chronic wounds. He also had the following orders: suprapubic catheter to continuous drainage due to neuromuscular dysfunction of the bladder, catheter care every shift and monitor, and document output every shift. Observation on 05/27/25 at 8:52 A.M. revealed Resident #12 had a suprapubic catheter and wound care dressing to his bilateral feet but there was no signage on the outside of his doorway that indicated he was on EBP. Observation on 05/28/25 at 6:36 A.M. revealed Certified Nursing Assistant (CNA) #393 entered Resident #12's room to provide catheter care. CNA #393 proceeded to perform hand hygiene, applied gloves but no gown. CNA #393 then retrieved two wet washcloths (one to use as rinse washcloth and one with soap on it) and one dry washcloth. CNA #393 placed the dry washcloth on his nightstand next to his bed over unknown brown dried substances. CNA #393 then placed the two wet washcloths on top of the dry washcloth. CNA #393 took the washcloth with the soap and proceeded to wash around his suprapubic catheter and then placed the washcloth on the nightstand (that contained brown dried substances). CNA #393 then took the other wet washcloth and rinsed around the suprapubic catheter and then laid this washcloth over the other wet washcloth on the nightstand. Then, CNA #393 took the dry washcloth (that had come in contact with the nightstand with the dried brown substances) to dry around the suprapubic catheter. During the care, CNA #393's uniform had come in direct contact with Resident #12 as she did not wear a gown. CNA #393 then proceeded to empty his catheter drainage bag into a graduate by unclipping the drainage bag port. After the bag had emptied into the graduate, CNA #393 took the (used) rinse washcloth that she had used to clean around his suprapubic catheter to then wipe off the port to the drainage bag. CNA #393 then proceeded to empty the graduate, remove her gloves, wash her hands and leave the room as she stated she needed to get the resident's socks. Interview on 05/28/25 at 6:45 A.M. with CNA #393 verified there was no signage on the outside of Resident #12's doorway that indicated Resident #12 was on EBP. CNA #393 verified she did not wear a gown while completing catheter care as she stated she gets Resident #12 up almost everyday, and nobody had ever told her Resident #12 was on EBP and CNA #393 needed to wear a gown during his care including catheter care and other high contact care activities. CNA #393 also verified the nightstand that she placed the dry and wet wash clothes on had brown substances as she stated, yes it probably was not clean. CNA #393 verified she had taken the used washcloth that she had cleaned around his suprapubic catheter site and cleaned the drainage bag port with the same cloth. CNA #393 stated, yeah I can see how that is cross contamination I never considered that. Interview on 05/28/25 at 8:34 A.M. with Infection Control Coordinator (ICC) #355 stated residents who should be on EBP were the residents who had wounds and PEG tubes. ICC #355 was unsure if residents including Resident #12 who had a suprapubic catheter should be on EBP. ICC #355 stated she was not 100 percent sure but did not feel Resident #12 needed EBP precautions when staff completed his catheter care. ICC #355 stated do not need to wear EBP for all high contact care activities and only need to wear it when providing wound care. She verified CNA #393 should not have placed the wash clothes on a nightstand that contained brown substances as well as clean the catheter drainage bag port with the same used washcloth that she used to clean his suprapubic catheter site. Subsequent interview on 05/28/25 at 9:16 A.M. with ICC #355 revealed she misspoke as she had reviewed further, and staff should wear EBP for all high contact care activities for Resident #12 including catheter care. Review of facility policy titled Suprapubic Catheter Care dated October 2010 revealed the purpose of the policy was to prevent skin irritation and prevent infection of the resident's urinary tract. The policy revealed to place the clean equipment on the bedside stand or over the bed table. There was nothing in the policy ensuring the bedside stand was clean. The facility titled Emptying a Urinary Drainage Bag dated October 2010 revealed the purpose of the policy was to prevent the drainage bag from becoming full, to measure the output and obtain a specimen. After the drainage bag was emptied, staff were to close the drain and wipe the drain with an alcohol sponge or swab. The facility policy titled Enhanced Barrier Precautions dated 04/24/24 revealed EBP was to be utilized to prevent the spread of multi-drug-resistant organisms to residents. EBP was indicated for any resident with wounds and/or indwelling medical device. Gloves and gowns were to be applied prior to performing high contact resident care activities. High contact care activities that required the use of gown and gloves included dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assistance with toileting, device care (central line, urinary catheter, feeding tube, tracheostomy) and wound care. Signs were to be posted in the door or wall outside the resident's room indicating the type of precaution and PPE required. Review of CDC guidance titled Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) found at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html and dated 04/02/24 revealed MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status.

Based on observation, record review, policy review, and staff interview, the facility failed to ensure falls were investigated thoroughly. This affected one (Resident #9) of three residents reviewed for falls. The facility census was 68. Findings include: Review of the medical record for Resident #9 revealed an admission date of 07/10/19. Diagnoses included viral hepatitis, anxiety and arthritis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was cognitively intact and required partial to moderate assistance for toileting. Review of the care plan dated 01/01/25 revealed Resident #9 was at risk for falls due to muscle weakness and difficulty walking. Interventions included ensuring his pathway was clear of clutter, keeping his call bell within reach at all times, a perimeter mattress on the bed and non skid socks or shoes on at all times. A revision to the care plan on 03/13/25 revealed the resident was placed on 15 minute checks. There was no fall intervention to include a mattress next to his bed, which was a fall intervention implemented on 02/12/25. Review of the fall risk assessment dated [DATE] revealed Resident #9 was not at risk for falls. Review of the fall investigation dated 02/12/25 at 11:30 A.M. revealed Resident #9 was in the dining room when he slipped and fell. The resident did not hit his head, but reported pain in his right knee and right elbow. Resident #9 said he didn't really know what happened he just found himself on the floor. 15 minute checks were initiated. X-rays were obtained of Resident #9's right knee and right wrist with negative findings. The fall investigation did not address if he was wearing shoes or non skid socks at the time of the fall. Review of the fall investigation dated 02/12/25 at 4:50 P.M. revealed Resident #9 was lying on the floor by his bed and said he rolled off the bed and fell. His range of motion was within normal limits. A mattress was placed beside the bed to prevent future falls. No injuries were noted. The fall investigation did not address if a perimeter mattress was on the bed, or if Resident #9 was wearing non skid socks or shoes. Observation on 05/29/25 at 8:00 A.M. revealed a perimeter mattress was in place on Resident #9's bed. There was no evidence on a mattress to the floor. Interview on 05/29/25 at 9:01 A.M. with the Director of Nursing (DON) revealed Resident #9 had an acute change in condition at the time of the falls on 02/12/25 and shortly after was diagnosed with the flu. The facility was of the belief this may have contributed to both falls. The DON confirmed the investigation for the first fall on 02/12/25 did not include evidence if non skid socks or shoes were in place at the time. She stated 15 minute checks were only temporary until Resident #9 felt better. The DON confirmed the investigation into the second fall on 02/12/25 did not include if the fall interventions were place at the time of the fall, which included if a perimeter mattress was on the bed or if he was wearing non skid socks or shoes. The DON also stated the mattress to the floor was only a temporary intervention. Review of the facility policy titled Falls and Fall Risk, Managing dated December 2007 revealed the facility would monitor and document a resident's response to interventions which were in place to attempt to reduce falls or the risk of falls. Interventions that were not successful would be reevaluated and reconsidered to determine if interventions were still required or if the problem that require the intervention, such as dizziness or weakness, had been resolved.

Based on record review, policy review, and staff and resident interview, the facility failed to ensure care plans were completed accurately to include fall interventions and behaviors exhibited by the resident. This affected two (Residents #9 and #58) of 21 residents reviewed for care plans. The facility census was 68. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 07/10/19. Diagnoses included viral hepatitis, anxiety and arthritis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was cognitively intact. Review of the fall investigation dated 02/12/25 revealed Resident #9 was lying on the floor by his bed and said he rolled off the bed and fell. A mattress was placed beside the bed to prevent future falls and was reported to have already been on 15 minute checks. Review of the care plan dated 05/20/25 revealed Resident #9 was at risk for falls. Interventions included ensuring his pathway was clear of clutter, 15 minute checks, keeping his call bell within reach at all times, a perimeter mattress on the bed, and non skid socks or shoes on at all times. The fall intervention for placing a mattress beside the bed was not listed in the care plan. Interview on 05/29/25 at 9:01 A.M. with the Director of Nursing (DON) verified Resident #9's care plan did not include the fall intervention for placing a mattress beside the bed. The DON stated the mattress beside the bed and 15 minute checks were only temporary interventions and were no longer in place. The DON confirmed the mattress next to the bed was never listed as a fall intervention in Resident #9's care plan. 2. Review of the medical record for Resident #58 revealed an admission date of 10/09/23. Diagnoses included anxiety and viral hepatitis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 was cognitively intact. Resident #58 had behavioral symptoms including confusion, forgetfulness and difficulty remember anything shortly after discussed. Review of the care plan dated 04/30/25 revealed Resident #58 was at risk for behavioral symptoms due to confusion and forgetfulness. Interventions included diverting her attention when she became agitated or combative, refraining from arguing with the resident and discussing behaviors if reasonable, explaining and reinforcing why the behavior was inappropriate. Interview on 05/27/25 at 10:40 A.M. with Resident #58 reviewed there was a certified nursing aide who called her derogatory names and yelled at her. Interview 05/27/25 at 10:50 A.M. with the Director of Nursing (DON) revealed Resident #58 had behaviors of accusing staff of false accusations and not listening to her which had been occurring for at least the past year with an increase in the past six months. She confirmed this information was not in Resident #58's care plan. Review of the policy titled Care Plans, Comprehensive Person-Centered dated December 2016 revealed care plans should be revised as information about the residence condition changed and would identify problem areas and risk factors.

