Every finding on record at Crystal Care Center of Mansfie

Based on observations, medical record review, review of infection control documents, staff interview, review of Centers for Disease Control and Prevention (CDC) guidance, and review of the facility policy, the facility failed to ensure resident infections were adequately tracked for potential trends, failed to ensure residents who required Enhanced Barrier Precautions (EBP) had signage in place to including instructions for use of specific personal protection equipment (PPE), failed to ensure staff wore PPE during high-contact resident care activities with residents in EBP, and failed to ensure indwelling catheters were stored appropriately. This affected Residents #1, #6, and #49 and had the potential to affect all 60 residents residing in the facility. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date on 06/07/23. Diagnoses included paraplegia, chronic kidney disease, and cholecystitis. Review of the care plan dated 05/25/26 revealed Resident #1 had alteration in elimination due to having an indwelling urinary catheter from urinary retention and neurogenic bladder. Interventions included monitoring for signs and symptoms of urinary tract infection (UTI), and indwelling urinary catheter care every shift and as needed. Review of the entry Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact and had a indwelling catheter. The care plan dated 06/23/26 revealed Resident #1 had an area of concern to the left heel. Interventions included monitoring for signs and symptoms of infection. The care plan dated 06/28/26 revealed Resident #1 required EBP due to a chronic wound and indwelling urinary catheter use. Interventions included using PPE in conjunction with standard precautions which included using gown and gloves during high contact resident care activities. Review of the physician's orders revealed on 06/24/26, an order for right foot apply dry sterile dressing and kerlix with ace wrap everyday use [NAME] heel for protection in the morning every other day for right foot ulcer. On 06/20/26, an order for left heel cleanse with normal saline, apply xeroform dry sterile dressing, kerlix and ace wrap every day in the morning. There were no physician orders for Resident #1 to be on EBP. Observation and interview on 06/28/26 at 8:53 A.M. revealed Resident #1 sitting in his wheelchair. Resident #1's catheter bag was underneath of the wheelchair touching the floor. Licensed Practical Nurse (LPN) #378 confirmed the catheter bag was on the ground and confirmed the catheter bag should off of the floor to prevent infection. Observation on 06/28/26 at 9:00 A.M. of Resident #1's room revealed there were no signs for EBP posted on the door or PPE outside of the room. Interview on 06/28/26 at 9:45 A.M. with Licensed Practical Nurse (LPN) #378 confirmed Resident #1 did not have a sign on the door for EBP and confirmed there was no order for EBP. 2. Review of the medical record for Resident #6 revealed an admission on [DATE]. Diagnoses included chronic metabolic acidosis, and hydronephrosis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively intact and was dependent on staff for activities of daily living (ADLs). Review of the care plan dated 06/05/26 revealed Resident #6 required EBP due to indwelling urinary catheter and wound to right heel. Interventions included using PPE in conjunction with standard precautions of using a gown and gloves during high contact resident care activities. Review of the physician's orders revealed on 06/09/26, an order for indwelling urinary catheter to continuous drain every shift related to obstructive and reflux uropathy. On 05/29/26, there was a treatment in place for Resident #6's right heel treatment. There were no physician orders for Resident #6 to be on EBP. Observation on 06/28/26 at 9:32 A.M. revealed Certified Nursing Assistant (CNA) #402 entered into Resident #6's bedroom without any PPE on. Interview on 06/28/26 at 9:40 A.M. with CNA #402 revealed Resident #6 had a bowel movement on the bedpan and required assistance with care. Resident #6 confirmed PPE was not worn during care. 3. Review of the medical record for Resident #49 revealed an admission on [DATE]. Diagnoses included overactive bladder, dysuria, and anemia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was cognitively intact. Review of the care plan dated 05/05/26 revealed Resident #49 had an alteration in elimination by indwelling urinary catheter. Interventions included catheter care every shift and as needed. There was no care plan for Resident #49 to be in EBP. Review of the physician's orders dated 06/08/26 revealed an order for indwelling urinary catheter to continuously drain every shift for urinary retention. There were no physician orders for Resident #49 to be on EBP. Observation on 06/28/26 at 9:14 A.M. of Resident #49's bedroom revealed no sign on the door for EBP. Interview on 06/28/26 at 9:45 A.M. with Licensed Practical Nurse (LPN) #378 confirmed Resident #49 did not have a sign for EBP and did not have a physician order or care plan for EBP. Review of the 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 is 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. 4. Review of the facilities infection surveillance on 06/29/26 at 1:30 P.M. revealed there was no monitoring of trends in infections from 01/01/26 through 06/29/26. Interview on 06/29/26 at 1:45 P.M. with Registered Nurse (RN) #345 who was the facilities Infection Preventionist (IP) revealed she was not aware she had to track infections that did not meet McGreer's criteria and confirmed there was no tracking of trends in infections. Review of the CDC guidance titled CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings dated 04/12/24 and found at https://www.cdc.gov/infection-control/hcp/core-practices/index.html revealed under Performance Monitoring Feedback, a core practice included to monitor the incidence of infections that may be related to care provided at the facility and act on the date and use information collected through surveillance to detect transmission of infectious agents in the facility.

Based on medical record review, staff interview, observation and policy review, the facility failed to ensure residents dependent on staff for activities of daily living (ADL) received adequate nail care and personal hygiene assistance. This affected two residents (#5 and #43) of three residents reviewed for ADL care. The facility census was 60. Findings include: 1. Review of Resident #5's medical record revealed an admission date of 04/21/20. Diagnoses included anxiety disorder, diabetes mellitus (DM), and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had severely impaired cognition and was dependent on staff with personal hygiene. Review of the care plan dated 05/07/26 revealed Resident #5 had DM with an intervention to refer to the podiatrist or foot care nurse to monitor foot care needs and to cut long nails. Resident #5 had an ADL self-care performance deficit with and intervention to inspect Resident #5's skin weekly and to observe for redness, open areas, scratches, cuts, and to report changes to the nurse. Review of Resident #5's shower sheets for the months of May 2026 and June 2026 revealed the last time Resident #5's nails were documented to be cleaned and trimmed was on 05/26/26. Observation on 06/28/26 at 9:23 A.M. revealed Resident #5's fingernails on his left hand were long. Due to the contracture of his left hand, Resident #5's fingernails were digging into the palm of his hand. Interview on 06/30/26 at 8:33 A.M. with Certified Nurse Aide (CNA) #398 verified Resident #5's fingernails on his left hand were long and digging into his palm. CNA #398 stated Resident #5 had DM and required the nurse to cut his fingernails. Review of the undated facility policy titled Resident Nail Care revealed the facility shall provide routine nail care as necessary to maintain resident comfort, hygiene, and skin integrity while ensuring services are provided safely and within each staff members scope of practice. 2. Review of Resident #43's medical record revealed an admission date of 11/13/23. Diagnoses included dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had severely impaired cognition and required supervision or touching assistance from staff with personal hygiene. Review of Resident #43's care plan dated 05/15/26 revealed Resident #43 was at risk for Activities of Daily Living (ADL) decline with interventions that included to encourage resident participation while performing ADLs and to try to make the ADL routine consistent to foster recognition of necessary tasks. Observations on 06/28/26 at 8:31 A.M. and 06/29/26 at 8:31 A.M. revealed Resident #43 who was a female had facial hair surrounding her mouth. Interview on 06/29/26 at 4:07 P.M. with Activities Assistant #343 verified Resident #43 still had facial hair surrounding her mouth. Review of the undated facility policy titled Resident Dignity revealed staff would provide care that preserves each resident's dignity by maintaining the resident's personal appearance and hygiene consistent with their preferences and care plan.

