Every finding on record at Eagle Pointe Skilled Nursing & Rehab

Based on record review, resident and staff interviews and facility policy review, the facility failed to make prompt efforts and resolve a resident grievance involving staff smelling of marijuana while providing care. This affected one resident (Resident #21) of two residents reviewed for resident concerns. The facility census was 53. Findings include:Review of the medical record for Resident #21 revealed an admission date of 07/15/23 with diagnoses including pan lobular emphysema, chronic obstructive pulmonary disease (COPD), insomnia, dependence on respirator, muscle wasting, heart failure, type two diabetes, and anxiety. Review of the facility document titled Witness statement dated 03/19/26 and authored by Unit Manager (UM) #336 revealed Resident #21 notified UM #336 that Certified Nursing Assistant (CNA) #315 and CNA #339 smelled like marijuana. UM #336 stated she could smell a faint odor and that the CNA did not appear impaired. UM #336 stated she spoke with CNA #315 and #339 and told them it was not appropriate to come to work smelling like marijuana. Message was left for the Administrator to notify him of the situation. Review of facility document titled Resident Concerns/Complaints dated 03/20/26, revealed Resident #21 had a chief complaint that STNA smell like marijuana. The document did not state who the concern was reported to but stated interventions included addressing the aids and all staff. The complaint was considered closed. Review of facility document titled Resident/Family Concern/Grievance Form dated 03/20/26, revealed Resident #21 described CNA #315 and CNA #339 smelled like marijuana on night shift. The concern was received from a resident. Action taken included the Administrator spoke with the evening supervisor (UM #336). UM #336 stated the CNA did not show any signs of impairment during their shift but stated She could smell the odor. The Administrator spoke to the aids about it, and reviewed they were not to smell like of marijuana. The DON was to address the situation at the monthly meeting. The document was signed by the administrator on 03/20/26. In section three: Follow Up with Resident/Family Member, the section was not filled out regarding name and date of the individual contacted, comments and name of the staff member completing follow-up.Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #21's cognition was intact. Resident #21 was totally dependent on staff for toilet hygiene, putting on footwear, transferring from bed to chair, and in and out of the tub. Review of facility document titled Ad-HOC Learning Circle dated 03/27/26, revealed the DON educated all staff with 29 staff names and signatures (14 Certified Nursing Assistants, five Housekeepers, one Maintenance, one Scheduler, three Licensed Practical Nurses, two Activities and three Nursing) regarding the following content: no one should be coming to work smelling like marijuana. It may be legal in Ohio, but it is not legal in a healthcare setting because the facility was federally regulated. Residents were complaining they were smelling it on staff. Staff were educated not to be in work attire if exposed to marijuana, because it was like smelling cigarettes on oneself or excessive perfumes. An interview on 04/29/26 at 12:40 P.M. with Resident #21 revealed he spoke to the Director of Nursing (DON) and Assistant Director of Nursing (ADON) about Certified Nursing Assistant (CNA) #315 and #339 smelling like marijuana while providing care to him. Resident #21 stated he also spoke to the facility Scheduler #303 and Social Service Designee (SSD) #353 but it continued to be a concern. Resident #21 stated he did not want CNA #315 and #339 caring for him because he believed they were impaired while caring for him. Resident #21 stated the odor of marijuana on CNA #315 and #339 was so strong it upset him because he depended on them to lift him with a mechanical lift and he felt he could not trust them. Resident #21 stated both CNA #315 and #339 worked the night shift. An interview on 04/29/26 at 12:45 P.M. with CNA #317 revealed CNA #317 stated CNA #339 always smelled of marijuana, and the administration did nothing about it. CNA #317 stated there was one meeting about not having odors on them while working and not doing drugs, but CNA #339 still smelled of marijuana when at work, so the meeting did not do any good. CNA #317 stated that it was a known thing that CNA #339 smelled of marijuana while doing her job. An interview on 04/29/26 at 12:55 P.M. revealed Resident #46 was alert, and oriented to person, place, time and situation. Resident #46 stated CNA #339 smelled of marijuana and did not like the way she smelled because it was very strong like she just smoked it or was around it before caring for him. Resident #46 stated CNA #339 moved very slowly while caring for him so he was concerned she was impaired while caring for him. Resident #46 stated CNA #315 and #339 smelled of marijuana more than once while caring for him and stated the smell was so bad he could smell it while the aids were behind the nurse station and he was in the common area so others would be able to smell it. Resident #46 verified he had not been interviewed by administration about the concerns. An interview on 04/29/26 at 12:57 P.M. with CNA #319 revealed she had smelled both CNA #315 and #339 odor of marijuana while caring for residents. CNA #319 stated she believed they were working impaired because she had witnessed their work from the night before not getting done. An interview on 04/29/26 at 1:00 P.M. with Resident #30 revealed she regularly attended resident council meetings and residents have stated to her they smell marijuana in the building and have smelled it on staff members. Resident #30 stated residents have told the administrative staff about their concerns regarding the marijuana odor, and it was an ongoing problem including the odor of marijuana on CNAs. An interview on 04/29/26 at 4:59 P.M. with Licensed Practical Nurse (LPN) #343 verified CNA #315 attended work with an odor of marijuana during the night shift, and residents complained about her odor while caring for them. LPN #343 stated she did not know what to do since marijuana was legal but was concerned for the welfare of the residents. An interview on 04/29/26 at 5:18 P.M. with CNA #323 revealed CNA #323 stated she witnessed CNA #315 and #339 vaping during smoke break and the vape odor had a strong smell of marijuana. CNA #323 stated she alerted the night UM #336 but nobody does anything about it because it was an ongoing problem. An interview on 04/29/26 at 6:00 P.M. with Social Service Designee (SSD) #353 revealed Resident #21 did not want CNA #315 taking care of him anymore because Resident #21 was concerned about his safety due to CNA #315 had a strong odor of marijuana on her. SSD #353 stated Resident #21 stated CNA #315 smelled bad of marijuana. SSD #353 stated she notified the Director of Nursing (DON) and the Administrator when Resident #21 notified her of the concern. An interview on 04/29/26 at 6:25 P.M. with the DON verified an education was given to all staff on 03/27/26 about no strong odors while on duty working in the facility. The DON stated a nurse could smell like marijuana and still work on the floor. The DON verified the facility was a drug-free workplace and the facility policy stated administration could test staff if there was a reasonable suspicion. The DON stated a staff member smelling of marijuana was suspicious. The DON verified that besides the education provided on 03/27/26 no further corrective action was completed to ensure CNA #315 and #339 were not working while smelling like marijuana or possibly impaired by marijuana. The DON verified the incomplete grievance documentation. An interview on 04/29/26 at 6:43 P.M. with the Administrator verified he was aware CNA #315 and #339 smelled of marijuana while working with residents. The Administrator stated he was told the aids were not impaired. The Administrator verified he did not get statements from staff members or residents regarding their concerns. The Administrator stated he did get a statement from UM #336 who stated she smelled marijuana on CNA #315 and #339 while they were caring for residents. The Administrator stated education on staff odors was a sufficient corrective action because the odor of marijuana was the same as a staff member smoking a cigarette or having excessive perfumes. An interview was attempted by phone on 4/30/26 with UM #336 and no return phone call was received. A follow-up interview on 04/30/26 at 1:09 P.M. with Resident #21 revealed he had notified Scheduler #303 on 03/06/26 at 7:52 P.M. per his record of text messages that he was concerned because CNA #315 smelled of marijuana and stated this was not the first time that she smelled of it. Resident #21 proceeded to read his record of text and stated that Scheduler #303 responded back by text message on 03/06/26 at 8:27 P.M. that CNA #315 was working on the South wing that night and she would have another talk with CNA #315. Resident #21 stated he sent another text message to Scheduler #303 that CNA #315 smelled of marijuana again, and Scheduler #303 stated she would notify the DON and the Administrator. Resident #21 stated he spoke with the DON several times regarding his concerns, but still nothing had been done to stop it. Resident #21 stated he had also sent a text on 03/07/26 to Social Service Designee (SSD) #353 about the CNAs on the South wing smelling like marijuana and this was not the first time, and SSD #353 replied on 03/07/26 that she would notify the ADON and the Administrator. An interview on 04/30/26 at 1:30 P.M. with Scheduler #303 verified Resident #21 notified her by text on 03/06/26 of CNA #315 and CNA #339 smelling of marijuana and she reported it to the Administrator. An interview on 04/30/26 at 1:31 P.M. with SSD #353 verified Resident #21 had texted her on 03/06/26 expressing concern twice about CNA #315 working while smelling like marijuana, had also verbally told her of his concerns and SSD #353 notified the Administrator immediately. SSD #353 stated the Administrator waited to provide an all-staff education because there was a planned meeting then. Review of the facility policy titled Resident Rights, dated 02/2021, revealed employees shall treat all residents with kindness, dignity and respect. Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the residents' right to: voice grievances to the facility without fear of reprisal or discrimination and have the facility respond to grievances. This deficiency represents non-compliance investigated under Complaint Number 2982896.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, interview, observation, self-reported incident (SRI) review and facility policy review, the facility failed to ensure residents were free from misappropriation. This affected five Residents (#20, #35, #46, #54, and #55) out of six residents reviewed for misappropriation. The facility census was 53.Findings include:1. Review of the closed medical record for Resident #54 revealed an admission date of 02/19/24. She passed away at the facility on 08/28/25. Her diagnoses included rheumatoid arthritis, chronic pain, and chronic obstructive pulmonary disease (COPD). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #54 had intact cognition and was on a scheduled pain medication regimen that included opioids (medications prescribed to treat severe or persistent pain, but they can also be addictive). Review of July 2025 physician orders revealed Resident #54 had an order dated 09/09/24 for Oxycodone hydrochloride (HCL) 5 milligram (mg) tablet (opioid pain medication) give one tablet by mouth two times a day for pain. 2. Review of the medical record for Resident #20 revealed an admission date of 07/15/23 with diagnoses including COPD, diabetes, and morbid obesity. Review of the July 2025 physician orders revealed Resident #20 had an order dated 03/05/25 for Oxycodone HCL 5 mg tablet take one tablet by mouth every eight hours as needed for pain. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #20 had intact cognition and received scheduled and as needed pain medications including opioid usage. Interview and observation on 04/07/26 at 8:20 A.M. with Resident #20 revealed he was not aware of any misappropriation, including medications. He revealed he received his medications as ordered and felt his pain was well managed. He displayed no signs of pain on observation. 3. Review of the medical record for Resident #35 revealed an admission date of 11/06/23 with diagnoses including schizophrenia, phantom limb pain (real pain felt in a limb or body part that had been amputated), and muscle wasting. Review of the July 2025 physician orders revealed Resident #35 had an order dated 05/28/24 for Gabapentin (anti-convulsant medication also used for nerve pain) 600 mg by mouth three times a day for pain. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #35 had intact cognition and received pain medications. Interview and observation on 04/08/26 at 11:10 A.M. revealed Resident #35 was not aware of any misappropriation, including medications. He revealed he received his medications as ordered and felt his pain was well managed. He displayed no signs of pain on observation. 4. Review of the medical record for Resident #46 revealed an admission date of 05/13/20 with diagnoses including arthritis of the right hip, muscle wasting, and COPD. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #46 had intact cognition. Review of the July 2025 physician orders revealed Resident #46 had an order dated 05/28/24 for Gabapentin 100 mg give one capsule by mouth three times a day for pain. Interview and observation on 04/07/26 at 8:03 A.M. with Resident #46 revealed he was not aware of any misappropriation, including medications. He revealed he received his medications as ordered and felt his pain was well managed. 5. Review of the closed medical record for Resident #55 revealed an admission date of 06/24/25. She was discharged on 07/31/25. Her diagnoses included osteomyelitis, rheumatoid arthritis, and muscle wasting. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #55 was cognitively intact and received an opioid. Review of the July 2025 physician orders revealed Resident #55 had an order dated 06/24/25 for Oxycodone HCL 10 mg give one tablet by mouth every four hours as needed for pain. 6. Review of controlled substance (medications with a risk of misuse and dependence that were regulated) delivery sheet dated 06/23/25 revealed the facility received 28 tablets of Oxycodone HCL 5 mg for Resident #54. The facility Individual Patient Controlled Substance Administration Record for this medication was missing. Review of controlled substance pharmacy delivery sheet dated 07/21/25 revealed the facility received 28 tablets of Oxycodone 5 mg for Resident #20. The facility Individual Patient Controlled Substance Administration Record for this medication was missing. Review of staffing schedule for 07/22/25 to 07/23/25 revealed from 7:00 P.M. to 7:30 A.M. Agency Registered Nurse (RN) #661 was assigned to the south side and Agency Licensed Practical Nurse (LPN) #662 was assigned to the north side. There were no other nurses scheduled. Review of Individual Patient Controlled Substance Administration Record for Former Resident #54 revealed on 07/22/25 at 11:10 P.M. Agency RN #661 had wasted one Oxycodone HCL 5 mg tablet (#28) on the count sheet and the initials next to Agency RN #661 were unrecognizable. The facility stated the initials were not from any staff working on 07/22/25 that had witnessed Agency RN #661 waste this medication. Review of Individual Patient Controlled Substance Administration Record for Former Resident #55 revealed on 07/23/25 at 3:15 A.M. Oxycodone HCL 5 mg tablet number 23, and number 24 were signed out and initialed by Agency RN #661 as wasted. The initials next to Agency RN #661 were unrecognizable and the facility stated they were not from any staff working on 07/23/25 that had witnessed her wasting these medications. Review of SRI tracking number 263138 with date of discovery date of 07/23/25 revealed the facility filed an alleged allegation of misappropriation involving Residents #20, #35, #46, and #54. The SRI revealed on 07/23/25 Agency RN #661 was finishing her assigned shift (7:00 P.M. to 7:00 A.M.) and conducted controlled substance shift-to-shift counts with LPN #639 and LPN #660. Agency RN #661 reported that the nurse from the other side (Agency LPN #662) had come down and helped her organize the controlled substances because she had dropped the cards and that they were out of order. They completed the controlled substance count, and Agency RN #661 left the facility. Within ten to 20 minutes, LPN #639 started to question items in the cart and requested LPN #660 to recount with her. During the recount it was discovered that a full card (28 tablets) of Oxycodone HCL 5 mg was missing as well as another card (four tablets) of Oxycodone HCL 5 mg. The SRI revealed the corresponding controlled substance sheets were missing from the above medications. Also, the nurses noticed some of the controlled substances signed off as wasted during the night had initials as cosigning the observation of the medication as being wasted not matching any of the staff that were in the building the night of 07/22/25 to 07/23/25. The facility attempted to reach Agency RN #661, but there was no answer. All narcotics in the facility were audited, and no other discrepancies were noted, but three cards of Gabapentin (non-controlled medication) were noted to be missing. Police were notified and report #2025-0353 was filed. Agency LPN #662 (the only other nurse on night shift from 07/22/25 to 07/23/25) was contacted and she denied ever going to the south side assisting Agency RN #661 to reorganize the controlled substances and/or witness any controlled substances being wasted. The Medical Director/Primary Care Physician (PCP) #663, pharmacy, residents, family and Board of Nursing were notified of the incident. The medications were replaced by the facility at the cost of the facility. Review of the Controlled Medication Shift Change Log for South B/C cart revealed on 07/22/25 at 7:00 P.M. there were 25 cards and 25 sheets, and the shift-to-shift count was completed by LPN #639 and Agency RN #661. The log revealed before the next shift-to-shift count ,four cards and sheets were removed including Resident #54's Oxycodone, Resident #35's Oxycodone/Acetaminophen (APAP) (controlled substance pain medication), Resident #55's Clonazepam (controlled substance benzodiazepine used to treat seizures or panic disorder) and a (unrecognizable name) for a Tramadol (controlled substance pain medication) card and sheet. The facility revealed no residents on 07/22/25 and/ or 07/23/25 had an order for Tramadol on the south B/C cart during this time frame. The log revealed on 07/23/25 at 7:00 A.M. there were 21 cards and 21 sheets when Agency RN #661 and LPN #639 counted. Review of the incident reports dated 07/23/25 at 7:30 A.M. and completed by LPN/Minimum Data Set (MDS) #634 revealed Resident #54 was missing four tablets of oxycodone HCL 5 mg as well as the count sheet, Resident #20 was missing 28 tablets of oxycodone HCL 5 mg as well as the count sheet that went along with the medication, Resident #35 was missing two cards of Gabapentin 300 mg, and Resident #46 was missing one card of Gabapentin 300 mg. Review of the undated and unauthored Explanation of Events revealed Resident #54 received 28 tablets of Oxycodone HCL 5 mg on 06/23/25, and the card and sheet was completed on 07/10/25 at 7:25 P.M. Resident #54 received a new card on 07/04/25 and that sheet started on 07/11/25 at 8:00 A.M. The summary revealed Resident #54's card and sheet were missing. Resident #54 also had a new Oxycodone HCL card that the facility received on 07/22/25 and one tablet was wasted with initials next to but was not the other nurse's initials in the building. Resident #20 received a card of Oxycodone HCL 5mg (28 tablets) with a count sheet on 07/21/25 and when counting on 07/23/25 the card and sheet were missing. Review of the witness statement dated 07/23/25 at 7:50 A.M. and completed by LPN #639 revealed she came on duty on 07/23/25 at 7:00 A.M., and Agency RN #661 asked her to clock her out before report. Agency RN #661 proceeded to give report and complete controlled substance count, but before counting, Agency RN #661 stated she dropped all the cards, and the other nurse from the north side came over and helped her organize the cards. The statement revealed they counted and the controlled substance count was correct. LPN #639 started putting the controlled substances back in alphabetical order with LPN #660 beside her and noticed that Resident #20 had gotten a new Oxycodone HCL card on Monday night, 07/21/25 with 28 tablets. The card and the count sheet were not in the cart, and the book and the card were not signed off as taken out of the cart. LPN #639 then had LPN #660 check, and they also could not find Resident #54's controlled substance sheet as it was taken out of the cart. Review of the witness statement dated 07/23/25 at 8:00 A.M. and completed by LPN #644 revealed she arrived on the shift on 07/23/25 at 7:02 A.M. and Agency RN #661 was trying to have staff sign her out on the agency app. LPN #644 completed controlled substance count on the south A/ B cart and the count was correct. Then Agency RN #661 counted with LPN #639 on the south B/C cart, and Agency RN #661 stated she had dropped the cards, and the nurse from the north side last night had helped her put them back in order. The statement revealed she proceeded to complete the shift-to-shift count, and all the pages and count were correct, and Agency RN #661 left. LPN #639 then stated something was not right and recounted at which time she noted a card of Oxycodone HCL that she had signed in from pharmacy a few days ago was not in the drawer. The statement revealed both, LPN #644 and LPN #639 recounted the pages, cards and looked to see when cards were signed in and out of the cart. They discovered on 07/21/25 the card of Oxycodone HCL was signed into the cart on 07/21/25; however, the card and controlled count sheet was missing, and another controlled substance was signed out that was not taken out and was fully accounted for, present in the cart and the sheet was in book. The statement revealed management was immediately notified. Review of the witness statement dated 07/23/25 at 4:32 P.M. and completed by the Administrator revealed on 07/23/25 at 7:38 A.M. he was notified of suspected drug diversion involving Agency RN #661. Resident #20 was missing a card (28 tablets) of Oxycodone HCL, and Resident #54 was missing four tablets of Oxycodone HCL 5 mg. The statements also revealed he was notified of other discrepancies with medications that had been wasted. Review of the witness statement dated 07/23/25 at 5:00 P.M. and completed by LPN/MDS #634 revealed LPN #639 had contacted her on 07/23/25 at 8:00 A.M. regarding the shift-to-shift controlled log revealed Agency RN #661 had signed out that four medications were completed throughout the night but that there were only two papers located for the completed medications. Review of the witness statement dated 07/24/25 at 3:00 A.M. and completed by Former RN #664 revealed he was performing medication pass and noticed missing medications: Resident's #46's one card of Gabapentin 300 mg and Resident #35's two cards of Gabapentin. The statement revealed the facility had received Resident #35's Gabapentin on 07/16/25 and Resident #46's Gabapentin on 07/20/25. Review of the witness statement dated 07/24/25 at 2:56 P.M. and completed by Agency LPN #662 revealed she worked the north side on 07/22/25 at 7:00 P.M. to 07/23/26 at 7:00 A.M. and never stepped foot on the south side. She revealed during the shift she had seen Agency RN #661 one time when she came to the north side asking if she had seen any of her aides. The statement revealed she never wasted any controlled substances with Agency RN #661. Interview on 04/07/26 at 10:22 A.M. with LPN #660 revealed she and LPN #639 came on duty on 07/23/25 at approximately 7:00 A.M. to relieve Agency RN #661 including obtain report and complete shift-to-shift count on the south A/B cart. She revealed the south A/B cart was correct, and then Agency RN #661 counted the south B/C cart with LPN #639. She revealed prior to giving report and counting, Agency RN #661 wanted to leave as she was trying to get LPN #639 to sign her out on the agency app. After LPN #639 counted, she realized a whole Oxycodone card for Resident #20 was missing from the cart. She felt it was odd as she had remembered she had just recently signed in Resident #20's card, and it was no longer in the cart. They also found other sheets with Oxycodone marked as wasted, but the person that cosigned witnessing was not a nurse that they recognized initials for. They immediately notified management of the misappropriation of medications. Interview on 04/07/26 at 12:42 P.M. with MDS/LPN #634 and the Director of Nursing (DON) revealed the DON was on vacation at the time of the incident on 07/23/25. MDS/LPN #634 verified she was involved in investigating the incident and verified medications were misappropriated including Resident #54 was missing four tablets of Oxycodone 5 mg as well as the count sheet, Resident #20 was missing 28 tablets of Oxycodone 5 mg as well as the count sheet that went along with the medication, Resident #35 was missing two cards of Gabapentin 300 mg, and Resident #46 was missing one card of Gabapentin 300 mg. They also verified Former Resident #54's Individual Patient Controlled Substance Administration Record on 07/22/25 at 11:10 P.M. revealed Agency RN #661 had wasted one Oxycodone 5 mg tablet (#28) on the count sheet, and the initials next to Agency RN #661 were unrecognizable. They revealed the initials were not from any staff working on 07/22/25 that had witnessed her wasting this medication. They also verified Individual Patient Controlled Substance Administration Record for Former Resident #55 revealed on 07/23/25 at 3:15 A.M. Oxycodone HCL 5 mg tablets number 23 and number 24 were signed out and initialed by Agency RN #661 as wasted. The initials next to Agency RN #661 were unrecognizable, and the facility stated they were not from any staff working on 07/23/25 that had witnessed her wasting these medications. They felt the medications were misappropriated by Agency RN #661 but that they unsubstantiated the SRI as from their understanding the case was still being investigated and prosecuted. Interview on 04/07/26 at 3:06 P.M. with LPN #639 revealed she came on duty on 07/23/25 at approximately 7:00 A.M. and before counting and getting report found it odd that Agency RN #661 was trying to get her to clock her out on the agency app. She obtained report and completed the shift-to-shift count for the B/C cart with Agency RN #661. Prior to counting, Agency RN #661 stated she had dropped all the controlled substance cards and that they may be out of order as she had the nurse from the other side come over and assist in putting the cards back in order. She revealed the number of cards and the amount of medication in the cards were correct. After Agency RN #661 left, she realized Resident #20 did not have his Oxycodone HCL card in the cart which she found was odd as she had just recently added it to the cart on 07/21/25 when it was delivered. She requested LPN #660 assist in recounting and at that time they discovered that Agency RN #661 had documented that she removed (an unrecognizable name) for a Tramadol card and sheet. There were no residents with an order for Tramadol. She also noted that medications were signed out as wasted with initials cosigning that they were witnessed, but they were not recognized as initials of staff that worked at the facility. She immediately contacted management, and an immediate investigation was conducted including notifying the police. Review of the policy labeled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigation, last revised September 2022, revealed all reports of resident abuse including theft and misappropriation were to be reported to local, state and federal agencies as required. There was nothing in the policy in regard to residents were to remain free from misappropriation. The deficient practice was corrected on 07/25/25 when the facility implemented the following corrective actions:- On 07/23/25, the Administrator filed an SRI to the state agency involving misappropriation of medications for (Residents #20, #35, #46, and #54) that involved Agency RN #661 and completed an investigation including witness statements that were conducted by Former Regional Director #667, Administrator, LPN/MDS #634 and Former RN/Assistant Director of Nursing (ADON) #666.- On 07/23/25, Former Regional Director #667, Administrator, and LPN/MDS #634 attempted to contact Agency RN #661 to obtain statement but were unable to reach her. The agency and police attempted but were also unable to reach her.- On 07/23/25, the police department was notified by the Administrator, and a police report #2025-0353 was filed. They were unable to obtain the report at this time due to the incident being prosecuted. - On 07/23/25, the agency was contacted by the Administrator to report the incident of misappropriation involving Agency RN #661 and to have her account deactivated to not return to the facility.- On 07/23/25, Agency LPN #662 was notified by Former Regional Director #667 and denied assisting Agency RN #661 reorganize the controlled substances and/or witnessing wasting any controlled substances.- On 07/23/25, all the narcotics in the facility were audited by Former RN/ ADON #666 to ensure that there were no other missing narcotics. At this time, it was determined that three Gabapentin cards were found to be missing. - On 07/23/25 and 07/24/25, all residents were interviewed by Former RN/ADON #666 that were capable of being interviewed and those not able to be interviewed were assessed for their pain management. No issues were noted. An audit of resident records revealed no residents missed any medications. This audit was completed by Former Regional Director #667 and Former RN/ADON #666.- On 07/23/25, incident reports and head-to-toe assessments were completed by LPN/MDS #634 on affected residents (Residents #20, #35, #46, and #54), and they were all at baseline. Additional head-to-toe assessments were completed by LPN/MDS #634 on residents unable to be interviewed. No concerns were identified. - On 07/23/25, Medical Director/Primary Care Physician (PCP) #663 was notified of the incident by Former RN/ADON #666.- On 07/23/25, vital signs and pain evaluations were completed for affected residents (Residents #20, #35, #46, and #54). This was overseen by Former RN/ADON #666.- On 07/24/25, all nurses were in-serviced on controlled substance counts by the Administrator and Former RN/ADON #666.- On 07/24/25, controlled substance sign off audits were initiated: five residents three times a week for three weeks and then five residents weekly and then randomly. These were completed by Former RN/ADON #666.- - On 07/24/25, The Ohio Board of Nursing was contacted by Former Regional Director #667 regarding the incident.- On 07/24/25, the facility pharmacy was contacted by Former RN/ADON #666 regarding the incident and reported the incident to the Board of Pharmacology. The facility replaced all medications at the facility cost. - On 07/24/25 a Quality Assurance and Performance Improvement (QAPI) meeting was held 07/24/25 at 2:00 P.M. and the Medical Director/PCP #663, Administrator, Former Director of Clinical Services #667, Medical Records #602, Former RN/ADON #666, MDS/LPN #634, Rehabilitation Director #657, Activities Director #601, Scheduler #603 attended. - On 07/25/25, psychosocial follow up was completed per the Administrator for the affected residents (Resident #20, #35, #46, and #54), and no adverse effects were identified.This deficiency was an incidental finding identified during the complaint investigation.