3. Review of the medical record for Resident #1 revealed an admission dated [DATE]. Diagnoses included schizoaffective disorder, dementia and severe morbid obesity. Review of the physician orders dated [DATE] revealed Resident #1's advance directive was Do Not Resuscitate Comfort Care - Arrest (DNRCC-Arrest) (would receive standard medical care until experiencing a cardiac or respiratory arrest). The comprehensive care plan for Resident #1 dated [DATE] did not address Resident #1's advance directives. Review of the DNR Identification Form for Resident #1 revealed the top portion was filled out with Resident #1's name, address, birthday and signature of legal guardian. At the bottom of the form, the check box for Do-Not-Resuscitate Order (DNR) was checked stating my signature below constitutes and confirms a formal order to emergency medical series and other health care personnel that the person identified above is to be treated under the State of Ohio DNR protocol. At the bottom of the form revealed the physician did not sign or date this documentation. Interview on [DATE] at 8:35 A.M. with Licensed Practical Nurse (LPN) #323 stated Resident #1 was a DNRCC-Arrest and verified the DNR form was not signed by the physician or dated. LPN #323 stated if the DNR form was not signed by the physician, then cardiopulmonary resuscitation (CPR) would be performed if the resident was unresponsive. Review of the facility policy titled Advance Directives dated [DATE] revealed advance directives would be respected in accordance with state law. Information about if the resident executed an advance directive, the advance directive would be displayed prominently in the medical record. The care plan for each resident would be consistent with the resident's documented advance directive preference. There was nothing in the policy regarding ensuring the advance directives matched including the order in the electronic medical record and what was on the DNRCC form. Based on staff interview, record review and review of facility policy, the facility failed to ensure residents had accurate advance directives orders and information in place throughout the medical record and failed to ensure the resident's advance directive form was signed and dated by the physician. This affected three residents (#1, #6, and #12) of three residents reviewed for advance directives. The facility census was 68. Findings include: 1. Review of medical record for Resident #12 revealed an admission date of [DATE] and his diagnoses included chronic obstructive pulmonary disease and paraplegia. Review of Do Not Resuscitate Comfort Care (DNRCC) form dated [DATE] (located in his hard medical record) and completed by Nurse Practitioner (NP) #900 revealed Resident #12 was a DNRCC-Arrest (would receive standard medical care until experiencing a cardiac or respiratory arrest). The comprehensive care plan for Resident #12 dated [DATE] did not address Resident #12's advance directives. Review of [DATE] physician orders in the electronic medical record revealed on [DATE], Resident #12 had an advance directive order for DNRCC (comfort measures effective at the time the form is signed). Interview on [DATE] at 1:48 P.M. with Licensed Practical Nurse (LPN) #316 verified the advance directives did not match in Resident #12's medical record. LPN #316 verified the electronic medical record for Resident #12 indicated Resident #12 was a DNRCC but in his hard medical record the DNRCC-Arrest was elected on the DNRCC from signed by the NP. LPN #316 took the discrepancy to the Director of Nursing (DON) for review. Interview on [DATE] at 1:49 P.M. with the DON verified Resident #12's advance directives were not accurate in the medical record. 2. Review of the medical record for Resident #6 revealed an admission date of [DATE] and her diagnoses included chronic obstructive pulmonary disease, dementia, and schizoaffective disorder. Review of undated care plan revealed Resident #6's preferred code status was a Do Not Resuscitate Comfort Care (DNRCC). Review of undated DNRCC form (located in Resident #6's hard medical record) revealed the form was blank. Review of [DATE] physician orders per Resident #6's electronic medical record revealed she had an order dated [DATE] indicating she was a DNRCC. There was no advance directive form signed by the physician in Resident #6's electronic medical record. Interview on [DATE] at 1:48 P.M. with Licensed Practical Nurse (LPN) #316 verified Resident #6 did not have an advance directive form signed by the physician. LPN #315 verified Resident #6 had a physician order for DNRCC. LPN #315 verified he looked through the entire medical record and was unable to find a signed DNRCC form. LPN #312 stated he was unsure what he would do in case of an emergency. Interview on [DATE] at 1:49 P.M. with the Director of Nursing (DON) verified Resident #6's DNRCC form in her hard medical record was blank and did not have a signed advance directive form. Interview on [DATE] at 10:37 A.M. with LPN #346 revealed if a resident was found to be unresponsive, she would first check the physician order in the electronic medical record and then she would go to the hard medical record to verify the DNRCC form that was located in the front of the chart. LPN #346 would not know what to do in case of an emergency.

Based on record reviews and interviews, the facility failed to ensure comprehensive care plans were initiated for all resident care needs. This affected four residents (Resident #7, Resident #11, Resident #25, and Resident #48's) out of five residents reviewed for comprehensive care plans. The facility census was 56. Findings included: 1. Review of the medical record for Resident #48 revealed an admitted [DATE]. Diagnosis included but not limited to cerebral infarction, vascular dementia, unspecified severity with other behavioral disturbance, unspecified psychosis not due to substance or known physiological condition, dementia with behavioral disturbance, hypertension, and difficulty walking. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 had intact cognition and always incontinent of bladder and bowel. Review of the laboratory results for urinalysis culture and sensitivity dated 08/26/24 revealed Resident #48 was positive for Escherichia Coli of the urine and had a urinary tract infection (UTI). Review of the physician order dated 08/26/24 revealed an order for Levofloxacin 750 milligram (MG) (antibiotic for UTI) administer one time a day for five days. Review of Resident #48's medical record revealed there was not a comprehensive care plan in place for urinary incontinence or urinary tract infections. Interview 11/21/24 at 10:59 A.M. with MDS Nurse #147 revealed she didn't know she needed to care plan for incontinence care. Interview on 11/26/24 at 8:49 A.M. with Director of Nursing (DON) confirmed care plans were not done correctly. DON reported QAPI Action Plans were initiated to address these concerns and Resident #48 had no UTI care plan. DON did not provide evidence of QAPI plans in place at the time of survey. Interview on 11/26/24 at 12:23 P.M. with Assistant Director of Nursing (ADON) confirmed care plans were not done correctly, and interventions were not updated on some of the care plans. 2. Review of the medical record for Resident #25 revealed an admitted [DATE]. Diagnosis included but not limited to Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, depression, anxiety disorder Review of the quarterly MDS assessment dated [DATE], revealed Resident #25 was occasionally incontinent of bladder. Interview 11/21/24 at 10:59 A.M. with MDS Nurse #147 revealed she didn't know she needed to care plan for incontinence care. Interview on 11/26/24 at 8:49 A.M. with DON confirmed care plans were not done correctly and interventions were not updated on falls care plan. Interview on 11/26/24 at 12:23 P.M. with ADON confirmed care plans were not done correctly and interventions were not updated on some of the care plans. 3. Review of the medical record for Resident #7 revealed an admitted [DATE]. Diagnosis included but not limited to cerebral infarction, unspecified dementia with behavioral disturbance, type two diabetes mellitus, major depressive disorder, seizures. Review of the quarterly MDS assessment in progress, dated 11/12/24, revealed Resident #07 was occasionally incontinent of bladder. Review of the care plan dated 08/26/19 revealed no care plan for incontinence. Interview 11/21/24 at 10:59 A.M. with MDS Nurse #147 revealed she didn't know she needed to care plan for incontinence care. Interview on 11/26/24 at 8:49 A.M. with DON confirmed care plans were not done correctly, and interventions were not updated on falls care plan. Interview on 11/26/24 at 12:23 P.M. with ADON confirmed care plans were not done correctly and interventions were not updated on some of the care plans. 4. Review of the medical record for Resident #11 revealed an admitted [DATE]. Diagnosis included but not limited to chronic kidney disease, schizoaffective disorder and major depressive disorder. Review of the quarterly MDS assessment, dated 08/26/24/24, revealed Resident #11 was occasionally incontinent of bladder and bowel. Review of the care plan dated 08/26/19 revealed no care plan for incontinence. Interview 11/21/24 at 10:59 A.M. with MDS Nurse #147 revealed she didn't know she needed to care plan for incontinence care. Interview on 11/26/24 at 8:49 A.M. with DON confirmed care plans were not done correctly. DON reported she didn't realize the large knowledge deficit of the MDS #147 had and education was provided to her. Interview on 11/26/24 at 12:23 P.M. with ADON confirmed care plans were not done correctly, and interventions were not updated on some of the care plans. Review of facility policy, Charting and Documentation, revised July 2017, revealed documentation in the medical record will be complete and accurate. Review of facility policy, Care Plans, Comprehensive Person - Centered, revised December 2016, revealed a comprehensive, person-centered care plan to meet resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. This deficiency represents non-compliance investigated under Complaint Number OH00159309.

Based on record review and interviews, the facility failed to ensure residents were timely assessed for risk of falls to ensure appropriate interventions were in place to prevent falls. This affected three residents (Resident #11, Resident #21, and Resident #48) out of five residents reviewed for accident hazards. Findings included: 1. Review of the medical record for Resident #48 revealed an admitted [DATE]. Diagnosis included but not limited to cerebral infarction, vascular dementia, unspecified severity with other behavioral disturbance, unspecified psychosis not due to substance or known physiological condition, dementia with behavioral disturbance, hypertension, and difficulty walking. Review of the falls risk assessment revealed Resident #48's latest fall risk assessments were completed on 10/02/24 and 10/31/24. Prior to 10/31/24 the resident was not assessed for falls since 03/08/21. Interview on 11/26/24 at 8:49 A.M. with Director of Nursing (DON) confirmed falls risk assessments were not being completed as required. 2. Review of the medical record for Resident #21 revealed an admitted [DATE]. Diagnosis included but not limited major depressive disorder, and chronic viral hepatitis C. Review of the falls risk assessment revealed Resident #21's fall risk assessment completed on 10/06/24. There was no evidence the resident's risk of falls were assessed upon admission to ensure appropriate fall prevention interventions were in place. Interview on 11/26/24 at 8:49 A.M. with DON confirmed falls risk assessments not being completed as required. Interview on 11/26/24 at 12:23 P.M. with Assistant Director of Nursing (ADON) confirmed falls risk assessments not completed as required. 3. Review of the medical record for Resident #11 revealed an admitted [DATE]. Diagnosis included but not limited to chronic kidney disease, schizoaffective disorder and major depressive disorder. Review of the falls risk assessment revealed Resident #11's last fall risk assessment was completed 11/17/24. Prior to 11/17/24, the resident's risk of falls was not assessed since 03/10/21. Interview on 11/26/24 at 8:49 A.M. with DON confirmed falls risk assessments were not being completed as required. Interview on 11/26/24 at 12:23 P.M. with ADON confirmed falls risk assessments not completed as required. Review of the QAPI Action Plan dated 11/15/24 for Quarterly Assessments timely completion, revealed the facility initiated a plan to address timely assessments dated for 11/22/24 which identified need for additional nursing hours to complete quarterly assessments. ADON/Designee was to complete or delegate risk assessments. Review of the facility policy, Fall Risk Assessment revised December 2007, revealed staff will identify and document resident risk factors for falls and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. Review of the facility policy, Falls and Fall Risk Managing revised in December 2007, revealed based on previous evaluations and current date the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. This deficiency represents non-compliance investigated under Complaint Number OH00159309.