Based on observation, record review, policy review, and staff interview, the facility failed to ensure insulin medications were labeled appropriately with a date when opened and resident's names were on the medication, and medications were not left at a resident's bedside. This affected two of six medication carts observed for medication storage and the facility identified there were six medication carts in the facility. This affected Residents #32, #57, and #64. The census was 60. Findings Include: 1. Observation on 06/29/26 at 7:41 A.M. of the 100-Hall A medication cart revealed an insulin Novolin R solution multi-dose vial 100 unit per milliliter (ml) with a dispense date from the pharmacy on 05/30/25 was not dated when opened for Resident #57. a Novolin R injection pen 100 units dispensed from pharmacy on 03/08/26 was not dated when opened for Resident #57, and a multi-dose vial of Lantus 100 units per ml dispensed from pharmacy on 03/08/26 was not dated when opened. Interview on 06/29/26 at 7:48 A.M. with Registered Nurse (RN) #399 verified the three insulin pens were not dated when opened and should be discarded after 28 days. 2. Observation on 06/29/26 at 7:50 A.M. of the 300-Hall medication cart revealed Lispro Kwik Pen injection dispensed from pharmacy on 10/20/25 was not dated when opened for Resident #32, Novolog 100 unit per milliliter (ml) multi-dose vial dispensed from pharmacy on 05/05/26 was not dated when opened and did not have a resident's name on it, and Lispro kwik pen injection was not dated when opened and did not have a resident's name on it. Interview on 06/29/26 at 7:59 A.M. with Licensed Practical Nurse (LPN) #359 verified three insulins were not dated when opened. LPN #359 stated she believed the NovoLog was being used for Resident #57 and the Lispro insulin that did not have a name on it was for Resident #32. Review of the Insulin reference chart on the medication cart from pharmacy revealed Novolin R solution, Lantus 100 units per ml and Lispro Kwik Pen injection should be discarded when not in the refrigerator for 28 days. 3. Review of the medical record for Resident #64 revealed an admission on [DATE]. Diagnoses included depression, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 was cognitively intact. Review of the care plan dated 03/19/26 revealed Resident #64 did not have a focus area stating Resident #64 can self-administer medication. Review of the physician's orders revealed no order for Resident #64 to self-administer medication, or leaving medications at bedside. Observation and interview on 06/28/26 at 8:25 A.M. revealed Resident #64 had a cup of unknown pills with Resident #64's name on them sitting on her bedside table. Resident #64 revealed the medications on the bedside table were her morning medications. Resident #64 stated the staff trust her to take her medications. Interview on 06/28/26 at 8:35 A.M. with Licensed Practical Nurse (LPN) #378 confirmed the medications on Resident #64's bedside table were the morning medications. LPN #378 confirmed Resident #64 did not have an order to leave medications at bedside. LPN #378 stated Resident #64 was reliable, so she thought it was ok to leave medications with her. Review of the facility's undated policy titled Medication Management revealed medications will be checked for expiration dates, and expired drugs will be pulled at least once a month. Medication carts must be used for storage of all medications managed by the community.

Based on record review, policy review, and staff interview, the facility failed to implement their policy by ensuring all employees were screened in the Ohio Nurse Aide Registry (NAR) prior to or on their first day of work/hire to ensure the employee did not have a finding entered into the NAR concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property as required. This had the potential to affect all 60 residents residing in the facility.Findings include:1. Review of the personnel file for the Licensed Nursing Home Administrator (LNHA) revealed a hire date of 01/06/26. There was no evidence of the LNHA being screened in the NAR.2. Review of the personnel file for Dietary Aide (DA) #310 revealed a hire date of 03/12/26. There was no evidence of DA #310 being screened in the NAR.3. Review of the personnel file for Registered Nurse (RN) #399 revealed a hire date of 10/27/25. There was no evidence of RN #399 being screened in the NAR.Interview on 06/29/26 at 11:25 A.M. with Human Resource Manager (HR) #377 verified the LNHA, DA #310, and RN #399 were not screened in Ohio's NAR. HR #377 stated she only screened the certified nursing aides (CNAs) in Ohio's NAR.Review of the facility's policy dated 04/29/26 titled Resident Abuse, Neglect, Exploitation and Misappropriation of Property, revealed all individuals applying for employment at (the facility) are screened through an interview process which includes questions about convictions, a thorough check of references and contact with the State's Nurses Aide Registry or other appropriate licensing board.

Based on record review, observation, and staff interview, the facility failed to implement protective boots designed to maintain skin integrity per the plan of care for Resident #55. This affected one (Resident #55) of 19 residents reviewed for care plan implementation. The facility census was 61. Findings include: Review of the medical record revealed Resident #55 was admitted to the facility on [DATE]. Diagnoses included heart failure, spinal stenosis, and dementia. Review of the quarterly Minimum Data Set assessment, dated 06/11/24, revealed Resident #55 was cognitively intact and required substantial to maximal assistance from staff for putting on and taking off footwear. Review of Resident #55's physician orders for August 2024 identified an active order dated 01/18/24 for prevalon boots on while in bed, every shift for redness to bilateral heels. Review of the plan of care dated 01/12/24 revealed Resident #55 was at risk for impaired skin integrity related to impaired circulation, impaired mobility, advanced age, eczema, psoriasis, and incontinence. Interventions included padding and protecting skin as needed and pressure reduction devices if ordered. Observations on 08/25/24 at 11:20 A.M., 08/26/24 at 1:34 P.M., and 08/27/24 at 9:59 A.M. revealed Resident #55 was lying in bed with her heels lying directly on the mattress. The boots were not in place and were lying on the floor near the foot and partially underneath of the resident's bed. During an interview on 08/27/24 at 10:28 A.M., State tested Nurse Aide (STNA) #353 reported they provided care for Resident #55 on a regular basis. STNA #353 verified Resident #55 did not have the boots in place while lying in bed. STNA #353 reported the resident never wore the boots while in bed during the day.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure assistive devices were used appropriately to ensure a safe transfer. This affected one (Resident #41) of four residents reviewed for accidents. The facility census was 61. Findings include: Review of the medical record for Resident #41 revealed an admitted [DATE]. Diagnoses included dementia, Parkinson's disease, and heart failure. Resident #41 had impaired cognition. Review of the care plan dated 09/28/23 for Activities of Daily Living (ADLs) revealed staff were to use a mechanical lift for transferring Resident #41. Observation of 08/28/24 at 4:22 P.M. revealed State tested Nurses Assistant (STNA) #346 was transferring Resident #41 to her wheelchair out in the hall. STNA #346 was observed using the standing Hoyer (mechanical lift) on her own. As STNA #346 was unhooking the Hoyer arm, it hit the hand sanitizer on the wall and the hand sanitizer fell hitting Resident #41 in her left arm. Interview on 08/28/24 at 4:25 P.M. with STNA #346 stated when using the standing Hoyer lift or the ceiling Hoyer lift, you only need one staff member to transfer residents. STNA #346 verified she transferred Resident #41 with the standing Hoyer lift by herself. Interview on 08/28/24 at 4:29 P.M. with the Director of Nursing (DON) verified when transferring a resident with a standing Hoyer, staff always need two staff members and when using the ceiling Hoyer lift, you can use one or two staff members. Review of the facility policy titled Sit to Stand/Hoyer Lift Usage Policy, dated 08/22/23 revealed operate the lift according to the manufacture's instructions, with one staff member operating the lift and another supporting the resident.

Based on observation, resident and staff interview, medical record review, and policy review, the facility failed to assess the resident for the risks of entrapment with the use of bed rails prior to installation or use. This affected one resident (#168) of seven residents identified with orders for bed rails. The facility census was 61. Findings include: Review of Resident #168's medical record revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis, cerebrovascular disease, a stroke, muscle weakness, and seizures. The medical record revealed no evidence of an assessment for bed rails. There was a signed consent form for bed rails dated 08/08/13. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #168 had intact cognition and required substantial to maximum assistance of staff with bed mobility, and was dependent on staff for toileting, hygiene and transfers. The assessment did not identify bed rails as a restraint. Review of the care plan dated 07/17/24 revealed Resident #168 was at a fall risk and had seizures. Interventions included a bilateral half size bed rail. Review of the physician orders dated August 2024 revealed an order for padded bilateral half size bed rails to the bed at all times. Observation on 08/26/24 at 9:17 A.M. revealed Resident #168 was lying in bed. Resident #168's bed had padded metal bed rails on both sides of the bed and both rails were in the raised position. Interview at this time with Resident #168 stated she was afraid of falling out of the bed and needed the bed rails. Interview on 08/29/24 at 2:30 P.M. with MDS Nurse #331 verified there was no assessment for the use of side/assist/bed rails for Resident #168. MDS Nurse #331 stated she just started auditing assessments for bed rails and did not get to Resident #168. Review of the facility policy titled Bedrails dated 02/25/20 revealed when a bed or side rail is issued, the facility will ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. Assessing the resident for risk of entrapment from bed rails prior to installation. Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. Follow the manufactures' recommendations and specifications for installing and maintaining bed rails.