Based on record review, interviews, review of a grievance form, and facility policy review, the facility failed to ensure that care was provided in a manner that maintained the resident's dignity and honored the resident's right to be informed of and refuse treatment. This failure affected one resident (Resident #20) of three residents reviewed for resident rights. The facility census was 53.Findings include:Record review revealed Resident #20 was admitted on [DATE] with diagnoses including panlobular emphysema, acute and chronic respiratory failure, and severe morbid obesity.Review of a grievance form dated 11/10/25 revealed Resident #20 reported that Certified Nursing Assistant (CNA) #625 used vinegar on him during his shower. The facility investigated the incident and educated CNA #625 on customer service and patient care. The grievance documentation indicated vinegar was not to be used with Resident #20 in the future, and CNA #625 was removed from his care assignment.Review of nurse's notes dated 11/01/25 through 12/01/25 revealed no documentation that Resident #20 was educated on the use of vinegar during bathing or personal hygiene.Review of the physician orders dated 11/01/25 through 04/07/26 revealed no orders for the use or application of vinegar as a treatment.Further review of nurse's notes dated 11/01/25 through 04/07/26 revealed no documentation that vinegar had been used during Resident #20's showers, and no documentation that the resident reported on 11/09/25 he was upset that vinegar had been used without his prior knowledge or consent.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 was cognitively intact and required moderate assistance with bathing and personal hygiene.An interview with Resident #20 on 04/07/26 at 8:20 A.M. revealed that during a shower on 11/09/25, CNA #625 told him she needed to pour vinegar on him and then applied it to his leg. He stated he told her no, but she proceeded anyway. He further reported that CNA #625 stated she had been instructed to do so by Social Service Designee (SSD) #654.An interview with CNA #625 on 04/07/26 at 9:05 A.M. revealed that some residents previously requested vinegar during baths to help with odor and yeast issues. She stated she added vinegar to a washcloth with soap and water while assisting Resident #20. According to CNA #625, the resident asked what she was using and why, but did not tell her no. She stated that after the shower, Resident #20 began yelling no means no, at which time she apologized.An interview with SSD #654 on 04/07/26 at 9:22 A.M. revealed Resident #20 reported to her that he told CNA #625 he did not want vinegar used, and that CNA #625 told him SSD #654 instructed her to do so. SSD #654 stated she never told staff to use vinegar on any resident. She reported that vinegar was removed from the unit, discontinued from use, and an investigation was completed.Review of the facility's policy titled Resident Rights, revised 02/2021, revealed residents have the right to be informed of and participate in their care planning and treatment.This deficiency represents noncompliance investigated under Complaint Number 2655050.

Based on record review, interview, review of a grievance form and facility policy review, the facility failed to ensure treatments were provided in accordance with professional standards and failed to obtain a physician's order prior to administering a topical treatment. This resulted in vinegar being applied to Resident #20 without a physician's order and against the resident's expressed refusal. This deficient practice affected one (Resident #20) of three residents reviewed for physician-ordered treatments. The facility census was 53.Findings include:Review of medical record for Resident #20 revealed he admitted on [DATE] with diagnoses including panlobular emphysema, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), insomnia, congestive heart failure (CHF), gastroesophageal reflux disease (GERD), deep vein thrombosis (DVT), Lupus anticoagulant syndrome, anemia, muscle wasting and atrophy, difficulty walking, pain, major depressive disorder, anxiety, iron deficiency, bilateral primary osteoarthritis (OA) hips, acute and chronic respiratory failure, and morbid severe obesity.Review of the grievance form dated 11/10/25 showed Resident #20 reported Certified Nursing Assistant (CNA) #625 used vinegar on him during a shower despite him refusing. The facility educated CNA #625 and removed vinegar from future use with Resident #20. Review of physician orders dated 11/01/25-04/01/26 revealed no physician order for the application or use of vinegar for Resident #20. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 was cognitively intact and required moderate assistance with bathing and personal hygiene.Interview with Nurse Practitioner (NP) #665 on 04/07/26 at 8:00 A.M. revealed he had not ordered vinegar for resident baths and stated he would not order acetic acid for bathing. Interview with Resident #20 on 04/07/26 at 8:20 A.M. revealed on 11/09/25 he was getting a shower with assistance from CNA #625, and she told him she had to pour vinegar on him. Resident #20 stated he said no, but she applied it anyway. Interview with Primary Care Physician (PCP)/Medical Director #663 on 04/07/26 at 8:55 A.M. revealed she had discussed vinegar conceptually with staff but had never written an order for vinegar use for any resident. Interview with CNA #625 on 04/07/26 at 9:05 A.M. confirmed she used vinegar on Resident #20 on 11/09/25 and stated vinegar baths were used for some residents to minimize yeast and odors. Interview on 04/07/26 at 9:22 A.M. with Social Services Designee (SSD) #654 revealed Resident #20 came to her about the vinegar used in his bath. She revealed Resident #20 stated he told CNA #625 he did not want to use it, and that she said SSD #654 told her to. SSD #654 denied telling CNA #625 to use vinegar, and stated vinegar was removed from the floor after the incident. Interview on 04/07/26 at 2:15 P.M. with CNA #625 revealed vinegar baths were still being done for residents who requested them. She revealed the vinegar was now kept in the Director of Nursing (DON's) office and the CNA must request it.Review of the facility policy titled Medication and Treatment Orders, dated 2001 and revised July 2016, revealed medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state.Review of the facility policy titled Wound Care, revised 10/2010, revealed to verify that there was a physician's order for any procedure involving skin and wound management.This deficiency represents non-compliance investigated under Complaint Number 2655050.

Based on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident #43 had adaptive equipment as ordered when eating. This affected one resident (#43) out of one resident reviewed for adaptive equipment when eating. This had the potential to affect seven residents (#5, #10, #11, #17, #30, #32, and #43) that had orders for adaptive equipment while eating. The facility census was 50. Findings included: Review of the medical record for Resident #43 revealed an admitted [DATE] with diagnoses including multiple sclerosis, muscle weakness, and schizoaffective disorder. Review of the March 2025 physician's orders revealed Resident #43 had an order dated 11/03/23 to have built-up utensils and a two handled mug for all meals. Review of the care plan dated 03/11/25 revealed Resident #43 had a nutritional problem related to excessive energy intake and self-feeding deficit which required adaptive equipment with meals. Interventions included occupational therapy screening and providing adaptive equipment for feeding including non-spill cups and built-up utensils. Observation on 03/17/25 at 8:06 A.M. revealed there was no adaptive equipment on Resident #43's meal tray including built-up utensils and a two handled mug. Resident #43 refused her breakfast tray. Review of the Meal Ticket on Resident #43's meal tray dated 03/18/25 revealed there was no indication she was to have adaptive equipment while eating including built- up utensils and/or a two handled mug. Interview on 03/18/25 at 11:48 A.M. with Certified Nursing Assistant (CNA) #737 revealed Resident #43 did not have any adaptive equipment for meals. She had never seen adaptive equipment on her tray including built-up utensils and a two handled mug. Observation on 03/18/25 at 12:15 P.M. revealed Resident #43 was in her room eating. She had regular silverware and a plastic cup without two handles. Interview on 03/18/25 at 12:15 P.M. with Resident #43 revealed she never received built-up utensils and/or a two handled mug. She revealed she did not feel they were necessary as she felt she ate and drank without any difficulty. Interview on 03/18/25 at 12:19 P.M. with Licensed Practical Nurse (LPN) #733 verified Resident #43 had a physician's order to receive built-up utensils and a two handled mug. She verified the adaptive equipment was not on her tray, and the kitchen was responsible for ensuring anyone with adaptive equipment had it on their meal tray. Interview on 03/18/25 at 12:27 P.M. with Dietary Manager #746 revealed she started in November 2024 and stated I will be honest, when started it was a cluster mess because the adaptive equipment that she had in the kitchen did not match what nursing had as orders. She revealed she had been meaning to complete an audit to ensure they matched but had not had a chance. She verified Resident #43's meal ticket did not have that Resident #43 was to receive adaptive equipment including built-up utensils and a two handled mug. Interview on 03/18/25 at 1:12 P.M. with Dietician #747 revealed she was not aware Resident #43 had a physician's order to receive built-up utensils and/or a two handled mug. Review of the facility policy labeled, Assistive Devices and Equipment, dated 2001, revealed the facility maintains and supervises the use of assistive devices and equipment for residents. Certain devices and equipment that assisted with resident mobility, safety, and independence were provided for residents that may include specialized eating utensils and equipment. The policy recommended the use of devices and equipment was based on comprehensive assessment and documented in the resident care plan.