Based on interviews and record reviews, the facility failed to ensure residents were administered medication per physician orders. This affected two residents (#7 and #48) out of three residents reviewed for medication administration. Findings included: 1. Review of the medical record revealed Resident ##7 revealed an admitted [DATE]. Diagnosis included but not limited to cerebral infarction, unspecified dementia with behavioral disturbance, type two diabetes, major depressive disorder, and seizures. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had intact cognition. Review of the laboratory results for urinalysis culture and sensitivity dated 08/04/24 revealed Resident #7 was positive for Staphylococcus Haemolyticus of the urine and had a urinary tract infection (UTI). Review of the physician order dated 08/04/24 revealed an order for Macrobid (antibiotic) 100 milligrams (mg) every twelve (12) hours for five (5) days. Review of the medication administration records (MAR) dated August 2024 revealed Resident #7 received Macrobid (antibiotic for UTI) 100 mg on 08/05/24 at 9:00 A.M. but did not receive the evening dose at 9:00 P.M. as ordered per physician. The MAR had a #9 code, indicating other and to see nurses' notes with initials for Licensed Practical Nurse (LPN_ #106. On 08/06/24 Macrobid 100 mg was administered twice a day (BID) as ordered. The MARS for 08/07/24, 08/08/24, and 08/09/24 were blank. Review of the paper MARS dated August 2024 revealed for 08/07/24, 08/08/24, and 08/09/24 Resident #7 reviewed Macrobid 100 mg BID as ordered per physician. Interview on 11/26/24 at 10:43 A.M. with Director of Nursing (DON) confirmed Resident #7 missed the evening dose of Macrobid 100 mg on 08/05/24. DON reported she did not know why it wasn't administered. DON reported there was a starter box in the facility which carries the antibiotic. Review of facility policy, Medication Utilization and Prescribing - Clinical Protocol, revised July 2016, revealed staff will ensure medications are given appropriately. Review of facility policy, Antibiotic Stewardship - Orders for Antibiotics, revised December 2016, revealed antibiotics will be prescribed and administered under the guidance of the facility's Antibiotic Stewardship Program and in conjunction with the facility's general policy for Medication Utilization and Prescribing. 2. Review of medical record revealed Resident #48 was admitted to the facility on [DATE]. Diagnosis included but not limited to cerebral infarction, vascular dementia, unspecified severity with other behavioral disturbance, unspecified psychosis not due to substance or known physiological condition, dementia with behavioral disturbance, hypertension, and difficulty walking. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 had intact cognition. Review of the laboratory results for urinalysis culture and sensitivity dated 08/26/24 revealed Resident #48 was positive for Escherichia Coli of the urine and had a urinary tract infection (UTI). Review of the physician order dated 08/26/24 revealed an order for Levofloxacin 750 milligram (MG) (antibiotic for UTI) administer one time a day for five days. Review of the medication administration records (MAR) dated October 2024 revealed Resident #48 received Levofloxacin 750 mg on 08/26/24, 08/27/24 and on 08/29/24. On 08/28/24 it was coded #3, absent from home as she did not receive any Levofloxacin 750 mg on 08/28/24. Resident #48 missed two doses of her antibiotic in total. Interview on 11/26/24 at 10:43 A.M. with DON confirmed the order was entered incorrectly and Resident #48 missed 3 doses of Levofloxacin 750 mg. DON reported she did not know why it wasn't administered. DON reported there was a starter box in the facility which carries the antibiotic. Review of facility policy, Medication Utilization and Prescribing - Clinical Protocol, revised July 2016, revealed staff will ensure medications are given appropriately. Review of facility policy, Antibiotic Stewardship - Orders for Antibiotics, revised December 2016, revealed antibiotics will be prescribed and administered under the guidance of the facility's Antibiotic Stewardship Program and in conjunction with the facility's general policy for Medication Utilization and Prescribing. This deficiency represents non-compliance investigated under Complaint Number OH00159309.

Based on record review and interviews, the facility failed to ensure comprehensive care plans were revised to reflect new fall interventions. This affected three residents (Resident #7, Resident #25, and Resident #48) out of five residents reviewed for comprehensive care plans. Findings included: 1. Review of the medical record for Resident #48 revealed an admitted [DATE]. Diagnosis included but not limited to cerebral infarction, vascular dementia, unspecified severity with other behavioral disturbance, unspecified psychosis not due to substance or known physiological condition, dementia with behavioral disturbance, hypertension, and difficulty walking. Review of care plan dated 09/11/20 revealed Resident #48 had a fall on 10/31/24 and the care plan was not revised to reflect new interventions of non skid socks when out of bed to prevent falls. Interview on 11/26/24 at 8:49 A.M. with Director of Nursing (DON) confirmed care plans were not done correctly and fall interventions were not updated on the care plan. 2. Review of the medical record for Resident #25 revealed an admitted [DATE]. Diagnosis included but not limited to Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, depression, anxiety disorder Review of Resident #25's medical record revealed the resident had a fall on 08/06/24 with the intervention of educate on use of call light to prevent further falls. The care plan dated 07/31/23 was not revised with the call light education. Interview on 11/26/24 at 8:49 A.M. with DON confirmed Resident #25's care plan was not revised to reflect new fall interventions. 3. Review of the medical record for Resident #7 revealed an admitted [DATE]. Diagnosis included but not limited to cerebral infarction, unspecified dementia with behavioral disturbance, type two diabetes mellitus, major depressive disorder, and seizures. Review of Resident #7's medical record revealed the resident has a fall on 08/10/24 with a new intervention of offer assistant with toileting at bed. The care plan dated 08/26/19 revealed the new intervention was not added to the care plan. Interview on 11/26/24 at 8:49 A.M. with DON confirmed Resident #7's care plan was not revised to reflect new fall interventions. Review of facility policy, Care Plans, Comprehensive Person - Centered, revised December 2016, revealed a comprehensive, person-centered care plan to meet resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' condition change. This deficiency represents non-compliance investigated under Complaint Number OH00159309.

Based on observation, interview and policy review, the facility failed to maintain a clean and sanitary environment for residents, employees and visitors. This affected all 58 residents in the facility. Findings include: General observations made on 08/22/22 at 9:15 A.M. revealed the carpeted hallways were significantly stained and worn. Observation of the smoking area on 08/22/22, 08/23/22 and 08/24/22 revealed two long wrought iron couches. One couch had no cushions. The other wrought iron couch had three discolored cushions. The cushions were lumpy and not flat. The smokers from the secured unit were observed being led to the designated smoking area. There were nine residents identified as smokers who resided on the secured unit (#11, #20, #27, #44, #48, #51, #54, #156 and #207). Four Residents (#20, #27, #54 and #156) were identified as ambulatory and would need a seat during smoking. Interview with Resident #26 on 08/22/22 at 12:08 P.M. reported his wheelchair was not cleaned. Observation of Resident #26's wheelchair at the time of the interview revealed the rungs under the seat were thick with dust and debris. Interview with Resident #45 on 08/22/22 at 2:24 P.M. reported his air conditioner vent and fans were thick with dust. He and his roommate were oxygen dependent and felt this was not good for them. Observations at the time of the interview revealed Resident #45's air conditioner was located near the ceiling. The louvers were thick with gray dust and debris and the fan was also thick with dust and debris. Interview with Environmental Services Director (ESD) #647 on 08/24/22 at 7:15 A.M. reported a few residents sat in the dining room and watched television until late at night and there were spills and other food stuffs. There was no third shift housekeeper so it would be the responsibility of the aides to clean up spills after hours. ESD #647 reported she cleaned air conditioner vents and personal fans as needed. Personal fans would be brought to the basement, the cages removed and they would be thoroughly cleaned. The aides were responsible for the cleaning of wheelchairs. Interview with Resident #1 on 08/25/22 at 11:00 A.M. reported there was no place for all the residents from the secured unit to smoke. She pointed out they all have to smoke at designated times and there was no where for them to sit. Observations with ESD #647 on 08/24/22 at 7:36 A.M. verified the air conditioning vent and fan were heavily soiled in Resident #45's room. On 08/25/22 at 8:09 A.M. the administrator verified the severely stained and worn carpet of black, brown and red. The centers of the hall carpet were much darker than the perimeter. The small hall from the dining room to the nurses station was severely worn and black in the middle. The administrator reported he had reported the concern related to the condition of the carpet to the owner. Further observation and interview revealed the smoking area had two ashtray stacks. There were three residents smoking, Resident #45, Resident #3, and Resident #35. Resident #35 said there was not enough ashtrays for all who smoked. There were two wrought iron couches and one chair. One of the couches had no cushions and the seat of the chair was broken and sharp. The residents reported they couldn't have cushions because people were burning holes in them. Resident #3 said his butt hurt from sitting directly on the wrought iron. Review of the housekeeping and pest control policy revised in March 2004 indicated the procedure was to provide guidelines for cleaning and disinfecting the environment in order to reduce the potential or spread of nosocomial infections due to environmental contamination and vector borne spread. Room cleaning, clean personal use items (lights, phone, call bells, beds rails) with disinfectant at least twice weekly. Clean curtains, blinds and walls when visibly soiled or dusty. Review of the resident smoking policy revised 09/20/21 indicated the facility would establish and maintain safe resident smoking practices. Prior to, or upon admission, residents would be informed of the facility smoking policy, including designated smoking areas and the extent to which the facility could accommodate their smoking or nonsmoking preferences. Metal containers, with self-closing cover devices were available in the smoking areas. Ashtrays were emptied only into designated receptacles. Any smoking-related privileges, restrictions and concerns should be noted on the care plan and all personnel caring for the resident should be alerted to these issues. This deficiency substantiates Complaint Number OH 592.

Based on observation, staff interview and policy review, the facility failed to maintain the kitchen area in a clean and sanitary condition. This had the potential to affect 57 of 58 residents who resided in the facility. The facility identified one resident (#30) who did not receive food from the kitchen. Findings include: Observation during the tour of the kitchen with Assistant Dietary Manager #624 on 08/22/22 at 8:30 A.M. revealed the following: - An accumulation of dust on the evaporator fans hanging from the ceilings of both the walk in freezer and walk in refrigerator. There was so much dust on them you could see strings of dust blowing from the fans. Food items were stored in both of these areas. - Four sealed boxes (one each of broccoli, Brussel sprouts, oriental blend, and carrots) sitting on the floor of the walk-in freezer. - One undated and resealed bag of three breaded chicken patties; one undated and resealed bag of ten lasagna rolls; one undated and resealed half full bag of diced chicken; and one undated and resealed bag of eight country fried steak patties sitting on the walk-in freezer shelving. - One square plastic storage container of tuna salad in the reach-in refrigerator dated 08/15/22 on the lid. - Four loaves of wheat bread on the bread rack in the dry storage room with a use by date of 08/13/22 printed on the bread bag. - Brown splash marks on the base and underside of the stand mixer. - One white plastic scoop stored in the plastic bulk sugar container. Interview at the time of the observation with Assistant Dietary Manager #624 verified the above findings. Observation of the kitchen on 08/23/22 at 9:10 A.M. revealed visible dust in the filters above the stove. Interview at the time of the observation with Assistant Dietary Manager #624 confirmed the filters were dusty. Review of facility policy titled Dry Storage, with a revised date of 12/01/15, indicated scoops are stored, covered and outside of dry bulk containers, open packages are stored in closed containers, tightly secured with ties or in food quality storage bags and included the use by date. Review of facility policy titled Refrigerated/Frozen Storage, with a review date of 10/01/15, indicated food is dated with a use by date when opened. If removed from original container, foods are completely covered and labeled with the name of the product and use by date. Freezers and refrigerators are to be kept clean and organized.