Based on resident personal needs accounts (PNA) balances review, surety bond review and staff interviews, the facility failed to ensure the surety bond covered the entire balance maintained in the resident PNA account. The facility maintained 44 (#1, #2, #3, #5, #8, #9, #10, #11, #12, #13, #14, #16, #17, #19, #20, #21, #22, #23, #25, #24, #26, #27, #28, #29, #30, #32, #33, #34, #35, #37, #38, #39, #40, #43, #45, #46, #50, #53, #58, #59, #60, #61, #62 and #214) of 44 personal needs accounts funds. The facility census was 68. Findings include: Review of the facility's personal needs account total balance revealed the total account balance was $24,603.59 on 05/02/22. The balance included 44 (#1, #2, #3, #5, #8, #9, #10, #11, #12, #13, #14, #16, #17, #19, #20, #21, #22, #23, #25, #24, #26, #27, #28, #29, #30, #32, #33, #34, #35, #37, #38, #39, #40, #43, #45, #46, #50, #53, #58, #59, #60, #61, #62 and #214) residents whom currently reside in the facility. Review of facility surety bond identified it covered the facility for losses up to $20,000. Interview on 05/04/22 at 7:07 A.M. , with Financial Director #104, revealed due to many residents with stimulus checks the balance of the residents Personal needs accounts (PNA) is $24,603.59 and the facility's current bond covers $20,000.

Based on observations, review of tracking logs, review of manufacture's instructions and staff interviews, the facility failed to ensure security bracelets used to identify potential elopements were monitored for expiration dates and tracked during nightly checks. This affected seven (#9, #20, #22, #28, #33, #34 and #113) residents whom currently have security bracelets and one (#12) resident who had an expired security bracelet. The facility had four additional spare security bracelets, that were not being tested . The facility also failed to ensure fall interventions were in place for one (#21) of three sampled residents identified high risk for falling. The facility census was 68. Findings include: 1. Review of Resident #12's medical record revealed an admitted [DATE], with medical diagnoses including: [CONDITION(S)], [CONDITION(S)], dementia and [CONDITION(S)]. Review of the monthly physician's orders for [DATE], revealed an order for a security bracelet place on her wheelchair since [DATE]. The orders identified the security bracelet was discontinued on [DATE]. Observation on [DATE] at 4:32 P.M., of Resident #12 was sitting in her wheelchair in the television room. The back section of the chair was observed with a security bracelet bracelet device attached to the back of the chair. Observation of the device security bracelet bracelet identified it had expired in [DATE]. Observation and interview with the facility Assistant Director of Nursing (ADON) #105 on [DATE] at 4:52 P.M., verified Resident #12's security bracelet located on the wheelchair is expired. The interview additionally verified the testing book located at the nursing station for all residents with a device does not list the expiration dates for any of seven devices being used currently for Resident Resident #9, #20, #22, #28, #33, #34,#113 . ADON #105 stated the testing logs are completed by the night shift licensed nursing staff and are tested every night. ADON #105 stated the expiration date for each device should be listed on the testing log, to ensure devices are changed out when they expire. Interview on [DATE] at 8:34 A.M. ,with the Director of Nursing (DON) verified the facility has four extra security bracelets located in a box to be used when needed. The DON stated these four have not been tested and logged. Review of the Secure Care (security bracelet) manufactures instruction dated [DATE], revealed to ensure proper operation of the transmitter it must be upright or vertical position on the ankle. The policy also identified a documented test of each ankle device must be made daily including transmitters not in use. The instructions revealed the actual expiration date is the last day of the month engraved on the transmitter. 2. Review of Resident #112's medical record revealed an admitted [DATE], with medical diagnoses including: chronic pancreatitis, muscle weakness, [CONDITION(S)] and dementia. Review of the [DATE] physician's orders identified on [DATE] a security bracelet was placed on the left ankle. Review of Resident #112's security bracelet, nightly Wander-guard (security bracelet) Prevention form identified no evidence of the date the bracelet expires. 3. Review of Resident #21's medical record revealed an admitted [DATE],with medical diagnosis including; [CONDITION(S)], urinary tract infections, depression, dementia, [CONDITION(S)], and bilateral femur fractures. Review of the quarterly assessment dated [DATE] identified Resident #21 was cognitively intact and required extensive assistance of one person for bed mobility. Resident #21 was identified to have fallen from the bedside on [DATE] and fractured both legs. Review of Resident #21's written plan of care for fall prevention included interventions of mat to the bedside, winged pressure reduction mattress and voice activated alarm to bed. Review of the [DATE] physician orders identified winged mattress. Observation on [DATE] at 7:00 A.M., of Resident #21 was observed in bed revealed there was no mat next to the bed or winged mattress on the bed. Observation on [DATE] at 2:43 P.M., of Resident #21 reveled upon returning from [CONDITION(S)] and was placed in bed. There was no fall mat located next to the bed, the voice alarm was sitting on the bedside stand unattached and the mattress was not winged type after the resident was placed in bed. Observation and interview on [DATE] at 3:05 P.M., with Licensed Practical Nurse (LPN #102) verified Resident #21's voice alarm was laying on the bedside table unattached, no winged mattress was on the bed and the fall mat was placed at the end of the bed, instead of the bedside. LPN #102 verified Resident #21 fall interventions were not in place. 4. Review of Resident #20's medical record revealed an admission on [DATE], with medical diagnosis including gastro-[CONDITION(S)] reflux disease, [CONDITION(S)], [CONDITION(S)], ataxia, diabetes mellitus type 2, [CONDITION(S)], and hypertension. The physician orders identified Resident #20 to have a wander-guard placed on her right ankle starting on [DATE]. Observations of Resident #20's security bracelet to be present on her right ankle in the up-right position from [DATE] through [DATE]. Observation of the device identified with an expiration date of [DATE]. Interview and observation on [DATE] at 8:32 A.M., with RN #51 verified Resident #20's security bracelet is tested every night by licensed nurse and confirmed the expiration date to be in [DATE]. However, the expiration date was not present on the testing log book.

Based on record review, policy review, and staff interview, the facility failed to accurately complete the Minimum Data Set (MDS) assessment to reflect the residents current condition. This affected one (#19) of 22 residents reviewed for assessments. The facility census was 68. Findings include: Record review revealed Resident #19 had an admitted [DATE]. Resident was discharged to the hospital on 01/14/22 and returned on 01/17/22. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the pressure injury grid dated 01/30/22 (untimed) revealed Resident #19 had acquired a fluid filled blister that was unstageable to the right heel. Review of the MDS assessment dated [DATE], created by LPN #20 revealed under section M skin condition asking does the resident have a pressure ulcer injury? The answer was no. Other ulcers, wound or skin problems? The answer was no. Interview on 05/04/22 at 9:54 A.M., with MDS Nurse, LPN #20, verified the 02/04/22 MDS was incorrect for wounds. Review of the policy titled, Resident Assessment Instrument dated 10/01/10, revealed the Resident Assessment Instrument correctly and effectively help provide appropriate care. It helps nursing home staff gather definitive information on the residents strengths and needs which must be addressed in an individual care plan.

Based on medical record review and staff interview, the facility failed to ensure a plan of care was revised timely to meet the current needs of the resident. This affected two (#21 and #19) of 22 residents care plans reviewed. The facility census was 68. Findings include: 1. Review of Resident #21's medical record revealed an admission to the facility on [DATE], with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #21's written plan of care for nutritional aspects revealed an 1500 cubic centimeters (cc) fluid restriction with renal diet. Interview on 05/04/22 at 7:58 A.M., with the Director of Nursing (DON) revealed Resident #21 has not been on a fluid restriction since 10/18/20. The DON stated Resident #21's diet changed from renal to regular on 07/27/20. The DON verified the written plan of care was not accurate for Resident #21 in regards to nutritional issues. 2. Review of the medical record for Resident #19 revealed a re-admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan initiated 01/04/17, revealed the resident had the potential for impairment to skin integrity. Interventions include to provide a pressure reduction mattress and an egg crate overlay to the bed. There were no specific interventions listed for Resident #19's heels. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #19 had recent surgery with repair of a fracture. Resident #19 was extensive assistance of one staff for bed mobility and had no pressure ulcers. Resident #19 was assessed as being at risk for the development of pressure ulcers. Record review of the form titled Pressure Injury Skin Grid, dated 01/30/22, revealed Resident #19 obtained an unstageable wound to the right heel. The facility added pressure reducing boots on 01/30/22, after the wound developed. Review of the skin grid dated 04/27/22, revealed the resident continued to have an unstageable pressure ulcer to the right heel with eschar present. Record review of the care plan revealed a care plan was initiated for alteration in skin integrity, deep tissue injury to the right heel on 03/03/22. Interview on 05/04/22 at 09:54 A.M., with MDS Nurse, LPN #20, verified there was no care plan for the heels until 03/03/22.