Based on record review, interview and review of the facility policy, the facility failed to ensure labs were obtained as ordered for Resident #5. This affected one resident (#5) out of five residents reviewed for unnecessary medications/labs. The facility census was 50. Findings include: Review of the medical record for Resident #5 revealed an admitted [DATE] with diagnoses including diabetes, dementia, hypertension, and seizures. Review of the lab work completed from 02/25/23 to 03/18/25 revealed there was no documented evidence a ferritin level (lab that indicated the amount of iron stored in the body) or a Keppra level (lab that monitored the anticonvulsant (seizure) drug level) was completed as ordered. A Vitamin D level was completed on 07/15/24 and was 17 indicating it was low (normal range was 30 to 100 nanograms (ng)/ milliliter (mL). There were no further Vitamin D levels noted on review. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had intact cognition and was on an anticonvulsant medication. Review of the March 2025 physician's orders revealed Resident #5 had a physician order dated 02/25/23 to have a Complete Blood Count (CBC), Hemoglobin A1c (HbA1c), Liver Function Test, Lipid Panel, Thyroid-Stimulating Hormone (TSH), Keppra, Vitamin D and Ferritin levels every six months. Resident #5 had an order for Vitamin D3 50,000 units one capsule every Monday morning, and Keppra 500 milligram (mg) tablet by mouth two times a day for seizures. Interview on 03/19/25 at 11:02 A.M. with the Director of Nursing (DON) verified there was no documented evidence a Keppra level and/or a Ferritin level was completed since admission. The last Vitamin D level was completed on 07/15/24, and it should have been completed every six months. She verified that the Vitamin D level should have been done 01/15/25. Review of the facility policy labeled, Lab and Diagnostic Test Results- Clinical Protocol, last revised November 2018, revealed the physician would identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. The policy revealed the staff would process test requisitions and arrange for tests.

Based on record review, interview and facility policy review, the facility failed to provide culturally competent, trauma-informed care in accordance with professional standards of practice or account for experience and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of Resident #52's post-traumatic stress disorder (PTSD). This affected one resident (#52) of two residents reviewed for trauma informed care. The facility census was 50. Findings include: Review of the medical record revealed Resident #52 was admitted to the facility on [DATE] with diagnoses of PTSD, morbid (severe) obesity due to excess calories, and anxiety disorder. Review of the undated comprehensive care plan revealed the absence of a care plan addressing PTSD or associated triggers and the absence of a psychosocial assessment for Resident #52. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #52 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. Interview with Resident #52 on 03/17/25 at 8:35 A.M. revealed a history of PTSD from sexual abuse as a minor and a sexual assault that occurred in the shower room of the nursing facility (NF) where he previously lived. He stated his triggers were the shower room in the NF and having to receive personal care from male staff members. Resident #52 stated he had requested to not have male caregivers and stated the facility had honored that request. He further stated he frequently refused showers and preferred bed baths because of his triggers. Interview with Resident #52 on 03/18/25 at 8:26 A.M. revealed he was receiving supportive services from contracted Psychological Services and enjoyed talking with his counselor. He also stated he felt very safe in this facility. Interview with Social Service Designee (SSD) #743 on 03/18/25 at 3:37 P.M. revealed psychosocial assessments were not completed for all residents. She stated she didn't complete psychosocial assessments unless the MDS nurse instructed her to do so. SSD #743 also stated the MDS nurse completed all care plans for all residents' psychosocial issues. Interview with the MDS/Licensed Practical Nurse (LPN) #727 on 03/18/25 at 3:45 P.M. revealed her understanding was contracted Psychological Services would complete psychosocial assessments on all residents. MDS/LPN #727 stated she was unsure who provided staff in-services and education about PTSD. She verified the absence of a care plan for PTSD and the absence of a psychosocial assessment. Interview with LPN #736 on 03/19/25 at 12:33 P.M. revealed she was aware of Resident #52's request for no male caregivers but was unaware of other PTSD triggers. LPN #736 further stated the facility had a male aide on night shift, but all staff knew not to allow him to provide care to Resident #52. LPN #736 stated those instructions were not written down anywhere but were passed along in report. Interview with Certified Nursing Assistant (CNA) #750 on 03/19/25 at 12:35 P.M. revealed she was unaware of any of Resident #52's PTSD triggers, was never told about triggers and had never been educated about the resident's history of PTSD or triggers associated with his diagnosis of PTSD. Review of the facility policy titled Trauma Informed Care and Culturally Competent Care, dated 2001, revealed the facility would perform universal screening of residents for exposure to traumatic events, utilize screening tools and methods that were facility-approved, competently delivered, culturally relevant and sensitive, and utilize initial screening to identify the need for further assessment and care. The policy further stated the facility would complete an assessment that would evaluate the presence of PTSD symptoms, their relationship to trauma and the identification of triggers. The policy also stated the facility would develop an individualized care plan that addressed past trauma to identify and decrease exposure to triggers that may re-traumatize the resident.

Based on observation, interviews, review of facility records and review of facility policy, the facility failed to ensure the low temperature dish machine was being appropriately monitored for levels of chemical sanitizer, and the kitchen was clean and sanitary. This had the potential to affect all 54 residents. The facility identified no residents as receiving nothing by mouth. The census was 54. Findings include: 1. Observation of the low temperature dish machine on 03/25/24 from 9:05 A.M. to 9:13 A.M. with Regional Director (RD) #353 revealed the dish machine had not met the recommended sanitation level of 50 parts per million (ppm) when RD #353 tested the dish machine's rinse water with a QAC QR Code 2951 sanitation test strip. The strip turned a pale green color which indicated the sanitizer level did not meet the sanitation level of 50 ppm. Further observation of the low temperature dish machine and interview on 03/25/24 at 2:15 P.M. with RD #353 revealed when RD #353 used a QAC QR Code 2951 test strip to test the sanitation level of the dish machine, the test strip turned a pale green color which indicated the sanitation level did not meet the level of 50 ppm. RD #353 at the time of observation confirmed the dish machine was not meeting the recommended sanitation levels; however, the test strips were past their expiration date, and he was going to get new test strips. Further observation of the low temperature dish machine and interview on 03/25/24 at 2:26 P.M. with Dietary Manager (DM) #350 revealed she had found a different brand of test strips to check the sanitation level of the dish machine. When DM #350 tested the dish machine's rinse water with hydrion chlorine sanitizer test strips, the test strip turned an indigo blue which indicated 200 ppm. DM #350 repeated the same process, and the test strip turned a color between dark purple and indigo blue which indicated the sanitation level was between 150 and 200 ppm. DM #350 confirmed the dish machine's sanitation level was now reading too high and should be reading at 50 ppm. Observation of the test strips containers with DM #350 on 03/25/24 at 2:36 P.M. revealed the QAC QR Code 2951 test strips RD #353 used had an expiration date of 2017, and the hydrion chlorine sanitizer test strips DM #350 used had an expiration date of July 2022. At the time of observation, DM #350 confirmed both test strips were outdated. Further observation of the low temperature machine and interview on 03/26/24 between 8:30 A.M. and 8:35 A.M., with RD #353 revealed when he put a hydrion chlorine sanitizer test strip into the dish machine rinse water, the test strip turned an indigo blue color indicating a sanitation level of 200 ppm. When RD #353 repeated the process, the test strip turned a color between dark purple and indigo blue which indicated a sanitation level between 150 ppm and 200 ppm. Interview with RD #353 at the time of observation revealed he was able to obtain test strips with an expiration date of August 2025, and he confirmed the dish machine was providing too much sanitizer. Interview and observation with Service Tech (ST) #360 from the dish machine chemical supply company on 03/26/24 at 10:42 A.M. revealed ST #360 tested the chemical sanitizer and the level of chemical sanitizer was reading between 150 and 200 ppm. ST #360 stated the dish machine sanitizer levels needed to be titrated, he titrated the chemical levels, and the dish machine was now meeting the recommended sanitation level of 50 ppm. ST #360 voiced using outdated testing strips could affect the reliability of the test results. Observation of ST #360 testing the sanitation level of the dish machine with a hydrion chlorine sanitizer test strip revealed the test strip turned purple, indicating the sanitation level was 50 ppm and was meeting the recommended level for sanitation. Review of facility policy Sanitization, revised November 2022, revealed low temperature dish machine's final rinse should read 50 ppm and the chemical was to be maintained at the correct concentration, based on periodic testing, at least once per shift and for the corrective contact time according to manufacturer's guidelines. 2. Observation during initial kitchen tour on 03/25/24 from 8:03 A.M. to 8:25 A.M. with Dietary Cook #355 and Dietary Aide #356 revealed the following concerns: In the walk-in cooler on the right-hand side, there were two cases of liquid eggs sitting on the open wired shelf above an open case of apples and an open case of oranges sitting on the bottom shelf. The floor of the walk-in freezer had a buildup of debris around the perimeter of the floor with four dried up green bean pieces in the middle of the floor The two-door reach in freezer revealed a buildup of debris on the base of the unit. A large white plastic circular container of sugar, located on a metal shelf between the three compartment sink and the oven, had a white Styrofoam cup stored in the container. The plugged-in black metal circular fan, located on the floor near the kitchen doors and pointing towards the tray line, revealed a buildup of black dust on the blades and cage of the unit. At the time of observation, Dietary Aide #356 confirmed the liquid egg should not have been stored above the oranges and apples, the floor of the walk-in freezer and two door reach in cooler needed cleaned, and there was a Styrofoam cup being stored in the bulk sugar. Dietary Cook #355 confirmed the fan was dirty and needed to be cleaned. Interview with Dietary Manager #350 on 03/25/24 at 8:39 A.M. revealed nothing should be stored in bulk containers and confirmed the Styrofoam cup should not have been stored in the sugar. Review of facility policy Food Receiving and Storage, revised November 2022, revealed uncooked and raw animal products would be stored in drip proof container and below fruits to prevent juices from dripping onto those foods. Review of facility policy Sanitization, revised November 2022, revealed all kitchen areas were to be kept clean and free from debris. This deficiency represents noncompliance investigated under Complaint Number OH00151786.

Based on observation, interview, and review of facility documents, the facility failed to ensure they had a three-day emergency supply of food as required. This had the potential to affect all 54 residents. The facility identified no residents as receiving nothing by mouth. The census was 54. Findings include: Observation during initial tour of the kitchen on 03/25/24 from 8:03 A.M. to 8:25 A.M. with Dietary Cook (DC) #355 and Dietary Aide (DA) #356 revealed a minimal supply of foods in dry and cold storage areas of the kitchen. The walk-in cooler and freezer revealed the shelves held minimal foods available to cook for the meals. The bread rack had multiple empty shelves with a few packages of bread products. There was no instant powdered milk or canned meat items available for an emergency food supply. Dietary Aide #356 at the time of observation confirmed the facility did not have a three-day emergency supply of food. Interview on 03/25/24 at 8:39 A.M. with Dietary Manager (DM) #350 confirmed the facility did not have a three-day supply of food on hand in the facility. She stated there had never been a three-day supply of food since she started at the facility six months ago. DM #350 stated she had gotten a quote from the food vendor on everything she needed for a three-day supply of food and had presented it to the Administrator. DM #350 stated the Administrator would get back to her. Review of the facility document Three Day Emergency Menu, dated 12/06/22, revealed for all three days for breakfast corn beef hash, assorted cereals, orange juice, instant powdered milk and spring water would be served. For day one lunch, chili beef with beans, saltines, wheat bread, mandarin oranges, instant powdered milk, and spring water and for dinner peanut butter and jelly sandwiches, carrots, potato chips, apple sauce and [NAME] cookies, powdered milk, and spring water would be served. For day two lunch, chicken and dumplings, carrots, wheat bread, fruit cocktail, instant milk, and spring water and for dinner sloppy joe sandwich, green peas canned, pretzels, chilled peaches, [NAME] cookies, instant powdered milk, and spring water would be served. For day three lunch, beef stew, green beans, graham crackers, wheat bread, pineapple chunks, instant powdered milk and spring water and for dinner, tuna salad sandwich, beets, potato chips, fruit cocktail, [NAME] cookies, instant powdered milk and spring water would be served. Review of the Three Day Emergency Menu and interview on 03/25/24 at 4:33 P.M. with DM #350 confirmed the facility couldn't provide the emergency menu since the facility did not have powdered milk, canned meats, potato chips, pretzels, and Loorna [NAME] cookies in stock. Review of the Emergency Menu Quote List revealed on 02/21/24 the food vendor had given a price for everything needed for the emergency menu. Review of email to Regional Director #353 and District Director #354 from DM #350, dated 03/21/24 and timed at 1:31 P.M., indicated there was zero emergency food in the facility, and DM #350 had given the administrator a quote for the food vendor and was waiting on authorization from him to allow her to purchase the items needed for the emergency menu. DM #350 stated she had been following up almost weekly to see if he has heard anything back from his boss. This deficiency represents noncompliance investigated under Complaint Number OH00151786.