Based on record review and interview, the facility failed to ensure a representative of the Office of the State Long-Term Care Ombudsman was notified of facility initiated discharges. This affected 18 residents (Residents #18, #51, #206, #207, #208, #209, #210, #211, #212, #213, #214, #215, #216, #217, #218, #219, #220 and #221.) The census was 58. Findings include: Interview on 08/24/22 at 11:45 A.M. with Social Services (SS) #608 revealed the facility had not been notifying the State Long-Term Care Ombudsman of facility-initiated discharges. SS #608 verified the last notification to the Ombudsman was on 02/02/21 for January 2021 facility discharges. Review of a facsimile transmittal report, dated 02/02/21, addressed to Ombudsman from the facility regarding discharge notification revealed a list of discharges from the facility during January 2021. Review of the facility admission/discharge report, dated 08/24/22, for residents discharged from 02/01/21 to 08/24/22 revealed the following residents received a facility-initiated discharge to an acute care hospital: - Resident #206 was discharged on [DATE] and again on 02/21/21 - Resident #51 was discharged on [DATE], on 05/05/21 and again on 05/13/21 - Resident #207 was discharged on [DATE] - Resident #208 was discharged on [DATE] - Resident #209 was discharged on [DATE] and again on 11/04/21 - Resident #210 was discharged on [DATE] - Resident #18 was discharged on [DATE] - Resident #211 was discharged on [DATE] - Resident #212 was discharged on [DATE] - Resident #213 was discharged on [DATE] and again on 08/06/21 - Resident #214 was discharged on [DATE] - Resident #215 was discharged on [DATE] - Resident #216 was discharged on [DATE] - Resident #217 was discharged on [DATE] - Resident #218 was discharged on [DATE] - Resident #219 was discharged on [DATE] - Resident #220 was discharged on [DATE] - Resident #221 was discharged on [DATE]

Based on observation, resident and staff interview, medical record review, review of the facility investigation and review of the facility abuse policy, the facility failed to ensure their abuse policy and procedure was implemented related to reporting of abuse and correcting and intervening in situations in which abuse was likely to occur. Resident #60, who was cognitively intact demonstrated increased attention toward Resident #39 who had severely impaired cognition. This resulted in Immediate Jeopardy on 11/10/17 at 11:15 P.M. when increased supervision was not provided by the facility and Resident #60 was found naked in Resident #39's bed. Resident #39's incontinence brief was pulled down and Resident #60 was touching her perineal/vaginal area. This action had the potential for serious harm to occur to Resident #39, and had the potential to affect eight other female residents who resided on the secured unit (Residents #40, #41, #47, #51, #52, #53, #54and #55). In addition, the facility failed to ensure prompt reporting of verbal and physical abuse affecting Residents #13 and #18. This affected two of seven residents rviewed for abuse which had the potential for more than minimal harm that did not rise to the level of Immediate Jeopardy. This affected three of seven residents reviewed for abuse. The facility census was 58. The administrator, Licensed Practical Nurse (LPN) #105, Facility Liaison #200, Facility Lawyer #205, Registered Nurse (RN) #210 and LPN #125 were notified on 11/17/17 at 4:15 P.M. Immediate Jeopardy began on 11/09/17 at 10:00 P.M. when Resident #60 was first observed in the room of Resident #39 and appropriate supervision was not put in place. Resident #60 entered Resident #39's room on 11/10/17 at 11:15 P.M. where he was found naked in her bed with her incontinence brief pulled down and his hand touching her perineal/vaginal area. The Immediate Jeopardy was removed on 11/27/17 when the facility implemented the following corrective actions. · On 11/07/17, STNA #200 was in-serviced by LPN #206 on abuse and the need to report all suspected or witnessed abuse to a charge nurse or facility administrative staff immediately. · Between 11/18/17 and 11/21/17, LPN #206 and LPN #105 completed interviews with 39 residents who resided on the open unit to ensure they felt safe in the facility and had not sustained sexual, physical or verbal abuse. The medical records of the 39 residents were audited to ensure weekly skin assessments had been completed for each resident and were absent of suspicious skin impairments that could signify abuse. · On 11/27/17, the administrator, LPN #105 and LPN #206 completed in-services for one RN, 19 LPNs, 38 STNAs, two maintenance staff, two activity staff, two therapy staff, 12 dietary staff, nine housekeeping and laundry staff and 10 administrative staff. This in-service reviewed the abuse policy, including prevention, identification, notification, reporting and documentation. · On 11/27/17 from 10:00 A.M. to 1:30 P.M. interviews with Housekeeper #210, Dietary Aide (DA) #211, STNA #220, STNA #221, STNA #222, STNA #223, STNA #224, LPN #212 and LPN #215 revealed each had been in-serviced on abuse prevention, identification, intervention and reporting. Each verbalized knowledge of the policy and procedures. Findings include: 1. Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Admission nursing notes dated 11/07/17 timed 1:45 P.M. revealed Resident #39 was alert and oriented to self only, unable to follow simple tasks or comprehend due to mental status. Subsequent progress notes revealed the resident would ambulate in the hall, and had difficulty with redirection when ambulating without her walker due to her mental status. A care plan, dated 11/21/17, revealed Resident #39 had severe cognitive limitations and dementia with delusions and hallucinations. A nursing note dated 11/11/17 timed 2:49 A.M. revealed at 11:15 P.M. on 11/10/17, Resident #39 was found by STNA #100 with another resident in bed with her. STNA #100 called for LPN #103 who went to the room and found Resident #39 with her brief down. When asked if she was okay, Resident #39 was quiet and would only say things that did not make sense, talking about flowers and things she needed to do. The note indicated Resident #60 was observed dressing at the side of the bed. Resident #39 was transferred to the hospital on [DATE] at 1:45 P.M. Review of a state reported incident dated 11/11/17 revealed STNA #100 observed Resident #60 naked in the bed with his hand on Resident #39's vagina. The report revealed Resident #39's incontinence brief was pulled down to her knees and Resident #60's hand was noted in Resident #39's vaginal area. Resident #60 stated to the staff I know I am wrong. The report indicated the nurse at the hospital had been called after Resident #39 had been admitted for observation and indicated there were no signs of sexual penetration or bruising or of mental or emotional distress. An interview with the Assitant Director of Nursing (ADON) on 11/17/17 at 8:45 A.M., revealed she received a phone call on 11/09/17 around 11:00 P.M. from LPN #103 indicating Resident #60 had been found in Resident #39's room with the door closed. She stated she told the staff to document the behavior and keep someone outside Resident #39's door that night to monitor that he did not make further attempts to go into the room. The ADON verified there was no physician order for [REDACTED].M. revealed the resident had been found standing over Resident #39, who was sleeping. With staff sitting outside Resident #39's room, Resident #60 attempted to go into her room again. The ADON verified the note on 11/17/17 at 11:03 P.M. which indicated Resident #60 was found inside Resident #39's room, shutting the door behind him, prior to running out when staff approached. The ADON verified these behaviors would indicate Resident #60, who was cognitively intact and independently ambulatory, had an interest in Resident #39, who was severely cognitively impaired. The ADON verified she requested supervision on the night shift of 11/09/17 into 11/10/17 due to Resident #60's behaviors. The ADON verified there was no documentation addressing further interventions after that night shift. The ADON verified Resident #60 was able to enter the room of Resident #39, remove his clothing, get into bed with Resident #39, lowering her incontinence brief and touching her perineal area in less than 15 minutes, starting after a discussion with a staff member at approximately 11:00 P.M. until he was found at 11:15 P.M. The ADON also verified the resident was independently ambulatory and was put on 15 minute checks when he returned from the hospital on [DATE]. 2. Review of Resident #18's medical record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18 had severe cognitive impairment and required extensive assistance for activities of daily living (ADLs). Review of a self reported incident dated 11/07/17 revealed STNA #200 informed staff that on 11/06/17 at approximately 2:20 P.M., STNA #201 called Resident #18 an ugly (expletive) because she wouldn't stand up. STNA #201 was suspended pending investigation. 3. Review of Resident #13's medical record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #13 had severe cognitive impairment and required extensive assist for ADLs. Review of the facility self reported incident dated 11/07/17 revealed STNA #200 informed facility staff that on 11/06/17 at approximately 2:45 P.M., STNA #201 asked for assistance with the care of Resident #13. During the care Resident #13 and STNA #201 got into a verbal altercation and Resident #13 attempted to pinch STNA #201. STNA #201 stated to Resident #13 during the altercation don't hurt me because I'll hurt you back. STNA #201 then proceeded to grab Resident #13's finger and bend it backward. STNA #201 then stated to Resident #13 I am helping you by cleaning your stank (expletive) don't pinch me. STNA #201 was suspended pending investigation. Review of the facility investigations related to the allegations revealed STNA #200 reported the incidents approximately 18 hours after they occurred. STNA #200 stated she did not report the incidents because of fear of retaliation. Interview with STNA #200 on 11/21/17 at 12:14 P.M. revealed she did not report the allegations of abuse immediately due to feeling intimidated by STNA #201. STNA #200 was fearful that if reported, STNA #201 would commit harm to her outside of the work environment. She verified if she had reported the incident which occurred on 11/06/17 at 2:20 P.M., STNA #201 would not have had an opportunity to verbally and physically abuse Resident #13 on 11/06/17 at 2:45 P.M. An interview with the administrator on 11/27/17 at 12:15 P.M. verified STNA #201 had bent back Resident #13's finger and verbally abused her. He verified STNA #200 did not report the witnessed abuse immediately. An interview with the unit manager, LPN#206, on 11/28/17 at 9:30 A.M. revealed STNA #200 was in-serviced on 11/07/17 on abuse and the need to report all suspected or witnessed abuse to a charge nurse or facility administrative staff immediately. Review of the facility's undated policy on Abuse, neglect and misappropriation revealed every resident had the right to be free from verbal, sexual, physical or mental abuse by anyone, including other residents. Sexual abuse was defined as, but not limited to, sexual harassment, sexual coercion or sexual assault. Review of the prevention section of the policy revealed the facility would strive to identify, correct and intervene in situations in which abuse was more likely to occur, including the assessment, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents who had behaviors such as entering other resident rooms. The policy indicated all alleged violations of abuse were to be reported immediately to prevent further abuse.