Based on observations, resident and staff interviews, medical record review, and review of policy, the facility failed to ensure a dependent resident was safely and comfortably position to eat while in bed. This affected one (#213) of four residents observed eating in bed. The facility census was 68. Findings include: Review of Resident #213's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed resident was cognitively intact. Resident #213 was total dependence of two for bed mobility and required setup help for meals. Review of the care plan dated 04/07/22 revealed the resident had potential for nutritional impairment, dehydration and significant weight changes. Resident#213 had an activities of living self-care performance deficit-functional impairment related to right femur fracture. Interventions included the resident required supervision and set-up help by staff to eat. Observation on 05/03/22 at 11:54 A.M., revealed Resident #213 was lying in bed. The head of the bed was slightly raised. Residents right leg was propped up on a pillow. Resident #213's body had slightly slid down in bed. State tested Nursing Assistant (STNA) #86 was passing lunch trays and entered Resident #213's room with the lunch tray. STNA #86 placed Resident #213's bed side table over the residents lap then sat her lunch tray on the bed side table. STNA #86 then left the room. Observation revealed the position of the bed side table was at Resident #213's eye level and the head of the bed was only slightly (approximately 20 to 30 degrees) elevated. Resident #213 reached up feeling the tray for her glass of juice. Resident then moved the juice toward her mouth using her tongue to feel for the edge of the glass to not spill the juice on her. Resident #213 was not able to take a drink without spilling the juice and sat the glass back on the tray. Interview on 05/03/22 at 11:56 A.M., with Resident #213 confirmed she was unable to drink the juice without spilling it and was unable to see the food on top of the tray due to her position in bed. Resident #213 confirmed it was difficult to eat and staff did not offer or attempt to reposition her prior to leaving the lunch tray. Resident #213 revealed she did not ask to be repositioned because the staff were busy and she did not want to burden them. Observation and interview on 05/03/22 at 11:58 A.M., with Licensed Practical Nurse (LPN) #56 confirmed Resident #213's head of bed was in a lowered position, the resident's body had scooted down in bed and the resident was unable to see the food on top of her lunch tray to safely eat. Interview on 05/03/22 at 11:59 A.M., with STNA #86 confirmed she served Resident #213's lunch tray and did not position resident to be able to safely see and eat her food. STNA #86 stated, I don't know why I didn't reposition her, I just didn't. STNA #86 confirmed staff were available to assist with repositioning. Observation on 05/04/22 at 4:51 P.M., revealed Resident #213 was lying in bed. The head of the bed was slightly raised. Residents right leg was propped up on a pillow. Resident #213's body had slightly slid down in bed. STNA #94 was passing dinner trays and entered Resident #213's room with the dinner tray. STNA #94 placed Resident #213's bed side table over the residents lap then sat her dinner tray on the bed side table. STNA #94 then left the room. Observation revealed the position of the bed side table was at Resident #213's eye level and the head of the bed was only slightly (approximately 20 to 30 degrees) elevated. Resident was unable to see the food in the dishes on top the tray. Observation of dinner tray revealed tomato soup and a sandwich was served. Observation revealed resident was reaching up with the spoon to the bowl and as she brought the spoon back to her moth, the soup was spilling onto her gown from the spoon. Interview on 05/04/22 at 4:52 P.M. with Resident #213 verified she was unable to see the food on her tray and it was difficult to eat. Resident stated, I don't know why they don't put me up more, they will if i ask but i don't always ask. I don't want to bother them, they are busy. Observation and interview on 05/04/22 at 04:55 P.M., with Registered Nurse (RN) #51 verified Resident #213's position in bed while trying to eat and had food spilled on her gown. Resident #213 stated to RN #51, It's not feasible. Interview on 05/04/22 at 5:01 P.M. ,with STNA #94 confirmed she delivered the dinner tray and did not reposition Resident#213 for her meal. STNA #94 stated, I didn't realize. STNA #94 confirmed staff were available to assist with repositioning a resident. Review of the undated policy titled, Positioning During Eating revealed residents were to be sitting up straight or slightly forward with head upright during meals.

Based on review of the medical record, observations, family and staff interviews, and policy review, the facility failed to ensure a resident's range of motion and application of orthotic devices were maintained with continuous restorative care. This affected one (#31) of one resident reviewed for range of motion. The facility census was 68. Findings include: Review of Resident #31's medical record reveal an admitted [DATE]. The resident was discharged to the hospital on 02/02/22 and returned to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly minimum data set (MDS) assessment, dated 03/04/22, revealed the resident was cognitively impaired. The resident had a documented limitation in Range of Motion (ROM) for both upper extremities (shoulders, elbows, wrists, hands). Review of the Occupational Therapy (OT) evaluation and plan of treatment, dated 02/11/22, revealed the goal of increasing Resident #31's ROM of the bilateral upper extremities. Review of the OT discharge recommendations, dated 03/03/22, revealed the resident was recommended to have a palm protector to the left hand and Comfy Grip hand orthosis to the right hand. Review of the restorative plan of care dated 04/01/22 through 05/03/22, revealed the resident would participate in ROM exercises for her bilateral upper extremities daily, and would participate with splinting of bilateral hands after ROM exercises for between two and three hours daily. Review of the corresponding restorative documentation, dated 04/01/22 through 05/03/22, revealed restorative services were provided to Resident #31 on 04/09/22, 04/10/22, 04/19/22, 04/20/22, and 04/21/22. Restorative services including ROM and splinting were not documented as provided for the other 28 days within this time period. Observation on 05/02/22 at 11:24 A.M., revealed both the left and right hands of Resident #31 were contracted. Resident #31 was unable to fully open either hand. At no time during the annual survey on 05/02/22, 05/03/22, or 05/04/22 over multiple observations, was any type of splint or orthotic device observed in place for Resident #31. Interview on 05/03/22 at 4:16 P.M., with Licensed Practical Nurse (LPN) #102 verified Resident #31 was only documented as receiving restorative services for five out of 33 days. LPN #102 reported State tested Nurse Aides (STNA) were responsible for providing restorative services such as ROM and application of splints or other orthotic devices. Interview on 05/04/22 at 1:41 P.M., with STNA #50, revealed she was frequently assigned to work with Resident #31 and was unaware of any orthotic devices or splints in place for either of the resident's hands. Interview on 05/04/22 at 2:00 P.M., with Resident #31's husband, revealed Resident #31's husband was typically at the facility on a daily basis from 11:00 A.M. to 6:00 P.M. Resident #31's husband reported LPN #102 brought down and placed palm protectors on each of Resident #31's hands on 05/03/22 and he had never seen them prior to then. Review of the policy titled, Restorative Nursing Program, dated 12/06/17, revealed restorative programs would be documented on the facility designated restorative care form.