Based on record review, review of psychotropic medication information, facility policy review and interview, the facility failed to prevent a significant medication error for Resident #26 when the resident's psychotropic medication, for reducing risk of recurrent suicidal behavior with schizophrenia was not administered as ordered by the physician from 11/20/23 until 12/06/23. The facility also failed to ensure the physician was notified timely that the medication was unavailable for administration. Actual Harm occurred on 12/07/23 when Resident #26 was admitted to the hospital with psychosis (having increased behaviors and hallucinations), suicidal ideations, threatening to kill herself and slit her throat with a knife as a result of the missed doses of the psychotropic medication, Clozapine. This affected one resident (#26) of four residents reviewed for medication administration. The facility census was 52. Findings Include: Review of the medical record for Resident #26 revealed an initial admitted [DATE] with a hospital stays from 10/13/23 to 11/20/23 and from 12/07/23 to 12/29/23. Diagnoses included schizoaffective disorder bipolar type, dementia, anxiety disorder, drug induced akathisia (inability to remain still), and insomnia. Resident #26 had a court appointed guardian. Review of the Admission Minimum Data Set (MDS) assessment, dated 12/03/23, revealed Resident #26 had no cognitive impairment and received antipsychotic medications. Review of physician's orders revealed Resident #26 had a re-admission order dated 11/20/23 for Clozapine (antipsychotic) 300 milligrams (mg) daily for seven days then give 350 mg daily for seven days followed by 400 mg daily for 14 days. On 12/04/23, the Clozapine order was changed to 100 mg for one day as a titrating dose, then give 150 mg on 12/05/23, 200 mg on 12/06/23, 250 mg on 12/07/23, 350 mg on 12/08/23, 350 mg on 12/09/23, 400 mg on 12/10/23, then 400 mg daily at bedtime thereafter. Review of the progress notes revealed Resident #26 was admitted to the hospital on 10/13/23 due to increasing behaviors and was refusing medications. On 11/20/23, Resident #26 was readmitted . Clozapine 300 mg was documented as not available to administer, being on order, awaiting pharmacy delivery from 11/20/23 through 11/26/23. On 11/25/23, laboratory tests were re-faxed to the pharmacy. On 11/26/23, pharmacy requested Physician #240 to submit required information to dispense the Clozapine. The request to complete the required information was faxed to Physician #240's office. On 11/28/23, Clozapine 350 mg was documented as not available to administer, being on order, awaiting pharmacy delivery. On 11/29/23, Physician #240 examined Resident #26 via telehealth. Staff reported to Physician #240 of Resident #26 being more agitated for the past seven days. Physician #240 ordered fluphenazine (antipsychotic) to be administered at 25 mg for one dose, then 10 mg daily for seven days due to Resident #26's behaviors. There was no evidence the staff informed Physician #240 of the multiple missed doses of Clozapine. On 12/01/23, Clozapine 350 mg was documented as being not found in the medication cart or medication room and was awaiting on pharmacy. On 12/03/23 Clozapine 350 mg was documented as not administered due to waiting on pharmacy required information. Review of the Medication Administration Record (MAR) for November 2023 to December 2023 revealed Resident #26 did not receive the physician ordered Clozapine 300 mg daily from 11/20/23 to 11/26/23. Clozapine 350 mg daily was not administered on 11/27/23, 11/28/23, 11/30/23, 12/01/23 and 12/03/23. The nursing staff signed the MAR record to indicate Clozapine 350 mg was administered on 11/29/23 and 12/02/23. On 12/04/23, Clozapine 100 mg for one dose was not administered. On 12/05/23, Clozapine 150 mg for one dose was documented as administered. On 12/06/23, Clozapine 200 mg was documented as not administered. Review of an email from Director of Nursing (DON) to Physician #240 dated 12/04/23 at 9:33 A.M. reported Resident #26 needed required information for pharmacy to deliver Clozapine, and Resident #26 was out of the medication for a few days. Review of an email from Physician #240 to the DON dated 12/04/23 at 9:44 A.M. questioned DON on how many days Resident #26 had not received Clozapine as it would need re-titrated if more than three days. Review of an email from Physician #240 dated 12/04/23 at 9:46 A.M. revealed the required information was completed. Review of an email from the DON to Physician #240 dated 12/04/23 at 10:27 A.M. reported Resident #26 had missed three days of Clozapine. Review of an email from Physician #240 to the DON dated 12/04/23 at 10:42 A.M. indicated Resident #26's Clozapine would need re-titrated due to missing three days and could be more aggressive since it had only been three days. Physician #240 ordered to give Clozaril 100 mg on 12/04/23, 150 mg on 12/05/23, 200 mg on 12/06/23, 250 mg on 12/07/23, 300 mg on 12/08/23, 350 mg on 12/09/23 then 400 mg thereafter. Additional directions were provided to the DON regarding adverse effects including orthostatic hypotension or over-sedation. Physician #240 indicated follow-up with Resident #26 at a telehealth appointment on 12/06/23. Review of progress notes revealed on 12/05/23, Clozaril 100 mg was not available and waiting on pharmacy to deliver. On 12/07/23, Resident #26 was agitated throughout the day with multiple occasions of hallucinations with redirection having little to no effect. Resident #26 had refused all medications in the morning. A message was left with Physician #240 to contact the facility to be informed of missed medications. Physician #240 responded and indicated Resident #26 would benefit from hospitalization to evaluate medications. Resident #26 was transferred to the hospital with Assistant Director of Nursing (ADON) #220 in accompaniment to assist with behaviors, and Resident #26 was admitted . On 12/29/23, Resident #26 was returned from the hospital. Review of hospital documentation from 12/07/23 to 12/29/23 revealed Resident #26 was admitted for psychosis and suicidal ideation. On 12/08/23, Physician #240 documented the facility reported Resident #26 missed doses of Clozapine from 12/01/23 to 12/03/23 due to a pharmacy error and required re-titration. The last reported dose received was on 12/06/23. ADON #220 reported Resident #26 had decompensated since 12/06/23 after being without Clozapine from 12/01/23 to 12/03/23 and requiring re-titration. Resident #26 was now paranoid, threatening to kill herself, and to cut her throat with a knife. Interview on 01/09/24 at 1:41 P.M. with Registered Nurse (RN) #234 indicated Resident #26 had baseline schizophrenic behaviors such as agitation and rocking. RN #234 confirmed there was an issue with getting the Clozapine from pharmacy, and it probably aided the agitation. RN #234 stated the nurses followed-up with pharmacy to find out why a medication was not available and contact the physician for directions. Interview on 01/09/24 at 2:36 P.M. with the DON and ADON #220 verified Resident #26 was readmitted on [DATE] and the ordered Clozapine was not administered from 11/20/23 to 11/26/23. On 11/27/23 the physician was notified of the pharmacy need for REMS (Risk Evaluation and Mitigation Strategy) documentation to be completed to dispense Clozapine. At the time, the physician was not made aware of the missed Clozapine doses. On 11/27/23, 11/28/23, 11/30/23, 12/01/23 and 12/03/23, the ordered Clozapine was also not administered due to the medication not being available. On 12/04/23, the physician was contacted, and new orders were received for re-titration. Clozapine was not administered on 12/04/23 and 12/06/23, then Resident #26 went to the hospital on 12/07/23. Interview on 01/09/24 at 3:58 P.M. with DON and ADON #220 confirmed Resident #26's physician was not notified of the missed doses of Clozapine until 12/04/23. ADON #220 indicated contacting the physician and reported increased agitation and Resident #26 was deteriorating due to the change in medication. On 12/07/23, Resident #26 was sent to the hospital due to increased behaviors, starting to refuse medications, and being suicidal. With a medication that requires REMS, laboratory results are sent to the pharmacy, and the pharmacy will notify the physician of the required documentation needed. If the physician does not complete it, then the pharmacy will notify the facility. The DON and ADON #220 verified it was the nurse's responsibility to contact the physician to obtain required documentation for the pharmacy. Interview on 01/10/24 at 9:29 A.M. with Physician #240 indicated being unaware Resident #26 missed more than three days of Clozapine. It was not until 12/04/23 when an email was received from the facility which reported a need for REMS documentation for the Clozapine and missed doses from 12/01/23 to 12/03/23. The facility had access to both Physician #240's phone number and email to contact at any time each day. It was the DON who provided information when anything was needed for medication dispensing. Physician #240 confirmed Resident #26's hospitalization on [DATE] for suicidal tendencies, paranoia, and agitation was a direct result from the lack of administration of Clozapine. Interview on 01/10/24 at 9:41 A.M. with Pharmacist #241 confirmed Resident #26's Clozapine was not delivered to the facility for administration between 11/20/23 and 12/04/23. Communication for REMS documentation was between the facility and the physician with the facility faxing laboratory values to the pharmacy. Pharmacist #241 verified the abrupt stopping of Clozapine had possible adverse effects including increased agitation and psychosis. Review of drug information on Clozapine retrieved from Medscape on 01/10/24 at https://reference.medscape.com/drug/clozaril-versacloz-clozapine-342972 revealed Clozapine was indicated for reducing risk of recurrent suicidal behavior in patients with schizophrenia or schizoaffective disorder, and in patients who are judged to be at chronic risk to re-experience suicidal behavior. Reduce doses gradually over a period of one to two weeks and taper gradually to avoid withdrawal symptoms and minimize risk of relapse for schizophrenia. Guidelines recommend gradual taper over six to 24 months. The American Psychiatric Association guidelines recommend reducing dose by 10 percent each month. Review of the facility policy titled Administering Medications, revised April 2019, revealed medications were administered in accordance with prescriber orders, including any required time frame. If a medication was suspected of being associated with adverse consequences, the physician would be contacted to discuss the concerns. This deficiency represents non-compliance investigated under Complaint Number OH00149534.

Based on record review and staff interview, the facility failed to ensure resident care plans were revised to reflect current resident medical/behavioral conditions. This affected one resident (Resident #34) of eight residents reviewed for elopement care plans. Findings include: Review of the medical record for Resident #34 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress note dated 06/08/22 and timed 5:44 P.M. revealed Resident #34 was walking in town when a police officer found her. When Resident #34 returned to the facility, the Director of Nursing (DON) was notified of the incident and contacted the guardian. It was agreed Resident #34's privileges to leave the facility would be revoked. Review of the care plan dated 08/23/22 revealed Resident #34 was a low risk for elopement. Interventions included ensuring safety during periods of confusion or anxiety, unsupervised smoke breaks and being able to walk to the store per the resident's Power of Attorney (POA). Review of the elopement/wandering assessment dated [DATE] revealed Resident #34 was at a low risk for wandering and elopement. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #34 was cognitively intact and exhibited no physical, verbal or wandering behaviors. Resident #34 had a legal guardian. Review of the nurse's notes dated 07/11/22, 08/13/22, 09/23/22, 10/03/22, 10/04/22 and 10/05/22 revealed Resident #34 left the building without permission from her guardian. Interview with the Director of Nursing on 10/13/22 at 1:34 P.M. verified Resident #34's care plan was not updated to reflect current elopement behaviors.

Based on interview, and record review, the facility failed to ensure Resident #41's bowel pattern was effectively managed. This affected one resident (Resident #41) of two residents reviewed for constipation. Findings include: Review of medical record for Resident #41 revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He did not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of care plan dated 12/22/21 revealed Resident #41 had an activities of daily living self-care performance deficit related to impaired balance, and [CONDITION(S)]. Interventions included he required staff assist with transfers, bed mobility, and toileting. Review of comprehensive care plan dated 12/22/21 revealed Resident #41 did not have a care plan for constipation. Review of electronic medical record dated from 09/14/22 to 10/13/22 under bowel continence task bar revealed Resident #41 had a large bowl movement on 09/14/22 but then did not have another bowel movement until 09/22/22 (seven days later) and it was documented that Resident #41 was constipated, and the bowel movement was hard. Resident #41 then did not have another large bowel movement documented until 10/02/22 (ten days later). Resident then had a large bowel movement 10/08/22 (five days later) and it was documented that Resident #41 was constipated and the bowel movement was hard. Review of nursing notes from 09/14/22 to 10/13/22 revealed there was no documentation Resident #41's Primary Care Physician #900 was notified that Resident #41 went from 09/15/22 to 09/22/22 (7 days), 09/23/22 to 10/10/02/22 (10 days), and 10/3/22 to 10/08/22 (five days) without bowel movements. There also was no documentation the Primary Care Physician #900 was notified on 09/22/22 and on 10/08/22 that Resident #41 was constipated and had a hard bowel movement. Review of quarterly Minimum Data Set (MDS) 3.0 dated 09/21/22 revealed Resident #41 had intact cognition. He required extensive assist of two people with bed mobility and was totally dependent of two people with transfer. He was totally dependent of one person with toileting and was unable to ambulate. Review of October 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 10/13/22 at 10:30 A.M. with Resident #41 revealed he had issues with constipation all his life especially because he takes a lot of medications that caused him to be constipated. He also revealed he had not been out of bed since admission mainly because of his obesity which also caused him to be constipated. He revealed sometimes he went four to five days without having a bowel movement and possibly longer as Resident #41 stated he did not keep track. Resident #41 revealed the nursing staff at the facility never checked to see if he had any signs of constipation and/ or never offered any as needed medications to assist in having a bowel movement. He revealed at times his bowel movement was very hard. Interview on 10:33 A.M. with Director of Nursing verified the documentation per the electronic task bar that Resident #41 did not have a bowel from 09/15/22 to 09/22/22 (7 days), 09/23/22 to 10/10/02/22 (10 days), and 10/3/22 to 10/08/22 (five days). She also verified in the task bar it was documented on 09/22/22 and on 10/08/22 that Resident #41 was constipated and had hard bowel movements. She verified Primary Care Physician #900 was not notified regarding Resident #41 not having a routine bowel movement and/ or Resident #41 being constipated and having hard bowel movement. She revealed the nurse was to check the electronic medical record and if a resident did not have a bowel movement within three days the nurse should either give if ordered an as needed medication for constipation and if a resident did not have an as needed medication ordered for constipation, then the nurse was to contact the physician for orders. Review of facility policy labeled, Bowel (Lower Gastrointestinal Tract) Disorders- Clinical Protocol, dated September 2017 revealed the staff and physician would monitor the individual's response to interventions and overall progress for example overall degrees of comfort or distress, frequency, and consistency of bowel movements. The policy revealed the physician would adjust interventions based on identification of causes, responses, and other relevant factors.

Based on interview and record review, the facility failed to ensure Resident #39 received her medications consistently per physician orders. This affected one resident (Resident #39) of eight residents reviewed for pharmacy services. Findings include: Review of the medical record for Resident #39 revealed she was admitted on [DATE] with diagnoses including chronic pancreatitis, major depressive disorder, anxiety, [CONDITION(S)], type II diabetes and [CONDITION(S)] disorder. Review of physician orders revealed the resident received [MEDICATION(S)] Solution Prefilled Syringe 162 milligrams (mg)/0.9 milliliter (ml) subcutaneously one time a day every 14 days related to [CONDITION(S)], [MEDICATION(S)] tablet 2 mg in the morning related to constipation, and [MEDICATION(S)] Capsule 30 mg tablet and 40 mg tablet, each once a day related to attention deficit-[CONDITION(S)] disorder. Review of the annual Minimum Data Summary (MDS) 3.0 of 09/24/22 revealed Resident #39 was cognitively intact, had severe depression, was independent for activities of daily living and received scheduled medication for pain. Review of the care plan of 09/28/22 revealed care areas for pain, [CONDITION(S)], and the potential for constipation. Review of the medication administration records from 06/01/22 to 10/12/22 revealed Resident #39 did not receive: [MEDICATION(S)] 06/029/22 through 07/20/22, [MEDICATION(S)] 30 mg 08/25/22 through 08/28/22, [MEDICATION(S)] 40 mg 08/15/22 through 08/24/22. The [MEDICATION(S)] Solution Prefilled Syringe scheduled for 08/20/22 was not received until 08/24/22 and the dose scheduled for 09/17/22 was not received until 10/01/22. Review of progress notes from 06/30/22 to 09/17/22 revealed Resident #39's medications mentioned above were not available for refill due to a lack of insurance authorization. Interview on 10/13/22 at 10:07 A.M. with Licensed Practical Nurse (LPN) #209 verified Resident #39 goes without her [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] due to waiting for insurance approvals. The physician was notified and the resident was able to voice her needs, including need for an enema if needed. Interview on 10/13/22 at 10:14 A.M. with Resident #39 revealed she had an increase in pain and discomfort when she did not receive her medications as prescribed. Interview on 10/13/22 at 11:02 A.M. with Director of Nursing (DON) revealed she completes a request for the medications and sends to the insurance company every time Resident #39 runs out of [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)]. She verified the resident went without her medications during this process. The resident's insurance, managed medicaid, had quit paying her stay at the facility due to her level of functioning. The resident was considered private pay and had a significant outstanding balance. She was unable to provide an option to ensure the resident continued to receive her medications as ordered. Interview on 10/13/22 at 2:14 P.M. with Regional Registered Nurse (RN) #200 verified Resident #39 should not be going without her medication and there should be some way to cover the cost, as they were covering her room and board. The resident's level of care needed reviewed and other options explored.

Based on interview, observation, and record review, the facility failed to ensure Resident #31's insulin was dated after it was opened. This affected one resident (Resident #31) out of four residents (Resident #5, #28, #31, #39) that received insulin on the north cart two. Findings included: Review of medical record for Resident #31 revealed an admitted [DATE] and her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of care plan dated 11/05/18 revealed Resident #31 had diabetes and her interventions included administer insulin per physician orders, and check blood glucose levels per orders. Review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] ., 12:00 P.M. and 5:00 P.M. Observation on 10/12/22 at 11:32 A.M. revealed Resident #31's [MEDICATION(S)] insulin was undated when Licensed Practical Nurse (LPN) #210 took out the insulin out of north cart two. Observation then revealed LPN #210 administered six units of the [MEDICATION(S)] insulin as ordered to Resident #31's left arm. Interview on 10/12/22 at 11:39 A.M. with LPN #210 verified Resident #31's [MEDICATION(S)] insulin was not dated when it was opened, and she did not now when it was opened. She verified the insulin should have been dated when it was opened. Review of [MEDICATION(S)] Injection package insert/ prescribing information dated 10/01/21 revealed the insulin should be refrigerated until first used, after first used the insulin was to be stored at room temperature and discarded after 28 days. Review of facility policy labeled, Labeling of Medication Containers, dated April 2019, revealed all medication maintained in the facility were to be properly labeled in accordance with current state and federal guidelines and regulation. The policy did not include anything in regard to ensuring insulin and/ or other medications were dated when opened.

Based on observation, record review, and interview, the facility failed to ensure Resident #4 was provided a reasonable accommodation to enter the facility and did not ensure Resident #50's wheelchair was serviced and repaired in a timely manner. This affected two residents (Residents #4 and #50) of two residents reviewed for accommodation of needs. Findings include: 1. Review of the medical record for Resident #4 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the smoking assessment dated [DATE] revealed the resident was an unsupervised smoker, but required assistance getting outside in her wheelchair. Review of Resident #4's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact. She was totally dependent on two people for transfers and she required extensive assistance of two people for bed mobility, dressing and toilet use. Review of Resident #4's care plan dated 08/30/22 revealed the resident had [CONDITION(S)] due to smoking. Interventions included avoiding extreme hot and cold temperatures, monitoring for signs and symptoms of respiratory insufficiency, and oxygen as tolerated. Observation on 10/12/22 at 8:22 A.M. revealed Resident #4 in a motorized wheelchair on the smoking patio. Interview at the time of the observation revealed she knew the code to get back into the building, but she could not reach the keypad. She would wait until another resident went back into the building and held the door for her so she could maneuver her wheelchair through the door. Interview on 10/12/22 at 8:30 A.M. with State tested Nursing Assistant (STNA) #204 revealed she was aware Resident #4 was outside, but there was no procedure for letting residents back in when they went outside. She opened the door for Resident #4 so she could reenter the building. STNA #204 needed to ask this surveyor to hold the door open so Resident #4 could safely enter as the door did not stay open on its own. Observation on 10/13/22 at 10:02 A.M. revealed a doorbell had been installed on the door frame used to enter the smoking patio, directly underneath the keypad. This surveyor pushed the doorbell button and waited for an employee to respond. Within approximately two minutes, STNA #208 looked down the hall through the window of the door and saw this surveyor standing outside. She then opened the door. Interview at the time of the observation with STNA #208 revealed she did not think the doorbell worked, she just happened to see me standing outside. She confirmed staff have to let residents outside to use the smoking patio and other residents will usually open the door if a resident does not know the code or cannot let themselves back in. Interview on 10/13/22 at 1:07 P.M. with Registered Nurse #200 confirmed there was no procedure for residents getting back into the building from the smoking patio. Review of the facility policy titled, Smoking policy - Residents, revised 04/2012 revealed smoking was only permitted outside the building, and any smoking related concerns will be noted in the resident's care plan and staff would be alerted. 2. Review of the medical records for Resident #50 revealed she was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 06/14/22 invoice for Resident #50's wheelchair revealed it was a tilt in space with elevating manual leg rests and adjustable foot plates. Review of Resident #50's care plan of 07/22/22 revealed care areas for a traumatic brain injury related to a motor vehicle accident, chronic pain, extensive assistance of two for ADLs. The resident had received occupational therapy from 09/12/22 to 09/28/22. Review of the quarterly MDS 3.0 of 09/24/22 revealed the resident was severely cognitively impaired, required extensive assist of two for ADLs and was at risk of pressure ulcers. Interview on 10/11/22 at 11:04 A.M. with Resident #50 and her father revealed the facility was supposed to lengthen her wheel chair so she could fully extend her left leg about two months ago. The resident was seated in her tilt in space custom wheelchair and her left leg was in a slightly bent position with both legs elevated on an armless chair. Their were no legs rests on her wheelchair. One leg rest was visible laying against the wall in the resident's room. Further observations of Resident #50 on 10/12/22 at 10:45 A.M. and 1:55 P.M. and on 10/13/22 at 11:35 A.M. revealed the resident was using a chair to put her legs up since there were no leg rests on her chair. Interview on 10/12/22 at 8:47 A.M. with the Director of Rehab (DOR) #207 revealed that she was aware of Resident #50's not being able to fully extend her legs for awhile. DOR #207 had tried extending the wheelchair herself but she did not have the proper tools. She reported she did not call the wheelchair company for service at that time because she forgot things sometimes. She reported the one leg rest fell off recently and she had a call in for repair. Interview on 10/13/22 at 10:12 A.M. with Licensed Practical Nurse (LPN) verified Resident #50 and her father had requested the leg rests be extended on her wheelchair over a month ago but it was not done. The leg rest fell off sometime in the past week. Interview on 10/13/22 at 10:28 A.M. with Regional LPN #212 verified the service needed for Resident #50's wheelchair was not addressed in a timely manner.