Based on observation, resident and staff interview, medical record review, review of the facility investigation and review of the facility abuse policy, the facility failed to provide adequate supervision of one male resident (Resident #60) to prevent inappropriate/sexual touching of one severely cognitively impaired female resident (Resident #39). This resulted in Immediate Jeopardy on 11/10/17 at 11:15 P.M. when Resident #60, who was cognitively intact was found naked in Resident #39's bed, placing Resident #39 at risk for serious harm. Resident #39's incontinence brief was pulled down and Resident #60 was touching her perineal/vaginal area. This affected Resident #39, and had the potential to affect eight other female residents who resided on the secured unit (Residents #40, #41, #47, #51, #52, #53, #54 and #55). In addition, the facility failed to ensure Residents #5, #13 and #18 were free of verbal and physical abuse from State tested Nursing Assistant (STNA) #201 and STNA #202 that had the potential for more than minimal harm that did not rise to the level of Immediate Jeopardy. This affected four of seven residents reviewed for abuse. The facility census was 58. The administrator, Licensed Practical Nurse (LPN) #105, Facility Liaison #200, Facility Lawyer #205, Registered Nurse (RN) #210 and LPN #125 were notified on 11/17/17 at 4:15 P.M. Immediate Jeopardy began on 11/09/17 at 10:00 P.M. when Resident #60 was first observed in the room of Resident #39 and appropriate supervision was not put in place to protect Resident #39. On 11/10/17 at 11:15 P.M. Resident #60 was again found in Resident #39's room, naked, in her bed with her incontinence brief pulled down and his hand touching her perineal/vaginal area. The Immediate Jeopardy was removed on 11/27/17 at 1:30 P.M. when the facility implemented the following corrective actions. · On 11/10/17 at Resident #60 was kept in his room until transfer to the hospital for evaluation. Upon his return on 11/11/17 at 5:03 A.M. Resident #60 was kept on every 15 minute checks until he was discharged on [DATE] at 2:19 P.M. · On 11/07/17, STNA #200 was in-serviced by LPN #206 on abuse and the need to report all suspected or witnessed abuse to a charge nurse or facility administrative staff immediately. · On 11/18/17, the facility initiated a new computerized behavioral assessment that would be completed on admission and updated with any changes in behavior for all residents. On 11/18/17, LPN #206 began in-servicing all LPNs on the behavioral assessment and need to report changes in behavior. · Between 11/18/17 and 11/21/17, LPN #206 completed assessments of 19 residents on the secured unit to ensure they felt safe and to ensure all residents had recent skin assessments for any skin impairments that could signify abuse. · Between 11/18/17 and 11/21/17, LPN #206 and LPN #105 completed interviews with 39 residents who resided on the open unit to ensure they felt safe in the facility and had not sustained sexual, physical or verbal abuse. The medical records of the 39 residents were audited to ensure weekly skin assessments had been completed for each resident. · On 11/21/17 all LPNs had completed the behavioral assessment in-service provided by LPN #206. · On 11/21/17, audits were initiated to review all new admissions to ensure behaviors were assessed and interventions were put in place as appropriate. Audits were to be completed daily by LPN #206 or her designee. · On 11/21/17, all residents were assessed by LPN #206 or LPN #105 for behaviors. Care plans were reviewed and updated to ensure appropriate interventions were in place for documented behaviors. · On 11/27/17, the administrator, LPN #105 and LPN #206 completed in-services for one RN, 19 LPNs, 38 STNAs, two maintenance staff, two activity staff, two therapy staff, 12 dietary staff, nine housekeeping and laundry staff and 10 administrative staff. This in-service reviewed the abuse policy, including prevention, identification, notification, reporting and documentation. · On 11/27/17 from 10:00 A.M. to 1:30 P.M. interviews with Housekeeper #210, Dietary Aide (DA) #211, STNA #220, STNA #221, STNA #222, STNA #223, STNA #224, LPN #212, and LPN #215, revealed each had been in-serviced on abuse prevention, identification, intervention and reporting. Each verbalized knowledge of the policy and procedures. Although the Immediate Jeopardy was removed on 11/27/17, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of completing audits and was in the process of verifying the corrective action taken was effective. Findings include: 1. Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Admission nursing notes dated 11/07/17 timed 1:45 P.M. revealed Resident #39 was alert and oriented to self only and unable to follow simple tasks or comprehend. Subsequent progress notes revealed the resident ambulated in the hall and had difficulty with redirection when ambulating without a walker. A care plan, dated 11/21/17, revealed Resident #39 had severe cognitive limitations and dementia with delusions and hallucinations. A nursing note dated 11/11/17 timed 2:49 A.M. revealed at 11:15 P.M. on 11/10/17, Resident #39 was found by STNA #100 with another resident in bed with her. STNA #100 called for LPN #103 who went to the room and found Resident #39 with her brief down. When asked if she was okay, Resident #39 was quiet and would only say things that did not make sense, talking about flowers and things she needed to do. The note indicated Resident #60 was observed dressing at the side of the bed. LPN #103 contacted the assistant director of nursing (ADON), LPN #105 and attempted to call the resident's power of attorney. The note indicated the Certified Nurse Practitioner (CNP) #107 was notified at 11:56 P.M. and initially stated she did not want the resident sent to the hospital due her mental status and desire to not further agitate the resident. The local police department was notified, arrived and initiated an investigation. The note indicated evidence was collected including the resident's clothing and bedding. The note indicated at one point, the resident stated a man was here, and when asked what happened, the resident started talking about flowers. The police officer indicated the resident had to go to the hospital. Resident #39 was transferred to the hospital on [DATE] at 1:45 P.M. Review of the hospital emergency room note dated 11/11/17 timed 5:27 A.M. revealed Resident #39 was admitted to the hospital after being sexually assaulted by a male resident at her nursing home this evening. The note indicated a nursing home care giver had found a male resident on top of her, touching her vagina with his hands. The resident was examined by a sexual assault nurse examiner (SANE nurse) and no evidence of vaginal trauma was noted. A pelvic exam was not completed as the resident refused and there was no evidence of penile penetration. The resident was admitted for observation because it was not safe for her to return to the nursing home, as the resident who assaulted her was still there. Review of the hospital discharge summary dated 11/13/17 timed 9:48 A.M. revealed adult protective services had been notified of the incident, and the resident had been kept in the hospital for observation while a safe discharge plan could be made. The note indicated the facility had indicated the assailant (Resident #60) had been discharged to another facility on 11/13/17 and Resident #39's daughter preferred the resident return to the facility, as long as the assailant was no longer there. Resident #39 returned to the facility on [DATE] at 6:00 P.M. Review of the record of Resident #60 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident was cognitively intact and exhibited verbal behaviors of threatening, screaming or cursing at others, as well as other behaviors, one to three days out of seven. Resident #60 was independently ambulatory, requiring only supervision for activities of daily living. Review of the nursing notes revealed behaviors on 09/13/17 which included pacing the unit, yelling on the phone and eating sugar packets. Review of Resident #60's care plans, dated 09/11/17, revealed he had impaired thought processes/paranoia related to paranoid [MEDICAL CONDITION], with interventions to administer medications as ordered, give simple directions, provide a consistent routine and observe and report changes in cognitive function. The resident also was at risk for depression and difficulty with adjustment to the nursing home with interventions including affirming his feelings, monitor mood, affect and behavior and refer to psych services as needed. There were no specific interventions for supervision regarding behaviors. Review of a nursing note dated 11/09/17 timed 10:05 P.M. revealed Resident #60 had been uncooperative with staff throughout the shift, pacing and yelling out at staff. The resident had concerns with his medications and had a discussion with the nurse. The note also indicated Resident #60 was observed in the room of Resident #39, standing over Resident #39 who was asleep. The resident was redirected. The note indicated while staff were sitting outside of the room of Resident #39, Resident #60 was observed again attempting to go into Resident #39's room, with redirection required. A nursing note dated 11/09/17 timed 11:03 P.M. revealed Resident #60 was again noted in the room of Resident #39 and ran out immediately, once he heard staff approaching. A nursing note dated 11/11/17 timed 2:14 A.M. revealed on 11/10/17 at 11:00 P.M. Resident #60 was observed at the nursing station asking for change for five dollars. The nurse (LPN #103) stated that she would help him with change after she received report and he walked away. The note indicated the nurse was notified at 11:15 P.M. by an STNA that she needed to go the room of Resident #39. She and the second shift nurse went to the room and observed Resident #60 standing at the side of Resident #39's bed, getting dressed. The note indicated STNA #100 told LPN #103 that when she entered the room, Resident #60 was in bed with Resident #39. Resident #60 was undressed and Resident #39's brief was down with Resident #60's hand in her vagina. The noted indicated the resident was escorted to his room, and the ADON, medical doctor and CNP #107 were notified. An order was given to call the police and send Resident #60 to a local psychiatric hospital. The resident remained in his room until he was transferred out by ambulance at 1:45 A.M. Review of emergency room notes dated 11/11/17 revealed Resident #60 was in the emergency room for a psychiatric evaluation after he assaulted another patient in the nursing home. The note indicated he admitted he went to a female resident's room and had consensual sexual contact with her. The note indicated he understood that his behavior was inappropriate and against the facility rules. Review of a nursing progress note dated 11/11/17 timed 5:03 A.M. revealed Resident #60 returned to the facility and 15 minute checks were implemented. No further behaviors were noted in the record. He was transferred to another facility on 11/13/17 at 2:19 P.M. Review of a self-reported incident to the State Agency dated 11/11/17 revealed STNA #100 observed Resident #60 naked in the bed with his hand on Resident #39's vagina. The report revealed Resident #39's incontinence brief was pulled down to her knees and his hand was noted in her vaginal area. Resident #60 stated to the staff I know I am wrong. The report indicated the nurse at the hospital had been called after Resident #39 had been admitted for observation and indicated there were no signs of sexual penetration or bruising or of mental or emotional distress. The report indicated abuse was not suspected as the evidence was inconclusive. Review of a statement given by Resident #60, dated 11/11/17 and written by LPN #105, revealed the resident was interviewed after he returned from the hospital. He stated he went into the room of Resident #39 and kissed her a couple of times. He said he took his clothes off and got in bed with her, he touched her breast and that was it and said she didn't want anything else to happen. He said he did not have sexual intercourse with her because she didn't want it to happen, I know it was wrong and it will never happen again. An interview with the ADON on 11/17/17 at 8:45 A.M., revealed she received a phone call on 11/09/17 around 11:00 P.M. from LPN #103 indicating Resident #60 had been found in Resident #39's room with the door closed. She stated she told the staff to document the behavior and keep someone outside Resident #39's door that night to monitor that he did not make further attempts to go into the room. The ADON verified there was no physician order for [REDACTED].M. revealed the resident had been found standing over Resident #39, who was sleeping. With staff sitting outside Resident #39's room Resident #60 attempted to go into her room again. The ADON also verified the note on 11/17/17 at 11:03 P.M. which indicated Resident #60 was found inside Resident #39's room, shutting the door behind him. The ADON verified the behaviors would indicate Resident #60, who was cognitively intact and independently ambulatory, had an interest in Resident #39, who was severely cognitively impaired. The ADON verified she requested supervision on night shift on 11/09/17 into 11/10/17 due to Resident #60's behaviors, but there was no documentation addressing further interventions after that night shift. The ADON