Based on observations, medical record reviews, and staff interviews, the facility failed to ensure residents were provided supplemental dietary foods to maintain nutritional health. This affected two (#19 and #21) of five residents reviewed for nutrition. The facility census was 68. Findings include: 1. Record review for Resident #19 revealed an admitted [DATE] and a re-admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had no swallowing disorders and no known weight loss. Resident #19 required supervision with set up help only for meals. Record review of the care plan dated 01/24/22 revealed a potential for nutritional impairment and dehydration due to variable meal intakes. Interventions included a house supplement three times a day, obtain/record weight per facility policy and monitor for significant changes. Review of the Nutritional assessment dated [DATE], completed by Registered Dietitian (RD) #115, revealed the resident received a house supplement two times a day and consumes 25 % of meal intakes. A Readmitting Nutrition Assessment was completed. Resident #19 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #19 was noted with poor meal intakes/refusals since return. A mechanical soft diet will continue with a house supplements two times a day. Resident #19 was accepting the house supplements per nursing staff. Potential for significant weight changes with fluid shifts, will monitor effects on appetite. Will recommend increasing the house supplement to three times a day at this time to increase calorie/protein/fluid intakes and will continue to monitor intakes, weights and laboratory tests for need of additional interventions. There was no weight listed for the resident. Record review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR for February 2022 and March 2022 revealed no record of a house supplement being offered. Review of the MAR for April 2022 revealed on 04/26/22, health supplement three times a day was added to the MAR. The health supplement three times a day was also added to the MAR for May 2022. Interview on 05/04/22 at 2:30 P.M., with the Director of Nursing (DON) confirmed the house supplement was not on the MAR for February and March 2022 and was not restarted until 04/26/22. The DON revealed this was a transcription error and confirmed the house supplement was not given during that period. Interview on 05/04/22 at 2:57 P.M., with RD #115 revealed Resident #19 received and would accept the house supplements when offered. RD #115 revealed she was not made aware the resident had not received the supplements as ordered. 2. Review of Resident #21's medical record revealed an admission to the facility on [DATE], with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #21's nutritional assessment dated [DATE] identified the resident should be getting a regular diet with large meat portions, super-cereal in the morning and pudding every day. Review of Resident #21's diet card (used by kitchen to prepare meals) identified no evidence of super-cereal every morning. Review of Resident #21's May 2022, physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident #21's breakfast meals occurred on 05/03/22 and 05/05/22 with no super-cereal observed provided for Resident #21. Interview on 05/05/22 at 8:02 A.M., with the DON verified Resident #21 did not received super cereal and the dietary recommendations and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on record review, observation, interviews with resident, staff and [CONDITION(S)] center staff, the facility failed to ensure a resident was provided a meal prior to leaving for regular [CONDITION(S)] appointments. This affected one (#21) of one reviewed for [CONDITION(S)] services. The facility identified three current residents receiving [CONDITION(S)] services. Facility census was 68. Findings include: Review of Resident #21's medical record revealed an admission to the facility on [DATE], with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #21's written plan of care for nutritional aspects revealed an 1500 cubic centimeters (cc) fluid restriction with renal diet. Interview on 05/04/22 at 7:58 A.M., with the Director of Nursing (DON) revealed Resident #21 has not been on a fluid restriction since 10/18/20. The DON stated Resident #21's diet changed from renal to regular on 07/27/20. The DON verified the written plan of care was not accurate for Resident #21 in regards to nutritional issues. Observation on 05/03/22 at 2:28 P.M., revealed Resident #21 had returned to the facility from [CONDITION(S)]. Resident #21 identified she does not get any lunch on her [CONDITION(S)] days (Tuesday, Thursday and Saturdays). Resident #21 stated no one is allowed to have any food at the [CONDITION(S)] center and therefore nothing is sent with her to the center. Resident #21 stated she was very hungry at this time. Interview on 05/03/22 at 3:05 P.M., with Licensed Practical Nurse (LPN) #102 verified the facility does not have anything specific scheduled for Resident #21 to receive food just prior to leaving or returning from [CONDITION(S)]. LPN #102 verified the facility needs to do something for Resident #21 on those days. Interview via telephone, on 05/03/22 at 3:19 P.M., with the [CONDITION(S)] Center Representative #400 verified the center does not allow for food to be brought in and this will not be changing this practice.

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure adequate supervision for a resident when in the bathroom. This resulted in actual harm when a resident fell in the bathroom and sustained a [MEDICAL CONDITION] clavicle (collarbone). This affected one resident (#63) of two reviewed for falls. The facility census was 68. Findings include: Medical record review revealed Resident #63 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #63's care plan dated 03/15/18, revealed the resident was at risk for falls related to gait/balance problems. Interventions included to not leave the resident in the bathroom unattended. Review of Resident #63's nurse's note dated 03/06/19 revealed State tested Nursing Assistant (STNA) #231 reported to the nurse she had assisted Resident #63 on the toilet and walked away to get toothpaste. When STNA #231 went back to the bathroom she saw the resident slide off the toilet and landed on her right shoulder. Review of Resident #63's fall investigation dated 03/06/19 revealed the resident's fall occurred on 03/06/19 at 7:10 A.M. STNA #231 witnessed the fall. Review of STNA #231's statement revealed Resident #63 had been on the toilet when she walked away to get toothpaste. When she returned to the bathroom she witnessed the resident fall off the toilet and hit her right shoulder. Review of Resident #63's nurse's note dated 03/06/19 revealed the physician had visited the resident after the fall due to pain in her right arm. The physician ordered an x-ray and the results revealed a fractured right clavicle. A sling was provided for the resident's right arm and a follow up visit with an orthopedic was made. Review of Resident #63's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident required extensive assistance of one person for transfers and toilet use. Further review revealed the resident was not steady moving on and off the toilet and had impairment on one side. Interview on 05/16/19 at 8:56 A.M., with STNA #231 verified she had left Resident #63 unattended on the toilet on 03/06/19 and the resident fell off the toilet. Review of facility policy titled Fall Prevention Program undated revealed the facility will identify patients at risk for falls and initiate interventions to prevent falls and reduce the risk of injury due to falls.

Based on medical record review and staff interview, the facility failed to develop a care plan for one resident with a hand contracture. This affected one resident (#58) of one reviewed for range of motion. The facility census was 68. Findings include: Review of Resident #58's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #58's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident as having impairment on one side. There was no evidence in the medical record of a are plan for Resident #58's left-hand contracture, or any interventions to prevent further decreases in range of motion Interview on 05/15/19 at 2:07 P.M., with Registered Nurse (RN) #400 verified Resident #58's care plan did not address the resident's hand contracture.

Based on observations, staff interview, and record review, the facility failed to ensure a resident was appropriately positioned during meals. This affected one (Resident #46) of 36 residents observed for dining positioning. The facility census was 69. Findings include: Review of the face sheet of Resident #46 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the 11/03/16 quarterly Minimum Data Set (MDS) of Resident #46 revealed the resident required extensive assistance of one person for eating. Review of the State tested Nursing Assistant (STNA) charting for level of assistance needed for eating for Resident #46 from 12/01/16 through 01/05/17, revealed the resident was usually totally dependent for eating, but was marked as requiring extensive assistance on 12/20/16 and 12/25/16, and marked as requiring limited assistance on 12/16/16 and 12/18/16. Review of the care plan of Resident #46, with a goal date of 02/17/17, revealed Resident #46 required extensive assistance by staff for eating. During observation of the lunch meal on 01/04/17 at 11:58 A.M., Resident #46 was sitting in the main dining room at a table. The top of the table came up to the residents shoulders, and the resident was eye level with her food. During the lunch meal, Resident #46 was not observed to attempt to assist herself with eating. During observation of the breakfast meal on 01/05/17 at 7:35 A.M., Resident #46 was sitting in the main dining room at the same high table, with the top of the table at shoulder level. The resident was not observed to be assisting with feeding herself. During an interview on 01/05/17 at 8:22 A.M., STNA #51 stated Resident #46 had been sitting at the high table. STNA #51 was not sure how long the resident had been sitting at that table for meals. STNA #51 stated Resident #46 was usually totally dependent on staff for eating meals, but that the resident would sometimes help take sips of drinks if a cup was handed to her. During an interview on 01/05/17 at 8:25 A.M., Licensed Practical Nurse (LPN) #31 stated Resident #46 had somewhat recently had a decline in ability to feed self with progression of Dementia. LPN #31 stated the resident was not on a restorative dining program due to inability to take direction with feeding. The resident was moved to a table where resident were assisted with feeding when her ability to feed herself declined. LPN #31 stated the table was at a tall height for Resident #46 and that the maintenance department was working on getting a new table that was a more appropriate height, or cutting down the height of the tall table. LPN #31 stated the maintenance person would be installing a new table that afternoon. During an interview on 01/05/17 at 9:30 A.M., the Director of Nursing (DON) confirmed that the table for Resident #46 should not have come up to the residents shoulder height. The DON confirmed the resident would not be comfortable with the table that high.