Based on interview, record review and policy review, the facility failed to ensure a comprehensive care plan was implemented identifying fall risk and interventions to potentially prevent falls for Resident #5, who was assessed at high risk for falls and had falls at the facility. This affected one resident (Resident #5) of three residents reviewed for falls. The facility census was 49. Findings include: Review of the medical record for Resident #5 revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Fall Risk assessment dated [DATE] revealed Resident #5 was at high risk for falls due medications she was on that may contribute to falls, memory and recall impairment, vision impairment, incontinence, agitated behaviors, and decreased muscle coordination. Review of the Fall Incident Report dated 09/03/21 at 10:48 P.M. and authored by Licensed Practical Nurse (LPN) #611 revealed Resident #5 was found lying in a prone position (face down) with her cheek resting on the base of her intravenous pole. The report revealed the immediate intervention was to always place a mattress to the side of the bed on the floor and half side rails up. Review of the Medicare five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #5 had impaired cognition as she was rarely or never understood. Resident #5 required total dependence of two staff for bed mobility and toileting. Resident #5 was only transferred once or twice during the seven-day assessment period which required two staff assistance. Resident #5 was unable to ambulate. Resident #5 had no behaviors and was always incontinent of bowel and bladder. Review of the Fall Incident Report dated 10/16/21 at 4:06 P.M. and authored by LPN #604 revealed Resident #5 was in another resident's room lying on the floor. LPN #604 assessed Resident #5 and noted no visible injuries. She completed neurological checks which were within normal limits. LPN #604 notified Resident #5's Primary Care Physician #900. The report revealed the immediate intervention that was implemented was to place stop signs on the doors of the other rooms that Resident #5 was attempting to enter as a visual reminder that the room was the wrong room. Review of the Fall Risk assessment dated [DATE] revealed Resident #5 continued to be at high risk for falls. Review of the undated comprehensive care plan revealed Resident #5 did not have a comprehensive care plan identifying she was at high risk for falls and interventions identified to potentially prevent falls. Interview on 11/01/21 at 9:32 A.M. with LPN/ MDS Coordinator #606 verified Resident #5 was at high risk for falls but did not have a comprehensive care plan identifying she was at risk or interventions documented in the care plan to potentially prevent falls. Interview on 11/01/21 at 12:05 P.M. with Regional Director of Clinical Services #600 verified Resident #5 was assessed on admission on 09/03/21 as high risk for falls and continued to be at high risk for falls on the assessment dated [DATE]. Regional Director of Clinical Services #600 verified Resident #5 had falls at the facility on 09/03/21 and 10/16/21. Regional Director of Clinical Services #600 verified Resident #5 did not have a comprehensive care plan implemented identifying she was at high risk for falls, had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility policy titled Care Plans, Comprehensive Person- Centered, dated December 2016, revealed the facility was to ensure a comprehensive person-centered care plan that included measurable objectives to meet the resident's physical, psychosocial and functional needs was to be developed and implemented for each resident. The policy revealed the facility was to ensure the compressive person-centered care plan identified the problem areas and their causes, and the facility was to develop interventions that were targeted and meaningful to the resident. The policy also revealed care plan interventions were chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's identified problem areas, causes and relevant decision-making interventions. Review of facility policy titled Falls and Fall Risk, Managing, dated March 2018, revealed the facility was to ensure, based on evaluations and current data, staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling as the staff would implement a resident-centered fall prevention plan to reduce the specific risk factor. This deficiency substantiates Complaint Numbers OH 788.

Based on interview, record review and policy review, the facility failed to ensure Resident #5 who was assessed at high risk for falls on admission had a baseline care plan that included specific interventions to prevent falls and failed to have documented evidence the baseline care plan was reviewed with Resident #5's representative. This affected one resident (Resident #5) of three residents reviewed for falls and baseline care plans. The facility census was 49. Findings include: Review of the medical record for Resident #5 revealed an admitted [DATE] and a a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the undated and unauthored form labeled Baseline Care Plan revealed under the category of safety, Resident #5 had documented Fall Precautions, but there were no specific fall precautions/interventions listed. The care plan revealed Resident #5 was unaware of safety needs and required two staff assistance with bed mobility, transfers, and toileting. The care plan revealed Resident #5 was unable to ambulate. The baseline care plan revealed under the areas for staff signature, resident signature, and representative signature, the areas were blank as well as the baseline care plan completion date and date reviewed with the resident and/or representative were also blank. Review of the admission Fall Risk assessment dated [DATE] revealed Resident #5 was at high risk for falls due medications she was on that may contribute to falls, memory and recall impairment, vision impairment, incontinence, agitated behaviors, and decreased muscle coordination. Review of the Fall Incident Report dated 09/03/21 at 10:48 P.M. and authored by Licensed Practical Nurse (LPN) #611 revealed Resident #5 was found lying in a prone position (face down) with her cheek resting on the base of her intravenous pole. LPN #611 assessed Resident #5, and she had no injuries. The report revealed the immediate intervention was to always place a mattress to the side of her bed on the floor and half side rails up. Review of the Medicare five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #5 had impaired cognition as she was rarely or never understood. Resident #5 required total dependence of two staff for bed mobility and toileting. Resident #5 was only transferred once or twice during the seven-day assessment period which required two staff assistance. She was unable to ambulate. Resident #5 had no behaviors and was always incontinent of bowel and bladder. Review of the Fall Incident Report dated 10/16/21 at 4:06 P.M. and authored by LPN #604 revealed Resident #5 was in another resident's room lying on the floor. LPN #604 assessed Resident #5 and noted no visible injuries. LPN #604 completed neurological checks which were within normal limits. LPN #604 notified Resident #5's Primary Care Physician #900. The report revealed the immediate intervention implemented was to place stop signs on the doors of the other rooms that Resident #5 was attempting to enter as a visual reminder that the room was the wrong room. Review of the Fall Risk assessment dated [DATE] revealed Resident #5 continued to be at high risk for falls. Interview on 11/01/21 at 9:32 A.M. with LPN/ MDS Coordinator #606 verified Resident #5 was at high risk for falls on admission per Resident #5's risk assessment, and she verified the baseline care plan only revealed Fall Precautions. She revealed any resident identified at risk for falls should have individualized specific interventions listed on the baseline care plan. Interview on 11/01/21 at 12:05 A.M. with Regional Director of Clinical Services #600 verified Resident #5 was assessed on admission, 09/03/21, and was determined at high risk for falls. Regional Director of Clinical Services #600 verified the baseline care plan only had listed under the safety section, Fall Precautions but did not include specific precautions the staff should implement despite Resident #5 being high risk for falls. Regional Director of Clinical Services #600 also verified the baseline care plan was not dated when it was completed, was not signed by the nurse that completed the baseline care plan and was not signed and dated if the care plan was reviewed with the resident and/or the resident representative. Review of facility policy titled Care Plans- Baseline, dated December 2016, revealed the facility was to initiate a baseline plan of care to meet the resident's immediate needs within 48 hours of admission. The policy revealed the baseline care plan would be used until staff conducted the comprehensive assessment and developed an interdisciplinary person-centered care plan. The policy revealed the facility was to ensure the resident and their representative was provided a summary of the baseline care plan that included but not limited to any services and treatments to be administered by the facility. Review of facility policy titled Falls and Fall Risk, Managing, dated March 2018, revealed the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling as the staff would implement a resident-centered fall prevention plan to reduce the specific risk factor. This deficiency substantiates Complaint Numbers OH 788.

Based on observation and interview, the facility did not maintain garbage and refuse properly in closed dumpsters. This had the potential to affect all residents residing in the facility. The census was 44. Findings include: Interview on 11/27/19 at 8:20 [NAME]M. with Housekeeping #211 indicated feral cats were observed in the facility dumpsters. Interview on 11/27/19 at 8:31 [NAME]M. with Housekeeping #216 indicated feral cats were observed in the facility dumpsters. Interview on 11/27/19 at 9:30 [NAME]M. with State tested Nursing Assistant (STNA) #219 indicated feral cats were observed in the facility dumpsters. Observation on 11/27/19 at 4:27 P.M. of two outside facility dumpsters revealed one closed top loading dumpster and one open side loading dumpster. Interview with Dietary Manager #205 at the time of the observation confirmed the side loading dumpster was open and indicated both dumpsters should remain closed. This deficiency substantiates Complaint Number OH 286.

Based on record review, interview and policy review, the facility failed to implement the facility policy and procedure by reporting an injury of unknown origin for Resident #34. This affected one Resident (#34) of three Residents (#26, #30 and #34) reviewed for incidents/accidents. The facility census was 44. Findings include: Review of the medical record for Resident #34 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/07/19, revealed the resident had impaired cognition. The resident required extensive assistance of two staff for bed mobility, transfers and personal hygiene, extensive assistance of one staff for toileting and eating, and total dependence of one staff for bathing. The assessment indicated resident received hospice care. Review of the progress note dated 11/12/19 indicated a bruise was identified on Resident #34's right thigh. The resident was unable to communicate how or when it occurred, and the Director of Nursing and Administrator were notified. Review of the resident incident report form dated 11/12/19 for Resident #34 indicated a right thigh bruise of unknown origin. Review of the incident/accident tracking log dated (MONTH) 2019 through (MONTH) 2019 revealed a bruise on 11/12/19 for Resident #34. Review of Resident #34's bath sheets indicated no bruises on 11/10/19, 11/17/19, 11/20/19, 11/24/19, and bruising on the right thigh, right arm, right breast, left foot, and abrasions on the left foot and left thigh on 11/13/19. Interview on 11/27/19 at 9:30 [NAME]M. with State tested Nursing Assistant (STNA) #219 indicated she identified bruising on Resident #34's chest, right leg, left upper arm and feet a couple of weeks prior while providing a shower. STNA #219 confirmed she notified the nurse and documented the bruises on the shower sheet. Interview on 11/27/19 at 10:32 [NAME]M. with STNA #246 indicated she identified bruising on Resident #34's right hip, right chest below the nipple, and left foot a couple of weeks prior while providing a shower. STNA #246 confirmed she notified the nurse and documented the bruises on the shower sheet. Interview on 11/27/19 at 12:24 P.M. with the Administrator confirmed there was no progress note to verify an assessment was completed for bruising identified on 11/13/19, no incident report completed for bruising identified on 11/13/19, and no mandatory reporting or investigation of the 11/13/19 bruising of unknown origin as required. Interview on 11/27/19 at 11:58 [NAME]M. with Licensed Practical Nurse (LPN) #227 confirmed observing Resident #34's bruising on or after 11/13/19. Interview on 11/27/19 at 3:40 P.M. with STNA #221 confirmed observing Resident #34's bruising on or after 11/13/19. Interview on 11/27/19 at 4:02 P.M. with STNA #247 confirmed observing Resident #34's bruising on or after 11/13/19. Review of the facility policy, The Elder Justice Act and Reporting Suspected Crimes Against Residents Policy and Procedure, revised 10/10/19, revealed the facility has a duty to report all alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property as well as the results of all investigations of alleged violation pursuant to 42 CFR 483.12(c). This deficiency substantiates Master Complaint Number OH 557. This is an example of continued noncompliance from the survey completed on 10/21/19.

Based on record review and interview the facility failed to report an injury of unknown origin to the State Agency identified for Resident #34. This affected one Resident (#34) of three Residents (#26, #30 and #34) reviewed for incidents/accidents. The facility census was 44. Findings include: Review of the medical record for Resident #34 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/07/19, revealed the resident had impaired cognition. The resident required extensive assistance of two staff for bed mobility, transfers, and personal hygiene, extensive assistance of one staff for toileting and eating, and total dependence of one staff for bathing. The assessment indicated resident received hospice care. Review of the progress note dated 11/12/19 indicated a bruise identified on Resident #34's right thigh, the resident was unable to communicate how or when it occurred, and the Director of Nursing and Administrator was notified. Review of resident incident report form dated 11/12/19 for Resident #34 indicated a right thigh bruise of unknown origin. Review of incident/accident tracking log dated (MONTH) 2019 through (MONTH) 2019 revealed a bruise on 11/12/19 for Resident #34. Review of Resident #34's bath sheets indicated no bruises on 11/10/19, 11/17/19, 11/20/19, 11/24/19, and bruising on the right thigh, right arm, right breast, left foot, and abrasions on the left foot and left thigh on 11/13/19. Interview on 11/27/19 at 9:30 [NAME]M. with State tested Nursing Assistant (STNA) #219 indicated she identified bruising on Resident #34's chest, right leg, left upper arm and feet a couple of weeks prior while providing a shower. STNA #219 confirmed she notified the nurse and documented the bruises on the shower sheet. Interview on 11/27/19 at 10:32 [NAME]M. with STNA #246 indicated she identified bruising on Resident #34's right hip, right chest below the nipple, and left foot a couple of weeks prior while providing a shower. STNA #246 confirmed she notified the nurse and documented the bruises on the shower sheet. Interview on 11/27/19 at 12:24 P.M. with Administrator confirmed there was no mandatory reporting of the 11/13/19 bruising of unknown origin as required. Interview on 11/27/19 at 11:58 [NAME]M. with Licensed Practical Nurse (LPN) #227 confirmed observing Resident #34's bruising on or after 11/13/19. Interview on 11/27/19 at 3:40 P.M. with STNA #221 confirmed observing Resident #34's bruising on or after 11/13/19. Interview on 11/27/19 at 4:02 P.M. with STNA #247 confirmed observing Resident #34's bruising on or after 11/13/19. Review of facility policy, The Elder Justice Act and Reporting Suspected Crimes Against Residents Policy and Procedure, revised 10/10/19, revealed the facility has a duty to report all alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property as well as the results of all investigations of alleged violation pursuant to 42 CFR 483.12(c). This deficiency substantiates Master Complaint Number OH 557. This is an example of continued noncompliance from the survey completed on 10/21/19.