verified the incident of 11/10/17 when Resident #60 sexually assaulted Resident #39. Review of a statement by STNA #120, dated 11/09/17, revealed she came in to work night shift on 11/09/17 and received report from the second shift staff. She was informed by an STNA that she needed to watch Resident #60 because he had been going into the room of Resident #39. The statement indicated she saw Resident #60 leave his room and walk toward the room of Resident #39 as she was talking to the nurse. She was instructed by the nurse to check on Resident #39 and as she approached the room, she saw the door being closed slowly. She called the nurse who came down the hall and found Resident #60 in the room. Resident #60 was instructed to return to his room. An interview with STNA #120 on 11/17/17 at 1:10 P.M. revealed she received report from second shift STNA #130 on 11/09/17 around 11:00 P.M. She stated STNA #130 told her Resident #60 had been observed walking into the room of Resident #39 and she should watch him closely. STNA #120 said she had previously shut the door of Resident #39's room, as she knew she liked to have her door shut. She said while she was talking with the nurse, she noted Resident #60, who had been walking in the hall, was no longer visible. She went down the hall to the room of Resident #39 and saw the door closing. Resident #60 was in the room and was told to come out and go to his room. STNA #120 stayed in the hall through the rest of the night shift to ensure Resident #60 did not enter the room again. She said she worked the night of 11/10/17 but was in another resident's room on a one to one assignment and did not witness the events of that night. Review of a statement from STNA #100, dated 11/10/17, revealed she arrived for her shift on 11/10/17 and started to make rounds. She walked into the room of Resident #39 and observed Resident #39 was in her bed with another resident, Resident #60, who was completely naked in the bed with his hand on the female resident's (Resident #39's) vagina. The statement indicated STNA #100 had been warned from another aide that he was suspicious because he was going in and out of different female rooms uninvited. The note indicated that to protect everyone's safety, she checked all the rooms and that's when she found Resident #60 in the female resident's room. The note indicated Resident #60 was saying I know I'm wrong. STNA #100 reported the incident to the nurse immediately. An interview with STNA #100 on 11/17/17 at 1:30 P.M. revealed she had been told by STNA #120, at the change of shift around 11:00 P.M. on 11/10/17, Resident #60 had been going in and out of women's rooms. She stated she had seen him go into another female resident's room (Resident #54) several days or a week prior. She redirected the resident when she saw him do this and he told STNA #100 Resident #54 owed him money. She stated he had also been observed talking with another female resident, Resident #51. She said when she came on the unit to work night shift on 11/10/17 around 11:00 P.M. she was told by STNA #120 Resident #60 had been entering rooms and needed to be watched closely. She began to check on her residents and noted the door to Resident #39's room was closed. She knocked and did not hear an answer, so she opened the door and observed Resident #60 naked in Resident #39's bed. She stated Resident #39 was lying on her back and had her arms bent at the elbows, with her hands near her shoulders. Resident #60 immediately said he knew he was wrong and got up from the bed and started to get dressed. She called for the nurse immediately and waited as the nurse came from down the hall. Resident #39 appeared confused when she asked the resident if she was okay, talking about the wall and the table. Review of the undated statement of LPN #103 revealed when she arrived on the secured unit for night shift on 11/10/17 around 11:00 P.M., she spoke with Resident #60, who saw her come in the doors and asked her if she had change for a five dollar bill. She said she would check after she got report from the other nurse, and Resident #60 walked away. While she was receiving report at the nursing station, around 11:15 P.M., she was called by STNA #100 to come to the room of Resident #39. She went to the room and saw Resident #60 standing at the side of the bed of Resident #39 putting on his clothes. The statement indicated STNA (#100) told her Resident #60 had been found naked in bed with the other resident. Resident #39 was wearing a shirt and hoodie and her brief was pulled down. LPN #103 asked Resident #60 to get out of the room and she then notified the ADON, the physician and the resident's responsible parties. An interview with LPN #103 on 11/17/17 at 2:40 P.M. revealed she had heard Resident #60 had been going into other female resident rooms but had not observed this. She stated she worked on 11/09/17 on second shift and the resident was more agitated than usual, and she saw him standing outside female resident rooms. She kept her eye on him and told staff to monitor him. She said she remembered someone saying the resident had been standing over Resident #39 as she lay in her bed but she did not witness this. LPN #103 said during report on 11/09/17 around 11:00 P.M., she said an STNA was watching him and he disappeared. He was found in the room of Resident #39, just shutting the door. LPN #103 next worked the night shift on 11/10/17. She said around 11:15 P.M., STNA #100 yelled that she needed to come to the room of Resident #39 right away. She said as she walked into the room, Resident #60 was getting dressed. He did not say anything when she asked him what he was doing in the room. After he was dressed, he went back to his room and laid in his bed, curled in a fetal position, all covered up. She said he stayed in his room under observation until he was discharged to the hospital. She said Resident #39 was typically very soft spoken and was confused, unable to give any description of what happened. An interview with STNA #130 on 11/17/17 at 3:30 P.M. revealed he worked on 11/09/17 second shift. He stated he had observed Resident #60 on that shift looking into the room of Resident #39. He said Resident #60 told him Resident #39 owed him a dollar. He was unsure of the time of this interaction, but stated he reported the interaction to the nurse because it seemed unusual. He worked closely with the residents and thought he would have known if money had been exchanged between the two residents, especially since Resident #39 was very confused. He stated later in the shift, he saw Resident #60 walking by Resident #39's room, pausing outside the door. He then observed Resident #60 in Resident #39's room later in the shift around 10:00 PM. Resident #60 was standing at the foot of Resident #39's bed, gazing at her. STNA #130 stated the door was open, and he directed Resident #60 out of the room. STNA #130 stated he passed this information on to the nurse and to the STNA who was coming on the next shift (STNA #100). He stated he also worked the night shift 11/09/17 into 11/10/17, but had no further interactions or observations of Resident #60, as he was assigned as a sitter and spent the shift in another resident's room, providing one to one supervision. An interview was attempted with Resident #39 on 11/17/17 at 10:20 A.M. She was lying in bed and awakened easily to her name. She could state her first name but not her last name. She was pleasant, appeared comfortable and denied needs or concerns. She was very confused and unable to answer questions in detail. She was asked if staff at the facility were nice to her and helped her with her needs and she agreed. She was asked if the other residents in the facility were nice. She stated, Some of them but could not or would not provide any other information when questioned further, giving a rambling, incoherent response. Resident #39 was observed throughout the survey in her bed, resting quietly. 2. Review of Resident #13's medical record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 had a brief interview for mental status score (BIMS) of seven indicating severe cognitive impairment and required extensive assist for activities of daily living (ADLs). Review of the facility self-reported incident dated 11/07/17 revealed STNA #200 informed facility staff that on 11/06/17, STNA #201 asked for assistance with the care of Resident #13. During the care Resident #13 and STNA #201 got into a verbal altercation and Resident #13 attempted to pinch STNA #201. STNA #201 stated to Resident #13 during the altercation don't hurt me because I'll hurt you back. STNA #201 then proceeded to grab Resident #13's finger and bent it backward. STNA #201 then stated to Resident #13 I am helping you by cleaning your stank (expletive), don't pinch me. STNA #201 was suspended pending investigation. When confronted with the allegations of abuse, STNA #201 became verbally abusive to administrative staff, did not deny allegations and abruptly quit her employment with the facility. Review of the facility investigation into the incident revealed STNA #200 reported the incident approximately 18 hours after it happened. STNA #200 stated she did not report the incident of abuse right away because of fear of retaliation. Interview with STNA #200 on 11/21/17 at 12:14 P.M. revealed she did not report the allegation of abuse immediately due to feeling intimidated by STNA #201. STNA #200 was fearful that if reported, STNA #201 would commit harm to her outside of the work environment. Resident #13 was observed on 11/21/17 at 4:42 P.M. sitting in a wheelchair in her room. She was neatly groomed and appropriately dressed and showed no signs of physical or psychosocial distress. Resident #13 could not provide information regarding the allegation of abuse by STNA #201 due to her cognitive impairment. An interview with the administrator on 11/27/17 at 12:15 P.M. verified STNA #201 had bent back Resident #13's finger and had verbally abused her. 3. Review of Resident #18's medical record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #18 had a BIMS score of three indicating severe cognitive impairment and required extensive assistance for ADLs. Review of a self-reported incident dated 11/07/17 revealed STNA #200 informed staff that on 11/06/17 STNA #201 called Resident #18 an ugly (expletive) because she wouldn't stand up. STNA #201 was suspended pending investigation. When confronted with the allegation of abuse STNA #201 became verbally abusive to administrative staff, did not deny allegations and abruptly quit her employment with the facility. Review of the facility investigation revealed STNA #200 reported the incident approximately 18 hours after it happened. STNA #200 stated she did not report the incident of abuse right away because of being afraid of retaliation. Interview with STNA #200 on 11/21/17 at 12:14 P.M. revealed she did not report the allegation of abuse immediately because of feeling intimidated by STNA #201. STNA #200 was fearful that if reported STNA #201 would commit harm to her outside of the work environment. Resident #18 was observed on 11/21/17 at 4:46 P.M. sitting up in bed watching television. She was neatly groomed and appropriately dressed and showed no signs of physical or psychosocial distress. Resident #18 could not provide information regarding the allegation of abuse by STNA #201 due to her cognitive impairment. An interview with the administrator on 11/27/17 at 12:15 P.M. verified STNA #201 had verbally abused Resident #18. 4. Review of Resident #5's medical record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #5 had a BIMS score of 0 indicating severe cognitive impairment and required extensive assistance for ADLs. Review of the self-reported incident dated 11/02/17 revealed at approximately 11:20 P.M. on 11/01/17 STNA #202 was heard by multiple staff members yelling and cursing at Resident #5. STNA #202 was immediately escorted out the building and suspended pending investigation. Review of the facility investigation including witness statements revealed the facility substantiated the abuse claim and STNA #202 was terminated. Resident #5 was observed on 11/21/17 at 5:05 P.M. sitting up in bed watching television. He was neatly groomed and appropriately dressed and showed no signs of physical or psychosocial distress. Resident #5 could not provide information regarding the allegation of abuse related to STNA #202 due to his cognitive impairment. An interview with the administrator on 11/27/17 at 12:15 P.M. verified STNA #202 had verbally abused Resident # 5. Review of the facility's undated policy on Abuse, neglect and misappropriation revealed every resident had the right to be free from verbal, sexual, physical or mental abuse by anyone, including other residents. Sexual abuse was defined as, but not limited to, sexual harassment, sexual coercion or sexual assault. Review of the prevention section of the policy revealed the facility would strive to identify, correct and intervene in situations in which abuse was more likely to occur, including the assessment, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents who had behaviors such as entering other resident rooms. Any alleged violations or known reasonably suspicious occurrences involving mistreatment, neglect, abuse, or misappropriation, including injuries of unknown source, must be reported immediately to the administrator. This deficiency substantiates Complaint Number OH 614 and Complaint Number OH 595.