Based on observations, medical record review and staff interview, the facility failed to ensure medications had an adequate indications for use. This affected one (#63) out of five residents reviewed for unnecessary medications. The facility identified 46 residents who receive psychoactive medications. Facility census was 69. Findings include: Review of Resident #64's medical record revealed the resident was admitted on [DATE] with medical [DIAGNOSES REDACTED]. The record identified a comprehensive assessment ((MDS) dated [DATE] which identified Resident #64 has history of exhibiting behaviors, however none during this report. The record lacked any evidence of behaviors other than picking her skin. Observations of Resident #64 occurred on 01/4/17 at 11:26 A.M. and continued through lunch. Resident #64 was noted to sleep in the tilt back wheelchair during the entire meal as staff were unable to wake her. On 01/4/17 at 4:58 P.M. Resident #64 was in the main dinning room and was observed asleep in her wheelchair. Review of the medication administration records for January 2017 identified Resident #64 was receiving [MEDICATION NAME] (mood stabilizer) and [MEDICATION NAME] (benzodiazepine) twice a day. Interview with Licensed Practical Nurse (LPN) #30 occurred on 01/4/17 at 5:08 P.M. and confirmed Resident #64 was receiving [MEDICATION NAME] and [MEDICATION NAME] for behaviors. The interview identified the facility tracks behaviors in the nursing progress notes. LPN #30 identified Resident #64 spits and picks at her skin. Review of the progress notes was completed for the past six months. Resident #64 was identified was noted to scratch her arm multiple times in the progress notes. The notes lacked any evidence of behaviors that would be adequate indications for use of [MEDICATION NAME] and [MEDICATION NAME]. Review of the record lacked any evidence of medical or behavioral conditions to warrant to use of [MEDICATION NAME] and [MEDICATION NAME]. The record lacked other alternative interventions for the scratching. The record lacked any alternative approaches for any behaviors Resident #64 was exhibiting, other than pharmalogical. Review of Resident #64 pharmacy recommendation dated 12/15/16 listed clarify [DIAGNOSES REDACTED]. The response was listed medications just ordered due to acting out behaviors; they are working so will not decrease.

Based on observation, record review, policy review and staff interview, the facility failed to maintain equipment at the proper temperature range for refrigerated medication storage. This had the potential to effect all 72 residents residing in the facility. Findings include: Observation of medication storage of the facility at 10:00 A.M. on 08/07/14, revealed the medication refrigerator on the 100 and 200 halls had a thermometer reading of 28 degrees Fahrenheit. The daily monitoring documentation of the refrigerator temperatures revealed that temperatures had been below the 36 to 46 degree Fahrenheit required range from 06/01/14 through 08/07/14 excluding four days of proper temperature range being documented. This observation and record review was verified by Licensed Practical Nurse (LPN) #20 at 10:03 A.M. on 08/07/14. Continued observation of the medication storage of the facility at 10:10 A.M. on 08/07/14, revealed that the medication refrigerator for the 300 hall was observed to be at 28 degrees Fahrenheit. The daily documentation monitoring of the refrigerator temperatures again revealed that temperatures had been below the 36 to 46 degree Fahrenheit required range from 11/01/13 through 08/07/14, excluding four days of the proper temperature range being documented. This observation and record review was verified by Registered Nurse (RN) #10 at 10:13 A.M. on 08/07/14. This information was shared with the consulting pharmacist located at the nurse's station on the 300 hall at 10:15 A.M. on 08/07/14. Pharmacist #1 stated that "the proper temperatures for medication storage of refrigerated medications should range from 35 to 45 degrees Fahrenheit" at 10:30 A.M. on 08/07/14. The facility policy on storage and maintenance of medications dated 10/01/12, instructed that the refrigerator must maintain a proper temperature of 36 to 46 degrees Fahrenheit and be kept clean and organized. Interview on 08/07/14 at 3:05 P.M. with the Director of Nursing (DON) verified the observations and documentation of medication temperature readings were not in the proper range.