Based on review of the medical record, facility investigation, and associated investigation documents, the facility policy titled Freedom from Abuse, Neglect, and Exploitation, and The Elder Justice Act and Reporting Suspected Crimes Against Residents, and interview with staff the facility failed to implement the facility abuse policy following an allegation of resident to resident sexual abuse. This resulted in Immediate Jeopardy and the likelihood of serious physical and emotional harm for one cognitively impaired resident (Resident #38) when the administrator became aware of an allegation of sexual abuse by a resident with known sexual behaviors (Resident #47) and failed to report the allegation to local authorities. This affected one of five residents reviewed relative to investigations of physical or sexual abuse. The facility identified 12 additional cognitively impaired residents the alleged perpetrator had access to (Residents #5, #11, #21, #24, #25, #26, #30, #33, #35, #40, #41, and #196). The facility census was 46. On 10/09/19 at 4:58 P.M., the Administrator and Regional Director of Clinical Services #27 were informed that Immediate Jeopardy began on 07/17/19 at 3:15 P.M. when Social Service Designee (SSD) #267 reported an allegation of sexual abuse on behalf of Resident #38 and the administrator failed to report the suspicion of sexual abuse to the local authorities. The resident perpetrator (Resident #47) remained in the facility on 15-minute checks from 07/17/19 at 3:30 P.M. through 07/19/19 at 11:45 P.M., at which time he was removed from monitoring. Resident #47 remained in the facility until discharge on [DATE] at 10:30 [NAME]M. The Immediate Jeopardy was removed on 10/10/19 at 10:00 [NAME]M. when the facility implemented the following corrective actions: · On 07/17/19 at 3:54 P.M., Resident #38's power of attorney (POA) was notified of the sexual abuse allegation and that the facility had completed a head to toe assessment with no negative findings. The POA declined to have Resident #38 transferred to the hospital for a rape test. · On 07/24/19 at 10:30 [NAME]M., Resident #47 was discharged to a secured nursing home with a large population of residents with behavioral health needs. · On 10/09/19 at 6:00 P.M., Licensed Practical Nurse (LPN) #228 and LPN #264 initiated body audits of all cognitively impaired residents. On 10/10/19 by 10:00 [NAME]M., the body audits of all cognitively impaired residents (Residents #5, #11, #21, #24, #25, #26, #30, #35, #38, #40, and #41) were completed. · On 10/09/19 at 6:00 P.M., the administrator began interviewing staff regarding their knowledge of inappropriate sexual contact between Resident #47 and Resident #38. · On 10/09/19 at 6:18 P.M., the administrator submitted a self-report incident (SRI) for an allegation of sexual abuse to the State Agency. · On 10/09/19 at 7:29 P.M., the administrator contacted the local police department. · On 10/09/19 at 7:45 P.M., the local police officer arrived at the facility to initiate an investigation. · On 10/10/19 at 6:30 [NAME]M., Registered Nurse (RN) #276, SSD #267, and LPN #268 initiated staff education on the facility's policies titled Freedom from Abuse, Neglect, and Exploitation and The Elder Justice Act and Reporting Suspected Crimes Against Residents. By 4:00 P.M. the Minimum Data Set 3.0 Coordinator #256, four of six Registered Nurses (#226, #249, #257, and #261), 11 of 14 LPNs (#217, #228, #229, #231, #232, #236, #247, #260, #262, #264, and #282), 18 of 28 State tested Nursing Assistants (#218, #219, #22, #224, #227, #230, #231, #234, #235, #248, #250, #251, #252, #253, #259, #263, and #265) , Activity Director #200, three of three Housekeepers (#211, #212, #213), Laundry Aide #215, Dietitian #204, Dietary Director #206, six of seven Dietary Aides (#205, #207, #209, #210, #280, and #281), Maintenance Staff #214, Certified Occupation Therapy Assistant #266, and Physical Therapy Assistant #269 had received the training. · On 10/10/19 from 8:00 [NAME]M. to 4:00 P.M., LPN #245 conducted resident interviews. Twenty eight of 45 residents residing in the facility were interviewed (Residents #3, #4, #7, #8, #9, #10, #12, #13, #14, #15, #16, #17, #18, #19, #20, #22, #23, #29, #31, #32, #34, #36, #37, #39, #42, #43, #45, and #146). The residents indicated they had not been abused, had not witnessed any other resident being abused, and had no concerns with any other resident. · On 10/10/19 at 10:00 [NAME]M., Vice President of Operations #275 provided education to the administrator and the director of nursing on abuse reporting and the facility policies titled Freedom from Abuse, Neglect, and Exploitation and The Elder Justice Act and Reporting Suspected Crimes Against Residents. · On 10/10/19 at 2:15 P.M., an interview with Medical Director #290 revealed she was made aware of the sexual abuse allegation and was involved in the facility's corrective action plan. · On 10/10/19 at 5:00 P.M., Interview with Vice President of Operations #275 revealed any staff that had not yet received the education on abuse reporting and the facility policy for abuse would receive the training prior to working their next scheduled shift. The training would be provided by RN #276, SSD #267, and LPN #268. · The administrator/designee will perform random weekly audits by interviewing five residents with Brief Interview of Mental Status (BIMS) scores of ten or higher four times a week for four weeks and perform random weekly audits by completing skin assessments for five residents with BIMS of nine or less four times a week for four weeks. The administrator/designee will perform random weekly audits by interviewing five random staff members to ensure staff understands the abuse, neglect and misappropriation policy four weeks. Although the Immediate Jeopardy was removed, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Review of the medical record revealed Resident #38 was admitted on [DATE]. Her [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #38 had severe cognitive deficits with signs of [MEDICAL CONDITION] including inattention, disorganized thinking, and altered level of consciousness which fluctuated. The resident had no behaviors directed towards others or self. She needed limited physical assistance of one staff for transfers and activities of daily living. Review of the care plan for communication dated 02/28/19 indicated Resident #38 was sometimes understood and sometimes understood others. She jumped from one topic to another and would become anxious. Interventions included communication techniques to enhance interactions. Staff were to allow adequate time to respond, repeat as necessary, do not rush the resident, request feedback, and clarify with Resident #38 to ensure understanding. Review of the closed record for Resident #47 revealed the [AGE] year-old male was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #47 was discharged to a secured facility on 07/24/19. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #47 had no cognitive deficits. He displayed behaviors including physical behavioral symptoms directed towards others. Resident #47 was independently ambulatory. Review of the care plan for behaviors dated 03/19/18 indicated Resident #47 had the potential to demonstrate verbally abusive behaviors related to ineffective coping skills, mental/emotional illness, and poor impulse control. The resident tended to go into resident rooms on the north side of building and pester the residents. He was currently not allowed past the nurses' station per the guardian. Resident #47 had walked to the store to purchase alcohol for others. In (MONTH) 2019, the resident had a verbal altercation with another resident. Review of the facility's summary of the investigation initiated 07/17/19 at 3:15 P.M., revealed SSD #267 reported to the administrator Resident #47 may have attempted sexual advances towards Resident #38. Resident #47 was placed on 15-minute visual checks. Resident #38 had a head to toe assessment with no negative findings. The administrator accompanied by SSD #267 interviewed Resident #38. It was difficult at times to understand what the resident was attempting to communicate. During the interview, Resident #38 stated hoochie koochie which she stated often and pointed to her perineal area. The administrator interviewed Resident #47 who denied the allegation. Resident #47 expressed understanding that he needed permission prior to entering another resident's room. Staff statements were obtained. All cognitively intact residents were interviewed and voiced no concern. According to the administrator, SSD #267 stated later that same day that she no longer felt physical contact occurred between Resident #47 and Resident #38. The administrator contacted both residents' responsible parties and the primary care physician (the medical director). Resident interviews were completed with all residents with intact cognition. Review of the facility's investigation revealed no statement from SSD #267 who initially alleged sexual abuse on 07/17/19. The investigation included two statements: One dated 07/17/19 by LPN #270 who observed Resident #47 in Resident 38's room on 07/15/19 and one dated 07/17/19 by the administrator. There was no evidence the local authorities or State Agency were notified. There was no evidence Residents #5, #11, #21, #24, #25, #26, #30, #35, #40, #41, and #196 who were identified as cognitively impaired and residing in the facility on 07/17/19 were assessed for signs of sexual abuse or physical injury. Review of 15-minute check sheets revealed visual checks were completed 07/17/19 from 3:30 P.M. through 07/19/19 at 11:45 P.M., at which time Resident #47 was taken off monitoring. On 10/08/19 at 5:10 P.M., an interview with the administrator indicated she started at the facility on 04/15/19. She reported there have been no self-report incidents (SRIs) involving sexual abuse. On 10/08/19 at 7:05 P.M., an interview with SSD #267 revealed Resident #47 had a [MEDICAL CONDITION]. When he was admitted he did not want to be in the facility. At first, Resident #47 was acclimating without problems. However, he started to change, picking on the elderly residents. Administration then moved him to a private room on the South Hall and he was no longer allowed on the North Hall. SSD #267 indicated Resident #47 knew right from wrong sexually. The last straw was her aunt, Resident #38. Her aunt repeated something to her several times then said That boy referring to Resident #47. SSD #267 stated she immediately notified the administrator. She and the administrator interviewed Resident #38. During the interview Resident #38 kept pushing her hands in her pants. The administrator then stated, So he did do it. The administrator reported the allegation to the corporate director of nursing. The administrator and the corporate director of nursing asked SSD #267 what she wanted. She instructed them to call Resident #38's son. The son said he did not want Resident #38 sent out for a rape test. SSD #267 indicated to her knowledge, Resident #38 was not assessed nor were any other confused residents, and no one was immediately interviewed. SSD #267 never indicated she changed her mind regarding whether the physical contact between Resident #47 and Resident #38 occurred. An interview on 10/09/19 at 3:50 P.M., with the administrator revealed immediately following SSD #267 alleging something occurred she and SSD #267 interviewed Resident #38. At 3:58 P.M., SSD #267 joined the interview with the administrator. They agreed Resident #38 kept pushing on the front of her pants in the area of her privates (groin area) then said, No. SSD #267 asked the resident who? and Resident #38 responded, He did. At this point, the administrator indicated she did not feel Resident #38 was alleging sexual abuse. The administrator indicated she notified the resident's POA on 07/17/19 at 3:54 P.M. The POA did not want her sent to the hospital for a rape test. The administrator did not notify the local authorities or State Agency because she did not feel it was an allegation sexual abuse. Review of the facility policy titled Freedom from Abuse, Neglect, and Exploitation revised 10/10/19 revealed it was the facility's policy to provide for the safety and dignity of all its residents by implementing proper procedures for enforcing the residents' right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility must ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, thoroughly investigated, and must prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. If the facility reasonably suspected that a crime had occurred against a resident or person receiving care, the facility must report that suspicion to the police, State survey agency, and Adult Protective Services. Review of the facility policy titled The Elder Justice Act and Reporting Suspected Crimes Against Residents dated (YEAR) indicated all associates have a duty to report any reasonable suspicion of a crime. The facility has a duty to report all alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown sources and misappropriation as resident property. This deficiency substantiates Complaint Number OH 652.

Based on review of the medical record, facility investigation, and associated investigation documents, the facility policy titled Freedom from Abuse, Neglect, and Exploitation, and The Elder Justice Act and Reporting Suspected Crimes Against Residents, and interview with staff the facility failed to implement the facility abuse policy following an allegation of resident to resident sexual abuse. This resulted in Immediate Jeopardy and the likelihood of serious physical and emotional harm for one cognitively impaired resident (Resident #38) when the administrator became aware of an allegation of sexual abuse by a resident with known sexual behaviors (Resident #47) and failed to report the allegation to the State Agency as required. This affected one of five residents reviewed relative to investigations of physical or sexual abuse. The facility identified 12 additional cognitively impaired residents the alleged perpetrator had access to (Residents #5, #11, #21, #24, #25, #26, #30, #33, #35, #40, #41, and #196). The facility census was 46. On 10/09/19 at 4:58 P.M., the Administrator and Regional Director of Clinical Services #27 were informed that Immediate Jeopardy began on 07/17/19 at 3:15 P.M. when Social Service Designee (SSD) #267 reported an allegation of sexual abuse on behalf of Resident #38 and the administrator failed to report the allegation to the State agency. The resident perpetrator (Resident #47) remained in the facility on 15-minute checks from 07/17/19 at 3:30 P.M. through 07/19/19 at 11:45 P.M., at which time he was removed from monitoring. Resident #47 remained in the facility until discharge on [DATE] at 10:30 [NAME]M. The Immediate Jeopardy was removed on 10/10/19 at 10:00 [NAME]M. when the facility implemented the following corrective actions: · On 07/17/19 at 3:54 P.M., Resident #38's power of attorney (POA) was notified of the sexual abuse allegation and that the facility had completed a head to toe assessment with no negative findings. The POA declined to have Resident #38 transferred to the hospital for a rape test. · On 07/24/19 at 10:30 [NAME]M., Resident #47 was discharged to a secured nursing home with a large population of residents with behavioral health needs. · On 10/09/19 at 6:00 P.M., Licensed Practical Nurse (LPN) #228 and LPN #264 initiated body audits of all cognitively impaired residents. On 10/10/19 by 10:00 [NAME]M., the body audits of all cognitively impaired residents (Residents #5, #11, #21, #24, #25, #26, #30, #35, #38, #40, and #41) were completed. · On 10/09/19 at 6:00 P.M., the administrator began interviewing staff regarding their knowledge of inappropriate sexual contact between Resident #47 and Resident #38. · On 10/09/19 at 6:18 P.M., the administrator submitted a self-report incident (SRI) for an allegation of sexual abuse to the State Agency. · On 10/09/19 at 7:29 P.M., the administrator contacted the local police department · On 10/09/19 at 7:45 P.M., the local police officer arrived at the facility to initiate an investigation. · On 10/10/19 at 6:30 [NAME]M., Registered Nurse (RN) #276, SSD #267, and LPN #268 initiated staff education on the facility's policies titled Freedom from Abuse, Neglect, and Exploitation and The Elder Justice Act and Reporting Suspected Crimes Against Residents. By 4:00 P.M. the Minimum Data Set 3.0 Coordinator #256, four of six Registered Nurses (#226, #249, #257, and #261), 11 of 14 LPNs (#217, #228, #229, #231, #232, #236, #247, #260, #262, #264, and #282), 18 of 28 State tested Nursing Assistants (#218, #219, #22, #224, #227, #230, #231, #234, #235, #248, #250, #251, #252, #253, #259, #263, and #265) , Activity Director #200, three of three Housekeepers (#211, #212, #213), Laundry Aide #215, Dietitian #204, Dietary Director #206, six of seven Dietary Aides (#205, #207, #209, #210, #280, and #281), Maintenance Staff #214, Certified Occupation Therapy Assistant #266, and Physical Therapy Assistant #269 had received the training. · On 10/10/19 from 8:00 [NAME]M. to 4:00 P.M., LPN #245 conducted resident interviews. Twenty eight of 45 residents residing in the facility were interviewed (Residents #3, #4, #7, #8, #9, #10, #12, #13, #14, #15, #16, #17, #18, #19, #20, #22, #23, #29, #31, #32, #34, #36, #37, #39, #42, #43, #45, and #146). The residents indicated they had not been abused, had not witnessed any other resident being abused, and had no concerns with any other resident. · On 10/10/19 at 10:00 [NAME]M., Vice President of Operations #275 provided education to the administrator and the director of nursing on abuse reporting and the facility policies titled Freedom from Abuse, Neglect, and Exploitation and The Elder Justice Act and Reporting Suspected Crimes Against Residents. · On 10/10/19 at 2:15 P.M., an interview with Medical Director #290 revealed she was made aware of the sexual abuse allegation and was involved in the facility's corrective action plan. · On 10/10/19 at 5:00 P.M., Interview with Vice President of Operations #275 revealed any staff that had not yet received the education on abuse reporting and the facility policy for abuse would receive the training prior to working their next scheduled shift. The training would be provided by RN #276, SSD #267, and LPN #268. · The administrator/designee will perform random weekly audits by interviewing five residents with Brief Interview of Mental Status (BIMS) scores of ten or higher four times a week for four weeks and perform random weekly audits by completing skin assessments for five residents with BIMS of nine or less four times a week for four weeks. The administrator/designee will perform random weekly audits by interviewing five random staff members to ensure staff understands the abuse, neglect and misappropriation policy four weeks. Although the Immediate Jeopardy was removed, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Review of the medical record revealed Resident #38 was admitted on [DATE]. Her [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #38 had severe cognitive deficits with signs of [MEDICAL CONDITION] including inattention, disorganized thinking, and altered level of consciousness which fluctuated. The resident had no behaviors directed towards others or self. She needed limited physical assistance of one staff for transfers and activities of daily living. Review of the care plan for communication dated 02/28/19 indicated Resident #38 was sometimes understood and sometimes understood others. She jumped from one topic to another and would become anxious. Interventions included communication techniques to enhance interactions. Staff were to allow adequate time to respond, repeat as necessary, do not rush the resident, request feedback, and clarify with Resident #38 to ensure understanding. Review of the closed record for Resident #47 revealed the [AGE] year-old male was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #47 was discharged to a secured facility on 07/24/19. Review of the quarterly MDS 3.0 assessment dated [DATE] Resident #47 had no cognitive deficits. He displayed behaviors including physical behavioral symptoms directed towards others. Resident #47 was independently ambulatory. Review of the care plan for behaviors dated 03/19/18 indicated Resident #47 had the potential to demonstrate verbally abusive behaviors related to ineffective coping skills, mental/emotional illness, and poor impulse control. The resident tended to go into resident rooms on the north side of building and pester the residents. He was currently not allowed past the nurses' station per the guardian. Resident #47 had walked to the store to purchase alcohol for others. In (MONTH) 2019, the resident had a verbal altercation with another resident. Review of the facility's summary of the investigation initiated 07/17/19 at 3:15 P.M., revealed SSD #267 reported to the administrator Resident #47 may have attempted sexual advances towards Resident #38. Resident #47 was placed on 15-minute visual checks. Resident #38 had a head to toe assessment with no negative findings. The administrator accompanied by SSD #267 interviewed Resident #38. It was difficult at times to understand what the resident was attempting to communicate. During the interview, Resident #38 stated hoochie koochie which she stated often and pointed to her perineal area. The administrator interviewed Resident #47 who denied the allegation. Resident #47 expressed understanding that he needed permission prior to entering another resident's room. Staff statements were obtained. All cognitively intact residents were interviewed and voiced no concern. According to the administrator, SSD #267 stated later that same day that she no longer felt physical contact occurred between Resident #47 and Resident #38. The administrator contacted both residents' responsible parties and the primary care physician (the medical director). Resident interviews were completed with all residents with intact cognition. Review of the facility's investigation revealed no statement from SSD #267 who initially alleged sexual abuse on 07/17/19. The investigation included two statements: One dated 07/17/19 by LPN #270 who observed Resident #47 in Resident 38's room on 07/15/19 and one dated 07/17/19 by the administrator. There was no evidence the local authorities or State Agency were notified. There was no evidence Residents #5, #11, #21, #24, #25, #26, #30, #35, #40, #41, and #196 who were identified as cognitively impaired and residing in the facility on 07/17/19 were assessed for signs of sexual abuse or physical injury. Review of 15-minute check sheets revealed visual checks were completed 07/17/19 from 3:30 P.M. through 07/19/19 at 11:45 P.M., at which time Resident #47 was taken off monitoring. On 10/08/19 at 5:10 P.M., an interview with the administrator indicated she started at the facility on 04/15/19. She reported there have been no self-report incidents (SRIs) involving sexual abuse. On 10/08/19 at 7:05 P.M., an interview with SSD #267 revealed Resident #47 had a [MEDICAL CONDITION]. When he was admitted he did not want to be in the facility. At first, Resident #47 was acclimating without problems. However, he started to change, picking on the elderly residents. Administration then moved him to a private room on the South Hall and he was no longer allowed on the North Hall. SSD #267 indicated Resident #47 knew right from wrong sexually. The last straw was her aunt, Resident #38. Her aunt repeated something to her several times then said That boy referring to Resident #47. SSD #267 stated she immediately notified the administrator. She and the administrator interviewed Resident #38. During the interview Resident #38 kept pushing her hands in her pants. The administrator then stated, So he did do it. The administrator reported the allegation to the corporate director of nursing. The administrator and the corporate director of nursing asked SSD #267 what she wanted. She instructed them to call Resident #38's son. The son said he did not want Resident #38 sent out for a rape test. SSD #267 indicated to her knowledge, Resident #38 was not assessed nor were any other confused residents, and no one was immediately interviewed. SSD #267 never indicated she changed her mind regarding whether the physical contact between Resident #47 and Resident #38 occurred. An interview on 10/09/19 at 3:50 P.M., with the administrator revealed immediately following SSD #267 alleging something occurred she and SSD #267 interviewed Resident #38. At 3:58 P.M., SSD #267 joined the interview with the administrator. They agreed Resident #38 kept pushing on the front of her pants in the area of her privates (groin area) then said, No. SSD #267 asked the resident who? and Resident #38 responded, He did. At this point, the administrator indicated she did not feel Resident #38 was alleging sexual abuse. The administrator indicated she notified the resident's POA on 07/17/19 at 3:54 P.M. The POA did not want her sent to the hospital for a rape test. The administrator did not notify the local authorities or State Agency because she did not feel it was an allegation sexual abuse. Review of the facility policy titled Freedom from Abuse, Neglect, and Exploitation revised 10/10/19 revealed it was the facility's policy to provide for the safety and dignity of all its residents by implementing proper procedures for enforcing the residents' right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility must ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, thoroughly investigated, and must prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. If the facility reasonably suspected that a crime had occurred against a resident or person receiving care, the facility must report that suspicion to the police, state survey agency, and Adult Protective Services. Review of the facility policy titled The Elder Justice Act and Reporting Suspected Crimes Against Residents dated (YEAR) indicated all associates have a duty to report any reasonable suspicion of a crime. The facility has a duty to report all alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property. This deficiency substantiates Complaint Number OH 652.