Based on observation, resident and staff interview, medical record review, review of the facility investigation and review of the facility suicide policy, the facility failed to implement comprehensive and individualized interventions and provide adequate supervision for Resident #49 to prevent self-harm/mutilation. This resulted in Immediate Jeopardy on 09/28/17 when Resident #49, who had a history of [REDACTED]. The resident was sent to the hospital and later returned from the hospital on [DATE] at 2:50 A.M. The facility failed to implement interventions to address the behavior and to ensure adequate supervision was provided to the resident to prevent further self-harm after his return. On 10/22/17, Resident #49 approached Licensed Practical Nurse (LPN) #230 stating he had harmed himself again. The resident was transferred to the hospital and was assessed to have a 10.4 centimeter (cm) by 4.8 cm object, consistent with an intact florescent light bulb, in his rectal stump (a pouch left behind after the colon is diverted surgically to an opening in the abdominal wall, a colostomy). Serious, life-threatening harm occurred when Resident #49 engaged in self-harm/self-mutilating behaviors on two separate occasions resulting in hospitalization and surgical intervention. This affected one resident (Resident #49) of one resident identified to exhibit self-harming behaviors. The facility census was 59. The Administrator, the Assistant Director of Nursing (ADON), LPN #105, the facility liaison (Liaison #200), the facility lawyer (JD #205), Registered Nurse (RN) #210 and the unit manager, LPN #125, were notified on 11/17/17 at 4:15 P.M. that Immediate Jeopardy began on 09/28/17 at 5:11 P.M. when Resident #49, who had a history of [REDACTED].#230 he had inserted an object into his rectum and was transported to the hospital for treatment. The Immediate Jeopardy was removed on 11/21/17 when the facility implemented the following corrective action: · On 11/18/17, the unit manager, LPN #206 and LPN #105 began assessing all residents for self-harm/mutilating behaviors. Care plans were reviewed and updated as needed to ensure appropriate interventions for behaviors were in place. This was completed by 11/21/17. · On 11/18/17 the Administrator and LPNs #105 and #206 began in-services related to suicidal and self-harm behaviors and interventions for staff to implement if the behaviors were witnessed by staff, to include prompt reporting of the behaviors to the charge nurse for one RN, 19 LPNs, 38 state tested nursing assistants (STNAs), two maintenance staff members, two activity staff members, two therapy staff, 12 dietary staff, 9 housekeeping and laundry staff and 10 administrative staff members. As of 11/27/17, all facility staff had been in-serviced. · On 11/18/17, the facility initiated a new computerized behavioral assessment that would be completed on admission and with any changes in behavior for all residents. On 11/18/17, all 20 LPNs were in-serviced by LPN #206 on the new behavioral assessment and the need to report changes in behavior to charge nurses or the unit managers. This was completed by 11/21/17. · On 11/21/17, audits were instituted to review new admissions and all nurse's notes for the prior day to ensure behaviors were assessed and interventions were put in place as appropriate. Audits were to be completed daily by LPN #206 or her designee. · On 11/27/17 from 10:00 P.M. to 1:30 P.M. interviews conducted revealed Housekeeper #210, Dietary Aide (DA) #211, STNA #220, STNA #221, STNA #222, STNA #223, STNA #224, LPN #212 and LPN #215, had all been in-serviced on behaviors regarding self-harm assessment, reporting and documentation. Although the Immediate Jeopardy was removed on 11/21/17, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing on-going monitoring of the corrective actions and education of new staff. Findings include: Record review revealed Resident #49 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of information sent to the facility prior to his admission revealed a history and physical completed in the hospital dated 09/08/17 which referenced Resident #49 had a history of [REDACTED]. He had previously been admitted to the hospital after inserting a screw into his colostomy. The assessment indicated he had an extensive history of previous inpatient psychiatric admissions for insertions (of items into his colostomy) and cutting/mutilating his ostomy with the goal of obtaining surgery, care and attention. Resident #49 denied frank suicidal ideations, but said he was bored at the nursing home he resided at and wanted care and attention, and threatened to insert things into his ostomy for similar reasons. Resident #49 also had a history of [REDACTED]. The history and physical also indicated Resident #49 was at high risk for deliberating self-harm. The assessment indicated he was a self-abusive man with compulsive behaviors of inserting objects into his colostomy. Review of information from Resident #49's previous admission on the hospital behavioral unit dated 09/20/17 at 12:00 P.M. indicated Resident #49 remained on one on one continuous safety monitoring, with a caregiver stationed in the doorway at all times to ensure no self-injurious behavior occurred. A nurse's note dated 09/21/17 at 11:08 P.M. revealed the resident was discontinued from suicide precautions. The note also revealed although the resident was at low risk for suicide, homicide or aggression, he continued to be high risk for deliberate self-harm and moderate risk of imminent physical self-impairment. Review of the discharge plan from the hospital (printed 09/22/17) revealed the resident was to have a psychiatry follow-up appointment with the staff psychiatrist at the nursing facility. The documentation from the hospital including the history and physical, behavioral notes dated 09/20/17 and 09/21/17 and the discharge plan were all found in Resident #49's medical record at the nursing facility with dates indicating they had been printed on 09/22/17 and sent to the nursing facility with the resident when he was admitted . Review of the nursing facility admission assessment dated [DATE] at 8:26 P.M. revealed the resident had a goal to get better regarding self-mutilation. Review of Resident #49's interim care plan dated 09/22/17 revealed a goal for Resident #49 to remain safe. Interventions included for staff to encourage activity involvement, monitor lab tests, medicate as ordered and provide one to one intervention as needed. The care plan did not indicate Resident #49 was at risk for self-harm and the facility did not implement interventions to provide for his safety. Review of a progress note written by Nurse Practitioner (NP) #300, dated 09/26/17, revealed Resident #49 was admitted from an inpatient behavioral health unit and had a history of [REDACTED]. Resident #49 was ordered an anti-anxiety medication to be given as needed. Resident #49 signed an informed consent for the assessment and treatment by psychological services on 09/26/17. Review of a note by NP #300 dated 09/28/17 revealed Resident #49 had lots of racing thoughts and stated the anti-anxiety medication helped at times. The note indicated the NP reassured the resident that someone from psychiatric services would be in to evaluate him. On 09/28/17 at 5:11 P.M., Resident #49 approached LPN #230 to say that he had injured himself. He initially would not allow staff to examine him but eventually allowed the staff to check him briefly and small lacerations were observed in the anal area and on his fingertips. NP #300 was called and ordered a KUB (an x-ray of the abdomen including the kidneys, ureters and bladder). The initial reading of the KUB on 09/28/17 at 7:08 P.M. did not show evidence of any foreign objects. The nursing note on 09/28/17 at 7:35 P.M. revealed Resident #49 was pacing the floor very anxiously and stating, I do have something inside me and I am very sorry I put it there. The note indicated LPN #230 attempted to help him calm down, giving him an anti-anxiety medication. The resident told the nurse he could not help himself and said he was addicted to surgery. The resident began to call 911 on his cell phone multiple times and asked the nurse to talk with the police. LPN #230 told the police operator no medical attention was needed at that time as the concerns were being addressed. The nursing note on 09/28/17 at 7:55 P.M. revealed Resident #49 approached LPN #230 again and stated he had injured himself. He went into the bathroom and with LPN #230 observing; he squatted and put his hand and fingers into his anal area. Feces and blood began to come from the anal area and Resident #49 pulled an object out of the anal area. The nurse called NP #300 who gave an order to send the resident to the emergency room . A social service history completed on 09/29/17 did not address the resident's history or potential for self-harm. Review of nursing progress notes from admission through 09/28/17 did not reveal assessments or interventions regarding the resident's risk of self-harm/mutilation. The resident was alert and oriented and required only supervision for all his activities of daily living. He could independently walk about the facility. An addendum to the KUB reading, dated 10/02/17 at 8:56 A.M., revealed there was a metallic foreign body which appeared to be a razor blade. The note indicated the resident was to abstain from using sharp objects and utensils and staff were to check on him every 15 minutes to ensure his safety. Record review revealed Resident #49 returned to the facility on [DATE] at 2:50 A.M. Hospital notes indicated Resident #49 was stable with no other foreign objects found in him and he was denied psychiatric evaluation by the psychiatrist. The resident education section of the discharge instructions indicated putting foreign objects in your body on purpose is a very serious problem that could cause injury due to the risk of infection and had the possibility of harming internal organs and could lead to death. Review of the September, 2017 treatment administration record (TAR) revealed on 09/29/17 the resident was to be checked for any new self-inflicted injuries and staff were to ensure he was free from foreign object insertion into body orifices. This was to be completed every shift. Additionally, the TAR indicated Resident #49 was to be free from unsafe items, with signatures required by the nurse on each shift to ensure this had been checked and completed. There was no evidence in the medical record that Resident #49 was put on specific safety checks such as every 15 minute safety checks or placed on one to one continuous supervision. He was independently ambulatory in the facility. Review of a note written by the psychiatric NP, RN #301, dated 10/04/17 (no time indicated) revealed Resident #49 expressed a desire to injure himself. The note indicated the resident stated his mood was depressed and he appeared anxious, depressed and irritable. Resident #49 stated he had been having a lot of thoughts and had a plan to kill himself but that no one believed him. The note indicated the resident stated he had a plan and was going to wait until 10/16/17 to do it. This note also included the information that Resident #49 had been admitted to the nursing facility because of self-mutilation with razors in his rectum and stomach and stated he wanted to be put under anesthesia because he liked the way it made him feel. The note indicated Resident #49 was put on every 15 minute suicide checks until he could be transferred to the hospital. Resident #49 was sent to the hospital on [DATE] at 3:25 P.M. He was not admitted and returned to the facility on [DATE] at 9:32 P.M. with an order for [REDACTED]. Review of the discharge instructions from the hospital on [DATE] indicated Resident #49 was evaluated for depression with suicidal ideation. The note indicated the resident had a plan to use a light bulb to perforate his stoma (the opening of his colostomy to his bowels). He stated he was feeling like this for the past five days. He was requesting a psychiatric admission. The note indicated the resident stated he had started feeling this way last week and had planned to insert the broken glass from a light bulb into his stoma and rectum. The notes indicated Resident #49 was seen by a physician who recommended outpatient follow-up and discharged him back to the nursing home with