Based on closed medical record review, staff interview, review of a self reported incident and investigation report and review of the facility's abuse policy, the facility failed to take immediate action to protect residents after an incident of alleged staff-to-resident (#76) abuse. This resulted in Immediate Jeopardy from potential physical and psychosocial harm for one of two sampled residents (#76) and 19 additional residents who lived on the 200 unit (#24, #25, #26, #27, #28, #29, #30, #31, #33, #34, #37, #38, #39, #40, #42, #43, #77, #78 and #79). The facility also failed to thoroughly investigate the allegation of abuse which placed residents at risk for more than minimal harm that is not Immediate Jeopardy. On 11/19/10 at 9:30 A.M., the Administrator and Director of Nursing (DON) were notified that Immediate Jeopardy began on 08/15/10 at 6:45 P.M., when State tested Nurse Aide (STNA) #13 observed LPN #23 attempt to place Resident #76's nasal cannula into the resident's nose. The resident resisted by pulling his blanket up to the bottom of his nose. LPN #23 pulled the blanket and sheet over the resident's head and tucked them in at the headboard. LPN #23 told Resident #76 the blanket needed to cover his whole head so he could not breathe, pass out and go to the hospital. LPN #23 was allowed to remain on duty and provide care to residents on the 200 unit (including Resident #27) until the Director of Nursing (DON) arrived at approximately 7:30 P.M. and escorted her to the conference room. The Immediate Jeopardy continued on 11/18/10 at 12:30 P.M. when LPN #22 did not accurately describe procedures to assure residents would be immediately protected after an allegation or suspicion of abuse. On 11/19/10 at 2:45 P.M., LPN #21 did not accurately describe procedures to assure residents would be immediately protected after an allegation of abuse. The Immediate Jeopardy was removed and the deficiency was corrected on 11/22/10 at 1:30 P.M. when the facility implemented the following corrective actions: ? On 10/21/10 from 1:30 P.M. to 2:45 P.M., the facility completed in-services with all staff on how to handle catastrophic scenarios, and how to properly diffuse these events. Topics included verbal, physical, mental abuse, sexual misconduct, staff/resident to resident abuse, refusal of care and following facility policies on reporting, ensuring safety, and documentation. ? On 11/19/10, the facility revised the Abuse Policy to include staff training related to abuse prohibition including staff frustration, signs of burnout, quick response, reporting, monitoring, keeping residents safe, assessments of residents, and thorough investigations, including witness statements. ? On 11/19/10 at 7:00 A.M., the surveyor observed staff to resident interactions. Six staff, Unit Manager #3, LPNs #16 and #22, Registered Nurses (RN) #27 and #36 and STNA #14 were providing appropriate care and services to the residents on the 100, 200, and 300 Wing. ? On 11/19/10 at 10:15 A.M., the DON began in-service training for all staff regarding the revised Abuse Policy. The training included catastrophic scenarios to enact difficult/resistive resident behavior and show staff how to properly handle different types of situations. ? On 11/22/10 at 5:45 A.M., 10:00 A.M., and 1:30 P.M., facility administration conducted random audits of 69 employees regarding the new abuse procedures which included Nurses, STNAs, and Ancillary Staff. All employees were able to correctly verbalize proper procedures. ? On 11/23/10 between 11:40 A.M. and 12:25 P.M., surveyors interviewed STNAs #84 and #88, LPN #30, Social Services Designee #132 and Housekeeper #115. They were knowledgeable about the facility's revised abuse policy and procedure. They were able to respond correctly to direct questioning about what constituted an abusive act, how to protect the residents, and to whom they should report such actions. ? LPN #21 and LPN #22 were interviewed on 11/23/10 at 1:48 P.M. and 2:45 P.M., respectively. Both LPN's confirmed they had recent in-service training about abuse and neglect and described the steps they would take to immediately protect residents and report any allegations or suspicion of abuse. Findings include: (See also findings at F223) 1) Review of Resident #76's medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessments dated 06/30/10 and 08/06/10 revealed Resident #76 had short/long term memory loss and exhibited modified independence in decision making skills. Resident #76 was unable to perform activities of daily living without extensive assistance from staff. Resident #76's plan of care, dated 08/12/10, identified the resident displayed signs of shortness of breath related to [MEDICAL CONDITION]. The interventions in the plan of care included administration of oxygen as ordered and to monitor and record the resident's response. Interview with LPN #22 on 11/18/10 at 12:30 P.M., revealed on 08/15/10 she was the second shift charge nurse on the 300 Wing. LPN #22 stated she was approached by STNA #13 about an allegation of physical abuse. STNA #13 stated she witnessed LPN #23 placing a blanket over Resident #76's head. LPN #22 instructed STNA #13 to step outside and call the DON. LPN #22 stated she immediately assessed Resident #76. Resident #76 was lying in bed with his oxygen on at two liters per minute via a nasal cannula. LPN #22 stated at the time of the assessment, the resident had a sheet laid across his body and denied anyone had harmed him. LPN #22 stated she did not document her assessment. Interview with the DON on 11/18/10 at 10:05 A.M. revealed she received a call from STNA #13 on 08/15/10 around 7:15 P.M. stating she witnessed LPN #23 placing a blanket over Resident #76's head because the resident refused to wear his oxygen. The DON stated after she finished talking with STNA #13 she called the administrator and informed him of the situation. She then called LPN #21 and told her not to leave LPN #23's side. She also called Unit Manager #16 and informed her of the situation and to meet her at the facility. The DON stated it took her approximately 10 minutes to arrive at the facility. Upon arrival, she met Unit Manager #16 in the parking lot and immediately went to Nurse's Station 200. When the DON arrived on the Unit, she stated LPN #23's medication cart was outside room [ROOM NUMBER]. The DON and Unit Manager #16 entered room [ROOM NUMBER] and found LPN #23 unsupervised finishing an aerosol treatment on Resident #27. The DON and Unit Manager #16 escorted LPN #23 to the conference room. After being questioned, LPN #23 refused to leave the facility until she had charted on Resident #76. The DON stated LPN #23 went back to the Nurse's Station (200 Wing) and charted for over an hour. The DON and Unit Manager #16 sat at the Nurse's Station with LPN #23 until she finished the charting. LPN #23 was then escorted out of the building by the DON. The DON stated she assessed Resident #76 and observed a white sheet and white blanket on his bed. Review of the self-reported incident and the facility's investigation report dated 08/15/10 revealed STNA #13 stated LPN #23 pulled a blanket and sheet over Resident #76's head and made numerous comments about "him passing out from lack of oxygen and that the blanket needed to cover his whole head to pass out and go to the hospital." LPN #23 asked Resident #76, "is it getting hot under there yet, I bet it is" and the resident replied, "Yes." LPN #23 responded, "I can't hear you, you have a blanket over your head." LPN #23 was not removed from the nursing floor until the DON arrived at the facility. The facility's investigation report did not contain evidence that an assessment of Resident #76 was completed by the DON, Unit Manager LPN #16, or other nurses on duty on 08/15/10. Interview with LPN #21 on 11/19/10 at 2:45 P.M. revealed she was approached by STNA #13 on 08/15/10 between 6:45 P.M. and 7:00 P.M. concerning an allegation of abuse toward Resident #76. LPN #21 stated she was busy with a family member and instructed STNA #13 to tell LPN #22. LPN #21 stated she did not witness the interactions between LPN #23 and Resident #76 but did witness the resident's head covered by a tucked blanket. LPN #21 stated she completed an assessment of Resident #76 after the abuse allegation but stated she did not chart the results of the assessment in the medical record. During an interview on 11/23/10 at 1:48 P.M., LPN #21 verified she did not stay by LPN #23's side as she was instructed to do so by the DON. LPN #21 stated she observed LPN #23 from a distance and allowed LPN #23 to go in and out of room [ROOM NUMBER] without supervision. Review of the facility' s policy entitled Resident Abuse, Neglect, and/or Misappropriation of Resident Funds or Property dated 08/28/10 revealed any suspected abuse will be brought immediately to the Administrator or in his/her absence, to the Director of Nursing. The policy documented the facility will protect the alleged victim from further abuse during the investigation. When the accused or suspected person is a staff member, the facility will suspend that staff member until the results of the investigation is complete. The policy did not include provisions to assure the alleged victim or any other residents would be immediately protected upon allegation or suspicion of abuse or neglect. An interview with the administrator was conducted on 11/19/10 at 9:10 A.M. The administrator verified LPN #23 was not immediately removed from contact with residents by LPN #21 on 08/15/10. LPN #23 was not removed from resident contact until the Director of Nursing arrived at the facility. LPN #22 was interviewed by the surveyor on 11/18/10 at 12:30 P.M. LPN #22 was asked what she would do in a scenario where a resident abuse occurred in the resident's room. LPN #22 stated she would immediately leave but did not describe procedures to assure resident protection or safety. LPN #21 was interviewed by the surveyor on 11/19/10 at 12:30 P.M. LPN #21 was asked what she would do in a scenario where a resident abuse occurred in the resident's room. LPN #21 stated she would immediately leave but did not describe procedures to assure resident protection or safety. 2) Review of the self-reported incident and the facility's investigation report dated 08/15/10 revealed an allegation of staff (LPN #23) to resident (#76) abuse on 08/15/10. The incident report and investigation report included no statements from the following eyewitnesses: LPN #23, Phlebotomist (PHLE) #26, LPN #21, LPN #22 and Registered Nurse (RN) #27. Interview with LPN #21 on 11/19/10 at 2:45 P.M. revealed she was not asked to provide a witness statement to the Director of Nursing regarding her knowledge of what transpired after she was aware of the allegation of physical abuse involving LPN #23 and Resident #76. The DON was interviewed on 11/18/10 at 10:05 A.M. The DON verified she did not obtain witness statements from LPN #21 and LPN #22. Interview with the administrator on 11/19/10 at 9:10 A.M. verified the facility's resident abuse policy and procedure was not implemented to ensure witness statements were obtained from LPN #21 and LPN #22. Review of the facility's policy on resident abuse entitled Resident Abuse, Neglect, and/or Misappropriation of Resident Funds or Property dated 08/28/10 revealed any suspected abuse will be brought immediately to the Administrator or in his/her absence, to the Director of Nursing. The facility will obtain written statements from each witness if possible. Upon completion of the investigation the administrator will meet with the Director of Nursing to determine if modification to existing policies and procedures are needed to prevent similar incidents from occurring in the future.