Based on review of the medical record, facility investigation, and associated investigation documents, the facility policy titled Freedom from Abuse, Neglect, and Exploitation, and The Elder Justice Act and Reporting Suspected Crimes Against Residents, and interview with staff, resident, and resident families the facility failed to implement their abuse policy following an allegation of resident to resident sexual abuse. This resulted in Immediate Jeopardy and the likelihood of serious physical and emotional harm for one cognitively impaired resident (Resident #38) when the administrator became aware of an allegation of sexual abuse by a resident with known sexual behaviors (Resident #47) and failed to ensure adequate monitoring of the alleged resident perpetrator, thoroughly investigate the allegation and report the allegation to law enforcement and the State Agency. This affected one of five residents reviewed relative to investigations of physical or sexual abuse. The facility identified 12 additional cognitively impaired residents the alleged perpetrator had access to (Residents #5, #11, #21, #24, #25, #26, #30, #33, #35, #40, #41, and #196). The facility census was 46. On 10/09/19 at 4:58 P.M., the administrator and Regional Director of Clinical Services #27 were informed Immediate Jeopardy began on 07/17/19 at 3:15 P.M. when Social Service Designee (SSD) #267 reported an allegation of sexual abuse on behalf of Resident #38 and the administrator failed to follow their policy and procedure for investigation of the allegation and providing safety for the residents from the alleged perpetrator (Resident #47). Resident #47 remained in the facility on 15-minute checks from 07/17/19 at 3:30 P.M. through 07/19/19 at 11:45 P.M., at which time he was removed from monitoring without the facility completing a thorough investigation of the sexual abuse allegation. Resident #47 remained in the facility until discharge on [DATE] at 10:30 [NAME]M. The Immediate Jeopardy was removed on 10/10/19 at 4:00 P.M. when the facility implemented the following corrective actions: · On 07/17/19 at 3:54 P.M., Resident #38's power of attorney (POA) was notified of the sexual abuse allegation and that the facility had completed a head to toe assessment with no negative findings. The POA declined to have Resident #38 transferred to the hospital for a rape test. · On 07/24/19 at 10:30 [NAME]M., Resident #47 was discharged to a secured nursing home with a large population of residents with behavioral health needs. · On 10/09/19 at 6:00 P.M., Licensed Practical Nurse (LPN) #228 and LPN #264 initiated body audits of all cognitively impaired residents. On 10/10/19 by 10:00 [NAME]M., the body audits of all cognitively impaired residents (Residents #5, #11, #21, #24, #25, #26, #30, #35, #38, #40, and #41) were completed. · On 10/09/19 at 6:00 P.M., the administrator began interviewing staff regarding their knowledge of inappropriate sexual contact between Resident #47 and Resident #38. · On 10/09/19 at 6:18 P.M., the administrator submitted a self-report incident (SRI) for an allegation of sexual abuse to the State Agency. · On 10/09/19 at 7:29 P.M., the administrator contacted the local police department. · On 10/09/19 at 7:45 P.M., the local police officer arrived at the facility to initiate an investigation. · On 10/10/19 at 6:30 [NAME]M., Registered Nurse (RN) #276, SSD #267, and LPN #268 initiated staff education on the facility's policies titled Freedom from Abuse, Neglect, and Exploitation and The Elder Justice Act and Reporting Suspected Crimes Against Residents. By 4:00 P.M. the Minimum Data Set 3.0 Coordinator #256, four of six RNs (#226, #249, #257, and #261), 11 of 14 LPNs (#217, #228, #229, #231, #232, #236, #247, #260, #262, #264, and #282), 18 of 28 State tested Nursing Assistants (#218, #219, #22, #224, #227, #230, #231, #234, #235, #248, #250, #251, #252, #253, #259, #263, and #265) , Activity Director #200, Social Service Designee #267, three of three Housekeepers (#211, #212, #213), Laundry Aide #215, Dietitian #204, Dietary Director #206, 6 of 7 Dietary Aides (#205, #207, #209, #210, #280, and #281), Maintenance Staff #214, Certified Occupation Therapy Assistant #266, and Physical Therapy Assistant #269 had received the training. · On 10/10/19 from 8:00 [NAME]M. to 4:00 P.M., LPN #245 conducted resident interviews. Twenty eight of 45 residents residing in the facility were interviewed (Residents #3, #4, #7, #8, #9, #10, #12, #13, #14, #15, #16, #17, #18, #19, #20, #22, #23, #29, #31, #32, #34, #36, #37, #39, #42, #43, #45, and #146). The residents indicated they had not been abused, had not witnessed any other resident being abused, and had no concerns with any other resident. · On 10/10/19 at 10:00 [NAME]M., Vice President of Operations #275 provided education to the administrator and the director of nursing on abuse reporting and the facility policies titled Freedom from Abuse, Neglect, and Exploitation and The Elder Justice Act and Reporting Suspected Crimes Against Residents. · On 10/10/19 at 2:15 P.M., an interview with Medical Director #290 revealed she was made aware of the sexual abuse allegation and was involved in the facility's corrective action plan. · On 10/10/19 at 5:00 P.M., interview with Vice President of Operations #275 revealed any staff that had not yet received the education on abuse reporting and the facility policy for abuse would receive the training prior to working their next scheduled shift. The training would be provided by RN #276, SSD #267, and LPN #268. · The administrator/designee will perform random weekly audits by interviewing five residents with Brief Interview of Mental Status (BIMS) scores of ten or higher four times a week for four weeks and perform random weekly audits by completing skin assessments for five residents with BIMS of nine or less four times a week for four weeks. The administrator/designee will perform random weekly audits by interviewing five random staff members to ensure staff understands the abuse, neglect and misappropriation policy four weeks. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Review of the medical record revealed Resident #38 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #38 had severe cognitive deficits with signs of [MEDICAL CONDITION] including inattention, disorganized thinking, and altered level of consciousness which fluctuated. The resident displayed no behaviors directed towards others or self. She required limited physical assistance of one staff for transfers and activities of daily living. Review of the care plan for communication dated 02/28/19 indicated Resident #38 was sometimes understood and sometimes understood others. She jumped from one topic to another and would become anxious. Interventions included communication techniques to enhance interactions. Staff were to allow adequate time to respond, repeat as necessary, not rush the resident, request feedback, and clarify with Resident #38 to ensure understanding. Review of the closed record for Resident #47 revealed the [AGE] year-old male resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #47 was discharged to a secured facility on 07/24/19. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #47 had no cognitive deficits. He displayed behaviors including physical behavioral symptoms directed towards others. Resident #47 was independently ambulatory. Review of the care plan for behaviors dated 03/19/18 indicated Resident #47 had the potential to demonstrate verbally abusive behaviors related to ineffective coping skills, mental/emotional illness, and poor impulse control. The resident tended to go into resident rooms on the north side of building and pester the residents. He was currently not allowed past the nurses' station per the guardian. Resident #47 had walked to the store to purchase alcohol for others. In (MONTH) 2019, the resident had a verbal altercation with another resident. Review of the facility's summary of the investigation initiated 07/17/19 at 3:15 P.M., revealed SSD #267 reported to the administrator Resident #47 may have attempted sexual advances towards Resident #38. Resident #47 was placed on 15-minute visual checks. Resident #38 had a head to toe assessment with no negative findings. The administrator accompanied by SSD #267 interviewed Resident #38. It was difficult at times to understand what the resident was attempting to communicate. During the interview, Resident #38 stated hoochie koochie which she stated often and pointed to her perineal area. The administrator interviewed Resident #47 who denied the allegation. Resident #47 expressed understanding that he needed permission prior to entering another resident's room. Staff statements were obtained. All cognitively intact residents were interviewed and voiced no concern. According to the administrator, SSD #267 stated later that same day that she no longer felt physical contact occurred between Resident #47 and Resident #38. The administrator contacted both residents' responsible parties and the primary care physician (the medical director). Resident interviews were completed with all residents with intact cognition. Review of the facility's investigation revealed no statement from SSD #267 who initially alleged sexual abuse on 07/17/19. The investigation included two statements: One dated 07/17/19 by LPN #270 who observed Resident #47 in Resident 38's room on 07/15/19 and one dated 07/17/19 by the administrator. Review of LPN #270's statement revealed on 07/15/19 at approximately 6:00 P.M. she observed Resident #47 seated on Resident #38's bed and Resident #38 seated in her recliner. No inappropriate touching or interaction was observed. The residents were separated with no further contact observed on that date. There was no evidence the local authorities or State Agency were notified. There was no evidence Residents #5, #11, #21, #24, #25, #26, #30, #35, #40, #41, and #196 who were identified as cognitively impaired and residing in the facility on 07/17/19 were assessed for signs of sexual abuse or physical injury. Review of 15-minute check sheets revealed visual checks were completed 07/17/19 from 3:30 P.M. through 07/19/19 at 11:45 P.M., at which time Resident #47 was taken off monitoring. Observation on 10/06/19 at 11:35 [NAME]M. revealed Resident #38 was awake and alert sitting in a chair in her room. An attempt to interview Resident #38 was unsuccessful. Resident #38 was confused to time and place and unable to answer questions. On 10/08/19 at 4:30 P.M., an interview with State tested Nurse Assistant (STNA) #218 indicated it was rumored Resident #47 got into bed with a female resident, Resident #38. The two residents' rooms were right next to each other on the South Hall. On 10/08/19 at 4:45 P.M., an interview with Activity Director #200 revealed she never trusted Resident #47. He made her feel uncomfortable, safety-wise. Before being discharged in (MONTH) 2019, Activity Director #200 stated Resident #47 would have guys in his room watching pornography. On 10/08/19 at 5:10 P.M., an interview with the administrator indicated she started at the facility on 04/15/19. She reported there had been no SRIs involving sexual abuse. On 10/08/19 at 5:20 P.M., an interview with Dietary Director #206 revealed Resident #47 had sexually inappropriate behavior, mostly verbal. He said things to both staff and other residents. Dietary Director #206 indicated she never observed him display inappropriate touching. Resident #47 used to go into North Hall resident rooms. Dietary Director #206 stated she heard Resident #47 went into another female resident's room, Resident #38, sometime during the summer of 2019 just before he was discharged from facility. On 10/08/19 at 6:00 P.M., an interview with LPN #217 indicated the facility moved Resident #47 from the North Hall to the South Hall because he was inappropriate and arguing with other residents. On 10/08/19 at 6:20 P.M., an interview with STNA #253 revealed Resident #47 was stalking her on Facebook, copying images of her and her child onto his Facebook page. He messaged the STNA that she was hot. STNA #253 stated Resident #47 would make weird noises when she passed him. When the resident was acting inappropriate towards her, she went to her supervisor. STNA #253 stated Resident #47 was inappropriate verbally to everyone, staff and residents, sometimes sexually. Staff and administration knew the resident was inappropriate and that was why he was not allowed on the North Hall. STNA #253 indicated she heard stories of Resident #47 being inappropriate with another resident, Resident #38. STNA # 253 stated Resident #38 reported he touched her. On 10/08/19 at 6:33 P.M., an interview with STNA #224 indicated Resident #47 tried getting flirty with her. STNA #224 indicated she heard a rumor that Resident #47 went into Resident #38's room. Resident #38 later pointed at her private area and then at Resident #47. STNA #224 stated she could not remember when that occurred. She referred the surveyor to Resident #38's niece, SSD #267, who knew more about the incident. On 10/08/19 at 7:05 P.M., an interview with SSD #267 revealed Resident #47 had a [MEDICAL CONDITION]. When he was admitted he did not want to be in the facility. At first, Resident #47 was acclimating without problems. However, he started to change, picking on the elderly residents. Administration then moved him to a private room on the South Hall and he was no longer allowed on the North Hall. SSD #267 indicated Resident #47 knew right from wrong sexually. The last straw was her aunt, Resident #38. Her aunt repeated something to her several times then said That boy referring to Resident #47. SSD #267 stated she immediately notified the administrator. She and the administrator interviewed Resident #38. During the interview Resident #38 kept pushing her hands in her pants. The administrator then stated, So he did do it. The administrator reported the allegation to the corporate director of nursing. The administrator and the corporate director of nursing asked SSD #267 what she wanted. She instructed them to call Resident #38's son. The son said he did not want Resident #38 sent out for a rape test. SSD #267 indicated to her knowledge, Resident #38 was not assessed nor were any other confused residents, and no one was immediately interviewed. SSD #267 never indicated she changed her mind regarding whether the physical contact between Resident #47 and Resident #38 occurred. On 10/09/19 at 10:06 [NAME]M., a phone interview with Resident #47's guardian revealed Resident #47 had off the wall behaviors. The behaviors scared some residents. The resident's guardian stated at times, Resident #47 was sexually inappropriate. Resident #47 was asked to leave the facility in mid (MONTH) 2019. The guardian indicated the last straw was Resident #47 gave an alert and oriented female resident a sex toy which she had not asked for or wanted. The facility helped find placement for him after asking the resident to leave. On 10/09/19 at 10:20 [NAME]M., a phone interview with the POA for Resident #38 revealed he was made aware a male resident entered his mother's room and that he did something with her. The POA was asked if he wanted his mother sent to the hospital to get a rape test which he did not. The POA stated he spoke to Resident #38 and felt the incident did not go that far. An interview on 10/09/19 at 3:50 P.M., with the administrator revealed immediately following SSD #267 alleging something occurred she and SSD #267 interviewed Resident #38. At 3:58 P.M., SSD #267 joined the interview with the administrator. They agreed Resident #38 kept pushing on the front of her pants in the area of her privates (groin area) then said, No. SSD #267 asked the resident who? and Resident #38 responded, He did. At this point, the administrator indicated she did not feel Resident #38 was alleging sexual abuse. The administrator indicated she notified the resident's POA on 07/17/19 at 3:54 P.M. The POA did not want her sent to the hospital for a rape test. The administrator did not notify the local authorities or State Agency because she did not feel it was an allegation sexual abuse. An interview on 10/10/19 at 8:35 [NAME]M., with the administrator and Regional Director of Clinical Services #295 revealed SSD #267 reported the allegation of sexual abuse at 3:15 P.M. on 07/17/19. The administrator notified Resident #38's son (POA) then initiated an investigation. They confirmed there was no evidence of cognitively impaired residents being assessed for signs of sexual abuse or injury. On 10/10/19 at 2:15 P.M., an interview with Primary Care Physician-Medical Director #290 revealed she was made aware of the sexual abuse allegation at the time of the allegation (MONTH) and again on 10/09/19. Review of the facility policy titled Freedom from Abuse, Neglect, and Exploitation revised 10/10/19 revealed it was the facility's policy to provide for the safety and dignity of all its residents by implementing proper procedures for enforcing the residents' right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy indicated the facility must ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, thoroughly investigated, and must prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress. If the facility reasonably suspected that a crime had occurred against a resident or person receiving care, the facility must report that suspicion to the police, state survey agency, and Adult Protective Services. Review of the facility policy titled The Elder Justice Act and Reporting Suspected Crimes Against Residents dated (YEAR) indicated all associates had a duty to report any reasonable suspicion of a crime. The facility had a duty to report all alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown origin and misappropriation of resident property. This deficiency substantiates Complaint Number OH 652.