close follow-up. The physician indicated Resident #49 had multiple recent admissions that did not benefit him and he was discharged out of the emergency room . Review of a nursing note dated 10/05/17 at 12:29 P.M. revealed Resident #49 was anxious and LPN #310 spoke with him. The resident said when he thinks too much, he wants to do things to his body and stated he could use light bulbs or the springs from his bed. The noted indicated the nurse discussed other options and the resident stated he was reassured. Review of a note from NP #300, dated 10/05/17 revealed Resident #49 was on one to one supervision/care due to attempts at self-harm. The note indicated the resident would follow-up with the psychiatric NP regarding self-harm with sharp objects. Review of a care conference note dated 10/09/17 revealed Resident #49 had previous behaviors including harm to himself, rectal and colostomy behaviors and was on safety checks and one to one supervision. The activities section of the care plan note indicated the resident refused in room activities. Resident #49 was encouraged to participate in activities and art work. He was seen by the nurse practitioner and psychologist and wanted to return to the community when deemed ready. The care conference note indicated the resident was without any attempts to harm himself or others and the every 15 minute safety checks were discontinued. The last 15 minute safety check sheets filled out by staff ended on 10/09/17 at 10:00 A.M. There was no evidence Resident #49 was seen by the psychiatry staff for a follow-up visit when they were in the facility seeing residents on 10/11/17. Review of a note dated 10/18/17 by a social worker from the psychiatry service revealed she had obtained a more in-depth history for Resident #49, including multiple hospitalization s as a child, a [DIAGNOSES REDACTED]. The assessment indicated Resident #49 felt depressed most days, felt lonely in the facility and had daily thoughts of hurting himself. The note indicated Resident #49 just wants to go to the hospital, where he remembers growing up. The note indicated the social worker verified safety checks and a safety plan with the DON regarding Resident #49's suicidal ideation and gestures, and discussed with the resident to let staff know if he experienced urges to harm himself. Review of a nursing note dated 10/22/17 at 4:34 P.M. revealed Resident #49 told a nurse (identified in the charting as LPN #230) he had injured himself. The nurse observed a small amount of blood in the resident's briefs and by his anal area. Resident #49 repeatedly stated he was sorry and didn't mean to do this, he just couldn't help himself. The resident was sent out to the hospital. Review of the notes from the hospital indicated a computerized tomography (CT) exam of Resident #49's abdomen and pelvis completed on 10/22/17 revealed a foreign body in the rectal stump that measured 10.4 cm in length and 4.8 cm in width, demonstrating a configuration consistent with an intact fluorescent light bulb. Resident #49 was taken to surgery and the item was removed under general anesthesia. He returned to the facility on [DATE] and was ordered one to one monitoring by staff. Review of nursing progress notes dated 10/30/17 at 1:37 P.M. revealed the resident returned to the nursing facility. The care plan related to behaviors included an updated intervention dated 10/30/17 for Resident #49 to have a one to one sitter with him until further notice to ensure his safety. An interview with LPN #230 on 11/15/17 at 3:05 P.M. revealed Resident #49 approached her initially on 09/28/17 and said he had put something in his rectum. She did not remember if he said what the item was, but found out later it was a razor blade. LPN #230 stated she called NP #300, who gave an order for [REDACTED].M. she told him the x-ray did not show anything. LPN #230 said Resident #49 remained anxious and began calling 911. She said he then asked her to come to his room and he removed the object from his rectum. LPN #230 stated she called NP #300 again and Resident #49 was sent to the hospital. LPN #230 said the resident approached her on 10/22/17 saying he did something to himself. She said he showed her pieces of glass on the floor in his bathroom. She said he told her he removed the light bulb from the fixture above his bed, broke it on the floor and inserted the three biggest pieces of the bulb into his rectum. She said she did not see the base or the filament section of the bulb, so she assumed he had inserted that piece into his rectum as well. She said he had some blood on his fingers and some drops of blood were in the bathroom but he did not appear to be in pain, or show any other signs of anxiety. She stated she immediately called his physician and for emergency transfer to the hospital. Review of the nursing notes dated 10/23/17 at 10:44 P.M. reveled the resident was admitted to the hospital due to complications from self-injuries. An interview with NP #300, on 11/16/17 at 9:55 A.M. revealed she saw Resident #49 on 09/28/17 to address his medical concerns. She stated she briefly reviewed his record and was aware the resident was in the facility for behavioral concerns, but stated she had not reviewed the record thoroughly to understand the full history of his behaviors. She stated she recommended a consult to psychiatric services. She stated the psychiatric service staff visited the facility on 09/27/17, but Resident #49 had not been seen on that weekly visit. The NP verified Resident #49 was not seen until 10/04/17, the next time the staff from psychiatric services visited the facility. Resident #49 was interviewed on 11/17/17 at 10:15 A.M. He was in his room with a state tested nursing assistant (STNA) who was providing one to one continuous supervision. The resident was standing in his room during the interview. He verified that a staff member stayed in his room all the time because he had thoughts of hurting himself. He said these thoughts had been better recently and agreed that staff at the facility wanted to ensure his safety. The resident's room was observed with a single light bulb above the bed of his roommate. The Administrator and ADON, LPN #105, confirmed on 11/17/17 at 3:00 P.M. that Resident #49's pertinent medical history and behavioral information was sent with the resident on admission. An interview with the DON on 11/21/17 at 9:00 A.M. verified Resident #49 was independently ambulatory and that no extra supervision or safety checks were implemented to ensure his safety and to prevent him from further self-harm upon readmission. An interview on 11/27/17 at 3:15 P.M. with the Administrator and LPN #206, the unit manager who attended the care plan meeting, revealed Resident #49, his parents, Social Service Designee (SSD) #305, Physical Therapist (PT) #307, Activity Director (AD) #306) and another unit manager, LPN #125, had all attended the care conference meeting. LPN #206 stated the resident's managed care case manager, RN #302, was present by phone during the meeting. LPN #206 verified the proceedings of the meeting as outlined in the care conference note. She stated the one to one referred to in the meeting notes was conversational interactions, not one to one supervision or safety monitoring. She stated the meeting was very positive and Resident #49 stated he wished to get better to be able to get his colostomy removed/reversed. She stated the 15 minutes checks had been put in place when the resident returned from the hospital on [DATE] due to nursing judgment. She verified the resident had goals to refrain from self-injury, but had injured himself on 09/28/17 while in the facility, had expressed specific plans to injury himself with a light bulb on a particular date, 10/16/17, and had expressed to a nurse on 10/05/17 his continuing thoughts related to lights bulbs and harming himself. The Administrator indicated he had not attended the care plan meeting, but had been told Resident #49 was tired of the increased monitoring (the 15 minutes checks) particularly at night, and felt the resident's right to privacy had been weighed versus his need for supervision. However, the Administrator verified there was no documentation that Resident #49 expressed any privacy concerns related to the safety checks. A telephone interview with the psychiatric NP, RN #301, on 11/27/17 at 3:50 P.M. verified the details of her interactions with Resident #49 on 10/04/17. She stated he seemed to be internally stimulated and that he had related a plan to kill himself on the 16th. She stated the resident did not indicate why that date was significant, but after completing her assessment and reviewing the case with the psychiatrist in her practice, she ordered him be sent out to the hospital, anticipating he would be admitted for inpatient psychiatric treatment. She stated she asked the staff to monitor the resident every 15 minutes until he left the building to ensure his safety. She stated she did not order the 15 minute checks to continue, as she thought he would be admitted . She stated she was not notified by the facility staff that he had had not been admitted but had returned to the facility later that night. An interview with LPN #310 by phone on 11/28/17 at 11:15 A.M. verified she had written the note after speaking with Resident #49 on 10/05/17. She stated she understood the resident's comments about the light bulbs and bed springs and that he meant if he wanted to hurt himself, he could. She said the other options discussed specifically referred to telling staff when he was having those feelings and trying to keep busy with other activities. She said she notified the unit manager, LPN #125, who told her to document her concerns and maintain the ordered 15 minute checks on the resident. An interview with the DON on 11/28/17 at 12:15 P.M. revealed she did not remember any interaction with the psychiatric services social worker and had not been aware of the findings of her interview with Resident #49. An interview with LPN #125 on 11/28/17 at 12:20 P.M. revealed she was unaware of Resident #49's comments regarding light bulbs and bed springs contained in the nursing note written on 10/05/17. She verified there were no documented interventions put in place to address his threats regarding the use of light bulbs or bed springs to harm himself. An interview by phone with the psychiatric services social worker, Social Worker (MSW) #315, on 11/28/17 at 1:25 PM verified the concerns identified by the resident when she interviewed him on 10/18/17. She verified he said he had daily thoughts of hurting himself and stated she talked with nurses at the facility to ensure he was being checked and his room was monitored for safety. She stated she was assured he was on safety checks, but was not aware of how often he was being checked. She verified he was independently ambulatory and could move freely through the facility. Review of the prevention section of the facility policy on Abuse, Neglect and Misappropriation (undated) revealed the facility would strive to identify, correct and intervene in situations in which abuse is more likely to occur, including the assessment, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors and with residents with self-injurious behaviors. Review of the facility policy on Suicide Threats (revised December 2007) revealed staff should report threats of suicide immediately and these threats should be reported to the resident's attending physician to seek further direction form the physician. If the resident remained in the facility, staff would monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present. An interview with the ADON on 11/28/17 at 2:50 P.M. verified the suicide policy was the only policy the facility had regarding self-harm. She verified the policy contained interventions to include notification of the physician to determine the presence of suicide risk prior to discontinuation of interventions, including safety checks. The ADON verified the facility did not follow this policy and discontinued the 15 minute safety checks without contacting the physician. An interview with the Administrator on 11/27/17 at 8:30 A.M. revealed Resident #49 had been sent back to the hospital and would not return to the facility, as his needs for supervision had exceeded the limits the facility could provide. This deficiency substantiates Complaint Number OH 461.