Based on closed medical record review, staff interview, phlebotomist interview, medical director interview, Ohio Board of Nursing investigator interview, review of a witness statement, review of a police report and review of the facility's abuse policy, the facility failed to prevent staff to resident physical and mental abuse for one of two sampled residents (#76). This resulted in Immediate Jeopardy from potential physical and psychosocial harm when a nurse intentionally placed a blanket and sheet over Resident #76's face and head and made comments about the resident passing out from a lack of oxygen. On 11/19/10 at 9:30 A.M., the Administrator and Director of Nursing (DON) were notified that Immediate Jeopardy began on 08/15/10 at 6:45 P.M., when State tested Nurse Aide (STNA) #13 observed LPN #23 attempt to place Resident #76's nasal canula into the resident's nose. The resident resisted by pulling his blanket up to the bottom of his nose. LPN #23 pulled the blanket and sheet over the resident's head and tucked them in at the headboard. LPN #23 told Resident #76 the blanket needed to cover his whole head so he could not breathe, pass out and go to the hospital. The Immediate Jeopardy was removed on 08/15/10 at 9:43 P.M. when LPN #23 was escorted out of the facility by the DON and subsequently terminated on 08/16/10. Although the Immediate Jeopardy was removed, 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) for 19 residents on the 200 unit until 11/23/10 at 12:25 P.M., when the facility implemented the following corrective actions: ? On 10/21/10 from 1:30 P.M. to 2:45 P.M., the facility completed in-services with all staff on how to handle catastrophic scenarios, and how to properly diffuse these events. Topics included verbal, physical, mental abuse, sexual misconduct, staff/resident to resident abuse, refusal of care and following facility policies on reporting, ensuring safety, and documentation. ? On 11/19/10, the facility revised the Abuse Policy to include staff training related to abuse prohibition including staff frustration, signs of burnout, quick response, reporting, monitoring, keeping residents safe, and assessments of residents. ? On 11/19/10 at 7:00 A.M., the surveyor observed staff to resident interactions. Six staff, Unit Manager #3, LPNs #16 and #22, Registered Nurses (RN) #27 and #36 and STNA #14 were providing appropriate care and services to the residents on the 100, 200, and 300 Wing. ? On 11/19/10 at 10:15 A.M., the DON began in-service training for all staff regarding the revised Abuse Policy. The training included catastrophic scenarios to enact difficult/resistive resident behavior and show staff how to properly handle different types of situations. ? On 11/22/10 at 5:45 A.M., 10:00 A.M., and 1:30 P.M., facility administration conducted random audits of 69 employees regarding the new abuse procedures which included Nurses, STNAs, and Ancillary Staff. All employees were able to correctly verbalize proper procedures. ? On 11/23/10 between 11:40 A.M. and 12:25 P.M., surveyors interviewed STNAs #84 and #88, LPN #30, Social Services Designee #132 and Housekeeper #115. They were knowledgeable about the facility's revised abuse policy and procedure. They were able to respond correctly to direct questioning about what constituted an abusive act, how to protect the residents, and to whom they should report such actions. ? LPN #21 and LPN #22 were interviewed on 11/23/10 at 1:48 P.M. and 2:45 P.M., respectively. Both LPN's confirmed they had recent in-service training about abuse and neglect and described the steps they would take to immediately protect residents and report any allegations or suspicion of abuse. Findings include: Review of Resident #76's medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessments dated 06/30/10 and 08/06/10 revealed Resident #76 had short/long term memory loss and exhibited modified independence in decision making skills. Resident #76 was unable to perform activities of daily living without extensive assistance from staff. Resident #76's plan of care, dated 08/12/10, identified the resident displayed signs of shortness of breath related to [MEDICAL CONDITION]. The interventions in the plan of care included administration of oxygen as ordered and to monitor and record the resident's response. LPN #23's nurse's notes dated 08/15/10 at 6:10 P.M. revealed she and a STNA (#13) assisted Resident #76 from a wheelchair to his bed. LPN #23 documented repeated attempts to place oxygen via nasal cannula on Resident #76. LPN #23 documented Resident #76 placed his arms in front of his face, held the sheet and blanket up to his nose, turned his head side to side, and refused to allow placement of the oxygen/nasal cannula. LPN #23 documented Resident #76 held the sheet and blanket over his head and she provided education on the dangers of being without oxygen with the possibility that he "may pass out." LPN #23 documented she informed the resident it was difficult to breath under a blanket and his compliance would prevent him from being sent to the hospital against his wishes. Interview with LPN #22 on 11/18/10 at 12:30 P.M., revealed on 08/15/10 she was the second shift charge nurse on the 300 Wing. LPN #22 stated she was approached by STNA #13 about an allegation of physical abuse. STNA #13 stated she witnessed LPN #23 placing a blanket over Resident #76's head. LPN #22 instructed STNA #13 to step outside and call the DON. LPN #22 stated she immediately assessed Resident #76. Resident #76 was lying in bed with his oxygen on at two liters per minute via a nasal cannula. LPN #22 stated at the time of the assessment, the resident had a sheet laid across his body and denied anyone had harmed him. LPN #22 stated she did not document her assessment. Interview with the DON on 11/18/10 at 10:05 A.M. revealed she received a call from STNA #13 on 08/15/10 around 7:15 P.M. stating she witnessed LPN #23 placing a blanket over Resident #76's head because the resident refused to wear his oxygen. The DON stated after she finished talking with STNA #13 she called the administrator and informed him of the situation. She then called LPN #21 and told her not to leave LPN #23's side. She also called Unit Manager #16 and informed her of the situation and to meet her at the facility. The DON stated it took her approximately 10 minutes to arrive at the facility. Upon arrival, she met Unit Manager #16 in the parking lot and immediately went to Nurse's Station 200. When the DON arrived on the Unit, she stated LPN #23's medication cart was outside room [ROOM NUMBER]. The DON and Unit Manager #16 entered room [ROOM NUMBER] and found LPN #23 unsupervised finishing an aerosol treatment on Resident #27. The DON and Unit Manager #16 escorted LPN #23 to the conference room. The DON instructed Unit Manager #16 to assess Resident #76 for signs of physical abuse. The DON questioned LPN #23 about the incident and LPN #23 denied she had done anything wrong. The DON then called the local police department. The DON stated LPN #23 did not chart any assessments, blood draws or monitoring of Resident #76's condition until after she was questioned extensively about the physical abuse allegation. After being questioned, LPN #23 refused to leave the facility until she had charted on Resident #76. The DON stated LPN #23 went back to the Nurse's Station (200 Wing) and charted for over an hour. The DON and Unit Manager #16 sat at the Nurse's Station with LPN #23 until she finished the charting. LPN #23 was then escorted out of the building by the DON. The DON stated she assessed Resident #76 and observed a white sheet and white blanket on his bed. Interview with STNA #14 on 11/20/10 at 10:55 A.M. revealed she entered Resident #76's room on 08/15/10, prior to the DON's arrival. STNA #14 saw a blanket tucked in approximately four inches above Resident #76's head. She stated the resident was too weak to pull the blanket down. STNA #14 stated she untucked the "covers" from behind Resident #76's head and placed them at mid-chest prior to the DON entering the room. Review of STNA #13's written statement dated 08/15/10 (no time) indicated LPN #23 activated Resident #76's call light around 6:45 P.M. to 7:00 P.M. Upon STNA #13's arrival to the room, she assisted LPN #23 in placing Resident #76 in his bed. When LPN #23 attempted to place the resident's oxygen on, the resident refused and stated "today is the day I die." LPN #23 stated to STNA #13, "not today, that's why he needs his oxygen." Resident #76 pulled his blanket up to his nose and LPN #23 asked him if "he wanted to pass out from not being able to breathe and go to the hospital." The resident replied "yes." LPN #23 grabbed the blanket and said "well you have to cover your whole head to pass out to go to the hospital." LPN #23 covered his entire head with the blanket. STNA #13 lifted the blanket from the side to put the tab alarm on. STNA #13 intentionally did not put the blanket back down (on his head) on her side so he could breathe. LPN #23 asked Resident #76 "if it was getting hot under there yet." Resident #76 said something (unintelligible) and LPN #23 said "I bet it is." At that time, STNA #15 brought Phlebotomist #26 into the room while the blanket was still over Resident #76's head. According to STNA #13's statement, both STNA #15 and Phlebotomist #26 heard LPN #23 ask Resident #76 "if it was getting hot under there." The resident answered "yes" and LPN #23 said "I can't hear you. You have a blanket on over your head." LPN #23 asked STNA #13 to go and get the pulse oximeter and bring it back to her. LPN #23 placed the pulse oximeter on Resident #76's finger and watched as Phlebotomist #26 tried to draw blood. Neither removed the blanket until Phlebotomist #26 could not get the blood so Phlebotomist #26 pulled the blanket to the side and put the oxygen on Resident #76. Later when STNA #13 and STNA #14 went to check on Resident #76, they found the blanket tucked in over and around his head. STNA #14 pulled the covers "out" and placed them at Resident #76's mid chest. Interview with Phlebotomist #26 on 11/19/10 at 11:45 A.M. revealed she entered Resident #76's room on 08/15/10 to draw blood for laboratory work. Phlebotomist #26 verified she saw the blanket tucked in over Resident #76's head. Interview with LPN #21 on 11/19/10 at 2:45 P.M. revealed she also saw Resident #76 in bed on 08/15/10 with a blanket tucked in over his head. Interview with the Medical Director on 11/20/10 at 9:35 A.M. revealed it was not acceptable to place a blanket over Resident #76's head. Resident #76 had been hosptalized on [DATE] to 08/01/10 for an infection. He further stated Resident #76 was actively dying and was on comfort care and the family did not want the resident to go to the hospital. The Medical Director stated it was within Resident #76's right to refuse to wear the oxygen. Review of the local police department's Incident/Investigation Report (#10- 1), dated 08/15/10 at 9:55 P.M., conducted by Police Officer #24 revealed the reporting party (complainant) was the DON of the facility. The complainant reported the victim was on oxygen and was not cooperating with LPN #23 with keeping the oxygen tubes in place. STNA #13 alleged LPN #23 became angry and pulled the victims blanket over his head and tucked the blanket around Resident #76's head to prevent the resident from breathing then stated "is it getting hot under there?" Interview with the Ohio Board of Nursing (OBN) Investigator #31 on 11/17/10 at 1:30 P.M. revealed the Board of Nursing was conducting an ongoing investigation regarding the allegation of physical abuse against LPN #23. OBN Investigator #31 stated he had been in contact with Police Detective #25 and had been informed felony charges of patient /resident abuse were filed with the county prosecutor's office. Review of the facility's policy entitled Resident Abuse, Neglect, and/or Misappropriation of Resident Funds or Property dated 08/28/10 revealed the facility does not tolerate verbal, sexual physical or mental abuse, involuntary seclusion, neglect of residents or misappropriation of resident's funds or property by any person. Any suspected abuse will be brought immediately to the Administrator or in his/her absence, the Director of Nursing. The facility will protect the alleged victim from further abuse during the investigation. When the accused or suspected person is a staff member, the facility will suspend that staff member until the results of the investigation are complete. The facility will obtain written statements from each witness if possible. Upon completion of the investigation the Administrator will meet with the Director of Nursing to determine if modification to existing policies and procedures are needed to prevent similar incidents from occurring in the future.