Based on observation, interview and record review revealed harm occurred to resident #38 when the facility failed to adequately monitor and failed to provide interventions as ordered which resulted in the decline of the right heel wound as well as two additional deep tissue injury wounds to the right lateral ankle and the right lateral distal foot and failed to ensure wound care for pressure ulcers were completed using appropriate infection control precautions. This affected one (Resident #38) of one resident reviewed for pressure ulcers of 17 sampled residents. The census was 58 residents. Findings include: Resident #38 was admitted on [DATE] with [DIAGNOSES REDACTED]. The skin risk assessment dated [DATE] indicated the resident was high risk for developing pressure ulcers. The care plan dated 07/28/12 regarding pressure areas indicated the resident had altered skin integrity related to decreased mobility. The care plan indicated the resident was admitted with a pressure area wound to the coccyx. The care plan indicated there were pressure areas to the right heel as of 09/06/12 and pressure areas to the right ankle and right lateral foot as of 10/05/12. The interventions included turn side to side every two hours and a low air loss mattress dated 08/24/12. The care plan did not include any interventions regarding the treatments for the wounds. Review of the Wound Management Service dated 09/07/12 ordered to offload/float the resident's heels when in bed. The care plan did not include the intervention of off loading or floating the resident's heels. The minimum data set (MDS) assessment dated [DATE] indicated the resident had moderate cognitive impairment and required limited to extensive assistance for activities of daily living. The skin risk assessment dated [DATE] indicated the resident was high risk for developing pressure ulcers. The wound/skin record indicated the right heel date of onset was 09/22/12. The wound/skin record dated 09/25/12 revealed the coccyx wound was a Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.) and the right heel was unstageable. The wound/skin record indicated the right ankle ulcer and right lateral foot ulcer were discovered on 10/05/12. The wound/skin record dated 10/09/12 revealed the right heel ulcer and right lateral foot ulcer were scabbed. The physician orders [REDACTED]. The coccyx wound treatment included to cleanse with normal saline, apply [MEDICATION NAME] to periwound, apply Santyl "nickel thick" to open area to wound edges, apply calcium alginate daily. The right heel treatment included to cleanse with normal saline, apply calcium alginate with silver to open areas, apply ABD, and Kerlix three times a week and as needed. The orders also included side to side turns every two hours. The right lateral ankle/right lateral foot treatment included to cleanse with normal saline, pad and protect three times a week and as needed. The treatment administration record (TAR) for October 2012 included to cleanse the coccyx wound with normal saline, apply [MEDICATION NAME] to periwound, apply Santyl "nickel thick" to open area to wound edges, apply calcium alginate daily. Right heel treatment: cleanse with normal saline, apply calcium alginate with silver to open areas, apply ABD, and Kerlix three times a week and as needed. The orders also included side to side turns every two hours. The right lateral ankle/right lateral foot treatment included to cleanse with normal saline, pad and protect three times a week and as needed. The wound management service form dated 10/05/12 revealed the resident was admitted with the coccyx wound that was presently unstageable. The right heel had a deep tissue injury that had hard black eschar (A thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissue that has lost its usual physical properties & biological activity.) that was discovered on 09/06/12 in the facility. The right lateral ankle was a deep tissue injury that was deep purple in color and discovered on 10/05/12 in the facility. The right lateral foot was a deep tissue injury that was deep purple and was discovered on 10/05/12 in the facility. There was no documentation of monitoring of the skin every shift prior to the discovery of the right foot and heel wounds. The resident was observed in the low bed on 10/09/12 at 10:32 A.M. and 5:00 P.M., on 10/10/12 at 1:12 P.M. and 3:40 P.M. and on 10/11/12 at 7:05 A.M. The resident was observed on 10/11/12 for dressing changes to the pressure areas that began at 7:05 A.M. and concluded at 7:55 A.M. The ABD was loosely applied over the coccyx. The coccyx wound bed had slough (a necrotic/avascular tissue in the process of separating from the viable portions of the body & is usually light colored, soft, moist, & stringy (at times).) The licensed practical nurse (LPN) #9 cleansed the wound with normal saline. The purulent drainage and the normal saline drained toward the resident's rectum. LPN #9 applied [MEDICATION NAME] Ointment to the intact skin around the wound. She attempted to apply the Santyl Ointment to the wound bed, but was unsuccessful due to the moist wound bed. LPN #9 took a towel from the shelf in the resident's room and patted the wound bed. She attempted to apply the Santyl Ointment with cotton tip applicators and only placed a small amount on the wound bed. She applied Algicell AG (a calcium alginate) to the wound bed and applied a dressing that did not require tape ([MEDICATION NAME]). LPN #9 stated the coccyx wound had worsened since she saw it last. LPN #9 removed the right foot dressing. The right heel wound was necrotic with a small amount of sanguineous drainage. The right outer ankle and right lateral foot were reddened with a small scabbed area. LPN #9 cleansed the heel and the ankle areas with normal saline, applied Santyl Ointment and applied Algicell AG to both areas. She placed a dry dressing over the areas and was about to wrap the areas with gauze. The surveyor questioned if there was any treatment to the right lateral foot. She stated she was unaware of that area. She applied the Santyl Ointment to the right lateral foot and wrapped all three areas with gauze. The state-tested nurse aide (STNA) #11 cleansed the residents rectal area. The area was dark red. STNA #11 and the LPN verified the rectal area was dark red. STNA#11 applied [MEDICATION NAME] Ointment to the rectal area after cleansing the area. There was no documentation regarding the red rectal area. At the completion of the wound care on 10/11/12 at 7:55 A.M. LPN #9 verified she used a towel to pat the coccyx wound bed during the dressing change. She verified she did not apply the Santyl Ointment to the entire coccyx wound bed as ordered. She verified she was unaware of the right lateral foot wound. She verified she did not follow the physician orders [REDACTED]. An interview with the director of nursing (DON) on 10/11/12 at 3:45 P.M. verified the pressure ulcers on the right heel, right ankle and right lateral foot developed in the facility. An interview with the clinical nurse practitioner (CNP) #10 on 10/11/12 at 4:20 P.M. revealed the coccyx wound could be covered with [MEDICATION NAME] or an ABD dressing (a dry dressing). She stated the Santyl Ointment should be applied to the coccyx wound bed by placing it on the Algicell AG then place it on the wound bed. She verified the right heel, ankle and lateral foot wounds were not discovered until they were purple in color. She verified there was no documentation that indicated the resident had suffered a deep tissue injury. She verified the resident was at risk for developing pressure ulcers and her skin should be monitored frequently which included when she was repositioned every two hours.

Based on observation, record review and interview, the facility failed to ensure the open areas on Resident #43's left upper thigh were documented and treatments ordered, and treatment orders were obtained for an unstageable left heel ulcer for Resident #65. This affected two residents of four residents observed during skin care of seven residents with pressure ulcers. Findings include: 1. Resident #65 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The wound management form dated 11/30/12 indicated the resident had a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister.) pressure ulcer to the left heel. The progress notes dated 12/07/12 indicated Resident #65 was admitted to the hospital on that date. The progress notes indicated the resident returned from the hospital on [DATE]. The wound/skin record dated 12/10/12 indicated the left heel pressure ulcer was an unstageable pressure ulcer. The wound/skin record indicated the left heel ulcer had worsened since the hospital admission. The physician orders [REDACTED]. An observation made on 12/13/12 at 4:20 P.M. revealed Licensed Practical Nurse (LPN) #10 was about to apply a dry dressing and wrap Resident #65's left heel with gauze. She stated there was no pressure wound on the left heel. She stated the treatment was to protect the heel from developing a pressure ulcer. The surveyor identified an unstageable ulcer on the left inner heel prior to the dressing application. LPN #10 stated she was unaware of the pressure ulcer. She verified she was caring for the resident that day. She stated the resident had just returned from the hospital last night and she needed to get treatment orders from the physician for the left heel pressure ulcer. An interview with the director of nursing on 12/13/12 at 5:20 P.M. verified Resident #65 returned from the hospital on [DATE]. She verified the most recent treatment order for the left heel was dated 11/09/12. She verified the documentation indicated the resident was admitted to the hospital with [REDACTED]. She verified there were no new treatment orders or documentation of physician contact regarding the worsening of the left heel ulcer. 2. Resident #43 had [DIAGNOSES REDACTED]. An observation was made of State tested Nurse Aide (STNA) #11 during perineal care on 12/13/12 at 3:30 P.M. The resident was alert and oriented. Multiple small open areas with a small amount of bloody drainage was noted on the left upper thigh. The STNA and the resident indicated the open areas had been there for "awhile". The medical record contained no documentation or treatment orders regarding the open areas on the thigh. An interview with the director of nursing on 12/13/12 at 5:20 P.M. verified there was no documentation or treatment orders for the open areas on the upper thigh. This is a recite to the annual survey dated 10/11/12.

The following finding pertains to an incident of past non-compliance that was subsequently corrected prior to this survey. Based on medical record review, staff interview, observations, review of the facility's Incident/Accident report, review of the facility's policies, Elopement of a Resident and Hypothermia and review of The National Institute of Health and the Centers for Disease Control information on hypothermia and the National Weather Service Report, the facility failed to ensure adequate supervision was provided to prevent the elopement of one cognitively impaired resident (Resident #10), who had a history of [REDACTED]. This resulted in Immediate Jeopardy for one resident identified at risk for elopement from a total resident census of 46. Resident #10 was placed at risk for serious injury or death from hypothermia or a fall. On 11/29/11 at 1:22 P.M. the administrator and director of nursing (DON) were notified that Immediate Jeopardy began on 10/27/11 at 9:00 P.M. when State tested Nurse Aides (STNAs) #63 and #64 were unable to locate Resident #10. At approximately 9:30 P.M. STNAs #63 and #64 found Resident #10 outside of the front exit door on the ground with the wheelchair tipped over and an alarming unattached self-releasing seat belt. Resident #10 was not wearing a coat, was shivering and complained she was cold. Resident #10's temperature was 95.4 degrees Fahrenheit (F). According to the national weather service the low temperature for 10/27/11 was 42 degrees Fahrenheit and the area received 0.10 inches of precipitation. Resident #10 sustained multiple reddened areas on the mid back, left shoulder, right hip, right foot, left knee and swelling of the right knee. The Immediate Jeopardy was removed on 10/27/11 at 9:35 P.M. when Licensed Practical Nurse (LPN) #61 applied a motion detector alarm to the double fire doors of the new unoccupied addition to alert staff if residents attempted to enter. First aid measures were immediately implemented for Resident #10 to raise her body temperature. Although the Immediate Jeopardy was removed, the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 11/21/11 when the facility implemented the following corrective actions: 1. On 10/27/11, the facility identified no other residents at risk for elopement. 2. Beginning on 10/31/11 and concluding on 11/21/11, the DON conducted education of all staff regarding the current policy, Elopement of Resident (undated), and management of wandering residents. 3. On 11/29/11 from 2:40 P.M. through 4:21 P.M., interviews with LPN #60, #61 and #62 and STNAs #63, #64, #65 and #66 confirmed their knowledge of the elopement policy and procedure and monitoring of residents with wandering behaviors, including Resident #10. All the above staff confirmed no elopements occurred since the 10/27/11 incident. 4. During the tour on 11/29/11 at 8:20 A.M., the double fire doors between the original facility and the new addition were open and the exit doors were observed with key pad locks. The new addition contained residents and staff to assist in monitoring residents. Findings include: Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive assessment dated [DATE] indicated the resident was severely cognitively impaired and had wandering behaviors. Review of the risk of elopement/wandering review assessments dated 01/05/11, 03/30/11, 06/23/11 and 09/14/11 confirmed the resident was at risk for elopement and included "resident exit seeking". The behavior management plan developed by Licensed Psychologist #1 and revised on 09/12/11 indicated target behaviors of wandering, asking to go home and exit seeking. The behavior management plan listed 15 methods to consider to manage the target behaviors including: if she is wandering toward a door, consider stating "that door doesn't work" and then redirect with statements like "you stated you liked it here" or "you said the people were nice here" or "can you tell me about the farm you grew up on?"; engage resident in physical activities; and offer diversional activities. Review of the Incident/Accident Report dated 10/27/11 at 9:30 P.M. by LPN #60 and her nurse's note entry dated 10/27/11 at 9:30 P.M. indicated she was summoned outside and saw Resident #10 lying on her right side on the ground. She was located in front of the exit door of the new wing. The wheelchair had tipped over with the self-release alarmed seatbelt activated. Resident #10 was assisted into the wheelchair and brought to the shower room. The resident's clothing was removed. The resident moved all extremities well and was able to bear weight on lower extremities without signs or symptoms of discomfort. A body check was performed that revealed a 16.0 centimeter (cm) by 14.0 cm reddened area to the mid back, a 3.0 cm by 2.0 cm reddened area to the left shoulder, a 10.0 cm by 8.0 cm reddened area to the right hip, a 3.0 cm by 2.0 cm reddened area to the top of the right foot, a 8.0 cm by 3.0 cm reddened area with slight swelling to the right knee and a 2.0 cm by 1.5 cm reddened area to the left knee. Neurological checks were initiated. The resident was unable to recall how or why she was outside. The resident denied pain and discomfort. Resident #10 was shivering and complained of being cold. A warm shower was provided. The resident was then placed in bed under heated blankets. The resident's body temperature was 95.4 degrees F. The resident's blood pressure measured 160 over 85, pulse was 113 and respirations were 22. The physician was notified at 10:15 P.M. on 10/27/11 and ordered X-rays. The X-rays were negative for fractures but showed severe osteoporosis and mild spondylosis. The family was notified at 10:35 P.M. on 10/27/11. LPN #60 recorded on the neurological assessment form that Resident #10 was assessed beginning at 10/27/11 at 9:30 P.M. The resident's body temperature at 9:30 P.M., was 95.4 degrees F; at 9:45 P.M., her body temperature measured 95.6 degrees F; at 10:00 P.M., her body temperature measured 95.8 degrees F; and at 10:30 P.M., her body temperature measured 96 degrees Fahrenheit. On 10/28/11 at 12:30 A.M., her body temperature measured 96.2 degrees F; at 1:30 A.M., her body temperature measured 96.4 degrees F; at 2:30 A.M., her body temperature measured 96.8 degrees F; at 6:30 A.M., her body temperature measured 97 degrees F. Another assessment of Resident #10's body temperature was not completed until 11:30 P.M., when her body temperature measured 98 degrees F. On 11/29/11 at 2:55 P.M. interview with STNA #64 revealed she was not assigned to Resident #10 on 10/27/11. She confirmed knowledge that Resident #10 constantly wandered throughout the facility and was exit seeking. She stated she redirected the resident when she would see her near an exit door. She stated she teamed with STNA #63 to help get Resident #10 to bed. She stated they looked for the resident and went room to room because Resident #10 would fall asleep in the wheelchair. They then checked the dining room and heard a faint buzz. They entered the unoccupied new addition to the facility and checked each room then found the resident outside the front exit door. The door alarm was sounding. STNA #64 stated it was audible at the exit door but not throughout facility. She stated the resident was found on the ground. STNA #63 ran to get LPN #60. STNA #64 stated she tried to calm the resident because she was trying to get up. She stated the wheelchair was tipped backward and her head was on the seat of the wheelchair and her buttocks were on the headrest. She stated it was cold outside. STNA #64 helped the nurse get the resident into the wheelchair and got her into bed. Then the resident was put in the shower so the nurse could better assess the resident to check for marks and warm her. Once the resident was put to bed, blankets were put into the dryer to warm then put onto the resident. LPN #60 stated during her interview on 11/29/11 at 3:02 P.M., she was assigned care for Resident #10 10/27/11. She confirmed knowledge that Resident #10 constantly wandered throughout the facility and was exit seeking. She stated she redirected the resident when she would see her near an exit door. She reported that at 8:45 P.M., Resident #10 was in the common room and had given her an as needed medication for ear pain. This was verified with the medication administration record. She stated that was the last time she saw her before STNA #63 informed her that the resident was found outside at about 9:25 P.M. She stated she immediately went outside to assess the resident. She stated she found the resident on the ground trying to get up. She stated the wheelchair was tipped over on its side. She stated it was cold outside but the resident had on an undershirt, long sleeve T-shirt (this description conflicted with STNA #63's description of clothing worn), slacks, socks and slippers. She stated she helped bring the resident to her bed and found superficial abrasions on the mid back, left shoulder, right hip, right foot, left knee and swelling and pain of the right knee. She indicated the resident was then brought to the shower to warm her up, bath blankets were heated and she was dressed warmly. She informed the physician who ordered X-rays and notified the family. STNA #63 stated during her interview on 11/29/11 at 3:36 P.M,. that she was assigned to Resident #10 the evening of 10/27/11. She confirmed knowledge that Resident #10 constantly wandered throughout the facility and was exit seeking. She stated she redirected the resident when she would see her near an exit door. She saw her at dinner and again around 8:30 P.M. Around 9:00 P.M., she looked for Resident #10 to put her to bed and was not able to locate her. She searched each room then went into the dining room and heard a door alarm. She stated she went into the unoccupied new addition and found Resident #10 outside flipped over in the wheelchair. The door alarm and the seat belt alarm were sounding. She confirmed it was "a little chilly" outside and the resident was wearing a short sleeve shirt, pants and socks. She helped give the resident a warm shower and put her to bed. She confirmed the nurses heated up blankets and put them on Resident #10 to warm her up. On 11/29/11 at 4:21 P.M.LPN #62 stated during her interview that on 10/27/11 upon arrival for third shift, she began helping LPN #60 heat bath blankets to raise her low body temperature. She stated it was chilly outside and sprinkling on and off. She stated Resident #10 was fine the rest of the night and she checked on her often. She stated Resident #10 was laughing and denying that she went outside. The next morning she wanted up and out of bed as per her usual routine and began wandering doorway to doorway. Interview with the assistant director of nursing on 11/29/11 at 3:47 P.M., indicated all facility doors were alarmed and functioning at the time of the incident on 10/27/11. She reported that a motion detector was added after this incident to the double fire doors dividing the original facility and the new addition until the new addition was occupied. Resident #10 was observed on 11/29/11 during the initial tour of the facility at 8:20 A.M., seated in a wheelchair with a Velcro seat belt attached across the waist. The wheelchair had front and rear anti-tip devices. The resident was thin and frail in her appearance. She had a bandage over her left ear. She propelled the wheelchair with her feet up and down the hallway and went into other resident rooms. She briefly made eye contact but did not communicate with the surveyor. Nursing staff and other residents were observed to verbally and physical redirect the resident at various times during the investigation on 11/29/11. The resident did not attempt to exit the facility during the surveyor ' s observations. Review of the facility's undated policy and procedure (Elopement of a Resident) indicated to search the entire building and grounds, immediately notify the administrator and DON, if not found within 15 minutes to search all areas in the vicinity of the facility, notify the local police if not found in 30 minutes, notify the family/guardian. Once the resident was found, the administrator, director of nursing, police and family/guardian were to be notified. The DON would ensure the risk of elopement had been addressed on the care plan and approaches in place to prevent future elopement problems. Review of the facility's undated policy and procedure (Hypothermia), indicated it was for residents who were exposed to cold for a period of time. The policy lacked identification of a low body temperature. The procedure indicated to monitor the resident's vital signs, central venous pressure (CVP) and urinary output, re-warm the resident including warm drink and food, blankets, rub external limbs and trunk and provide oxygen if needed. The National Institute of Health and the Centers for Disease Control indicated a body temperature below 95 degrees F constitutes a medical emergency and can lead to death if not treated promptly. This deficiency substantiates Complaint Number OH 335.